Care and Cure

care
and
cure
An Introduction to Philosophy of Medicine
jacob stegenga
the university of chicago press
Chicago and London

c o n t e n ts
Acknowledgments xi
Note to Teachers xiii
Introduction 1
part i. concepts
Chapter 1. Health 7
1.1 Summary 7
1.2 Neutralism and Naturalism 8
1.3 Well-Being and Normativism 11
1.4 Objectivism and Subjectivism 16
Further Reading & Discussion Questions 20
Chapter 2. Disease 21
2.1 Summary 21
2.2 Naturalism 22
2.3 Normativism 26
2.4 Hybridism 30
2.5 Eliminativism 32
2.6 Phenomenology 34
Chapter 3. Death 36
3.1 Summary 36
3.2 Defining Death 37
3.3 The Badness of Death 40
3.4 Ethics of Killing 44
part ii. models and kinds
Chapter 4. Causation and Kinds 51
4.1 Summary 51
4.2 Three Theories of Causation 52
4.3 Diseases: Monocausal or Multifactorial? 54
4.4 Nosology 58
4.5 Precision Medicine 62
Chapter 5. Holism and Reductionism 67
5.1 Summary 67
5.2 Disease 68
5.3 Medical Interventions 73
5.4 Patient-Physician Relationship 76
Chapter 6. Controversial Diseases 80
6.1 Summary 80
6.2 Medicalization 83
6.3 Psychiatric Diseases 87
6.4 Culture-Bound Syndromes 89
6.5 Addiction 94
part iii. evidence and inference

Chapter 7. Evidence in Medicine 103
7.1 Summary 103
7.2 Phases of Medical Research 104
7.3 Bias 106
7.4 Animal Models 109
7.5 Randomization 115
7.6 Meta-analysis 118
7.7 Mechanisms 120
Chapter 8. Objectivity and the
Social Structure of Science 125
8.1 Summary 125
8.2 Industry Funding and Publication Bias 126
8.3 Demarcation 128
8.4 Value-Laden Science 130
8.5 Social Epistemology 134
Chapter 9. Inference 140
9.1 Summary 140
9.2 Causal Inference 141
9.3 Extrapolation 144
9.4 Measuring Effectiveness 147
9.5 Theories of Statistical Inference 151
9.6 Testing Precision Medicine 156
Chapter 10. Effectiveness, Skepticism,
and Alternatives 159
10.1 Summary 159
10.2 Defining Effectiveness 160
10.3 Medical Nihilism 162
10.4 Alternative Medicine 166
10.5 Placebo 170
Chapter 11. Diagnosis and Screening 175
11.1 Summary 175
11.2 Diagnosis 176
11.3 Logic of Diagnostic Tests 178
11.4 Screening 181
part iv. values and policy
Chapter 12. Psychiatry: Care or Control? 191
12.1 Summary 191
12.2 Psychiatric Nosology 192
12.3 Anti-psychiatry 197
12.4 Delusions and Exclusions 201
Chapter 13. Policy 207
13.1 Summary 207
13.2 Research Priorities 208
13.3 Intellectual Property 212
13.4 Standards for Regulation 216
Chapter 14. Public Health 222
14.1 Summary 222
14.2 Social Epidemiology 223
14.3 Preventive Medicine 226
14.4 Health Inequalities 230
Further Reading & Discussion Question 233
References 235
Index 243
i n t r o du c t i o n
Philosophy of medicine has become a vibrant intellectual landscape.

This book is a map of that landscape.
Medicine is, of course, a hugely important practice in our soci-
ety. Two of the main aims of medicine are to care and to cure. That
sounds simple. But in the pursuit of these aims, medicine relies on
concepts, theories, inferences, and policies that are complicated and
controversial. This book describes some of these philosophical com-
plications and controversies underlying medicine.
What makes a problem philosophical? This, unfortunately, is not a
simple question. Indeed, it is itself a philosophical question. In this
book I avoid heady debates about what counts as philosophy and
adopt a pragmatic view: philosophical problems are those for which
there exist multiple compelling and competing views, and which
cannot be answered straightforwardly by empirical means. There
are many problems like this in various domains of life, such as eth-
ics, religion, and politics. A prominent subdiscipline of philosophy
is philosophy of science, and philosophy of medicine is a relatively
recent field of study within philosophy of science. Philosophy of sci-
ence is the application of philosophical methods to science and the
study of philosophical puzzles that arise within science. Philosophy of
science usually addresses the epistemology, metaphysics, and logic
of science, though it also addresses the history, sociology, and poli-
tics of science. Philosophy of medicine, in turn, is the study of epis-
temological, metaphysical, and logical aspects of medicine, with oc-
casional forays into historical, sociological, and political aspects of
medicine.
Each chapter in this book presents difficult puzzles about medi-
cine and discusses and evaluates prominent positions on these puz-
zles. Does being healthy involve merely the absence of disease, or
does being healthy require some other positive factors? Is a disease
[1]
simply an abnormal physiological state, or is a disease a state that
has an evaluative component? Is social anxiety disorder a genuine
disease? What sort of evidence is required to justify causal inferences
about the effectiveness of medical interventions? Is medicine good
at achieving its aims of caring and curing—are most mainstream
medical interventions effective? Is homeopathy effective? Does psy-
chiatry aim to care for patients with mental illnesses, or rather does
psychiatry aim to control feelings and behaviors that do not fit well
with modern society? Should medical innovations be protected by
patent, or should such innovations be contributions to the common
good, unprotected by intellectual property laws?
Many of these questions are interrelated. For example, consider
this seemingly straightforward question: are antidepressants effec-
tive for treating depression? Of course, this is in part an empirical
question, and so answering the question requires a compelling view
about what sort of evidence is required to answer such questions.
Since that evidence comes out of a thorny social, legal, and financial
nexus, a full understanding of an answer to this question requires
insight into that nexus. Since antidepressants are said to target local-
ized microphysiological entities, answering the question depends on
a view about the relationship between the experiences of people—
their feelings and behaviors and symptoms—and the activities of
chemicals. Since the question is about a disease category that many
people consider to be poorly understood and indeed controversial,
properly understanding the question requires insight into the gen-
eral nature of health and disease. These topics and more are dis-
cussed throughout the book, and insights from one part of the book
help elucidate puzzles from other parts of the book.
Though this is an introduction to philosophy of medicine, this is
not a book on medical ethics. There are already many fine introduc-
tions to medical ethics available. Rather, this book is about concep-
tual, metaphysical, epistemological, and political questions that arise
in medicine. That said, positions on these questions have ethical im-
plications, as you will see throughout this book. Although this is an
introductory text, it surveys both the canonical core of philosophy
of medicine and the discipline as it is now practiced by its leading
2 ] i nt r o du c t i o n
researchers, at the cutting edge. The landscape has changed in the
past fifteen years, and this book describes not just its archaeological
substratum but also its current terrain.
Some very particular concerns in philosophy of science underly
questions in philosophy of medicine. Classic topics in philosophy of
science include the nature of explanation, the reality of scientific con-
structs, the demarcation of good science from bad science or pseu-
doscience, difficulties with inductive inference, and the role of val-
ues in science. Sometimes philosophers of science illustrate general
philosophical problems with examples from medicine. For example,
Semmelweis’s discovery that the incidence of childbed fever could be
minimized by careful hand sanitation in obstetrical clinics has been
used to illustrate the importance of what philosophers call inference
to the best explanation. No doubt inference to the best explanation
plays a significant role in medicine, including diagnosis and causal
inference. However, inference to the best explanation is foremost a
general philosophical topic and not an issue specific to medicine. The
focus of this book is predominantly on philosophical problems that
arise specifically or frequently within medicine. Of course, many of
the philosophical problems discussed in this book have more general
import and arise in other domains. But in this book most of the focus
is on philosophical problems that are central to medicine itself.
There are many ways to do philosophy. A philosophical approach
I favor is sometimes called analytic because it involves the careful
analysis of scientific ideas, using logic and expository clarity. An-
other philosophical approach I favor is sometimes called naturalistic
because it appeals to facts about nature, gleaned from empirical sci-
ence and the study of history. Much philosophy of science and med-
icine in recent years employs both approaches in a philosophical
method that we could call analytic naturalism. This book predomi-
nantly employs analytic naturalism. However, to be a good philoso-
pher one should draw on all the intellectual resources that one can,
and so in places throughout the book I include discussions of other
types of philosophical approaches to medicine.
Medicine is a vast enterprise. Clinical medicine is the familiar prac-
tice of physicians and other healthcare workers attempting to care for
i nt r o du c t i o n [ 3
patients in a multitude of ways. Clinical research is the study of the
efficacy of interventions, but of course medicine relies on more fun-
damental scientific research (sometimes called bench science) prior
to testing interventions in humans. Medicine has many subspeciali-
ties, such as internal medicine, surgery, psychiatry, and epidemiology.
Governmental policies and regulations control medicine. Medical re-
search and clinical practice are guided by numerous intellectual and
institutional movements, such as evidence-based medicine and per-
sonalized (or “precision”) medicine. Philosophical problems arise in
all of these aspects of the wide domain of medicine.
Since this book is meant as an introduction to philosophy of medi-
cine, it has no unifying thesis. However, there is more to this book
than a simple introduction to an exciting intellectual field. Precisely
because this field is so young, distilling many of its salient problems
into an accessible text has forced me to engage in novel philosophi-
cal work throughout the book. That said, I have striven to keep my
own philosophical pretensions as silent as possible.
4 ] i nt r o du c t i o n

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What are some of the main aims of medicine discussed in the introduction?

What are some philosophical approaches mentioned in the introduction?

care

the university of chicago press

Chicago and London

part iii. evidence and inference

Philosophy of medicine has become a vibrant intellectual landscape.

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