New essays in the philosophy of medicine.
Edited by Gerard Lambert, Marc Silberstein and Philippe Huneman.
Table of Contents.
Elodie Giroux (Lyon)
Risk factors and causation in epidemiology.
Steeves Demazeux (Paris)
The concept of function in the contemporary psychiatric discourse
Catherine Dekeuwer (Lyon)
Defining genetic disease.
Joël Coste (Paris)
Causal and probabilistic inferences in diagnostic reasoning : casting a historical light onto the current debates.
Samuel Alizon & Pierre Olivier Méthot (Paris / Exeter)
Evolutionary Models of Virulence: Concepts, History and Current Applications
The question “why do parasites harm their hosts?” is central for the health sciences and has
implications at both the practical and the theoretical level. From an historical point of view,
however, this question has received different answers in the past century. In the first part of
this article we review a number of explanations proposed as to why parasites harm their host
and we highlight the changing role of the concept of “virulence” in medical microbiology
and evolutionary ecology of host-parasite interactions. Whereas the former uses molecular
techniques to explain changes in virulence, the latter conceptualizes virulence as a trait that
can evolve by natural selection. In the second section we show how these fields provide
different explanations of the 1917-1918 Spanish flu and HIV-AIDS pandemic. Finally, we
argue that an evolutionary approach is necessary to understand the dynamics of disease
transmission and evolution but that a broader understanding of virulence will ultimately
benefit from articulating the ecological dynamics with cellular mechanisms of virulence. In
short, both evolutionary and functional explanations are required to answer the opening
question and to devise appropriate health care measures in order to prevent and predict
future pandemics.
Dominic Murphy (Sydney)
The Epistemology of Mental Illness.
This paper discusses the representation and explanation of complex mental illness in the
context of the medical model, and the extent to which mental illnesses may be natural kinds.
I suggest that modern psychiatry aims at uncovering the causal structure of mental illness,
but that assumptions about that causal structure can be deformed by two ill-advised
epistemic constraints: the first is a general commitment to reductionism that neglects causes
that cannot be reduced, and the second is a set folk psychological assumptions about the
nature of the mind that commit psychiatry to pictures of higher cognition that may be of
dubious value. I discuss the implications of both constraints for accounts of mental illnesses
as natural kinds.
Patrick Singy (Schenectady)
Forensic Psychiatry and the Misuse of the DSM.
In this paper I criticize how the DSM is used in forensic settings. Lawyers routinely ask
forensic experts whether a defendant suffers from a mental disorder, especially when they try
to establish legal responsibility or the necessity for civil commitment. Forensic psychiatrists
rely heavily on the DSM to pronounce their expertise.
In the first part of my paper I argue that the relation between the DSM and forensic
psychiatry is in fact based on a misunderstanding, which consists in regularly confounding
the concept of “incapacity” with the concept of “mental disorder.” Lawyers are concerned
with incapacities, such as lack of self-control, while the DSM is concerned with mental
disorders, such as the paraphilias. This conceptual distinction is crucial since the DSM itself
warns explicitly that there is no perfect overlap between incapacities and mental disorders.
For instance, a paraphiliac might, or might not, be able to control himself; a diagnosis of
paraphilia does not determine the issue of self-control—and yet it is precisely this issue that
matters legally. The use of the DSM in the courtroom can therefore only be misleading,
since it answers with “disease” a question about “incapacity.” For this reason, the DSM
should no longer be invoked in legal decisions, and should become a purely clinical tool.
In the second section of my paper I look at the consequences, for both parties, of
the divorce between forensic psychiatry and the DSM.
For forensic psychiatry, the divorce would force this discipline to focus on the right
question: not, Does a defendant have a disorder or not? But, Does a defendant have an
incapacity or not? I then focus more specifically on the issue of lack of self-control, and
argue that forensic psychiatry, because it is a deterministic science, will never be able to
answer scientifically a question that is ultimately about free will.
For the DSM, if it is no longer used in the courtroom, then all the diagnoses that
serve a forensic function should be removed from the DSM. By way of a short historical
detour, I show in particular how the paraphilias have always had a forensic function. I
conclude that they should be removed from the DSM.
Thomas Cunningham (Pittsburgh)
What is ‘Group Deliberation’? The case of shared decision-making as a normative
model of medical choice.
Diverse scholars have long had an interest in describing and developing
norms for rational deliberation and choice. In philosophical studies of medicine,
the rational and deliberative aspects of treatment choices have long been of
primary interest, beginning with early work on the physician-patient
relationship and medical practice (e.g. Cassell and Siegler 1979; Faden and
Beauchamp 1986; Pelligrino and Thomasma 1981; Eddy 1996). By far the two
most prominent models of medical choice are paternalism and autonomy-based
informed consent, which can be distinguished according to whether patients or
physicians retain ultimate responsibility for making medical choices (Emanuel
and Emanuel 1992). These models have faced growing opposition in recent
years, primarily from clinicians who argue that while they have their usefulness
as ideals, both are outstripped by common experiences in clinical practice. This
has led to movements promoting new models of medical choice, such as
“narrative evidence based medicine” and “shared decision-making” (Charon
2008; Frosch and Kaplan 1999; Whitney et al. 2003). A central tenet of both of
these models is that physicians and patients should make decisions together
through processes of constructing shared narratives or undertaking shared
deliberations. In their emphasis on group deliberation, these models appear
committed to an account of choice with compelling epistemological implications.
That is, as medical choice becomes an activity that is distributed across cognitive
agents, it appears that cognition in the clinical context has itself become a social
activity. Consequently, one is motivated to ask, just what is group deliberation
and what does it imply about the type of thinking that ought to occur in medical
practice? In this paper a two-part answer is given to this question. First, and
rather obviously, shared decision-making is a normative model of group
deliberation in medicine, which is argued for by clinicians in light of their
experience and empirical data. Yet, to say this is to suppress the meaningful
question of what is implied by that model. Here it is further argued that the
normative model requires an extended account of rationality in order to be
coherent. On such an account, cognition is distributed across multiple agents
within the clinical environment. As such, in group deliberation the hallmark of
rationality becomes orientation toward a goal, which in this context is increasing
patients’ health outcomes in light of their personal ethical commitments and
values, as well as their medical status. In such a model cognition is distributed,
however, this does not entail that the explicit desire for responsibility found in
received accounts of medical choice must be abandoned; it must instead be
located in properties of deliberative groups rather than individual agents (cf.
Hutchins 1995).
Works Cited:
Cassell, Eric J. and Mark Siegler (1979). Changing Values in Medicine. New York: University
Publications of America, Inc.
Charon, Rita (2008). “The Art of Medicine: Narrative Evidence Based Medicine.” The Lancet 371: 296-297.
Eddy, David M. (1996). Clinical Decision-making From Theory to Practice: A collection of essays from the Journal of the
American Medical Association. Sudbury, MA: Jones and Bartlett Publishers.
Emanuel, Ezekiel J. and Linda L. Emanuel (1992). “4 Models of the Physician-Patient
Relationship.” Journal of the American Medicine Association 267: 2221-2226.
Faden, Ruth R. and Tom L. Beauchamp (1986). A History and Theory of Informed Consent. New York, NY:
Oxford University Press.
Frosch, Dominick L. and Robert M. Kaplan (1999). “Shared Decision-making in Clinical
Medicine: Past research and future directions.” American Journal of Preventive Medicine 17:285-294.
Hutchins, Edwin (1995). Cognition in the Wild. Cambridge, MA.: MIT Press.
Pellegrino, Edmund D. and David C. Thomasma (1981). A Philosophical Basis of Medical Practice. Oxford:
Oxford University Press.
Whitney, Simon N., Amy L. McGuire, and Laurence B. McCullough (2003). “A typology of
Shared Decision-making, Informed Consent, and Simple Consent.” Annals of Internal
Medicine 140: 54-59.