Analytic Philosophy of Clinical and Community Medicine

By Lucien Karhausen

The present volume is about philosophy of medicine and integrates philosophy of medicine as a chapter of philosophy of science. It is neither about bioethics, nor about the history of medicine, but it is comprehensive and encompasses the whole field of medicine including psychiatry. It is grounded on a first-order standpoint, and it strives to stay close to clinical or community medicine: it bestows an epistemological bottom-up account. It is not a review of the literature, and it is not intended to frame the debates, or to analyse and compare the various and substantial number of viewpoints although some authors’ account may form the basis of the book when they fit into the development of its philosophical view of medicine.

• Language: English
• Publisher: Xlibris US
• Release date: Oct 6, 2022
• ISBN: 9781669850571

Book preview

Copyright © 2022 by Lucien Karhausen.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Any people depicted in stock imagery provided by Getty Images are models, and such images are being used for illustrative purposes only.

Certain stock imagery © Getty Images.

Rev. date: 10/05/2022

Xlibris

844-714-8691

www.Xlibris.com

847540

CONTENTS

Introduction

ZERO

The Logical Roots of Medicine

The Archê of Medicine and its Logical Genealogy

Not Diseases

First Position and Second Position

The Trajectory from Suffering to Disease.

Summary

ONE

Intrinsic Negativities: The Biological Roots of Medicine Suffering, Discomfort and Harm

Physical Pain

Contra Putnam

First Person Privileged Access

Pain is not a brain-state

Malfunctional Pain

The Reversal of Values and The Symbolic Meaning of Pain.

Mental Suffering: Clinical Anxiety and Clinical Depression

Harm and Detriment

When Harm and Detriment are Dilemmatic

Conclusion

TWO

Normal, abnormal, and pathological

Norms

Normal as Natural

Christopher Boorse’s Naturalism:

Biostatistical Theory. Methodological Naturalism

The Homeostatic View of Normalcy

Medical Statements Are Both Prescriptive and Descriptive.

Taking Stock: Defining the Term Normal

The Nature of Medical Norms

The Semantic of the Normal/Abnormal Divide

Distinguishing Abnormal from Pathological

The Logical Priority of the Pathologic.

The Clinical Epistemic Priority of Normality

Specification of Pathologic Boundary: The Case of Hypertension

Harmful and Pathologic

When Being Abnormal is Advantageous

Summary

THREE

Explanation

Explanation or Causation?

A thirst for generalities

The Quorum of Language: Family Resemblances, (Familienähnlichkeit) or Similarities (Ähnlichkeit)

J Sadegh-Zadeh, Prototypes and Fuzzy Logic.

Two Strategies: Biomedical or Epidemiological

The Hypothetico-Deductive Model

Induction and Abduction: Inference to the Best Explanation

There Can be No Laws in Biology

The Pragmatics of Explanation

The Contrastive Counterfactual Nature of Medical Explanations

Methodological Reductionism

Hierarchical Systems

The Pivotal Clinical Level

Pathogenesis and Mechanistic Vertical Explanation

Critique of the Hierarchical Model.

The Limits of Reductionism

Emergence

Realization and Supervenience

Causal Versus Non-Causal Supervenience

The Twofold Context of Explanation in Psychiatry

Darwinian Medicine and the Panglossian Fallacy

Conclusion

FOUR

Causation and Aetiology

Sufficient and Necessary Causes

Aetiology and Deviation from the Norm.

Are Causes in Medicine External or Internal to their Effects?

Contributing Causes

Causal Role and Causal Capacity

The Concept of Causality

Analytical Epidemiology

Causal Tendencies

Risks and Measures of Effects

Relative Risk and Odds Ratio²⁹²

The meaning and relativity of risk

Contrast Case

The Causa Vera Fallacy

The Web of Causation: Plurality of Causes and Causal Diversity

Back to Sufficiency and Necessity

Reverse Causality

The Structural Equation Framework

The Unnatural Nature of Causality

Conclusion

FIVE

Function and Medicine’s Hybrid Concepts

The Received View

Biological Functions and the Machine Analogy

Teleological Explanation vs. Naturalistic Understanding

Function as an Activity, a Biological Role, or a Historical Concept

Teleology: The Naming-Explaining Fallacy

Getting out of the predicament: John Searle

Functions and Their Effects

Functional Role and Functional Capacity

Physiology is False

Functions are Hybrid-Concepts: they are Empirical and Normative, Descriptive and Prescriptive

Are Diseases Malfunctions?

A Naturalistic View: What Malfunctions Are Not About

Malfunctioning

Conclusion:

SIX

Prudential Objectives Needs and Demand

Prudence and the Authority of Medical Judgment

Time Preference

The Structure of Medical Needs

Three Types of Needs

The Instrumental Necessity of Health Needs.

Needs are Objective and Demands Subjective.

Extensional and Intensional Context

The Grammar of Needs and Demand in Health Care.

The Genealogy of Our Prudential Concepts and Practices.

First-Person Indexicalized Account: Naturalistic Inferences

First-Person Indexicalized Account: A Prescriptivist Account

Second-Person Indexicalized Account: The Clinical Encounter

Third-Person De-Indexicalized Inference: From a Prudential to a Moral Account

Conclusion

SEVEN

Diagnosis Clinical Epistemology

Signs and Symptoms

Are symptoms in medicine private objects?

The Semantics of Diagnosis

Facts or Events

The Meaning of Clinical Manifestations

The Nature of Diagnosis

The Limits of Diagnosis

Diagnosis as an ampliative procedure

Diagnostic Criteria

Conclusion: Constructing an Epistemology of Medicine

EIGHT

Diseases, Injuries, and Impairments

Defining Disease

Syndromes

Diseases Have Causes

Diseases Have a Natural History⁴⁵⁵

Enduring Pathologic States⁴⁵⁹

The Need for Intervention is Constitutive of Our Notion of Diseases.

Illness

Sickness Behaviour and the Sick Role

Two Types of Diseases and a Semantic Digression

Manifestations Diseases

Single-Criterion or Causal Diseases

Causal Disorders and Their Semantics

Moving from Manifestational to Causal Diseases

Grades of Naturalness

Are Controversial Diseases Clinical Entities or a Lexical conundrum?

Death

Conclusion

NINE

Psychiatric Disorder

Defining Mental Disorder

Fragmentation of the Self. ⁵¹⁶

Epistemic Breakdown

Syntactic Breakdown: Deterioration of Coherent Thinking, Perception and Emotion

Semantic Breakdown

Arationality⁵³²

The Interactive Stance: Breakdown of Interpersonal Relations

Responsibility and the Sick-Role

Breakdown of Autonomy and Enforced Treatment

Are Mental Disorders Natural Kinds?

Interactive Kinds

Psychiatric Nosology

Diagnostic Validity, Utility and Reliability

The Spectrum Perspective

The Fragility of Diagnosis

Psychiatric Diseases or Syndromes

Strawson and the Span of the Concept of Mental Illness.

The two Explanatory Roots of Mental Disease: Hippocrates and Samuel Tuke

Splitting Mental Disorders from Neurological Disorders

Can Mental States be Multiply Realized?

May Mental Disorders be Adaptive?

Is Schizophrenia Adaptive?

Disease Mongering: The Case of Mental Illness

Wittgenstein and the concept of psychosis.

Conclusion

TEN

Socially Deviant Behaviour

Social Deviance vs. Mental Disorder

Two Complementary Views

Is Alcohol Abuse a Mere Bad Habit?

Self-Harm

Medicalization of Criminal Deviance

Conclusion

ELEVEN

Unexplained Physical Symptoms and Functional Disorders

Recent History of Unexplained Symptoms and Functional Disorders

The Symptom Iceberg.

Unexplained Physical Symptoms and Health Anxiety Observed in the Doctor’s Office

Somatoform Disorders: Symptoms-Only Conditions in the Medical Setting

Medically Unexplained Disorders

Factitious Disorders and Illness Behaviour

Taking Stock

Summary

TWELVE

A Critique of The Disease Concept

1. Are Diseases Natural Kinds?

2. Diseases, Type and Token

3. The Ontology of Disease

4. Defining Diseases

THIRTEEN

Health

Health Status: Negative or Positive

The Interconnectedness Between Mind and Body

Conclusion

FOURTEEN

Preventive, Therapeutic, and Palliative Care

Therapeutic Doctrines

Efficacy and Effectiveness

The Myth of the Magic Bullet and its Return

From Wants to Needs

Defining Treatment

Placebos

The Nature of the Placebo Effect

Placebos in Clinical Trials

Explaining the Placebo Effect

Surgery and Placebos

The Placebo Effect is Sometimes Fictitious

Randomized Control Trials

Evidence-Based Medicine (EBM).

The Double Meaning of Treatment

Direct Realism and Instrumentalism in Health Care

The case of George Canguilhem

Prevention and Health Maintenance

Screening

Scrutiny--Dependent Incidence and Risk Factors of Cancer

Herd Immunity

The Paradox of Health Education

Conclusion

FIFTEEN

The Clinical Relationship. The tale of two stories

Narrative Medicine

The Therapeutic Alliance

The Doctor’s Authority

The Trade-Offs Between Needs and Demands: Acceptance and Acceptability

Truth and Truthfulness in the Clinical Transaction

Expectancy

The Fault Lines of the Caring Relationship

Autonomy and Paternalism

The Three Positions

Conclusion

SIXTEEN

The Limits of Medicine

Epistemic Limits of Clinical Care

Ethical Limits

Ontological Limits

Contextual Limits: Medicalization

Is Medical Enhancement a Faustian Deal?

Summary

SEVENTEEN

Tragedy

Contrasting Two Types of Illness-Narratives

Aristotle on the Tragic⁹⁷⁸

The Value of Life

The Induced Disconnection of Life Events

Human and Non-Human Sentient Beings

The Physician’s Predicament.

Concluding Thoughts

Notes and References

Bibliography

There are four types of things contrary to nature: the activity that is damaged, the disposition responsible for it, the cause which produces the disposition, and the symptoms that follow upon it.

— GALEN¹

TO

Micheline Iannuzzelli

1931-2019

INTRODUCTION

Nullius addictus iurare in verba magistri quo me cumque rapit tempestas, deferor hospes²

"Philosophy of science, wrote Dr R. S. Downie³, is a flourishing discipline and so also is moral philosophy. Medicine, which combines elements of both, has not had so much attention. This is partly a result of the attention to medical ethics which has obscured the need for a philosophical foundation for medicine."

A rthur Caplan claimed that philosophy of medicine as a subdiscipline of philosophy of science does not exist despite a great deal of literature, teaching and professional activity carried out explicitly in the name of ‘philosophy of medicine’. ⁴ He gave the following stipulative definition: The philosophy of medicine is the study of epistemological, metaphysical and methodological dimensions of medicine; therapeutic and experimental; diagnostic, therapeutic, and palliative. Broadbent, in his critique of what he calls the ‘natural turn’ in the philosophical literature on health and disease, underscored the gap that separates philosophy of medicine and the grand tradition of analytic philosophy. ⁵ Philosophy of medicine, according to Jacob Stegenga, is a relatively recent field of study within philosophy of science. "It is the study of epistemological, metaphysical, and logical aspects of medicine, with occasional forays into historical, sociological, and political aspects of medicine." ⁶ Even then, some philosophers of science have been successfully dealing with medicine, such as Mario Bunge ⁷, John Margolis ⁸ or Lawrie Reznek ⁹.

Philosophy of biology has won its spurs over the years ever since the biologist JH. Woodger and the philosopher Morton Beckner published major works on the philosophy of biology in the 1950s. However, philosophy of biology became a mainstream part of philosophy of science with the publication of David Hull book¹⁰, after which the field expanded, and it became one of the most exciting new areas in the field of philosophy of science. Philosophy of social sciences followed the same trend.

Contrariwise, philosophy of medicine has lagged. Even though in the history of philosophy some of the great thinkers had things of very great importance to say, an important part of medicine was neglected. Initially, it was mainly concerned with medical ethics, but it progressively got interested in the broad philosophical issues pertaining to medicine. Often, it also consists in literary reflection on medicine, what Pellegrino calls medical philosophy, or in what Caplan calls philosophy and medicine, a strategy of parceled philosophical approach of medicine, that leads to various speculations as well as to a diversity of conflicting opinions.

In the past ten or fifteen years, philosophers moved to understand and work on the conceptual analysis of problems that are raised by medical science, medical practice, and public health. In this way, philosophy of medicine progressively emerged as a new vigorous area, although it might be argued that what is lacking is a canon of unified consistent issues against the backdrop of philosophy of science.¹¹

Although medical care is a profession that has for a long time been wedded to irrational and unjustifiable assumptions, it can now be taken for granted that medicine is a science, and as such it has cognitive and instrumentalist dimensions.

Medicine is being defined by what physicians do, and it includes clinical medicine, public health, epidemiology, and biomedical research. It may also be defined by the diversity of topics included in standard medical textbooks, and this is what philosophy of medicine should be about¹²

The present volume is about philosophy of medicine, as a subset of philosophy of science. It integrates philosophy of medicine as a chapter of philosophy of science. It is neither about bioethics, nor about the history of medicine, but it is comprehensive and encompasses the whole field of medicine including psychiatry¹³.

Admittedly, medicine starts not as a philosophical issue, but at the clinical level, when health professionals attempt to help people who are suffering. It is probable that many disagreements in the literature of medical philosophy spring from the fact that some distinctions have been introduced and may seem legitimate for philosophers but could be bypassed if one looks at medical practice. It is astonishing, wrote William James, to see how many philosophical disputes collapse into insignificance the moment you subject them to this simple test of tracing a concrete consequence. ¹⁴ Medicine tells how physicians intuitively organize nature, not how nature is organized.

This volume is grounded on a first-order standpoint, namely the clinical gaze and it strives to stay close to clinical medicine or epidemiology: it bestows an epistemologic bottom-up account that arises from the clinical situation, the epidemiologic and the resulting public health account. It is not a review of the literature, and it is not intended to frame the debates, or to analyse and compare the various and substantial number of viewpoints. Some authors’ account may form the basis of my presentation when they fit into the development of my philosophical view of medicine. Philosophical analysis should progress from multiple small subsets and from small details and works up to some high conceptual level or to some general ideas.

The philosophical viewpoint of medicine should be parsimonious in that it should avoid any unnecessary complexity and be as simple as possible, avoiding venturing into far-fetched philosophical speculations. This is directly in line with what P.F. Strawson—the late English philosopher and professor of philosophy at Oxford University—termed ‘descriptive metaphysics’¹⁵, which should bring into clear view the conceptual structures and interrelationships that constitute the central core of medicine. It falls a long way short of an inquiry into the ultimate nature of reality itself that is the target of orthodox metaphysics. Medical terms are tools, like a stethoscope, instruments to be used in the daily occasions of the health-care professions: our definition of the term ‘disease’ should match the use which nurses, physicians and community physicians are making of it, which is also the way they have learned to use it. We should avoid, in medical philosophy, straying from actual linguistic practice. If our metaphysics does not fit it, so much the worse for it.

The set of statements constituting this philosophical representation of medicine must be capable of being simultaneous true and deductively closed: this means that any statement, which is logically entailed by the theory belongs to the theory.¹⁶

Finally, the interchange between medicine and philosophy leaves the medical topology unaltered, since philosophy makes nothing happen.

The question of the nature of medicine is not a problem internal to the medical discipline. Medicine is a set of activities but talking about medicine is not a medical activity. In other words, talking about medicine is external to medicine, but it is internal to philosophy.

Medicine begins with its first question: what is normal and what is abnormal? This question is so specific to medicine that it might be considered as one of its criteria: medicine is the human activity, which begins by a linguistic act that identifies the negative norms of health. These descriptive medical norms are not items in the basic inventory of the world.

It follows that medicine is pervaded with vague dichotomous concepts such as semantic vs pragmatic meaning, descriptive vs normative discourse, function, and malfunction, abnormal and pathologic, needs and wants, causation and explanation, clinical vs. community-oriented care, physical vs. psychiatric diseases, mental illness vs. deviancy, organic diseases vs. functional disorders, biological faults vs. psychosocial distress, curing vs. healing and suchlike. These duple terms represent a complete range of features that are laid down in a spectrum conventionally categorized in binary order. Medical thinking has two dimensions intrinsically interweaved, namely a constant amalgam or admixture of biological and normative as well as of scientific and pragmatic aspects. This essential hybrid nature of the grammar of medicine explains the endless controversies wondering whether medicine should be naturalistic or normativist, biological or value-laden, realist or instrumental, reductionist or holistic, eliminativist or pragmatic, phenomenological or analytic.

Imprecision is common in medical language. Philosophy attempts through conceptual analysis, to define concepts and to use terms without ambiguity. Yet, these attempts might be confusing when imprecision in medically unavoidable, which leads to endless debates about the nature of diseases, of risk factors, of functions or of causality.

Medicine is understood as a theoretical science and an instrumental discipline, namely a body of knowledge and an activity concerned with a limited number of prudential interests, which pertain, minimally, to the preservation of life and the ability to use our bodies and minds as effective instruments. It is a blend of knowing that and knowing how, made of an agglomeration of loosely connected models, inquiries and techniques, which coalesce through some common conceptual framework into an open-ended task: it is a forma mentis belonging to various specialties in virtue of some unique ontology or some specific method. Physicians are usually not interested in philosophical issues or in abstract generalities.¹⁷ Physicians are doers and, at least in the typical case, have an extremely pragmatic attitude.

The question What is medicine? should be reformulated as What is medical?. One could paraphrase Ludwig Wittgenstein in saying that medicine is not a theory but an activity.¹⁸

This book is about occidental medicine, namely a discipline which is based on research, and which goes back to the tradition of the Enlightenment. This credo assumes that all medical questions can, in principle, be answered, that the answers can be discovered by careful look at the evidence, that they can be learnt, and taught to other persons and that they must be compatible with one another since nature for sure is a rational entity. It also relies, in the vision of progress, on our capacity to correct, develop and accumulate knowledge.

Meanwhile, medicine has specific priorities. Although constantly expanding, its demesne is narrow like that of engineering or chemistry, the reverse of that of literature or philosophy. Its representation is constrained by very specific and pragmatic imperatives. Physicians dispose, within their own discipline, of a limited number of conceptual instruments that are sufficient for their own purposes. On this score, medical insight is exposed to a permanent temptation of broadening its scope to topics, which lie outside its remit and its language. But when applied beyond its purview, it forces the analysis into a straitjacket, which results in a loss of information as it delineates the limits of medicine.

Leaving apart the ethical aspects, this book endeavours to uncover the implicit conceptual network, the chief implicit junctures of medicine, should they be found, and their articulation with clinical or community medicine.

A reader may get the gist of my argument by reading only Chapter Zero, One, Two, Three, Four, Eight and Twelve.

Chapter Zero introduces a kind of shuttling back and forth between a syntactic stance for which abnormal conditions are foundational so that physiology is a default, and a semantic stance, at the clinical level for which physiology is conceptually prior to pathophysiology and diseases are altered states.

Chapter One introduces the primary features from which medical thinking is being logically deduced, namely the biological roots of medicine: suffering, discomfort, and harm, which plays a pivotal role in the normal/abnormal divide, that is, in the theoretical articulation of all medical concepts.

Chapter Two looks at the distinctions that split biological processes into two conventional parts, normal and pathologic. Neither of them is a natural kind. Being abnormal is intrinsically bad and admits of degrees. But abnormal, as it were, is real and empirical, while normal is factitious, so that being normal is counterfactual much the same as frictionless planes in physics. Being normal does not affirm anything positive, it excludes suffering and pain: it is a default concept; but for clinical medicine it represents a silent background.

Chapter Three tackles the topic of explanation and its two dimensions, biomedical and epidemiological. Medical research applies a downward-reduction hierarchical model, although it may well turn out to be a mere methodological contingent stance rather than a fundamentalist representation. Reductionism might have to be weakened and replaced either by a supervenience story or some sort of emergentism. Finally, Darwinian explanation has limited explanatory power in medicine.

Chapter Four covers causality and aetiology. It analyses the various components of causation in medicine: manipulability, comparative form, causal roles vs causal capacities, plurality of causes and probabilistic causality, and the formal logic of counterfactual dependence. There are neither necessary nor sufficient causes in medicine, but tendencies toward necessity or tendencies toward sufficiency may be quantified by using epidemiologic methods. What we call causes in medicine are only partial, contributive causes. Causation is epistemic, and not something in the world since causes are like inference tickets.

Chapter Five analyses the concept of function and how to avoid teleological standpoints. Functions are not natural facts, but they depend on our set of values. Physiologists study functions just like physicists describe the ideal gas laws. Malfunctions define functions counterfactually.

Chapter Six outlines medicine’s prudential objectives as well as distinctions between s and demand. Medical needs are prudentially minded, and medical care is essentially a prudential activity relying on needs for intervention, namely prevention, care, or cure. Personal demands or preferences provide no foundation for proper medical interventions.

Chapter Seven covers the epistemology of medical care, diagnosis and concepts of signs and symptoms.

Chapter Eight and Nine come to grips with diseases, injuries, and impairments as well as with mental disorders. An attempt is made to define those conditions, how they are being construed and some of the features, which constitute them, though most of them are provisional conventions. Diseases are clusters of signs and symptoms. An important distinction is being made between manifestational or purely observational, and causal disorders: causal disorders cut across manifestational agglomerates; we accept them because they create links between different levels of hierarchical analysis. Mental disorders differ from so-called physical diseases in the sense that their limits are broader than those of the affected body. What’s more, what distinguishes physical from psychological medicine is not some ontological difference between body and mind, but that we grasp mental disorders in terms of reasons rather than causes through a dialogue with the patient. It shows the role of Ludwig Wittgenstein’s philosophy in the development of the notion of psychosis.

Chapter Ten deals with social deviant behaviour, namely social undesirable behaviour, which is distinct from, although often confounded with mental disorders.

Chapter Eleven covers unexplained symptoms and functional disorders. More than half of the patients observed in primary care or in population-based studies are medically unexplained, so persons manifesting symptoms, whether they seek treatment or not, may or may not suffer from some identifiable disease. The symptom iceberg represents the visible fraction observed by physicians. If one excludes respiratory infections and skin disorders, the incidence of unexplained conditions rises to more than 50 to 70 per cent. If the concept of disease dominates our medical thinking, functional disorders, by contrast, make the lion’s share of medical care as they make up the bulk of reported and unreported medical complaints, and are responsible for a large amount of loss of absenteeism, productivity, and medical expenses.

Chapter Twelve brings in a critique of the disease concept. Diseases are neither natural kinds, nor social constructs. There are no necessary and sufficient conditions for belonging to those classifications. Considering a given disease each patient shares characteristics with many but not all of the others. The categories of diseases are neither mutually exclusive, not jointly exhaustive and there are neither necessary, nor sufficient conditions for belonging to those classifications.

-Chapter Thirteen outlines some of the conceptual and ideological confusions associated with the notion of health. What moves people are suffering, unmanageable disability and disease, i.e., unhealth. When expectations are not met, a call for help goes up. When expectations are fulfilled, usually nothing is said, so that health consists of having the same disease as your neighbours.

-Chapter Fourteen covers the concept of health.

-Chapter Fifteen turns to medical interventions, that is, preventive, therapeutic and palliative, effectiveness, and efficacy, as well as to the complex question of placebos and nocebos, their role in clinical trials and in clinical medicine, evidence-based medicine, cancer screening and the paradox of health education.

Chapter Sixteen discusses the caring relationship, autonomy, and paternalism, the three models of doctor-patient relationship, the trade-off between acceptance and acceptability and the importance of narrative medicine.

Chapter Seventeen asks what limits there are to the medical realm, epistemic, ethical, ontological or contextualist. Placebo, interactive kinds, non-natural kinds & comorbidity, merge randomly into one another with no clear border in between, and are blurring the boundaries of medicine. In addition, do functional disorders and the question of medical enhancement lie beyond the edges of medicine?

Chapter Eighteen the last chapter, studies the core role of tragedy inherent to medical care, how suffering raises questions related to the meaning of life as well as to the physician’s predicament.

This book took its origins during my training in the Department of Internal Medicine, Memorial Hospital-Sloan-Kettering Institute, Cornell Medical School in New York, and at the Harvard School of Public Health.

I might never have written this book, had I not acquired during my medical education a genuine vision of medicine and an intellectual heritage from three late outstanding teachers, Professor Henry Tagnon from Brussels Free University, Dr Mort Lipsett from the National Institute of Health, Bethesda, and Professor Brian MacMahon from the Harvard School of Public Health.

A special debt is owed to Jonathan Glover, professor of philosophy from King’s College, London, for his motivation and sustained patient guidance, who provided detailed comments on an earlier draft of this book. I have gained much from my discussions with him, and I am overall grateful to him for his help and support. Needless to say, this does not imply that he agrees with my views, and he should not be responsible for my mistakes.

I wish to record debts to Dr Frédéric Wittek, Dr RS. Downie, and Professor M. Lemoine who read and commented on some chapters on this book.

I am particularly pleased to acknowledge the encouragement and help I got years ago, from the late Chaim Perelman, Professor of Philosophy at the Free University of Brussels. I also take this opportunity to express my great appreciation for the opportunity to attend Jacques Bouveresse’s lectures on Philosophy of Knowledge at the Collège de France.

ZERO

The Logical Roots of Medicine

Medicine is a curious discipline in some respects, because it is very nearly the sole professional specialty that claims the credentials of a science and renders its judgement chiefly in terms of prescriptive norms...

— MARGOLIS¹⁹

M edicine like economic sciences or political sciences, has a cognitive and an instrumentalist dimension. For one thing, the physician is a pure spectator, characterized by descriptivist, empirical, and propositional knowledge. ²⁰ But for another, the norm-following stance is at the root of medicine: it does not state facts of nature, but expresses a valuational attitude toward a range of situations such as suffering, disabilities, diseases, handicaps, premature death, or some biological negativities that call for appropriate medical interventions. This is tantamount to saying that there is an alternation between two views of medical language, descriptive and normative.

The Archê of Medicine and its Logical Genealogy

Archê, according to Aristotle, is the first thing, the principle of which something consists of and from which it comes to be. How does medicine originate, not historically and not culturally, but conceptually? Where and how does medicine split from biology? What are the premises that support the logical architecture of medicine and that give rise to medical science, medical practice, and public health? Understanding is rooted in atoms of intelligibility. Thoreau contended that ‘there is a solid bottom everywhere’.²¹

Not Diseases

For most, if not all books, texts, or treatise of philosophy of medicine, medical science is about disease. "The pivotal concept in clinical medicine is disease".²² The concept of disease is usually considered to be central to medicine.²³ Horacio Fabrega contends that "Medicine, an institution of society, is defined in terms of its concern for disease".²⁴ Fred Gifford adds: "The concepts of health and diseases appear to be quite fundamental for medicine as we take medicine to have the goals of diagnosis, prevention and cure of diseases or the achievement of health.²⁵ Jeremy R. Simon in a long and detailed essay on Medical Ontology²⁶, indicates that a prime desideratum in any field of philosophy is a clear understanding of the entities under consideration. In philosophy of medicine, this calls for an understanding of the nature of individual diseases." Maël Lemoine states that disease is the object of medicine.²⁷ For Jacob Stegenga, disease is a foundational question of medicine.²⁸ Corbellini at the end of his book ‘History and theory of health and disease’ writes an appendix on the "epistemological evolution of medicine" that covers essentially the concept of disease.²⁹ From Hippocrates and Galen until the second half of the 20th century, the term—if not the concept of— ‘disease’ was what medicine was all about. All in all, for most authors of philosophy of medicine, health and diseases are the first-order standpoint that is up for grabs.

John Margolis and Mario Bunge reject this approach and do not belong to this broad consensus; they do not hypostatize the universal ‘disease’, but they don’t deny the real existence of sick people either. The patient lists symptoms (how he feels), and the physician looks for corresponding objective indicators called signs or biomarkers. The physician distinguishes what their patients tell them (symptoms) and their objective signs, from the assumption that there may be diseased people there.³⁰ Sick individuals are real, whereas diseases are hypothetical kinds, species or types.

People do not complain about diseases but about departures from allegedly normal and not merely statistical modes of human beings, such as pain, suffering, unexplained somatic symptoms, or signs, which are not necessarily disease manifestations. Peter Schwarz, professor of medicine at Indiana University, claims that diseases are not interesting or not coherent enough theoretical entities, and that there is no general underlying concept of disease within the biomedical sciences.³¹ Diseases do not lie in the core of medicine, any more than constellations lie in the core of astronomy.

Health is not the absence of diseases, because diseases are a fraction, often a small fraction of medical conditions observed in clinical medicine. Several studies have shown that in 50 to 79% of all patients presenting to a family doctor, no evidence for a specific organic diagnosis could be found.³² During the twentieth century patients became more and more prone to anxieties about their health, and readier to consult their doctors. What is called the symptom iceberg instead of the disease iceberg becomes a new and major socio-medical phenomenon. ³³

"Doctors do not treat diseases, they treat patients" writes Eric Cassell. How do we differentiate what pertains to medical science from what fall within the scope of biology? Granted that the border that separates biology from medicine is not part of the furniture of the earth, medicine, before anything else, needs some set of rules and criteria that separate normal from pathologic features. Eric Cassell concludes: "Knowing diseases, in the old-fashioned sense, is not nearly as important as knowing pathophysiology."³⁴

All in all, those descriptive norms are medical conventions, and not social normative norms; they are thus correct or incorrect, being grounded on biological, empirically describable facts. But surely, once adopted, the norms form part of clinical medicine: being then stored in medical texts and of constant use in medical care, bestows them descriptive status, so they become true or false.

To sum it up then, what divides biology from medicine is that the first one is descriptive, and the second one both descriptive and normative.

First Position and Second Position

Medical thinking rests on the sequence of two obverse basic tacit conventions, which create the possibility of medical care.

Firstly, it divides biological features into medically good and bad ones, between harm, detriment and suffering and the absence thereof; it decides what is normal and what is pathologic and lays out the medical topography along an asymmetrical spectrum in which pathologic features have an ontologic priority.

Next, a second convention reverses the order of priority: standards of normalcy termed health, physiology or anatomy and the need to maintain or restore normalcy take epistemic and praxiologic priority over abnormalcy and pathological features.

We may now attempt to grasp, even though in metaphor, how these two starting conventions might cohere. What follows is not a description of some premeditated and intentional rendering carried out by physicians or philosophers. But the reasoning is tacitly implied rather than wilfully stated. To be sure nobody ever knowingly construed or carried out the logical path I shall sketch. Obviously, there is no path, but this is, I should conjecture, a mere way of picturing logical steps towards a coherent position that seems forced upon us.

The brute fact of negativities, i.e., current, or potential suffering, incapacity, increased mortality, and harmful biological conditions directly affecting bodies or minds are legitimately allowed at the beginning of the story: they are the port of access to medicine. They are bad or aversive, have serious consequences for the agent and they call for help.³⁵

Having acknowledged the existence of current or potential suffering, infirmity, complaints and disabilities, medicine comes into existence with a decision to divide biological features into normal and pathologic. If normal and pathologic features are factual, the line of demarcation that separates them is not: it is a tacit agreement, so that ascription of these two terms is conventional, normative, and prescriptive, and is thus neither true nor false; this convention is anchored to the intrinsically negative value-loaded side: abnormal features are the prior core of reference and normal traits represent the contrast case.

With this syntactic perspective, such bivalent medical norms and the boundary that separates them, though grounded on descriptions, are not items in the basic inventory of the world but are prudential and deontic.

This demarcation is so specific to medicine that it might be considered as one of its criteria: medicine, the human activity, which is concerned with separating normal from pathological. So, if we took away or deducted every single abnormal feature or pathologic processes from the biological reality, we would be left with a remain, namely a default position called ‘normalcy’, usually christened health. Physiology, anatomy, or biochemistry at this point are true by default and are grounded in the absence of pathologic features. This is the starting point of the bottom-up ontology of medicine, what Broadbent calls the metaphysical stance.³⁶

Call this the first position.

Secondly, this first position then dissolves in clinical medicine. The previous line of argument performs a sharp and unanticipated dizzying volte-face, moving from cognition to action, from ontology to praxiology. I call this logical line of argument the initial move. The medical rationale is thus suddenly swinging round and, from then on, as though to forget it has done so, it takes those two normative categories as if they were scientific descriptive epistemic truths: the terms ‘normal’ and ‘abnormal’ are no more conventional, but are now taken as naturalistic, as if true or false.

That is, ontology precedes epistemology. If, in the first position, abnormalcy is logically primary, the second position reverses priorities and affirms the clinical privileged status of normalcy, which is then in the driving seat. The picture is now the mirror image of the starting situation. By way of metaphor, the negatives of the photographic film are now printed, and the print is now light where the negative is dark and conversely. In the initial asymmetrical splitting, abnormal or pathologic situations were pivotal, but in the language of clinical medicine, priorities are being reversed and normality is now epistemically in control of the situation.³⁷

For most clinicians, being normal, is a counter-instance of being abnormal and ‘normal’ is defined as a positive standard of reference; hence, diseases are construed as privative in nature and medical conditions are deviations from ideal design, as departures from the norm.³⁸ This is a case where the ontological order of logical priority is not the same as the order of discovery. If ‘normal’ and ‘abnormal’ are equally meaningless for a biologist, qua biologist, normalcy is apprehended as factual by physicians.

This top-down account admits a background of some sort of abstract prudential standard of normality against which pathological, intrinsically negative features such as diseases, disabilities and malfunctions will be constructed and defined. It follows that the wedge that has been driven in the clinical findings splits them in two descriptive groupings, normal and pathological, arising out of the surface of the world, which are laid out as if they were factual in nature and value-free. By this pragmatic turn, physiology, or anatomy, which are essentially counterfactual, disregard their ontological and conventional origins and hence appear to be empirically true and to describe regularities of ‘natural order’. Physiology and the fixed life cycles of living organisms are taken for granted: they are the neutral contrast state. Medical students indeed learn anatomy and physiology before pathology and pathophysiology. With this turnabout, normative language turns into indicative language that is true or false. With this second position, medical thinking becomes naturalistic. This is what Broadbent calls the epistemic stance that leads to the practical stance.³⁹

With the first convention of the first position, pathology is made of suffering, biological negativities, or the nearing of death, which are additive intrinsic negativities, so that one single affected organ is sufficient for the patient to be sick. Contrariwise, Lars Bergström has proposed a principle of non-additivity of utility⁴⁰, that applies with the second convention, when physiological standards of normalcy take precedence:⁴¹ a normal functioning heart does not make up for a failing kidney. More of this in Chapter Five.

Although medical insight springs, in the first position, from inaugural conventions and value-concepts, in the second position, it draws a veil over those grounds and brackets them off. With these erasures, medical thinking comes out clean as it gives way to a seemingly robust naturalism—a case eloquently described by Boorse—thereby avoiding the cumbersomeness of asking ontological questions about itself. It does not matter whether this picture is fraught with philosophical hurdles.⁴² And, however philosophically meaningful medicine’s contorted birth process might be, it is clinically invisible and ought to remain so.

Even then, very few physicians, openly or consciously at least, might subscribe to what precedes. The reasoning is implied rather than openly stated. Stephen Toulmin captures the same intuition in the common law: "When first promulgated, the force of verdicts and rulings, decisions and findings, is unambiguously prescriptive... Yet, those same decisions subsequently become items in the judicial record, to be cited as historical ‘matters of fact’. As such, they are reported and criticized, quoted, and glossed, using a descriptive idiom".⁴³

In summary, the first ontological position consists in forcing, for prudential reasons, the empirical, natural descriptions of the biological world into medical conventional norms by bisecting the biological realm into normal and abnormal. Although this first position is located among biological processes, its conventional divide may be correct or incorrect but has no objective residency in the biological world. Hence, abnormality is foundational, and normality is being defined negatively as contradictory to abnormality. All the same, this first position is being reversed in clinical and preventive medicine, as normality surfaces in the positive role of a fundamental seemingly natural though revisable standard against which diseases and conditions of medical concern will be being defined and identified. With this move, the demarcation between normal and abnormal, or normal and pathologic, is being put to cognitive use to describe clinical facts in descriptive sentences that may now be taken to be true or false: it bestows descriptive status to the language of pathology. What started as a mere normative convention ends up as a medical quasi-naturalistic representation.

The Trajectory from Suffering to Disease.

Pathos is defined by Aristotle: "The painful and destructive evils are: death in its various forms, bodily injuries and afflictions, old age, diseases, starvation."⁴⁴ "Suffering which we may define as action that involves destruction or pain, e.g. death", seems to play in the structure of empirical knowledge, a role similar to that of axioms in deductive reasoning.

First, current, or potential suffering is the starting point of medicine since one knows it directly and not through anything else.

Second, suffering some intrinsic, biological evil⁴⁵, be it physical or mental, is unpleasant, disruptive and disvaluable. Identifying among abnormal biological features those that are harmful, i.e., those that are being termed pathologic is the foundational convention of medical thinking. Ellen K. Feder contends: "At the center of medical knowledge lies the distinction between ‘normal’ and ‘abnormal".⁴⁶ Ruth Chadwick in an interesting essay on ‘Normality as Convention and as Scientific Fact’ underlines the importance of understanding what is normal since it is an important background of the notions of diseases and health.⁴⁷

Third, the occurrences of suffering and biological intrinsic negativities, are ligated with the need for interventions. «The obligation to treat suffering, writes Eric Cassell, stretches back into antiquity".⁴⁸ Aristotle claimed that the main aspect of prudence, or practical wisdom, does not lay in the field of knowledge but rather in acting.

And therewith begins medicine.

Summary

1. Medicine does not originate, as usually admitted, with the notion of diseases. Concepts of disease, malfunction, or health are evolved, sophisticated and advanced constructs.

2. Various types of biological intrinsic negativities (sufferings, harm, discomfort, unmanageable disability, injury, death) are being selected and construed as medical norms. Being pathologic takes logical precedence over being normal, and this is the launching pad of medicine. This is medical ontology. Those medical norms (normal, abnormal, and pathologic) are neither factual nor non-factual and they are neither true nor false, but they may be correct or incorrect.

3. These conventional intrinsically negative norms are then overturned, and the attraction exerted by those new counterfactual, normative, positive concepts such as those of normality, physiology, sanity, health, safety, salubrity or functions, bring on a ministration that is intended to alter the course of pathologic processes. This is clinical medicine.

4. The need for intervention is constitutive of the medically defined convention of ‘pathologic’, since medicine appeals to restorative, corrective, palliative, therapeutic or prophylactic interventions. On this score, if biology has a monadic perspective, medical insight is dual.

5. Prudence ligates suffering, medical norms, and medical interventions.

6. Diseases are conventional constructs defined either by listing, or instrumentally.

ONE

Intrinsic Negativities: The Biological Roots of Medicine Suffering, Discomfort and Harm

Ask a man why he uses exercise, he will answer, because he desires to keep his health. If you then enquire why he desires health, he will readily reply because sickness is painful. If you push your enquiries further, and desire a reason why he hates pain, it is impossible that he can give any. This is an ultimate end and is never referred to any other object ... Something must be [un]desirable on its own account, and this because of its immediate accord or agreement with human sentiment and affection.

— DAVID HUME⁴⁹

T his chapter introduces the primary features from which medical thinking is being logically deduced. Medicine grew out of the fundamental call for the alleviation of current or potential suffering, discomfort, and harm.

Eric Cassell writes: "Suffering occurs when an impending destruction of the person is perceived; … although it often occurs in the presence of acute pain, shortness of breath, or other bodily symptoms, suffering extends beyond the physical". Suffering is then "a state of severe distress with events that threaten the intactness of the person".⁵⁰

Suffering, in an important sense, is a group of experiences, sensations or moods that have an objective disvalue. Those negativities are intrinsically bad and are abhorred in and of themselves. They may be ordered along some dimensionalized continuum describing the magnitude or intensity of the aversion. Pain ranks in the top and irritability may rank last. Side by side with current or potential pain we find various kinds of intrinsic biological disadvantages meriting intervention, such as increased mortality, reduced fertility, incapacitating or life-threatening conditions, anxiety, stress, acquired blindness, nausea, panic attacks, phobias, compulsions, severe obsessions, dyspnoea, and suchlike.⁵¹ Further on the scale we have various degrees of discomfort and fatigue, dizziness, cough, dysuria, paraesthesia, or anything of that ilk. Some symptoms may be located anywhere on the scale depending on their intensity such as oedema, insomnia, depression, itching, deafness, or somnolence.

"Medicine, writes Joseph Margolis, is a professionalized specialty concerned with a limited range of general prudential objectives: just those that depend, minimally, on the state of the body adjusted to enable, so far forth, the realization of such objectives or, by extension, the analogous state of the mind or of the person…Medicine is concerned with the capacity to use our bodies and our minds and ourselves as effective instruments, insofar as all our projects depend on personal exertion of some sort…Clearly, to define medicine this way is to provide as well a basis for variable conceptions of medical norms."

All in all, prudential norms, rather than diseases, malfunctions or any such complex theoretical concepts and their significant departures, have a certain stability and authority even if what is seen as abnormal or pathologic may, within limits, depend on socio-cultural factors.⁵² Those norms are broadly unassailable and have remained fairly stable throughout history.⁵³ "The prudential norms are not assigned by the science of medicine: they represent a statistically dominant pattern of determinate interests, as nearly cross-cultural as possible, that serves the greatest or at least a great variety of ulterior and overriding objectives".⁵⁴ And this legitimizes their foundational role. The human body or the cheetah’s body and their various organs and systems have altered relatively little since there are human beings or cheetahs on the earth, least of all through the whole of the history of medicine. In view of their biological roots, the resulting norms of prudence stem from antecedent interests, namely some of the most enduring though not unchanging cross-cultural features.

Physical Pain

Pain is the intrinsic evil: it is one of the most common symptoms met in the clinical encounter, and it is the paradigm of the kind of things that have intrinsic negative value.

Pain cannot be described or defined any more than pleasure, writes Locke: we can only know them by experience.⁵⁵ Gilbert Ryle writes that pain "is what anodynes and anaesthetics exist to relieve or prevent".⁵⁶ Putnam writes: ... there is no satisfactory way of answering the question, What does ‘pain’ mean? except by giving an exact synonym (e.g. Schmerz"); but there are a million and one different ways of saying what pain is."⁵⁷ So, pain cannot be described since ‘pain’ is one of those terms we understand through having felt or experienced what it applies to: we know how to apply it, when to apply it and when not to apply it. Pain, as it seems, is painful. Prædicatum inest subjecto.⁵⁸

But perceiving in its various modalities can be the subject of attitudinal qualities (agreeable, horrible, unpleasant) each with a different modality. Pain does not have an agreeable or an aversive character, but the person who experiences the experience does.⁵⁹ If so, then, pain is not painful. Furthermore, one does not, as often assumed, have pain ‘in the brain’. Pain is not in the head. This is not to deny that in the absence of a proper functioning brain, one would feel no pains.

David Hume wrote that it is impossible to give any reason why we hate pain: "This is an ultimate end and is never referred to any other object."⁶⁰ Suffering drains meaning from everything that is valuable in life. "To be in pain, writes Raymond Tallis, is to be in the brazier of unmeaning." Being in pain is thus a mongrel concept: it is descriptive since it states a fact, an inexpungible fact; but it is also evaluative since one cannot be in pain without suffering and disliking it.

All those experiences are greatly influenced by the meaning the sufferer ascribes to his painful experience and by the context in which they are experienced. Epicureans praised ataraxia i.e., tranquillity of soul; they emphasized that, although pleasure consists in the absence of pain and pain is evil, suffering is part of nature. Life is not complete freedom from pain or illness and suffering is part of the furniture of the world.

The suffering level, then, does not necessarily correspond to the intensity of the experienced pain as it depends on contextual factors: what the attitude is of the individual towards the pain, whether he expects his pain will soon go away, whether it is interpreted as the sign of an incurable or permanently disabling condition, whether he is part of a close-knit family or of a circle of close friends. And people who have had a lobotomy although they feel severe pain may just shrug it off.

Physical pain is being pinpointed where it is felt, namely at the place where it hurts. Identifying the location of pain is one of the foremost tasks of physicians. Yet locating pain in the body may trap us into odd considerations. By way of illustration, people who had a limb amputated may feel pain as if in the limb that is not there. One can also experience a referred pain in which case its cause is situated elsewhere. Actually, a pain is located where it is felt: it may thus be localized in the body or "whatever is so recognized by the ego"⁶¹, namely the body image, in case of phantom limb pain. Pain is suffered in one’s arm, leg, or head not with an organ.

Nevertheless, pain is usually a signal of physical harm, and it functions as such a signal because we spontaneously shun it.

Contra Putnam

Factual evidence warrants the claim that the higher mammals and conscious beings in general, experience pain sensations at least as acute as our own. Furthermore, their central nervous system is almost selfsame to ours, and their responses to pain similar. The emotional component is evident, mainly in the form of fear and anger. Physiological reactions include immediate withdrawal reflex, screaming, moaning, weeping, and a rise in blood pressure, dilating pupils, gasping breathing, and tachycardia ending in a state of shock.

Hilary Putnam set out some audacious extrapolations, as functionalism licenses the view that ‘feelings of pain’ can be compared to logical states of a computer: "machines can be equipped with pain signals. These pain states will normally be caused by damages to some part of the machine’s body and will give rise to spontaneous inclinations to avoid whatever causes the pain in question."⁶² It was the hope of Putnam that through those conjectures, talk of pain feelings would become autonomous and independent from neurophysiological descriptions of the brain.

The theory herewith becomes unwieldy. We now have two opposite extremes of mental activity and pain experiences representing the opposite ends of a spectrum. A medical, empirically rooted one and, poles apart, a philosophical one modelled on artificial intelligence. In between, Putnam contends that "octopus, molluscs certainly feel pain".⁶³ But where then lies the dividing line between the ability to experience pain and its absence? Could a cyborg have pain?

My sense is that the possibility of ascribing pain feelings to robots or Turing machines may seem crude and deliberately provocative. It seems there is something wrong in the characterization it suggests. Has Putnam widened the idea of being in pain beyond any reasonable counter instance?

"The question is, said Alice, whether you can make words mean so many different things." Meanings are given to words not built-in them. If so, words such as ‘pain’, ‘feelings of pain’, ‘pain experiences’ are usually learned within the circumstances in which they are properly used, and they secure meaning within that context.

Wittgenstein writes: "You learned the concept of pain when you learned language".⁶⁴ When is it legitimate to believe that someone else is in pain? It is to know what role does the word ‘pain’ play in our lives. It is to recognize when it makes sense to question whether someone else is in pain, and when this does not make sense. We have the notion of pain, and we thus can believe that another person is in pain through participating in a form of life (Lebensform), in a way of living, a certain social and cultural background that involves a person who is in pain being cared for, being tended by others.⁶⁵ So, the whole meaning of the term ‘pain’ is rooted in that context, and it becomes vacuous outside that frame of reference.

Of course, we know what the word pain means and what robot means when taken separately but it does not follow that we understand their meaning when used together. Robert Musil mentioned the zoologist who would classify dogs, tables, chairs and fourth-degree equations among four-legged animals.

To be able to answer a question, it must be intelligible. And the notion of being in pain becomes less and less intelligible as we try to apply it further and further into the biological world, farther away from our conscious experience. And when we come to robots, it may be hardly translatable into the language of our lives.

First Person Privileged Access

Pain differs from most of what takes place in the body. The complex biochemical processes and the activity of our organs occur without our being aware of their occurrence. But pain is different. I do not have to check with a gastroenterologist to know whether I have a stomach-ache.

Is pain an inner sensation? Bishop Berkeley (1685-1753) who held that unperceived objects do not actually exist, we only have knowledge of our own sense experiences; there are not both trees and corresponding sensory representations of trees; we only perceive our experience of tree. He used pain to illustrate his argument in favour of esse est percipi. Knowledge here is unmistakable and therefore pain is a favourite in the epistemological quest for certainty. But is this correct?

Physiologists construe and measure pain as a sensation, which can be sparked off independently of the emotional state of the individual. As a matter of fact, the term ‘pain’ is a