Evidence-based medicine

During the COVID-19 pandemic, scientists and policymakers have responded with unprecedented solutions. The pandemic has also forced a rethinking of science, public health and their relationship to the public. How can philosophy of medicine help us respond to the fundamentally philosophical problems that this rethinking involves? In May of 2021, I hosted a panel discussion with experts in health science, public health and philosophy titled Philosophy of Medicine on COVID-19. We talked about normal science and fast science; modeling and evidence in public health; science, uncertainty and decision-making; expertise and science communication; and the relationship between public health and the publics. In today’s consultation, we revisit that conversation with Trisha Greenhalgh (University of Oxford), Ross Upshur (University of Toronto), Alex Broadbent (University of Johannesburg), Maya Goldenberg (University of Guelph), and Sang-Wook Yi (Hanyang University).

There is renewed research and attention to race in epidemiology and medicine, partly owing to developments in population genetics. Yet race is a contested category and poses philosophical questions about the reality of racial categories as well as the ethical and social-political implications of using them. For instance, is race a social construction; and if so, how do racial categories line up with the world? Perhaps more pressingly, should we be using racial categories in epidemiology and medicine in the first place? Today’s consultation is with philosopher Sean Valles, Associate Professor at Michigan State University.

Medical Nihilism. Is it vestige of a bygone age in medicine beset with treatments like mercury and bloodletting? Or the proper conclusion of a line of argument about our current medical interventions citing problems with contemporary medical research? These problems include the complex pathophysiology of contemporary diseases, the malleability of medical research methods, the biased social nexus of medical research, and a small effect size crisis. Should we have low confidence on average in medical interventions today? And is this the kind of question that we can answer with a dose of data and philosophy? Today’s consultation is with philosopher Jacob Stegenga, Reader in History and Philosophy of Science at the University of Cambridge.

In medicine, consensus statements abound. They’re issued by government agencies and professional societies as the official word on the science and practice of medicine. But what role does expert consensus serve? To summarize the evidence? To deliberate over decision-making? Or to command change? In an era of evidence-based medicine, is expert consensus going extinct? Or is it perhaps more important now than ever? Philosophers studying the social context of medical knowledge may have some answers. Today’s consultation is with philosopher Miriam Solomon, Professor of Philosophy at Temple University.

The cause of tuberculosis is the germ Mycobacterium tuberculosis. Meanwhile, the causes of heart disease are variable: smoking, sedentary lifestyle, bad genes, and so on. Is this just a fact? Did the German microbiologist Robert Koch really discover that Mycobacterium tuberculosis is the cause of tuberculosis? According to some historians and philosophers, it’s more than just a matter of fact. It’s partly a conceptual choice of how we classify diseases, one with important implications for how epidemiology and medicine are practiced today. Thankfully, conceptual understanding and analysis is part of the scope of practice of a philosopher. Today’s consultation is with philosopher Alex Broadbent, Professor of Philosophy at the University of Johannesburg.

Evidence-based medicine or EBM was introduced in the early 1990s as a move to increase medicine’s uptake of published scientific evidence, especially evidence from clinical epidemiology. It is now the standard, such that its underlying philosophical ideas have become invisible to many. However, since its launch, evidence-based medicine has had its critics, including healthcare professionals and philosophers. Philosophers began to ask questions: what is ‘evidence’ according to evidence-based medicine? What justifies EBM’s confidence in some forms of evidence – namely, randomized trials and meta-analyses – over others like observational studies or evidence of biologic mechanisms? Evidence-based medicine led to a renaissance in philosophical attention towards medicine and medical evidence. In today’s consultation, I speak with four philosophers of medicine: Ross Upshur, Jeremy Howick, Jacob Stegenga and John Worrall. Here’s my conversation with Ross Upshur, Professor in the Dalla Lana School of Public Heath at the University of Toronto.

Mental disorders cause suffering for many and pose challenges for the psychiatric profession. Throughout history, the way that society and psychiatry have thought about mental disorders has changed greatly. One area of great difficulty and great change has been psychiatric classification – how psychiatry carves up the realm of mental illness into diagnostic categories. During the second half of the Twentieth Century, the Diagnostic and Statistical Manual of Mental Disorders, the DSM, became the bible of psychiatry, the most influential psychiatric classification system. But through its several editions, criticism has followed the DSM, which serves as a target for debates about how psychiatric diagnosis and research should be done. At the head of these debates have been several philosophers. In today’s consultation, I speak with three philosophers of psychiatry: Rachel Cooper (Professor in the Department of Politics, Philosophy and Religion at Lancaster University), Jonathan Tsou (Associate Professor in the Department of Philosophy and Religious Studies at Iowa State University) and Kathryn Tabb (Assistant Professor of Philosophy at Bard College).

Health and disease are two concepts that dominate our lives. Analyzing these concepts has also dominated much of the discussion in the philosophy of medicine. Is health merely the absence of disease? Is disease a biological concept, a value-laden concept, or both? Why is it important that we dissect these concepts? Should we do away with them altogether, at least when it comes to the hard cases that generate controversy over who counts as healthy or diseased? In this episode, we provide a small primer on this big discussion. Today’s consultation is with philosopher Marc Ereshefsky, Professor of Philosophy at the University of Calgary.

The mastery of clinical judgment is what separates the expert clinician from the novice. Yet clinical judgment remains somewhat obscure. Is it a tacit knowledge? Or one that can be formulated according to explicit rules? Is it a science? Or a virtue? Has it been replaced or its importance reduced by evidence-based medicine? Or will it soon be taken over from clinicians by intelligent machines? And what is clinical judgment, anyway? In today's consultation, I sit down with four guests ahead of a clinical judgment symposium to see how they use philosophy to understand clinical judgment.

Delusions are often defined as fixed false beliefs. They run contrary to common sense or counter-evidence that would convince any rational person, like the idea that aliens are communicating with me through a radio chip implanted in my brain, or the thought that my father has been replaced by an imposter, albeit an imposter that is identical to my father in every discernible way. But why do people acquire delusions in the first place? Philosophy is often thought to be a rational activity of the highest order. Maybe philosophers can shed some light on what is going wrong with the reasoning of people who have delusions? Today’s consultation is with philosopher Matthew Parrott, Birmingham Fellow in Philosophy at the University of Birmingham (formerly at King’s College London).