2008 SAAP Panel Submission
3 Confirmed Participants
Before and Beyond Bioethics: Philosophy, Medicine and Health
This panel centers primarily around the issue of medical knowledge and the role philosophy, particularly pragmatism, can and should play in its formation, interpretation, and application in clinical, laboratory, and theoretical settings. Although the panel is not explicitly focused on bioethics, all three papers connect with issues in that field such as the foundations of our concept(s) of health, the gap between the causal worldview of medicine and the inherent uncertainty of the clinical encounter, and the formation of medical knowledge. The operative hypothesis of the panel is that pragmatism, in dialogue with other philosophical perspectives, offers unique insights from which patients, practitioners, and researchers can benefit in their personal and professional lives.
The first paper, taking a cue from recent work in pragmatist bioethics, questions the compatibility of pragmatism and biomedicine, and hence, the wisdom of uncritically accepting the biomedical model of health in bioethical reflections. While clearly a more successful alternative to its historical forerunners, the biomedical model is obliged to commitments that pragmatists have consistently and forcefully criticized in other areas of inquiry. Under the biomedical gaze, the self is separate from and eclipsed by the body, which alone counts as “objective.” By contrast, at the heart of pragmatism is a rich account of the embodied self that sees bodies as central to persons, but just as importantly sees selves as irreducible to bodies. Whereas biomedicine ignores the self and sees the body as ahistorical, pragmatism sees embodied selves as contextual and social, and thus historical in the thickest possible sense. Given such a radical difference in perspective, pragmatists must reject and reconstruct the biomedical view of health.
The second paper also notes biomedicine’s success, attributing it in large part to its ordered and causal worldview. This essay, however, focuses not on what biomedicine can do, but rather on what it remains unable to do. Biomedicine cannot eradicate the experience of uncertainty and chance, which remain beyond the scope of its powers of detection and intervention. What biomedicine needs and what pragmatism offers is a worldview in which science and medicine still do real work, but where uncertainty and chance are also given their due, accorded proper significance, and given a meaningful role in the clinical setting. To the extent that biomedicine fails to make room for chance amidst its “quest for certainty,” it runs the risk of becoming inhuman, all of its clinical efficacy notwithstanding. Rather than viewing uncertainty as a disease to be cured, pragmatists like Dewey and Royce have suggested that this feature of experience may in fact offer us greater clarity on the good we seek and hence guide reflections on the pursuit of it.
The final essay, like the second, addresses uncertainty in medical science and practice. It examines two incompatible yet commonly applied evidentiary approaches to medical reasoning – the epistemological or “individual epistemological” and the sociological. The “individual epistemological” approach understands justifications in terms of what individuals could have and assess on their own. By contrast, the sociological approach conceives justifications in terms of the sociological fact that the medical community has come to some sort of consensus on a matter. The tension between these two confused and conflated methods of reasoning can be seen in a number of areas, such as debates surrounding randomized clinical trials, disputes over the use of “consensus conferences” in making medical recommendations, and on alternate sides of “evidence-based medicine.” What becomes apparent across each of these contexts is the role that values play in medical science and practice.
Is Pragmatism Well-Suited to Biomedicine?
Paper 1 Abstract
Those acquainted with the literature in pragmatist bioethics no doubt will recognize the title of this paper as a play on Hester’s “Is Pragmatism Well-Suited to Bioethics.” Hester’s conclusion in that piece is affirmative, albeit not without qualification. Pragmatism is well-suited to bioethics and Hester does a fine job of showing how pragmatism’s bioethical detractors have either entirely misunderstood or else narrowly construed pragmatism to arrive at the opposite conclusion. Elsewhere Hester has gone even further, arguing that not only is pragmatism well-suited to bioethics, indeed it is better suited to bioethics than its rivals, particularly its Kantian competitor. What rival positions leave out but what is so central in ethical deliberation, Hester asserts, is context, the social and narrative nature of selves and a view of individual agency as always communal and situational. By contrast, the point of this paper strikes at a level prior the bioethics debate, inquiring into the compatibility of pragmatism and biomedicine itself. For the aim of the medical encounter, prior to and guiding any actual occurrence of it, is to achieve health for the patient. Bringing about the good of health is therefore the common purpose bringing doctor and patient together in the first place and therefore constitutes the most basic context out of which any medical-ethical quandary emerges.
The question, Along what theoretical lines health ought to be conceived, is therefore one of great importance for pragmatist bioethicists specifically, but also pragmatists more generally, to consider if they are to avoid unwittingly falling into the kinds of misconceptions in our thinking about health and its related domains that they so astutely criticize in other arenas of inquiry. Many other philosophical outlooks have generated forceful critiques of biomedicine, so it is somewhat perplexing to find pragmatists restricting their innovative and useful work simply to the ethical dimension alone without attending to the biomedical dimension, that is, without having addressed the issue of whether or not pragmatism and biomedicine, clearly the dominant model of health (and the model most often, if not always, presupposed in bioethical theory), are compatible in the first place. Much to his credit, Hester recognizes this challenge and even offers suggestions, brief though they are, for how a pragmatist theory of health might be developed.
Taking this gap in the literature seriously, this paper’s central contention is that to the extent that pragmatism, most especially a Deweyan expression of it, remains committed (even if only ever provisionally) to the social construction of selves, the mutual co-constitution of organism and environment, and a view of ‘objectivity’ as situational, contextual, and communal, it is mistaken for pragmatists to uncritically accept the biomedical view of health. Thus, it contests Hester’s claim of the well-suitedness of pragmatism to bioethics, or, more accurately, argues that any such well-suitedness is still pending, contingent upon work yet to be done by pragmatists in philosophy of health and medicine to bring about what might be called a “pragmatist recovery of health.”
Without denying biomedicine’s success, pragmatists can and should be critical of its theoretical underpinnings. Its success has to do primarily with its ability to manipulate the physiological body through various technical and technological means (although a host of political and economic factors have also played an immeasurably influential role). This ability in turn has led to unprecedented effectiveness in treatment, and hence a level of reliability previously unknown to medicine; hence the overwhelming allegiance to the biomedical view. Nevertheless, biomedicine’s powers of manipulation are a consequence of an overly reductive, materialist conception of objectivity, rooted in the quantifiability of the body. It is questionable whether thinking as such can avoid reductionism, and yet while biomedical reductivism is not entirely without its merits – among other things, it allows for the universalization and normalization of health criteria, for instance – it nevertheless comes at the cost of what a number of thinkers have called the territorialization of the subject, or the relegation of the subject to the territory “within” the body, what pragmatists might call “bad objectivity.” Biomedicine’s exclusive focus on the objective - that is, quantifiable – body, is a direct inheritance of the Cartesian body-machine and modeled on the human corpse (the historical source of the notion of the patient), to the virtual dismissal of the subject. Being unquantifiable, the self is something to be amputated, cut off from the body, which alone offers reliability; severed from its lived context, the self is made a foreigner and trespasser in the territory of the body.
All of this is something to which pragmatism seems rather ill-suited, however. For pragmatism takes selves to be crucial, certainly not dispensable. It should be stressed here however that pragmatism does not make the opposite mistake of valorizing selfhood at the expense of the body. Rather, pragmatism takes the self’s embodiment as fundamental and irreducible, though, as transactionally co-constituted with its environment, nevertheless open to a variety of possible meanings and significances. The self, in all her social, contextual, historical thickness, is not “in” her body but rather lives her body and moreover does so not merely in the context of an environment, which extends beyond the natural-physical to the social, but indeed because of that environment. Thus, since it is selves and not merely bodies which suffer the pains of illness and disease as well as the joys and security of health, it would seem to behoove those working within pragmatism to develop theories of health and medicine which reflect the kinds of philosophical commitments they espouse in other domains. Indeed contra Hester, what this analysis suggests is that a Kantian approach may, after all, be better suited to bioethics – at least if the view of health under which one is operating is the biomedical model, since both biomedical and Kantian models presume an ahistorical view of the person/self who is the object of medical care, and consequently of medical-ethical concern. If, however, pragmatism is to be well-suited to bioethics, it must take up the task of reconstructing models of health commensurate with its broader philosophical vision.
The Limits of Medicine: Embracing Uncertainty
Paper 2 Abstract
I, like my colleagues, will question the picture of biomedicine as currently understood, and argue in this essay that that it needs significant critique and revision. My emphasis, however, will be not on what the current biomedical view leaves out (context, history, environment, sociality and society, self and subjectivity) but rather on that which it can neither eradicate nor adequately account for: the experience of chance, luck, and uncertainty. It is definitely the case that medicine’s focus on the double helix of causation – disease and treatment – has led to much-appreciated advances in both therapy and prevention. Certain questions, however, remain beyond biomechanical causal chains, and can be devastating for patient and healthcare practitioner alike. Biomedical science cannot adequately explain (for the most part) why this particular person has cancer, predict whether treatment will be successful for the same patient, or foresee what the patient’s life will be while dealing with the disease. Not only do we need a worldview that allows for such uncertainty, we must also appreciate the uncertainty for what it is – a mark of humanity, and, in fact, a contributor to the good life and human excellence. In other words, we need a worldview that embraces those aspects of life that seem utterly unpredictable and left to chance. Pragmatism, particularly that of Dewey and Royce, can account for both the success of biomedical science as well as the uncertain and unknown (perhaps even unknowable) aspects of life that must be grappled with in medicine.
In his book Community As Healing, Micah Hester, following John McDermott and Richard Zaner, rightly argues that illness is experienced as a “break” in our everyday, taken-for granted experiences or life plans, and conversely, experienced “breaks” are pathological. The goal of medicine, then, ought to be the return of a person to state of “living healthily,” which is a vital state of relation, activity, growth, and the pursuit of meaningful experiences. This essay attempts to provide an account of the “breaks” described by Hester and others, and argue for their importance.
Dewey provides an account of the world where science still “works,” that is, where adequate causal chains are understood and manipulated, but also naturalistically accounts for the precariousness of life. Not only is existence an ongoing and cyclical movement from stability to uncertainty, but the uncertain itself leads to satisfaction, fulfillment, and satiation, which we then judge good. Dewey explains, “We long, amid a troubled world, for perfect being. We forget that what gives meaning to the notion of perfection is the events that create longing, and that, apart from them, a ‘perfect’ world would mean just an unchanging brute existential thing” (LW1 1925, 58). It is precisely because illness and other pathologies threaten “living healthily” that we value and wish to return to it.
Royce, too, pays close attention to those moments in which causality seems to abandon us and the devastation often experienced in the wake of such moments while allowing for the successful pursuit of science. Humans seek security and stability, but are unable to ultimately procure these goods simply because we are imperfect creatures living in an imperfect world. Perhaps foreshadowing Dewey, Royce, too, asserts that these moments of failure (experienced as luck, chance, fate, and representative of uncertainty in general) may provide insight in to the good that we seek, as well as a suggestion for a return to this good. More specifically, some sorrowful events illuminate the relations we rely upon and value, or, in Hester’s words, the relationships necessary for living healthily.
I do not claim that the healthcare practitioner must necessarily provide answers to questions such as “why me?” and “why now?”, but rather that the practitioner must understand that these questions may lack answers. Biomedicine, informed by pragmatist (ever-entwined) theory and practice, must make room for that which it cannot know, and legitimate the experiences of patients and healthcare providers when faced with this limitation. The good life depends on it.
Paper 3 Abstract
This paper articulates the distinction and then explores the tension between two broad conceptions of evidence in medicine (as in science in general), two different perspectives concerning what we know or have reason to believe, how we conceptualize and deal with uncertainty, and how we ought to act. The first is what might be called an “epistemological” or “individual epistemological” approach, and the second is what might be called a “sociological” approach. Both of these play a role in our practice and thinking concerning our medical knowledge.
In the first case, we give justifications in terms of reasons that individuals could have and assess by themselves. (For instance, the application of explicit theories of evidence or confirmation, such as Bayesianism, would fit into this category, but it is not an essential feature of this conception that it involve some formal theory.) In the latter case, what matters is a certain social fact -- the fact that “the medical community” has come to an agreement.
The contrast and tension between these two conceptions, as well as, sometimes, the failure to distinguish them, is played out in a variety of contexts within medicine or medical thinking. But these are on the face of it incompatible conceptions, and it is important to address their relationship explicitly.
Proponents of the “epistemological” standpoint will likely view the sociological turn as leading to a conception which is insufficiently normative, as giving up on the question of what really counts as good evidence in favor of the mere sociological fact of professional opinion. But those taking the sociological perspective will of course see the first group as failing to recognize or take seriously the extent to which medicine (like science as a whole) is a social process. This debate – sometimes at the surface, sometimes more unconsciously – will mirror debates about the sociology of scientific knowledge that have taken place in the history, philosophy of sociology of science, as well as discussions of social epistemology.
To explore the meaning and significance, as well as the relative merits, of these conceptions, and the extent to which they could be integrated, I will consider their application in a number of realms in medicine.
One important context is the debate concerning ethical tensions in the practice of randomized clinical trials (RCTs), and, in particular, what counts as evidence sufficient to impose on us a moral tension that needs to be taken seriously. Benjamin Freedman’s “clinical equipoise” solution states that one should address this question not from the point of view of whether you, the individual investigator, believe that there exists evidence that favors one treatment over another, but rather whether there is agreement in the medical community about this. That is, the morally and scientifically relevant place to focus is not on whether you can point to arguments, utilizing normative theories of evidence, that show the probability of a given hypothesis (that treatment A is better than treatment B) being true to be such and such, but on whether a set of members of the community have been swayed by these and other considerations. There are good reasons to be skeptical of this solution, but the main point here is that resolution of this debate concerning such practical ethical decisions requires that we address this question of the connection between and the relative merits of the epistemological and sociological perspectives.
There are other applications as well. One concerns debates about the use of “consensus conferences” in making determinations of what should be believed or recommended concerning some medical matter. Another is the creation, implementation and use of “practice guidelines” in medicine. Yet another example involves two different sides of “evidence-based medicine”: the gaining of critical skills to read properly the evidence that exists, and the social process of generating guidelines that others then are made to follow. Of course, each of these contexts illustrates the role of values in medical science and practice – practitioners in the medical community can differ with respect to their values, their conceptions of health and disease, as well as their methodological stances. They also illustrate the tension between art and science in medicine and the role of clinical judgment. But the central issue here will be how this connects with the epistemological/sociological distinction.
Through such cases as these, I will show how this duality applies throughout medical decision making, and how it leaves us with certain puzzles that require further examination. This exploration will help us think more generally about the utility and limits of these two conceptions.
 For the purposes of this essay, I will rely upon an experiential understanding of chance, luck, and uncertainty. I take instances of chance and luck, and the presence of uncertainty, not to signify a lack of causation, but rather to signify an inability to grasp the causal factors at work such that the given event may be adequately explained – it feels like bad luck or utter chance.
 The practitioner may be able to answer these questions satisfactorily in more “straight forward” instances of illness, such as in cases of food poisoning. I am, however, concerned with precisely those instances in which healthcare providers are unable to provide such an account. The question of whether practitioners will be able to someday provide an account for all instances of illness remains beyond the scope of this essay, although it seems safe to respond, “not anytime soon.” Further, even though biomedicine may provide causal explanations of events such as death, it cannot explain why humans die, and must therefore still welcome uncertainty.