Causal pluralism and medical diagnosis
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International Workshop on Logic, Philosophy, and History of Medicine, University of Seville
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Causal pluralism and medical diagnosis
- 1. Causal pluralism and medical diagnosis Federica Russo Philosophy & ILLC, University of Amsterdam Science&Technology Studies, University College London http://russofederica.wordpress.com | @federicarusso
- 2. Overview • Phil Med • From ethics to methodology (and back) • Relocating evidence • Evidential pluralism in the framework of causal pluralism • The causal challenges of medical diagnosis: a causal mosaic approach • Zoom in: technological construction of diagnostic tests 2
- 3. The scope of Phil Med 3
- 4. From ethics to methodology Originally, Phil Med is about the ethical challenges arising in the field Gradually, and since the early 2000s, Phil Med has opened up to questions about methodology As we speak, philosophers of science working on Medicine increasingly discuss methodology and epistemology with ethics 4
- 5. A core question of medical methodology 5
- 6. Causes and effects of health and disease C causes E Red meat consumption causes cancer Breathing glyphosate causes cancer Statins lower cholesterol Exercising reduces cardiovascular disease … How do we know that? What makes a causal claim true /versus/ What evidence supports a causal claim 6
- 7. Evidential pluralism To establish a causal claim we need multiple sources of evidence: That C makes a difference to E Correlations, counterfactuals, … That C produces E Mechanisms, processes, … A collaborative enterprise: Russo & Williamson >> Clarke, Gillies, Illari, Russo, Williamson >> EBM+ >> … Perspectives: historical, practical, underexplored areas (e.g. sport studies), … 7
- 8. Relocating the debate on evidence 8
- 9. A plurality of causes Phil Med in the Philosophy of Science in Practice tradition: “medicine” in the broadest possible terms to include all clinical, scientific, and political forms of engagement with health and disease” “our medicine is a disunion, with the consequence that our definition might well include forms of practice that not all would recognize as medicine in some more restrictive way” Epidodes of medical causation show that even if we can formulate a problem as “Does C cause E?”, they rarely reduce to this exact formulation How to make justise to the variety and diversity of ways of understanding, studying, establishing causal relations in medicine? 9
- 10. The mosaic of causal theory 10
- 11. Causal pluralism 11 Causality cannot be reduced to one single concept but has to be analysed using several concepts
- 12. 5 philosophical questions Metaphysics What is causality? What kind of things are causes and effects? Semantics What does it mean that A causes B? Epistemology What notions guide causal reasoning? Methodology How to establish whether A causes B? Or how much of A causes B? Use What to do once we know that A causes B? 5 scientific problems Inference Does A cause B? To what extent? Prediction What to expect if A does (not) cause B? Explanation How does A cause or prevent B? Control What factors to hold fixed to study the relation between A and B? Reasoning What considerations enter in establishing whether / how / to what extent A causes B? 12
- 15. Tiles for the Causal Mosaic … necessary and sufficient; levels; evidence; probabilistic causality; counterfactuals; manipulation and invariance; processes; mechanisms; information; dispositions; exogeneity; Simpson’s paradox; regularity; variation; action; inference; validity; truth; … To be arranged by: Philosophical Questions Metaphysics, Semantics, Epistemology, Methodology, Use Scientific Problems Inference, Prediction, Explanation, Control, Reasoning 15
- 16. A causal mosaic A picture made of tiles Each tile has a role that Is determined by the scientific problem / philosophical question it addresses Stands in a relation with neighbouring concepts A causal mosaic is dynamic, partly depends on scientists’ / philosophers’ perspectives 16
- 17. What about medical diagnosis? 17
- 18. Causal challenge Description Philosophical Question Scientific Problem levels of causation How to infer token causes of disease from generic knowledge. How to generate generic medical knowledge from token instantiations of disease and from population level data Epistemology Use Reasoning (Abduction) Inference Control types of causes How to explain disease using biological and / or social factors Metaphysics Explanation Control causal narrative How to choose the most effective way to explain disease - from doctor’s perspective (diagnosis, prognosis) - from patient’s perspective (self diagnosis) - from different worldview perspectives (Western medicine vs Eastern vs indigenous knowledge) Epistemology Metaphysics Explanation Prediction Control evidential pluralism How to select diagnostic tests and to combine results of several diagnostic tests Epistemology Use Inference Explanation Control Reasoning construction Diagnostic tests do not always give direct epistemic access to the ‘disease’ phenomenon, but involve an element of (technological) construction (e.g. x-rays, FMRI, …) Epistemology Metaphysics Inference Reasoning Explanation definition of disease How to disentangle symptoms, causes, effects … Semantics Metaphysics Inference Control Reasoning 18
- 19. The construction of diagnosis 19
- 20. What nobody would disagree with There is a whole range of diagnositc tests Diagnositic tests involve analysis through instruments of various degrees of sophistication A simple termother … A Positron emission tomography 20
- 21. What we often forget From the simple termomether to the sophisticated PET scan, diagnosis involves elements of construction Epistemic Technological 21
- 22. The technological construction of diagnosis Epistemology, Metaphysics Gathering evidence to establish some causal claim Confront symptoms and evidence with generic medical knowledge What causes disease Inference, reasoning, explanation Inferring causes from effects Inferring causal relations in the single case from generic medical knowledge / protocols Supporting causal reasoning with evidence Explaining symptoms 22
- 23. Why does it matter? 23
- 24. Recalibrating certainty How certain are scientific claims / results? And for the matter, claims about diagnosis How to walk the thin line between We know that we can’t claim absolute certainty (see history of science) We do have some basis to make decision and take action (however fallible and uncertain) 24
- 25. Returning the argument on its head? Phil Sci / Phil Med Instead of talking about certaining, the ‘best’ evidence, ‘gold standards’ Consider: How fragile is evidence and causal reasoning? What makes it so fragile? Can we distinguish proper epistemic from sociological reasons for this fragility? … Where to make this narrative shift? Phil Sci / Phil Med Science and Medicine Doctor – Patient communication Schools 25
- 26. Rethinking doctor-patient communication Convey the idea of construction, to give a sense of the difficulty of coming up with diagnosis See e.g. work by Annamaria Carusi & collaborators, studying interdisciplinary groups in hospitals examining diagnostic tests Relatedly, descronstruct the idea of certainty and of direct epistemic access to the causes of disease and illness Lots of work ahead for Phil Sci and Phil Tech Regain a holistic understanding of the aetiology of health and disease The diagnostic tests may explain part of the aetiology (the biological one), but certainly not the whole of socio-cultural part 26
- 27. In sum 27
- 28. Medical diagnosis is a fascinating and underexplored area in Phil Med Medical diagnosis is a multifaceted form of inference from effects to causes By adopting the pluralistic approach of causal mosaic we can study many of these dimensions, moving freely across ontological and epistemological levels By detailing the ways in which inference and reasoning are (technologically) constructed, we are invited to re-think doctor-patient communication, inter alia 28
- 29. Causal pluralism and medical diagnosis Federica Russo Philosophy & ILLC, University of Amsterdam Science&Technology Studies, University College London http://russofederica.wordpress.com | @federicarusso Thanks for your attention!
Editor's Notes
- Here sketch the way the philosophical debate has framed questions about causality, i.e. in terms of truth of causal claims. One shift consists in looking at the *evidence* that support said claims, rather than their truth. This doesn’t mean that questions about truth are dismissed, rather they are reconceptualised (but I will not discuss in the talk, I leave it to Q&A). If needed, background of this shift: see Illari and Russo 2014
- Present evidential pluralism. An epistemological thesis. Surely, metaphysical implications (but here these are orthogonal to the argument). Instead: the epistemological thesis has, arguably, direct bearing on methods for causal assessment and for decision making. Highlight: The collaboration grew (Russo & Williamson >> Clarke, Gillies, Illari, Russo, Williamson >> AHRC project Evaluating Evidence in Medicine) Consequently, the project also grew in terms of interests, perspectives, case studies, etc Some perspectives are more historically oriented (e.g. Gillies), others more practically oriented (see e.g. Kelly, former director of NICE, UK; Straif, current head of IARC monographs )