Philosophy of Medicine Midterm Flashcards
What is it that the physicians and researchers were debating when discussing the COVID drug wars?
They debated what the best approach was when providing drugs to treat COVID patients. There was one group of physicians that wanted to try drugs that are hypothesized to be effective for COVID patients but haven’t been tested by an RCT, and there was one group that wanted to conduct an RCT before administering a drug.
In one case, a physician wanted to give an anticoagulant to a patient who had cardiac arrest from COVID, but the patient was enrolled in research determining if an anticoagulant works better than a normal dose. There was a debate since the physician wanted to take the patient out of research and give a higher dose while the researchers wanted to test the efficacy before giving a higher dose
Why are RCTs considered the gold standard in medicine?
They are defended as being the least likely to yield biased results since double blind studies avoid selection bias, set standards of significance, can distinguish placebo from other specific medication effects, avoid salience which is when clinicians bias outcomes by choosing patients based on prior assumptions about the effectiveness of a treatment
Are there circumstances where an RCT may not be warranted? What are parachute cases?
In circumstances where not treating a patient may lead to serious consequences such as disability or death (parachute cases) or if there is a global crisis and health care facilities are overwhelmed by the number of ill patients, such as COVID, it may be necessary for physicians to make judgment calls prescribing patients drugs that may not always have gone through rigorous scientific testing via RCTs or may not completely fit with hospital protocols.
RCTs were deemed to be important due to the onset of a movement valuing evidence based medicine. What are some criticisms of evidence based medicine that may underscore the necessity of RCTs?
EBM may overlook the role of clinical experience, expert judgment from physicians, medical authority, variability between patients, the need for individualized treatment, patient goals, health care constraints, and medical theory that links causal relationships for different conditions
More criticisms of RCTs in particular are that they are not fast science and difficult to carry out ethically in all cases, a significant percentage of studies fail to replicate, there have been many medical reversals, and studies funded by pharmaceutical companies by and large have a much higher chance of demonstrating a positive effect. They may also be subject to confirmation bias, funding bias, self-selection bias where an individual may self-select into a group where shared characteristics may be present and bias results, and data-fishing bias where data analysis is misused
GRADE ranking system
Classifies quality of evidence. High quality is when further research is unlikely to change confidence of the estimate of an effect. Moderate quality is when further research is likely to have an important impact on our confidence in the estimate of effect or may change the estimate. Low quality is when further research is likely to have an important effect on the confidence in the estimate of an effect and is likely to change it. Very low quality is when any estimate of an effect is uncertain.
What is Boorse’s argument?
He argues that disease is a disruption of natural functions where these functions play a role in survival and reproductive success. Since somatic diseases require physical functions there must also be mental functions. Certain mental functions seem to perform universal functions in human behavior and contribute to survival and reproductive success such as perception and memory. He therefore offers a definition of disease where he argues that if there are any mental diseases, they must disrupt this process
He also argues that the criteria for identifying a condition as a mental illness either affirms societal values, abstracts from diagnostic cases, or involves social judgment so if there is a mental illness conditions must be disruptions to normal functions of mind, and none of these conditions are provided in mental health literature. Therefore, the criteria for mental health that is provided in most literature is unsatisfactory.
What is Boorse’s naturalist account of disease?
Disease is a deviation from species-typical function. Whether or not something counts as a disease is independent of whether or not people value or disvalue it. A trait is functional if it is species-typical and contributes to survival and reproduction. Whether or not a trait has a function depends exclusively on its consequences.
He argues that diseases are deviations from species design and their recognition is a matter of natural science rather than an evaluative decision. Science is therefore purely based on physiology rather than biology
Why is Boorse considered a philosopher and why is he different from social scientists?
Social scientists are usually concerned with how different cultures and societies use a term. They do not stipulate or explicate it, but rather they describe it. Boorse, however, is more concerned with explication or providing a definition, and he offers a definition that retains the central use of the term disease but makes the definition more precise
How does Boorse argue his view?
- He first argues that previous discussions of health have failed
- He then points out what is distinctive about his method and introduces important distinctions that ought to be granted
- He then gives his positive account of what should be considered a disease
- Fourth, he considers the advantages and disadvantages of his view
- Then finally, he uses analysis to explain and describe why positive accounts of health seem value laden and how we can retain the idea of health as an absence of disease
How can we construe the question of whether or not diseases are real
Whether diseases are independently existing external entities (nominalism vs universals)
Whether disease taxonomy is artificial or natural (are disease classifications real/distinct in nature)
Different views on disease
Hybrid view: Disease ascriptions require both functional and normative judgements
Normativist: Disease ascriptions are normative and purely based on value judgements rather than dysfunction
Naturalist: Disease ascriptions only require an assessment of function. According to Boorse, a healthy physiological function has to be species-typical and contribute to survival and reproduction
Eliminativist: Disease ascriptions ought to be done away with since we can simply describe physiology and then make normative judgements. No evidence of “dysfunction” is required.
What is Stegenga’s main argument?
He argued that either the neutral view where health is the absence of disease and the positive view and the positive view where health is over and above the absence of disease is inconsistent
Or that we can use the term health in two paradigmatic ways where “health” is only used as a contrast to disease or it refers to an ideal or achievement over and above merely eliminating disease. In this case, we have to ensure health is not used equivocally
Are objectivism, subjectivism, naturalism, and normativism mutually exclusive?
Objectivism and naturalism tend to overlap since both posit that health depends on natural facts that can be determined objectively
Normativism and subjectivism tend to overlap since both posit that health depends on values that are either societal or held by the subject
In health care practice, hybrid views tend to be taken into consideration since a judgment of whether or not something is healthy involves a combination of “natural” indicators of dysfunction and normative judgements, such as impairment or undesirability. Objective factors such as test results or x-rays/screenings along with subjective factors such as the patient’s experience with a condition are also generally taken into consideration before a condition is determined to be a disease.
How do Lila and Elena reflect the two accounts of health?
Elena has a better quality and satisfaction of life while Lila is more dissatisfied. According to the neutral view on health, both are equally health since neither has any objective indicators of dysfunction
According to the positive view on health, Elena is more healthy than Lila since Elena has a better well-being and is less stressed. The positive view on health posits that there is no upper limit to a healthy state and well-being should be considered when considering health
Why would someone reject subjectivism? Give examples
One’s subjective experience with a condition may not always correlate with more “objective” indicators of disease such as the presence of sufficient nutrients. The subjectivist view posits that a person is healthy if they believe that they are, but a monk believes himself to be healthy even though he is lacking in nutrients, starving himself, and compromising his survival through his fasting. The naturalistic, objectivist view would reject this since this view would argue that compromising potential survival means compromising health, so we should regard the monk as unhealthy and the subjectivist assessment is flawed.
What rationale did the AMA offer for classifying obesity as a disease?
The AMA believed that recognizing obesity as a disease will help change the way the medical community tackles it. They also believed that it would reduce the incidence of cardiovascular disease and type 2 diabetes and communicate the risk to long term health
May promote/enable coverage for dieticians, medications, and surgery
May reduce stigma
Why was there opposition?
It was argued that there was a lack of a clear definition of what constitutes a disease and whether obesity fits criteria
BMI is not a suitable measure of overall health nor a good clinical measure
Economically disadvantaged people are disproportionately targeted
It may lead to worse outcomes since diets can lead to swings in weight
Overweight is not always harmful
Is obesity really a disease? Are there any benefits?
Hip fracture risk in postmenopausal women reduces with increasing BMI and overweight and class I obese individuals have a lower mortality risk than those with normal weight. Obese individuals also have a lower mortality than normal weight individuals for a range of diseases (cardiac failure, coronary syndromes, chronic kidney disease, etc)
What are four ways of going “wrong?”
Dysfunction where a biological structure is unable to fulfill the causal role for which it has been selected in the evolutionary past
Abnormal environment where a given mechanism is operating in accordance with its design but outside the operating parameters for that design
Heuristic failure where developmental trajectories initiated in the setting of imperfect information leads to a non-ideal state
Normal but inhospitable environment
What is the normativist vs naturalist view? What justifies taking a biological norm to be “natural?”
Normativist view posits that all judgements of health are value laden and the naturalist view posits that health is a purely natural category
A biological norm may be natural if there is projectability, shared evolutionary history, shared causal/physical realization/constitution, and shared mechanistic organization. If it “keeps with species design”
What is Greene’s goal?
To tell a story of the role pharmaceuticals have played in medical knowledge, disease categorization, rise of a risk factor, transformation of the risk thresholds for chronic conditions, a practice of medicine and biomedical science, relationships between science and business/insurance companies/regulatory bodies, and the creation of profit
What does he argue?
He documents the history of three drugs (Diuril, Orinase, and Mecavor) for high blood pressure, diabetes, and high cholesterol. He explains the science between how these drugs work, the marketing of drugs, the transformation of research surrounding drug discovery/development, the transformation of medicine, and the economics/politics of pharma-policy interface
He ultimately argues that medicine shifted. Treatments used to only be used for specific diseases now they’re used to encompass broader populations who may have risk factors but no immediate symptoms. There can also be a cycle where drugs can expand disease categories and enlarge markets where risk factors can be “transformed” into treatable conditions
What is Greene’s argument about the epidemiological shift regarding treatments?
He argued that the epidemiological shift was not simply a shift to better science and pharmaceuticals played a more central and active role in the newfound definitions of disease categories. The social histories behind new categorization and epidemiological shifts are more complex than just a shift in the way diseases are studied
Rather than an epidemiological transition where it was posited that the study of chronic diseases led to more discovery and preceded the inquiry into drugs to treat risk factors rather than diseases, he posited that a therapeutic transition occurred. He thought that the inquiry into drugs shaped the knowledge and understanding of which risk factors shape chronic disease and our very conception of disease. Rather than thinking of disease as overt symptoms we think of people who are at risk as diseased
