Thesis (Ph. D.)--University of Texas at Austin, 2005. / Supervisors: Lesley Dean-Jones and Robert J. Hankinson. Vita. Includes bibliographical references.

Evidence based medicine (EBM) offers an established framework for the generation, interpretation, and utilisation of information in medicine and the health sciences. Central to the practice of EBM is, I argue, the notion of causation. This thesis makes an original contribution to the philosophy of EBM through a unique identification of a causal theory in EBM, and then by demonstrating a reconceptualised theory of causation better suited to evidence based person centred care. PART 1 of this thesis demonstrates that a very specific idea of causation can be witnessed within the structure of EBM. This idea is typically Humean. Through a consideration of the structure and textual narrative of EBM, it is proposed that the framework substantiates central and canonical claims. These claims relate to the core activity of EBM being the informing of clinical decision-making through the transference of causal claims from prioritised research methods. I argue that a Humean notion of causation is problematic for the central and canonical claims, thereby presenting a paradox – EBM is structured to inform clinical decision-making about causation but is inhibited from doing so by the way this very structure conceptualises causation. In PART 2 I argue for a reconceptualisation of causation that offers some solutions to the problems identified in PART 1. This theory relates to a dispositionalist ontology and takes causes to be derived from properties of an individual and as being things that merely tend towards an effect. Causes are seen as complex and context-sensitive, and whereby a traditional Humean account sees these factors as challenges to its epistemological reading, causal dispositionalism takes them as its starting point. To present this theory, desiderata are developed from existing narratives on EBM and elements of the theory set against these. In conclusion, I argue that if medicine and health care desire a framework of practice that is both evidence based and person centred, its causal theory must be reconceptualised. Causal dispositionalism offers an encouraging reconceptualisation.

<p>  </p> <p>Medicine is often referred to as both a science and an art. The scientific rigor of medicine has allowed for the advanced and effective treatment of disease whereas the humanistic art of medicine has allowed for clinicians to uncover how best to care for their patients in a compassionate manner. This dissertation hopes to discover how medicine can coordinate scientific expertise with compassionately focused care. The goal of this dissertation, then, is to uncover how medicine can begin to develop a more personalized medicine in which patient’s values and life-plans are coordinated with a scientific understanding of the treatment of disease. First, this dissertation establishes how medicine can be split into two perspectival understandings of disease (a first-personal and second-personal understanding), then it argues how these two understands can be coordinated with one another to develop a more holistic understanding of patient care. Next, this dissertation illustrates how concepts from phenomenology hold relevance within clinical practice in order to show how clinicians can develop a more robust understand of their patients as persons. This understanding is then used to recapture an account of the clinical relevance of empathy so that clinicians are better able to imagine what it might be like to be a patient living through illness.</p>

Medical decisions should be based on good evidence. But this does not mean that health care professionals should practice evidence-based medicine. This dissertation explores how these two positions come apart, why they come apart, and what we should do about it. I begin by answering the descriptive question, what are current standards of evidence in medicine? I then provide a detailed critique of these standards. Finally, I address the more difficult normative question, how should we determine standards of evidence in medicine? In medicine, standards of evidence have been established by the pervasive evidence-based medicine (EBM) movement. Until now, these standards have not been subjected to comprehensive philosophical scrutiny. I outline and defend a theory of knowledge – a version of Helen Longino’s Critical Contextual Empiricism (CCE) – which enables me to critically evaluate EBM. My version of CCE emphasizes the critical evaluation of background assumptions. In accordance with this, I identify and critically evaluate the three substantive assumptions underlying EBM. First, I argue that medicine should not be held to the restrictive definition of science assumed by proponents of EBM. Second, I argue that epidemiological evidence should not be the only “base” of medical decisions. Third, I argue that not only is the particular hierarchy of evidence assumed by EBM unjustified, but that any attempt to hierarchically rank research methods is incoherent and unjustifiably restricts medical knowledge. Current standards of evidence divert attention from many legitimate sources of evidence. This distorts medical research and practice. In the remainder of the dissertation I propose means for improving not only current standards of medical evidence but also the process of producing and defending future standards. On the basis of four CCE norms, I argue that we have reason to protect and promote those features of the medical community that facilitate diversity, transparency, and critical interaction. Only then can we ensure that the medical community retains its ability to produce evidence that is both rigorous and relevant to practice.

Medical decisions should be based on good evidence. But this does not mean that health care professionals should practice evidence-based medicine. This dissertation explores how these two positions come apart, why they come apart, and what we should do about it. I begin by answering the descriptive question, what are current standards of evidence in medicine? I then provide a detailed critique of these standards. Finally, I address the more difficult normative question, how should we determine standards of evidence in medicine? In medicine, standards of evidence have been established by the pervasive evidence-based medicine (EBM) movement. Until now, these standards have not been subjected to comprehensive philosophical scrutiny. I outline and defend a theory of knowledge – a version of Helen Longino’s Critical Contextual Empiricism (CCE) – which enables me to critically evaluate EBM. My version of CCE emphasizes the critical evaluation of background assumptions. In accordance with this, I identify and critically evaluate the three substantive assumptions underlying EBM. First, I argue that medicine should not be held to the restrictive definition of science assumed by proponents of EBM. Second, I argue that epidemiological evidence should not be the only “base” of medical decisions. Third, I argue that not only is the particular hierarchy of evidence assumed by EBM unjustified, but that any attempt to hierarchically rank research methods is incoherent and unjustifiably restricts medical knowledge. Current standards of evidence divert attention from many legitimate sources of evidence. This distorts medical research and practice. In the remainder of the dissertation I propose means for improving not only current standards of medical evidence but also the process of producing and defending future standards. On the basis of four CCE norms, I argue that we have reason to protect and promote those features of the medical community that facilitate diversity, transparency, and critical interaction. Only then can we ensure that the medical community retains its ability to produce evidence that is both rigorous and relevant to practice.

No description available.

This interdisciplinary dissertation is a study of the ways in which we sensually embody and experience ow world. It is a metaphilosophical account that begins within orporeality; indeed, it is suggested that this isthe place where the philosophic urge is argued, elaborated, and reflected upon. While many studies of embodiment tend to focus upon "the body" as object, cultural artefact, or text for cultural inscription, the approach used in this dissertation is with the incarnation (the making flesh) of interaction in particular socio-physical milieux. The shift is thus from investigation of bodies to bodying, from noun form to transitive verb of incorporealization. This shift is felt necessary in order to better understand the so-called dualisms of traditional Western philosophic thought: mindbody, self-other, self-world, nature-culture, etc., and Tantric inspired Eastern philosophies of self-all relationality. It will be suggested, taking the lead from Leder (1990), that these apparent dualisms are not so much "add-ons" to philosophies of being, but arise in the experiential body itself. This dissertation endeavours to rethink certain "givens" of everyday life, such as perception of time and space, place, enacted memory, having empathic feelings for others, and so on, from within bodily experience and occidental-oriental philosophies of being. Certain neurological disorders are examined for their way of deconstructing elements required to construct a meaningful incarnated life-world. The process of embodiment is not only what the body is, but what it does. My construction of what is necessary for embodiment studies therefore considers bodily praxes (cultural and individual), as well as the sensual, sensate experiences arising in the body. The image of a ball game is evoked in various ways throughout the dissertation not only because it well describes the dense layers of interaction and an emergent sense of bodiliness, but it also illustrates reciprocity and situatedness. This thesis is intended to contribute to the health sciences as well as cultural studies. It draws upon the phenomenology of Merleau-Ponty, J. J. Gibson's ecological psychology, neurological studies and case histories, and the Eastern tradition of Tantrism in its Mahayanist Buddhist and Taoist forms.

A travers notre pratique de pédopsychiatre confronté au vécu de familles interpellées par la question du don de gamètes ou d'organes, il nous a semblé que nombre d'apories traversant les phénomènes de la donation et de l'anonymat n'étaient pas pris en compte par la médecine.Si le don et l'anonymat traversent toute la médecine au point que celle-ci les a hissé au rang de principes, ils ne font pas l'objet d'un enseignement ou d'une réflexion approfondie. La philosophie et la littérature apportent aussi certaines réponses possibles . Le don est un présent sans la présence, portant en lui une part d'abandon, sans raison, à quelqu'un qui ne demande rien, puisque justement il ne saurait pas qu'on lui a donné. L'anonymat permet de s'effacer, pour pouvoir rencontrer l'Autre, au plus prés. Ceci commence dès l'origine, pour permettre au sujet d'approcher dans l'errance et le doute une rencontre avec l'inconnu et le dehors, loin d'une altérité qui ne serait que radicale. Enfin, la question du don d'organes, du don de gamètes, de l'anonymat obligent à repenser simultanément la question de la relation et celle de l'identité. Le donneur et le receveur se rencontrent, l'un est obligatoirement plongé dans le temps de l'autre : comment construire une sphère propre et une sphère de l'autre, une intersubjectivité qui rendrait possible la communication entre matériaux d'origine différente ? Comment reconnaître ego et alter, comme des ipséités ? Les concepts d'identité narrative, d'histoires empêtrées, permettent de dépasser la question de l'anonymat. L'anonymat protégerait alors l'identité. Et mieux, permet alors à la reconnaissance, toute éthique, d'advenir. / Through our practice of child psychiatry and confronted with the lived of families concerned with the question of gametes or organs donation, it seems that numerous aporia related to donation and anonymity experiences have not been considered by medicine. If donation and anonymity have been central to medicine to the point that they have become principles, they have never been subjects of education or profound reflection. Philosophy and literature also bring some possible answers. Donation is a present without the presence, carrying with itself some abandonment, without reason, to someone who doesn't ask for anything, precisely because he would not know that he was given something. Anonymity gives an opportunity to fade away, just to be able to meet the other, closer. This obliteration starts from the very beginning. It aims at any founding trace, in order, paradoxically to allow the subject to approach in wandering and doubt a possible encounter with the unknown and the outside, far from an otherness that be only would be radical.Finally, the issue of organ donation, of gamete donation, of anonymity, forces us to rethink simultaneously the question of relationship and identity. The donor and recipient, meet and are necessarily immersed in the other's time: how to build a sphere for oneself and a sphere for the other, an intersubjectivity which would enable the communication between materials of different origin? How to recognize ego and alter, as ipseities? Concepts of narrative identity, entangled stories allow to pass over the question of anonymity. Anonymity would then protect identity. And better still, would allow for an ethical recognition to happen.

In this dissertation, I apply Gadamerian philosophical hermeneutics to examine interpretations of the food-drug relationship within the contexts of health and medicine. Assumptions regarding the relationship between these categories undergird a substantial academic discourse and function as key components in worldviews beyond the academy. Despite this, little work has been done in foregrounding them to allow for critique and consideration of alternative perspectives. Unearthing philosophical assumptions within various fields, epistemic systems, and regulatory bodies, I classify food-drug interpretations into two main categories: dichotomous interpretations of the categories of "food" and "drugs" as ontologically distinct, and continuum-based interpretations where these categories overlap. Rather than arguing for a single appropriate way of understanding the food-drug relationship, my project aims to disclose the complexities of both sets of interpretations, illustrating their virtues and vices, and underscoring the need for people to call their own interpretations into question while taking seriously those of others. The dialogical structure of philosophical hermeneutics provides a useful foundation for dialogue within and between dichotomous and continuum-based interpretations. We do not have unmediated access to a mind-independent reality, the terms "food" and "drugs" do not necessarily refer to natural kinds, and all interpretations likely have different degrees of strengths and blind spots. Food-drug interpretations are bound up with larger worldviews, holistic systems that generate meaning for their adherents. Granting this, conversation partners can seek to gain a clearer picture of differing interpretations, what they can learn from these interpretations, and how they can interrogate their own interpretive modes.

<div>This dissertation redefines the placebo effect in light of new empirical observations and certain strands of philosophical ethics. </div>Chapter 1 critically reviews available definitions of placebo responsiveness against their abilities to hang together the diversity of empirical observations and emerging research interests. Projecting Wittgenstein's example of a child learning pain language, Chapter 2 redefines the phenomenon as a particular kind of experience of meaning and reconsiders clinical empathy in terms of the loss and recovery of language that belongs to illness experience and diagnosis. Chapter 3 broadens the account of psychosomatic responsiveness from the experience of meaning to the experience of values, utilising Canguilhem's definition of health and Nietzsche's genealogical account of the health of values. Chapter 4 explores the foregoing by recounting how Wittgenstein's moral philosophy might hold together the traditional ethical and bioethical question of what makes life worth living with psychosomatic responsiveness.