Medicine has been called a science, as well as an art or a craft, among other terms that express aspects of its practical nature. Medicine is not the abstract pursuit of knowledge. Medical researchers and clinical practitioners aim primarily to help people. As a first approximation then, given its practical focus on the person, the most important question in medicine is: what works? To answer that question, however, we need to understand how we know what works. What are the standards, methods and limits of medical knowledge? That is the central focus and subject of this inquiry: how we know what works in medicine. To explore medical knowledge and its limits, this thesis examines the common notion that laughter is the best medicine. Focusing on laughter provides a robust case study of how we know what works in medicine; it also, in part, reveals the thin, perhaps even non-existent, distinction in medicine between empirically-grounded knowledge and intuition. As there is no single academic discipline devoted to laughter in medicine, the first chapter situates and charts the course of this unusual project and explains why inquiry into laughter in medicine matters. In the following chapters, we encounter claims from distinguished sources that laughter and humor are the best medicine. These claims are examined from a variety of perspectives including not only the orthodox view of evidence-based medicine, but also from narrative, evolutionary and complexity views of medicine. The rarely explored serious negative side of laughter is also examined. No view provides a firm foundation for belief in laughter medicine. A general conclusion from this inquiry is that none of the approaches effectively tame the complexity of medical phenomena; indeed each starkly reveals a greater complexity than found at first glance. A narrower conclusion is that providing a basis for claims about laughter in medicine poses its own specific challenges. A third conclusion is that, as things stand, none of the existing approaches seems up to the task of determining whether something such as laughter is the best medicine.

Medicine has been called a science, as well as an art or a craft, among other terms that express aspects of its practical nature. Medicine is not the abstract pursuit of knowledge. Medical researchers and clinical practitioners aim primarily to help people. As a first approximation then, given its practical focus on the person, the most important question in medicine is: what works? To answer that question, however, we need to understand how we know what works. What are the standards, methods and limits of medical knowledge? That is the central focus and subject of this inquiry: how we know what works in medicine. To explore medical knowledge and its limits, this thesis examines the common notion that laughter is the best medicine. Focusing on laughter provides a robust case study of how we know what works in medicine; it also, in part, reveals the thin, perhaps even non-existent, distinction in medicine between empirically-grounded knowledge and intuition. As there is no single academic discipline devoted to laughter in medicine, the first chapter situates and charts the course of this unusual project and explains why inquiry into laughter in medicine matters. In the following chapters, we encounter claims from distinguished sources that laughter and humor are the best medicine. These claims are examined from a variety of perspectives including not only the orthodox view of evidence-based medicine, but also from narrative, evolutionary and complexity views of medicine. The rarely explored serious negative side of laughter is also examined. No view provides a firm foundation for belief in laughter medicine. A general conclusion from this inquiry is that none of the approaches effectively tame the complexity of medical phenomena; indeed each starkly reveals a greater complexity than found at first glance. A narrower conclusion is that providing a basis for claims about laughter in medicine poses its own specific challenges. A third conclusion is that, as things stand, none of the existing approaches seems up to the task of determining whether something such as laughter is the best medicine.

xii, 163 p. / The principle of respect for autonomy has been the center of gravity for the doctor-patient relationship for forty years, replacing the previous defining concept of physician paternalism. In this work, I seek to displace respect for patient autonomy with narrative and phronesis as the skills that must be mastered by the physician to engender a successful therapeutic clinical relationship. Chapter I reviews the current state of affairs in the philosophy of medicine and the doctor-patient relationship and explains how and why autonomy has become so central to physicians' understanding of how to conduct a clinical encounter with a patient. Chapter II argues that "respect for autonomy," while remaining a valid rule to be considered in some clinical relationships, cannot be the central concept that defines the relationship both because it fails to describe accurately human selfhood and also because it empirically lacks universal applicability--many humans, and most seriously ill patients, actually lack autonomy. Shared decision making, an autonomy-based model of the doctor-patient relationship, suffers from this critique of autonomy as well as its own shortcomings in that it maintains a strict fact/value distinction that is untenable. Chapter III introduces narrative philosophy and its extrapolation, narrative medicine, as a possible alternative to an autonomy model of care. I defend a narrative view of selfhood, while recognizing that even if we are in some sense narratively constituted, this still leaves many questions regarding the relationship between story and self, particularly in a clinical encounter. In Chapter IV, I seek to limit the claims of narrative by arguing that story and self can never be fully equated and that narrative must be understood as demonstrating alterity rather than eliminating it. In Chapter V, a new conception of the physician's role in the doctor-patient relationship is presented, combining phronesis, or practical wisdom, with narrative skill in four aspects of the clinical encounter: diagnosis, treatment, assistance in medical decision making, and emotional support of the patient. / Committee in charge: Naomi Zack， Chairperson； Cheyney Ryan， Member； Mark Johnson， Member； Mary Wood， Outside Member

<p>This dissertation is a rhetorical-historiographic analysis of the emergence and dissolution of a model of therapy, one that showed promise in the 1950s as a treatment for a deadly disease (alcoholism) using a recently developed pharmaceutical drug (LSD-25). By the time this treatment model, called “psychedelic therapy,” was fully developed and ready to be tested, the rhetoric surrounding LSD in the 1960s public sphere had already turned mainstream psychiatry against the drug. Psychedelic therapy became rhetorically inextricable from the counterculture that grew out of its fringes, although its basic principles were actually borrowed from the widely-accepted Alcoholics Anonymous recovery movement. Moreover, the therapy only worked if the patient took the drug in a context designed to facilitate a particular type of experience, akin to a spiritual conversion. This method flew in the face of psychiatry’s insistence on double-blind placebo-controlled trials, which could only account for the drug’s strictly biochemical effects, regardless of therapeutic context. Through my analysis of archival sources, letters, conference proceedings, and research publications, I argue that psychedelic therapy’s failure to gain legitimacy despite its early success indicates how attributions of  rhetorical action (or lack thereof) serve to mark out the boundaries of discursive arenas. These demarcations of <em>rhetorical </em>legitimacy thus allow for disciplinary legitimacy, even while the techniques, strategies, and materials of particular rhetorical appeals circulate among disciplines and other arenas without regard for these limits of legitimate persuasion. A drug may undeniably affect a person’s behavior, but to assert that the drug is persuasive will necessarily raise questions of legitimacy that must be resolved before it can be incorporated into a set of disciplinary practices.</p>

Doctor of Philosophy / The aim of the research presented in this thesis was to come to a deeper understanding of clinical decision making from within the interpretive paradigm. The project draws on ideas from a number of schools of thought which have the common emphasis that the interpretive use of language is at the core of all human activity. This research project studied settings where health professionals and medical students engage in clinical decision making in groups. Settings included medical students participating in problem-based learning tutorials and a team of health professionals working in a multidisciplinary clinic. An underlying assumption of this project was that in such group settings, where health professionals are required to articulate their clinical reasoning for each other, the individuals involved are likely to have insights that could reveal the nature of clinical decision making. Another important assumption of this research is that human activities, such as clinical reasoning, take place in cultural contexts, are mediated by language and other symbol systems, and can be best understood when investigated in their historical development. Data were gathered by interviews of medical students and health professionals working in the two settings, and by non-participant observation. Data analysis and interpretation revealed that clinical decision making is primarily a social and linguistic skill, acquired by participating in communities of practice called health professions. These communities of practice have their own subculture including the language game called clinical decision making which includes an interpretive repertoire of specific language tools and skills. New participants to the profession must come to embody these skills under the guidance of more capable members of the profession, and do so by working through many cases. The interpretive repertoire that health professionals need to master includes skills with words, categories, metaphors, heuristics, narratives, rituals, rhetoric, and hermeneutics. All these skills need to be coordinated, both in constructing a diagnosis and management plan and in communicating clinical decisions to other people, in a manner that can be judged as intelligible, legitimate, persuasive, and carrying the moral authority for subsequent action.

Problem-based learning (PBL) is a popular curricular approach in medical education. This thesis asks the question: How does PBL teach medical students about what matters in medicine using qualitative methods. The research demonstrates that PBL contributes to the on-going marginalisation of social issues in medical education.

Doctor of Philosophy / The aim of the research presented in this thesis was to come to a deeper understanding of clinical decision making from within the interpretive paradigm. The project draws on ideas from a number of schools of thought which have the common emphasis that the interpretive use of language is at the core of all human activity. This research project studied settings where health professionals and medical students engage in clinical decision making in groups. Settings included medical students participating in problem-based learning tutorials and a team of health professionals working in a multidisciplinary clinic. An underlying assumption of this project was that in such group settings, where health professionals are required to articulate their clinical reasoning for each other, the individuals involved are likely to have insights that could reveal the nature of clinical decision making. Another important assumption of this research is that human activities, such as clinical reasoning, take place in cultural contexts, are mediated by language and other symbol systems, and can be best understood when investigated in their historical development. Data were gathered by interviews of medical students and health professionals working in the two settings, and by non-participant observation. Data analysis and interpretation revealed that clinical decision making is primarily a social and linguistic skill, acquired by participating in communities of practice called health professions. These communities of practice have their own subculture including the language game called clinical decision making which includes an interpretive repertoire of specific language tools and skills. New participants to the profession must come to embody these skills under the guidance of more capable members of the profession, and do so by working through many cases. The interpretive repertoire that health professionals need to master includes skills with words, categories, metaphors, heuristics, narratives, rituals, rhetoric, and hermeneutics. All these skills need to be coordinated, both in constructing a diagnosis and management plan and in communicating clinical decisions to other people, in a manner that can be judged as intelligible, legitimate, persuasive, and carrying the moral authority for subsequent action.

Cette thèse développe une réflexion épistémologique autour de la notion de biomarqueurs dans le cas de la maladie d’Alzheimer. Elle est centrée sur le transfert des connaissances du domaine de la biologie à celui de la pratique médicale et clinique, avec une attention particulière aux techniques de diagnostic précoce et aux Big Data. La maladie d’Alzheimer présente une temporalité particulière, son apparition étant insidieuse et sa phase asymptomatique longue. Elle se différencie des cancers en ne se prêtant pas à l’analyse génomique de cellules spécifiques, et permet ainsi d’aborder différemment le statut épistémique des biomarqueurs. Le biomarqueur (que ce soit une molécule, un réseau d’interactions, voire un algorithme), est porteur d’information sans pour autant établir un lien de causalité directe avec la maladie. C’est essentiellement un indice et non la représentation de la condition réelle d’un sujet ; c’est ensuite un objet entouré d’incertitude ; c’est enfin un objet dont la maîtrise n’est pas totale, un objet qui n’est jamais complètement donné. Enfin, les relations entre le biomarqueur et le milieu extérieur font partie intégrante de son fonctionnement. Les biomarqueurs sont essentiels dans la transformation des pratiques médicales vers l’anticipation et le suivi de l’évolution de la condition d’un sujet. En mettant en évidence des éléments transformant des facteurs de risque en une pathologie, les biomarqueurs invitent chacun à se surveiller et permettent un accompagnement des personnes dans une situation où elles n’ont encore aucun signe clinique d’une maladie évolutive. / This dissertation develops epistemological reflections on the notion of biomarkers in the case of Alzheimer’s disease. It focuses on the challenge posed by the transfer of knowledge from the field of biology to medical and clinical practices, with a special attention to the techniques of early diagnosis and especially the role of Big Data. Alzheimer's disease presents a particular temporality, its appearance being insidious with a long asymptomatic phase. It differs from cancer by not being amenable to genomic analysis of specific cells, and thus allows a different approach to the epistemic status of biomarkers. The biomarker whether it be a molecule, network of interactions, or even an algorithm, sheds light on the disease in the absence of any direct causal links between the biomarker and the disease. It is primarily an indicator rather than the representation of a body condition. As a consequence, it is always surrounded by uncertainty and never fully mastered, nor fully given. The biomarker is an object whose relations with the environment are an integral part of its functioning. Biomarkers are essential in transforming medical practices towards anticipating and monitoring the evolution of a subject's health condition. By highlighting elements that transform risk factors into a pathology, biomarkers invite everyone to monitor themselves and make it possible to support people well ahead of the appearance of clinical signs of an evolving disease.

Cette thèse est consacrée à un examen critique des tentatives actuelles pour donner à l’appel à « plus d’humanisme » en médecine un fondement philosophique. En effet, comme je le montre, les deux approches « humanistes » aujourd’hui prédominantes – la médecine narrative et la phénoménologie de la médecine – échouent à donner un sens convaincant au concept même d’humanisme. Les deux approches ont d’abord en commun de se construire en opposition à ce qu’elles appellent le modèle biomédical, mais sont incapables d’en donner une caractérisation cohérente et d’en produire une critique convaincante, qu’elles le considèrent comme un produit de la science (cas de la médecine narrative) ou comme avatar du naturalisme (cas de la phénoménologie de la médecine). En deuxième lieu, les deux approches s’enlisent dans des problèmes qui leur sont propres. La médecine narrative s’appuie sur des thèses problématiques : thèse de l’unicité de l’expérience subjective, thèse de la narrativité. La phénoménologie de la médecine rencontre de son côté des problèmes métaphilosophiques quant à la définition de la phénoménologie elle-même, qu’elle tend à réduire à l’étude de l’expérience vécue ou psychologique. Enfin, je critique la stratégie qui leur est commune, consistant à mettre l’empathie au centre de leur conception de l’humanisme. J’esquisse pour conclure une voie possible pour reformuler le problème initial et déplacer la discussion vers des questions de justice et d’accès aux systèmes de santé. / This dissertation is a critical appraisal of contemporary attempts at giving a philosophical basis to the claim that medicine is in need of “more humanism”. I argue that two prominent medical “humanistic” approaches today – narrative medicine and phenomenology of medicine – fail to give a convincing account of the concept of humanism. Both approaches are reactions against what they call the biomedical model, yet they fail to provide either a coherent account or a convincing criticism of that model, whether they define it as an instance of science (as does narrative medicine) or as a product of naturalism (as does phenomenology of medicine). Moreover, both approaches founder on issues in their own terms. Narrative medicine is built on problematical theses, notably the narrativity thesis and the singularity of subjective experiences thesis. Meanwhile, phenomenology of medicine runs into meta-philosophical obstacles regarding the definition of phenomenology itself, notably by reducing it to the study of lived or psychological experience. Finally, I criticise what brings together their humanistic strategy and which consists in putting empathy at the centre of their definition of humanism. By way of conclusion, I then sketch an alternative path for medical humanism, focused on issues of justice and access in health systems.

<p>This dissertation traces both professional and public concerns about the Earth’s environmental limits from the late 1960s to 1990s, at the intersection of reproductive rights and aerospace technology. It considers two rather ‘radical’ and opposing grassroots activist approaches for how to best address the environmental and population crises that gained public traction at the turn of the 1970s: zero population growth and space settlement. The current scholarship has examined the ‘era of limits,’ and modern environmentalism and population control activism from both U.S. and global perspectives, considering how policy, science, gender, politics, and the media shape public understandings and both local and state responses. Zero growth proponents, through both coercive and voluntary campaigns, sought to demonstrate and halt the damage that unchecked economic and population growth was causing the planet. Yet these histories rarely consider the rise of new spaceflight technologies and thought during the same period, which promised a pro-growth, technology-infused solution to the limits to growth, one that would not impose restrictions on consumptive, environmental, or reproductive behavior. Responding to recent scholarly efforts to better contextualize aerospace technology into social and cultural histories of the post-Apollo era, this dissertation focuses on the grassroots activism of two organizations: Zero Population Growth (ZPG), which advocated for zero growth, and the L-5 Society (including a student-run affiliate chapter called the Maryland Alliance for Space Colonization), which promoted space settlement and the manufacturing of clean, pollution-free energy and mining resources for Earth. In this dissertation, I argue that in order to fully understand the implications of ‘Earthly limits’ on American society, we need to look at the role of grassroots activists. How did their concerns form, persist, and change over the course of the late twentieth century? Using primary and archival material and oral histories of the members, it analyzes their dynamics, goals, and stakes in ideas about limits to growth and a finite Earth. Centering on the diverse personal stories and experiences of former activists reveals their unique motivations for joining their respective groups, why they advocated for such different approaches to the limits to growth, and how their drive for a better future continued long after popular enthusiasm for zero growth and space settlement waned by the late 1970s.</p>