Elisabetta Lalumera

Cognitive biases are widely discussed in the medical literature as systematic deviations from rational judgment and as significant contributors to diagnostic error. However, the prevailing view of cognitive biases as inherently epistemically detrimental may be challenged by recent research highlighting their potential utility. In this paper, we argue that the impact of cognitive biases in medicine depends not only on their internal cognitive structure, but also on the ecological characteristics of the medical environments in which they operate. We develop a conceptual framework that distinguishes between three types of cognitive biases: (1) those that are epistemically reliable (and practically useful) in so-called “safe cognitive environments”, where ecological informational structures reliably support the use of “fast and frugal” heuristics; (2) those that are practically useful in “pragmatically permeable contexts” such as emergency care or public health, where time pressure, uncertainty, or resource constraints justify decisions that are epistemically suboptimal but action-guiding; and (3) those that are neither epistemically nor pragmatically defensible, and thus constitute clear targets for mitigation. By offering this taxonomy, we aim to clarify when and why cognitive biases hinder or support medical reasoning and practical actions. Our analysis also emphasizes the need to reframe some traditional assumptions in medical epistemology and education. Rather than attempting to eliminate all cognitive biases, we advocate for a more nuanced, context-sensitive, and ecologically informed approach in medicine. We conclude by outlining the implications of this framework for improving diagnostic accuracy, professional training, and institutional practices in healthcare.

This chapter examines health as complete well-being, focusing on the World Health Organization’s (WHO) definition and its philosophical underpinnings. The holistic concept is adequate to its goal, as it legitimizes the WHO’s expansive public health initiatives but faces criticism for being unattainable, ambiguous, and promoting medicalization. The chapter then shows that well-being is ambiguous—a “Babel” of definitions and measures—complicating its application across contexts. Philosophical theories—hedonism, desire-satisfaction, and flourishing—inform models of subjective and eudaimonic well-being, influencing tools like quality-adjusted life years (QALYs) and health-related quality of life (HRQoL). The chapter argues for conceptual clarity, suggesting a distinction between health (e.g., absence of disease) and well-being (e.g., flourishing), emphasizing the need for context-sensitive frameworks tailored to clinical, organizational, and policy goals.

This chapter explores health as adaptation and balance, emphasizing self-management, resilience, and environmental interplay. While the concept broadens traditional biomedical models, it faces significant challenges. Defining health as capacity to adapt and self-manage places responsibility on individuals, and it risks victim-blaming, as social and economic disparities influencing health behaviors are overlooked. “One Health” expands the focus to human, animal, and ecosystem health, but its broad scope challenges medicine’s boundaries and raises operational difficulties. The analysis highlights a recurring tension between inclusivity and clarity, explanatory depth with practical and ethical coherence. Distinguishing conceptual components of health from determinants of health is a possible way out.

Revisiting the metaphor of a medical bag, this book highlights the importance of specialized conceptual tools for addressing health, well-being, and quality of life. Its main theses are (1) Concepts and Models Are Different: concepts define while models explain and may accommodate all the complexities of health phenomena. (2) Health Concepts Can Be Evaluated and Refined: conceptual choice involves analyzing needs, assessing alternatives, and prioritizing goals to ensure context-specific application. (3) Health as Absence of Disease Is a Valuable Tool: it provides a clear foundation for addressing care and inequality while avoiding overreach into non-medical domains. (4) Richer Concepts Pose Epistemic or Ethical Challenges: broader definitions of health risk ambiguity and overburdening systems. Philosophy is essential for refining these tools.

This chapter explores the concept of health as the absence of disease. It distinguishes between the pathologist’s focus on functional normality and the clinician’s emphasis on clinical relevance. Defining health as the absence of clinical disease separates individual issues from those needing social action. It also shields medicine from political and ideological influence. The chapter questions the superiority of holistic or patient-centered definitions. Instead, it highlights the practical benefits of a minimalist approach. Stable and objective criteria help advance universalist goals in healthcare. They also aid in identifying and addressing health inequalities. The chapter concludes that this concept’s greatest strength is its ability to protect health as a shared and universal good.

This chapter explores health as the capacity to achieve vital goals. Democratically defining such goals makes them hard to specify, while individual definitions risk conflating health with personal life preferences. The concept is valuable for assessing recovery and addressing cases where medicine fails to explain patients’ conditions such as diseases with unknown etiologies. However, it blurs the boundaries between disability and poor health, and between health and environmental or personal circumstances. While measures of capacity are useful for understanding functionality, health is not synonymous with functionality. Specialized tools, like functionality measures, better assess capacities without embedding them in a broad, multipurpose concept of health, which risks overgeneralization and conceptual confusion.

This chapter examines the philosophical and practical challenges of health measurement, a crucial tool for understanding treatment impacts, addressing inequalities, and guiding policy. Despite its importance, health measurement often operates as a “black box,” with constructs and validity remaining unclear. Instruments like the SF-36 and EQ-5D, widely used for health-related quality of life (HRQoL), reflect diverse approaches, yet their conceptual underpinnings often go unexamined. Measures are not neutral; they embody ethical and political assumptions that shape how health is defined and assessed, especially when used as tools to allocate healthcare resources. Structural injustices further complicate measurement, with marginalized groups facing significant data quality issues.

This introductory chapter proposes that medicine, beyond its physical tools, relies on conceptual tools such as health, well-being, and quality of life. Reflection on these concepts as medical tools is timely, driven by scientific advancements, evolving attitudes toward inclusivity, increasing medicalization, and the healthcare system’s role in addressing inequalities. The two unfashionable theses of the book are anticipated: first, that the philosophy of medicine should prioritize a study of health concepts as defined in medical practice—a task of conceptual choice rooted in the tradition of conceptual analysis; second, that the concept of health as the absence of disease possesses significant merits. The chapter concludes by presenting an overview of the book’s structure and the content of subsequent chapters.

This chapter examines the diverse roles medicine assigns to health concepts and the multiple ways these are defined to fulfill those roles. It identifies four families of health concepts illustrating how constructs and measures correspond to each. Philosophers of medicine have often focused on objectivity and normativity, leaving the evaluation of these health concepts’ merits largely unexplored. The chapter then addresses the “Babel of health concepts” in medicine and the challenges this diversity poses. It transitions to philosophical discussions on monism and pluralism, distinguishing various pluralist positions. Ultimately, it argues that pluralism must be justified through a critical evaluation of each concept and measure, introducing a methodological approach termed “conceptual choice,” which will be elaborated in the next chapter.

This chapter introduces conceptual choice in medicine through three examples: cancer classification, obesity as a disease, and the definition of pain. Conceptual choice assesses concepts based on their goals, questioning whether specific goals are worth pursuing. Two objections are addressed. The implementation challenge argues that concepts are too entrenched to change, but conceptual work focuses on expert conceptions—definitions in guidelines and research protocols—that are stable, normative, and shaped by medicine’s procedural objectivity. The irrelevance objection, prevalent in the philosophy of medicine, dismisses conceptual work as unnecessary. This is countered by demonstrating that conceptual choice complements inquiries into the reality of phenomena, enriching health models and theories. The chapter concludes with the need to distinguish concepts from models.

This book analyses and discusses from a philosophical perspective the concepts of health, well-being and quality of life in contemporary biomedical research. The guiding idea of the book is that different concepts of health, well-being, and quality of life lead to different types of projects, actions and policies, both at the individual and institutional level. For this reason, it is important to analyse them and make them clear, in their interweaving of objective dimensions (the facts) and evaluative dimensions (the values).

This chapter discusses the potential of digital phenotyping to ameliorate epistemic injustice in mental health. Digital phenotyping, which analyses behavioural patterns from user data or smart devices, shows promise in improving mental health care. Whilst concerns exist that it may exacerbate epistemic injustice by overshadowing individual experiences, the chapter presents a different viewpoint. Through a fictional case study, digital phenotyping is portrayed as aiding individuals seeking help by offering more accurate evidence and supporting shared decision-making. The objection that digital technology overrides personal claims is countered by arguing against absolute epistemic priority for any diagnostic tool in medicine. The chapter acknowledges the need for technological advancements and ethical considerations but maintains a positive outlook on the future of digital phenotyping in mental healthcare.

In this paper I claim that concepts taken from Wittgenstein's philosophy can shed light on the phenomenon of schizophrenia in at least three different ways: with a view to empathy, scientific explanation, or philosophical clarification. I consider two different “positive” wittgensteinian accounts—Campbell’s idea that delusions involve a mechanism of which different framework propositions are parts, Sass’ proposal that the schizophrenic patient can be described as a solipsist-, and a “negative” wittgensteinian account, namely Rhodes’ and Gipp’s, where epistemic aspects of schizophrenia are explained as failures in the ordinary background of certainties. I argue that none of them amounts to empathic-phenomenological understanding, but they provide examples of how philosophical concepts can contribute to scientific explanation, and to philosophical clarification respectively.

I argue that a concept is applied correctly when it is applied to the kind of things it is the concept of. Correctness as successful kind-tracking is fulfilling an externally and naturalistically individuated standard. And the normative aspect of concept-application so characterized depends on the relational (non-individualistic) feature of conceptual content. I defend this view against two objections. The first is that norms should provide justifications for action, and the second involves a version of the thesis of indeterminacy of reference.

Philosophers interested in medicine and healthcare research should focus on the choice of health concepts. Conceptual choice is akin to conceptual engineering but, in addition to assessing whether a concept suits an objective, or offering a better one, it evaluates objectives, ranks them, and discusses stakeholders’ entitlement. To show the importance of choosing health concepts, I summarize the internal debate in medicine, showcasing definitions, constructs, and scales. To argue it is a philosophical task, I analyze the medical controversy over health as adaptation and self-management. I conclude with a to-do list of conceptual choice tasks, generalizable beyond medicine.

Different definitions of well-being result in different choices regarding policies, research, medical practices, and personal decisions. This book provides an overview of well-being sciences, focusing on health, well-being, and quality of life in both biomedical and social settings. In seven chapters meant for a broad audience, the author looks at health as both the lack of disease and overall well-being, discusses various philosophical views on well-being, examines challenges in measurement, and considers the effects on older adults, people with disabilities, and those with chronic illnesses.

This chapter aims to shed light on the normative questions raised by medical imaging (MI), paving the way for interdisciplinary dialogue and further philosophical exploration. MI comprises noninvasive techniques aimed at visualizing internal human body structures to aid in explanation, diagnosis, and monitoring of health conditions. MI requires interpretation by specialized professionals, and is routinely employed across medical disciplines. It is entrenched in clinical guidelines and therapeutic interventions. Moreover, it is a dynamic research field, witnessing ongoing technological advancements. After surveying philosophical issues arising from MI, which are relatively unexplored, the chapter focuses on the epistemology of diagnostic imaging. Specifically, it delves into what constitutes an image as evidence and how radiological procedures generate knowledge. The discussion dissects three facets of the radiological process: image interpretation, radiological reporting, and semantic analysis. Each facet carries distinct epistemic implications, as errors can manifest in various ways, affecting the acquisition of patient-relevant knowledge.

The resurgence of interest in psychedelic substances for psychiatric treatment has sparked both excitement and scepticism within the scientific community. This paper addresses the moralisation and hype surrounding psychedelic therapies. Through a systematic review of the literature and a detailed case study, we illustrate that the therapeutic effect of psychedelics is not solely pharmacological but is instead facilitated by their ability to enhance psychotherapy. The paper explores the historical context of psychedelics in psychiatry, their mechanism of action, and evidence of their efficacy in treating depression. We highlight the necessity of integrating psychedelics with psychotherapeutic interventions and emphasise the importance of methodological rigour and ethical standards in psychedelic research and practice. By presenting an informed understanding of psychedelic treatments, we advocate for their consideration as legitimate alternatives alongside traditional therapies, offering a potential paradigm shift in psychiatric care.

This contribution focuses on what type of question “Are mental disorders brain disorders?” is and what task Anneli Jefferson performs in her book with the same title. I distinguish between conceptual engineering and conceptual choice, the former involving the individuation of an adequate concept for a specific goal, and the latter involving the normative problem of whether we should employ the concept at hand. I contend that Anneli Jefferson’s book is a work of conceptual engineering, which is valuable in and of itself, but that this is insufficient to answer an equally essential version of the question, “Are mental disorders brain disorders?”, namely, whether we should adopt the newly engineered concept or not, considering a broader range of goals for mental health research and practice.

The concept of moralisation of health behaviours was introduced in social psychology to describe the attribution of moral properties to habits and conditions like smoking or being a vegetarian. Moral properties are powerful motivators for people and institutions, as they may trigger blame, stigma, and appraisal, as well as the polarisation of interest and scientific hype. Here I extend the concept and illustrate how medicines and treatments can be seen as if they had moral properties, too, when they come to be regarded as good or bad in the moral sense, and not just in the instrumental sense of benefiting or harming health. I propose the hydroxychloroquine (HCQ) controversy of 2020 as an example of moralisation of a medicine. HCQ and chloroquine are anti-malarial drugs, whose off-label use for Covid-19 was hotly discussed in the early months of the pandemic, both in the media and within the scientific community, and eventually dismissed when robust evidence came out. The point of the paper is to show that moralisation of health products and treatments may influence individual and institutional decisions in significant ways, and also affect research. For these reasons, it should be carefully monitored and critically assessed.

Philosophers of medicine have formulated different accounts of the concept of disease. Which concept of disease one assumes has implications for what conditions count as diseases and, by extension, who may be regarded as having a disease and for who may be accorded the social privileges and personal responsibilities associated with being sick. In this article, we consider an ideal diagnostic test for coronavirus disease 2019 infection with respect to four groups of people—positive and asymptomatic; positive and symptomatic; negative; and untested—and show how different concepts of disease impact on the disease and sickness judgements for these groups. The suggestion is that sickness judgements and social measures akin to those experienced during the current COVID-19 outbreak presuppose a concept of disease containing social harm as a component. We indicate the problems that arise when adopting this kind of disease concept beyond a state of emergency.

Classical philosophical notions, such as conceptual truth, analyticity, and a priori knowledge, have recently re-entered the mainstream philosophical debate, after fifty years of depreciation. This paper illustrates how such notions are reintroduced and discussed in a current debate on the nature of concepts, along with the idea that a concept is individuated by an implicit definition. This traditional Neopositivist device has recently been redeployed by writers such as Peacocke, Horwich, and Boghossian. Implicit definitions raise a variety of interesting issues, from semantics to epistemology: how can they succeed in fixing a concept’s semantic property, if not by convention? are they analytic, in the Quinean sense? Do they provide with a priori knowledge? Which constraints are appropriate, for some formulation genuinely to pick up the semantic property of a concept?.

There is a lot of conceptual engineering going on in medical research. I substantiate this claim with two examples, the medical debate about cancer classification and about obesity as a disease. I also argue that the proper targets of conceptual engineering in medical research are experts’ conceptions. These are explicitly written down in documents and guidelines, and they bear on research and policies. In the second part of the chapter, I propose an externalist framework in which conceptions have both the explanatory power of psychological concepts and that of semantic concepts. It is likely, however, that human activities and practices distinct from medical research, and regulated by different practices and epistemic rules, call for different targets for conceptual engineering. I conclude by indicating an open agenda of problems for philosophers of medicine interested in conceptual engineering.

Le controversie nosologiche in psichiatria siano orientate da ragioni sia epistemiche che non epistemiche, da questioni di evidenza ma anche di etica e sociologia della scienza, data la presenza di vari programmi di ricerca, di metodologie e anche di agenti differenti che si focalizzano sul problema del disturbo mentale. I due casi qui brevemente considerati, quello della Disposofobia e quello del Disturbo di personalità narcisistica mostrano, assieme al ruolo dell’evidenza empirica, da un lato il peso delle ragioni etiche dei gruppi di pazienti e di quelle culturali della società allargata, dall’altro le dinamiche del consenso tra esperti. Che i disturbi mentali siano o non siano generi naturali, la loro classificazione è un processo razionale complesso che comprende norme e deviazioni dalle norme di diverso tipo.

This is the first book to explore the epistemology and ethics of advanced imaging tests, in order to improve the critical understanding of the nature of knowledge they provide and the practical consequences of their utilization in healthcare. Advanced medical imaging tests, such as PET and MRI, have gained center stage in medical research and in patients’ care. They also increasingly raise questions that pertain to philosophy: What is required to be an expert in reading images? How are standards for interpretation to be fixed? Is there a problem of overutilization of such tests? How should uncertainty be communicated to patients? How to cope with incidental findings? This book is of interest and importance to scholars of philosophy of medicine at all levels, from undergraduates to researchers, to medical researchers and practitioners (radiologists and nuclear physicians) interested in a critical appraisal of the methodology of their discipline and in the ethical principles and consequences of their work.

The distinction between concept and conception has been widely debated in political philosophy, whereas in the philosophy of psychology is frequently used, but rarely focused on. This paper aims at filling in this lacuna. I claim that far from being explanatorily idle, the distinction makes it possible to provide an adequate description of phenomena such as genuine disagreement, and concept contestation, which would otherwise remain implausibly puzzling. I illustrate and assess three accounts of the concept-conception distinction. Finally I propose a social externalist account, which relies on deference to experts, and builds on Tyler Burge’s ideas of many decades ago. The debate on concepts and conceptions thus shows a connection with the increasing research work on experts and expertise in psychology and social epistemology.