Federica Russo

In this chapter we put forward more theoretical proposals for gathering evidence of mechanisms. Specifically, the chapter covers the identification of a number of mechanism hypotheses, formulation of review questions for search, and then how to refine and present the resulting evidence. Key issues include increased precision concerning the nature of the hypothesis being examined, attention to differences between the study population (or populations) and the target population of the evidence assessors, and being alert for masking mechanisms, which are other mechanisms which may mask the action of the mechanism being assessed. An outline example concerning probiotics and dental caries is given. (Databases that may be helpful for some searches can be found online in Appendix A ).

Further considerations need to be borne in mind for evidence appraisal in areas beyond clinical medicine, such as public health. This chapter looks at how public health has treated associations and correlations. Then it examines the importance to public health of mechanisms operating at the group and individual level, concerning social interactions and support, access to socio-sanitary infrastructures, psychological factors, and so on, which have to be explored in the appraisal of public health evidence. Finally, the chapter considers the relationship between biological and social factors, and the difference between mechanisms of disease and mechanisms of prevention.

Current research in molecular epidemiology uses biomarkers to model the different disease phases from environmental exposure, to early clinical changes, to development of disease. The hope is to get a better understanding of the causal impact of a number of pollutants and chemicals on several diseases, including cancer and allergies. In a recent paper Russo and Williamson (Med Stud, 2012) address the question of what evidential elements enter the conceptualisation and modelling stages of this type of biomarkers research. Recent research in causality has examined Ned Hall’s distinction between two concepts of causality: production and dependence (Hall in Causation and counterfactuals. MIT Press, Cambridge, pp 225–276, 2004). In another recent paper, Illari (Philos Technol, p 20, 2011b) examined the relatively under-explored production approach to causality, arguing that at least one job of an account of causal production is to illuminate our inferential practices concerning causal linking. Illari argued that an informational account solves existing problems with traditional accounts. This paper follows up this previous work by investigating the nature of the causal links established in biomarkers research. We argue that traditional accounts of productive causality are unable to provide a sensible account of the nature of the causal link in biomarkers research, while an informational account is very promising.

This chapter offers a brief summary of mechanisms, as including complex-system mechanisms (a complex arrangement of entities and activities, organised in such a way as to be regularly or predictably responsible for the phenomenon to be explained) and mechanistic processes (a spatio-temporal pathway along which certain features are propagated from the starting point to the end point). The chapter emphasises that EBM+ is concerned with evidence of mechanisms, not mere just-so stories, and summarises some key roles assessing evidence of mechanisms can play, particularly with respect to assessing efficacy and external validity.

This chapter introduces the idea of EBM+, which adopts the explicit requirements of EBM, to (1) make all the key evidence explicit and (2) adopt explicit methods for evaluating that evidence. EBM+ then sets out to get us better causal knowledge by explicitly integrating evidence of mechanism alongside evidence of correlation. This chapter summarises some important benefits of including evidence of mechanism, particularly given how highly idealised study populations typically are, and introduces the need to make uses of evidence of mechanism more explicit.

This chapter introduces how to assess evidence of mechanisms, explaining a summary protocol for use of evidence of mechanisms in assessing efficacy, then external validity (developed theoretically in Part III, with tools for implementation offered in Part II). An outline of quality assessment—of a whole body of evidence, rather than individual studies—is given. The chapter finishes with a brief introduction to the ideas developed in Part III: gathering evidence of mechanisms (Chap. 5 ); evaluating evidence of mechanisms (Chap. 6 ); and using evidence of mechanisms to evaluate causal claims (Chap. 7 ).

If theoretical developments in evidence assessment are to prove useful, guidance on implementation is essential, and this chapter fills that need. A variety of tools are offered, which can be used either in isolation, or in the various combinations suggested. The starting point is an Is your policy really evidence-based? tool which should be very widely usable to give a very quick overview. Then two tools are offered for guideline developers for medical practice; these offer improved assessment of evidence of mechanism in assessing clinical trials, and, if needed, in basic science papers. For politicians, journalists, academics, and so on, a critical appraisal tool is offered alongside GRADE-style tables for mechanism assessment. A final tool is designed specifically for public health and social care.

Key Terms in Logic offers the ideal introduction to this core area in the study of philosophy, providing detailed summaries of the important concepts in the study of logic and the application of logic to the rest of philosophy. A brief introduction provides context and background, while the following chapters offer detailed definitions of key terms and concepts, introductions to the work of key thinkers and lists of key texts. Designed specifically to meet the needs of students and assuming no prior knowledge of the subject, this is the ideal reference tool for those coming to Logic for the first time.

Key Terms in Logic offers the ideal introduction to this core area in the study of philosophy, providing detailed summaries of the important concepts in the study of logic and the application of logic to the rest of philosophy. A brief introduction provides context and background, while the following chapters offer detailed definitions of key terms and concepts, introductions to the work of key thinkers and lists of key texts. Designed specifically to meet the needs of students and assuming no prior knowledge of the subject, this is the ideal reference tool for those coming to Logic for the first time.

Key Terms in Logic offers the ideal introduction to this core area in the study of philosophy, providing detailed summaries of the important concepts in the study of logic and the application of logic to the rest of philosophy. A brief introduction provides context and background, while the following chapters offer detailed definitions of key terms and concepts, introductions to the work of key thinkers and lists of key texts. Designed specifically to meet the needs of students and assuming no prior knowledge of the subject, this is the ideal reference tool for those coming to Logic for the first time.

Causal claims in biomedical contexts are ubiquitous albeit they are not always made explicit. This paper addresses the question of what causal claims mean in the context of disease. It is argued that in medical contexts causality ought to be interpreted according to the epistemic theory. The epistemic theory offers an alternative to traditional accounts that cash out causation either in terms of “difference-making” relations or in terms of mechanisms. According to the epistemic approach, causal claims tell us about which inferences (e.g., diagnoses and prognoses) are appropriate, rather than about the presence of some physical causal relation analogous to distance or gravitational attraction. It is shown that the epistemic theory has important consequences for medical practice, in particular with regard to evidence-based causal assessment

According to current hierarchies of evidence for EBM, evidence of correlation (e.g., from RCTs) is always more important than evidence of mechanisms when evaluating and establishing causal claims. We argue that evidence of mechanisms needs to be treated alongside evidence of correlation. This is for three reasons. First, correlation is always a fallible indicator of causation, subject in particular to the problem of confounding; evidence of mechanisms can in some cases be more important than evidence of correlation when assessing a causal claim. Second, evidence of mechanisms is often required in order to obtain evidence of correlation (for example, in order to set up and evaluate RCTs). Third, evidence of mechanisms is often required in order to generalise and apply causal claims. While the EBM movement has been enormously successful in making explicit and critically examining one aspect of our evidential practice, i.e., evidence of correlation, we wish to extend this line of work to make explicit and critically examine a second aspect of our evidential practices: evidence of mechanisms.

Causal inference is perhaps the most important form of reasoning in the sciences. A panoply of disciplines, ranging from epidemiology to biology, from econometrics to physics, make use of probability and statistics to infer causal relationships. The social and health sciences analyse population-level data using statistical methods to infer average causal relations. In diagnosis of disease, probabilistic statements are based on population-level causal knowledge combined with knowledge of a particular person’s symptoms. For the physical sciences, the Salmon-Dowe account develops an analysis of causation based on the notion of process and interaction. In artificial intelligence, the development of graphical methods has leant impetus to a probabilistic analysis of causality. The biological sciences use probabilistic methods to look for evolutionary causes of the state of a current species and to look for genetic causal factors. This variegated situation raises at least two fundamental philosophical issues: about the relation between causality and probability, and about the interpretation of probability in causal analysis. In this book we bring philosophers and scientists together to discuss the relation between causality and probability, and the applications of these concepts within the sciences.

We argue that the health sciences make causal claims on the basis of evidence both of physical mechanisms, and of probabilistic dependencies. Consequently, an analysis of causality solely in terms of physical mechanisms or solely in terms of probabilistic relationships, does not do justice to the causal claims of these sciences. Yet there seems to be a single relation of cause in these sciences - pluralism about causality will not do either. Instead, we maintain, the health sciences require a theory of causality that unifies its mechanistic and probabilistic aspects. We argue that the epistemic theory of causality provides the required unification.

Key Terms in Logic offers the ideal introduction to this core area in the study of philosophy, providing detailed summaries of the important concepts in the study of logic and the application of logic to the rest of philosophy. A brief introduction provides context and background, while the following chapters offer detailed definitions of key terms and concepts, introductions to the work of key thinkers and lists of key texts. Designed specifically to meet the needs of students and assuming no prior knowledge of the subject, this is the ideal reference tool for those coming to Logic for the first time.

Key Terms in Logic offers the ideal introduction to this core area in the study of philosophy, providing detailed summaries of the important concepts in the study of logic and the application of logic to the rest of philosophy. A brief introduction provides context and background, while the following chapters offer detailed definitions of key terms and concepts, introductions to the work of key thinkers and lists of key texts. Designed specifically to meet the needs of students and assuming no prior knowledge of the subject, this is the ideal reference tool for those coming to Logic for the first time.

The use of evidence in medicine is something we should continuously seek to improve. This book seeks to develop our understanding of evidence of mechanism in evaluating evidence in medicine, public health, and social care; and also offers tools to help implement improved assessment of evidence of mechanism in practice. In this way, the book offers a bridge between more theoretical and conceptual insights and worries about evidence of mechanism and practical means to fit the results into evidence assessment procedures.

Evidence-based medicine (EBM) makes use of explicit procedures for grading evidence for causal claims. Normally, these procedures categorise evidence of correlation produced by statistical trials as better evidence for a causal claim than evidence of mechanisms produced by other methods. We argue, in contrast, that evidence of mechanisms needs to be viewed as complementary to, rather than inferior to, evidence of correlation. In this paper we first set out the case for treating evidence of mechanisms alongside evidence of correlation in explicit protocols for evaluating evidence. Next we provide case studies which exemplify the ways in which evidence of mechanisms complements evidence of correlation in practice. Finally, we put forward some general considerations as to how the two sorts of evidence can be more closely integrated by EBM

According to Russo and Williamson (Int Stud Philos Sci 21(2):157–170, 2007, Hist Philos Life Sci 33:389–396, 2011a, Philos Sci 1(1):47–69, 2011b ), in order to establish a causal claim of the form, ‘_C_ is a cause of _E_’, one typically needs evidence that there is an underlying mechanism between _C_ and _E_ as well as evidence that _C_ makes a difference to _E_. This thesis has been used to argue that hierarchies of evidence, as championed by evidence-based movements, tend to give primacy to evidence of difference making over evidence of mechanisms and are flawed because the two sorts of evidence are required and they should be treated on a par. An alternative approach gives primacy to evidence of mechanism over evidence of difference making. In this paper, we argue that this alternative approach is equally flawed, again because both sorts of evidence need to be treated on a par. As an illustration of this parity, we explain how scientists working in the ‘EnviroGenomarkers’ project constantly make use of the two evidential components in a dynamic and intertwined way. We argue that such an interplay is needed not only for causal assessment but also for policy purposes.