Nicholas Binney

Although pain is considered a central object of medicine, it remains poorly understood. This is especially true for chronic pain conditions, in which an underlying cause often cannot or can no longer be found. Over the past decades, new scientific, technological, and social developments have led to the reconceptualization of chronic pain. In the latest edition of the International Classification of Diseases (ICD-11), chronic pain conditions are ascribed to a separate nosological category. Importantly, cases of chronic primary pain are now defined as a ‘disease in its own right’. This is in stark contrast to how pain has traditionally been understood in medicine: as a symptom/sign of tissue damage. While this conceptual shift is considered an important landmark in pain medicine, the reconceptualization of chronic pain has also been criticized. This is especially so because the conceptual shift was primarily explained by its practical benefits, while the etiology and pathophysiological mechanism remain unclear. Hence, the disease status of chronic pain remains unclear. In this paper, we argue that the understanding of chronic pain as a disease can be defended from a philosophical pragmatist perspective. By looking through the lens of philosopher of science Ludwik Fleck, we demonstrate that (1) the problematic status of chronic pain is historically contingent upon the mechanistic ‘Cartesian’ conceptualization of pain, but not problematic in itself; and (2), the view of chronic (primary) pain as a disease in its own right can be justified on pragmatist grounds.

In this chapter, the research group on the project “Health and disease as practical concepts” set out the main tenets of their research program and discuss the connection of their approach with the classical American pragmatists. In this pragmatic vein, the project seeks to identify, articulate and address problematic situations from clinical practice that involve concepts of health and disease. Some of these problematic situations are briefly described, as they served to inspire the contributions to the edited volume.

Starting in the late twentieth century there was considerable overdiagnosis of thyroid cancer, especially papillary thyroid carcinoma. Intriguingly, thyroid cancer researchers have suggested that knowledge of the history of thyroid cancer would have helped prevent this problem. Their intuition is that history has an epistemic role to play in justifying contemporary medical knowledge. This conflicts with an opposing intuition that history is irrelevant to the justification of contemporary knowledge. This chapter provides a Fleckian analysis of the history of thyroid cancer. It describes the development of a fluctuating network of active and passive elements of knowledge, out of which knowledge of cancer, malignancy, and papillary carcinoma emerge. What these objects are is shown to depend on this history. Whether physicians see the various forms of thyroid cancer as homogeneous kinds or as composite objects is shown to depend on this history. Therefore, the observations made of these objects also depend on this history. Justification of knowledge claims is a function of observations made of these objects, and the observations made of these objects is a function of their history. Therefore, justification of knowledge is a function of this history, which gives history an epistemic role to play in medical practice.

This open access book is an integrated historical and philosophical investigation of several problematic situations that emerge from diverse areas of medical practice. These include (but are not limited to): Paying less attention to patients who are suffering with symptoms because no identifiable pathological lesion or pathophysiological process can be found. Paying too much attention to patients who are not suffering with symptoms because pathological lesions or pathophysiological processes have been found. The tendency to understand patients at risk of developing pathology as being diseased. The tendency to disregard the importance of wider societal consequences of definitions of disease and health. The book shows that many of these problems are related to what disease and health are considered to be and argues that these problems can be addressed by reconsidering the concepts of health and disease employed in practice. It argues for a pragmatic reconceptualization of health and disease that allows clinicians, researchers, and lay people to understand health and disease in many ways, depending on the specific context in which they find themselves and the problems they are trying to solve. In doing so, authors are careful to show how this pragmatism does not endorse “silly” forms of relativism, in which knowledge is reduced to belief or to whatever people find expedient to believe. This work is relevant for philosophers and historians a well as for doctors, health policy makers and other health professionals because it addresses problems sourced from medical practice, albeit using philosophical and historical methods.

Two distinct forms of fairness in sport are regularly conflated, which produces confusion in important debates concerning the participation of transgender women in female sporting contests. The distinct forms of fairness arise in two distinct forms of sporting contest: the handicap contest and the championship contest. Handicap contests seek to ‘level the playing field’ by ensuring that all participants have an equal or ‘sporting’, chance of winning. Championship contests seek to find the person or team that is best at a particular event – to find a champion. Each form of contest makes use of female categories, although for different reason. Arguments for and against the use of handicapping to ensure fairness in championship contests such as the Olympics conflate these forms of contest and their distinct accounts of fairness.

Elselijn Kingma argues that Christopher Boorse’s biostatistical theory (the BST) does not show how the reference classes it uses are objective and naturalistic. Recently, philosophers of medicine have attempted to rebut Kingma’s concerns. I argue that these rebuttals are theoretically unconvincing, and that there are clear examples of physicians adjusting their reference classes according to their prior knowledge of health and disease. I focus on the use of age-adjusted reference classes to diagnose low bone mineral density in children. In addition to using the BST’s age, sex, and species, physicians also choose to use other factors to define reference classes, such as pubertal status, bone age, body size, and muscle mass. I show that physicians calibrate the reference classes they use according to their prior knowledge of health and disease. Reference classes are also chosen for pragmatic reasons, such as to predict fragility fractures.

Exploring the early development of an area of medical literature can inform contemporary medical debates. Different methods of inference include deduction, induction, abduction, and inference to the best explanation. I argue that early shaken baby research is best understood as using abduction to tentatively suggest that infants with unexplained intracranial and ocular bleeding have been assaulted. However, this tentative conclusion was quickly interpreted, by some at least, as a general rule that infants with these pathological signs were certainly cases of abuse. Rather than focusing on inductive arguments, researchers today may be better off focusing on making a compelling inference to the best explanation.

An ongoing project in the philosophy of science and medicine is the effort to articulate a form of relativism about science that can find a path between strongly realist and pernicious relativist poles. Recent scholarship on relativism has described the characteristics a philosophy must have in order to be considered a thoroughgoing relativism. These include non-absolutism, multiplicity, dependence, incompatibility, equal validity and non-neutrality. Critics of relativism maintain that these requirements cannot be met without collapsing into a pernicious form of relativism and that attempts to do so have failed. Against this view, I argue that the early twentieth century philosophy of Ludwik Fleck satisfies these requirements. Paying attention to the scientific details of Fleck’s account of active and passive elements of knowledge, and the resistance generated by them, reveals a thoroughgoing and yet reasonable relativism about science.

Elselijn Kingma argues that Christopher Boorse’s biostatistical theory does not show how the reference classes it uses—namely, age groups of a sex of a species—are objective and naturalistic. Boorse has replied that this objection is of no concern, because there are no examples of clinicians’ choosing to use reference classes other than the ones he suggests. Boorse argues that clinicians use the reference classes they do because these reflect the natural classes of organisms to which their patients belong. Drawing on a thorough exploration of how the disease osteoporosis is defined in adults, I argue that clinicians do indeed make choices about which reference classes to use in diagnosis. Clinicians use young adult reference classes to diagnose osteoporosis in elderly patients. They also use young female reference classes to diagnose osteoporosis in elderly males. Clinicians adjust their reference classes so that the diagnosis of osteoporosis reflects a person’s risk of sustaining a fragility fracture. The ethical intuition that people with the same risk of fracture should receive the same diagnosis overwhelms the naturalistic intuition that reference classes should reflect natural classes of organisms of uniform functional design. Clinicians construct a variety of reference class types, including pathological reference classes and epidemiological population-specific reference classes, to serve this ethical intuition. I show how clinicians use several reference classes at once so that they can more accurately predict risk of fracture. Ultimately, the reference classes chosen and used in medical practice are quite different from those proposed in naturalistic philosophy of medicine.

Even though medics in the present day may think that clinical pathology is derived from normal physiology, I argue here that this is not necessarily the case. Historically, physiology may have been derived from clinical pathology. After deriving physiological knowledge like this, medics can reverse the conceptual priority, to make believe that physiological knowledge is at the foundation of medical practice. This implies that supposedly objective physiological knowledge can be influenced by the evaluative judgements made to define practical concepts of clinical pathology. I argue for this view using the history of the disease heart failure, drawing on an argument made by Georges Canguilhem.

Although it is commonly said that the notions of sensitivity and specificity were first defined by Jacob Yerushalmy in 1947, the sensitivity and specificity of diagnostic tests have been assessed as far back as the early 1900s. These notions share a common origin with the development of serology. They were originally immunologic concepts, closely associated with the development of complement fixation reactions for syphilis. Here, the authors trace how immunologic sensitivity and specificity were transformed into diagnostic sensitivity and specificity. By relocating the origins of these concepts to the early 20th century, they highlight how these origins were bound to then-commonplace assumptions about specific infectious disease entities.

The measurement of diagnostic accuracy is an important aspect of the evaluation of diagnostic tests. Sometimes, medical researchers try to discover the set of observations that are most accurate of all by directly inspecting diseased and not-diseased patients. This method is perhaps intuitively appealing, as it seems a straightforward empirical way of discovering how to identify diseased patients, which amounts to trying to correlate the results of diagnostic tests with disease status. I present three examples of researchers who try to produce definitive diagnostic criteria by directly inspecting diseased and not diseased patients. Despite this method’s intuitive appeal, I will argue that it is impossible to carry out. Before researchers can inspect these patients to discover definitive diagnostic criteria, they must be able to distinguish diseased and not-diseased patients; and they do not know how to do this, because this is what they are trying to discover. I suspect the intuitive appeal of directly inspecting patients makes this difficult to appreciate. To counter this difficulty, I present this problem as a manifestation of ‘Meno’s paradox’, which was described in classical antiquity, and of ‘the problem of nomic measurement’, described more recently. Considering these philosophical problems may help researchers address the methodological issues they face when evaluating diagnostic tests.