Robyn Bluhm

The purpose of this chapter is to describe what we see as several important new directions for philosophy of medicine. This recent work (i) takes existing discussions in important and promising new directions, (ii) identifies areas that have not received sufficient and deserved attention to date, and/or (iii) brings together philosophy of medicine with other areas of philosophy (including bioethics, philosophy of psychiatry, and social epistemology). To this end, the next part focuses on what we call the “epistemological turn” in recent work in the philosophy of medicine; the third part addresses new developments in medical research that raise interesting questions for philosophy of medicine; the fourth part is a discussion of philosophical issues within the practice of diagnosis; the fifth part focuses on the recent developments in psychiatric classification and scientific and ethical issues therein, and the final part focuses on the objectivity of medical research.

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition.

Neuroscience research examining sex/gender differences aims to explain behavioral differences between men and women in terms of differences in their brains. Historically, this research has used ad hoc methods and has been conducted explicitly in order to show that prevailing gender roles were dictated by biology. I examine contemporary fMRI research on sex/gender differences in emotion processing and argue that it, too, both uses problematic methods and, in doing so, reinforces gender stereotypes

Feminist scholars have shown that research on sex/gender differences in the brain is often used to support gender stereotypes. Scientists use a variety of methodological and interpretive strategies to make their results consistent with these stereotypes. In this paper, I analyze functional magnetic resonance imaging (fMRI) research that examines differences between women and men in brain activity associated with emotion and show that these researchers go to great lengths to make their results consistent with the view that women are more emotional than men

Joshua Greene and his colleagues have proposed a dual-process theory of moral decision-making to account for the effects of emotional responses on our judgments about moral dilemmas that ask us to contemplate causing direct personal harm. Early formulations of the theory contrast emotional and cognitive decision-making, saying that each is the product of a separable neural system. Later formulations emphasize that emotions are also involved in cognitive processing. I argue that, given the acknowledgement that emotions inform cognitive decision-making, a single-process theory can explain all of the data that have been cited as evidence for Greene’s theory. The emotional response to the thought of causing harm may differ in degree, but not in kind, from other emotions influencing moral decision-making

This book explores the central questions and themes lying at the heart of a vibrant area of philosophical inquiry. Aligning core issues in psychiatry with traditional philosophical areas, it presents a focused overview of the historical and contemporary problems dominating the philosophy of psychiatry. Beginning with an introduction to research issues, it addresses what psychiatry is and distinguishes it from other areas of medical practice, other health care professions and psychology. With each section of the companion corresponding to a philosophical subject, contributors systematically relate themes in philosophy of psychiatry to topics in philosophy of mind, phenomenology, philosophy of science, ethics, social and political philosophy, metaphysics, epistemology, and philosophy of medicine. Looking ahead to new research directions, chapters address recent issues including the metaphysics of mental disorders, gender and race in psychiatry and psychiatric ethics. Featuring discussion questions, suggestions for further reading and an annotated bibliography, The Bloomsbury Companion to Philosophy of Psychiatry is an accessible survey of the debates and developments in the field suitable for undergraduates in philosophy and professional philosophers new to philosophy of psychiatry.

Robert Truog describes the controversial randomized controlled trials (RCTs) of extracorporeal membrane oxygenation (ECMO) therapy in newborns. Because early results with ECMO indicated that it might be a great advance, saving many lives, Truog argues that ECMO should not have been tested using RCTs, but that a long-term, large-scale observational study of actual clinical practice should have been conducted instead. Central to Truog’s argument, however, is the idea that ECMO is an unusual case. Thus, it is an open question whether Truog’s conclusions can be extended to other areas of medical research. In this paper, I look at epistemological and ethical issues arising in the care of patients with chronic diseases, using ECMO as a starting point. Both the similarities and the dissimilarities of these two cases highlight important issues in biomedical research and support a conclusion similar to Truog’s. Observational studies of clinical practice provide the best evidence to inform the treatment of patients with chronic disease.

Although depression is among the more common types of mental disorders, it is significantly more common in women than in men. In this article, I draw on feminist analyses of personhood and of autonomy to explain the greater prevalence of depression among women. I argue that such an approach builds on earlier feminist critiques of psychiatry, but provides a more nuanced explanation of how social factors can affect women’s mental health by emphasizing that women with depression are not merely passive victims of oppressive social practices, but rather that these women are actively responding to their environment and interpreting their own experiences.

As neuroscience has gained an increased ability to enchant the general public, it has become more and more common to appeal to it as an authority on a wide variety of questions about how humans do and should act. This is especially apparent with the question of gender roles. The term ‘neurosexism’ has been coined to describe the phenomenon of using neuroscientific practices and results to promote sexist conclusions; its feminist response is called ‘neurofeminism’. Here, our aim is to survey the phenomena of neurosexism and neurofeminism using a largely philosophical approach, incorporating concepts from the philosophy of mind, the philosophy of science, ethics, and feminist philosophy. First, we delineate how neuroscientific studies purporting to show sex brain differences may be prone to bias at a number of methodological levels – including the choice of categories to be studied, and the choice of tools for data gathering, analysis, and presentation. Then, we show how interpretations of such studies may wrongly assume the notion of ‘hard-wiring’. Furthermore, lack of attention to distinctions within philosophy of mind may result in a mistaken supposition that brain differences lead to mental and/or psychological and/or behavioral ones. It is not difficult to see how these forms of neurosexism, leading to claims of ‘hard-wired’ gender differences that map onto traditional and harmful gender stereotypes, raise ethical questions. We conclude by briefly considering one: are the harms caused by neurosexist studies and their interpretations outweighed by their potential benefits?

The suggestion that at least some emotions are modular captures a number of our intuitions about emotions: they are generally fast responses to a stimulus, they are involuntary, and they are easily distinguished from one another; we simply know that, for example, anger feels different than fear. Candidates for modular emotions are usually the so-called “basic” emotions - anger and fear are good examples of these. Defenders of emotion theories that focus on basic emotions, such as Paul Ekman in psychology and Paul Griffiths in philosophy, emphasize the advantages of theories that stress the evolutionary continuity of emotional expression and link emotions to the activity of neural circuits that are similar in human beings and other animals.In this paper, however, I will examine arguments for the discontinuity of emotions in human beings, as compared with other animals. Owing to a combination of cultural practices and neuroanatomy, both our emotional “wiring” and our emotions are unique.

Although researchers in psychiatry have been trying for decades to elucidate the pathophysiology underlying mental disorders, relatively little progress has been made. One explanation for this failure is that diagnostic categories in psychiatry are unlikely to track underlying neurological mechanisms. Because of this, the US National Institutes of Mental Health has recently developed a novel ontology to guide research in biological psychiatry: the Research Domain Criteria. In this paper, I argue that while RDoC may lead to better neuroscientific explanations for mental disorders, it is unlikely that this new knowledge will then lead to an improved diagnostic system. I therefore suggest that researchers in psychiatry should work toward the development of two new ontologies: one for research and one for clinical practice.

Feminist Bioethics: At the Center, on the Margins is a collection of essays that “reflect on the positioning of feminist bioethics” (xi). The volume editors suggest that the discipline of feminist bioethics, twenty years after it began, faces tension between becoming incorporated into mainstream bioethics, which would mean that it has greater influence on bioethics as a whole, and remaining “on the margins,” where it can perhaps better continue its critical project of drawing attention to the ways in which “dominant ways of doing bioethics” are gendered and “thus contribute to culturally inscribed oppressive practices” (3). The volume includes papers with diverse theoretical and methodological approaches and ..

Arguments in favor of greater research-practice integration in medicine have tended to be ethical, political, or pragmatic. There are good epistemic reasons to pursue greater integration, and it is important to think through these reasons in order to avoid inadvertently designing new systems in ways that replicate the epistemic elitism common within current systems. Meaningful transformation within health care is possible with close attention to all reasons in favor of greater research-practice integration, including epistemic reasons.

A number of reports have suggested that patients who undergo deep brain stimulation may experience changes to their personality or sense of self. These reports have attracted great philosophical interest. This paper surveys the philosophical literature on personal identity and DBS and draws on an emerging empirical literature on the experiences of patients who have undergone this therapy to argue that the existing philosophical discussion of DBS and personal identity frames the problem too narrowly. Much of the discussion by neuroethicists centers on the nature of the threat posed by DBS, asking whether it is best understood as a threat to personal identity, autonomy, agency, or authenticity, or as putting patients at risk of self-estrangement. Our aim in this paper is to use the empirical literature on patients’ experiences post-DBS to open up a broader range of questions - both philosophical and practical, and to suggest that attention to these questions will help to provide better support to patients, both before and after treatment.

Evidence-based medicine was developed to ensure that health-care decisions are based on the best available research evidence. Making this evidence available to patients is supposed to increase their autonomy by putting them in a position to make better-informed choices. In this paper, I draw on work in feminist bioethics to critique EBM’s approach to involving patients in decision making, in which patients are asked merely to select their preferences among various possible treatment outcomes but are not encouraged to actively contend with the effects of illness on their lives as a whole.