PHILOSOPHY OF MEDICINE
ALEX BROADBENT
Reviewed by Shane N. Glackin
Philosophy of Medicine
Alex Broadbent
Oxford: Oxford University Press, 2019, £64.00/£19.99
ISBN 9780190612139/ 9780190612146
Despite what the title might suggest, this handsome new volume is neither a textbook nor a comprehensive treatment of the field of philosophy of medicine; apart from the now-standard eschewal of medical ethics, there is minimal overlap with Broadbent’s previous Philosophy of Epidemiology ([2013]). It is, rather, a treatise advancing a particular philosophical view of the nature, aims, and ‘business’ of medicine, and might more informatively have been named Medical Cosmopolitanism after the distinctive view Broadbent advances. That title reflects the profound influence of Kwame Anthony Appiah—along with historian Roy Porter—on this work.
Though the book is divided into two sections—‘What Is Medicine?’ and ‘What Should We Think of Medicine?’—it is probably better thought of as comprising three, of which the first and third are more-or-less continuous. The first, occupying Chapters 1–3, attempts to characterize medicine—its history, traditions, institutions, and practices—descriptively, while the last (Chapters 5–9) proceeds to develop a particular normative view of medicine: medical cosmopolitanism. Chapter 4, which expands upon an important article previously published in the British Journal for the Philosophy of Science (Broadbent [2019]), therefore constitutes something of a digression, being focused on defining health and disease. Since this is a familiar problem in the field, I’ll begin my remarks there.
The chapter begins an unusually nuanced dissection of the hoary old ‘normativist–naturalist’ dichotomy about health and disease. Broadbent distinguishes two debates going on concurrently in the literature: whether or not health and disease are objective, and whether or not they are value-laden. He convincingly populates the resulting quadrants with various figures and positions in the disease-concept debate, before proposing his own view of disease as value-free yet non-objective. Specifically, by analogy with Menzies and Price’s ([1993]) view of causation, he argues that health (and a fortiori disease) is a secondary property like colour: one that things possess not intrinsically, but as a consequence of their human observers’ cognitive architecture. And our cognitive architecture, he further contends, results from selection for the ability to recognize and favour just the sort of species-specific normality Boorse ([1977]) famously identified with health.
How tempting is this view? That depends on one’s resistance to seeing disease-judgements as inherently evaluative, and one’s appetite for evolutionary-psychological speculation. I’ve explained elsewhere why I think such resistance is mistaken, and won’t belabour the point here. But regarding the evolutionary-psychological component, I’m unpersuaded by Broadbent’s analogies. In the case of colour vision, there is a specific apparatus—retinal rods and cones, and so on—that invites (suitably cautious) adaptive explanation; no analogous health-perceiving apparatus is known, and the only reason to posit one here is to fit the adaptive conjecture purporting to explain it. Causal reasoning is so centrally ubiquitous to our agential experience of the world, conversely, and conscious agency so obviously pertinent to survival and reproduction that an evolutionary Menzies/Price approach effectively treats our entire cognitive apparatus as adapted to the purpose. This is itself extremely speculative, but at least there’s a known entity here to tell the ‘just-so’ story about.
If the account of health and disease here seems doubtful, it is stand-alone; none of the main thread of the book’s argument depends on it. The first part is taken up with an investigation into the goal and ‘core business’ of medicine. Chapter 1, drawing heavily on Porter’s work, considers ‘The Varieties of Medicine’ from early human history, across continents, cultures, and civilizations, through to modern scientific medicine and the range of alternative medical traditions in the present day. This focus on medicine’s diversity will be important later in the text, but also informs the immediately following discussions of ‘The Goal of Medicine’ (Chapter 2) and ‘The Business of Medicine’ (Chapter 3). The ultimate ‘goal’ of all these diverse medical traditions, Broadbent argues, is the curing of disease, where this is construed broadly to include its prevention (p. 53). Activities such as pain relief are uses of medical skills and tools, but not themselves the goals of medicine (pp. 46–51); others, like the profit of medical practitioners, are clearly goals, but equally clearly ancillary ones (p. 41). This presents a problem, however: a vast number of the practices and traditions described in Broadbent’s first chapter appear not to have cured diseases at all, either now or in the past.
To explain this conundrum, Broadbent makes an important distinction between the ‘goal’ and ‘business’ of medicine. He therefore rejects what he calls the curative thesis that ‘medicine is the sustained and organized effort to heal the sick, or prevent them getting sick in the first place’ (p. 35) in favour of the inquiry thesis that ‘medicine is an inquiry into the nature and causes of health and disease, for the purpose of cure and prevention’ (p. 64). While all these traditions aim to prevent and cure disease, what they actually occupy themselves with is inquiry into its causes and course.
Before considering Broadbent’s argument for this view, it’s worth considering whether it tallies with observation or not. A great deal of medical practice takes the form of what is euphemistically called ‘empiric therapy’: without seeking any deeper theoretical understanding, doctors simply try one treatment after another until something works. Indeed, diseases frequently end up being classified simply on the basis of which treatments they respond to, and which prove refractory. That the practice of empiric therapy is decried for its role in promoting the evolution of antibiotic resistance, among other things, is a mark of how widespread it is. And one stance that Broadbent will laud later in the book as part of his medical cosmpolitanism is what he terms the ‘primacy of practice’, which privileges ‘agreement […] as regards what to do (rather) than why to do it’ and enjoins doctors from different traditions to ‘seek to reach agreement in matters of practical action first, pursing agreement about principle, theory, and so forth only when practical matters are not pressing’ (p. 196). So it’s far from clear that inquiry, in this sense, really is or ought to be regarded as the essential ‘business’ of medicine.
Moreover, I have some doubts about Broadbent’s philosophical argument for the inquiry thesis. It begins with what he terms the ‘bullshit objection’ to curativism; the claim that medicine is (in Frankfurt’s ([2005]) sense, viz. indifference to the truth or falsehood of its claims) bullshit. Most medical treatments through history have been entirely ineffective as far as curing disease is concerned, and many continue to be. Assuming they are not acting maliciously, practitioners who prescribe them are thus at best carelessly indifferent to the truth of their claims. This generates what Broadbent terms the ‘no bullshit premise’ of his syllogistic argument: ‘If the core business of medicine were to cure the sick, then medical traditions, disciplines, practices, interventions, or practitioners that were unable to reliably cure the sick would not persist’. Such traditions and so on do persist (Broadbent’s ‘empirical thesis’), therefore curing the sick cannot be the core business of medicine (p. 60).
But medicine is not bullshit, Broadbent argues, because it may be performing its true business properly despite being curatively ineffective. Even in cases such as the common cold, herniated lumbar discs, and depression, which it cannot cure, medicine can nevertheless have profoundly—lifesaving, in the case of Broadbent’s ‘probably asthmatic’ young daughter (p. 81)—positive effects. And the ability to predict, manage, and ease the course of disease is a valued one among medics, even when that course is inevitably fatal. So if medicine is in the business not of curing disease, but of understanding it with a view to cure, it looks successful enough to evade the bullshit objection.
But perhaps it evades that argument in any case. Broadbent himself points to both the self-limiting character of most diseases, which pass in days whether or not any ‘medical’ intervention is attempted, and the familiar folk-Bayesian association of post hoc, ergo propter hoc to explain how some bullshit medicine may appear effective. But once this pathway is recognized, a Sherlockean dog-that-has-not-barked interjects itself. There are three mentions of placebo responses, that I can find, in the whole volume (pp. 218, 219, 221), of which only two appear in the index. But placebos are surely of the first importance here! Indeed, the omission is perhaps a mark of how much the philosophy of medicine still has not properly reckoned with placebos. A perfectly well-known peculiarity of medicine is that while treatments may themselves have no curative effect, administering them in good faith nonetheless seems to. Indeed, we measure the efficacy of treatments not against non-treatment, but against biochemically ineffective treatments administered in good faith. Nobody seems to know why placebo responses occur; but once we add them to the known fact that people will trust cures that have appeared to work for them—rationally, Broadbent later says (pp. 228ff.) —the bullshit objection, and the no bullshit premise, look completely defanged; of course ineffective treatments will persist if they so outperform non-treatment that the null intervention itself must be redefined.
In the final part of the book, Broadbent considers three broad philosophical views of medicine as a whole: medical nihilism, medical Whiggishness, and medical cosmopolitanism. Nihilism, the subject of Chapter 6, is the view ‘that there is something deeply wrong with medicine, and that it is less beneficial than commonly thought, or not beneficial, or harmful’ (p. 157). He engages thoughtfully here with both Wootton ([2006]) and Stegenga ([2018]); both are nihilist about the medicine of the past, but whereas Wootton’s is a ‘Whiggish’ nihilism that believes modern (post-1865) medicine to be effective, Stegenga doubts that any real progress has been achieved in this regard. The argument against Stegenga is careful and sympathetic, but boils down in the end, again, to the denial of the curative thesis in favour of Broadbent’s ‘inquirism’ (p. 179); failing to produce a cure is not failing altogether, and progress need not mean progress in curing if medicine’s nature is that of an enquiry.
Again, this distinction underpins the response to both parts of Wootton’s ‘Whiggish nihilism’. The historical nihilism fails, says Broadbent, because historical medicine was successful when construed as an inquiry. But contemporary medicine does not then represent a clear break and improvement, both because its predecessor had not failed and because, even construed in terms of cure, it is not remotely as effective as Wootton supposes. Wootton’s faith is based primarily on the claims of the evidence-based medicine (EBM) movement, which Broadbent discusses in Chapter 5; summarizing recent debates about EBM, he draws deeply critical conclusions. It makes no sense in any case, he argues, to posit sharp discontinuity pre- and post-1865, when Joseph (twice referred to as ‘William’) Lister began the use of carbolic acid during surgery: ‘Surely the process of enquiry that led him to do this must count as part of the medicine he practiced as much as the actual act of employing antiseptic procedures itself’ (p. 164).
With both Whiggism and nihilism off the table, Broadbent outlines his medical cosmopolitanism (Chapter 7). I’ve disagreed with the route he takes to it, but the position itself seems intuitively correct, extrapolating from reasonable-looking premises to a tolerant, humane, attractive, and surprisingly radical view of medicine. Based on the general ethical outlook developed by Appiah ([2007]), it involves four distinct stances: a realist metaphysics, eschewing relativist claims about medical matters; an epistemology of humility, open to reconsidering beliefs when faced with disagreement; an egalitarian moral stance; and the aforementioned ‘primacy of practice’, which seeks to supplant disagreements over principle and theory with consensus over effective action.
Two final chapters work through the practical implications of this position. Chapter 8 considers ‘alternative’ or ‘dissident’ medical traditions like homeopathy and physiotherapy, while Chapter 9—tellingly, for a South African philosopher, entitled ‘Decolonizing Medicine’—focuses on non-Western ‘traditional medicine’, though Broadbent admits the boundary is ‘not sharp’ (p. 212). Regarding the former, he concludes, we find ourselves in a tricky epistemic position if we try to uphold the superiority of mainstream medicine; any such claim is based on the testimony of experts no less than those of the dissidents, while the support lent to the mainstream by EBM is, he judges, worthless. So if we are to have any chance of weeding out the true charlatans and quacks, we must be more respectful and tolerant of patients’ experiences of apparent cure, and the subjective evidence it constitutes, than advocates of mainstream medicine have frequently been. The point is well taken, though placebo responses again look like a huge elephant in the argumentative room. The situation is still more complicated where traditional medicine is concerned, given the (current) power imbalances between the ‘Western’ societies that tend to uphold mainstream medicine, and societies where other traditions predominate; any claim of superiority is fraught with the risk of epistemic injustice (Fricker [2007]). But decolonizing uncritically can be disastrous, as South African AIDS policy under Thabo Mbeki demonstrated (p. 252). So a critical and pragmatic decolonization of medicine, underpinned by the primacy of practice, by epistemic humility, and yet by a realist advocacy of the best available medical doctrines is necessary.
I’ve been critical regarding various details of Broadbent’s argument, but make no mistake: I thoroughly admire the enterprise as a whole. Rarely can a single book have so crystallized and advanced an entirely new agenda for a field that had no idea it needed it. One needn’t agree with his answers to see that Broadbent has opened up a whole new range of questions for the philosophy of medicine, and vastly expanded its critical scope in doing so. The rest of us in the field will spend the coming years grappling with its implications.
Shane N. Glackin
University of Exeter
S.N.Glackin@exeter.ac.uk
References
Appiah, K. A. A. [2007]: Cosmopolitanism: Ethics in a World of Strangers, London: Penguin.
Boorse, C. [1977]: ‘Health as a Theoretical Concept’, Philosophy of Science, 44, pp. 542–73.
Broadbent, A. [2013]: Philosophy of Epidemiology, London: Palgrave MacMillan.
Broadbent, A. [2019]: ‘Health as a Secondary Property’, British Journal for the Philosophy of Science, 70, pp. 609–27.
Frankfurt, H. [2005]: On Bullshit, Princeton, NJ: Princeton University Press.
Fricker, M. [2007]: Epistemic Injustice: Power and the Ethics of Knowing, Oxford: Oxford University Press.
Menzies, P. and Price, H. [1993]: ‘Causation as a Secondary Quality’, British Journal for the Philosophy of Science, 44, pp. 187–203.
Stegenga, J. [2018]: Medical Nihilism, Oxford: Oxford University Press.