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Daly P. A New Approach to Disease, Risk, and Boundaries Based on Emergent Probability. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2022; 47:457-481. [PMID: 35779075 DOI: 10.1093/jmp/jhac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The status of risk factors and disease remains a disputed question in the theory and practice of medicine and healthcare, and so does the related question of delineating disease boundaries. I present a framework based on Bernard Lonergan's account of emergent probability for differentiating (1) generically distinct levels of systematic function within organisms and between organisms and their environments and (2) the methods of functional, genetic, and statistical investigation. I then argue on this basis that it is possible to understand disease in terms of biological or higher intra-level dysfunction, risk factors-including genetic risk factors-in terms of statistical inter-level conditioning of a given stage or developmental sequence of systematic functioning, and the empirical boundaries of disease in terms of the limits of both functional categorization (from an epistemic standpoint) and upper-level integration of lower-level processes and events (from an ontological standpoint).
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Affiliation(s)
- Patrick Daly
- Lonergan Institute at Boston College, Boston, Massachusetts, USA
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2
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Hofmann B. Vagueness in Medicine: On Disciplinary Indistinctness, Fuzzy Phenomena, Vague Concepts, Uncertain Knowledge, and Fact-Value-Interaction. AXIOMATHES 2022. [PMCID: PMC8256401 DOI: 10.1007/s10516-021-09573-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
This article investigates five kinds of vagueness in medicine: disciplinary, ontological, conceptual, epistemic, and vagueness with respect to descriptive-prescriptive connections. First, medicine is a discipline with unclear borders, as it builds on a wide range of other disciplines and subjects. Second, medicine deals with many indistinct phenomena resulting in borderline cases. Third, medicine uses a variety of vague concepts, making it unclear which situations, conditions, and processes that fall under them. Fourth, medicine is based on and produces uncertain knowledge and evidence. Fifth, vagueness emerges in medicine as a result of a wide range of fact-value-interactions. The various kinds of vagueness in medicine can explain many of the basic challenges of modern medicine, such as overdiagnosis, underdiagnosis, and medicalization. Even more, it illustrates how complex and challenging the field of medicine is, but also how important contributions from the philosophy can be for the practice of medicine. By clarifying and, where possible, reducing or limiting vagueness, philosophy can help improving care. Reducing the various types of vagueness can improve clinical decision-making, informing individuals, and health policy making.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, 2802 Gjøvik, Norway
- Centre of Medical Ethics at the University of Oslo, Oslo, Norway
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3
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Simon JR, Lemoine M. Philosophy of medicine in 2021. THEORETICAL MEDICINE AND BIOETHICS 2021; 42:187-191. [PMID: 35220514 PMCID: PMC8882247 DOI: 10.1007/s11017-022-09562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Jeremy R. Simon
- Department of Emergency Medicine, Columbia University, New York, NY USA
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4
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Walker MJ, Nielsen J, Goddard E, Harris A, Hutchison K. Induced Pluripotent Stem Cell-Based Systems for Personalising Epilepsy Treatment: Research Ethics Challenges and New Insights for the Ethics of Personalised Medicine. AJOB Neurosci 2021; 13:120-131. [PMID: 34324412 DOI: 10.1080/21507740.2021.1949404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ABSTRACTThis paper examines potential ethical and legal issues arising during the research, development and clinical use of a proposed strategy in personalized medicine (PM): using human induced pluripotent stem cell (iPSC)-derived tissue cultures as predictive models of individual patients to inform treatment decisions. We focus on epilepsy treatment as a likely early application of this strategy, for which early-stage stage research is underway. In relation to the research process, we examine issues associated with biological samples; data; health; vulnerable populations; neural organoids; and what level of accuracy justifies using the iPSC-derived neural tissue system. In relation to clinical use, we examine potential uses in pre-natal screening, and effects on clinical decision-making. Although our focus is providing recommendations for researchers developing work in this area, we identify the novel issue of deciding on an acceptable accuracy level for the system. We also emphasize an issue thus far neglected in the ethics of PM: PM tends to represent treatment decisions as though they should be directed solely by biomedical information, but this in itself could be detrimental to best personalizing treatment decisions in the clinic.
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Affiliation(s)
- Mary Jean Walker
- La Trobe University.,ARC Centre of Excellence for Electromaterials Science, University of Wollongong
| | - Jane Nielsen
- ARC Centre of Excellence for Electromaterials Science, University of Wollongong.,University of Tasmania
| | - Eliza Goddard
- La Trobe University.,ARC Centre of Excellence for Electromaterials Science, University of Wollongong
| | - Alex Harris
- ARC Centre of Excellence for Electromaterials Science, University of Wollongong.,University of Melbourne
| | - Katrina Hutchison
- ARC Centre of Excellence for Electromaterials Science, University of Wollongong.,Macquarie University
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5
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Green S, Hillersdal L. Aging biomarkers and the measurement of health and risk. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2021; 43:1. [PMID: 33620613 DOI: 10.1007/s40656-020-00352-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Prevention of age-related disorders is increasingly in focus of health policies, and it is hoped that early intervention on processes of deterioration can promote healthier and longer lives. New opportunities to slow down the aging process are emerging with new fields such as personalized nutrition. Data-intensive research has the potential to improve the precision of existing risk factors, e.g., to replace coarse-grained markers such as blood cholesterol with more detailed multivariate biomarkers. In this paper, we follow an attempt to develop a new aging biomarker. The vision among the project consortium, comprising both research and industrial partners, is that the new biomarker will be predictive of a range of age-related conditions, which may be preventable through personalized nutrition. We combine philosophical analysis and ethnographic fieldwork to explore the possibilities and challenges of managing aging through bodily signs that are not straightforwardly linked to symptomatic disease. We document how the improvement of measurement brings about new conceptual challenges of demarcating healthy and unhealthy states. Moreover, we highlight that the reframing of aging as risk has social and ethical implications, as it is generative of normative notions of what constitutes successful aging and good citizenship.
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Affiliation(s)
- Sara Green
- Section for History and Philosophy of Science, Department of Science Education, University of Copenhagen, Copenhagen, Denmark.
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Line Hillersdal
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Anthropology and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
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6
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Green S, Hillersdal L. Aging biomarkers and the measurement of health and risk. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2021; 43:28. [PMID: 33620613 PMCID: PMC7901506 DOI: 10.1007/s40656-021-00367-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 01/09/2021] [Indexed: 05/11/2023]
Abstract
Prevention of age-related disorders is increasingly in focus of health policies, and it is hoped that early intervention on processes of deterioration can promote healthier and longer lives. New opportunities to slow down the aging process are emerging with new fields such as personalized nutrition. Data-intensive research has the potential to improve the precision of existing risk factors, e.g., to replace coarse-grained markers such as blood cholesterol with more detailed multivariate biomarkers. In this paper, we follow an attempt to develop a new aging biomarker. The vision among the project consortium, comprising both research and industrial partners, is that the new biomarker will be predictive of a range of age-related conditions, which may be preventable through personalized nutrition. We combine philosophical analysis and ethnographic fieldwork to explore the possibilities and challenges of managing aging through bodily signs that are not straightforwardly linked to symptomatic disease. We document how the improvement of measurement brings about new conceptual challenges of demarcating healthy and unhealthy states. Moreover, we highlight that the reframing of aging as risk has social and ethical implications, as it is generative of normative notions of what constitutes successful aging and good citizenship.
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Affiliation(s)
- Sara Green
- Section for History and Philosophy of Science, Department of Science Education, University of Copenhagen, Copenhagen, Denmark.
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Line Hillersdal
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Anthropology and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
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7
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Abstract
Courtesy of the development of the Internet, bursts of information technology, and globalization, huge multicenter studies along with meta-analyses have been introduced to the medical sciences society. Meta-analyses and multicenter studies revolutionized modern medicine and drug development, and empowered evidence based medicine by providing extremely high levels of evidence. Nevertheless, there are occasions that while results of local multi/single center studies showed efficacy of a new treatment, larger multicenter studies or meta-analyses failed to show efficacy, and vice versa. Generally, bigger studies are more powerful and we rely on their results in clinical decision making. Nevertheless, we should keep in mind that in certain circumstances, single center studies are of great importance, and are preferred to multicenter studies and meta-analyses. In order to have a better understanding of why and when multicenter studies along with meta-analyses might not be the best options, we have discussed three different scenarios.
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Affiliation(s)
- Soroush Seifirad
- Department of Medicine, Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, USA
| | - Lance Alquran
- Department of Medicine, Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, USA
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Burau V, Nissen N, Terkildsen MD, Væggemose U. Personalised medicine and the state: A political discourse analysis. Health Policy 2020; 125:122-129. [PMID: 33158608 DOI: 10.1016/j.healthpol.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
The last decade has seen a range of health policy initiatives relating to personalised medicine. There is an emerging body of studies that demonstrates the continued importance of states in the development of personalised medicine. This paper contributes to this literature by focusing on how political discourses construct the role of states in personalised medicine. Based on a case study of the introduction of a national programme in Denmark, the analysis identifies specific discursive mechanisms in this construction. The material consists of documents from key national stakeholders, media coverage and interviews with experts at the national level. The analysis found three types of discursive mechanisms. Firstly, mechanisms can relate to problem definitions, and these were concerned with a number of salient problems of health services. Secondly, mechanisms can relate to underlying assumptions, and these were about the possibility of engineering healthcare improvement through data and by extension personalised medicine. Thirdly, mechanisms can relate to discursive effects, and here the state emerged as a highly influential governor. These mechanisms are likely to be highly relevant for other countries, but future research needs to test this. Health policy practitioners and health administrators thus need to invest effort into influencing political discourses around personalised medicines, in addition to the formulation of policies itself.
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Affiliation(s)
- Viola Burau
- Department of Political Science, Aarhus University, Bartholins Allé 9, 8000, Aarhus C, Denmark; Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Nina Nissen
- DEFACTUM - Public Health and Health Services Research, Central Denmark Region, Olof-Palmes Allé 15, 8200, Aarhus N, Denmark.
| | - Morten Deleuran Terkildsen
- DEFACTUM - Public Health and Health Services Research, Central Denmark Region, Olof-Palmes Allé 15, 8200, Aarhus N, Denmark.
| | - Ulla Væggemose
- Prehospital Emergency Department, Aarhus University Hospital, Olof Palmes Allé 34, 8200, Aarhus C, Denmark.
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Hillert A, Albrecht A, Voderholzer U. The Burnout Phenomenon: A Résumé After More Than 15,000 Scientific Publications. Front Psychiatry 2020; 11:519237. [PMID: 33424648 PMCID: PMC7793987 DOI: 10.3389/fpsyt.2020.519237] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022] Open
Abstract
The "burnout" phenomenon, supposedly caused by work related stress, is a challenge for academic psychiatry both conceptually and professionally. Since the first description of burnout in 1974 until today, more than 140 definitions have been suggested. Burnout-symptomatology's main characteristic, the experience of exhaustion, is unspecific. Different development-models of burnout were proposed, assumed to depict a quasi-natural process. These could not be confirmed empirically. An expert consensus on the diagnostic criteria and the conceptual location, whether as an independent disorder or as a risk, could not be agreed on. Nevertheless, the phenomenon of burnout in the ICD-11 is considered to be categorized as a work-related disorder. Psychiatric research on the burnout-phenomenon ignores problems of definition resulting from different perspectives: It may meet societal expectations, but does not fulfill scientific criteria, and therefore is not suitable to establish an objective diagnosis and treatment. Parallel detection of ICD/DSM diagnoses from an expert perspective and subjective perturbation models are considered appropriate.
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Affiliation(s)
| | - Arnd Albrecht
- Munich Business School, München/Munich Business Coaching Institute, München, Germany
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10
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Alonso SG, de la Torre Díez I, Zapiraín BG. Predictive, Personalized, Preventive and Participatory (4P) Medicine Applied to Telemedicine and eHealth in the Literature. J Med Syst 2019; 43:140. [PMID: 30976942 DOI: 10.1007/s10916-019-1279-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/05/2019] [Indexed: 10/27/2022]
Abstract
The main objective of this work is to provide a review of existing research work into predictive, personalized, preventive and participatory medicine in telemedicine and ehealth. The academic databases used for searches are IEEE Xplore, PubMed, Science Direct, Web of Science and ResearchGate, taking into account publication dates from 2010 up to the present day. These databases cover the greatest amount of information on scientific texts in multidisciplinary fields, from engineering to medicine. Various search criteria were established, such as ("Predictive" OR "Personalized" OR "Preventive" OR "Participatory") AND "Medicine" AND ("eHealth" OR "Telemedicine") selecting the articles of most interest. A total of 184 publications about predictive, personalized, preventive and participatory (4P) medicine in telemedicine and ehealth were found, of which 48 were identified as relevant. Many of the publications found show how the P4 medicine is being developed in the world and the benefits it provides for patients with different illnesses. After the revision that was undertaken, it can be said that P4 medicine is a vital factor for the improvement of medical services. It is hoped that one of the main contributions of this study is to provide an insight into how P4 medicine in telemedicine and ehealth is being applied, as well as proposing outlines for the future that contribute to the improvement of prevention and prediction of illnesses.
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Affiliation(s)
- Susel Góngora Alonso
- Department of Signal Theory and Communications, and Telematics Engineering, University of Valladolid, Paseo de Belén, 15, 47011, Valladolid, Spain
| | - Isabel de la Torre Díez
- Department of Signal Theory and Communications, and Telematics Engineering, University of Valladolid, Paseo de Belén, 15, 47011, Valladolid, Spain.
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Walker MJ, Bourke J, Hutchison K. Evidence for personalised medicine: mechanisms, correlation, and new kinds of black box. THEORETICAL MEDICINE AND BIOETHICS 2019; 40:103-121. [PMID: 30771062 DOI: 10.1007/s11017-019-09482-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Personalised medicine (PM) has been discussed as a medical paradigm shift that will improve health while reducing inefficiency and waste. At the same time, it raises new practical, regulatory, and ethical challenges. In this paper, we examine PM strategies epistemologically in order to develop capacities to address these challenges, focusing on a recently proposed strategy for developing patient-specific models from induced pluripotent stem cells (iPSCs) so as to make individualised treatment predictions. We compare this strategy to two main PM strategies-stratified medicine and computational models. Drawing on epistemological work in the philosophy of medicine, we explain why these two methods, while powerful, are neither truly personalised nor, epistemologically speaking, novel strategies. Both are forms of correlational black box. We then argue that the iPSC models would count as a new kind of black box. They would not rely entirely on mechanistic knowledge, and they would utilise correlational evidence in a different way from other strategies-a way that would enable personalised predictions. In arguing that the iPSC models would present a novel method of gaining evidence for clinical practice, we provide an epistemic analysis that can help to inform the practical, regulatory, and ethical challenges of developing an iPSC system.
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Affiliation(s)
- Mary Jean Walker
- Monash University, Clayton, VIC, Australia.
- Australian Research Council Centre of Excellence for Electromaterials Science, Wollongong, NSW, Australia.
| | - Justin Bourke
- University of Melbourne, Parkville, VIC, Australia
- Australian Research Council Centre of Excellence for Electromaterials Science, Wollongong, NSW, Australia
| | - Katrina Hutchison
- Macquarie University, North Ryde, NSW, Australia
- Australian Research Council Centre of Excellence for Electromaterials Science, Wollongong, NSW, Australia
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Vegter MW. Towards precision medicine; a new biomedical cosmology. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2018; 21:443-456. [PMID: 29429062 PMCID: PMC6267256 DOI: 10.1007/s11019-018-9828-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Precision Medicine has become a common label for data-intensive and patient-driven biomedical research. Its intended future is reflected in endeavours such as the Precision Medicine Initiative in the USA. This article addresses the question whether it is possible to discern a new 'medical cosmology' in Precision Medicine, a concept that was developed by Nicholas Jewson to describe comprehensive transformations involving various dimensions of biomedical knowledge and practice, such as vocabularies, the roles of patients and physicians and the conceptualisation of disease. Subsequently, I will elaborate my assessment of the features of Precision Medicine with the help of Michel Foucault, by exploring how precision medicine involves a transformation along three axes: the axis of biomedical knowledge, of biomedical power and of the patient as a self. Patients are encouraged to become the managers of their own health status, while the medical domain is reframed as a data-sharing community, characterised by changing power relationships between providers and patients, producers and consumers. While the emerging Precision Medicine cosmology may surpass existing knowledge frameworks; it obscures previous traditions and reduces research-subjects to mere data. This in turn, means that the individual is both subjected to the neoliberal demand to share personal information, and at the same time has acquired the positive 'right' to become a member of the data-sharing community. The subject has to constantly negotiate the meaning of his or her data, which can either enable self-expression, or function as a commanding Superego.
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Affiliation(s)
- M W Vegter
- Faculty of Science, Institute for Science in Society, Radboud University Nijmegen, P.O. Box 9010, 6500 GL, Nijmegen, The Netherlands.
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