Table Of ContentRani Lill Anjum
Samantha Copeland
Elena Rocca Editors
Rethinking Causality,
Complexity
and Evidence for
the Unique Patient
A CauseHealth Resource for Healthcare
Professionals and the Clinical Encounter
Rethinking Causality, Complexity and Evidence
for the Unique Patient
Rani Lill Anjum • Samantha Copeland
Elena Rocca
Editors
Rethinking Causality,
Complexity and Evidence
for the Unique Patient
A CauseHealth Resource for Healthcare
Professionals and the Clinical Encounter
With contributions from
Brian Broom, Ivor Ralph Edwards,
Karin Mohn Engebretsen, Roger Kerry,
Anna Luise Kirkengen, Tobias Gustum Lindstad,
Matthew Low, Kai Brynjar Hagen, Christine Price
Editors
Rani Lill Anjum Samantha Copeland
NMBU Centre for Applied Ethics and Philosophy
Philosophy of Science of Technology Section
Norwegian University of Delft University of Technology
Life Sciences, Ås, Norway Delft, The Netherlands
Elena Rocca
NMBU Centre for Applied
Philosophy of Science
Norwegian University of
Life Sciences, Ås, Norway
ISBN 978-3-030-41238-8 ISBN 978-3-030-41239-5 (eBook)
https://doi.org/10.1007/978-3-030-41239-5
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In memory of Stephen Tyreman
vii
Preface
The Story of CauseHealth
This book is a result of the interdisciplinary research project CauseHealth,
Causation, Complexity and Evidence in Health Sciences, at the Norwegian
University of Life Sciences (NMBU) from 2015 to 2019. The core team of
CauseHealth during those years, located at NMBU, consisted of myself, Stephen
Mumford, Samantha Copeland, Elena Rocca and Karin Mohn Engebretsen. Our
international network of researchers and practitioners included more than 40 experts
from a wide range of specialities: general practice, pharmacology, surgery, oncol-
ogy, clinical psychology, experimental psychology, psychiatry, physiotherapy, oste-
opathy, immunology, cardiology, paediatrics, pharmacovigilance, nursing,
epidemiology, systems medicine, behavioural medicine, public health, medical
sociology, medical ethics, person-centred medicine and practice, evidence-based
medicine and practice, medical humanities, medically unexplained symptoms, phe-
nomenology and philosophy of medicine and causation.
The idea for CauseHealth was born back in 2011, after the first meeting of an
earlier research project, Causation in Science. This project addressed some practical
and methodological challenges for establishing causal relationships in science, by
tracing these challenges back to how to understand causality, philosophically. Four
broad areas were chosen: physics, biology, psychology and social science. Since
most of the collaborators were interested in biology, the first project event was on
this topic. We held an international conference: Causality and Reductionism in
Biology and Beyond. Coincidentally, a few of the talks were on medicine, and in the
afterthought of these, the first seed for the CauseHealth project was planted. After
all, if it is difficult to understand causality in physics, biology, psychology and
social science, then medicine must represent the ultimate challenge. The subject of
medicine, the human being, is the unity of them all: the physical, the biological, the
mental and the social. Our health affects, and is affected by, all these four dimensions.
There were three themes from the 2011 conference that inspired what later
became the CauseHealth project. First, Thor Eirik Eriksen discussed the practical
ix
x Preface
problem of dealing with so-called medically unexplained symptoms. In his presen-
tation ‘Waiting for an Explanation’, he mentioned how these chronic conditions
remain a challenge to the medical profession because of their heterogenic and com-
plex nature (Eriksen et al. 2013). Second, he used the term ‘medicalisation’, which
refers to a reductionist tendency in medicine to define more and more aspects of
human life as medical issues. Third, Roger Kerry gave a talk with the title ‘Causal
Dispositionalism in the Health Sciences’ where he argued that randomised con-
trolled trials, the gold standard for establishing causal relationships, have a strong
philosophical basis in the neo-Humean difference-making theory of causality.
Together, these ideas inspired the three pillars of CauseHealth, which are methodol-
ogy, ontology and practice:
– The philosophical and conceptual motivation for choice of scientific methodol-
ogy in medicine (methods)
– The reductionist tendency of treating complex psychosocial phenomena as bio-
medical ones (ontological model)
– The practical challenge of establishing medical causes in cases of complexity
and individual variation (practice)
Initially, the CauseHealth project was directed towards medicine and health sci-
ences in general, without a particular focus on clinical practice. It turned out, how-
ever, that the philosophical themes and slogans capturing the essence of the project,
such as ‘One size does not fit all’, ‘Statistics don’t get me’ and ‘N=1’, struck a chord
with clinicians. We therefore wanted to create a resource specifically directed at
healthcare practitioners. The plan was to gather the philosophical ideas that are
most relevant to the clinical encounter, which can then be used as an intellectual
resource for anyone working with individual patients. We have made an effort to
present the philosophical material in a way that is accessible for nonphilosophers
and to include contributions from eight clinicians and one patient from the
CauseHealth network who show a practical way forward that is in line with the
philosophical ideas. By including these texts, we hope that the more abstract philo-
sophical ideas will become more concrete and useful for clinical practice.
This book is made possible by the generous funding from the Research Council
of Norway and the Uppsala Monitoring Centre, the WHO Collaborating Centre for
International Drug Monitoring. As for the contents of the book, this is entirely the
result of all those people who have engaged with the CauseHealth project and
shared their expertise and ideas with us over these past few years. Without the peo-
ple who helped me develop and pilot the project from initial idea to proposal –
Stephen Mumford, Svein Anders Noer Lie, Thor Eirik Eriksen and Roger
Kerry – there wouldn’t even have been a CauseHealth project.
CauseHealth has been fuelled by the intellectual power, professional experience
and personal engagement of so many. Ever since the beginning of CauseHealth, our
collaborators and project network, many of whom have contributed to this book,
have been vital sources of insights into the practical concerns and challenges facing
clinicians and other healthcare professionals in their daily practice. We have been
surprised and overwhelmed by the enthusiasm of practitioners participating in our
Preface xi
CauseHealth events or engaging with us on Twitter. So many of them have been
invaluable ambassadors for the project by spreading and translating the philosophi-
cal ideas of CauseHealth to colleagues around the globe through talks, blogs, pod-
casts, articles and social media.
This book is written for and because of them.
Ås, Norway Rani Lill Anjum
January 2020
Reference
Eriksen TE, Kerry R, Lie SAN et al (2013) At the borders of medical reasoning - aetiological
and ontological challenges of medically unexplained symptoms. Philos Ethics Hum Med
8:1747–1753
Contents
Part I P hilosophical Framework
1 Introduction: Why Is Philosophy Relevant
for Clinical Practice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Rani Lill Anjum, Samantha Copeland, and Elena Rocca
2 Dispositions and the Unique Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Rani Lill Anjum
3 Probability for the Clinical Encounter . . . . . . . . . . . . . . . . . . . . . . . . . 37
Elena Rocca
4 When a Cause Cannot Be Found . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Rani Lill Anjum and Elena Rocca
5 Complexity, Reductionism and the Biomedical Model . . . . . . . . . . . . 75
Elena Rocca and Rani Lill Anjum
6 The Guidelines Challenge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Samantha Copeland
Part II Application to the Clinic
7 The Complexity of Persistent Pain – A Patient’s Perspective . . . . . . . 113
Christine Price
8 Above and Beyond Statistical Evidence. Why Stories
Matter for Clinical Decisions and Shared Decision Making . . . . . . . . 127
Matthew Low
9 Causality and Dispositionality in Medical Practice . . . . . . . . . . . . . . . 137
Ivor Ralph Edwards
xiii
