Since the recent growth of social epigenetics, a post-genomic science which examines within a molecular framework the impact of environmental context and social behaviors on human physiology, to move “from cell to society” has become a tempting program for public health researchers. Emerging frameworks explicitly link epigenetic regulation to social regulation in an attempt to capture social-to-biological transitions and make use of these explanatory models to guide public intervention.
The union of epigenetics and epidemiology is particularly fecund in social epidemiology, the discipline that explains how socio-structural factors influence the distribution of states of health within a population. The additional support brought by biology to the search for social determinants of health extends the analytical power of social epidemiology and hereby entails two (interrelated) effects:
Either in its explanatory or regulatory version – as a matter of scientific exploration or public intervention – the “from cells to society” approach hypothesizes the continuity of biological and social phenomena and the commensurability of biological and social knowledge. A metaphysical and epistemic commitment is therefore required to develop an integrative framework that intends to follow the (assumed) molecular paths that connect the ‘social’ to the ‘biological’ and to make sense of their connection in a causative fashion. The level of synthesis required to achieve such inter-theoretic explanation relies on hypotheses that cannot be said parsimonious. Hence our questioning as to the enthusiastic commitment to the “cells to society” approach in public health.
The following contribution consists in an attempt to examine the epistemic challenges and political implications of the recent rapprochement between social epigenetics and social epidemiology in public health. We propose to examine the social epistemology of the approach called “from cells to society” from different perspectives. From a historical point of view, the integration of molecular insights in epidemiological frameworks can be presented as an opportunity to “harden” the causal claims of epidemiology and to provide a strategic response to the identity struggles of the discipline. This rapprochement has however consequences in terms of research practices and the conception of the modes of intervention. We therefore propose to test the hypothesis that biological and social knowledge are commensurable through a comparison of the nature of ‘the social’ that social epidemiology explores in comparison with the material objects that stand for ‘the social’ in epigenetics’ laboratory practice. These philosophical insights serve as a basis for our (bio)political analysis of the modes of public health intervention that rely on the regulation of social environments.
In early forms of Evidence Based Medicine, mechanistic reasoning and experience were sharply critiqued in comparison with the “gold-standard” of evidence, randomized controlled trials. EBM supporters argued that these critiques were necessary in light of the authoritarian pedagogical strategies of medical school, where students were taught to do as their more experienced teachers did, and the horrors of past medical practices based on mistaken conceptions of the body’s mechanisms. Both philosophers and clinicians pushed back against this denigration of experience and mechanistic reasoning, arguing, among other things, that RCT’s failed to live up to EBMs high expectations, and that the problem with historical dangerous medical methods was a poor understanding of the body’s mechanisms, not that they relied on mechanisms at all. In response, later versions of EBM added these sources of medical knowledge into the hierarchy of evidence, although at very low positions in various rankings.
The most recent of these reconceptualization of EBM are the GRADE standards of evidence, which are now taken to be the unified account of EBM. Indeed, some critics of EBM have been chastised for not engaging with GRADE, but continuing to critique other earlier versions of EBM.
In this paper, I will examine the version of EBM expressed through GRADE to see if its treatment of clinical experience and mechanistic reasoning, important components of the clinical encounter in practice, vary from earlier versions of EBM. I will argue that the GRADE system’s treatment of clinical expertise and mechanistic reasoning is not fundamentally different from the earlier EBM stances on these topics, and so philosophical critiques on these topics apply equally to the new system. Lastly I will discuss what implications this continual denigration of clinical expertise and mechanistic reasoning means for clinical practice and where, if anywhere, they might fit in to a future account of EBM.
The plurality of representations in science is an important source of epistemological and metaphysical controversies. One of the major conflicts develops around the following questions: can we reach a unified vision of the external world? Or science can only provide us a patchwork of disjointed explanations, more or less compatible?
Out of the purest metaphysical plan, it appears that the concrete impact of these interrogations strongly depends on the field considered. For instance, the (non)-existence of plurality has not the same consequences in cosmology and in biomedicine. In the second case, a constitutive tension exists in between the desire to explain and the necessity to cure and it seems that plurality may not be accepted in the same way at each extremity of this spectrum -in a biologist's or in a clinician's mind. As a consequence, the question of plurality should be linked to the opposition between « pure » and « applied », or « use-inspired », research.
We first present in this paper the recent work of H.Longino, about the study of human behavior, as an interesting approach to illustrate this view To her, theoretical attempts at explaining human behavior and its correlative pathologies tend to generate sterile debates focused on irreconcilable positions, such as nature and culture. Longino argues that this attitude directly comes from a rejection of pluralism. By searching a unique explicative model for human behaviour, scientists naturally create fundamental opposition to justify the exclusivity of their approach. Yet, to her, irreducible pluralism has to be preferred to monism as a more relevant epistemological guideline. By contrasting this tendency of fundamentalist scientists with the clinical approach, Longino builds the idea of pragmatic pluralism.
To do so, she uses the works of the psychiatrist K-S.Kendler to defend the epistemic value of an approach focused on clinical practice. This one would bypass the monism rising from basic science by building descriptions of mental illness which are not grounded on theoretical concept, but on the effects of the therapeutic agents used in clinical practice, through the use of the interventionist model of causality, developed by J.Woodward.
Our paper aims to show how the field of cancerology can bring interesting additional remarks to the work of H.Longino. First, it appears that the controversy which opposes the two main theories of cacinogenesis (SMT and TOFT) has generated a sterile conflict between reductionism and holism, symmetrical to the debate between nature and culture denounced by H. Longino.
Secondly, some elements taken from the history of the fight against cancer tend to comfort the idea of an epistemic value of use-inspired research. This form of investigation, directly influenced by clinical needs, is efficient to generate global, valuable, knowledge. This idea has to be compared to the conclusions of T.Wilholt about research in industrial context.
Besides, use-inspired research seems to be less sensitive to monism than fundamental biology of cancer, indicating that the « Pasteur's Quadrant » could then be a « pluralist » space.
Meta-analysis is a method of synthesizing information from two or more studies by using statistical techniques. In evidence-based medicine and policy, meta-analyses are often placed on the top of the evidence hierarchies, which represent the assumed strength of different types of evidence. Meta-analyses are thought to provide more precise information on the effects of treatments than individual studies (Cochrane Collaboration 1.2.2.) and to amalgamate evidence in a less biased way than other means of synthesizing studies. This is because the formal rules of meta-analysis are supposed to ensure the objectivity of the process.
In his article (2011), Jacob Stegenga has argued that meta-analyses fail to be objective because conducting them involves making judgments. For instance, when choosing what primary data to analyse, a researcher needs to consider at least the following questions: What methodological quality criteria should the included studies meet? How to solve the problems caused by publication bias? (Stegenga 2011: 500–504.) In this paper, I show that Stegenga’s reasoning is based on the so-called procedural ideal of objectivity, according to which judgments necessarily threaten objectivity. I shall argue that the ideal of procedural objectivity as the guiding rule in medical research should be abandoned. This is because the ideal, on the one hand, is practically unattainable, and, on the other hand, does not help to evaluate all of the practices that are relevant in producing reliable medical knowledge. For instance, Stegenga himself discusses publication bias and the lack of evidential diversity, i.e., basing treatment guidelines on evidence from randomized controlled trials only. The ideal of procedural objectivity does not fully capture why these issues are problematic, and thus does not give us tools for counteracting them.
The use of the concept “objective” is eminently complicated, as recent philosophical (e.g., Douglas 2004) and historical (e.g., Daston & Galison 2007) analyses demonstrate. In this paper, the focus is on the practical consequences of different understandings of what kinds of practices ensure objectivity, particularly in the context of medical research. By introducing a case in research on the possible suicide risk related to the use of selective serotonin reuptake inhibitors, I demonstrate the weaknesses of the procedural ideal of objectivity. In addition, I show why the so-called social view on objectivity succeeds better in accommodating 1) the way in which scientific research necessarily involves judgments, 2) the possible risks involved in research, and 3) the influence that the institutional context has on research activities. Adopting the social view helps us to see why the evidence produced by meta-analyses may be more reliable than the results of some other means of amalgamating evidence without having to adhering to the unattainable ideal of procedural objectivity.