Knowledge in surgical specialties is powerful, in that it underlies decision-making regarding invasive procedures that are costly and irreversible. The goal of this paper is to review methods of knowledge production in otolaryngology and some of their limitations. Otolaryngology is the discipline of medicine focused on pathologies affecting the head and neck. Though considered a surgical specialty, otolaryngology also involves non-surgical management of disease, provided in clinic. This project is a critical analysis of the current state of knowledge in otolaryngology, and an exhortation towards greater quality of research and increased integration of various ways of knowing in this surgical subspecialty. I hope that this project will help otolaryngologists be more conscientious about knowledge generation and better identify potential sources of bias and error in their knowledge base and research methods.
First, I will look at sources of knowledge in otolaryngology, focusing on issues arising with the ever-expanding character of our sources of knowledge. I shall demonstrate that the knowledge base in otolaryngology, best represented by current published literature, is broad, in constant flux, often uncertain, difficult to navigate and not representative of the burden of head and neck disease.
Second, I will describe two longstanding paradigms in medical epistemology: rationalism, which focuses on mechanical and pathophysiological reasoning, and empiricism, which relies on clinical observations and epidemiology, and show that both are in a tug of war in otolaryngology. I will examine some limitations of each paradigm.
Third, I will look at the state of evidence-based medicine (EBM) in otolaryngology. I will demonstrate that otolaryngology, like other surgical specialties, is lagging behind in its adoption of EBM. The slow uptake of EBM methods has consequences for the purported quality and the funding of research in otolaryngology, and for health policy decisions impacting surgical practice.
Fourth, I examine the practical, epistemological and sociological reasons otolaryngologists have demonstrated a slow adoption of EBM. Practical challenges with performing surgical trials can be divided into three categories: challenges with the design and reporting of surgical RCTs, challenges related to the complex nature of surgical interventions, and challenges related to external factors, such as financial constraints and a lacking regulatory environment for surgical innovations. I will also argue that the nature of surgical craft promotes rationalism through mechanistic reasoning, over EBM’s empiricism. Surgical work involves manifold contingencies that are difficult to assimilate in the standardized and technical framework of EBM, leading to “occupational resistance” against the standardization thrust of EBM.
Finally, I will argue that otolaryngologists need to be aware of the background assumptions underlying their ways of knowing, in order to critically engage with their knowledge base. I will draw from Helen Longino’s analysis of the social dimension of scientific inquiry. I will suggest meta-research - a new field of medical investigation concerned with the aim of applying research methods to study how research is done and how to promote the use of best scientific practices - could be a tool in achieving critical awareness of background assumptions in otolaryngology.
In this paper, I argue that drug discovery involves multiple systems of practices. My aim in doing this is to articulate a normative account of epistemic pluralism, which we might define as a philosophical thesis that claims that no single system of practice can explore and explain all aspects of some phenomena of interest.
I use the case of neglected tropical diseases (NTDs), which are a group of infections that are under-researched by the pharmaceutical industry due to their low profit potential. More specifically, I concentrate on Human African Trypanosomiasis (HAT) research. HAT is a parasitic infection that is prevalent in sub-Saharan Africa affecting extreme poor in rural areas. Like other NTDs, HAT patients’ lack of ability to pay for market-financed therapeutics is the cause of the low profit potential and the lack of research in the field.
HAT research takes place in public-private-partnership (PPP), which are global networks of academia, industry, governmental and nongovernmental stakeholders. These PPP networks are an exemplary case study of the interactions between systems of practices: where they interact in order to investigate different aspects of the phenomenon - for instance, medicinal chemists’ work is informed by the work of structural biologists which is informed by the work of molecular biologists. Plurality in practices in this case is essential since none of these systems are capable of finding a desired cure for HAT alone. Moreover, HAT research allows us to further the normative aspect of pluralism by allowing to demonstrate benefit of pluralism based on the aim of research. The aim is to find an adequate cure to eradicate HAT, which is shaped by epistemic values (linked to furthering knowledge, understanding and explaining the phenomena) and non-epistemic values (linked to the broader social and historical context). PPPs undertaking HAT research determines the overall normative values that guide the process allowing us to underline how non epistemic values (whether linked to socio-economic conditions in disease endemic regions or values linked to economic interest) play a significant role in shaping the overarching values and therefore influences the scientific practice.
Here, each system of practice contributes towards aims that are defined by both epistemic and non-epistemic values. Moreover, the multiplicity of systems of practices in this kind of scientific inquiry is non-eliminable and it is beneficial to the aims of research.
Recently, a renewed interest in the topic of scientific understanding has arisen within philosophy of science. The topic is often approached from a very general point of view and specific philosophical theories of scientific understanding are thereby often defended on the basis of single case-studies that are supposed to be representative for science in general. My interest, to the contrary, lies in the opposite approach: trying to get a grip on scientific understanding by looking at what scientific understanding comes down to within specific domains of science (as has also been done by different contributors in the book of de Regt, Leonelli and Eigner (2009)).
My specific interest for this paper lies in the domain of the medical sciences - a domain which has, as far as I know, not yet been tackled within the literature on scientific understanding. In my talk, I will briefly present some classes and cases of diseases and their (possible) “explanations” or “interpretative frameworks” (cf. Boon 2009) – in terms of (pathological) mechanisms, proximate causes, risk factors, explanatory models or classifications. These cases will be compared and used as a basis for discerning and discussing different ways in which diseases can be said to be “scientifically understood”. I will further argue that it is useful to think about scientific understanding as a context-dependent matter: the question whether or not a certain explanation, theory or framework provides adequate scientific understanding of a phenomenon will need to be related to a certain underlying epistemic interest of the researcher, the research community, the society, the patients,... that are involved.
The cases further show that it is useful to think about different extents to which diseases can be scientifically understood. In other words: scientific understanding in medicine seems to be a gradual matter. I will focus on this graduality of scientific understanding in the remainder of my talk. The following questions will be tackled. Is there a way to pinpoint the extent to which scientific understanding is achieved in medicine? What makes partial explanations partial, and full explanations full? What makes partial explanations useful? Does something like full scientific understanding in medicine actually exist? How should we define it? And is it always useful to strive for it? Is full scientific understanding a central goal of medicine, or rather an illusion or even a useless aim?
Finally, I will briefly comment on some further consequences of my findings. Are my claims generalizable to other domains of science, or do they rather point at some peculiarities of scientific understanding in medicine? And what does all this imply for the existing theories of scientific understanding?
Naturalism in medicine aims to identify diseases as wrong conditions of the biological organization, understood as a complex abstraction in which of constitutive, interactive and experiential aspects need to coexist. The main naturalist approaches (functional, mechanist, systemic) fail to produce fully comprehensive descriptions of the “right” biological organization, or of the broken versions constituting diseases. As a consequence, a major philosophical issue is how medicine can rely on knowledge about biological organization to identify diseases and to propose how to cure or treat them.
To answer that question my strategy is to look at the practice of medicine in search of some basic presuppositions:
To conclude, the paper will argue in favour of a weak normativism compatible with methodological naturalism, according to which the normativity of medicine is grounded in different knowledge sources, as not always the same sorts of evidences are invoked, and diseases are ontologically characterised by a multiplicity of ways of being. Thus the knowledge of medicine is not fully conclusive: it can change in time, especially when conditions previously considered to be diseases are shown not to be so (because they are not objective) and, conversely, we might discover that something previously not considered to be a disease really is such (because there are arguments and evidences for objectivity). This position avoids both the excessive optimism and pessimism present in naturalism and strong normativism.