Medical Humanities Blog

On Causality and Mental Illness

Those of you who followed Patrick's fascinating post (and the debate that ensued in the comments) on causal models of psychiatry and mental illness might be interested in the abstract of this dissertation:

In contemporary biological approaches to psychiatry it is rarely questioned that psychiatric disorders stem from biological "dysfunctions". This assumption appears to be confirmed by the fact that biological research has been successful at uncovering diverse biological disparities between the brains of persons with mental illnesses and normal controls. However, the fact that something is different or unusual does not mean it is dysfunctional. The thesis of the dissertation is that there is little warrant for the claim that psychiatric disorders stem from biological dysfunctions. This prompts a question of definition: what does it mean to say that something--e.g., a given part of the brain or nervous system--is "functioning properly" or that it is "dysfunctional"? The dissertation argues that the theory of function appropriate for psychiatry is one that holds that the function of an entity consists in that activity that, in the past, contributed to the differential persistence or reproduction of that entity or type of entity. A consequence of this view is that just because something is not adaptive in a given environment, it is not necessarily dysfunctional. Finally, the dissertation examines two major neurobiological perspectives on schizophrenia--a neurochemical perspective and a neurodevelopmental perspective. From a neurochemical perspective, it argues that even if the dopamine system is abnormal in schizophrenia, it is not dysfunctional. It also shows that on certain neurodevelopmental hypotheses, schizophrenia could be said to stem from a biological dysfunction, but on other neurodevelopmental hypotheses, it could not. The fact that there is currently not enough information to decide which of these multiple hypotheses is correct means that there is currently little warrant for saying that schizophrenia stems from a biological dysfunction. Since this has been shown to be unwarranted through detailed analysis of some neurobiological examples, then it is reasonable to suspect that careful attention to neurobiological details associated with other mental disorders might reveal the same thing. Consequently, it should not be assumed that psychiatric disorders in general stem from biological dysfunctions on the part of the brain unless there is evidence for this conclusion other than the existence of biological abnormalities.

(h/t H-SCI-MED-TECH listserv)

The debate between Patrick and myself referenced below quickly morphed, in my view, to a discussion about disease causality, which is really the crux of the matter, in my view.  What does it mean to say that biological factors cause illness? More to the point, what are biological factors? Can these factors be separated from social, cultural, and environmental factors? One of the most important insights of Lewontin's work is what he terms the ideology of biology, the idea that biological entities exist in a metaphysical sense apart from the social and cultural worlds we inhabit.  Lewontin argues that this view is ideological in the sense that it is poorly supported by our understanding of what biology (i.e., life) actually consists of.

Nancy Krieger makes a similar point in her work on the effects of racism on health (that biological "causes" of illness are irreducibly social, that we bear the imprints of our social lives in our embodies selves).  This material is briefly addressed at the beginning of Unnatural Causes, and should also go some length to explaining why I am partial to a phenomenological account of illness in general, but mental illness in particular.

For those who doubt the significance of this issue, just take a look at this recent NY Times article, and Philip Dawdy's analysis at Furious Seasons.  The Times article is just disastrous for a variety of reasons related to this discussion on causality, some of which Dawdy notes.  This emphasis on discrete biological entities as causes for mental illness is, IMO, part of a larger (post-Enlightenment) focus of scientific and medical culture on these discrete causes, which really took off during the bacteriological revoultion, and has recently transferred to discourse on genes.  For those interested in exploring this issue more, I heartily recommend Sylvia Tesh's work.

The key is that there is a great deal at stake in the causal attributions we make as to disease and illness.  These attributions also have a profound effect on all manner of social and cultural issues, including disparities, stigma, and justice.  The latter is easily demonstrated by the longstanding tradition of blaming immigrants and foreigners for causing outbreaks of infectious disease.  How -- and to whom -- we attribute illness and disease says a very great deal about the social and cultural fabric of any given society.  No wonder some medical anthropologists argue that by studying the meaning of disease in any given culture, we can learn virtually anything that matters to the particular culture in question.

Thoughts?

On Measurement

One theme I find myself repeatedly returning to in thinking about the medical humanities is the idea that many phenomena and experiences that have great meaning are simply not susceptible to (quantifiable) measurement.  The history of quantification in the West is, of course, deeply intertwined with the history of objectivity, and both are highly relevant to my own (dissertation) work on pain.  As many have observed, phenomena that are not reducible to discrete, measurable units are frequently degraded in Western discourse, and particularly in scientific and biomedical discourse.  In short, if it can't be measured, calibrated, or counted, it is often deemed to be of comparatively little merit.

Even the most basic efforts to think about what it might be like for a human being to experience illness should suffice to show that certainly not all that is meaningful to humans about health, illness, and suffering can be measured and counted.  Yet, there is excellent evidence that such subjective phenomena and experiences are readily discounted or denigrated in scientific and biomedical culture.  I was struck by this again in reading the following editorial, which was jointly authored and signed by multiple editors of various history of science, medicine, and technology journals (and related interdisciplinary efforts, like science studies, social history, etc.).  I repost it here in full:

Journals under Threat: A Joint Response from History of Science, Technology and Medicine Editors

We live in an age of metrics. All around us, things are being standardized, quantified, measured. Scholars concerned with the work of science and technology must regard this as a fascinating and crucial practical, cultural and intellectual phenomenon.  Analysis of the roots and meaning of metrics and metrology has been a preoccupation of much of the best work in our field for the past quarter century at least. As practitioners of the interconnected disciplines that make up the field of science studies  we understand how significant, contingent and uncertain can be the process of rendering nature and society in grades, classes and numbers.

We now confront a situation in which our own research work is being subjected to putatively precise accountancy by arbitrary and unaccountable agencies. Some may already be aware of the proposed European Reference Index for the Humanities  (ERIH), an initiative originating with the European Science Foundation. The ERIH is an attempt to grade journals in the humanities - including "history and philosophy of science". The initiative proposes a league table of academic journals, with premier, second and third divisions. According to the European Science Foundation, ERIH "aims initially to identify, and gain more visibility for, top-quality European Humanities research published in academic journals in, potentially, all European languages". It is hoped "that ERIH will form the backbone of a fully-fledged research information system for the Humanities". What is meant, however, is that ERIH will provide funding bodies and other agencies in Europe and elsewhere with an allegedly  exact measure of research quality. In short, if research is published in a premier league journal it will be recognized as first rate; if it appears somewhere in the lower divisions, it will be rated(and not funded) accordingly.

This initiative is entirely defective in conception and
execution. Consider the major issues of accountability and transparency.  The process of producing the graded list of  journals in science studies was overseen by a committee of four (the membership is currently listed at http://www.esf.org/research-areas/humanities/research-infrastructures-including-erih/erih-governance-and-panels/erih-expert-panels.html). This committee cannot be considered representative. It was not selected in consultation with any of the various disciplinary organizations that currently represent our field such as the European Association for the History of Medicine and Health,  the Society for the Social History of Medicine, the British Society for the History of Science, the History of Science Society, the Philosophy of Science Association, the Society for the History of Technology or the Society for Social Studies of Science. Journal editors were only belatedly informed of the process and its relevant criteria or asked to provide any information regarding their publications. No indication was given of the means through which the list was compiled; nor how it might be  maintained in the future.  The ERIH depends on a fundamental misunderstanding of conduct and publication of  research in our field, and in the humanities in general. Journals' quality cannot be separated from their contents and their review processes. Great research may be published anywhere and in any language.

Truly ground-breaking work may be more likely to appear from marginal, dissident or unexpected sources, rather than from a well-established and entrenched mainstream journal. Our journals are various, heterogeneous and distinct. Some are aimed at a broad, general and international readership, others are more specialized in their content and implied audience. Their scope and readership say nothing about the quality of their intellectual content. The ERIH, on  the other hand, confuses internationality with quality in a way that is particularly prejudicial to specialist and non-English language journals. In a recent report, the British Academy, with judicious understatement, concludes that "the European Reference Index for the Humanities as presently conceived does not represent a reliable way in which metrics of peer-reviewed publications can be constructed" (Peer Review: the Challenges for the Humanities and Social Sciences, September  2007: http://www.britac.ac.uk/reports/peer-review).

Such exercises as ERIH can become self- fulfilling prophecies. If such measures as ERIH are adopted as metrics by funding and other agencies, then many in our field will conclude that they have little choice other than to limit their publications to journals in the premier division. We will sustain fewer journals, much less diversity and impoverish our discipline. Along with many others in our field, this Journal has concluded that we want no part of this dangerous and misguided exercise.

This joint Editorial is being published in journals across the fields of history of science and science studies as an expression of  our collective dissent and our refusal to allow our field to be managed and appraised in this fashion. We have asked the compilers of the ERIH to remove our journals' titles from their lists.

Hanne Andersen (Centaurus)

Roger Ariew & Moti Feingold (Perspectives on Science)

A. K. Bag (Indian Journal of History of Science)

June Barrow-Green & Benno van Dalen (Historia mathematica)

Keith Benson (History and Philosophy of the Life Sciences)

Marco Beretta (Nuncius)

Michel Blay (Revue d'Histoire des Sciences)

Cornelius Borck (Berichte zur Wissenschaftsgeschichte)

Geof Bowker and Susan Leigh Star (Science, Technology and Human Values)

Massimo Bucciantini & Michele Camerota (Galilaeana: Journal of Galilean Studies)

Jed Buchwald and Jeremy Gray (Archive for History of Exacft Sciences)

Vincenzo Cappelletti & Guido Cimino (Physis)

Roger Cline (International Journal for the History of Engineering & Technology)

Stephen Clucas & Stephen Gaukroger (Intellectual History Review)

Hal Cook & Anne Hardy (Medical History)

Leo Corry, Alexandre Métraux & Jürgen Renn (Science in Context)

D.Diecks & J.Uffink (Studies in History and Philosophy of Modern
Physics)

Brian Dolan & Bill Luckin (Social History of Medicine)

Hilmar Duerbeck & Wayne Orchiston (Journal of Astronomical History & Heritage)

Moritz Epple, Mikael Hård, Hans-Jörg Rheinberger & Volker Roelcke (NTM: Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin)

Steven French (Metascience)

Willem Hackmann (Bulletin of the Scientific Instrument Society)

Bosse Holmqvist (Lychnos)

Paul Farber (Journal of the History of  Biology)

Mary Fissell & Randall Packard (Bulletin of the History of Medicine)

Robert Fox (Notes & Records of the Royal Society)

Jim Good (History of the Human Sciences)

Michael Hoskin (Journal for the History of Astronomy)

Ian Inkster (History of Technology)

Marina Frasca Spada (Studies in History and Philosophy of Science)

Nick Jardine (Studies in History and Philosophy of Biological and Biomedical Sciences)

Trevor Levere (Annals of Science)

Bernard Lightman (Isis)

Christoph Lüthy (Early Science and Medicine)

Michael Lynch (Social Studies of Science)

Stephen McCluskey & Clive Ruggles (Archaeostronomy: the Journal of Astronomy in Culture)

Peter Morris (Ambix)

E. Charles Nelson (Archives of Natural History)

Ian Nicholson (Journal of the History of the Behavioural Sciences

Iwan Rhys Morus (History of Science)

John Rigden & Roger H Stuewer (Physics in Perspective)

Simon Schaffer (British Journal for the History of Science)

Paul Unschuld (Sudhoffs Archiv)

Peter Weingart (Minerva)

Stefan Zamecki (Kwartalnik Historii Nauki i Techniki)

(h/t H-SCI-MED-TECH listserv)

UPDATE 10.10.08: The Chronicle of Higher Education reports, and includes this interesting quote from "Michael J. Worton, vice provost of University College in London and a professor of French literature, who serves on the project's steering committee:"

"People may not like the results," Mr. Worton said. "They may not like the process. But the process is going to go ahead, because there is so much commitment in Europe to its going ahead."

I leave the able readers of MH Blog to form their own opinions.

New Bulletin of the History of Medicine

The latest issue of the Bulletin of the History of Medicine (82, no. 3), the preeminent journal of the history of medicine, is a treasure trove.

The TOC is here.  The first essay in particular, "From Foetid Air to Filth: The Cultural Transformation of British Epidemiological Thought, ca. 1780–1848," by Michael Brown, is outstanding.   I am partial, as I maintain that the discourse over disease causality in 19th c. conceptions of public health has crucial implications for contemporary public health policy.

Check it out.

On Prevention

Maybe someday someone will be able to explain to my satisfaction the reason why the vast majority of health policy attention as to prevention focuses on its costs, as compared to the question of whether it actually makes populations healthier.

Costs are not irrelevant, of course, but might we also not want to assess whether prevention reduces human suffering, morbidity, and mortality? Given the prevention paradox, the case for increasing investment to prevention obviously cannot rest on the claim that it results in substantial savings.  But if the costs are comparable, there are strong moral grounds for allocating more resources to policies and programs that we are justified in believing will improve health.  As a society, we have chosen not to do the latter thus far.  This is at least as relevant as inquiring into the costs of prevention.

On Charles Rosenberg

The latest issue of the Journal for the History of Medicine and the Allied Sciences (volume 63, no. 4) is a theme issue devoted to assessing the impact of one of the preeminent American historians of medicine, Charles E. Rosenberg.  The issue, arising out of "Charlesfest," a conference held in 2004, features a number of intriguing articles written by former students and other historians of medicine.

Considering that Rosenberg is probably my single favorite author I've had the pleasure of reading during graduate school, I'd say the issue is recommended for anyone interested in the history of medicine as a field of inquiry -- where it has been, where it is, and where it is going, as well as its significance for public health policy.

On the WHO & the Social Determinants of Health

After several years of work, the World Health Organization Commission on the Social Determinants of Health has issued its much-anticipated final report.  Chaired by Michael Marmot, whose work is incredibly important for population health, the report is a must-read.  You can find the press-release here, and can download the report (full-text) directly from the WHO.

On Race, Medicine, Genetics, and Disparities

Always a lively topic, the Kaiser Family Foundation recently sponsored an installment of their excellent webcast, "Today's Topics in Health Disparities," entitled, Race and Genetics: The Future of Personalized Medicine.  The webcast featured Clyde Yancy (a physician from Baylor University Medical Center, which is not affiliated with Baylor College of Medicine, where I work), Dorothy Roberts, and Richard Levy.  You can read their bios on the webcast page, and the webcast has been archived in various formats.  A transcript of the session is also available.

The webcast was extremely interesting, and Roberts, whose work on the subject I greatly admire, made a number of compelling points.  I won't review it here in detail, but I did want to discuss one intriguing exchange between Yancy and Roberts.  Roberts expressed concern over the geneticization of disparities -- a topic we've addressed here -- and noted the possibility that undue attention on the genetics of disparities could divert attention and resources away from the social and economic determinants that are largely responsible for producing health disparities.

Yancy acknowledged this, but noted that numerous studies controlled for SES and still found statistically significant differences among ancestral groups in conditions like CHF.  I want to make two quick points in response to this.  First, such a finding does not control for social and economic effects on health, for the simple reason that gene expression is a product of a nonlinear dynamical system that involves myriad social, environmental, and economic factors.  As Jeremy Freese has noted, it is crucial to avoid the fallacy which attributes x% of disease causality to social and environmental factors, and 1-x% to genetics.  This is an extremely common, but deeply fallacious conceptualization, because gene expression is inextricably linked to social, environmental, and economic conditions.  Therefore, controlling for SES assuredly does not justify the conclusion that the remaining disparities must be the result of extra-social forces.

I cannot stress this enough, as this mistake is lamentably common (though I am not necessarily suggesting Yancy made such a mistake). 

The second point is hearsay, but one of the participants in a rich discussion on the Spirit of 1848 listserv (the major listserv dedicated to public health & social justice) noted that Troy Duster, an expert on issues of race, genetics, and medicine, once remarked in response to a similar point that the investigators had successfully managed to control for everything about being black in America.  This may seem glib, but there is an important point underlying the statement: controlling for SDOH as to disparities risks overstating the role gene expression plays in disparities.  As Roberts noted, and none of the panelists disagreed, we already have outstanding evidence that the primary causes of health disparities are social and economic conditions.  Why should we control for those to ascertain the role GxE plays? How much benefit, from a public health perspective, will we gain?

For a blistering, and to my mind, persuasive critique of the notion that genetics will play a central role in public health, check out Claudia Chaufan's recent dialogue in Social Science & Medicine.   

On Fatness, Health, & Causality

Here at MH Blog we've tried to problematize the discourse on fatness and obesity, suggesting in various ways, that the evidence connecting fatness to illness does not come close to justifying the tone and certainty often adduced by professional healers, policymakers, laypersons, and media alike.

Though it is hardly the first of its kind -- which itself is interesting because the attention it is receiving suggests it is a bombshell -- a study just published in Archives reports a number of interesting findings regarding obesity, the general conclusion being that there does exist metabolically benign obesity.  Or, you cannot tell just by looking at someone who is fat their health status.

This, however, is most assuredly not a revelation, though it seems to be regarded as such.  Kate Harding titles her post on this study "The Duh Truck Rides Again."

She notes:

you can be normal weight and far less healthy than old tubby. You can be normal weight and just as badly off as your normal weight neighbor. You can be old tubby herself and be better — or worse — off than another old tubby across the street. You can be any weight and healthy, or any weight and sick. You can’t tell how healthy someone is just by looking.

This is exactly right, IMO, and again, enjoys ample support beyond this study.  (The best source for this latter claim is Gard and Wright's 2005 book, in which they review over 1100 food science and obesity studies and illustrate the uncertainty that surrounds the evidence connecting fatness to poor health).  Harding continues,

So yes, there is still a correlation between higher weights and metabolic abnormality. But as we’ve been saying all along, this does not apply to all fat people or let thin people off the hook — which is why there’s so much pants-shitting going on in the media over this.

I am guilty of this myself from time to time, but I recently read -- I cannot remember where -- that those who note that correlation is not causation often proceed to flout this admonition in the following sentences.  And, as usual when discussing health and illness, it is the issue of epidemiologic and disease causality that is crucial.  For a nice introduction to the social aspects of disease causality -- i.e., the social and cultural forces that influence our causal attributions -- Sylvia Tesh's work is an excellent place to start (I work on this area myself).  And in context of fatness, the best evidence, IMO, suggests quite strongly that we know orders of magnitude less about the causal connections between fatness and poor health than is reflected in the relevant public and professional discourses.

The study did find a significant correlation between waist circumference, visceral fat, and poor health, but Harding observes that

Sumo wrestlers tend to have low levels of visceral fat. And it’s usually sedentary thin people who have high levels of it. The evidence suggests that exercise is protective against visceral fat, even if it doesn’t make you thin — so if you’re able to exercise, there is something you “can do about it,” which doesn’t involve starving yourself or getting a tummy tuck.

Indeed.  Harding's take is, like virtually anything she writes on fatness, worth reading.  So is the study.  The key, from a medical humanities perspective, is to reflect critically on the evidence connecting fatness to poor health, and to assess what social and cultural beliefs, attitudes, and practices are also at work in shaping attitudes towards fatness in the West.   

On Bioethics & Disabilities

I'm getting to this late, but the Journal of Bioethical Inquiry's June 2008 issue is a theme on disability and bioethics.  A number of the most knowledgeable scholars are featured, including, among others, and in random order, Ron Amundsen, Margaret Shildrick, Adrienne Asch, and Sara Goering.  Shelley Tremain is the Guest Editor, and the entire issue looks to be well worth-reading.

On Increased Funding for Bioethics

The June 2008 issue of Academic Medicine published several articles relating to funding for bioethics.  One, authored by Ezekiel Emanuel, the Director of Bioethics at NIH, lamented the poor state of NIH-funded bioethics projects and made several recommendations:

Despite the National Institute of Health's (NIH's) long tradition of engagement with and support of bioethics, the current support for bioethics is very small. Accordingly, trained bioethics researchers and bioethicists are in short supply, and fundamental ethical issues that relate to the NIH's mission go unexplored or insufficiently explored. A bioethics initiative with clearly articulated goals is needed, to increase the number and quality of "producer" bioethicists who would undertake innovative research and educate future generations of bioethicists and biomedical investigators.

The author articulates a fourfold strategy for increased NIH support of bioethics: (1) educate and mentor sufficient numbers of producer bioethicists in well-designed postdoctoral programs; (2) support junior researchers with an increase in established K awards targeted at bioethics; (3) commit sufficient resources to ensure high-quality empirical and analytical bioethics research; and (4) develop dedicated study sections composed of qualified bioethicists to review bioethics-related grant proposals. An office, center, or authoritative body within the NIH accountable for bioethics-related activities is recommended by the author, to develop a strategic plan and to be accountable for generating high-quality research and scholarship.

The full text article is available for free here.  Though readers of this blog know I have serious reservations about the dominant traditions of bioethics scholarship and practice, I'm hardly opposed to increasing public investment in the field of inquiry.  But in an insightful commentary on Bioethics Forum, Dan Callahan -- undoubtedly one of the fathers of bioethics -- voices some concerns I admit that I had not considered:

There is, one the one hand, a general call for more people for “basic research and training in bioethics” and a vague mention of new issues, but on the other hand there is the persistent invocation of human subjects research as the main example of where the important problems in bioethics lie. It is as if the main role of bioethicists in the work of the NIH, and more broadly perhaps, is that of carrying out IRB research and serving as members of IRBs.

Bioethics in that role reduces, in effect, to a kind of service industry for biomedical research.

I'll not subject the readers here to my views on IRBs, but, in my view, a more impoverished notion of research ethics would be difficult to imagine than the vision which posits ethicists as service officials for IRBs.  Callahan continues, "While there are from time to time some knotty ethical problems, for the most part IRB work is regulatory in nature, insuring that federal ethical guidelines are being followed."  This is in some respect true -- IRBs as have they evolved are mostly about regulatory compliance; but I and many, many other scholars believe that this evolution has not been a boon to cultivating ethical practice in research, and that IRBs -- or some other relevant body -- can and should aspire to much more than compliance activities.

Callahan's chief concern is that bioethics not be reduced to "research ethics," which he believes goes way beyond the protection of human participants:

Protecting human subjects is surely one of its important topics, but so also are issues of conflict-of-interest, the cost and financing of pharmaceutical research and marketing, priority setting in research (especially NIH priorities), the extent and limits of a putative moral obligation to carry out research, the assessment of potentially hazardous forms of research or hazardous outcomes of research, controversial lines of research in a pluralistic society, and enhancement research.

However, Callahan is concerned that increased NIH support for research ethics writ large may pose its own kind of conflict-of-interest:

How acceptable would be research aiming to show how research has historically raised health care costs, and was thus itself part of the present cost crisis, probably needing some curtailment?

In short, how would bioethicists fare if they may bite the hand of those who feed them, and how would a program that might turn out, at least in part, those whose research agenda took on the establishment itself actually last?

These are some excellent questions, perhaps analogous to Christopher Meyers' recent article on conflicts of interest within clinical ethics, and obviously relevant to my own interests in public health and prevention.  And though he is a father of bioethics, Callahan is hardly unaware of the vigorous critiques of bioethics that have sprung up in the last decade or so.  He legitimately notes that increased NIH support might strengthen some of these criticisms:

Bioethics as a field has long been seen, at least by some, as a handmaiden of mainline medicine and health care, uncritical at the most basic levels and expected to provide moral band aids at the intermediate levels. Much greater NIH support could intensify that kind of worry, perhaps with good reason.

Indeed.  All good points.  Thoughts?