Raffaella Campaner, Philosophy of medicine. Causality, Evidence and Explanation, Bologna, Archetipo Libri, 2012

For more than a decade now, there has been a growing interest in the philosophy of medicine as a scientific discipline. Already in 2005, Raffaella Campaner published a monograph in Italian on causality and explanation in medicine (Spigazione e cause in medicina: un’indagine epistemologica) showing how philosophy of science could be successfully applied to biomedical research. Throughout this decade, Campaner published a series of papers in English on the same topics that are now compiled in the reviewed volume. Most of these papers were originally published in edited collections or journals where medicine was not the central topic, so re-publishing all together in a single volume makes sense for the interested reader. Moreover, the Italian publisher has produced a decently edited but inexpensive book, so all in all philosophers of medicine should welcome it.

Campaner has gathered here 9 papers plus an introduction. Their structure is somewhat similar: the author presents different philosophical positions (mostly on causality, but also on explanation) and proceeds to illuminate them with medical case studies, arguing on this basis for her own claims. The reader will find thus an introduction to the following accounts on causality: mechanistic (Salmon, Machamer-Darden-Craven, Glennan), interventionist (Woodward) and manipulative (Price and Menzies), with a brief digression on counterfactuals (Lewis). Despite featuring on equal rank in the book’s title, we do not find introductory accounts of philosophical theories of explanation and evidence. Campaner considers instead plenty of medical explanations and evidences and see how they may fit in the different philosophical accounts of causality presented. Among her case studies, two of the most detailed are on deep brain stimulation (a therapy for Parkinson’s disease) and anti-AIDS treatments. Campaner deals also in several papers with epidemiological and psychiatric causation.

The book puts forward a pluralistic perspective on causation, showing how in actual medical practice we may find all the above mentioned approaches complementing (rather than competing with) each other. The choice often depends on the methods implemented and the context of implementation. The author does not try to construct a principled argument for causal pluralism: as she acknowledges, “lots of work is still to be done before a plausible and coherent view will be settled on and shared” (p.60). The strength of her argument is empirical: there is no evidence that a “one size fits all” concept of causation can cope with the diversity of causal approaches at work in medical practice. However, Campaner also draws on a conceptual insight emerging from this diversity: diseases would be multilevel phenomena (ranging from cells, molecules, tissues upwards to the whole organism) and medicine (siding here with Schaffner, p. 11) would be a set of middle-range theories coping with them. Campaner adopts here a sort of meta-philosophical instrumentalism regarding such deeply entrenched methodological divides such as the one opposing reductionism and anti-reductionism: as she illustrates in chapter 7, both strategies have been fruitful in medicine and both might make sense contextually. In this respect, I think is worth noticing how difficult it is to sustain even moderately pluralist stances about medical causality such as the Russo-Williamson thesis –according to which we would need mechanistic and probabilistic evidence to properly ground causal discoveries. Yet, as Campaner argues in chapter 2, medicine has been quite capable of making progress without mechanisms and yet, when we have them, we often need manipulative evidence, in addition to statistics, to properly ground them.

Campaner constantly reminds us that her pluralism does not “amount to treat all available methodological options as equal in value” (e.g., p. 133), but the book focuses mostly on cases where there is more complementarity than straightforward competition between the alternatives considered and all of them are worth, at this point in time, of scientific consideration. Historically, though, medicine has not been as peaceful as it might seem today. In The Rise of Causal Concepts of Disease (2003), for instance, K. Codell Carter has forcefully argued that scientific medicine began with the adoption of the etiological standpoint, the view that every disease has a single cause which is both necessary and sufficient for the disease, showing how this approach was crucial for progress in its treatment. Even today, I would say that medicine is not really pluralist when it comes to decision making about new therapies: we still rely on their success in randomized clinical trials as a rule. Of course, trials might be interpreted from different causal stances, but not all of them are equally captured in their design: mechanistic knowledge, for instance, does not currently qualify the value of a trial in most hierarchies of medical evidence.  In other words, as of today, philosophical pluralism about causation may faithfully reflects the way medicine is practiced, and methodological diversity may be in itself a fruitful research strategy. But I think Campaner’s claim would have been more balanced if it also considered cases in which there was open disagreement about causality between competing research agendas.

My major qualm with this volume is that the papers were not edited for the compilation. Reading it from cover to cover might be a bit reiterative sometimes since the same items are often revisited in different chapters. However, it makes it really suitable for use in undergraduate courses, in particular when teaching philosophy of science to medical students, since most concepts are explained in an accessible manner detail and illustrated with theories they will be certainly familiar with. The name index at the end is particularly helpful in tracing different approaches throughout the book and keeping the original abstracts at the beginning of each chapter is equally useful to guide the uninitiated reader. Campaner’s is thus not only a good philosophy of science in practice book, but also a very accessible book in itself.

{October 2013}
{International Studies in the Philosophy of Science 27.4 (2013), 456-458}

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