Mostrando entradas con la etiqueta 2009. Mostrar todas las entradas
Mostrando entradas con la etiqueta 2009. Mostrar todas las entradas

10/5/09

T. Bayne and J. Fernández, Delusion and Self-Deception. Affective and Motivational Influences on Belief Formation, New York-Hove, Psychology Press, 2009.

In 2004, Macquarie Centre for Cognitive Science and the philosophy department at Macquarie University (Sydney) organized a conference on “Delusion, Self-Deception and Affective Influences on Belief Formation”, in which many of the papers of this volume were first presented. As the editors warn in their introduction, their aim was to foster empirical and conceptual connections between current research on delusion and self-deception. For this, they brought together a group of scholars in various disciplines, most of them with a remarkable competence for interdisciplinary discussion. The connecting thread in their analyses features in the title of the book: the role played by affects and emotions in the formation of delusional or self-deceptive beliefs. However, the unity of this compilation lies mostly in the extraordinary editorial work of Tim Bayne and Jordi Fernández, who have not only provided thorough author and subject indexes, but also encouraged cross-references between papers and wrote an introduction intended as a map for the terrain explored thereafter.

In my view, this volume hinges on five papers on two delusions: the Capgras delusion (the belief that a familiar person has been replaced by an impostor) and anosognosia for hemiplegia (the delusional belief of being able to move your paralysed limbs). These five papers present the standard theories of delusion, with special emphasis on the role of emotions in the explanation of the two cases in point, but with very few mentions of its connections to self-deception. Three additional papers bridge this gap, exploring possible connection between the explanation of these delusions and Mele’s theory of self-deception. Three more papers discuss the role of emotion in belief formation with no explicit link with any of the theories above. Following this division, I will provide a quick overview giving just a glimpse of the topics discussed. The reader is warned that the book is incredibly rich in ideas and evidence on every topic discussed and I am afraid many will be missing here.

The most successful empirical approach (so far) to explain the Capgras delusion focuses on the cognitive mechanisms of face recognition drawing on research on prosopagnosia. The Capgras delusion would arise when the subject is somehow able to recognize a familiar face but without experiencing the usual emotional response to it (as measured by skin conductance response). The damaged mechanisms in the brain explaining this diverging response are still under discussion, as Philip Gerrans informs us in ch. 7. There are different approaches to modelling the belief distortion in this delusion, namely two: endorsement models and explanationist models. In the former, the patient believes in the content of her experience, where the delusion lies. In the latter, the delusion is an attempt to explain an usual experience (e.g., the lack of emotional response). Gerrans develops an endorsement account focused on a purely cognitive misidentification (failure to acknowledge the numerical identity between the familiar face and the person the patient knows). Elisabeth Pacherie (ch. 6) considers alternative accounts of the Capgras delusion, pondering to what extent they support the endorsement approach. She is inclined to think that the delusion arises from the inability to process dynamic information about the emotions expressed by familiar faces. Pacherie furthers this approach with an argument for the modularity of the feelings of familiarity. If the delusion lies in the perceived experience, it is important to demarcate it from belief and Fodor claims that modularity is one such demarcation criterion. An additional argument against the explanationists provided by Pacherie is that, even if the subject forms a delusional belief, she applies correctly the usual checking procedures (further observation, background knowledge, testimony) but they fail to yield disconfirming evidence.

A second division in the approaches to delusion can be made between one and two-factor approaches. The former invoke a perceptual and/or affective deficit that generates the belief and the latter add a second deficit to explain why such belief is not rejected. Brian McLaughlin (ch. 8) takes issue with the standard one-deficit account of Brian Maher, according to whom delusional beliefs “function to explain anomalous experiences resulting from neuropsychological anomalies” and this would be a rational response. In the Capgras delusion, argues McLaughlin, this would not be the case by any standard of epistemic justification, since the delusional belief coheres badly with our background knowledge. McLaughlin proposes a model for the Capgras delusion in which two types of beliefs would be acquired by separate routes: a linchpin belief (about the unfamiliarity of the face) and a thematic belief (about the impersonation). It is epistemically irrational on the part of the patient not to reject this second belief, arrived at by paranoid-driven reasoning. McLauglin develops the concept of existential feelings, among which familiarity would feature. Given the characteristics of these feelings, McLaughlin is skeptical about our natural ability to override them. So much for the Capgras delusion

Anne Aimola Davies and co-authors (ch. 10) analyse anosognosia for hemiplegia in the two-factor framework for delusions presenting a broad review of the available empirical evidence (including their own data) about the role played by motivational and cognitive factors. The first factor would be here “an impairment that prevents the patient’s paralysis or weakness from making itself known to the patient through immediate experience of motor failure”. The second factor, in turn, would be “an impairment that prevents the patient from making appropriate use of other available evidence of his or her motor impairments”. The authors present their own conjectures about the functional nature (“an impairment of working memory or executive process”) and neural basis (“the right frontal region of the brain”) of this second factor. Frédérique de Vignemont (ch. 12) systematically compares hysterical paralysis and anosognosia, the former apparently being the mirror image of the latter: patients feel paralyzed although they are physically able to move. De Vignemont points out that hysterical paralysis is grounded in delusional beliefs about the extent and source of their inability to move. It is a local paralysis and does not arise from organic damage. However, the experience of being paralysed generates the delusion as a normal response. Their anxiety at the paralysis keeps them frozen: this explains their inability to reject the original delusion without the intervention of a second factor. They are indeed paralysed.

So much for the study of delusions. As for its connection with self-deception, Alfred Mele (ch. 3) presents a brief summary of his own deflationary theory of this latter and an analysis of a few delusions in this perspective. Since Mele’s account of self-deception hinges on the influence of motivational factors in lay hypothesis testing and such factors do not necessarily feature in the explanation of, e.g., the Capgras delusion, he concludes (tentatively) that deluded subjects may not be deceiving themselves. Martin Davies (ch. 4) makes the more significant effort in the volume to bring together the analysis of deception and self-delusion. After a brief review of the standard one- and two-factor accounts of this latter and a summary of Mele’s theory on the former, Davies discusses how motivational biases can feature in either factor or in the route from experience to belief. When they affect the second factor, Davies concludes that we have the clearest cases of an overlap of delusion with Mele’s self-deception. Neil Levy (ch. 11) argues, against Mele, that there is one real case of self-deception in which the subject believes a proposition and its negation. This would be anosognosia for hemiplegia, where subjects –in a certain sense that Levy specifies– simultaneously believe that their limb is healthy and significantly impaired

The remaining three chapters are somehow at odds with the theoretical approaches presented so far. In chapter 1, Peter Ditto provides a brief overview of fifty years of psychological research on motivated cognition, which serves as an introduction to his own contribution, the quantity of processing view. According to this view, we would we react more sceptically and invest more time and resources in the cognitive processing of those pieces of information inconsistent with our preferences. As the editors notice in their introduction, this view does not seem to encompass delusions, where it often happens that the subject cannot reject a delusional belief despite its negative affects. Drawing on recent research in cognitive neuroscience (namely, appraisal theory and the somatic marker hypothesis), Michael Spezio and Ralph Adolphs (ch. 5) substantiate the claim that emotions mediate in the processing of information in the brain. As an illustration, they briefly show how emotional processing underlies our moral judgments. The editors observe here that it is an open question whether this account may apply to belief formation in general. In the final chapter of the book, Andy Egan proceeds to a philosophical discussion of the status of delusions and self-deception as mental states. Invoking a functional role conception of mental states, Egan argues that delusions are intermediate states between belief and imagination whereas self-deception is an intermediate state between belief and desire. As the editors point out, this is at variance with the assumption that now orientates empirical research on both phenomena: they are just beliefs.

Despite the effort of the editors, this volume is often difficult to read. The different theories and empirical findings about the two delusions analysed are presented time and again throughout the eight core papers. However, were it not for Davies’ paper, I guess I would be lost as to the connection between the two phenomena. Or more precisely between the standard theories of delusion and Mele’s theory of self-deception: no alternative approach is discussed in the book. This volume features in a series that “provides readers with a summary of the current state-of-the-art in a field”. The disunity in the two fields of study covered in this volume is adequately captured in the papers compiled.

15/4/09

Jill Fisher, Medical Research for Hire. The Political Economy of Pharmaceutical Clinical Trials, Rutgers University Press, 2009

In Medical Research for Hire: The Political Economy of Pharmaceutical Clinical Trials, Jill Fisher presents the results of 12 months of fieldwork conducted around 2003 in two major cities in the southwestern United States. During this period, the author analyzed "more than twenty" for-profit research organizations performing clinical trials for the pharmaceutical industry. The main output is an ethnography of the identities adopted by the different participants in those trials. On this basis, Fisher denounces how unfair to patients this system is.

A clinical trial is a medical experiment in which a new drug is compared to the standard treatment or a placebo administering them to two groups of patients in order to test its efficacy. The American Food and Drug Administration (as most other regulatory agencies around the world since the 1960s) requires statistical evidence derived from clinical trials in order to authorize the commercialization of new drugs. Whereas until the 1990s a majority of these experiments were conducted in public medical centers, nowadays the pharmaceutical industry is contracting most of them with a variety of private companies. In exchange for many billions of dollars, these companies promptly deliver trial results that generate early profitable patents for their sponsors. The protocol of the experiment is pre-arranged by the pharmaceutical company, so the contractor can only play with the efficiency of the implementation, particularly in the recruitment and involvement of patients.

Fisher analyzes through interviews and direct observation the different roles involved in the management of these private trials. According to Fisher, driven by purely financial incentives, the physicians in these organizations adopt both of these two distinct roles (chapter 3): entrepreneurial agents (they run their companies) and pharmaceutical emissaries (they implement their sponsors' experimental design). Fisher shows that these two roles set very strict limits on their therapeutic obligations with their patients. Chapter 4 is devoted to research coordinators, whose assignment in the trial is namely to deal with patients (recruiting, screening, obtaining consent) and manage part of the trial bureaucracy. Their professional identity is defined mostly in terms of their obligation to care for the patients (many of them are former nurses and a majority are women). Again, their corporate responsibilities often constrain their care duties. In chapter 5, Fisher analyses the monitors appointed by the pharmaceutical sponsors to audit the trial and prevent frauds. This is a feminized profession too, with a very demanding administrative task and a multifaceted symbolic role, often contradictory: "protector of the public health, coordinator's 'best friend,' and scapegoat for the problems of outsourcing".

In chapter 6 Fisher profiles the types of patients most likely to be involved in private trials. In research conducted on healthy subjects to test the safety of a new drug, most of the volunteers are men from a minority (very often Hispanic), seeking a financial reward. In efficacy trials on patients, there is an increasing participation of white middle class women, who are sought by the companies because they are available and compliant with the protocol. According to Fisher, most of them are "neoliberal subjects motivated by their social and economic positions to benefit the best they can from the system of drug development" (p. 178). In the two following chapters Fisher tries to show that the informed consent that such patients sign is often conditioned by the weakness of their positions in American society (poor, uninsured, uneducated). Moreover the therapeutic benefit they derive from their participation in the trial is often minimal. This hinders their compliance with the trial protocol and puts the "managers in a difficult ethical position to persuade them to comply.

Medical research for hire combines indeed ethnography and ethics. The former prevails: the book is rich in quotations from the many interviews conducted by the author and we get to know how the participants in the private clinical trials studied perceive themselves. However, the author only visited a minor fraction of the many organizations conducting trials in the USA and had unequal access to the different types of participants. Her description may ring true, but I am afraid further studies are necessary to confirm that it is representative of a broader pattern. Informative as this ethnography is, its theoretical analysis is not satisfactory, at least in my view (the authoritative endorsements in the cover say otherwise). A substantial part of the analysis consists in glosses over the quotations, in which the author generalizes about her subjects as if they represented the "social and economic positions" of participants in trials across America. Her analysis is very local though (just two major southwest cities) and I would have appreciated a situated analysis in which the particular circumstances of the participants explained their testimonies. The author appeals instead to the "political economy" of "medical neoliberalism", understanding these concepts in a vaguely Foucaultian sense: pharmaceutical capitalism would be constraining the choices of trial participants to a point that often distorts their perception of their own actions. Perhaps it is just an effect of my excessive exposure to experimental social sciences (or actual political economy), but I miss an actual explanation of how this is happening.

I do not find the ethical analysis much deeper. Fisher shows that the discourses of the professionals involved in clinical trials often misrepresent the situation, making it better for the patients than it actually is. I will not dispute this (and it is certainly good to try to inform them). But I guess that Fisher's ethical target is more the for-profit conduction of clinical trials than the discursive misrepresentations of their conductors. Is there an ethical standard for private clinical trials? I guess the author is not very confident about it, but I would have appreciated a more explicit and articulated answer.

Julian Reiss, Error in Economics. Towards a more evidence-based methodology, London, Routledge, 2007.

Julian Reiss’ monograph presents a normative case for an empiricist methodology in economics. According to the author, economists should focus on measuring social variables in order to find causal relationships among them. They should investigate the stability of these relationships in different contexts and, in case it exists, inquire about the underlying abstract factors and establish economic laws. In this process, economists should bear in mind the practical purposes their research is supposed to serve (if there are any) so that the best methods to achieve those aims are always chosen.

The case for this evidence-based approach is articulated in nine chapters divided into three parts. In part one, Reiss discusses economic measurement in a single case study: the Consumer Price Index (CPI) controversy. The second part focuses on causality, drawing on different instances of actual economic research: experimental economics, thought experiments, instrumental variables, etc. The author is pessimistic about the number of economic factors with stable causal capacities found by economists so far, and therefore the third part is not about economic laws, but rather about the prospects of getting them and using them in policy-making. Provided there are good evidential grounds, the more pluralistic economists are in their methodologies, the more likely it seems they will be successful, even if the author makes no promises about it: “the empirical road has not been walked yet and we do not know where it would lead us if we do walk it” (183).

Reiss’ argument for a more evidence-based methodology does not rely on the virtues of a particular technique he wants to promote, but rather on the problems of the standard theory-driven approach discussed in the book. His trust in the possibility of an evidence-based alternative is a matter of philosophical conviction: if the epistemic prejudices of the economic profession against purely inductive methodologies can be removed, these could flourish and yield a more convincing economics. Reiss’ conviction owes much to Nancy Cartwright’s philosophy of the social sciences. This allows him, for instance, to be critical about the ability of mainstream economists to use clinching methods of causal inference. One possible response that Kevin Hoover explores below is that they may have been walking the vouching road to causality, a less demanding one but with no result in the end either. This does not imply that it cannot be done, but it should temper the author’s methodological hopes (and perhaps explain the profession’s pessimism). Aris Spanos challenges in turn the conceptual foundations of this optimism: Reiss can invoke Bacon and be confident on the possibility of correcting errors through a variety of methods to deal with evidence, but it takes a bit more statistical sophistication to define evidence in a way which warrants real error-correction.

Reiss’ programme hinges on evidence and causality, but also on a pragmatic view on values: evidence is sound when it gives a licence to act and attain our epistemic and non-epistemic aims. Depending on our purposes, we should choose the more adequate methodology to gather the relevant evidence. Reiss denounces how economists focus on certain kinds of epistemic values which prevent them from gathering the evidence politicians request (ch. 5, 10). Methodologists and economists are also criticised for adopting epistemic values that constrain empirical research without much scientific profit (ch. 8-9).

Error in economics opens with the explicit admission that evidence alone will not solve neither our theoretical nor practical disagreements: values are required to decide which is the correct CPI (ch. 2-4). But values are diverse and make us disagree, no matter how much causal evidence is gathered. Why should we expect evidence-based economics to overcome such controversies about values? An inspiring example for Reiss seems to be the community of physicists who constructed a unified scale to measure temperature throughout a century of experiments, even if there was no definition of temperature on which they could agree a priori. In his Inventing Temperature (2007) Hasok Chang shows that their success is better explained by a coherentist epistemology with a minimum of theoretical commitments. In order to measure temperature, a scale is necessary, but at first there were many and all of them arbitrary to a certain point. I.e., there was no self-evident basis to ground the inquiry. The choice between all these scales, claims Chang, was made possible by an implicit agreement on a set of epistemic values that presided over the experiments, independently of the theoretical commitments of each physicist. Gradually, the accumulation of evidence made them agree on a scale of measurement under the coherentist pressure of their shared values. In a similar vein, Reiss argues that if economists reached an empirically oriented agreement on their epistemic and non-epistemic aims, their measurements would progress (more than it did in the past century, at least). Yet, he admits, non-epistemic values make economists disagree as much as epistemic values. Can we expect that, once they agree on this latter, the former will cease to disturb their agreement?

I suspect that Reiss optimism about evidence-based economics presupposes some sort of affirmative answer. My own pessimism is based on the existence of empirical traditions in economics where, despite a certain number of shared values, disagreement in measurement persists. My example of choice is Milton Friedman, whose 1953 methodological piece is surprisingly parallel to Reiss’ in some respects. Friedman wanted the economic profession to align around the accuracy of predictions, keeping theoretical commitments to a minimum. The lighter the theoretical apparatus, the easier would be to classify data in separate markets (Marshallians are epistemic contextualists) and obtain predictions that should be judged for their success alone. Besides, for our practical purposes, argued Friedman, we need nothing more than predictive success (close to pragmatism as many were in Chicago). As Kevin Hoover puts it below, Friedman was an empiricist “just as Reiss thinks we ought to be”.

My pessimism about evidence-based economics à la Reiss comes thus from the fate of Friedman’s own evidence-based agenda. I have studied elsewhere how Friedman’s work on consumption usually elicited controversies that never yielded a professional consensus, despite both its solid methodological grounds and the accuracy of his predictions (Teira forthcoming). An issue very often at stake in these controversies was the definition of the variables in the analysis. Friedman’s predictions were always grounded on a classification of data under economic variables without much theoretical clinching. As he once put it, a commodity X is just a label, “not a word for a physical or technical entity to be defined once and for all independently of the problem at hand”. When the economist defined a commodity X once and for every market (as Walrasians intended), empirical analysis became increasingly complicated. More strict definitions, thought Friedman, made data sets unusable and, yet, economists are very often urged to use them by police-makers for whom a suboptimal response is better than none. And economists, thought Friedman, should provide it. Coherence in the definition of variables across their many uses did not count as much for Friedman as it did for Chang’s thermologists, who could safely ignore the practical implications of their experiments.

Yet, no matter how accurate Friedman’s predictions were, if anyone disagreed, one could always contest the definition of the variables used to obtain the predictions: “these data are not X” or “these data should be X as well” – Reiss himself notices this regarding money (p. 130). Unlike temperature, economic variables are difficult to define on the basis of a set of uncontroversial experiments acknowledged by everyone in the profession. As the CPI controversy shows, when disagreement on values occurs, disagreement on measurement procedures follows. Hence progress in economic measurement will only happen if either the community shares epistemic and non-epistemic values (so that they don’t have practical incentives to disagree) or the measurement procedure is strong enough to overcome political divergences.

Good science, says Reiss, “reduces the prejudices and preconceptions of the individual scientist to a minimum”. We may legitimately ask how evidence-based economics achieves this reduction and succeeds when other empiricist agendas in economics failed. Evidence-based economics is a “research project under construction” and indeed one of its many merits is that it raises issues that other approaches in economics neglect. It is open to debate whether Reiss’ evidence-based alternative offers any real hope of solving them, but epistemic optimists should certainly try to walk this road.

{January 2009}
{Economics and philosophy, 25.2 (2009), pp. 199-201}

14/4/09

Shaili Jain, MD, Understanding Physician-Pharmaceutical Industry Interactions. A concise guide, N. York, Cambridge University Press, 2007

Shaili Jain does not need much justification for writing this book: if the pharmaceutical industry is allocating nearly $100,000 and one representative for every eleven practicing physicians in the United States, these latter should ask themselves whether such investment has any effect on their prescriptions. At least, there is evidence that their patients (and often the taxpayer too) would want them to. There is indeed an extensive literature about consequences of pharmaceutical marketing on physicians, published not only in medical journals, but in many other social sciences outlets. It seems though that most doctors consider themselves impervious to the advertising strategies of the industry and Shaili Jain knows that they won’t spend much time learning about them.

This book offers to health care professionals a fast and frugal understanding of these strategies, as they are implemented in the United States: each chapter is about four pages long, of which the analytical presentation of the author’s case takes at most three. In addition there are quick fictional vignettes of each situation analysed, bullet point summaries and an updated reference list. Here goes a list of the topics addressed.

The first two chapters state the author’s main thesis: there is serious evidence that industry gifts create biases that influence physicians’ prescriptions and this has ethical consequences regarding their obligations to their patients. The following three chapters discuss the more prominent ways to create these biases. Namely, through medical detailing (pharmaceutical representatives visiting doctors to present their products), informal teaching to physicians in training, and also sponsoring clinical research to be later published in scientific journals. In chapters 6 and 7 Jain ponders the benefits and disadvantages of these sophisticated marketing mechanisms and provides a list of suggestions to constrain the promotional dimension of industry sponsored events. She offers a brief remainder of the existing professional guidelines about the topic, which are reproduced at length in a 60 pages closing appendix.

Chapters 8 to 11 deal with the public understanding of the interactions between physicians and the pharmaceutical industry. In chapter 8 Jain summarises evidence showing that patients often don’t know how many gifts their doctors receive from the industry and when they are informed, they do not approve of it. When patients receive medication samples as gifts themselves, they tend to overlook the inferior standards of care they are often associated with (physicians are often unaware too). Chapter 10 briefly explores the possibility of applying federal antikickback laws to punish pharmaceutical companies and physicians for exchanging gifts for prescriptions. Finally, in chapter 11, Jain considers the pros and cons of direct-to-consumer advertising of prescription drugs. The book closes with a glimpse of the situation in countries other than the USA and a brief list of internet resources on the topic.

Jain seems to be arguing namely to raise the awareness about the consequences of pharmaceutical marketing among health care professionals. Her review of the literature is often too quick, and sometimes may seem unconvincing or inconclusive. At least, if we compare it with the more “partisan” approaches which abound in this field (either for or against “Big Pharmas”). Yet the book is rich in checklists which allow the physician to ponder the dilemmas she is facing in her daily practice. This self-assessment may not automatically correct her biases (psychologists have experimentally documented our resilience to this kind of corrections), but may open a more informed discussion among health care professionals in which the possibility of biases is not discounted ex ante, as it usually happens now. Perhaps pharmaceutical companies should be compelled to include this book in their catalogue of promotional gifts for the coming years in order to see how it contributes to their sales.