Tuesday, 19 October 2021

Facts and Values in Mortality Data during the Pandemic

Today's post is by Maria Cristina Amoretti and Elisabetta Lalumera. This is their second of two blog posts on applied philosophy of science and conceptual analysis in the time of COVID-19.

Amoretti and Lalumera

As philosophers, one of our interests is the interplay of facts and values in medical sciences. We think that debunking the myth of science as purely factual is a contribution that philosophers can usefully bring to society. We also think that science can be nevertheless objective and trustworthy, but not in virtue of being purely factual – as many philosophers have argued recently. In a recent paper, we focused on mortality statistics during the pandemic. 

Mortality data have been very salient throughout the pandemic, both at the personal level, by influencing our emotional uptake of the situation, and at the level of society, as government’s decisions are based on epidemiological models, which, in their turn, are fed by mortality data. When is someone’s death due to COVID-19 or, more specifically, when does COVID-19 qualify as the underlying cause of death? For an answer, we analyzed the rules for the certification of death issued by the World Health Organization (WHO).

These rules, supplemented by instructions contained in the Reference Guide of the International Classification of Diseases (ICD) (WHO 2018), are adopted in most countries, so that the death certificate has the same format. According to these rules, the death certificate should contain all conditions the doctor considers causally and etiologically relevant to the person’s death, but one single underlying cause of death must be specified. It is defined as “the disease or injury that initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury” (WHO 2018, 2.17.1).

This definition underpins a mechanistic conception of causality. However, the guiding principle that should inform the selection of one single underlying cause is explicitly the possibility of prevention of deaths to the benefit of public health (WHO 2018, 2.19.2). Thus, we argued, a prudential or normative principle is used to select from among the causes pertinent to someone’s death. We also noted that the same prudential principle figures in the rules for certifying deaths due to HIV-AIDS, for analogous public health reasons, namely, to prevent the highest number of deaths.

In conclusion, a statement on a death certificate, identifying COVID-19 as the underlying cause of death, may be considered a non-purely descriptive predicate, as grounded on both factual (causal chains and the patient’s medical conditions before and at the time of death) and non-factual reasons (the importance of prevention of more deaths). We think that many arguments can be brought to defend such non-factual reasons. However, it is important to disentangle them from facts. Whereas facts can only be described, reasons can be argued for.

Tuesday, 12 October 2021

The Concept of Disease in the Pandemic

Today's post is by Maria Cristina Amoretti and Elisabetta Lalumera. They discuss the concept of disease in the time of COVID-19 which they also write about in a recent article in Theoretical Medicine and Bioethics. This is the first of two blog posts on applied philosophy of science and conceptual analysis in the time of COVID-19.

Maria Cristina Amoretti is Associate Professor at the University of Genoa, Department of Antiquity, Philosophy and History (DAFIST) and Vice-Director of PhilHeaD-Philosophy of Health and Disease Research Center. Elisabetta Lalumera is Assistant Professor at the University of Bologna, Department of Life Quality Studies (QUVI), and member of PhilHeaD.

Amoretti and Lalumera

During the pandemic, medical and non-medical interventions of institutions and governments became central to our lives. Sometimes we felt overwhelmed with worry and anxiety, conditions that do not favour philosophical reflection. In our paper we tried to put worry and anxiety in brackets, and critically engage with the question: What concept of disease is implicit in the interventions that institutions and governments are enforcing during the pandemic?

For doing so, we started with imagining an ideally accurate diagnostic test for COVID-19, with respect to which four classes of people can be identified: people who are positive and symptomatic (PS), positive and asymptomatic (PA), negative (N), and untested (U). Our aim was showing how different philosophical accounts of disease, amongst those discussed in the recent philosophical debate, would better describe the four classes of people. Or, alternatively, which concept of disease is implicit in certain patterns of disease and sickness judgements, like those experienced during the pandemic.

We therefore analyzed different versions of function-requiring and harm-requiring accounts of disease. Of all these, the only disease concept that, unlike the others, allows a positive sickness judgement, not only for the PS group, but also for both the PA and the U groups is the social (risk of) harm account, which equates disease with a condition associated with harm, or increased risk of harm, either to the subject or to someone other than the subject.

We then argued that the concept of disease as social (risk of) harm is the one that can be seen as implicit in many institutional interventions during the COVID-19 pandemic. Many countries have imposed strong lockdowns and quarantines for their whole population in order to suppress or mitigate the outbreak of the virus. Sickness exemptions and benefits were extended, including paid sick leave, tax credits, etc. These privileges also coincided with the imposition of social obligations and of limitations of individual freedom. What is important to our point, however, is that anyone, the U group included, was considered sick and, as an extension, diseased.

Our final point in the paper was that the concept of disease as social (risk) of harm should be adopted in emergency cases only and abandoned when the emergency is over. We gave three reasons for this conceptual revision claim. First, under the social (risk of) harm account, a condition that is harmful or potentially harmful for society is a disease irrespectively of its physiological basis. Therefore, perceived risky social deviances, such as homosexuality and drapetomania, or behavioural proclivities, such as heavy drinking, could come to be regarded as diseases. 

Second, in endorsing the social (risk of) harm account, the subjective and phenomenological aspects of disease would be overshadowed, as asymptomatic people would count as diseased simply because they represent a risk to society. Third, given that the social (risk of) harm account would classify not only the PS group but also the PA and U groups as diseased, the number of diseased people would dramatically increase, creating a problem of overdiagnosis and medicalization.

Tuesday, 5 October 2021

Isn't Everyone A Little OCD?

In today's post, Lucienne Spencer (University of Bristol) discusses the wrongful depathologization of serious mental conditions. The post is based on a paper co-authored with Havi Carel and published open access in Philosophy of Medicine.

Lucienne Spencer

The Mental Health Foundation states that ‘people with mental health problems are amongst the least likely of any group with a long-term health condition or disability to find work, be in a steady, long-term relationship, live in decent housing [or] be socially included in mainstream society’. Given the global decline in mental health following the coronavirus pandemic, addressing the marginalisation of people with psychiatric illness has never been more urgent. According to the literature, this marginalisation is grounded in sanist attitudes that portray people with psychiatric illness as ‘dangerous and frightening’, ‘incompetent to participate in “normal” activities’ and ‘morally repugnant’. 

Comic by Michael Seymour Blake
(Instagram @michaelseymourblake)

While some psychiatric illnesses are solely grounded in such stigmatisation (such as schizophrenia and other forms of psychosis), we argue that other psychiatric conditions may also be vulnerable to trivialisation. Have you ever heard someone say, ‘that football match last night gave me PTSD’ or ‘I can’t handle social situations, I’m so Autistic’ or even ‘I love having my kitchen organised- I’m slightly OCD’? 

When we make light of psychiatric illnesses in this way, we risk reducing a serious condition to a mere personality trait. Consequently, people with these kinds of psychiatric illnesses are more likely to be met with scepticism regarding the severity of their illness; characterised as ‘just like everyone else’, yet labelled as ‘difficult’, ‘manipulative’, or ‘attention-seeking’. Therefore, while these conditions are still subject to systematic stigmatisation, they can also be trivialised. We call this simultaneous operation of stigmatisation and trivialisation of a psychiatric illness ‘wrongful depathologisation’.

Our new article uses OCD as a case study to focus on one distinct harm that may emerge from wrongful depathologisation: epistemic injustice. First, if a condition like OCD is not perceived to be as complex or debilitating as the patient claims, testimony that goes beyond the palatable aspects of the condition is not taken seriously. This would constitute a case of testimonial injustice. 

Havi Carel

Second, wilful hermeneutical ignorance may occur if a diagnostic term, like that of ‘OCD’, is misappropriated by those who do not have the condition. Rather than using the term to refer to a serious psychiatric illness, ‘OCD’ is frequently used to describe an inclination towards tidiness and organisation. Through this misappropriation, the true meaning of the term ‘OCD’ is suppressed and loses its hermeneutical power.

We hope that the concept ‘wrongful depathologisation’ may open a space for new ways of understanding other marginalised experiences that are simultaneously stigmatised and trivialised. For example, cases of rape, sexual assault and domestic abuse, where the individual is vulnerable to stigmatisation and victim-blaming, yet their experiences may be trivialised due to cultural attitudes that normalise sexual and domestic violence. As a new contribution to the literature, we hope that the concept of wrongful depathologisation may bring to light further cases of epistemic injustice driven by the paradoxical twining of stigmatisation and trivialisation.

Friday, 1 October 2021

Belief and Evidence: An Interview with Carolina Flores

Today's post is part of a series on the AHRC funded project Deluded by Experience, ran by PI Ema Sullivan-Bissett and Co-I Paul Noordhof. In this post Harriet Stuart (Research Assistant for Deluded by Experience) interviews Carolina Flores about their research interests and most recent work. Carolina is a graduate student in Philosophy at Rutgers, New Brunswick, specialising in philosophy of mind, epistemology, and social philosophy.

Carolina Flores

HS: Your PhD work seeks to address questions around belief and interactions with evidence, how did you first become interested in these ideas?

CF: My interest in these questions has a theoretical and a political source. The theoretical source was my interest, as an undergraduate, in Davidson’s idea that to have beliefs is to be rational. Though I was intrigued by this view, it was also clear to me that it is in tension with the fact that we are frequently irrational, sometimes deeply so (as in the case of delusions). In my undergraduate thesis, I attempted to address this tension in a way friendly to Davidson’s view.

Irrationality and evidence-resistance turned out to be timely topics for political reasons. I finished my undergraduate thesis the year of the Brexit referendum and Trump’s election. As a response to these events, mainstream media propagated an irrationalist narrative which blamed them on ordinary people’s stupidity and irrationality. This political context made me even more interested in understanding belief and interactions with evidence in general, and in particular in pushing back against the narrative that people are epistemically irredeemable—as I attempt to do in my dissertation.

HS: In a paper you currently have under review, you introduce the notion of epistemic styles, could you briefly introduce the notion and explain why you think this notion is beneficial in your research?

CF: I introduce the notion of epistemic styles to help explain why people interact with evidence in different ways. Epistemic styles are ways of interacting with evidence that express a unified set of epistemic values, preferences, and other epistemic parameters. My idea is that differences in what evidence one finds persuasive, how many explanations for evidence one considers, how actively one seeks out evidence, etc. can often be explained in terms of the adoption of different epistemic styles.

There are two main advantages to appealing to epistemic styles. First, it does justice to the role both of situational factors (mood, social norms, etc.) and of agency in how we interact with evidence. In my account, people flexibly take up different epistemic styles in response to situational factors, where their style then governs their interactions with evidence. In this way, appeal to epistemic styles captures the positive aspects of both virtue-based approaches, which seek to explain our epistemic behavior in terms of deep, stable character traits, and situationism, which emphasizes the influence of trivial situational factors.

Second, appealing to epistemic styles can make others’ interactions with evidence intelligible at the personal level. Thinking in terms of epistemic styles can move us from being puzzled at others’ interactions with evidence, or finding them deeply irrational, to understanding how they interact with evidence in the light of the epistemic values, preferences, etc. that they have taken up.

HS: In your recent paper ‘Delusional evidence-responsiveness’, you argue that delusions are evidence-responsive but that patients can rarely be successful in exercising their capacity to respond to evidence. Can you briefly introduce this idea and talk about how this claim relates to your notion of epistemic styles?

CF: The central idea in this paper is that delusions do not erase the patient’s rational capacities. Patients with delusions have the capacity to respond to evidence bearing on their delusions. If they were to successfully exercise their capacities, they would rationally revise. Unfortunately, unusual perceptual experiences, cognitive biases, and the desire to avoid painful beliefs interfere with these capacities. For this reason, it is very hard for patients to abandon their delusions.

This view is independent of my discussion of epistemic styles. I don’t think delusional patients necessarily take up a distinctive delusional epistemic style when interacting with evidence. That said, there is interesting research in psychiatry that suggests that delusions in schizophrenia are underwritten by a distinctive epistemic style—a view I am developing in a new paper.

HS: Your project draws from many disciplines including philosophy and psychology, what are the advantages and disadvantages of interdisciplinary work? How have you overcome any difficulties?

CF: I love getting to learn from many disciplines! It helps me cultivate a sense of wonder at how much there is to learn and discover. I also think that it has improved my work, by making it sensitive to how actual humans interact with evidence and maintain their beliefs.

One downside of this approach is that it is often overwhelming to realize how much there is to learn. I also worry about not doing justice to scholarship in other fields. To combat this, I try to get very clear on what empirical resources a project requires and then go on a focused deep dive. And I strive to continually expand my general knowledge of other disciplines.

HS: What do you hope to see as the outcomes of your work?

CF: At a theoretical level, I hope to make progress in (1) understanding the nature of belief and (2) developing a clear framework in which to understand how people interact with evidence—one which does justice both to cognitive science and to our rational agency. I hope that this will be useful in understanding delusions, conspiracist beliefs, prejudice, ideologies, political beliefs, and so on. I also hope that this work finds practical application in helping us devise better strategies for changing minds and for rationally engaging across deep disagreement.