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Exposing the Vanities—and a Qualified Defense—of Mechanistic Reasoning in Health Care Decision Making

Published online by Cambridge University Press:  01 January 2022

Jeremy Howick
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Abstract

Philosophers of science have insisted that evidence of underlying mechanisms is required to support claims about the effects of medical interventions. Yet evidence about mechanisms does not feature on dominant evidence-based medicine “hierarchies.” After arguing that only inferences from mechanisms (“mechanistic reasoning”)—not mechanisms themselves—count as evidence, I argue for a middle ground. Mechanistic reasoning is not required to establish causation when we have high-quality controlled studies; moreover, mechanistic reasoning is more problematic than has been assumed. Yet where the problems can be overcome, mechanistic reasoning can and should be used as evidence.

Type
Research Article
Information
Philosophy of Science , Volume 78 , Issue 5 , December 2011 , pp. 926 - 940
Copyright
Copyright © The Philosophy of Science Association

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Footnotes

‡

This article is a development of work written in collaboration with Paul Glasziou and Jeffrey Aronson. It was written while I was a recipient of an MRC/ESRC Interdisciplinary Postdoctoral Fellowship (G0800055) and a lecturer in the Science and Technology Studies Department at University College London. Nancy Cartwright read and made invaluable comments on earlier drafts of this article, and John Worrall has been a continued inspiration. I am also grateful to Claire Blacklock, Brendan Clarke, Lindley Darden, Foad Dizadji-Bahmani, Donald Gillies, Stuart Glennan, Adam La Caze, Federica Russo, Jon Williamson, John Worrall, Raffaella Campaner, Maria Carla Galavotti, and Sir Iain Chalmers for useful comments and discussions. I also received enormously helpful comments from almost everyone at the conference Mechanisms and Causality in the Sciences, especially Alex Broadbent, Carl Craver, Phyllis McKay Illari, and Bert Leuridan.

References

Bechtel, William, and Abrahamsen, Adele. 2005. “Explanation: A Mechanist Alternative.” Studies in History and Philosophy of Biological and Biomedical Sciences 36:421–41.CrossRefGoogle ScholarPubMed
Bernard, Claude. 1957. An Introduction to the Study of Experimental Medicine. New York: Dover.Google Scholar
Bonnema, S. J., Nielsen, V. E., Boel-Jorgensen, H., Grupe, P., Andersen, P. B., Bastholt, L., and Hegedus, L.. 2008. “Recombinant Human Thyrotropin-Stimulated Radioiodine Therapy of Large Nodular Goiters Facilitates Tracheal Decompression and Improves Inspiration.” Journal of Clinical Endrocrinology and Metabolism 93 (10): 3981–84.Google ScholarPubMed
Cartwright, Nancy. 2009. “Presidential Address.” In American Philosophical Association Pacific Division. Vancouver: APA.Google Scholar
DesAutels, Lane. 2011. “Against Regular and Irregular Characterizations of Mechanisms.” Philosophy of Science, in this issue.CrossRefGoogle Scholar
Evans, Imogen, Thornton, Hazel, and Chalmers, Iain. 2006. Testing Treatments: Better Research for Better Healthcare. London: British Library.Google Scholar
Gerhard, Michal, ed. 1993. Biochemical Pathways. Roche Pharmaceuticals, http://www.expasy.org/cgi-bin/pathways/show_thumbnails.pl.Google Scholar
Gillies, D. 2005. “Hempelian and Kuhnian Approaches in the Philosophy of Medicine: The Semmelweis Case.” Studies in History and Philosophy of Biological and Biomedical Science 36 (1): 159–81.CrossRefGoogle ScholarPubMed
Glennan, Stuart S. 1996. “Mechanisms and the Nature of Causation.” Erkentnis 44 (1): 49–71.Google Scholar
Golomb, B. A., Erickson, L. C., Koperski, S., Sack, D., Enkin, M., and Howick, J.. 2010. “What's in Placebos: Who Knows? Analysis of Randomized, Controlled Trials.” Annals of Internal Medicine 153 (8): 532–35.CrossRefGoogle ScholarPubMed
Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., and Schunemann, H. J.. 2008. “GRADE: An Emerging Consensus on Rating Quality of Evidence and Strength of Recommendations.” British Medical Journal 336 (7650): 924–26.CrossRefGoogle ScholarPubMed
Hauben, M., and Aronson, J. K.. 2006. “Paradoxical Reactions: Under-Recognized Adverse Effects of Drugs.” Drug Safety 29 (10): 970.CrossRefGoogle Scholar
Hesslow, Germund. 1976. “Two Notes on the Probabilistic Approach to Causality.” Philosophy of Science 43:290–92.CrossRefGoogle Scholar
Howick, Jeremy. 2009. “Questioning the Methodologic Superiority of ‘Placebo’ over ‘Active’ Controlled Trials.” American Journal of Bioethics 9 (9): 34–48.CrossRefGoogle ScholarPubMed
Howick, Jeremy. 2011. The Philosophy of Evidence-Based Medicine. Oxford: Blackwell.CrossRefGoogle Scholar
Leibovici, L. 2001. “Effects of Remote, Retroactive Intercessory Prayer on Outcomes in Patients with Bloodstream Infection: Randomized Controlled Trial.” British Medical Journal 323 (7327): 1450–51.CrossRefGoogle Scholar
Louis, Louis Pierre Charles. 1836. Researches on the Effects of Blood Letting in Some Inflammatory Diseases, and on the Influence of Tartarized Antimony and Vesication in Pneumonitis. Trans. Putnam, C. G., with preface and appendix by J. Jackson. Boston: Hillart.Google Scholar
Machamer, Peter, Darden, Lindley, and Craver, Carl F.. 2000. “Thinking about Mechanisms.” Philosophy of Science 67:1–25.CrossRefGoogle Scholar
Mendelsohn, M. E., and Karas, R. H.. 1999. “The Protective Effects of Estrogen on the Cardiovascular System.” New England Journal of Medicine 340 (23): 1801–11.CrossRefGoogle ScholarPubMed
Mill, John Stuart. 1843/1973. “A System of Logic, Ratiocinative and Inductive: Being a Connected View of the Principles of Evidence and the Methods of Scientific Investigation.” In Collected Works of John Stuart Mill, ed. Robson, J. M., vols. 7–8. Toronto: University of Toronto Press.Google Scholar
Nielsen, V. E., Bonnema, S. J., Boel-Jorgensen, H., Grupe, P., and Hegedus, L.. 2006. “Stimulation with 0.3-mg Recombinant Human Thyrotropin prior to Iodine 131 Therapy to Improve the Size Reduction of Benign Nontoxic Nodular Goiter: A Prospective Randomized Double-Blind Trial.” Archives of Internal Medicine 166 (14): 1476–82.CrossRefGoogle ScholarPubMed
Petitti, D. B., Perlman, J. A., and Sidney, S.. 1987. “Noncontraceptive Estrogens and Mortality: Long-Term Follow-Up of Women in the Walnut Creek Study.” Obstetrics and Gynecology 70 (3): 289–93.Google ScholarPubMed
Pocock, Stuart. J., Hughes, M. D., and Lee, R. J.. 1987. “Statistical Problems in the Reporting of Clinical Trials: A Survey of Three Medical Journals.” New England Journal of Medicine 317 (7): 426–32.CrossRefGoogle ScholarPubMed
Rossouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., Kooperberg, C., Stefanick, M. L., Jackson, R. D., Beresford, S. A., Howard, B. V., Johnson, K. C., Kotchen, J. M., and Ockene, J.. 2002. “Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results from the Women's Health Initiative Randomized Controlled Trial.” Journal of the American Medical Association 288 (3): 321–33.Google ScholarPubMed
Russo, Frederica, and Williamson, Jon. 2007. “Interpreting Causality in the Health Sciences.” International Studies in the Philosophy of Science 21 (2): 1157–70.CrossRefGoogle Scholar
Schulz, K. F., and Grimes, D. A.. 2005. “Multiplicity in Randomized Trials.” Pt. 2, “Subgroup and Interim Analyses.” Lancet 365 (9471): 1657–61.CrossRefGoogle Scholar
Stampfer, M. J., and Colditz, G. A.. 1991. “Estrogen Replacement Therapy and Coronary Heart Disease: A Quantitative Assessment of the Epidemiologic Evidence.” Preventive Medicine 20 (1): 47–63.CrossRefGoogle ScholarPubMed
Worrall, John. 2007. “Evidence in Medicine.” Compass 2 (6): 981–1022.CrossRefGoogle Scholar
Worrall, John. 2010. “Evidence: Philosophy of Science Meets Medicine.” Journal of Evaluation in Clinical Practice 116:356–62.Google Scholar