Positive claims about narrative approaches to healthcare suggest they could have many benefits, including supporting person-centred healthcare (PCH). Narrative approaches have also been criticised, however, on both theoretical and practical grounds. In this paper we draw on epistemological work on narrative and knowledge to develop a conception of narrative that responds to these concerns. We make a case for understanding narratives as accounts of events in which the way each event is described as influenced by the ways other events in (...) the narrative are described. This view of narratives recognises that they can contribute knowledge of different kinds of connections between events: not just causal, and not just of patient’s perspectives. Additionally, narratives can add further epistemic value by suggesting potentially useful lines of inquiry. We take narrative approaches to healthcare to include clinicians considering both patients’ informational offerings and their own professional understandings as narratives. On this understanding, our account is able to overcome the major theoretical and practical criticisms that have been levelled against the use of narrative approaches in healthcare, and can help to explain why and how narrative approaches are consistent with PCH. (shrink)

Boorse’s biostatistical theory states that diseases should be defined in ways that reflect disturbances of biological function and that are objective and value free. We use three examples from contemporary medicine that demonstrate the complex issues that arise when defining the boundaries of disease: polycystic ovary syndrome, chronic kidney disease, and myocardial infarction. We argue that the biostatistical theory fails to provide sufficient guidance on where the boundaries of disease should be drawn, contains ambiguities relating to choice of reference class, (...) and is out of step with medical processes for identifying disease boundaries. Although proponents of the biostatistical theory might regard these practical issues as irrelevant to the aim of providing a theoretical account of disease, we take them to indicate the need for a theoretical account that is adequate for current needs—including limiting new forms of medicalization that are driven by the identification of disease based on dysfunction. Our processes for determining the boundaries for disease need to recognize that there is no value-free method for making these decisions. (shrink)

Evidence in medicine can come from more or less trustworthy sources and be produced by more or less reliable methods, and its interpretation can be disputed. As such, it can be unclear when disagreements in medicine result from different, but reasonable, interpretations of the available evidence and when they result from unreasonable refusals to consider legitimate evidence. In this article, we seek to show how assessments of the relevance and implications of evidence are typically affected by factors beyond that evidence (...) itself, such as our beliefs about the credibility of the speaker or source of the evidence. In evaluating evidence, there is thus a need for reflective awareness about why we accept or dismiss particular claims. (shrink)

Many health care systems include programs that allow patients in exceptional circumstances to access medical interventions of as yet unproven benefit. In this article we consider the ethical justifications for—and demands on—these special access programs (SAPs). SAPs have a compassionate basis: They give patients with limited options the opportunity to try interventions that are not yet approved by standard regulatory processes. But while they signal that health care systems can and will respond to individual suffering, SAPs have several disadvantages, including (...) the potential to undermine regulatory and knowledge-generation structures that constitute significant public goods. The “balance” between these considerations depends in part on how broadly SAPs are used, but also on whether SAPs can be made to contribute to the generation of knowledge about the effects of health interventions. We argue that patients should usually be required to contribute outcome data while using SAPs. (shrink)

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of “disease” is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept (...) is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept “disease” to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept. (shrink)

Recently, concerns have been raised about the phenomenon of ‘overdiagnosis’, the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises ques- tions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue (...) that ‘disease’ should be considered a vague concept with a non-classical structure. On this view, overdiagnosed cases are ‘borderline’ cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a pre ́cising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient. (shrink)

An increasing number of patients receive diagnoses of disease without having any symptoms. These include diseases detected through screening programs, as incidental findings from unrelated investigations, or via routine checks of various biological variables like blood pressure or cholesterol. In this article, we draw on narrative identity theory to examine how the process of making sense of being diagnosed with asymptomatic disease can trigger certain overlooked forms of harm for patients. We show that the experience of asymptomatic disease can involve (...) ‘mismatches’ between one’s beliefs about one’s health status on the one hand, and bodily sensations or past experience on the other. Patients’ attempts to integrate these diagnoses into their self-narratives often involve either forming inaccurate beliefs about bodily sensations and/or past experience, or coming to believe that feelings and experience do not necessarily track or predict health status, leading to an ongoing sense of vulnerability to ill health. These resulting alterations in self-understanding can sometimes be considered harmful, in view of their implications for ascriptions of responsibility and ongoing anxiety. (shrink)

Although health and disease occupy opposite ends of a spectrum, distinguishing between them can be difficult. This is the “line-drawing” problem. The papers in this special issue engage with this challenge of delineating the boundaries of disease. The authors explore different views as to where the boundary between disease and nondisease lies, and related questions, such as how we can identify, or decide, what counts as a disease and what does not; the nature of the boundary between the two categories; (...) and what sorts of considerations could justify the location of that boundary. In exploring these questions, the papers draw on detailed clinical examples, provide theoretical critiques of existing approaches to disease definition, and offer new ways to conceptualize key features in debates about disease, including harm and biological dysfunction. (shrink)

Surgery is an important part of contemporary health care, but currently much of surgery lacks a strong evidence base. Uptake of evidence-based medicine (EBM) methods within surgical research and among practitioners has been slow compared with other areas of medicine. Although this is often viewed as arising from practical and cultural barriers, it also reflects a lack of epistemic fit between EBM research methods and surgical practice. In this paper we discuss some epistemic challenges in surgery relating to this lack (...) of fit, and investigate how resources from feminist epistemology can help to characterize them. We point to ways in which these epistemic challenges may be addressed by gathering and disseminating evidence about what works in surgery using methods that are contextual, pluralistic, and sensitive to hierarchies. (shrink)

Biological dysfunction is regarded, in many accounts, as necessary and perhaps sufficient for disease. But although disease is conceptualized as all-or-nothing, biological functions often differ by degree. A tension is created by attempting to use a continuous variable as the basis for a categorical definition, raising questions about how we are to pinpoint the boundary between health and disease. This is the line-drawing problem. In this paper, we show how the line-drawing problem arises within “dysfunction-requiring” accounts of disease, such as (...) those of Christopher Boorse and Jerome Wakefield. We then provide several detailed examples to establish that biological dysfunction cannot provide a boundary. We examine potential ways of resolving the line-drawing problem, either by dropping one of the claims that generates it, or by appealing to additional criteria. We argue that two of these options are plausible, and that each of these can be applied with regard to different diseases. (shrink)

L'œuf de ver à soie qui se prête à de nombreuses recherches génétiques et physiologiques a été assimilé à un volume géométrique simple afin qu'on puisse calculer aisément l'aire de sa surface totale et son volume. On a d'abord cherché à justifier le modèle géométrique proposé grâce à une étude expérimentale et statistique. On a ensuite établi les formules mathématiques utiles. Enfin on a discuté de l'approximation donnée par ces formules et de leur signification biologique.The egg of the silkworm which (...) permits a lot of genetical and physiological researches has been assimilated to a simple geometric volume, so that the area of its total surface and its volume might be easily calculated. First we have tried to justify the geometrical model which is proposed by means of an experimental and statistical study. We have then demonstrated the useful mathematical formulas. Finally we have discussed the approximation given by these formulas and their biological significance.Das Seidenraupenei, das viele genetische und physiologische Forschungen ermöglicht, hat man mit einem einfachen geometrischen Modell verglichen, um seine ganze Fläche und sein Volumen leicht rechnen zu können. Zuerst hat man versucht, das vorgeschlagene geometrische Modell dank einer experimentalen und statistischen Arbeit zu rechtfertigen. Dann sind die nötigen mathematischen Formeln festgesetzt worden. Zuletzt hat man die durch diese Formeln gegebenen Annäherungen und ihre biologischen Bedeutung erörtert. (shrink)

L'art n'a cessé, depuis un siècle, de relativiser les topoï dans lesquels l'esthétique puisait jusqu'alors ses repères. La teneur n'en a pas été irrémédiablement invalidée, mais le contenu demandait à en être requalifié et redistribué à partir des problématiques qui s'imposent désormais à l'attention. Ce livre s'y efforce à travers un éventail de " questions " destinées à faire le point et à souligner la vitalité de la réflexion philosophique sur l'art à l'âge contemporain. Il offre une alternative aux options (...) méthodologiques courantes, dans le souci d'un meilleur accès aux questions et aux œuvres, et dans l'esprit d'un engagement philosophique qui privilégie l'argumentation et les thèses clairement définies. (shrink)

L'esthetique philosophique et la philosophie de l'art connaissent un essor important, particulierement dans la tradition de philosophie analytique. Ce volume examine d'abord leurs evolutions et perspectives depuis une vingtaine d'annees, grace a un panorama general des questions vives qui s'y posent et a travers une reflexion approfondie sur la notion meme d' esthetique. Une deuxieme partie porte sur la question de la representation, l'un des secteurs le plus profondement renouveles, avec la querelle opposant les tenants du conventionnalisme et ceux du (...) realisme iconique, et l'importance renouvelee des notions de ressemblance et d'imitation qu'on avait pu croire perimees. Enfin, une troisieme partie est consacree aux notions qui s'entrecroisent dans le paradoxe de la fiction: comment et pourquoi pouvons-nous etre emus par ce que nous savons ne pas exister, le destin tragique d'Anna Karenine, par exemple? Ce recueil ouvre un acces a quelques-unes des textes les plus significatifs de l'esthetique analytique des vingt dernieres annees, tout en apportant une contribution a une forme argumentative, directe et claire d'esthetique et de philosophie de l'art. (shrink)

Christopher Buondelmonti, famous «traveller, geographer, cartographer», priest of Florence, spent the last years of his life at Rhodes, where he served as dean of the cathedral chapter in 1430. This article reminds the substantial work that has been devoted to him in recent years. Then, it states much of what is known of the Latin Church of Rhodes, in particular of its cathedral chapter, in the early years of the fifteenth century. Finally, two acts of 1430 on Buondelmonti, dean of (...) this chapter, are presented here. (shrink)

This study examined the laboratory dream content reported by 14 patients with schizophrenia and 15 controls, with a focus on reports obtained from NonREM sleep. Both the controls’ and patients’ frequency of dream recall following awakenings from NonREM and REM sleep were similar to values reported for healthy participants. Patients’ NonREM sleep narratives were shorter than those from controls. When compared to their reports from REM sleep, both groups’ NonREM sleep reports included significantly fewer words and reportable items. The controls (...) were more likely to report a subjective feeling of bizarreness for their REM sleep reports as compared to their NonREM sleep reports. This difference was not observed in patients with schizophrenia. Taken together, these findings suggest few differences between the NonREM sleep mentation of patients with schizophrenia and of controls and that sleep stage cognitive style is comparable in both groups, with NonREM sleep reports being more thought-like, less elaborate and bizarre than REM sleep reports. (shrink)