Anti-essentialism, modal relativity, and alternative material-origin counterfactuals

In ordinary language, in the medical sciences, and in the overlap between them, we frequently make claims which imply that we might have had different gametic origins from the ones we actually have. Such statements seem intuitively true and coherent. But they counterfactually ascribe different DNA to their referents and therefore contradict material-origin essentialism, which Kripke and his followers argue is intuitively obvious. In this paper I argue, using examples from ordinary language and from philosophy of medicine and bioethics, that statements which attribute alternative material origins to their referents are useful, common in political and medical reasoning, and in many cases best interpreted literally. So we must replace the doctrine of material-origin essentialism with one that can make sense of ordinary discourse and the language of the medical sciences. I propose an anti-essentialist account of such counterfactuals according to which individuals’ modal properties are relative to a given inquiry.

Physicians’ preference towards the non-evidence based hydroxychloroquine treatment for COVID-19: the pandemic effect

OBJECTIVE: To evaluate whether there is a "pandemic effect" promoting irrational medical reasoning. METHODS: Cross-sectional study. Setting state medical councils were asked to send all registered physicians two sequential email invitations to complete a Google Form questionnaire. Between April 15 and May 3, 2020, 370 doctors answered our questionnaire with questions about the prescription of hydroxychloroquine for COVID-19 and vitamin C for sepsis. The questionnaire had a five-point Likert scale (greater number, greater support) on the degree of propensity to prescribe the medication and a binary question (yes or no) to express the doctor's final decision to prescribe. These two questions, in the same order, were asked for scenarios of mild, moderate and severe cases. RESULTS: The propensity to prescribe hydroxychloroquine for COVID-19 increased with the severity of the clinical presentation: for mild cases, 37% (95% CI 32%-42%) of the physicians chose "yes", increasing to 68% (95% CI 63%-72%) and 89% (95% CI 85%-92%) for moderate or severe cases, respectively (Cochran's Q test: P<0.001). The medians and interquartile ranges of the Likert scales for hydroxychloroquine were 2 (1-4), 4 (2-4), 4 (4-5) in mild, moderate and severe cases of COVID-19 (Friedman test: P<0.001). CONCLUSIONS: The propensity of the Brazilian physician to prescribe hydroxychloroquine for COVID-19 is high and, according to the severity of the disease, ranged from 37 to 89%. On the contrary, the propensity to prescribe vitamin C for sepsis, a non-pandemic situation, was lower and not associated with clinical severity. Our data suggest a "pandemic effect" promoting irrationality in medical reasoning.

Evolution of Medical Reasoning

The challenge to certainty in the face of enormous variability generates an epistemic conundrum. The response to this conundrum has driven the evolution of medicine. The rationalist/allopathic tradition holds that an economical set of principles and facts exists from which each patient’s unique situation can be constructed. There are striking parallels between the allopathic tradition and science. Indeed, it was the ascendency of biomedical science that enabled allopathic medicine to triumph over competitive schools of medicine, such as the empirics in the form of homeopaths. The ascendancy of scientific medicine that allopathics claimed is now institutionalized. However, such economization risks the inverse problem in that there may not be any unique explanation for a particular disease phenomenology, thus giving rise to the possibility of misdiagnosis and mistreatment. Nonetheless, the rationalist/allopathic tradition follows from Aristotle’s metaphysics translated into medical terms by Galen, whose influence is still felt.

Medical Reasoning

Modern medicine is one of humankind’s greatest achievements. Yet medical errors and irreproducibility in biomedical research suggest something is amiss. Concerns have driven considerable and thoughtful critical analyses, but the apparent intransigence of these problems suggests a different perspective is needed. The perspective pursued in this book begins with the idea that the need for certainty in medical decision-making has been and remains the primary driving force in medical reasoning. Faced with the unique challenges of having to treat the individual patient, the great variety of manifestations across patients is daunting. Either there are as many different “diseases” as there are patients, or there is some economical set of principles and facts that can be combined to explain each patient’s disease. Modern allopathic medicine follows from the presumption that economical sets of principles and facts exist. The challenge is to discover those principles and facts and develop means to reason from them to the individual patient in a way that provides certainty. Medical reasoning implicitly evolved from variations of logical deduction and induction reflected in the hypothetico-deductive, pattern recognition, and intuitive approaches used in medicine today. However, these require the judicious use of logical fallacies that increase utility but at the cost of certainty. Similarly, medical research necessarily requires the judicious use of a variation on syllogistic deduction. Their necessary use creates risks for errors. Many problems in medical reasoning and research are the consequence of injudicious uses. This book is a critical and historical analysis of medical reasoning from this perspective.

What Are We to Make of Reasoning in Modern Medicine?

The suasive power of clinicians depends on the projection of certainty; with that suasive power, responsibilities to the patient have not diminished even if the clinicians’ authority has. Certainty is reflected in understanding, which is more than knowledge. Understanding allows reasoning beyond the specifics of knowledge, beyond the particulars. The variation in human manifestations represents either variation or diversity. In variation, all specific instances are variations on some canonical form. Diversity holds each instance as an entity unto itself. The epistemic choice of variety as variation or diversity determines medical reasoning. Biomedical research is confronted with the same challenges. The resort is to a special form of logic and epistemology that is organic, responding to needs, and synthetic, the product of humans. This evolutionary logic embraces a necessary use of logical fallacies. Science requires these fallacies, and thus scientism is limited and cannot replace medical reasoning.