Rethinking Causality, Complexity and Evidence for the Unique Patient

Front matter

Rani Lill Anjum Samantha Copeland Elena Rocca Editors

Rethinking Causality, Complexity

and Evidence for

Preface

The Story of CauseHealth

This book is a result of the interdisciplinary research project CauseHealth, Causation, Complexity and Evidence in Health Sciences, at the Norwegian University of Life Sciences (NMBU) from 2015 to 2019. The core team of CauseHealth during those years, located at NMBU, consisted of myself, Stephen Mumford, Samantha Copeland, Elena Rocca and Karin Mohn Engebretsen. Our international network of researchers and practitioners included more than 40 experts from a wide range of specialities: general practice, pharmacology, surgery, oncology, clinical psychology, experimental psychology, psychiatry, physiotherapy, osteopathy, immunology, cardiology, paediatrics, pharmacovigilance, nursing, epidemiology, systems medicine, behavioural medicine, public health, medical sociology, medical ethics, person-centred medicine and practice, evidence-based medicine and practice, medical humanities, medically unexplained symptoms, phenomenology and philosophy of medicine and causation.

The idea for CauseHealth was born back in 2011, after the first meeting of an earlier research project, Causation in Science. This project addressed some practical and methodological challenges for establishing causal relationships in science, by tracing these challenges back to how to understand causality, philosophically. Four broad areas were chosen: physics, biology, psychology and social science. Since most of the collaborators were interested in biology, the first project event was on this topic. We held an international conference: Causality and Reductionism in Biology and Beyond. Coincidentally, a few of the talks were on medicine, and in the afterthought of these, the first seed for the CauseHealth project was planted. After all, if it is difficult to understand causality in physics, biology, psychology and social science, then medicine must represent the ultimate challenge. The subject of medicine, the human being, is the unity of them all: the physical, the biological, the mental and the social. Our health affects, and is affected by, all these four dimensions.

There were three themes from the 2011 conference that inspired what later became the CauseHealth project. First, Thor Eirik Eriksen discussed the practical x Preface problem of dealing with so-called medically unexplained symptoms. In his presentation “Waiting for an Explanation’, he mentioned how these chronic conditions remain a challenge to the medical profession because of their heterogenic and complex nature (Eriksen et al. 2013). Second, he used the term ‘medicalisation’, which refers to a reductionist tendency in medicine to define more and more aspects of human life as medical issues. Third, Roger Kerry gave a talk with the title ‘Causal Dispositionalism in the Health Sciences’ where he argued that randomised controlled trials, the gold standard for establishing causal relationships, have a strong philosophical basis in the neo-Humean difference-making theory of causality. Together, these ideas inspired the three pillars of CauseHealth, which are methodology, ontology and practice:

— The philosophical and conceptual motivation for choice of scientific methodology in medicine (methods)

— The reductionist tendency of treating complex psychosocial phenomena as biomedical ones (ontological model)

— The practical challenge of establishing medical causes in cases of complexity and individual variation (practice)

Initially, the CauseHealth project was directed towards medicine and health sciences in general, without a particular focus on clinical practice. It turned out, however, that the philosophical themes and slogans capturing the essence of the project, such as ‘One size does not fit all’, ‘Statistics don’t get me’ and ‘N=1’, struck a chord with clinicians. We therefore wanted to create a resource specifically directed at healthcare practitioners. The plan was to gather the philosophical ideas that are most relevant to the clinical encounter, which can then be used as an intellectual resource for anyone working with individual patients. We have made an effort to present the philosophical material in a way that is accessible for nonphilosophers and to include contributions from eight clinicians and one patient from the CauseHealth network who show a practical way forward that is in line with the philosophical ideas. By including these texts, we hope that the more abstract philosophical ideas will become more concrete and useful for clinical practice.

This book is made possible by the generous funding from the Research Council of Norway and the Uppsala Monitoring Centre, the WHO Collaborating Centre for International Drug Monitoring. As for the contents of the book, this is entirely the result of all those people who have engaged with the CauseHealth project and shared their expertise and ideas with us over these past few years. Without the people who helped me develop and pilot the project from initial idea to proposal — Stephen Mumford, Svein Anders Noer Lie, Thor Eirik Eriksen and Roger Kerry — there wouldn’t even have been a CauseHealth project.

CauseHealth has been fuelled by the intellectual power, professional experience and personal engagement of so many. Ever since the beginning of CauseHealth, our collaborators and project network, many of whom have contributed to this book, have been vital sources of insights into the practical concerns and challenges facing clinicians and other healthcare professionals in their daily practice. We have been surprised and overwhelmed by the enthusiasm of practitioners participating in our

Preface xi

CauseHealth events or engaging with us on Twitter. So many of them have been invaluable ambassadors for the project by spreading and translating the philosophical ideas of CauseHealth to colleagues around the globe through talks, blogs, podcasts, articles and social media.

This book is written for and because of them.

As, Norway Rani Lill Anjum January 2020

Reference

Eriksen TE, Kerry R, Lie SAN et al (2013) At the borders of medical reasoning - aetiological and ontological challenges of medically unexplained symptoms. Philos Ethics Hum Med 8:1747-1753

Part I Philosophical Framework

Introduction: Why Is Philosophy Relevant for Clinical Practice? 64 4.¢kch iid tie oer keen eee bees dev ead 3 Rani Lill Anjum, Samantha Copeland, and Elena Rocca

Rani Lill Anjum

Elena Rocca

Rani Lill Anjum and Elena Rocca

Elena Rocca and Rani Lill Anjum

The Guidelines Challenge. ...c0.42.0005saceseecse0 anew aar Kens 95 Samantha Copeland

Part II Application to the Clinic Fi

Christine Price

Above and Beyond Statistical Evidence. Why Stories Matthew Low

Ivor Ralph Edwards xiii

Lessons on Causality from Clinical Encounters

Kai Brynjar Hagen

Reflections on the Clinician’s Role in the Clinical Encounter ... .

Karin Mohn Engebretsen

The Relevance of Dispositionalism for Psychotherapy

Tobias Gustum Lindstad

Roger Kerry

Brian Broom

Anna Luise Kirkengen

Conclusion: CauseHealth Recommendations for Making Causal

Rani Lill Anjum, Samantha Copeland, and Elena Rocca

Contents

Notes on Editors and Contributors

Editors and Contributors to Part I

Rani Lill Anjum is Researcher in Philosophy and Principal Investigator of CauseHealth at the Norwegian University of Life Sciences (NMBU). She leads the NMBU Centre for Applied Philosophy of Science together with Elena Rocca, where she works on the philosophical foundations of science with focus on causality, probability and dispositions. She has written four books with Stephen Mumford: Getting Causes from Powers, Causation: A Very Short Introduction and Causation in Science and the Methods of Scientific Discovery, published with Oxford University Press, and What Tends to Be: The Philosophy of Dispositional Modality, with Routledge.

Samantha Copeland is Assistant Professor in the Ethics and Philosophy of Technology section at Delft University of Technology. She was a postdoctoral fellow with the CauseHealth project and is on the editorial board for the annual philosophy thematic of the Journal of Evaluation in Clinical Practice. Copeland has published on the ethics of addressing unexpected results in clinical research that involves human subjects, including “The Case of the Triggered Memory: Serendipitous Discovery and the Ethics of Clinical Research’ and ‘Unexpected Findings and Promoting Monocausal Claims, a Cautionary Tale’. She is also Coauthor of ‘Pharmacovigilance as Scientific Discovery: An Argument for Trans-disciplinarity’, written with Ralph Edwards and Elena Rocca.

Elena Rocca is an Interdisciplinary Researcher with background in pharmacy, biology and theory of science at the Norwegian University of Life Sciences (NMBU). She is Principal Investigator of the project CauseHealth Risk and Safety and leads the Centre for Applied Philosophy of Science with Rani Anjum. She is on the editorial board of the International Journal of Risk and Safety in Medicine. Rocca is interested in the role of philosophical bias in the production and evaluation of evidence. She is Author of ‘The Judgements that Evidence-Based Medicine Adopts’

XV xvi Notes on Editors and Contributors and ‘Bridging the Boundary Between Scientists and Clinicians’ and Coauthor of ‘Real or Ideal Risk? Philosophy of Causation Meets Risk Analysis’ with Rani Anjum.

Contributors to Part II

Brian Broom was until early 2019 a Clinical Immunologist at Auckland City Hospital and is Adjunct Professor in Psychotherapy at Auckland University of Technology. He is trained in internal medicine and psychotherapy and now works to train clinicians to practice whole-person medicine and healthcare. He has written three books addressing this issue: Somatic Illness and the Patient’s Other Story, Meaning-Full Disease: How Personal Experience and Meanings Cause and Maintain Physical Illness and Transforming Clinical Practice Using a MindBody Approach: A Radical Integration.

Ivor Ralph Edwards is Professor of Medicine and Senior Advisor (Former Director) at the Uppsala Monitoring Centre, the WHO Collaborating Centre for International Drug Monitoring. He has worked in clinical toxicology in the fields of drug abuse, acute and chronic poisoning, toxicity from industrial chemicals as well as adverse drug reactions. He now works on medical and legal aspects of causality evaluation, as well as issues of risk and benefit evaluation and data mining approaches to support signal detection and evaluation. He is Coeditor of Pharmacovigilance: Critique and Ways Forward and Author of ‘Causality Assessment in Pharmacovigilance: Still a Challenge’.

Karin Mohn Engebretsen is a Gestalt Psychotherapist, with over 15 years of clinical experience from private practice. Her doctoral dissertation is on phenomenology and medically unexplained symptoms, with particular focus on burnout. She has written ‘Suffering Without a Medical Diagnosis’, ‘Naked in the Eyes of the Public’ and ‘Burned Out or “Just” Depressed?’.

Kai Brynjar Hagen is Senior Consultant in the Regional Centre for Morbid Obesity, North Norway. He is also General Practitioner, District Medical Officer for Communicable Diseases and Advising Senior Consultant in the Norwegian Labour and Welfare Administration (NAV). He is Specialist in Community Medicine and is interested in ecological thinking in medicine, from individual to health policy. He is interested in primary causes of obesity development and factors that contribute to maintain obesity, such as trauma or other stressors.

Roger Kerry is Associate Professor in the Division of Physiotherapy and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, University of Nottingham. He specialises on risks and adverse events of manual therapy, neck pain and headache as well as clinical reasoning. He holds a PhD in Philosophy with the doctoral dissertation Causation and Evidence-Based Medicine. He is Author of

Notes on Editors and Contributors xvii

‘Expanding Our Perspectives on Research in Musculoskeletal Science and Practice’ and Coauthor of ‘The Form of Causation in Health, Disease and Intervention’ and ‘Causation and Evidence-Based Practice’.

Anna Luise Kirkengen is Professor of General Practice in the Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), and has worked as General Practitioner for 30 years. She specialises on the health impacts of childhood violation and is Author of The Lived Experience of Violation. How Abused Children Become Unhealthy Adults and Inscribed Bodies. Health Impact of Childhood Sexual Abuse, ‘Creating Chronicity’ and ‘From Wholes to Fragments to Wholes—What Gets Lost in Translation?’ .

Tobias Gustum Lindstad has extensive background as a Clinical Psychologist both within secondary public mental healthcare and community-based primary care services, as well as in private practice. His research concerns the relevance of philosophy for psychology, psychotherapy research and mental healthcare. He is the main Editor of the book Respect for Thought: Jan Smedslund’s Legacy for Psychology, coedited with Erik Sténicke and Jaan Valsiner, under contract with Springer.

Matthew Low is a Consultant Physiotherapist in Musculoskeletal Conditions at the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust. He is a Visiting Associate at the Orthopaedic Research Institute, Bournemouth University. He also teaches on the topics of clinical reasoning and the management of spinal conditions as well as spinal manipulative physiotherapy. He is Author of ‘A Novel Clinical Framework: The Use of Dispositions in Clinical Practice. A Person-Centred Approach’ and runs the blog Perspectives on Physiotherapy.

Christine Price is affected by neuropathic nerve pain, which she has lived with since an injury in 2008. Recently she started to write, blog and talk about her experiences of living well with pain, directed at both clinicians and patients. She has been invited to sit on research advisory panels and is the first patient representative on the executive board of the UK’s Physiotherapy Pain Association. She is Coauthor of ‘A Person-Centered and Collaborative Model for Understanding Chronic Pain: Perspectives from a Pain Patient, a Practitioner, and a Philosopher’ with Rani Anjum and Matthew Low.

Abbreviations

ADHD APA AUT BMI CBT CT DSM EBHC EBM EBP GP HP LBP MSK MUPS MUS OA OCD PTSD RCT RSSO SMT SSRI TOFT WHO WPC attention deficit hyperactivity disorder American Psychological Association Auckland University of Technology body mass index

cognitive behavioural therapy computed tomography

Diagnostic and Statistical Manual of Mental Disorders evidence-based healthcare evidence-based medicine evidence-based practice

general practice

helicobacter pylori

lower back pain

musculoskeletal

medically unexplained physical symptoms medically unexplained symptoms osteoarthritis

obsessive-compulsive disorder posttraumatic stress disorder randomised controlled trials

Regional Centre for Morbid Obesity somatic mutation theory

selective serotonin reuptake inhibitors tissue organization field theory

World Health Organization

whole person care

List of Figures

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4.1

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The original evidence hierarchy of EBM. ..ccccccsccccossscssscasssensaseces 16 The vector model of causality cscisisiasconismnainaisstdotnacipareanemnacan 26 SUPACIae: Mier EROS aiora aides aasa 27 Additive WASTE RATIOS sreioenneon n 28 Dispositions with different strength of tendency «0.0... teers 28 A threshold eheet T areara NN 29 A vulnerable situation, where R is close

to the threshold for WNNeSS.,...i..ccc.cccesascoctansemesnereoauscnsarearadonvancanwccava 60 A robust situation, where R is far from the threshold

ar Pi es AIM AES istic ao a A N A change in methods and practice must start

from A Change: TORT RY sssini 83 Dişspösitions ona good day oeenn rar een E 117 Dispositions on a difneult day susreces 118 A dynamic threshold Tor Weal acs ccssevssdivascavaiawsasceaeousesrusenrededvenenes 120 Threshold on a difNCWt day ainai 120 Die Medica! TIEN saissetiae aaa ea e 182 The vector model part 1: patient and his/her

situational CHC UNM BLATICES 4 sdassssia neeiasvdnedteiionistiaiieumesistosmemieatieests 195 The vector model part 1: patient, situational

List of Figures

Randomised controlled trial methodology

The randomisation and allocation processes

create the counterfactual conditions

by which B(x) — B(y) would, under a counterfactual

account of causation, constitute a causal claim.

However, causation is happening in each group,

Part I Philosophical Framework

Chapter 1 A Introduction: Why Is Philosophy Relevant = 3 for Clinical Practice? Rani Lill Anjum, Samantha Copeland, and Elena Rocca

1.1 Why Philosophy?

No practice takes place in a philosophical vacuum and medicine is no exception. Health sciences and healthcare practice are enabled, shaped and restricted by some tacit philosophical assumptions, of which practitioners should be aware. What, for instance, does it mean to say that clinical practice should be based on the best available evidence? What counts as the best evidence? And what is the most relevant evidence for the clinical encounter? Although the scientific evidence is itself largely empirical, many normative aspects of evidence based practice are not, as we will explain. In this sense medicine and health sciences, like all sciences, contain some non-empirical elements. These could be concepts, methods, tools, or what we call ‘basic implicit assumptions’ or philosophical bias. We define philosophical bias as

Basic Implicit Assumptions in Science about how the world is (ontology), what we can know about it (epistemology), or how science ought to be practiced (norms). (Andersen et al. 2019, p. 1)

They count as biases because they skew the development of hypotheses, the design of experiments, the evaluation of evidence and the interpretation of results in specific directions. How we think the world is (ontology) will be reflected in the way we study it (epistemology) and how we think that science ought to be practiced (norms). In medicine and healthcare, philosophical biases would typically influence

R. L. Anjum (4) - E. Rocca

NMBU Centre for Applied Philosophy of Science, Norwegian University of Life Sciences, As, Norway

e-mail: rani.anjum@nmbu.no; elena.rocca@nmbu.no

Ethics and Philosophy of Technology Section, Delft University of Technology, Delft, The Netherlands

e-mail: s.m.copeland @tudelft.nl

© The Author(s) 2020 3 R. L. Anjum et al. (eds.), Rethinking Causality, Complexity and Evidence for the Unique Patient, https://doi.org/10.1007/978-3-030-41239-5_1 choice of methods (e.g. the evidence hierarchy), norms of practice (e.g. standardised treatment) or scientific framework (e.g. the biomedical model).

In the CauseHealth project, Causation, Complexity and Evidence in Health Sciences, we wanted to show how philosophical assumptions motivate particular norms, methods and practices in medicine and healthcare. If we want to see a change in the way medicine and healthcare are practiced, we therefore cannot leave the philosophical foundation on which they are based untouched. Any competing practices will require different methods, norms and philosophical assumptions:

PHILOSOPHICAL ASSUMPTIONS — NORMS —> METHODS — PRACTICE

For instance, we might want a healthcare system that acknowledges the patient as an integrative whole, where medical issues must be understood not only on the physiological level, but also within a biographical, social and cultural context. However, if the practice of medicine is premised on Descartes’ mind-body divide (what is called dualism) then no such integration of the whole person can be achieved. It seems, then, that any genuine and permanent change in practice and methodology will have to be motivated by a change in how we think about the world on the most fundamental level. In the words of osteopath Stephen Tyreman:

..-progress and development is not simply a matter of making new discoveries. It is a complex, multi-faceted process that involves good science, yes, but in the context of prevailing socio-cultural ideas and, most importantly, of an individual’s world-view. (Tyreman 2018)

This book offers a guide for rethinking some of these more foundational assumptions, or world-views, within medicine and healthcare. Such a foundational rethink seems timely and warranted. Since the introduction of evidence based medicine in the 1990s, there has been an increasing interest in methodological, conceptual and ontological discussions among medical researchers, healthcare professionals and philosophers of medicine. There are emerging movements, such as Person Centered Medicine and Practice, the Campaign for Real Evidence Based Medicine and the Critical Physiotherapy Network, to mention only a few. The historian of science, Thomas Kuhn, saw it as a sign of a paradigm in crisis when its members start participating in philosophical discussions (Kuhn 1962). We should not, however, characterise what we see in medicine and healthcare as a scientific crisis so much as a crisis in the philosophy that grounds it (Anjum 2016; Eriksen et al. 2013), as we now go on to show.

1.2 Philosophical Debates in Medicine and Healthcare

A number of concerns have already been raised in the profession about how medicine is defined and practiced, especially when this affects the clinic. We now present briefly some of the debates that are most relevant for the context of this book: debates about medical models (ontology), scientific methodology (epistemology) and clinical practice.

1 Introduction: Why Is Philosophy Relevant for Clinical Practice? 5 1.2.1 Debating Models (Ontology)

Beyond the Biomedical Model. The biomedical model of health and illness assumes that all medical conditions should be explained as some physiological abnormality. Conditions lacking such biomedical explanation are then characterised as medically unexplained or psychosomatic (Wade and Halligan 2004). A criticism of this is that health complaints must be seen as more complex, containing biological, social and psychological elements. Even if it were desirable to separate the psychosocial causes of health from the ‘medical’ ones, it might not even be possible (Arnaudo 2017). The bio-psychosocial model proposed by Engel (1977) was thus an attempt to move beyond the biomedical model, though many argue that the biomedical model is still dominating the paradigm in healthcare, both in medicine and psychology (Engebretsen 2018; Engebretsen and Bjorbækmo 2019).

Fragmentation of Care. Although co- and multi-morbidity are the norm in the clinic, medicine and healthcare tend to be organised according to single diseases (Mercer et al. 2009; Parekh and Barton 2010; Vogt et al. 2014; Tómasdóttir et al. 2015). This specialisation of medical disciplines was brought about in order to enhance and deepen the specialists’ skills and expertise. On the other hand, healthcare has been criticised for becoming increasingly compartmentalised, organised into distinct and sometimes isolated ‘silos’. This means that patients with chronic and complex health complaints must go through the healthcare system by moving from specialisation to specialisation, treated as fragments, not as wholes (Kirkengen 2018).

Medicalisation of Life. In current healthcare there is the hope that a biomedical treatment, such as a drug, might ideally treat effectively even complex psychosocial phenomena (Ballard and Elston 2005). On the other hand, the expansion of the medical domain into most aspects of life, such as fertility, sexuality, sleeping patterns, angst, ageing and grief, has been criticised. Some are worried about placing experiences that all human beings are expected to have in the ‘healthy-unhealthy’ category. Ultimately, such a move suggests that it is imperative that we treat those experiences medically rather than accepting or living through them (Burgess 1993; Pilgrim and Bentall 1999; Moloney 2010).

1.2.2 Debating Methodology (Epistemology)

Information Gets Lost in Statistics. One ongoing debate is over what it means that clinical decisions should be evidence based. In evidence based medicine and practice, causally relevant evidence is taken to be statistical and population based, generated from large clinical studies. The aim is thus to ground the care of individuals in general knowledge about what is the most effective intervention in a studied population (Sackett et al. 2000). Critical voices have raised concerns about the tension between the public health interest in equality of care and the clinical needs of individuals. While evidence based policy is widely informed about what happens elsewhere, the worry is that causally relevant information about the unique local context is disregarded or lost (Cartwright and Hardie 2012).

The Importance of Mechanistic Knowledge. In evidence based medicine and practice, randomised controlled trials (RCTs) are seen as the gold standard for establishing causality (Howick 2011). This is because, thanks to their experimental design, a well conducted RCT is the best way to isolate one causal factor from potentially confounding factors and see whether it makes a statistical difference in outcome. In contrast, some argue that causal relationships cannot be established without the use of unquantifiable factors such as the theoretical knowledge coming from the laboratory and clinical science (Charlton and Miles 1998). This is parallel to the ongoing debate in philosophy of medicine on whether statistical knowledge must be accompanied by a theory of causal mechanism for the purpose of establishing causality (Russo and Williamson 2007; Osimani 2013; Anjum and Mumford 2018).

A Call for Phenomenology. For ethical reasons, it is not possible to establish whether psychosocial factors causally affect health in a negative way using clinical experiments. For instance, one cannot test the causal impact of childhood trauma, abuse, grief, psychological stress or social stigmatisation using RCTs, the gold standard for establishing causal relationships. One way to overcome this problem is to substitute RCTs with other statistical methods, such as cohort studies or case-control studies. This is still within the framework of evidence based medicine and practice. Other approaches emphasise instead individual uniqueness and phenomenology, urging the profession to change its focus to the whole patient experiencing the condition (Loughlin et al. 2018, see also Engebretsen, Chap. 11, Broom, Chap. 14 and Kirkengen, Chap. 15, this book).

Limited External Validity. In the health sciences, like in many natural sciences, causality is studied through experimentation, within controlled and somewhat artificial settings. Because of the need to control for confounders, clinical trials use strict inclusion and exclusion criteria for recruiting the participants. On one side, such controlled conditions increase the reliability of the experimental results, and the confidence that the observed result is actually due to the tested intervention. At the same time, however, this limits the external validity of the studies. When facing chronically ill patients, older patients, pregnant women, or even children, it is therefore not obvious that the results from clinical studies apply directly in respect to dosage, efficacy or even safety (Rothwell 2005, 2006; Baylis and MacQuarrie 2016).

1 Introduction: Why Is Philosophy Relevant for Clinical Practice? 7 1.2.3 Debating Practice

Upgrading Clinical Judgement and Knowledge. One motivation for the introduction of evidence based medicine and practice was to ensure that patients got the best available treatment, independently of the experience or preference of their healthcare practitioner. Rather than depending entirely on clinical judgement and the authority of expertise, treatment should be given according to the best scientific evidence, preferably from RCTs and meta-studies. Of concern among healthcare practitioners is how this depreciation of clinical judgement affects the clinical encounter. In particular, when practitioners are encouraged to use guidelines and computational tools to diagnose and make decisions about treatment, this leaves less room for their own clinical expertise and knowledge of the particular patient at hand. A worry is that, in the process of decision making, data from other patients will weigh more than the evidence from the person seeking care (Greenhalgh 2018).

Efficiency at the Cost of Individual Needs. New Public Management is an increasingly popular global phenomenon that started in the late 70s, with the aim of improving efficiency of public services by making them more similar to businesses (Diefenbach 2009). The introduction of New Public Management has affected the way in which healthcare is financed, organised and executed (Simonet 2008; Wyller et al. 2013). Health service delivery is supposed to be time- and cost-efficient and resources are allocated according to generic standards, such as type of diagnosis. On the other hand, proponents of person centered healthcare worry about the current trend towards package solutions and standardisation of care. This approach often hinders the assessment of individual needs, they warn. An alternative management ideology for the health services, according to these critical voices, could be one where the suffering individual, and not societal needs, has priority in setting the course of care. Calls for action have been raised among medical professionals, urging that the New Public Management approach is leading to a decay in healthcare, rather than to an improved quality and efficiency (Wyller et al. 2013).

1.3 Aims and Overview of the Book

This book is intended as an intellectual resource for clinicians and healthcare professionals who are interested in digging deeper into the philosophical foundations of their daily practice. It is a tool for understanding some of the philosophical motivations and rationality behind the way medicine and healthcare are studied, evaluated and practiced, at the interface of science and the humanities. We will show how a change in the ontological foundation could motivate a paradigmatic change in scientific methodology and clinical practice towards a genuine person centred approach, focusing on the whole person. In particular, this book illustrates the impact that our thinking about causality, both philosophically and conceptually, has on the clinical encounter.

By ‘clinical encounter’ we mean, in the broad sense, a consultation between the healthcare professional and the individual person seeking care. This is not limited to medical practice, but covers healthcare in general, including nursing, psychology, physical therapy, clinical pharmacy, rehabilitation, homecare services, as well as individual preventive care or any follow up of the patient. Although many of our examples come from medicine and general practice, the philosophical ideas should have a wider relevance also for these other parts of healthcare. If some of the philosophical biases that dominate current medical thinking actually limit the notion of evidence in a way that disadvantages the clinical encounter, then this needs to be critically discussed. Being able to identify the non-empirical foundation of scientific norms and practices is thus a first and necessary step for critically evaluating them.

In this book we want to prepare the ground for a genuine transdisciplinary discussion, not only between healthcare professionals and philosophers, but also one that expands to decision-makers and patients (Rocca et al. 2019). The main aim of this book is to engage and empower healthcare professionals to take part in changing and defining the premises for their own practice. After all, if clinical decisions should be based on evidence, this ought to be evidence that is relevant and wellsuited for the clinic.

We have organised the book into two parts, Philosophical Framework and Application to the Clinic. The first part is written primarily from the philosophical perspective, by philosophers, and presents a singular overall framework. The second part is written primarily by clinicians who address some implications of the philosophical framework for different aspects of their own practice. The philosophical framework will thus be presented from different angles throughout the book, with more or less explicit focus on clinical practice. We hope that the diversity of voices, focus and perspective reflected in the chapters will contribute to make the philosophical ideas more accessible and relevant for practitioners with different professional backgrounds.

In the first part, we give an overview of the philosophical framework and themes of CauseHealth. In Dispositions and the Unique Patient we introduce the theory of dispositionalism and explain how this offers a better foundation for understanding causality in the individual case. In Probability for the Clinical Encounter we show how dispositionalism challenges the way we think about probabilities and propose an alternative — a singularist propensity theory — that we argue is better suited for the clinic. In When a Cause Cannot be Found we discuss how dispositionalism can throw some new light on medically unexplained symptoms, since this theory treats causal complexity, individual variations and medical uniqueness as essential features of causality rather than as problems for causality. Next, in Complexity, Reductionism and the Biomedical Model, we argue that a dispositionalist approach would deny any form of reductionism and render the biomedical understanding of

1 Introduction: Why Is Philosophy Relevant for Clinical Practice? 9 health and illness deeply problematic. Finally, in The Guidelines Challenge, we discuss the tension between clinical guidelines, based on general medical knowledge and aimed toward standardisation, and their use in the clinical encounter, based on local knowledge about the patient and aimed toward tailored interventions.