the medicalization of back pain

Here. An excerpt:

Now as I have said so many times before, the placebo effect is not about a sugar pill, it’s about the cultural meaning of a treatment, and our expectations: we know from research that two sugar pills are more effective than one, that a salt water injection is better for pain than a sugar pill, that colour and packaging have a beneficial effect, and so on. Interestingly, there has even been a trial on patients with arm pain specifically comparing a placebo pill against a placebo ritual involving a sham medical device, modelled on acupuncture, which found that the elaborate ritual was more effective than the simple sugar pill. “Placebo” is not a unitary phenomenon, there is not “one type of placebo”.

But the most important background information missing from the news reports wasn’t about the details of the study: it was about back pain. Because back pain isnt like epilepsy or tuberculosis. Most of the big risk factors for a niggle turning into chronic longstanding back pain are personal, psychological, and social: things like depression, job dissatisfaction, unavailability of light duty on return to work, and so on.

And the evidence on treatments tells an even more interesting psychosocial story: sure, anti-inflammatory drugs are better than placebo. But more than that, bed rest is actively harmful, specific exercises can be too, and proper trial data shows that simply giving advice to “stay active” speeds recovery, reduces chronic disability, and reduces time off work.
We don’t like stories and solutions like that for our health problems. There are huge industries telling you that your tiredness is due to some “chromium deficiency” (buy the pill); your cloudy headed foggy feeling can be fixed with vitamin pills, pills, and more pills. It is a brave doctor who dares to bring up psychosocial issues for any complaint when a patient has been consistently told it is biomedical by every newspaper, every magazine, and every quack in town.

cooked up thought experiments and the viciousness of ethics

I've been working on these thoughts for a while, but I hope they will be particularly relevant given the recent discussions of the so-called problem of ethics professors.

There is something that has always bothered me about the thought experiments / intuition pumps that are the ultimate data for ethics according to many people, and for even more people, the rhetorical device driving ethical writing. Consider the following typical case (drawn from a pretty much random source):

You are out in a small boat and come upon fifty people in danger of drowning. Your boat can only accommodate ten people, and there is not time to make more than one trip to shore. Furthermore, there are no other boats in the area, and no one close enough to aid in any other way. No matter what you do, at least forty of the fifty will die.

My immediate inclination in these cases is always to try to find some way out of these situations. This, of course, is cheating, the ethicist will say. If you press them, they will add further constraints that frustrate your creative solutions, until you are left with the "hard choice" that the ethicist wanted to probe your intuition about.

I suspect my annoyance at this procedure is pretty universally understood as a sign that I am not serious about ethics, that I'm being annoying, or that I am too thick-headed to see the point. I also suspect that there is a strong pressure to stop suggesting the creative solutions, and to "play along" when these kind of cases are brought up, so that the ethics discourse can continue. And certainly, taking a certain conception of what ethics is to do for granted, this would be a totally reasonable way to go.

But I've still got a nagging bit of dissatisfaction, here, that I want to probe. Why do people react this way to thought experiments in ethics in particular? No one tries to "weasel out" of thought experiments in physics (do they?). I think my worries begin with a strong feeling that ethics ought to be tied to helping people make concrete moral decisions. I know this isn't universally accepted; it isn't uncommon to make a distinction between decision procedures and standards of value, to focus ethical theory on the latter, and to ignore any impracticalities of it, because those only matter for the former. I don't buy it; I think ethics has to be strongly concerned with both, and that they probably aren't totally separable. For a criterion in ethics to be true, it seems to me that a minimal condition is that it ought to be usable in (at least some) concrete situations.

Here's how I analyze my dissatisfaction. It seems like what I, or the undergrad ethics student, or others who cause this kind of trouble are trying to do is actually a sign of a good moral sensibility. It's not that we're not serious, or annoying, or thick-headed. It's that we're trying to do what most people try to do, what one ought to do when faced with a moral problem: we're trying to find a solution that maximizes all the types of value at hand. This kind of problem-solving activity uses a variety of resources, including background knowledge from any relevant area, to try to come up with a better solution than the immediately obvious ones.

Take the example above. As I read, I have in mind a picture of what my boat looks like (smallish wooden boat with oars), and I start using my background knowledge to come up with ideas about how we could save more people. Perhaps a few people could use the oars for flotation? Perhaps we could break up the boat and everyone could have a large enough piece to stay afloat? What if, instead of just letting 10 people in the boat, I let as many people as can manage grab on to the side to stay afloat? Etc.

And I start to think about reasons to take certain people over others. I should pick women and children, and probably I could fit more. I'd pick people who look weak or like poor swimmers, and try to come back for the others. Maybe I'd pick one or two stronger looking fellas who could paddle the boat faster than I could. And so on.

None of these considerations are supposed to be allowed, of course, because the point is that we want to theoretically explore the case when we can only save 10 out of 50. We want to ask something about our obligations, or their claims, or whether there is moral remainder, or whatever. They don't want the creative solution because it prevents us from facing genuine conflicts of value, which is one of the things they are interested in exploring. So the ethicist will keep adding stipulations until you are forced to deal with the issue that interests them.

And, given enough examples with this, you're probably going to get driven out of ethics, or you're going to fall in line. This actually strikes me as quite a vicious result! One of the results of studying ethics, then, is to squash one's ability to engage in ethical deliberation! No wonder that it's said: "nothing makes a man so much of a scoundrel as a prolonged study of ethics"[1]. In this case, we should recommending to students who might hope to become more skilled at solving moral problems, or become more reflective about right-behavior, to at all costs stay away from Ethics courses!

A further worry goes to the heart of the enterprise. I think the most sensible way to understand the point of intuition-pumping must be that it is supposed to make explicit the wisdom implicit in our practices of ethical choice-making, or, a bit more opaquely, to find out our core commitments or basic beliefs at the level of particular judgments. There is a worry, though, that since, in the course of intuition-pumping, we actually end up pretty far away from normal practices of ethical problem-solving, that whatever the thought experiments produces is going to be loosely if at all related to any actual implicit wisdom we have or practical judgments that we would make.

[1] It is quite difficult to find the original source of this saying. I've seen it alternatively attributed to C.S. Peirce and G.K. Chesterton.

Teaching Philosophy?

Howdy philosophers!

Well, in response to Matt's plea for posts, I thought I'd weigh in on a topic that I've
been thinking about recently, since I'm teaching existentialism (again) this summer.
Since I'm pretty certain that teaching will be the largest part of my academic life
after I leave here, I'd like to be able to articulate a coherent theory about how one
should teach philosophy (or maybe, how one should teach at the university level more
generally).  It's easy to fall into cynicism and apathy about teaching after a few bad
experiences, and I'm just as guilty of this as anyone else.  But given that most of our
students only get a single (or, if we can get them hooked, a couple years of) exposure
to philosophy, it seems like we should be thinking about how to make the most of that
opportunity (or those opportunities, if we're talking about majors).

I know that there are articles about this type of thing floating around; one author whose
work on pedagogy that I really like is Parker Palmer, and I could do a lot more reading to get
ideas.  But I'm sure some of you have thought about this as well.  Does anyone have
particular recommendations, or thoughts on the matter?

Common Sense and Scientific Inquiry, OR why I'm always tripping over my feet

Almost every day I trip over my feet: I catch my toe on a curb, shuffle over some uneven piece of pavement, mis-step down a stair, or trip over a shoelace. I've never met someone who stumbles as much as I do. But I almost never actually fall over. I'm a master in terms of using my momentum, flailing my arms, and other strategies that doubtlessly make me look ridiculous, but pretty much do a great job of keeping myself upright. And I was walking to LSE this morning, after such a close save, thinking about all this. And thinking about whether there might be something about the way I walk that causes the problem (doubtless this is the case).

Then it occurred to me that this was the perfect analogy for something I've been thinking about recently. John Dewey, perhaps notoriously, maintains that scientific and common sense inquiries are of fundamentally the same type, operating the same sort of way. This is extremely dubious to most people, given the obvious dissimilarities (how is Loop Quantum Gravity or Evolutionary Genetics anything like fixing a bike?). Dewey maintains that the only difference is that scientific inquiries are more systematic, more concerned with general relations and long-term consequences that immediate circumstances, but they have the same basic pattern, and they serve the same basic type of goal (solving a concrete problem rather an abstract one like "discovering the true structure of reality" or "saving the phenomena"). How to understand this?

Well, here's an analogy. Clearly, something like problem-solving has gone on as I attempt to compensate for my clumsiness. I have developed a set of solutions to help me recover from a fall (this has actually proved useful this year as I've pursued the quixotic venture of trying to learn how to skateboard, with only a few tumbles and even fewer serious ones, though many ungraceful recoveries). These solutions are more or less particular solutions to immediate problems. But when I begin to think more systematically about the way I walk, I begin an inquiry that is more scientific in nature. I'm concerned now not so much with an immediate problem, but a generic set of consequences and a systematic cause for them. To follow the inquiry out might take me through areas of physics and physiology, and perhaps ending in a general theory of walking that could be used to correct particularly clumsy gaits.

The advantages to this approach are the same advantages that Dewey names for science. Solutions developed here are potentially applicable to any person, if done well enough, and they cut to the problem right at the source, rather than develop more fragile and immediate solutions. It could be used to inform more immediate inquiries in a way that helps develop more permanent and robust solutions, though of course any application will itself require some degree of inquiry, rather than being totally automatic.

Anyhow, I thought that was a pretty neat illustration.

Kit? Fine.

Have ya'll seen this?



(props to Adam.)

Elements of a Pragmatist Theory of Social Inquiry

Part One: A Pragmatist Framework for Inquiry

First, I will defend a broadly pragmatist, Deweyan model of inquiry. Time does not permit me to flesh out Dewey's theory of inquiry in full detail, nor to explain the difference between my own views and his, but I will concentrate on the following features of the pragmatist framework of inquiry. First, inquiry begins with a situation that is pre-cognitively problematic; the problem is a matter of an objective but also qualitatively felt conflict in the situation, not merely due to subjective or theoretical factors, and the explicit formulation of the problem comes within inquiry itself, rather than occurring prior to inquiry. It is the objective, precognitive, problematic situation which lends significance to the problem at hand. Second, inquiry draws the resources for resolving problems from the situation itself; the materials of inquiry are always immanent, not transcendent. Third, inquiry proceeds by complementary processes of gathering data and proposing solutions; these processes coevolve and both facts and ideas are mutually revisable. Fourth and finally, competent inquiries require not only processes of reasoning but also experimental interventions.

The first key element of a pragmatist framework of inquiry is the claim that all genuine, significant inquiry begins not with mere "paper" problems, but with precognitively felt problematic situations, situations whose problematic nature arises from objective conflicts within the situations themselves. A crucial and ongoing part of inquiry is formulation and refinement of the problem itself, the attempt to explicitly represent the implicitly felt difficulty.

Inquiry must rely on resources within the situation in order to solve the problem: the accumulated wisdom of the inquirer in terms of facts, theories, methods, and values developed in prior inquiries, the factual conditions present in the situation, and the ongoing opportunities for tentative intervention and testing. There is no room for transcendent factors in a pragmatist account.

There are two major types of resources available to the inquirer: facts and ideas. Facts are data that represent concrete features of the situation, particular or universal. The main function of facts in inquiry is to indicate set conditions or constraints: first, in determining what the problem at hand is, then, in constraining the field of possible solutions. Ideas are representations of operations to be performed on the situation in order to solve the problem. Their content is conceptual or ideal in the sense that it represents not actually existent conditions, but rather future possibilities for activity that might result in problem solutions. Instead of constraining inquiry, ideas attempt to indicate the open possibilities of inquiry. They are doubly hypothetical: they are hypotheses for solutions of the problems, and they are hypothetical imperatives for action.

Besides two types of resources that are available to inquirers, there are also two broad types of techniques that are available: reasoning and experimentation. The role of reasoning is quite familiar: it helps us work out in an abstract way the consequences of certain ideas. Solving any problem also requires experimental operations of making and doing. Ideas cannot be tested by a purely passive collection of facts through observation. Active interventions of an experimental nature provide necessary evidence about the prospective effectiveness of solutions.

Part Two: Evaluative Inquiry and Social Problems

The theory of inquiry discussed up to this point is meant to apply generally to all types of inquiry. The theory is insofar necessarily quite schematic, and has often been criticized for being so general as to be empty (Rorty 1986). I hope that I have given you a flavor of the significant, substantive points made in a general theory of inquiry like Dewey's. Now we turn to what inquiry looks like in more specific terms once we turn to inquiry into values and social problems.

Social inquiry is necessary whenever the problematic situation is essentially a problem of social structure, coordination, or relationships. Problems of social inquiry often take the form of crises of value, where inquiry will focus on evaluation or reevaluation of previously held values. We need to know not just what is going on in the situation, or what is to be done in the situation, but how we should value (things in) the situation. The subject-matter of social inquiry generally has an emphasis of this kind.

In contrast to many philosophical traditions of social inquiry, the pragmatist must insist that the problems of social inquiry are not set prior to inquiry. Problems arise from concrete problematic situations, and are specified and revised in response to those situations. The problems of actual social inquiries, rather than mere intellectual games, are not "big questions" that have been set for social inquiry from time long forgotten. While the problems may be quite generic because of a very wide scope, they are also quite particular to a concrete, culturally and historically situated context.

The values that play a crucial role in inquiry are not brought in from outside of it, as unyielding constraints on inquiry. Values, as much as any material that plays a role of inquiry, are subject to revision and refinement in the attempt to resolve a problematic situation. Certain values may be rejected as too constraining; certain goals might be rejected as too utopian. Facts may come to light that show certain of our values to be in conflict with other deeply held values. There are in general many ways that the process may require the modification or rejection of values.

Experiment is practically more difficult in social inquiry than in physics; this much is obvious. Yet, methodologically, it is no less important. Experimentation should not be construed too narrowly: as much as we would like all manner of efficacious controls on our experiments, these will not be appropriate or practicable in every circumstance. The major opening for experimentation in social inquiry comes in the realm of policy: social policy ought always to be of the form of an experiment. There is no possibility of having all the evidence in before making policy recommendations; policy must always be seen in the logical role of ongoing experimentation.

Part Three: Politics As Method

In the prior section, we have discussed inquiries into problems whose subject-matter was explicitly social. But it should be fairly clear that these are not the only situations in which inquiry may evaluate or transform social structures. Indeed, we must all realize that, even if political values as ideology are not to be imported into inquiry, that inquiries take place in a socio-political context, and all the more so for scientific inquiry, which involves an entire social structure of its own.

That the social structures of science can have epistemological ramifications may appear quite obvious to many. In many circles, these effects are taken as resources for a kind of global skepticism about the prospects of science, while more moderate epistemologists and philosophers of science such as Kitcher, Longino, and Goldman attempt to provide a social epistemology of science that can allow us to evaluate the relationship between social practices of science and scientific knowledge. Yet few have recognized that the epistemic requirements of inquiry can have socio-political ramifications that reach beyond the structures of scientific institutions into political institutions more broadly.

James Robert Brown has argued in recent work (2006) that in the case of medical research, the structures of scientific funding and the practices of corporations create systematic biases that make reliable scientific research impossible. Solutions that focus narrowly on epistemological standards of research or on the internal political structures of science fail to remove the distortions. The problem lies instead in the very nature of corporate initiation and funding of research. Brown proposes a seemingly radical solution: remove the corporate funding by socializing medical research and abolishing intellectual property rights for drugs and medical procedures. Yet the argument relies not on radical political values, but on basic methodological concerns: when we discovered the placebo effects systematic distortion of results, we had to change our methods in order to remove the source of bias; hence, double-blind trials. When the systematic distortions come from the political structures that science is embedded in, we may need to alter those political structures, on purely methodological grounds.

Part Four: The Problem of the Criterion and an Adaptive Model of Value

We've seen a number of ways in which inquiry can be social: it can be inquiry into social problems, or it can be inquiry that requires social adjustments. Often, it is both. These inquiries depend crucially on epistemic, social, and political values. Social inquiry, like all inquiry, often requires an adjustment of our values. And yet, the pragmatist framework I've been discussing here provides no absolute standard for evaluating judgments. In order to judge whether the right or wrong decision has been made, don't we need a set of criteria in which such judgments can ultimately be grounded?

Consider the process of adaptive management in ecology (Norton 2005). Adaptive management is an iterative decision-making process under uncertainty that begins with a plurality of objectives and attempts to maximize those objectives along an adaptive path of development. Multiple criteria and multiple scales can be used, reflecting a plurality of interests and values, and a process of feedback, learning, and Bayesian inference can lead towards increased achievement of goals that also get refined in the process.

Adaptive management is an iterative process that leads to progress of both values and achievements. It requires no external standard of value to judge its success; rather, the internal concerns of participants are sufficient to identify that success. Pragmatism insists that such internal standards are all that is available within the situations in which inquiry takes place, and so an iterative process of evaluation is what we must settle for.

References

• Brown, James Robert. (2006). "Politics as Method: The Case of Medical Research," PSA 2006, not yet published.


• Norton, B. G. (2005). Sustainability: A Philosophy of Adaptive Ecosystem Management. U Chicago Press.


• Rorty, R. (1986). Introduction. In Boydston, J. A., editor, The Later Works of John Dewey, Volume 8: 1933, pages ix–xviii. Southern Illinois UP.

Blog Update

Hi there - I just updated the Blog to the new version of Blogger. I changed the template to a new option. Should I leave it or change it back?

For some authors, you'll be asked to change your Blogger account into a new/existing Google account, which is an easy process. And I guess that the "Contributors" list is gonna look small until everyone's accounts are updated. But things are rather nicer on the backend, anyhow.

Is everyone satisfied with the look and feel of the blog? With the title and description? Email me some new ideas, or post them in the comments here, and I'll update it to something more popular.