I.1 The Road to Medicine’s “Golden Age”

Among our most universal and intimidating human experiences, the confrontation with disease occupies a prominent rank. Throughout history, a plethora of varied forms of folk and professional healing practices have aimed to fight disease, to enhance the ability to cope with it, and to render it meaningful. But during the course of the nineteenth century, the emergence of scientific medicine quickly changed the relatively pluralistic landscape of healing practices. Major discoveries such as the cell at the center of pathological changes and the “germ theory of disease” dealt a deathblow to theories that had dominated Western medicine since the ancient Greeks (e.g., the humoral theory of disease). Advances in physics, chemistry, and biology converged to form a basis for the field of medicine, which rose from a craft based on observation accumulated at the patient bedside to the level of a respectable branch of science. Since then, apart from scientific and technological advances, two mutually reinforcing tendencies have fueled the unparalleled rise and expansion of medicine.

The first is the socialization of medicine, which refers to the increasingly organized allocation of public funds to more or less centralized health services. Policymakers discovered the potential of medicine. In times of peace, the efficient functioning of complex industrial economies required a population that was both literate and healthy. In times of war, substantial injections of public funds into centralized health care services helped to sustain civilian morale and keep soldiers in the field. The provision of health services through subsidized medical facilities (e.g., dispensaries and hospitals) and national insurance plans became a way to attain political stability, to moderate the menace of sickness among poor people, and to control dangerous environmental conditions caused by massive industrialization. By the mid-twentieth century, citizens of financially recovering Western European states had access to a variety of state-supported medical schemes. In the US, a national health program did not develop, but in spite of an ideological commitment to private medicine, the government carried a growing share of health care through the Armed Services, the Veterans Administration, and the Public Health Service (Porter Reference Porter2002).

The second tendency is what we could call the medicalization of the social realm, which refers to a development whereby medicine expands its reach into an increasing number of private and public areas of life. An increasing number of previously nonmedical conditions came to be defined as medical conditions, which required diagnosis, prevention, or treatment (Broom and Woodward Reference Broom and Woodward1996; Conrad, Mackie, and Mehrotra Reference Conrad, Mackie and Mehrotra2010). Social movements functioned as promoters for medicalization, helping change the understanding of behaviors formerly defined as deviant (i.e., immoral, sinful, or criminal) into disease symptoms. A number of conditions like alcoholism, psychopathy, eating disorders, sex addiction, and learning disabilities turned from badness to sickness. Alcoholism is a good example of a case in which a new understanding of alcoholism as a disease was chiefly accomplished by the efforts of a social movement (Alcoholics Anonymous), while the medical establishment initially held back. As the reach of medicine widened, emerging statistical knowledge about the distribution of disease and its relationship to other variables (e.g., class, education, housing, diet) gave rise to population-level measures targeting the seemingly healthy (e.g., screening, testing, prenatal care) and to appointing doctors as factory inspectors, medical officers, analysts, and forensic specialists to help implement policies and laws (e.g., food and drug control, workplace safety, sanitation).

Socialization and medicalization played substantial roles in the development of medical science in the twentieth century (Porter Reference Porter1997; Reference Porter2002; Le Fanu Reference Le Fanu2012). Medicine transformed from a small-scale practice into an immense global industry, and from a craft to something that many have regarded as an emblem of scientific progress living up to the ideals of the Enlightenment, overcoming ignorance, and superstition for the benefit of mankind. In particular, the mid-twentieth century is often portrayed as the “golden age of medicine,” an era characterized by scientific and therapeutic advances and high levels of public esteem bestowed upon the medical profession. To mention a few achievements, the main dangers to human life before World War II that were responsible for the deaths of millions of people (e.g., septicemia, tuberculosis, pneumonia, tetanus, polio, syphilis, meningitis) became treatable or preventable by vaccination by the 1980s.Footnote ¹ The discovery of insulin as a treatment for type 1 diabetes marked a key breakthrough, and so did the invention of high-tech tools that enable early diagnosis (e.g., cytogenetic, biochemical, and molecular testing) and formerly inconceivable forms of surgery (e.g., organ transplants, laser surgery).

It is important to point out that the talk of a “golden age” sometimes underestimates the effect of factors such as better living standards on improvements in health (McKeown Reference McKeown1976; for a discussion, see Bynum Reference Bynum2008; Kaplan and Milstein Reference Kaplan and Milstein2019) and that “revolutionary narratives” about advances sometimes interfere with more nuanced and critical analyses of therapeutic successes and contributions to longevity (Farmer, Basilico, and Messac Reference Farmer, Basilico, Messac, Greene, Condrau and Watkins2016). But while it is important to keep in mind that most of the gains in the first half of the century are associated with improved nutrition, sanitation, housing, and public health measures, medical advances (new drugs, devices, and procedures) have been a significant source of increases in longevity since World War II (Cutler, Deaton, and Lleras-Muney Reference Cutler, Deaton and Lleras-Muney2006b; Fuchs Reference Fuchs2010).Footnote ² This is true even if these successes coexist with numerous areas in which cures continue to elude medicine’s reach (e.g., cures for influenza, fibromyalgia, cancer, Parkinson’s, schizophrenia), or in which available interventions are of limited effect (e.g., statins, type 2 diabetes drugs, selective serotonin reuptake inhibitors [SSRIs]).

I.2 The Criticism of Medicine and the “Age of Disappointment”

Echoing themes from earlier criticisms of medicine as well as adding new aspects, the beginning of the twenty-first century has witnessed the emergence of a critical movement that advocates the reevaluation of medicine’s efficiency and societal role. Even though the social determinants of health are now more widely acknowledged (Aronowitz Reference Aronowitz2019), leading medical professionals, epidemiologists, and historians, as well as some voices among the general public, express doubt that the status medicine enjoys in contemporary Western societies is justified (see, e.g., Porter Reference Porter2002; Stegenga Reference Stegenga2018; Broadbent Reference Broadbent2019). For example, in a publication in The Lancet, prominent gastroenterologist Seamus O’Mahony (Reference O’Mahony2019a) argues that we have entered the “age of disappointment,” characterized by declining trust in medicine and growing criticism of it.

Three forms of criticism stand out, each highlighting challenges to contemporary medicine. First, skeptics, who rank among the most prominent and respected physicians and epidemiologists, maintain that confidence in the effectiveness of many medical interventions ought to be low (see Stegenga Reference Stegenga2018). Numerous medical interventions are unsuccessful, and many others do not fare considerably better than a placebo. Moreover, we often see evidence suggesting that an intervention is effective even when it is not, in part because the institutional structure producing medical research is biased in favor of positive evidence and against reporting negative findings.

Second, critics maintain that overmedicalization occurs, meaning that medical resources are improperly used to address political, social, and personal problems and turn these problems into pathological conditions (Parens Reference Parens2013). The expansion of the category of what demands medical intervention is often driven by predominantly social judgments about what is considered appropriate (in terms of body, behavior, personality, etc.). This contributes to the explosion of the costs of medical treatment, and leads to overtreatment (Scott Reference Scott2006; Conrad Reference Conrad2007).

Third, critics target what might be called objectification in medical care. Increasingly technologically mediated interaction contributes to discounting the personal experience of illness and the psychological and social dimensions of ailments (Cassell Reference Cassell2004; Marcum Reference Marcum and Marcum2012; Topol Reference Topol2019). It predisposes seeing the body of the patient as a system made up of interacting and separately operating parts, increasing the likelihood of medical professionals forgetting that they are engaged with persons in vulnerable states (Engelhardt and Jotterand Reference Engelhardt and Jotterand2008). These issues lead to an increasing dissatisfaction in patients, which may be one of the reasons for the growing popularity of complementary and alternative medicine (Astin Reference Astin1998; Bivins Reference Bivins2010).

Taken together, the charge is that medical science is less trustworthy than generally thought (skepticism), medical means are used to address nonmedical problems (overmedicalization), and medical care is inadequate (objectification). The criticism is thus comprehensive because it targets medicine both as medical science and medical practice, claiming that medicine has diverted from its course such that its aim fails to be realized in the current institutional settings.

I.3 The Aims of the Book

The sheer scope and depth of the criticism and the problems it highlights suggest that medicine has reached a critical threshold and indicate that medicine’s scope and role in society is fated to be altered in the twenty-first century. This situation provides a fertile ground for addressing fundamental, philosophical questions about medicine. In particular, the different strands of criticism seem to converge on fundamental questions, namely about (a) the nature of medicine and (b) the aim of medicine, while also implicating central concepts in medicine such as health and disease. First, whether medicine can be justifiably accused of failing as a science (skepticism) will depend on what its nature is, that is, to what extent it can be adequately described as science. Second, whether the charge of overmedicalization is warranted will depend on what the aim of medicine is. If medicine is aimed not merely at fighting disease, but at enhancing well-being in the widest sense, then the charge might not be justified. Third, whether the charge of objectification is vindicated will depend on what the aim of medical care is. If it is merely the removal and prevention of disease, then the charge might not be justified.

If these considerations are on the right track, then we may presume that a systematic philosophical examination of these fundamental questions carries the potential to assist in the approaching deliberation about the future of medicine as a science and clinical practice. Aspiring to assist such a deliberation, this book pursues three main goals. It offers:

1. (1)

   an account of the nature of medicine

1. (2)

   an account of the aim of medicine

1. (3)

   a Moderate Position based on these two accounts that rethinks the challenges to medicine and outlines possible solutions.

Much of the current literature operates with more or less implicit assumptions about the nature and aim of medicine. With respect to the question about the nature of medicine, one influential view is that medicine is something other than science, as it merely applies science and does not pursue knowledge for its own sake (see, e.g., Pellegrino Reference Pellegrino1998; Miller Reference Miller2014; Miller and Miller Reference Miller and Miller2014). With respect to the question about the aim of medicine, the standard view is that the aim of medicine is to cure diseases, or at least to deliver proper care by using the arsenal of available medical interventions. However, as we shall see in the course of this investigation, neither of these answers, nor recent alternatives, is satisfactory, which obstructs productive debates about medicine. Instead, this book proposes and defends more precise formulations of three broad theses about the nature and the aim of science and medicine:

Systematicity Thesis:

Medicine is science, that is, systematic inquiry.

Understanding Thesis:

Scientific inquiry in medicine aims at understanding.

Autonomy Thesis:

The primary purpose of understanding in medicine is to promote health, pursued to the extent that it serves or is at least consistent with the final aim of promoting autonomy.

To reach its objectives, the book outlines a particular way of philosophically engaging science and medicine that guides the investigation. It develops an approach, best described as a normative philosophy of medicine, which focuses, for example, not only on what medicine is, but also on what it should be, and not only on how medical knowledge is deployed, but how it should be deployed. The approach operates with three levels of analysis and shows that the current criticism and challenges to medicine require addressing basic questions on all three levels. The approach can be located at the intersection of two different philosophical approaches to medicine. One largely pursues analytic aspirations, clarifying metaphysical and epistemological issues in order to analyze theoretical and practical aspects of medicine. The other largely pursues normative aspirations, aiming to comprehend ethical issues in health care and apply ethical reasoning to assist decision-making. Neither of these is entirely suitable for the tasks of this book, as the separation of analytic and normative considerations would risk overlooking how fact and value are often inescapably joined in the realm of medicine.

I.4 The Structure of the Book

Chapter 1 lays the groundwork and contributes to comprehending normative issues in medicine by offering an analysis of three prominent forms of criticism that target contemporary medicine. First, the chapter explores skeptical criticism, which maintains that except for a few “magic bullets,” confidence in the effectiveness of medical interventions ought to be low (see Stegenga Reference Stegenga2018). Second, the chapter surveys the criticism of overmedicalization, defined, as opposed to the neutral term “medicalization,” as the improper usage of medical resources to address political, social, and personal problems. Engaging critics (e.g., Moynihan and Cassels Reference Moynihan and Cassels2005; Conrad Reference Conrad2007; Le Fanu Reference Le Fanu2012; Parens Reference Parens2013), five reasons are presented for thinking that overmedicalization is problematic. Third, the chapter explores the charge of objectification, which raises vital questions about medical care (e.g., Cassell Reference Cassell2004; Haque and Waytz Reference Haque and Waytz2012; Capozza Reference Capozza2016; Topol Reference Topol2019). The chapter clarifies this criticism and explores technological mediation and deindividualization in health care environments as contributing factors.

The last part of the chapter draws on work on criticism (e.g., Popper Reference Popper2000), arguing that two features unite the three predominant forms of criticism. The first feature is that the criticism is social in the sense that its object is a social practice and not merely the actions of individuals engaged in the practice (see Haslanger Reference Haslanger2018). The second feature is that the criticism is internal in the sense that the standards of evaluation employed are internal to the practices criticized and not external and independently justified. It is argued that the three forms of criticism build on the implicit assumption that medicine fails to meet its own internal standards: it has diverted from its course such that its aims are not adequately promoted in current institutional settings. But then, the different strands of criticism seem to converge on more fundamental questions about (a) the aim of medicine, (b) the nature of medicine, and (c) the key concepts of health and disease. The vast majority of the chapters in this book (Chapters 3–7) are predominantly dedicated to addressing these fundamental questions.

In order to achieve these aims, Chapter 2 presents and defends a particular type of philosophical engagement with medicine that guides this book: the normative approach. In a critical dialogue with existing work on normativity in the philosophy of science (e.g., Sober Reference Sober2008; Kitcher Reference Kitcher2011; Kaiser Reference Kaiser2019), the chapter outlines a normative approach to the philosophy of science that distinguishes between three levels of analysis (i.e., aims, nature, and key concepts), corresponding to the types of questions that current challenges to medicine raise. This grounds a particularly attractive normative approach to philosophy of medicine that considers philosophy of medicine as a proper subdiscipline of philosophy of science.

The approach deserves the label “normative” for several reasons. It uncovers norms linked to the aims, nature, and key concepts of medicine, assesses to what extent they are actually fulfilled in practice, and offers corrections based on these findings. Moreover, it allows for evaluating the merits of the current criticisms of medicine, and parts of the chapter are dedicated to showing how its three levels of analysis can contribute to addressing the criticism and challenges to which Chapter 1 drew attention. But, it is important to highlight that – consistent with what Chapter 1 said about internal criticism – the approach is normative in a particular manner: it is a second-order philosophical inquiry that is continuous with normative elements that are already more or less explicitly present in medical science and clinical medicine. This aspect, call this the Continuity View, breaks with an influential tradition in the philosophy of medicine, which sometimes openly advocates, and sometimes implicitly assumes, that philosophy is discontinuous with science and that philosophical work on medicine is therefore “detached from the method and content of medicine” (Pellegrino Reference Pellegrino1986, 13; Reference Pellegrino2001). The chapter offers a defense of the Continuity View against objections that could be launched by proponents of a traditional view in the philosophy of medicine like Edmund Pellegrino. It is shown that due to its scope and the three levels of analysis it highlights, the normative approach displays important advantages compared to traditional accounts and is particularly well positioned to help reach the goals of the investigation in this book.

In order to approach particular questions about the nature of medicine and the extent to which it is a genuinely scientific enterprise, Chapter 3 addresses the general question about the nature of scientific activity with special attention to medicine. While one influential view is that medicine is something other than science, as it merely applies science and does not pursue knowledge for its own sake (see, e.g., Pellegrino Reference Pellegrino1998; Miller Reference Miller2014; Miller and Miller Reference Miller and Miller2014), one main task is to defend the Systematicity Thesis, according to which medicine is science, that is, systematic inquiry.

The chapter starts by consulting the literature on the “demarcation” problem in the philosophy of science. It is argued that the failure of well-known approaches should not lead us to abandon the issue, but rather to pose the demarcation question in a different manner and proceed without entertaining essentialist expectations and hence ahistorical or discipline-independent necessary and sufficient conditions. Science is best seen as a family resemblance concept, and the most promising way to consider the sciences as united is not through some intrinsic property, but a relational property that only admits differences of degrees to nonscientific inquiries. The Deflated Approach adopted in this chapter is based on Paul Hoyningen-Huene’s (Reference Hoyningen-Huene2013) account of systematicity as a necessary condition for science. It is shown that medicine (i.e., medical science and clinical medicine) meets the requirement for systematicity. Of course, the fact that medicine fulfills a necessary criterion for science does not establish that it is one, but as it displays systematicity on all the considered dimensions and is more systematic than its everyday counterpart, we have good reasons to think of medicine as science. In the last part of the chapter, it is shown that the Systematicity Thesis is able to differentiate medicine from activities widely recognized as pseudoscience. In a critical dialogue with recent work (e.g., Oreskes Reference Oreskes2019), the chapter shows that homeopathy does not exhibit the type of synchronic and diachronic systematicity that characterizes scientific endeavors and it therefore remains susceptible to a variety of biases. Systematicity helps generate reasoning and inquiry that produce reliable knowledge and understanding.

The defense of the Systematicity Thesis helps clarify the nature of medicine in terms of systematic, scientific inquiry. But what is the aim of scientific inquiries in medicine? Focusing on the epistemic aim of inquiry, Chapter 4 seeks to make a critical step toward answering this question by focusing on medical science, which, as described in Chapter 3, encompasses clinical as well as medical laboratory research, and only counts as properly medical if it displays a practical orientation, that is, if it is ultimately motivated by contributing to the maintenance of health and the diagnosis, prevention, and treatment of disease. The main thesis of the chapter, the Understanding Thesis, holds that inquiry aims at understanding, while the question of what special kind of understanding is at stake in medicine is the topic of subsequent chapters. Drawing on recent debates in epistemology (e.g., Kvanvig Reference Kvanvig2003; Pritchard Reference Pritchard, Millar and Haddock2010; Grimm Reference Grimm and Fairweather2014) and in a critical interchange with prominent work in the philosophy of science (Kitcher Reference Kitcher2001; Reference Kitcher2008; Reference Kitcher2011; Bird Reference Bird2007; Reference Bird2019a; Reference Bird2019b; Douglas Reference Douglas2009; Potochnik Reference Potochnik2017), the arguments presented in favor of the Understanding Thesis break with an influential view that, due to its practical orientation, inquiry in medicine differs in kind from scientific inquiries, leading them to the conclusion that “medicine is not, and cannot be, a science” (Munson Reference Munson1981, 189; Pellegrino Reference Pellegrino1998; Miller and Miller Reference Miller and Miller2014). The chapter shows that the success of this argument depends on faulty assumptions about the aims of scientific inquiry. It is argued that the practical orientation of inquiry in medicine does not render it different in kind from scientific inquiries, and does not prevent it from being a science. However, there are important differences in degree, which make a difference for what counts as progress. Finally, the Understanding Thesis has some implications for thinking about responsibilities in scientific inquiry, which are clarified by extending systematicity to include considerations about the choice of an inquiry.

The starting point of the subsequent chapters ensues from a number of points made in previous chapters. If the Systematicity Thesis and the Understanding Thesis are correct, then we may derive the broad suggestion that (i) the aim of medicine is to understand pathological conditions, which (ii) serves the final objective to contribute to the endeavor of supporting human agency. After all, if the epistemic interest in understanding is motivated by practical interests, and if pathological conditions are in general detrimental to human agency, then it makes sense to assume that the goal of understanding pathological conditions is to be able to intervene (i.e., cure, treat, prevent them) in a way that promotes our abilities as agents. However, both (i) and (ii) deserve more detailed consideration, as much will depend on what exactly the character of understanding is in medicine and how exactly medicine contributes to supporting human agency. For this reason, Chapter 5 focuses on (i) while Chapter 6 deals with (ii).

Chapter 5 starts out with exploring a simple suggestion that has roots in the Understanding Thesis, and its main task is to shed light on the specific kind of understanding that medicine has as its aim. Taking into consideration work by Alex Broadbent (Reference Broadbent2019), current debates on the epistemology of understanding (e.g., Kvanvig Reference Kvanvig, Haddock, Millar and Pritchard2009; Grimm Reference Grimm2012; Khalifa Reference Khalifa2017), and recent scholarship on the aims of inquiry (e.g., Kelp Reference Kelp2021), the chapter first describes in more detail what it means to understand something, distinguishes types of understanding, and considers the history of scurvy to explore what understanding a disease involves in the context of medicine. The main hypothesis here is that objectual understanding of a disease (i.e., biomedical understanding) requires grasping a mechanistic explanation of that disease.

To see how causal and constitutive relationships are comprehended in the sciences, the chapter draws on an influential account of causation (Woodward Reference Woodward2003; Reference Woodward2010; Reference Woodward2015) and on work on mechanistic explanations in the biological sciences and neuroscience (Thagard Reference Thagard2003; Reference Thagard2005; Craver Reference Craver2007; Nervi Reference Nervi2010; Kaplan and Craver Reference Kaplan and Craver2011; Darrason Reference Darrason2018). However, alluding to debates on methodological principles in the humanities and social sciences, it is argued that biomedical understanding is necessary but not sufficient for understanding in a clinical context (i.e., clinical understanding). Rather, clinical understanding combines biomedical understanding of a disease with personal understanding of an illness. In some cases, personal understanding is extended, necessitating the adoption of a particular second-personal stance and using cognitive resources in addition to those involved in biomedical understanding. The attempt to support this hypothesis will include revisiting the distinction between “understanding” and “explanation” familiar from debates concerning methodological principles in the humanities and social sciences. While reflection on the everyday use of “knowledge” and “understanding” will offer guidance, it will not be sufficient for tackling substantial questions in the context of scientific inquiry. Thus, consistent with what was said about explication and conceptual engineering in Chapter 2, the task is not merely to analyze ordinary concepts, but to “engineer” appropriate concepts such that they assist with advancing the inquiry.

Chapter 6 also receives guiding impetus from the Systematicity Thesis and the Understanding Thesis, and it explicates how exactly understanding in medicine contributes to supporting human agency. The chapter starts by examining an initially plausible proposal according to which medicine is pathocentric (e.g., Pellegrino Reference Pellegrino2001; McAndrew Reference McAndrew2019; Hershenov Reference Hershenov2020), aiming to restore the health of individuals by curing or treating disease. Discussing and rejecting this opening proposal as well as competing ideas, the chapter presents and defends the Autonomy Thesis, which holds that medicine is not pathocentric, but aims to promote health with the final aim to enhance autonomy (understood as including competency and authenticity conditions; see Christman Reference Christman2009). Drawing on accounts in which health is more than the absence of disease (e.g., Venkatapuram Reference Venkatapuram2013; Nordenfelt Reference Nordenfelt, Schramme and Edwards2017), the chapter defends and adopts a “positive” notion of health and clarifies its relations to other concepts such as well-being and autonomy. It draws on the normative approach outlined in Chapter 1 and on recent work on “conceptual engineering” (e.g., Chalmers Reference Chalmers2020) to offer a pluralist perspective on some difficulties surrounding the concept of health. It closes by considering and defusing the objection that the Autonomy Thesis is overly permissive and allows many highly controversial procedures (e.g., forms of elective cosmetic surgery, prescribing steroids for athletes) as legitimate parts of medicine.

Two methodological considerations guide the chapter. First, the inquiry is limited to “mainstream medicine” (i.e., scientific Western medicine) that – at least on some level of abstraction – is sufficiently universal in spite of variation in local features of institutions and practices (see Broadbent Reference Broadbent2019, ch. 1). Second, the question about the aim of medicine is unearthed in tandem with a closely connected matter that concerns the “internal morality of medicine,” that is, the moral norms and values that govern the practice of medicine (e.g., Brody and Miller Reference Brody and Miller1998; Pellegrino Reference Pellegrino2001; Ben-Moshe Reference Ben-Moshe2019). These norms generate prima facie moral obligations on medical professionals independently of general morality and offer a normative backdrop against which inappropriate use of medical understanding can be identified.

While no narrowly confined aim will be able to capture the full complexity of medicine, the task here is to offer an account that is sufficiently broad to help address the challenges, yet sufficiently narrow to pass the requirements of philosophical rigor. Even though the chapter mainly focuses on clinical medicine, it is argued that aims pursued by other branches of medicine that acquire population-level data and biological knowledge of health and illness are fused with those of clinical medicine. Thus, the aim of medicine is explicated on a general level, such that it applies to clinical medicine but will also have implications for medical science, social medicine, and preventive medicine.

Chapter 7 continues our reflections on the aim of medicine, but is dedicated to exploring and critically engaging contemporary accounts from the literature. While the accounts by Edmund Pellegrino (Reference Pellegrino2001) and Alex Broadbent (Reference Broadbent2019) each identify an overarching aim of medicine, the chapter will also consider four “list approaches” that each offer a catalogue of aims, including the Hastings Center Report (Callahan et al. Reference Callahan1996) and lists produced by Howard Brody and Franklin G. Miller (Reference Brody and Miller1998), Bengt Brülde (Reference Brülde2001), and Christopher Boorse (Reference Boorse and Giroux2016). This is a rather considerable amount of material to explore in a single chapter; however, the aim of the reconstruction is not to do justice to many of their details, but to focus on examining to what extent they are able to overcome or bypass the challenges faced when defending the Autonomy Thesis. Subjecting these contemporary views to critical scrutiny is not merely an essentially adversarial procedure, but is also a means to assist framing the proposal presented in the previous chapter. By inspecting the most relevant aspects of these accounts in light of the challenges considered in Chapter 6, the chapter also provides further reinforcement for the Autonomy Thesis by considering paths that the proposed account chose not to take.

Chapter 8 returns to the challenges to medicine that have motivated the investigation in this book. The chapter is dedicated to showing how the account defended in this book can help address the three strands of criticism (skepticism, overmedicalization, and objectification) and the challenges to medicine they draw attention to. As the challenges converged on fundamental questions about medicine, and as the three theses defended in previous chapters (i.e., the Systematicity Thesis, the Understanding Thesis, and the Autonomy Thesis) have made progress on these issues, the chapter rethinks the challenges in light of the findings. Taken together, the three theses allow us to take up what we could call the Moderate Position that situates itself between more radical views. With respect to each of the challenges, the Moderate Position offers a better comprehension of the relevant problems, points toward possible solutions, and adds clarity to our thinking about the proper boundaries of medicine and the appropriate use of medical means.

Rethinking the challenges conveyed by skepticism, it is argued that they can be understood as violating the norms of scientific inquiry outlined by the Systematicity Thesis. Taking up a more Moderate Position than skeptics, the chapter shows that increasing systematicity in simple and extended senses offers ways to address the challenge of skepticism. Bringing into play the Understanding Thesis, it is argued that increasing systematicity would also require reconsidering resource allocation in medical research to prioritize certain research goals.

Rethinking overmedicalization in light of the Autonomy Thesis leads to a Moderate Position on the proper boundaries of medicine. Against a number of critics, it is argued that the medicalization of a condition does not amount to overmedicalization as long as the condition is harmful (i.e., causes or significantly increases the risk of suffering, harm, or death), and medicine offers an adequate understanding of it in the sense elaborated in Chapter 5. If these conditions are fulfilled, then the medicalization of a condition is consistent with the aim of medicine, regardless of whether medicine can offer effective treatment for it.

Finally, rethinking objectification in light of the Autonomy Thesis shows how objectification can hinder the pursuit of the aim of medicine by obstructing personal understanding (as outlined in Chapter 5), which thwarts systematic inquiry and can have a detrimental effect on the aim of promoting health and autonomy (as described in Chapter 6). At the same time, the Moderate Position highlights the essential function of standardization and technological advances for attaining systematic biomedical understanding, but stresses that medicine will fail to harvest the full benefits of these unless it implements measures that counteract the diminished personal understanding (and objectification) that they can contribute to.

I.5 Final Remarks

This book is motivated by current challenges that provide a fertile ground for addressing fundamental questions about medicine. It illustrates how the recent criticism of medicine converges on fundamental philosophical questions, outlines a specific approach (i.e., the normative philosophy of medicine), defends a novel account of the aim of medicine (i.e., the Autonomy Thesis) and the nature of medicine (i.e., the Systematicity Thesis and Understanding Thesis), and shows how these offer a new perspective on the challenges to medicine (i.e., the Moderate Position). The book tackles such questions hoping to assist an informed deliberation about medicine, to generate a constructive impact on rethinking its future trajectory, and to inspire further work at the intersection of philosophy and medicine.

The book contributes to the quickly growing field of philosophy of medicine, which thus far features relatively few book-length works. It discusses and supplements two important books on philosophy of medicine, namely Jacob Stegenga’s Medical Nihilism (Reference Stegenga2018) and Alex Broadbent’s Philosophy of Medicine (Reference Broadbent2019). Stegenga’s book focuses on defending the view that we should have little confidence in the effectiveness of medical interventions, and it offers a defense of a hybrid theory of disease. This book has different aims, operates with a broader notion of what constitutes a medical intervention, and offers an account of positive health associated with the aim of medicine. Broadbent’s book defends a theory of the nature of medicine that clarifies its purpose and meaning (i.e., medical cosmopolitanism), and it operates with a broad notion of what constitutes medicine, which also allows for exploring debates between competing medical traditions. While Broadbent’s book focuses on what unites different traditions, this book focuses on making sense of a particular tradition in a “bottom up” fashion. Also, another unique feature of this book is that it proceeds by integrating new developments in epistemology and philosophy of science (e.g., on understanding, progress, and inquiry) as well as debates on the internal morality of medicine.

Because the book incorporates new developments in epistemology and philosophy of science, it covers a relatively large amount of philosophical terrain and will mostly appeal to philosophers. Nonetheless, the book also hopes to speak to a philosophically informed readership that is interested in medicine, its place in society, and the moral and epistemic norms that guide medical research and medical care in various settings. The account presented in the book might be interesting to philosophically informed health professionals seeking new input for prioritizing research goals, for reflecting on the allocation of health care goods, or for pondering the relationship between alternative, traditional, and mainstream medicine. In addition, clarifying these issues might assist decisions in cases in which curing disease, promoting individual health, and promoting public health are at odds with one another.