## 1. Biomedicine as a Framework for Medicine + Biology



Consult with a primary care physician when feeling ill. Perhaps they
send you to a medical lab that will take a blood sample to run a
biochemical analysis. After the results arrive, consult with a
physician specialist whose expertise is the particular bodily organ or
system where the ailment is localized. The specialist prescribes a
drug that has been mass-produced in a factory, after a biology
laboratory extracted the active ingredient from a natural source, or
perhaps synthesized it from scratch. The drug's efficacy has
been proven by testing the drug experimentally on two groups with the
relevant disease, randomly sorted into an experimental group and a
control group so that the drug's measurable bodily effects could
be scrutinized and counted. This is biomedicine. It has quickly grown
to be so pervasive around the globe that it is difficult to
characterize biomedicine.


### 1.1 What is biomedicine?



As explored in this entry, and outlined in how the sections are
divided in the entry, biomedicine has many facets. It is a very large
and complex thing. It is a morphing historical product of the
post-World War Two West. It is a contemporary global social
institution. It is an epistemology of medical research and practice
(albeit with factions). It is a set of ontological and metaphysical
commitments. And more. 



The US National Cancer Institute defines biomedicine as synonymous
with "allopathic medicine, conventional medicine, mainstream
medicine, orthodox medicine, and Western medicine" (NCI
 Other Internet Resources,
 accessed 12 March 2020). By contrast, A. E. Clarke, Mamo, Fishman,
Shim, and Fosket (2003) takes an expansive view of the nature of
biomedicine, contending that it is an evolving entity, a cohesive and
developing whole that consists of elements ranging from the assertion
that good health is a personal moral obligation to the increasing
reliance on "computerization and data banking" (A. E.
Clarke et al. 2003: 173).



Krieger offers a detailed examination of the history and philosophy of
the "biomedicine approach," and extracts three key tenets
of the view.



> 
> 
> Among the many features of a biomedical perspective, three stand out
> as fundamental regarding its approach to investigating disease (Lock
> & Gordon 1988; Fee & Krieger 1994; Krieger 1994; Lawrence
> & Weisz 1998; Cambrosio & Keating 2001; Bynum 2008). They
> are:
> 
> 
> * First, specific to biomedicine: the domain of disease and its
> causes is restricted to solely biological, chemical, and physical
> phenomena;
> * Second, shared with many natural sciences: an emphasis on
> laboratory research and technology and, as translated to health
> research, a discounting of research questions that cannot be studied
> by randomized clinical trials (or their analogs, e.g., "natural
> experiments"); and
> * Third: an embrace of "reductionism," a philosophical
> and methodological stance (discussed more fully below) that holds that
> phenomena are best explained by the properties of their parts.
> (Krieger 2011: 130)
> 
> 
> 



Krieger's account of biomedicine offers a compelling
distillation of the philosophical commitments of biomedical science.
Though since this is an entry on *philosophy* of biomedicine,
the entry will be organized around philosophical dimensions and
debates, rather than being organized directly around these core
theoretical tenets (e.g., the upcoming section is on ontological and
metaphysical commitments). Additionally, this entry will supplement
the tenets identified by Krieger with discussion of connected issues,
such as philosophical critiques of biomedicine as a social institution
 (Section 4).



The terms "framework" and "approach" are used
here to describe biomedicine, in an attempt to avoid narrowly
overcommitting to any particular philosophical system. Biomedicine may
or may not qualify as one of Thomas Kuhn's
"paradigms", in the way that the heliocentric model of the
solar system is a paradigm--a complex worldview in which the
viewpoints cannot be straightforwardly translated back-and-forth with
an alternative paradigm (i.e., if we try to translate the concepts of
biomedicine to the pre-biomedical concepts of humoral theory,
discussed in
 Section 1.2
 (Kuhn 1962). Alternatively, biomedicine seems to qualify as one of
Imre Lakatos' Research Programmes, a different way of conceiving
of the way that research communities intellectually cohere (Lakatos
1968). It's a question of *how* biomedicine serves as a
means of organizing and guiding research.



Without getting too lost in the technical criteria, biomedicine shares
the Kuhnian paradigm quality of being incommensurable (or at least
more or less so) with other conceptions of biology and health.
Scholars of complementary medicine have spent enormous effort
searching for ways that traditional medical practices--e.g.,
herbal treatments handed down over generations--can get a
foothold in a medical world dominated by biomedicine. It is telling
that there is no question that 'proof' of a
treatment's efficacy requires starting from scratch, by
examining the herb's chemical makeup, isolating and analyzing
which chemical components are the active ingredients, and then testing
safety and efficacy, all entirely within biomedicine's rules.
Whatever explanations might have been offered by herbalists (e.g.,
'it calms turmoil in the stomach') are irrelevant
untranslatable knowledge. Biomedicine also shares the Lakatosian
Research Programme quality of (largely implicitly) dictating what
sorts of internal dispute about biomedicine is permissible. Within the
biomedical Research Programme, one is invited to question whether a
particular experimental design is suitable; one is not permitted to
reject experimentation entirely.


### 1.2 The history of biomedicine



Biomedicine as a global institution coevolved with its characteristic
philosophical positions. While key elements, such as laboratory
biology, were present in the nineteenth century and even before,
"World War II is usually presented as a turning point in the
'biomedicalization' process" (Lowy 2011: 117).
The term "biomedicine" was first used between the two
world wars as a shorthand for some of the medical and scientific work
being done on radioactive materials (Keating & Cambrosio 2003;
Lowy 2011: 49-55). But biomedicine only came into its own
during the period of economic and social transformation in
industrialized Western countries that followed World War Two:



> 
> 
> In industrialized countries, the post-World War II era was also
> characterized by important increases in public funding for medical
> research, the extension of health insurance to large parts of the
> population (a process that, in nearly all the Western countries, the
> United States excepted, was also supported by the state), and the
> rapid growth of the pharmaceutical industry. (Lowy 2011: 117)
> 
> 
> 



If biomedicine is a recent historical development, then what exactly
came before it? Many different frameworks for health existed before
the rise of biomedicine, though many such frameworks exist now despite
the dominance of biomedicine. Some have been distinctly influenced by
or merged with biomedicine. For instance, osteopathic medicine has
gradually gone from a full alternative system of medicine (focusing on
manipulation of body via pressure, stretching and other means of
readjustment of bodily structure in order to rebalance internal
processes), to an alternative track of medical education/practice that
has in large part converged with the biomedical/allopathic medicine
track (McClain 2017; Stark 2013).



Insofar as biomedicine formed in the West, it is helpful to see it in
contrast to the medical and philosophical traditions that preceded it.
The most influential Western tradition prior to biomedicine is the Hippocratic tradition--the views attributed
to Hippocrates and over two millennia of re-interpretations, riffs,
amendments, and other alterations. At the core of Hippocratic medicine
were two views. First, it made a commitment to methodological
naturalism--a refusal to attribute disease processes to the work
of gods and other supernatural beings (Conrad, Neve, Nutton, Porter,
& Wear 1995). Though, it is worth noting that for much of that
history, elements of astrology, talismans, and some forms of magic
were understood as essentially natural phenomena (e.g., the sun
obviously affects health via sunburns and such, so it is not absurd to
have inferred that planets could have their own subtle effects on
bodies too). Second, it understood health as a matter of
balance--and disease as a matter of imbalance--of the
humors. Humoral theory was interpreted in many different ways, but
centered on the idea that heath and disease are attributable to the
interactions of anatomical humors (blood, phlegm, yellow bile, and
black bile), which were in turn directly tied to a much larger
cosmology of the elements (e.g., blood is linked to air, the
springtime, a combination of heat and moisture, the heart, and the
astrological influence of the planet Jupiter) (see additional internet
resources below) (Conrad et al., 1995).



There is long-standing debate in health policy over exactly how
successful the biomedical model has been over its relatively short
historical trajectory. The growth of the biomedical model in Western
countries occurred at the same time as other social and economic
transformations (industrialization, urbanization, globalization, etc.)
and at the same time as improvements in life expectancy and a large
number of disease outcomes. The 'received view' of these
historical relations is that social and economic changes allowed the
growth of biomedicine, which in turn created new institutions,
professional health care practices, and technologies that, in turn,
caused vast improvements in health outcomes for the populations served
by biomedical institutions. Penicillin is the go-to example for
illustrating the positive health impacts of biomedicine (Lowy
2011). It is a medicine extracted from nature (mold), made into a
widely available 'magic bullet' thanks to biomedical
techniques of identifying its active components, and manufacturing
controlled doses of it at reasonable cost at massive scale. Suffering
and death from bacterial infections was rapidly alleviated; once
hopeless diseases were suddenly curable with a few (usually) benign pills.



Thomas McKeown was an influential critic of the biomedical institution
(including the work done during its early twentieth century
prehistory), having authored the blockbuster volume *The Role of
Medicine: Dream, Mirage, or Nemesis* (1976). McKeown reevaluated
the historical record and available evidence to instead hypothesize
that the social and economic changes in the West were more responsible
for the health improvements than biomedicine's growth. Put
bluntly, he argued that twentieth century modernity (economic development, improved nutrition, etc.) caused
populations in the West to get healthier over time, then modernity went on to also cause the growth of
contemporary medicine/biomedicine, but the medical advances themselves played a generally secondary role in
supporting the health improvements. His works has inspired decades
worth of debates over the validity of his bold claims, which have been
largely overturned or largely vindicated, depending on whom one asks
(Link & Phelan 2002).



Health theorist Nancy Krieger shows how the activity of finding ratios
of how much biomedical healthcare vs. socioeconomic environment
contributed to health improvements since the twentieth century is the
sort of debate that easily falls victim to the "fallacy of
treating causes of population health as if they sum to 100%"
(Krieger 2017). Causes overlap and interact in complex ways; e.g.,
individual diet, exercise, medications, and changing exposures to
smoking, etc. have all been contributing to changes in heart disease
rates. How much of the credit goes to biomedicine for studying the
effects of exercise on heart attack risk, for helping make the case
for the heart risks of smoking, and so on? Extracting and assessing
the contributions of biomedicine, an enterprise fully embedded in
Western countries' social systems and economies, is not
possible; biomedicine is firmly embedded. That is not to deny it is
impossible to attribute health effects in particular populations to
particular causes in general--there are methods allowing such
calculations--just that causes' interactions need to be
taken into consideration (Krieger 2017).


## 2. Ontological and Metaphysical Commitments in Biomedicine



Biomedicine is built around a conception of disease as a disfunction
of particular physical parts (organs, tissues, cells) of the body.
Despite being hegemonic in the global research community,
biomedicine's ontological and metaphysical commitments are not
self-evident, historically long-lived, nor universally embraced. In
contrasting Classical Chinese Medicine with biomedicine, Lee explains
that biomedicine is set apart by 



> 
> 
> the metaphysical thesis that only what is ascertainable by means of
> the five senses and by extension the use of instrumentation is real
> and exists 
> 
> 
> 



and a connected epistemic claim that legitimate health knowledge must
come to us via those means (Lee 2017: 2).


### 2.1 Ontology of the body and life in biomedicine



What makes patients and their bodies special? Some philosophers of
biomedicine have attempted to make headway in this question by
provocatively asking what it means for biomedical sciences to be
'chauvinist' and whether this is proper. Biomedical
discussions are in large part defined by what they exclude from
discussion. Curiously, there are two sides to the coin of biological
chauvinism: one that directly supports the biomedical framework and
one that challenges it. Both help shed light on the relationship
between biology and medicine.



Broadbent (2009) uses the helpful term, "biological
chauvinism" to describe the way that biomedicine actively
excludes consideration of entities and processes that don't fit
into its worldview: "a refusal to countenance causes of ill
health that are not biological" (Broadbent 2009: 305).
Biological chauvinists might appeal to ontological or epistemic
commitments, e.g., the assumption that knowledge of the body is
nothing but knowledge of organic chemical processes, and any processes
not clearly reducible to such terms are not yet worthy of being given
full consideration. But the strongest case for this chauvinism rests
more on pragmatic grounds than on such philosophical assumptions.
Biomedicine has built itself into a massive global institution and
research enterprise while operating under that assumption (to repeat
Krieger's phrasing from
 Section 1.1,
 the assumption is that "the domain of disease and its causes is
restricted to solely biological, chemical, and physical
phenomena" (Krieger 2011: 130)). This is a powerful argument,
though it cuts both ways;
 Section 5
 discusses critiques attempting to undercut the value of what
biomedicine has indeed built while operating under that approach.



On the other side of the coin, "biochauvinism" is the term
applied to the view that there is something philosophically unique
about biological organisms--due to their basic nature and/or the
limitations of human knowledge's access to them--that makes
them the biological world fundamentally unlike the rest of the world
(Wolfe 2015). Vitalism--the view that life has some animating
entity (along the lines of spirit) that animates matter into a living
being--is one form of such biochauvinism (Wolfe 2015). Another
form of biochauvinism is the use of phenomenology to assert that human
lived experience partly operates within a space-time context that is
different from that of a rock (Wolfe 2015). Wolfe finds that sort of
view inside the influential phenomenological work of
 Maurice Merleau-Ponty
 (Wolfe 2015) (See
 Section 5
 on phenomenology). Thus there are two rather opposite senses in which
we can chauvinistically hold that the biological world is special:


1. a specialness through what life *excludes* (medicine is
nothing but applied biology) or
2. a specialness through what life *includes* (an intangible
vital spirit; a unique frame of time and space).



Version (1) of biomedicine is consistent with biomedicine and version
(2) generally is not. The fact that the valorizing of biology can cut
both ways helps to show, though, that biomedicine has staked out a
sort of middle ground by insisting that understanding health and
medicine is accomplished through understanding the innumerable
subtleties of biological processes and substances, but that those
biological processes and substances must not be so subtle or
mysterious as to become untethered from properties and processes
condoned by physics and chemistry.



Put another way, the biomedical framework of the body can be
understood by considering what it excludes: spirit, vitality, and any
other entity or property unknown to mainstream physicists or chemists.
The concept
 Physicalism
 is closely related, but the term is perhaps not a perfect fit since
it has taken on conceptual connotations and baggage through its use by
analytic philosophers of metaphysics. The connection is that in the
psychological biosciences, the "hard problem of
consciousness" looms over everything: 



> 
> 
> It is widely agreed that experience arises from a physical basis, but
> we have no good explanation of why and how it so arises. Why should
> physical processing give rise to a rich inner life at all? It seems
> objectively unreasonable that it should, and yet it does. (Chalmers
> 1995) 
> 
> 
> 



While the human mind and consciousness attract a special sense of awe,
the hard problem of consciousness is not all that different from the
problems facing attempts to make sense of the patient as a whole.
Patients *live*; their bodies function every second of the day,
via an astounding series of interconnected processes. It stretches the
imagination to think that a vital spirit or such is giving unity to
each life (human or non-); it stretches the imagination in another way
to think that we humans are simply skin bags of chemical
reactions.


### 2.2 Biomedical conceptions of health and disease



The preceding section on purpose in biomedicine leads directly to the
related issue of how health and disease are conceptualized in
biomedicine. This is something that will only be dealt with very
briefly here, in part to avoid duplicating the content in the entry on
 Concepts of Health and Disease.
 Debates over the meaning of health and disease--including how
the two are connected--are central to philosophy of medicine.
This entry will not attempt to summarize that complex literature, and
rather focus on how conceptions of health and disease relate to
biomedicine, including related disputes over how disease relates to
disability justice matters, and ways in which purportedly objective
biomedical conceptions of disease can be co-opted for dubious
purposes.



Of the different philosophical accounts of health and disease,
Christopher Boorse's naturalistic Biostatistical Theory (BST) of
disease gives the account that is perhaps most tightly linked with the
philosophical commitments of biomedicine. Boorse's revised
account of the BST states:



> 
> 1. The *reference class* is a natural class of organisms of
> uniform functional design; specifically, an age group of a sex of a
> species.
> 2. A *normal function* of a part or process within members of
> the reference class is a statistically typical contribution by it to
> their individual survival [or] reproduction.
> 3. *Health* in a member of the reference class is *normal
> functional ability*: the readiness of each internal part to
> perform all its normal functions on typical occasions with at least
> typical efficiency.
> 4. A *disease* [later, *pathological condition*] is a
> type of internal state which impairs health, *i.e.*, reduces
> one or more functional abilities below typical efficiency (Boorse 2014:
> 684, amending Boorse 1977: 562).
> 
> 
> 



The idea is that we can wield insights of biochemistry, pathology, and
evolutionary biology to together yield an objective means of
'reading' nature to tell us which states are pathological
or diseased states, without the interference of messy and culturally
rooted/biased evaluations. One line of rebuttal is that there is no
principled way of objectively choosing a reference class against which
to judge that a given part or process is falling short (my blood sugar
levels are objectively too high compared to...what exactly?)
(Kingma 2014). Even if that problem is resolvable, Krueger argues that
an objective set of criteria for defining states as pathological or
not would be a very limited accomplishment. Knowing that my blood
sugar levels are objectively pathological does not really tell me much
about what, if anything, I or my physician ought to do about that
(Krueger 2015).



Fraught as it is to approach health via the functioning of components
in the body, it is also quite conceptually difficult to measure health
in a broader sense. Biomedical science practitioners tend to get
twisted into conceptual and epistemic knots when attempting to measure
general/overall health or well-being in a population (Hausman 2015).
One key philosophical dispute among health scientists engaged in
patient health measurement activities is over what sorts/amounts of
knowledge patients have about their own health states, and how this
knowledge ought to be accessed (McClimans forthcoming). How much can
we glean about a patient's physical comfort by asking them to
rate their level of pain on a scale of 1-10? How do we solicit
such information without repeating unethical patterns of trust or
mistrust, rooted in racist/sexist/etc. stereotypes about patients
(Buchman, Ho, & Goldberg 2017)?



The notion of disease is biological malfunction is also tied to a pair
of critiques of the "medical model" of disability and of
"medical model" of mental health. Both models are
criticized for reducing the complexities of disability or
psychological welfare to only the individual-level signs, symptoms,
and variables recognized by biomedicine (see:
 Disability: Definitions, Models, Experience).
 As traced in Hogan's history of the concept, the medical model
is either critiqued as insufficiently attentive to other dimensions
(especially the social dynamics that drastically shape the relevant
health experiences) or oppressive (since the model empowers biomedical
experts to unilaterally dictate the disability/psychiatric categories,
relevant evidence, diagnoses, treatments, etc.) (Hogan 2019). This is
in part a dispute over functioning since debates over normality,
difference, and pathology depend on whether/how we commit to the
notion that bodies or parts thereof have functions at all. If
one's legs do not perform the function of walking, are the legs
pathological? Is the person with those legs inherently diseased?
Disabled? Worse off than if they had legs that could walk? One
solution is to simply throw out the notion of normal functioning
(Amundson 2000). Another related option is to embrace pluralism in the
sense of accepting that the relationship between disability and
well-being or health is complex, variable, and dependent on
individual and social contingencies (Campbell & Stramondo
2017).



One philosophical complication is that a naturalistic concept of
disease, like Boorse's, does not prevent social processes from
altering the standards and practices of how the boundaries of these
natural categories are drawn in practice. Chronic diseases such as
cardiovascular diseases and type 2 diabetes have been targeted by drug
companies to not only create new treatments but to redraw the
boundaries between healthy vs. pathological, including boundary zones
such as "prediabetes" (Greene 2006). These efforts are in
part accomplished via the design of clinical trials, which have the
dangerous distinction of having very high epistemic value in the
biomedical community, while remaining highly susceptible to
manipulations to the experimental setup that push the evidence one
direction or another (Gonzalez-Moreno, Saborido, & Teira
2015).



While a naturalistic concept of disease is the most consistent with
the ontological assumptions and methodological practices of
biomedicine, that has not prevented biomedicine from accommodating a
certain type of dissent from the biomedical tenet that biomedicine
ought to focus on diseases and (only) the biological, chemical, and
physical aspects thereof (Krieger 2011: 130). The World Health
Organization (WHO)--founded in the same post-World War Two period
as biomedicine--adopted a holistic positive concept of health at
its founding. i.e., it said that health is the presence of complete
well-being (including mental and social well-being) rather than just
the absence of disease. This created a direct tension with the core
tenets of biomedicine, especially the reduction of disease to a set of
concrete observable and measurable physical bases (Valles 2018).
Historically, the tension was resolved in the case of the WHO by the
organization, shortly after its founding, effectively self-suppressing
the use of its own definition of health in favor of pursuing a
narrower set of initiatives to combat particular diseases (e.g., the
celebrated Smallpox Eradication Program) (Irwin & Scali 2007).
This seems to have been in part because cold war politics made it
pragmatic to not antagonize the United States with pushing a health
concept concerned with "social" well-being, sounding a bit
reminiscent of social*ism* (Irwin & Scali 2007). While a
WHO-type understanding of health is in genuine tension with the
philosophical tenets of biomedicine, the tension is manageable in this
case by simply pursuing areas of overlap between the different
conceptions of disease (e.g., investing in infectious disease-control
strategies for a population) while ignoring any purported aspects of
health beyond the absence of pathologies (e.g., declining to invest in
assessing how human-environment relations contribute to a
population's happiness or misery).


## 3. Epistemology of Biomedicine



There are philosophical disputes happening at the heart of the
biomedical enterprise and those disputes offer a means of
understanding the epistemological dimensions of biomedicine: the
nature of evidence and knowledge in the framework. The most
contentious of those internal biomedicine disputes center on what the
epistemology of biomedicine ought to be, with the rise of
"evidence-based medicine" (EBM) being the event that
provoked the largest segment of these disputes. By examining the
disputes surrounding EBM, we can gain a better understanding of the
epistemology of biomedicine, as illustrated in work such as
Solomon's *Making Medical Knowledge* (2015).



Evidence-based medicine is a tricky concept, since its name
misleadingly raises the question of who is practicing medicine that is
*not* based on evidence (Goldenberg 2006). Instead, the dispute
is over which evidence is best and how it ought to be used. For
instance, physicians will often advise patients on which home
treatments to use for minor lower back pain, with individual
physicians varying in which treatments they recommend, even aside from
differences in the advice based on differing patient characteristics.
Ibuprofen? Acetaminophen? Heat and/or cold compresses? Exercise? The
standard twentieth-century medical response would be to let physician
groups (including consensus groups convened for this purpose) lay out
the options and perhaps use their collective expertise to make a
recommendation, but giving great leeway to individual physicians to
use their individual accumulated expertise to choose another of the
available options seen as viable options by their peers. EBM instead
treats this as a matter to be largely decided by empirical research.
I.e., we ought to run randomized control trial experiments that
compare the efficacy of alternative options by randomly assigning
patients with lower back pain into *Treatment A* or
*Treatment B*--controlling for the single
variable--and measure the effects on patients using predetermined
metrics (change in reported pain severity, incidence of major side
effects, etc.). After doing multiple experiments we can then do a
"systematic review and meta-analysis" that compiles the
data trends across parallel research studies and helps us build an
evidence base for creating guidelines for which treatment clinicians
ought to use. Those guidelines dictate the proper default practices,
which individual clinicians can contravene if specific individual
patient needs are in conflict (e.g., a patient history of not
responding well to a certain medication).



EBM began as a self-described Kuhnian scientific revolution of
biomedicine--a fundamental change of worldview that is
incommensurable with the previous one; a paradigm shift
(Evidence-Based Medicine Working Group 1992). The most fundamental
dispute between advocates of the EBM movement and skeptics within the
biomedical community is, in one sense, over the epistemic and power
relationships between the two halves of biomedicine: biology and
medicine. In biology, experimental methodologies and attempts to find
generalizable population trends are valued highly; in clinical
medicine, the single patient and the clinician's accumulated
(and ineffable) expert evaluation of them has long been valued very
highly--much attention is paid to that individual patient's
contingencies (the particulars of their body and symptoms), with the
clinician's accumulated knowledge and know how being relied on
when determining how to proceed. Evidence-based medicine is not a
simplistic adoption of biology principles and their application to
medicine; it is not the triumph of biology over medicine in
biomedicine. Instead, EBM has helped to draw out deeper disagreements
about what it means to do and use biomedical science well.



There is a large philosophical literature on evidence-based medicine,
with the first monograph appearing in 2002 (Goodman 2002). Most of the
literature takes at least a partially skeptical stance on EBM
practitioners' various hardline stances on evidentiary matters:
the suitability of clinicians relying primarily on brief synopses that
attempt to synthesize massive bodies of evidence (Borgerson 2009); the
room for hidden biases in the process of evaluating medical data
(Stegenga 2011), and more. EBM has also inspired passionate disputes
among clinicians over how to apply its principles (Berwick 2005;
Greenhalgh, Snow, Ryan, Rees, & Salisbury 2015). One line of
criticism is that its aims are noble, but have been hijacked by bad
actors, namely corporations that learned to that by getting involved
in the production of randomized control trial evidence they could sway
the evidence for the apparent safety and efficacy of their own
products (Ioannidis 2016). Philosophy of EBM is given extensive
discussion in the entry on
 Philosophy of Medicine,
 and as with the rest of this entry, this entry will avoid needless
repetition and keep the focus on biomedicine *per se*.


### 3.1 Epistemology of expertise and experimental clinical data in biomedicine



Biomedicine is in a state of tension, between


1. a history of resolving evidentiary disputes using mechanistic
reasoning, consensus, and authority (see, e.g., Solomon [2015] on the
roles played by 'consensus conferences') vs.
2. a recent practice of creating predetermined evidentiary
ranking/ evaluating procedures designed to minimize the ability
of biased or erratic human judgments to unduly influence the
resolution of evidentiary disputes.



Clinical guidelines were once routinely created by what is
pejoratively called GOBSAT: Good Old Boys Sat Around A Table (and
reached a consensus by talking amongst themselves as leading experts
in the subject matter). As Greenhalgh puts it, "it is a major
achievement of the EBM movement that almost no guideline these days is
produced by GOBSAT!" (Greenhalgh 2014: 7). It remains a point of
philosophical contention just how epistemically different it is to
generate clinical practice guidelines using a consensus-based model
vs. an evidence-based model, in large part since, no matter what
evidence is prioritized, a group of experts will ultimately need to
interpret the data and make judgment calls on how to generate
practical guidelines based on the compiled evidence (Djulbegovic &
Guyatt 2019). Though even the meaning of clinical expertise is itself
not clearly defined and agreed upon, a matter further complicated by
the way that the meaning of expertise is tangled up with views about
what roles expertise ought to be playing in clinical practice (Wieten
2018).



Evidence-based medicine prizes certain types of biomedical
evidence--highly controlled and systematic evidence--more
highly than others. But that preference is a matter of much
contention. As noted above, experimental evidence from a randomized
experiment testing a treatment (a "randomized control
trial") is held as the best sort of evidence: the gold standard.
The one exception is that "meta-analyses" of multiple
experimental studies are perhaps a platinum standard better than gold
(Stegenga 2011), i.e., the thinking goes that the only evidence that
might be better than such experimental data is a rigorous quantitative
study rigorously looking for patterns and lessons by analyzing the
results many rigorous experimental studies. While the rigidity of EBM
thinking gets a great deal of criticism, there are elements of the
EBM's philosophy that implement the sort of pragmatism that many
critics desire, such as an epistemic openness in the community to
engage in "open-ended critical inquiry" (Goldenberg
2009).


### 3.2 Epistemology of basic and applied science in biomedicine



The status of laboratory evidence is a major point of contention in
philosophy of biomedicine disputes. "Bench science" is
often used as a catchall term in EBM for a wide variety of laboratory
evidence (biochemistry, pathology, digital models of drug metabolism,
animal studies of a treatment, etc.), and that evidence is pushed to
the very bottom of the evidence hierarchy (B. Clarke, Gillies, Illari,
Russo, & Williamson 2014). For example, green tea contains
epigallocatechin gallate (EGCG), which seems to be effective at
killing cancer cells in petri dishes and in mice (Eisenstein 2019).
EBM supporters would be inclined to look down on inferences that green
tea is therefore a wise anti-cancer home health behavior, until there
is at least epidemiological evidence that green tea drinkers genuinely
do have better cancer outcomes. Even then, EBM supporters would want
to know if the anti-cancer effects are due to EGCG, some combination
of multiple components of green tea, or perhaps just the relaxing
social act of having a hot beverage. Biomedicine has always valued the
sort of research that investigates EGCG in petri dishes, in mice, or
other models used on the laboratory bench, but the dispute is over how
reliable one takes that research to be for guiding real medical
decisions (ought physicians tell patients to drink green tea?).



The problem of how highly to value bench science is distinct from the
general objection to hierarchies of evidence (Bluhm 2005). Even if
evidence isn't treated as inherently rankable in value, one key
philosophical objection is that much of the biomedical research world
is treated by EBM as less important than clinical patient experiments,
or meta-analyses of such experimental data. Solomon explains that this
position is in tension with a simultaneous trend in biomedicine, an
increased concern with translational medicine (an effort to improve
the process of moving candidate treatments from (the laboratory) bench
to (the patient's) bedside (Solomon 2011). This effort to better
manage the biomedical research enterprise has brought with it, 



> 
> 
> a restoration of the recognition that clinical research requires an
> engagement with basic theory (e.g., physiological, genetic,
> biochemical) and a range of empirical techniques such as bedside
> observation, laboratory and animal studies. (Solomon 2011: 451) 
> 
> 
> 



In an openly conciliatory move, the "EBM+" group of
philosophers and clinicians (see
 Other Internet Sources),
 offers a defense of the view that mainstream EBM has erred by
essentially relegating mechanistic evidence, such as EGCG having
anti-cancer chemical properties, to a subsidiary role (B. Clarke et
al. 2014).


### 3.3 Epistemology of measurement in biomedicine



While epidemiology-focused EBM is partly in tension with most of the
rest of laboratory-focused biomedicine--needing it but seeing it
as in service to randomized control trials on patients--both EBM
and other branches of biomedicine are united by a valuing of precise
measurement. While precise measurement is achievable in the
biochemistry lab, the practical and philosophical challenges are
thornier when doing measurement at the level of the whole person or
the population. What *is* well-being (Alexandrova 2017)? By
what standards can we call a population healthy (Hausman 2015)? What
sorts of social structures, policies, and interventions are effective
for promoting health (Valles 2018)? How do we identify which subgroups
are left out of the benefits and prevent injustices being done to them
(Maglo 2010, 2012)? What sorts of values are at stake when we debate
biomedical evidence surrounding culturally issues such as birthing
practices (McClimans 2017)? A common theme shared by these critiques
is a concern about the fickleness and contingency of measurement
leaving much room for practitioners' values and motivations to
shape the results of the measurement process, for good or for ill.



The biomedical quest for precise and objective measurements leaves
some unsatisfied with the little room left for patient input in
clinical care decision-making. What roles are there for patient input
in the process of deciding the best course of treatment (Chin-Yee
& Upshur, 2018)? According to critiques, by trying to sideline
subjective factors in medical care and replace them with increasingly
objective factors, EBM especially (even among than other biomedical
perspectives), risks losing the humanistic aspects of medicine, an
ethical loss and an epistemic loss. By treating patients'
desires, goals, and values as largely irrelevant or a source of
interference with an objective process, EBM loses sight of medicine as
a means of helping real humans' real problems. Relatedly, by
shutting the patient out of the process, the notion of the best or
right treatment becomes hollowed out (McClimans forthcoming).



In the background is the important--and
meta-epistemic--problem that physicians are not educated to be
comfortable with uncertainty, and what to do in an objective
measurement-focused field when one finds oneself lacking the desired
evidence: inconclusive tests, treatments designed for patients unlike
the one being treated, etc. The very topic of uncertainty is
conspicuously absent from medical education (Tonelli & Upshur
2019).


### 3.4 Reductionism in epistemology of biomedicine



In biomedicine, it appears much of medicine is reduced to applied
biology--patients are just biochemical substances processes and
medical knowledge is just a complicated form of biological knowledge.
Keating and Cambrosio see the relationship between this reductionism
in biomedicine (the reducing of medicine to biology) as more a matter
of the two being aligned for complex historical and philosophical
reasons, instead of that reductionism being philosophically central to
biomedicine (Keating & Cambrosio 2003). According to them, after
World War Two, the fields of biology and pathology negotiated the
creation of "the institutional and epistemic hybrid we call
biomedicine," and neither component of this hybrid rules the
other (Keating & Cambrosio 2003, p. 368). They see this as
undermining claims of biomedicine being reductionist because such
assertions implicitly or explicitly mean that (micro)biology gets
epistemic priority because it is the true and stable foundation.



Part of the challenge is that there are multiple varieties of
 Reductionism in Biology.
 And there are a number of different reductionism disputes in biology,
and the overlaps with biomedicine vary--e.g., Rosenberg's
defense of reductionism in genetics overlaps with biomedicine in the
area of medical genetics (Rosenberg 2006). As discussed in
 Section 1,
 it is very difficult to tell the difference between the core
components of biomedicine and the bits of
philosophy/technology/sociology that aren't inherently part of
biomedicine, but have gotten tangled up in it. The rationale for
reductionism in biomedicine is explained with great care by
Andersen:



> 
> 
> Being able to successfully take a disease as complex as sickle cell
> anemia or Parkinson's and reduce it to a single genetic error
> that cascades through various systems, even if that reduction holds
> for only a proper subset of cases, illustrates that reduction can be a
> powerful tool for research and explanation in medicine. It cannot be
> the only tool in the toolkit, since some diseases or dysfunctions may
> be only partially reducible, or for which only some cases are
> reducible. But it is a good working assumption, as Oppenheim and
> Putnam put it, in tackling a problem with an unknown etiology, to look
> for ways to reduce it to a few or even a single causal driver at a
> molecular level (Andersen 2016: 86).
> 
> 
> 



In other words, the potential for success and record of prior
successes is an argument for at least operating under the assumption
that biomedical scholars ought to continue treating biomedical
mysteries as biochemical puzzles for which the relevant pieces have
not yet been identified or assembled.



Reductionism in biomedicine has been targeted by some committed
critics. For instance, Marcum explains that the process of reducing
the body to such component parts yields a vision of the body as
machine, a radically dehumanizing move.



> 
> 
> From the biomechanical point of view, the patient's body is
> often perceived as a material object that can be reduced to a system
> of physical parts. That body is viewed as a machine composed of
> individual body parts, which can be fixed or exchanged with new parts,
> when broken. By reducing the patient's body to an assemblage of
> body parts, the patient *qua* person vanishes (Marcum 2005:
> 318).
> 
> 
> 



While the critique stands on its own, it remains an open question what
other view ought to be adopted if not a reductionist biomechanical
one. Marcum contrasts the view most directly to phenomenological
views--which will be discussed in
 Section 5--arguing
 that a phenomenological approach is better suited to advancing
medicine, which he presents as being in a state of crisis.



EBM's reliance on randomized control trials as a cornerstone of
health data collection doubles down on the general reductionism of
biomedicine. Randomized control trials assume that health variables
can be observed, manipulated and controlled as largely independent
units. Yet, is a well-established problem that we simply don't
know all of the variables that might confound a clinical experiment
(Worrall 2007), so randomization can at most hope that the
'confounders' (e.g., unknown dietary factors that affect
metabolization of a drug) are randomly distributed between the
different treatment populations in an experiment. Taking the
reductionism a step further, the goal of exactly measuring the
differences between *Treatment A* and *Treatment B*
requires EBM to only look for effects that are precisely measurable in
the first place. This limitation is a deeply-rooted problem since even
the official list of clinical signs and symptoms of a given disease
can diverge from accumulated patient observations, and in cases such
as some psychiatric conditions, the symptoms--or lack
thereof--are overtly difficult to measure or factor into an
assessment of treatment efficacy (e.g., one's sense of self
and/or emotional life) (Kendler 2016).



While reductionist and antireductionist approaches are in direct
opposition, it is possible to take a pluralistic stance toward them:
both can be welcomed into health science. For instance, this is the
position taken by Campaner (2010). Though, as discussed in the next
section, the power of the biomedical institution makes it such that
biomechanical reductionist approaches can easily overwhelm alternative
views.


## 4. Biomedicine as an Institution



The disputes over biomedicine's virtues and flaws are tied to
the other aspects of Western cultural-political-economic influence
that coevolved with it, and travelled with it around the globe. The
dynamics between the institution of biomedicine--rooted in
wealthy Western countries--and low/middle-income countries is in
part a manifestation of the philosophical complexities of the
international political scene. See, for instance, the literature on
 International Distributive Justice.



As discussed in
 Section 1.2,
 biomedicine co-evolved with the West's social and economic
institutions in the aftermath of World War Two. Of particular
importance, the individualism of Western capitalism has meshed with
biomedicine's ontological view of the body as effectively
separable from its social context. Briggs and Hallin describe the how
contemporary media and biomedicine work to coproduce public knowledge
about health and disease, a process they dub biomediatization (Briggs
& Hallin 2016).



Metzl and Kirkland's influential edited volume *Against
Health:* *How Health Became the New Morality* lays out a
related case for how biomedicine exercised undue influence over
culture, including casting health ills as personal failings deserving
of public shaming and stigmatization (Metzl & Kirkland 2010). As
an illustration of the sort of stigmatizing strategies that they
condemn as unacceptable, bioethicist Daniel Callahan ethically
endorsed the social practice of 'fat shaming' as a means
of promoting public health (Callahan 2016). Empirical arguments on the
harms of stigmatization (Hatzenbuehler, Phelan, & Link 2013), and
contrary ethical arguments (Dean 2018), both rebut stigma as an
ethically viable health-promoting intervention.



Health/body stigma, public rhetoric over health, and moralism about
health behaviors are all subjected to scrutiny in critiques of
'self-care' strategies, e.g., telling
'overweight'/overtired/overworked employees feeling
stressed by their jobs that they should take better care of themselves
by doing yoga, more closely monitoring their eating at work, etc. The
critique is that the biomedical model can recast social problems
(including outright abuses--usually capitalist ones) as
individual responsibilities. Self-care can go well when it empowers,
such as the Women's Health Movement of the 1960s and 1970s that
fought against sexism by calling upon women to know their own bodies
and value that knowledge (Bueter 2017). Or self-care can become
regressive when it becomes 



> 
> 
> inner-directed, authoritarian, victim-blaming, manipulated by dominant
> forces, or diversionary from struggles for radical change in both
> medicine and the broader society. (Sidel & Sidel 1981: 656) 
> 
> 
> 



In recent discourse, in which the problem of stress has garnered
increased attention, 



> 
> 
> controlling the health problems associated with living in stressful
> situations therefore becomes the responsibility of the
> individuals--all too often, the responsibility of individuals who
> are already disadvantaged by their economic status, their race, or
> their social position more generally. (Kaplan 2019: 116) 
> 
> 
> 



Biomedicine has been used as one prong of colonial power dynamics
between Western institutions and non-Western peoples (including
indigenous peoples) (see Millum & Emanuel 2012). Colonial
governments and cultural imperialism have long undermined or directly
attacked local/indigenous medical frameworks and institutions. And
since biomedical education and practice are based on technologies and
education from the West, low- and middle-income countries are left
dependent on wealthy Western countries (Nunn 2009). As a result, local
would-be biomedical practitioners often travel to the West for
biomedical education and then have little incentive to return to their
home countries to practice techniques for which they will have
relatively few biomedical tools, lower pay, etc. This raises further
ethical questions related to which entities have which
individual/collective responsibilities to address this so-called
'brain drain' trend (Yuksekdag forthcoming). Meanwhile,
non-governmental organizations such as the Red Cross offer medical
aid, but generally in the form of sending temporary trained personnel
from the West, rather than building local capacity for medical
training and practice. And well-meaning Western biomedical students
travel to the same low- and middle-income countries, with limited
biomedical skills and little or no knowledge of the populations or
health needs, seeking to help populations assumed to be incapable of
helping themselves (Pinto & Upshur 2009).


## 5. Alternative Frameworks



As noted at the beginning of this entry, critiques of biomedicine tend
to focus on elements of biomedicine rather than the whole. There are
exceptions to this. This section will review some of the frameworks
that have been offered in place of biomedicine, though they vary in
how similar they remain to the biomedical framework. Before delving
into the alternative frameworks, it is important to discuss two
prominent critiques of biomedicine that are influential primarily as
holistic criticisms and not so much as sources of alternative visions
of what ought to be offered in place of biomedicine.



Michel Foucault's
 work, and use of the concepts biopower and biopolitics, remain
touchstones for much of the critical discourse surrounding
biomedicine. Foucault's critique of modern medicine is part of a
career critiquing other aspects of modernity, including the related
topic of psychiatry. His famous work *The Birth of the Clinic*
is written as a history, though in the process it highlighted aspects
of biomedicine that other scholars went on to critique as well, either
based on his critique or in parallel to it: dehumanization,
reductionism, measurement and observation methods of dubious value,
and the problem of the biomedicine's institutional power
(Foucault 1963 [2002]).



Ivan Illich's *Medical Nemesis* is perhaps the most
influential critique of biomedicine (Illich 1976). It combines
critiques of (bio)medicine for failing at its own goals (iatrogenic
disease--harms caused by medical treatment--are a large
component) and for having the wrong goals in the first place (he
valorizes death, disease, and pain as proper components of the human
experience rather than enemies to be automatically and constantly
opposed).


### 5.1 Traditional healing practices



"Complementary, alternative, or integrative medicine" is
biomedicine's 'big tent' category for non-biomedical
systems of health care (see NCCIH in
 Other Internet Resources).
 Philosophers have pointed out that biomedicine, specifically
evidence-based medicine, puts advocates of such non-biomedical systems
into a no-win position. One such philosophical challenge is that some
of the claims made by non-biomedical systems are claimed to be
non-measurable experiences, e.g., the experience of *Qi* life
force in traditional Chinese Medicine (Tonelli & Callahan 2001).
This means that advocates have to either submit to the epistemological
framework of biomedicine (which may be incapable of assessing some of
the effects claimed to exist), or refusing to play by medicine's
rules and hence being dismissed by as quackery by biomedicine.
Epistemically, it seems like the latter option is the better option,
but it would require advocates to "work to develop new research
designs and new standards of evidence that reflect their approach to
medical care" (Borgerson 2005: 502).



Classical Chinese Medicine (CCM) remains practiced in communities
around the world, and Lee draws out two core philosophical differences
between CCM and biomedicine. First, CCM has 



> 
> 
> a process ontology--it considers causal relationships between
> events and processes to be foundational, rather than things.
> Furthermore, it implies complex causal relationships between events
> and processes which may be said to be multi-factorial and non-linear.
> (Lee 2017: 2) 
> 
> 
> 



Second, it is holistic 



> 
> 
> the universe and everything in it, including human beings, constitute
> wholes which are different from the sum of their parts, and which in
> turn are related and as well as inter-related with other wholes. (Lee
> 2017: 2) 
> 
> 
> 



It is within this philosophical system that treatments such as
acupuncture and herbal/dietary remedies are used. While the gulf
between biomedicine and CCM is wide, it is not entirely dissimilar
from some Western scientific practices: CCM's approach to health
and the human body bear some resemblances to the ways that
epidemiologists approach populations' health and how ecologists
approach ecosystems. Among other similarities, in both fields there is
great respect for balance and dynamic interconnected processes (Lee
forthcoming).



Ayurvedic medicine takes a somewhat similarly holistic and
balance-oriented approach to the person and their health (Rastogi,
2014) (note also that holistic bodily balance is central to the
Hippocractic medicine described in
 Section 1.2).
 One way that manifests in Ayurvedic practice--in contrast with
biomedicine--is that the biological characteristics of two
individuals might be similar but their recommended treatments might be
quite different. For instance, while biomedicine routinely hands out
standardized advice on what sorts of foods are best for someone of a
given age and sex, Ayurvedic medicine rejects the assumption that such
standardization within a single age-sex grouping is even a good
default. Other factors play larger roles than in biomedicine,
including bodily changes over the course of the day and one's
(internal) body type (affecting how one metabolizes specific foods,
etc.). Complicating matters is that Ayurvedic medicine grew as a part
of Hinduism in South Asia, and Hinduism itself is a substantially
heterogeneous family of beliefs/practices that vary between
communities (Desai 1988).


### 5.2 Narrative and phenomenological approaches



Among the numerous humanistic critiques of biomedicine, coming from
the broad field of medical humanities (for an overview, see Marcum
2008), philosophers have paid particular attention to narrative and
phenomenology (Ferry-Danini 2018).



Narrative medicine offers a revision to the biomedical model
alternative based around the centrality of the story or narrative in
human life (Charon 2006). This notion that narrative is central to
human experience offers a variety of potential operationalizations in
clinical biomedical practice. For instance, it places additional value
on the patient consultation and asks for improved active listening
skills among clinicians, who must learn to elicit, receive, and
understand patients' stories about their health conditions. Such
listening has many potential benefits, including the potential to
understand the meaning(s) of what human dignity means for a given
patient, an important benefit given that biomedical settings are known
for being "dehumanizing" (Parsons & Hooker 2010).
Though, the proposition that humans are indeed narrative beings has
itself been disputed (Woods 2011).



As shown by Carel, phenomenology's value to medicine comes from
its insistence on taking illness seriously (Carel 2016).



> 
> 
> ...we must enlist philosophical analysis in order to fully
> appreciate the existential transformation illness brings about. This
> transformation cannot be accounted for as merely physical or mental
> (in the case of psychiatric disorder) dysfunction. Rather, there is a
> need for a view of personhood as embodied, situated, and enactive, in
> order to explain how local changes to the ill person's body and
> capacities modify her existence globally (Carel 2016: 14).
> 
> 
> 



Biomedicine takes illness seriously, but the philosophical framework
of biomedicine leaves no space for the notions of existential
transformation as part of illness--disease is reduced to the
state of a system in which there are malfunctioning parts (pathologies
in body parts). See also the discussion of phenomenology in
 Section 3.4.


### 5.3 Gentle medicine and population health framework approaches



Stegenga has argued in favor of "gentle medicine," a
conservative treatment mindset that stands in contrast to the
biomedical pursuit of ever-more interventions (Stegenga 2018)--a
pill for each ailment. This is in one sense a challenge to biomedicine
more in quantity than in quality; he does not advocate for switching
from pills to naturopathic diet-based treatments. He recommends this
(purportedly gentler) conservatism as a response to an epistemic
devaluing of biomedicine knowledge which he calls: "medical
nihilism...the view that we should have little confidence in the
effectiveness of medical interventions" (Stegenga 2018: 1). This
follows in the loose tradition of other writings, such as the text by
Illich discussed at the start of
 Section 5
 (Illich 1976). But Stegenga's critique and replacement remains
a radical challenge to biomedicine in the sense that it undercuts the
epistemic practices of biomedicine and pushes back on the
institutional practices (and the related infrastructure, including
massive pharmaceutical companies) by arguing that (bio)medical
treatments ought to be applied sparingly.



Valles offers an alternative--the population health
framework--that partly meshes with Stegenga's concluding
suggestion that "gentle medicine" ought to be accompanied
by interventions that refocus health promotion efforts on social
determinants of health, including "clean drinking water, better
nutrition, and greater socio-economic equality" (Stegenga 2018:
198). Valles expounds and defends the merits of the population health
framework, a view developed in response to frustrations with
biomedicine that coalesced in the 1990s in Canada as an alternative
theoretical framework, before expanding internationally (Evans, Barer,
& Marmor 1994; Valles 2018). The population health framework is
not nihilistic about medical care, but rather seeks to decenter
medicine and healthcare in the overall pursuit of health; most of the
problems and most promising solutions to ill health lay outside the
scope of biomedicine (safer workplaces, an end to racist housing
discrimination, neighborhoods where people can safely walk, socialize
and play, etc.) (Valles 2018).