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An account of medical treatment, with a preliminary account of medical conditions

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Abstract

In this article, I present a philosophical account of medical treatment. In support of this account, I offer a suggestive account of medical conditions. The account of medical treatment uses three desiderata to demarcate treatment from non-treatment. Namely, a treatment should: (1) be describable by features that enable it to be standardized and characterized as a discrete intervention, (2) target a specific medical condition, and (3) have the possibility of being effective. The account of medical conditions underlies the second desideratum and attempts to tie medical conditions closely to biological dysfunction, while also including some conditions for which biological dysfunction is absent or its presence uncertain. I offer a simple typology of treatments and show how the accounts are relevant to treatment effectiveness, disease, placebos, contested treatments, and treatment standardization.

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Change history

  • 09 September 2023

    Table format and titles in reference section has been corrected.

Notes

  1. My target in this article is medical treatment, not treatment in general. For simplicity, henceforth I simply mostly refer to “treatment”.

  2. Currently, as fecal microbiota transplantation for recurrent Clostridium difficile infection.

  3. In a work in progress, I answer this affirmatively. The implications of this — for characterizing placebos and placebo effects and establishing treatment effectiveness — are too complex to go into here, which is why I address it in another work. Nonetheless, such work is underscored by the importance that placebos-being-treatments holds for philosophical accounts of placebos. Importantly, for the present work, what have been used as placebos in clinical practice and clinical trials satisfy the “treatmenthood” desiderata I outline in the section on medical treatment desiderata.

  4. None of which should be taken to mean that I think there is a clear-cut individuation of treatments, but rather that certain classifications are useful for certain purposes.

  5. This approach, for example, is taken by Stegenga [13] (see also the section on pathology in the present article). This is different from requiring the possibility of effectiveness (discussed later), or something’s being effective offering presumptive evidence of treatmenthood. Knowing that a treatment is effective could be used as a meta-heuristic in cases of contested treatmenthood; i.e., something’s being effective could offer support for it being a treatment.

  6. Which can especially be the case when safety is subsumed under effectiveness, a situation illustrated by a medical advisory board meeting I once attended where a distinguished oncologist, in full view of representatives of the pharmaceutical company that sponsored the meeting, along with a room full of other oncologists, declared the company’s drug to be poison, despite the median one month extra survival it was shown to provide in clinical studies, though at the expense of intolerable side effects. Granted, this was a view not shared by the pharmaceutical company, who believed their drug to be effective because of the improvement in survival.

  7. Elaborating on these factors or other relevant factors and how they interact to differentiate specific treatments is beyond the scope of this article but may be a fruitful area for future research.

  8. Although it may seem like it, this does not make treatmenthood dependent on treatment effectiveness because a poorly characterized treatment with respect to treatment effectiveness can still be a treatment.

  9. A possibility borne out by a study conducted under the open–hidden paradigm which found the effectiveness of morphineo to be significantly higher than that of morphinec [27].

  10. I do not draw a distinction between illicit and licit drugs with respect to whether they can be treatments (and I thus reject the legality of something as a criterion of treatmenthood). I recognize that some people might not consider use of cocaine for its psychoactive properties to have any legitimate medical purpose, even independent of cocaine’s high risk of adverse events.

  11. I use here the terminology “medical condition” instead of “clinical condition” to avoid confusion with [32] where I list in my chart of clinical conditions what are better thought of as clinical conditions and clinical activities (such as blood donation), and which could imply that clinical conditions are characterized by their being addressed by clinicians, whereas I mean for “medical condition” to have no such necessary implication.

  12. Medical treatment could be considered a proper subset of medical interventions, the latter of which include diagnostic interventions (such as screening programs), public health interventions (such as water fluoridation), and medical procedures/activities (such as autopsy, euthanasia, cosmetic surgery, and interventions to improve sports performance). The feature distinguishing medical treatments from public health interventions appears to be that medical treatments are directed at the individual level whereas public health interventions are directed at the population level. Either can involve changing the social context. For medical treatments, however, a description on the individual level is needed. A public health intervention could accordingly be rewritten as an individual-level medical intervention. This description might vary depending on the person (see the section “Discreteness and standardization”). For example, fluoridation of a city’s water supply is a public health intervention that operationalized as an individual-level intervention could involve for one person drinking the water whereas for another person simply showering with it. Only the former usage would constitute medical treatment for caries.

  13. One could, by contrast, define medical conditions on the basis of what is potentially medically treatable (e.g., as Cooper [33] does with respect to defining disease). The onus then arises for defining treatment and medicine. Cooper [33, p. 278] offers the possibility of medicine being “the science practiced by doctors and other medical personnel,” and recognizes that it can be indeterminate as to what a medical treatment is.

  14. As Stegenga [38, p. 11] wryly notes, “Not all forms of suffering are in the domain of medicine. One need only consider the suffering caused by hunger or climbing high mountains or listening to country music.”

  15. This includes disease, environmental trauma (e.g., heatstroke, altitude sickness), injury, and poisoning.

  16. In personal communication, Stegenga has confirmed this accurately characterizes his view. See also the earlier section on effectiveness.

  17. As Aquino ([63], p. 7) writes “…dealing with a complaint of leg pain requires a medical understanding that can distinguish a normal response to physical exertion from a pathological condition. If the leg pain is pathological, adequate medical knowledge should enable doctors to diagnose and establish the cause, severity and complications of the condition. In cases when leg pain is not pathological, such as when it is caused by muscle fatigue after prolonged physical activity, a clinician offers reassurance and may decide that further medical investigation is not warranted. The clinical process of disease determination then involves a clinician’s use of her medical knowledge to distinguish the normal from the pathological.”

  18. This includes the mechanism of water memory, for which ample reasons exist to consider it to be highly implausible [71,72,73,74,75,76,77].

  19. I have argued [15] that a similar problem is also encountered with the Russo–Williamson thesis. More work is needed to identify what the criteria should be that demarcate a mechanism as being “plausible.”

  20. Especially since, for some, I do not mention the treatment target. Also, some I merely describe as nouns, whereas all treatments involve doing something, even if as simple as being administered.

  21. Fuller [85], for example, analyzes the concept of preventive and curative medical interventions using the concept of a medical condition. However, he admits [85, p. 14] that “[a]nalyzing a concept like ‘disease’ or ‘medical condition’ is a formidable (and frequently faced) problem of its own that I will not attempt here.” He instead examines medical interventions via what he views as representative examples (and like me he views medical conditions as the more general category than diseases). Authors in the medicalization literature are also aware of the importance of this question; as Sadler et al. [86, pp. 412–413] write, “whether a human problem is, or is not, metaphysically (‘‘really’’) medical would be a question at the core of a philosophy of medicalization.”

  22. However relevancy is determined, a matter I will not address here, other than to note that while effectiveness is typically how relevancy is determined, establishing effectiveness or its appropriate standard for any given treatment is no straightforward matter [14, 15]. Additionally, some healing traditions even determine relevancy on the basis of religious saliency. For highly specific treatments, relevancy may be a function of certain institutional features involving how the treatment is conceived and administered.

  23. I am aware that “individualized” and “specific” have similar denotations, but for lack of better terms I use them here idiosyncratically.

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Acknowledgements

Many thanks to Christopher Boorse, Andreas De Block, Bert Leuridan, Diane O’Leary, Jonathan Sholl, and Jacob Stegenga, plus two anonymous reviewers for this journal, for helpful comments on earlier drafts of this paper. The author was supported by the Fonds Voor Wetenschappelijk Onderzoek – Vlaanderen (FWO; Research Foundation – Flanders; 1130819N) during part of the writing of this paper and is grateful for their support.

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  1. Department of Philosophy, University of Antwerp, Rodestraat 14, Antwerp, 2000, Belgium

    Steven Tresker

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Tresker, S. An account of medical treatment, with a preliminary account of medical conditions. Theor Med Bioeth 44, 607–633 (2023). https://doi.org/10.1007/s11017-023-09641-3

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