CauseHealth: Causation, Complexity and Evidence in Health Sciences

CauseHealth gathers philosophers, medical researchers and clinicians to discuss foundational issues in medicine, mainly concerned with causal evidencing in cases of complexity, individual variation and medical uniqueness. Acknowledging that all patients are different, the public health perspective of evidence based medicine represents a challenge when results are expected to translate from populations to the clinic. That choice of medical treatment and health policy ought to be evidence based seems undeniable. The question of this project is whether one can use same type of evidence for populations and individuals. As a result of this focus, most of the enthusiasm for CauseHealth comes from clinicians and other healthcare practitioners who are concerned with the extensive use of population studies and statistical tools in medicine. These professional groups feel a pressure to treat individual patients as statistical average, with standardised treatments and package solutions. Looking at the philosophical biases underlying current evidence based frameworks, we can trace it back to the positivist ideal, based on the empiricist philosophy of David Hume. By replacing the positivist and Humean scientific framework with a dispositionalist one, we get a shift in focus: away from same cause, same effect, homogeneity, regularity, universal treatment, statistical correlations, and frequencies; towards causal singularism, heterogeneity, context sensitivity, tendencies, medical uniqueness, and individual propensities. This also affects how we search for causes in medicine. Evidence-based medicine was motivated by the idea that everyone should get the same treatment for the same medical condition, rather than treatment being decided by individual clinicians. Today we have clinical guidelines that recommend interventions based on what has been proven to work best for most patients in RCTs. But what works best for most might not work so well for some individual patients. In order to meet the philosophical interest among clinicians, we have written an open access book for this group in particular: Rethinking Causality, Complexity and Evidence for the Unique Patient. A CauseHealth Resource for Health Professionals and the Clinical Encounter, to be published with Springer in 2020. The book has a philosophical part, outlining the part of the CauseHealth research that is relevant for the clinical encounter, and then a practical part where 8 clinicians and one patient describe how this philosophical framework can work in practice. Most of the CauseHealth events have attracted clinicians and other healthcare practitioners. To appeal also to epidemiologists and guidelines developers, we organised a conference specifically on clinical guidelines. Clinical guidelines, for various reasons, are often used more rigidly in clinical settings than the developers intended. But evidence from the patient context can be more causally relevant in deciding treatment than what has been shown to work at the group level. The conference The Guidelines Challenge. Philosophy, Practice, Policy succeeded in bringing together practitioners, guidelines networks and philosophers of science to address the general problem of how to put the tools of philosophy to use in improving the development and implementation of healthcare guidelines. In particular, how do we reconcile the purpose of guidelines with the needs of the clinic? There is a growing movement towards the particular (e.g. person centred approaches, individualised treatments, incorporating patient narratives and clinical judgement), while guidelines must be general (e.g. providing evidence-based advice and methods for clinical decision-making). The conference was podcasted and published at the CauseHealth YouTube channel and many of the papers were published in the annual philosophy issue of Journal of Evaluation in Clinical Practice, which also includes a conference report. This journal also published a special section from the conference N=1 Causal Reasoning and Evidence for Clinical Practice.

Den disposisjonelle vektormodellen for kausalitet er blitt tatt i bruk av klinikere som et verktøy for å hjelpe pasienter med kroniske lidelser, særlig innen fysioterapi. I CauseHealth-boka viser en pasient hvordan hun bruker denne modellen for å forstå og kontrollere sin egen kroniske smerte. Verktøyet ble først utviklet av fysioterapeut og CauseHealth partner, Matthew Low. WHOs Uppsala Monitoring Center ønsket å få hjelp til å utvikle en bedre metode for å evaluere kausalitet i forbindelse med bivirkningsrapporter av medisiner. Statistiske metoder er lite egnet for sjeldne bivirkninger, mens det disposisjonelle rammeverket tar utgangspunkt i medisinsk unikhet og individuelle variasjoner. UMC finansierer et 3-årig spin-off prosjekt, CauseHealth Risk and Safety, med tidligere postdok Elena Rocca som prosjektleder. Også legemiddelverket og produsenter av medisinsk utstyr har vist sin interesse for å samarbeide om kausalitets- og risikovurdering av bivirkninger.

Causation is central to our understanding of human health and illness. Medical explanation, prediction and intervention are all premised on the reality of causation and philosophy is best placed to account for its nature. CauseHealth will bring together philosophers, medical researchers and practitioners to address a major challenge: how to understand causation in health sciences. A recent advance in the philosophy of causation, a theory developed by the Principal Investigator and her collaborators, will be applied to some of the cases in medicine where causation is least understood. In so doing, there is the potential to significantly advance the methods of medical research. The motivation for CauseHealth is an emerging problem of the increase in so-called medically unexplained symptoms (MUS), such as chronic fatigue syndrome (CFS/ME), irritable bowel syndrome (IBS), low back pain (LBP), multiple chemical sensitivity (MCS) and fibromyalgia (FM). MUS are widespread and by some estimates amount to 30 percent of the symptoms reported to doctors. "Medically unexplained" means that we are unable to find a common set of causes, a clear psyche-soma division, or obvious classifications for these conditions. Each patient seems to have a unique combination of symptoms and a unique expression of the condition. While the majority of existing methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their complex and heterogenic nature. As a result, MUS resist medical scrutiny in a way that other conditions do not. These chronic conditions are often depicted as outliers: atypical illnesses where standard causal explanation fails. Instead, CauseHealth regards their understanding as the key to a better grasp of causation in medicine. If we understand MUS, therefore, we will better comprehend the causes of health and illness generally.