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Explanatory pluralism in the medical sciences: Theory and practice

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Abstract

Explanatory pluralism is the view that the best form and level of explanation depends on the kind of question one seeks to answer by the explanation, and that in order to answer all questions in the best way possible, we need more than one form and level of explanation. In the first part of this article, we argue that explanatory pluralism holds for the medical sciences, at least in theory. However, in the second part of the article we show that medical research and practice is actually not fully and truly explanatory pluralist yet. Although the literature demonstrates a slowly growing interest in non-reductive explanations in medicine, the dominant approach in medicine is still methodologically reductionist. This implies that non-reductive explanations often do not get the attention they deserve. We argue that the field of medicine could benefit greatly by reconsidering its reductive tendencies and becoming fully and truly explanatory pluralist. Nonetheless, trying to achieve the right balance in the search for and application of reductive and non-reductive explanations will in any case be a difficult exercise.

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Notes

  1. The term “non-reductionism” gets different interpretations in the philosophical literature. However, we do not want to refer to the extensive philosophical debates on non-reductionism (and/or anti-reductionism) but will use the label “methodological non-reductionism” throughout the paper strictly as defined here.

  2. One might, for example, think that the genetic make-up of Asians compared to those of Europeans is a group characteristic, and hence, one that can act as a macro explanatory factor. However, if an Asian moves to Europe and takes a European nationality, he will still have the same genetic make-up. For this reason, reference to one’s genetic make-up in an explanation makes for a reductive explanation, as we will further explain.

  3. Non-reductive micro-explanations can sometimes easily be translated to the macro-level and the reverse. This depends on whether one focuses, for example, on unhealthy individual lifestyle choices or, rather, on the environmental factors that lead to these unhealthy lifestyles. This does not pose any problems because we can use the term “non-reductive explanation,” which covers both types.

  4. The adequacy, efficiency, and accuracy of explanations are elaborated in Van Bouwel and Weber [7].

  5. See Vanderbeeken and Weber [9], and Weber and Vanderbeeken [10] for a defense of explanatory pluralism in psychology. For explanatory pluralism in history and the social sciences, see Weber and Van Bouwel [11], Van Bouwel and Weber [7, 12], and Van Bouwel [13].

  6. Although different levels of explanation might be connected to the use of diverse forms of explanation-seeking questions, we will not focus on forms in this paper but rather on levels.

  7. We will further discuss arguments for the usefulness of reductive explanations in the “Epistemic interests in medicine support non-reductive and reductive explanations” section.

  8. See, e.g., [14, 19, 20].

  9. See also [26, 31–34].

  10. See, e.g., Fee and Krieger [35] with respect to AIDS, Smith and Ruiz [36] with respect to Coronary Heart Disease, Vinetz et al. [37] with respect to Leptospirosis, and Chaufan [29] with respect to Diabetes type 2.

  11. Nassir Ghaemi [38], for example, nicely describes in his recent book how the methodologically holistic stance of the biopsychosocial model made the approach unfeasible in practice by being too general and too vague.

  12. Although prevention and treatment can be interpreted as two forms of the broader epistemic interest of intervention/manipulation, the usefulness of distinguishing between the two in the context of medicine will become clear from what follows. In medical research, each of these epistemic interests may indeed lead to a different approach to the same research topic, possibly even focusing on different levels of explanation and, consequently, intervention.

  13. The most debatable form of which is neurobiochemicalization, where biochemical processes in the brain are influenced by means of a pharmacological intervention.

  14. This would suggest that prevention of the disease should involve changes at these higher levels.

  15. Hence, arguing for the primacy of the sociocultural explanation does not automatically entail the denial of reductionist aspects in the etiology of the disease. However, the importance of the reductionist aspects for prevention and intervention, for example, can be discussed and the weight given to them can differ depending on the context.

  16. The conviction that a reductive explanation will be found in the future and that such an explanation will support a reductive approach—rather than the fact that an actual reductive explanation justifies the reductive approach—seems to form a sufficient ground for medicine to base the bulk of the research and preferred treatments on these still to be found reductive explanatory factors, for example, in the case of ADHD. This contrasts sharply with, for example, the arguments given by Scheidt [43] for not translating the findings on psychological explanatory factors into clinical practice measures. His argument is the current lack of knowledge about the precise mechanisms whereby psychological issues cause or potentiate disease. In view of such arguments with respect to non-reductive causes, it is remarkable that knowledge of the precise mechanisms, whereby reductive elements cause or potentiate disease, is not always requested, for example, when administering stimulant drugs to treat ADHD.

  17. In fact, that stimulant medication could treat what we now know as ADHD was discovered before the addressed problematic behavior of children was actually conceptualized as a disease [44].

  18. The relation between epistemic motivations and non-scientific interests is in any case interesting enough to be further explored. The role of non-scientific interests is discussed in Gannett [45, p. 370] with respect to geneticization: “The context in which genes are chosen as the best ‘handles’ among these parts are not just scientific and clinical but economic and political. Geneticization finds a friendly home in a society less and less willing to commit resources to solving complex social problems.… Genetically engineered solutions make private investors money; serious attempts to counter poverty, environmental degradation, and tobacco, alcohol, and drug addiction just costs taxpayers money. The appreciation of the pragmatic dimensions of genetic explanations, and hence their contingency, not only provides good reason to be sceptical of what geneticization has to offer but, by forcing attention to context, asks us to examine the aims, interests, and orientations that lie behind the choices that are being made.”

  19. Since scientists hardly justify their choice to search for an explanation at a certain level, it is not possible to figure out whether or not these (and other) scientists just follow a general tendency to try to reduce everything to the level of the genes, or whether their work is grounded in the conviction that their results will serve specified epistemic interests.

  20. The fundamental theory should be distinguished from the basic theory. While the basic theory is more modest in answering the question, “What do genes do?”—i.e., that they “code for” or “determine” the linear sequences in RNA molecules and polypeptides synthesized in the cell—the fundamental theory is bolder, claiming that genes are “fundamental” entities that “direct” the development and functioning of organisms by “producing” proteins that in turn regulate all the important cellular processes [52].

  21. Cf. Keller [54], Waters [52, 53]. “In the case of molecular genetics, it is investigative pragmatics, not fundamental theorizing, that drives scientific research. The basic theory suffices to explain the investigative utility and results of gene-centered approaches. The fundamental theory is, in an important sense, epiphenomenal with respect to the design and implementation of gene-centered research. On this view, the role of the fundamental theory should be understood in Latourian terms… as a platform for rallying the troops and bringing resources to research endeavors. The design of the laboratory experiments and the reason why the experiments work, can be explained in terms of broad investigative strategies, the basic causal theory of molecular genetics, and the details of the experimental contexts” [52, section 6]. Lisa Gannett [45], too, explains the increasing geneticization as driven by pragmatic dimensions, especially manipulability: “[the change brought about by geneticization] lies not in using newly acquired technological prowess to confirm the truth of long standing suspicions about the primacy of genes. I suggest, instead, that we understand geneticization in pragmatic terms: the increasing focus on genes as causes mirrors the increasing ability to manipulate DNA in the laboratory and in the clinic in furtherance of what are perceived to be desirable ends” [45, pp. 369–370].

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Acknowledgments

Jeroen Van Bouwel is a post-doctoral fellow of the Research Foundation Flanders (FWO). We thank Jan De Winter, Bert Leuridan, and the anonymous referees for their comments on earlier versions of this article. The Research Foundation Flanders (FWO) supported the research for this article through research project G.0651.07.

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    Leen De Vreese, Erik Weber & Jeroen Van Bouwel

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De Vreese, L., Weber, E. & Van Bouwel, J. Explanatory pluralism in the medical sciences: Theory and practice. Theor Med Bioeth 31, 371–390 (2010). https://doi.org/10.1007/s11017-010-9156-7

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