Philosophy and History of Medicine

Unit guide and reader 2008-9

Philosophy and History of Medicine

(PHIL 30080/30082) Unit Director Michael Bresalier
Department of Philosophy email: plmcb@bris.ac.uk Office: B7 - 7 Woodland Road Office hours: Wednesday, Thursday, 3-4pm

Guest Lecturers Alexander Bird (Philosophy) Havi Carel (UWE) Andrew Morrice (Homeopathy Hospital) Trevor Thompson (Primary Care) Unit Objectives
Every society has developed healing practices and systems in response to human suffering and illness. Yet, medical ways of knowing are historically, socially and culturally contingent. Far from being a single, unified system of knowledge, medicine has been made up of a variety of ways of knowing, which are often incommensurable with each other. Taking this contingency and variety as its starting point, this unit surveys the making of modern medicine from the French Revolution to the AIDS pandemic. It explores some of the key epistemological frameworks of our medical world in their socio-historical context. It traces the creation in the nineteenth century of two new medical institutions, hospitals and laboratories, of new medical professionals working in them, and of new causal understandings of disease. Turning to the twentieth century, it then traces the formation of biomedicine and national health care systems, and examines the problem of standardizing medical knowledge and practice through the clinical trial and evidence-based medicine. Throughout, the unit explores the tensions between the increasing objectification of medicine and the subjective dimensions of doctors knowledge and patients illness. Addressing the changing relationship between the doctor and patient, science and medicine, and concepts of health and disease, the unit critically assesses the nature and status of disease categories, medical expertise and medical knowledge.

Timetable
Lectures: Mondays at 4pm starting 6 October (3F9 8 Woodland Road; entry via 12a Priory Road); additional Thursday lectures (LT2 11 Woodland Road) Seminars: Mondays at 1-2 pm; 2-3pm starting 13 October (G65, 15 Woodland Road)

Lectures
3F9 8 Woodland Road Mondays 4-5pm LT2 11 Woodland Road Thursdays 2-3pm (23, 30 Oct; 13 Nov) Week 1 Week 2 6 October 13 October 3:00 Introduction 4:15 Ways of knowing Concepts of Health and Disease Birth of the Clinic Defining Doctors Laboratory Revolution Experimental Bodies Biomedicine and national health systems RCT: Gold Standard or Fools Gold Evidence-Based Medicine and the Pitfalls of Standardization Managing Uncertainty

Seminars
G65 15 Woodland Rd Mondays Group1: 1-2pm Group2: 2-3pm

Approaches to the History and Philosophy of Medicine

No seminar Seminar Ways of Knowing Seminar Concepts of Health and Disease Seminar Birth of the Clinic Seminar Laboratory Revolution/Animal Models Seminar Biomedicine

Making Modern Medicine

Week 3 Week 4 20 October 23 October 27 October 30 October 3 November 10 November 13 November *Week 7 Assignment II Formative essay Week 8 17 November

Rationalizing Medicine
*Week 5 Assignment I Book review Week 6

Seminar RCT/EBM

Challenging Orthodoxies
24 November 27 November Week 9 Week 10 Week 11 1 December 8 December 12 January Homeopathy and Heterodox Medicine Patients and the Politics of Medical Knowledge Medicine and Death Conclusions Revision Seminar - Uncertainty

Seminar - Patients Seminar - Death No seminar

Philosophy lectures
Students who wish to study more closely basic concepts in philosophy can audit units in the Department of Philosophy. Units of particular relevance: PHIL10005: Introduction to Philosophy and PHIL20034: Realism. Please speak with the directors of the respective units.
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Assessment
Formative assessment one seminar presentation one book review (c. 750-1000 words) due: 1pm 27 October one essay (c. 1,500-2000 words) due: 1pm 17 November Details of each assignment will be handed out in lecture and posted on Blackboard. Summative assessment iBAMH students: take home examination in week beginning 19 January 2009. You will be given a list of titles on Monday 19 January and will be expected to submit two 3,000 word essays on titles from the list, by 4 p.m. on Friday 23rd January. Philosophy/Arts and Humanities students: 3hr exam at end of TB2.

Seminars
Weekly, one-hour seminars will be held before that weeks lecture. The topic for each seminar will be that of the preceding weeks lecture.
Mondays, 1-2pm; 2-3pm. G16 3-5 Woodland Rd.

Seminars will be divided into two parts: 1) analysis and discussion of selected primary texts/images and 2) analysis and discussion of required readings. Students are expected to read and prepare to discuss required readings and primary texts/images in advance of the seminar. Seminar questions for each week will be provided to help focus reading and discussion. Students are responsible for one seminar presentation in collaboration with another student on the required readings of that week. Presentations should not exceed 15 minutes and include a summary and analysis of the readings, taking into consideration their main arguments, how they relate to one another, and the seminar questions provided on Blackboard. In addition, presenters are expected to provide fellow students with a handout outlining their presentation (including further discussion questions).

Unit Materials
Unit readings and primary texts/images are collected in one of the following places: the Unit Reader (UR), Medical and Arts and Social Science Libraries, Department of Philosophy, and Blackboard. Unit Reader and Libraries Most required readings are collected in the Unit Reader (UR), which can be purchased from the Department of Philosophy office (1st floor, 9 Woodland Road). Readings not included in the UR can be found in the unit file in the Department of Philosophy Office, on Blackboard, or in university libraries. All required and most recommended books are held on short-term loan at the Arts and Social Sciences Library (ASS) and Medical Library (MED). Preliminary readings and other unit texts can been purchased at Waterstone's.
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Blackboard (http://www.ole.bris.ac.uk) All students will be enrolled on Blackboard. It functions as a parallel teaching forum to the unit guide. Here you will find: Announcements Unit Guide (pdf version) Lectures (Lecture slides and supplementary readings) Seminars (Primary texts/images and seminar questions) Assignments (Book review and essay questions) Assessment (feedback and evaluation of presentations, reviews, essays) Special seminars (PHM seminar series in the Department of Philosophy) Discussion Board (discussion and feedback on seminar presentations; q&a) Students should visit Blackboard regularly. Readings This unit demands a considerable amount of reading. To make things manageable, readings for each section in the UR have been prioritized as follows: ** Required reading students are responsible for all such readings. * Recommended reading important background for the lecture. Supplementary readings (unmarked) for the ambitious. ASS = Arts and Social Science Library MED = Medical Library DPF = Department of Philosophy File BB = Blackboard

General Readings and References

**Ludwik Fleck, Genesis and Development of a Scientific Fact, Chicago: University of Chicago Press, 1979/1935. (ISBN:0-226-25325-2) ASS (Q175.5 FLE). **Harry Collins and Trevor Pinch, Dr. Golem: How to Think about Medicine, London: University of Chicago Press, 2005. A useful introduction to key themes in the epistemology of medicine. (ISBN: 0226113663) MED (AA8a COL). **Roy Porter, The Greatest Benefit to Mankind, London: W.W. Norton, 1997. esp. Introduction and Chapters 10-22. The best survey of the history of medicine, by one of its foremost historians. (ISBN: 0006374549). ASS (R131 POR), MED. *John Pickstone, Ways of Knowing: A new history of science, medicine, technology and medicine, Manchester: Manchester University Press, 2000. (ISBN 0 7190 5994 1) MED.

Reference
*W.F. Bynum, Science and the Practice of Medicine in the Nineteenth Century, Cambridge: Cambridge University Press, 1994. Definitive historical synthesis of the social and epistemological changes in medicine that gave rise to scientific medicine in the nineteenth century. (ISBN-13: 9780521272056 | ISBN-10: 052127205X) ASS (R149 BYN), MED.

Andrew Cunningham, The Making of Modern Medicine, (Radio 4 Series), London: BBC Audiobooks, 2007. MED (ISSUE Desk AA3CUN) *Deborah Brunton, (ed.) Medicine Transformed: Health, Disease and Society in Europe 1800-1930, Manchester: Manchester University Press, 2004. (ISBN 0719067359) MED. Anne Hardy, Health and Medicine in Britain since 1860, Basingstoke: Palgrave, 2001. (ISBN: 0333600118). ASS (RA485 HAR) Christopher Lawrence, Medicine and the Making of Modern Britain, 1700-1920, London: Routledge, 1994. (ISBN: 0415091683) ASS (R487 LAW) W.F. Bynum and Roy Porter, (eds.) Companion Encyclopedia of the History of Medicine, London: Routledge, 1993. 2 v. MED (AA3 COM) W.F. Bynum. et al., (eds.) The Western Medical Tradition 1800-2000, Cambridge: Cambridge University Press, 2006. (ISBN: 0 521 47565 1) MED. Roger Cooter and John Pickstone (eds.) Companion to Medicine in the Twentieth Century, London: Routledge, 2003. (ISBN 04 415 28603 4) ASS (R149 MED), MED.

Web resources
UoB electronic journals: http://www.bristol.ac.uk/is/library/electronicjournals Medical Humanities New York Universitys Literature, Arts, and Medicine Database http://litmed.med.nyu.edu/Main?action=new eJournals: Medical Humanities; Journal of Medical Humanities History of Medicine eJournals (available through UoB information services): Medical History; Social History of Medicine; Journal of the History of Medicine and Allied Sciences; Studies in History and Philosophy of Biological and Biomedical Sciences UoB Medical Library http://www.bris.ac.uk/is/library/subjects/medfac/info/internetlinks.html#hist Wellcome Library http://library.wellcome.ac.uk Wellcome Medical Photographical Library http://medphoto.wellcome.ac.uk History of the Health Sciences World Wide Web Links http://www.mla-hhss.org/histlink.htm National Library of Medicine (US) http://wwwihm.nlm.nih.gov MedHist http://www.intute.ac.uk/healthandlifesciences/medhist Philosophy of Medicine eJournals: Journal of Medicine and Philosophy; Theoretical Medicine and Bioethics; Medicine, Healthcare and Philosophy; Philosophy, Ethics and Humanities in Medicine

Lectures
Approaches to the history and philosophy of medicine
Week 1 (6 October) Ways of Knowing (Bresalier) Far from being a single, unified system of knowledge, modern medicine is made up a variety of ways of knowing, which are often incommensurable with each other. Taking this variety as the starting point for the unit, this lecture outlines the problems it raises within modern medicine. It introduces different historical and philosophical approaches to understanding the complexity of modern medicine. Readings: Harry Collins and Trevor Pinch, Dr. Golem: How to Think about Medicine, London: University of Chicago Press, 2005. Introduction. Ludwik Fleck, Genesis and Development of a Scientific Fact, Chicago: University of Chicago Press, 1979/1935. (ISBN:0-226-25325-2) ASS (Q175.5 FLE), pp. 38-51; 98-111. **Thomas Kuhn, Postscript, The Structure of Scientific Revolutions, 2nd Edition, Chicago: University of Chicago Press, 1970, pp. 174-210. **John Harley Warner, The History of Science and the Sciences of Medicine, Osiris, 10(1995): 164-193. (UR) Annemarie Mol, Pathology and the clinic: an ethnographic presentation of two atheroscleroses, In. M. Lock, A. Young, and A. Cambrosio (eds.), Living and working with the new medical technologies, Cambridge: Cambridge University Press, 2000, pp. 82-102. DPF Week 2 (13 October) Concepts of Health, Disease and Medicine (Havi Carel) Medicine is defined by how health and disease are defined. Such definitions shape everything from medical practice and the allocation of healthcare resources to personal identity and understandings of what is normal and what is not. Concepts of health and disease thus have wide-reaching social, political and economic implications. This section contrasts historical and philosophical perspectives on modern biomedical concepts of health and disease. Readings: Fleck, Genesis and Development of a Scientific Fact, pp.1-23. **Charles Rosenberg, Disease in History: Frames and Framers, The Milbank Quarterly, 67, Supplement 1 (1989), pp.1-15. UR **Christopher Boorse, Health as a Theoretical Concept, Philosophy of Science 44 (1977), pp.542-573 (especially, 542-559). UR **J. Kovacs, The Concept of Health and Disease. Medicine, Health Care and Philosophy 1(1998): 31-39. UR

**D. Jennings, The Confusion between Disease and Illness in Clinical Medicine. Canadian Medical Association Journal 135(1986): 865-870. DPF *H. Carel, Can I be Ill and Happy? Philosophia 35:2(2006): 95-110. BB *Steven J. Peitzman, From Dropsy to Brights Disease to End-stage Renal Disease, The Milbank Quarterly, 67, Supplement 1 (1989), pp.16-32. BB. Rachel Cooper, Disease Studies in History and Philosophy of Biological and Biomedical Sciences. 33(2002), pp.263-282. BB

Making Modern Medicine

Week 3 (20, 23 October) (20 October) Birth of the Clinic (Bresalier) The anatomico-clinical method is a defining feature of medical practice. It is based on a particular way of seeing and knowing what has been called the clinical gaze that presupposes a particular way of organizing medicine in hospitals. Yet the structure and organization of the clinical gaze are relatively recent inventions. Some historians argue that they are rooted in dramatic changes in hospital medicine and knowledge that occurred during French Revolution at the end of eighteenth century. In this section we set the clinical gaze in this historical context to explore the particular way of knowing and seeing it has come to support. The clinical gaze involved a transformation in how and where disease, life and the body were perceived and practiced upon. Perhaps most profoundly, it fundamentally changed the doctor-patient relationship. We shall consider the ever-important question of whether the birth of clinic resulted in the death (or disappearance) of the patient. But the history of the clinical gaze raises other important historical and philosophical questions: How do medical ideas or practices change, spread and become generalized? What constitutes medical objectivity? And what is the relationship between the clinical method and medical power? Readings: **Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, New York: Vintage, 1973. Chps. 1, 8. ASS (R133 FOU), MED (Med.Hist.Room AA3o FOU), DPF. Gary Gutting Michel Foucault's Archaeology of Scientific Reason, (Cambridge : Cambridge University Press, 1989), Chp. 3. ASS (B2430.F724 GUT). Helpful introduction to Foucaults epistemology. **N.D. Jewson, The disappearance of the sick-man from medical cosmology, 1770-1870, Sociology, 10 (1976), pp.225-44. (UR) N.D. Jewson, Medical knowledge and the patronage system in Eighteenth-century England Sociology, 8 (1974), pp.369-85. DPF *L.C. Jacyna, The localisation of disease, In D. Brunton, (ed) Medicine Transformed: Health, Disease and Society in Europe 1800-1930, Manchester: Manchester University Press, 2004, 1-30. MED. Mary E. Fissell, Surgeons and the medicalization of the hospital, In idem., Patients, Power, and the Poor in Eighteenth Century Bristol, Cambridge: CUP, 1991, pp. 126-147. ASS (MWNL Fis); DPF.
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Thomas Schlich, The emergence of modern surgery In D. Brunton, (ed) Medicine Transformed: Health, Disease and Society in Europe 1800-1930, Manchester: Manchester University Press, 2004, 61-91. MED. Jens Lachmund, Making Sense of Sound: Auscultation and Lung Sound Codification in Nineteenth-Century French and German Medicine, Science, Technology, & Human Values, 24 4(Autumn 1999): 419-50. BB Thomas Osborne On anti-medicine and clinical reason, in Colin Jones and Roy Porter (eds), Reassessing Foucault: Power, Medicine and the Body, London: Routledge, 1994, pp.28-47. ASS (B2430.F724 REA), DPF. (23 October) Defining Doctors (Andrew Morrice) Historians have described the period between 1780 and 1858 as the era of medical reform, in which medicine was professionalized. This seminar will explore the process in Britain, examining the political and ethical tensions from which the 1858 Medical Act emerged, and the ongoing process of defining who and what a doctor was. We will focus on the history of two key organisations which emerged at this time: the BMA and the GMC. **Deborah Brunton, The Emergence of a Modern Profession? In idem., (ed) Medicine Transformed: Health, Disease and Society in Europe 1800-1930, Manchester: Manchester University Press, 2004, pp.119-150. MED. **Andrew Morrice, "'Honour and Interests': Medical Ethics and the British Medical Association", in Maehle and Geyer- Kordesch (eds), Historical and Philosophical Perspectives on Biomedical Ethics, Ashgate, Aldershot, 2002. ISBN 0754615294 UR. *Harold Perkin The Rise of Professional Society, Routledge, London 1989, pp. 1-26. (ISBN 0415008905) ASS (HN400.S6 PER), DPF. Vivian Nutton and Roy Porter (eds.) The History of Medical Education in Britain, Amsterdam: Rodopi, 1995, Introduction, pp. 1-15. (ISBN 905183571X) DPF. Primary text (also see Blackboard): Jukes de Styrap A code of medical ethics: with remarks on the duties of practitioners to their patients, etc. 3rd edn., H K Lewis, 1890 pp. 11-39. Copies in DPF. Week 4 (27 October, 30 October) (27 October) Laboratory revolution (Bresalier) Laboratories are an indispensable part of modern medicine. Besides their crucial role in diagnostics, they are key sites for medical training, experimentation and the production of knowledge and therapeutics. Though now virtually taken-for-granted, the laboratorys rise at the end of the nineteenth century as a necessary part of medicine involved what historians describe as a revolution in medical ways of knowing. This lecture traces the context of this revolution and explores how, and to what extent, the laboratory transformed medical understandings of health and disease.

Readings: For overviews, see: Bynum, Science and the Practice of Medicine, Chps.,4-5; Porter, Greatest Benefit, pp.320-47; 428-445. Fleck, Genesis and Development of a Scientific Fact, pp. 82-96. **D. Gillies 2005 Hempelian and Kuhnian Approaches in the Philosophy of Medicine: the Semmelweis Case Studies in History and Philosophy of Biological and Biomedical Sciences 36, pp.159-181. UR. **Andrew Cunningham, Transforming Plague: The laboratory and the Identity of Infectious Disease, In Andrew Cunningham and Perry Williams (eds.) The Laboratory Revolution in Medicine (Cambridge: CUP, 1992), pp.209-244. UR **Michael Worboys, Was there a Bacteriological Revolution in late nineteenth century medicine?, Studies in History and Philosophy of Biological and Biomedical Sciences, 38(2007): 20-42. UR. K. Codell Carter, Kochs Postulates in Relation to the Work of Jacob Henle and Edwin Klebs, Medical History, 29(1985), pp.353-374. BB *Christopher J. Lawrence, Incommunicable Knowledge: Science, technology and the clinical art in Britain, 1850-1910, Journal of Contemporary History 20, 1985, pp.503-20. BB K. Codell Carter, The Development of Pasteurs Concept of Disease Causation and the Emergence of Specific Causes in Nineteenth-Century Medicine, Bulletin for the History of Medicine, 65(1991), pp.528-548. BB Michael Worboys, Spreading Germs: Disease Theories and Medical Practices in Britain, 1865-1900, Cambridge: CUP, 2000, Chp. 6. (ISBN 0521773024) MED, DPF. Bruno Latour, The Pasteurization of France transl. Alan Sheridan and John Law Harvard: Harvard University Press, 1988, Part One. ASS (QR22.F8 LAT) (30 October) Experimental Bodies (Bresalier) Key aspects of medical knowledge, practice and treatments are derived from experimental bodies animals, organisms and statistical entities created and explored under controlled conditions. Of these bodies, experimental animals have stirred the greatest controversy. Since the nineteenth century, debates have focused on the moral and epistemic value of animal experimentation. Despite controversy, animal models of human physiology and pathololgy continue to play a crucial role in medicine. For this reason, it is important to examine their development and use and to ask questions about their nature and the nature of knowledge derived from them. What is an animal model? Why are certain animals selected as models of human health and disease? How relevant are animal models to clinical knowledge and practice?

**Ilana Lwy, The Experimental Body, In Roger Cooter and John Pickstone (eds.) Companion
to Medicine in the Twentieth Century, London: Routledge, 2003, pp.435-449. (ISBN 04 415 28603 4) (R149 MED), UR. **Christoph Gradmann, Experimental life and experimental disease: The role of animal experiments in Robert Kochs medical bacteriology, B.I.F. Futura 18(2003): 80-88. UR.
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**Hugh LaFollette and Niall Shanks, Animal Experimentation: the legacy of Claude Bernard, International Studies in the Philosophy of Science vol. 8 3(1994): 195-210. UR *William F. Bynum, Cest un malade: Animal models and concepts of human disease, Journal of the History of Medicine and Allied Sciences, 45(1990): 397-413. BB Daniel P. Todes, Pavlovs Physiology Factory, Isis 88(1997):205-246 (esp. 205-11; 213-16; 220-228; 239-46). BB Cheryl Logan, Before There Were Standards: The Role of Test Animals in the Production of Empirical Generality in Physiology, Journal of the History of Biology 35(2002): 329-2002. BB Primary texts: Claude Bernard, An Introduction to the Study of Experimental Medicine, [1865] New York: Dover, 1957, pp.1-26, 94-105, 140-150. ASS (R850 BER) DPF; Robert Koch, The etiology of tuberculosis. [1882] In Thomas D. Brock (ed., and trans.), Milestones in Microbiology, Englewood, CA: Prentice Hall, 1961, pp.109-115. BB

Rationalizing Medicine
Week 5 (3 November) Biomedicine and national health systems (Bresalier) Since World War II, two institutions have come to dominate Western medicine: hospitals and biomedicine. The first is dedicated to the provision of medical care; the second is dedicated to the production of knowledge, therapeutics, and technical innovations ultimately used in medicine. This lecture explores the relationship between these institutions as they were shaped in Britain and the United States. Comparing the British National Health Service (NHS) with the American health care system, we consider how biomedicine has impacted the objectives and organization of medical practice within both systems. In accounting for its implication, we shall attempt to define what is biomedicine. **Charles Webster, The National Health Service: A Political History, Oxford: Oxford University Press, 2nd edition, 2002. Chapter 1. ASS (RA413.5.G7 WEB), DPF. **Daniel J. Fox, The National Health Service and the Second World War: the elaboration of consensus, In Harold L. Smith, War and Social Change: British society in the Second World War, (Manchester: Manchester University Press, 1986), pp.32-57. (ISBN 0 71901777 7) UR. **Alberto Cambrosio and Peter Keating, Biomedicine and Platforms, In idem., Biomedical Platforms: Realigning the Normal and the Pathological in Late Twentieth Century Medicine, Cambridge MA: MIT Press, 2003, pp. 49-82 (esp. 49-57; 69-82) UR. **Jean-Paul Gaudilliere, Making Mice and Other Devices: The dynamics of instrumentation in American biomedical research, 1930-1960, In B. Joerges and T. Shinn (eds.) Instrumentation Between Science, the State and Industry, Dordrecht: Kluwer, 2000, pp.175-196. DPF. *Marc Berg, Turning a Practice into a Science: Reconceptualizing Postwar Medical Practice, Social Studies of Science, 25 3(1995): 437-76. BB, DPF. *Steve Sturdy and Roger Cooter, Science, Scientific Management, and the Transformation of Medicine in Britain c. 1870-1950, History of Science xxx vi (1998), 1-47. BB

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Robert Bud, Penicillin: Triumph and Tragedy, Oxford: OUP, 2007, Chapters 2-4. (ISBN 978-0-19925406-4). DPF. Christopher Lawrence, Clinical Research, In J. Krige and D. Pestre (eds.), Science in the Twentieth Century, Amsterdam: Harwood, 1997, pp. 439-460. (ISBN 90-5702-172-2). DPF. Anne Hardy, Health and Medicine in Britain since 1860, London: Palgrave, 2001, Chapter 5. ASS (RA485 HAR). Week 6 (10, 13 November) (10 November) The RCT: Gold standard or fools gold? (Trevor Thompson) The placebo controlled randomised clinical trial (RCT), and meta-analyses thereof, have become the primary means by which medical interventions (particularly pharmaceutical interventions) are deemed effective and worthy of funding. Given the power accorded to the RCT (known in epidemiological circles as the gold standard of medical research) it is essential that its epistemology is subject to rigorous scrutiny. In this seminar we will explore the theory and history of the RCT and examine a range of different critiques that challenge its hegemony. Readings: Harry Collins and Trevor Pinch, (2005) Dr. Golem: How to Think about Medicine, London: University of Chicago Press, Chp.1 **L. Gordis, Assessing the Efficacy of Preventive and Therapeutic Measures: Randomised Trials. Epidemiology. Philadelphia: Elsevier; 2004. 115-129. UR **H. Kiene, A critique of the double-blind clinical trial. Part 1. Altern Ther Health Med 1996; 2(1):74-80. UR. **H. Kiene, A critique of the double-blind clinical trial. Part 2. Altern Ther Health Med 1996; 2(2):59-64. UR *Harry M. Marks, Trust and Mistrust in the Marketplace: Statistics and Clinical Research, 1945-1960, History of Science, 38(2000):343-355. BB Ian Hacking, "Telepathy: Origins of Randomization in Experimental Design," Isis, 79(1988), pp.427-51. BB (13 November) EBM and the pitfalls of standardization (Alexander Bird) The practice of medicine has always been based on intangible and plural notions of evidence, such as clues, signs and symptoms, but what has counted as evidence has changed over time. Effectiveness of treatments, for example, was once judged on the basis of a complex mix of theory, clinical observation and testimony, but as case descriptions (and treatments) became more standardized and comparisons could be made, assessment of effectiveness moved beyond the single cases and case series, and adopted the population as the unit of assessment and analysis. This lecture explores how evidence has become an object of standardization and it examines the implications of a population-based knowledge for medical decision-making.

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**George Weisz, From Clinical Counting to Evidence-Based Medicine, In G. Jorland, A. Opinel, and G. Weisz (eds.) Body Counts: Medical quantification in historical and sociological perspectives, Montreal: McGill-Queens Press, 2005, pp. 377-393. UR
**John Worrall, "What Evidence in Evidence-Based Medicine?" Philosophy of Science, 69 (2002), pp.S316-S330. UR.

*David Armstrong, Professionalism, Indeterminacy, and the EBM Project, BioSocieties 2 (2007), pp. 73-84. BB John R. Hampton, Evidence-Based Medicine, Opinion-Based Medicine, Real-World Medicine, Perspectives in Biology and Medicine, 45 (2002), 554. BB. Douglas Black, The Limitations of Evidence, Perspectives in Biology and Medicine, 42 (1998), 4. BB. Joaquim S. Cuoto, Evidence-Based Medicine: A Kuhnian Perspective of a Transvestite NonTheory, Journal of Clinical Evaluation in Clinical Practice, 4(1998): 271. BB. Eyal Shahar, A Popperian Perspective of the Term Evidence-Based Medicine, Journal of Evaluation in Clinical Practice, 3(1997): 110. BB. Primary texts: Evidence-based Medicine Working Group, Evidence based medicine: A new approach to teaching the practice of medicine, JAMA 268 17(1992), 2420-25; D.L. Sackett and Rosenberg, "The need for evidence-based medicine," Journal of the Royal Society of Medicine, 88(1995), 620-624; D.L. Sackett, "Editorial: Evidence-based medicine: what it is and what it isn't," BMJ, 312(1996), 71-2. BB Week 7 (17 November) Managing Uncertainty (Bresalier) Uncertainty is an inherent part of medical knowledge, practice and innovation. Doctors, patients, social scientists and governments have developed various strategies to deal with this problem. Since the 1950s, uncertainty in clinical and epidemiological medicine has been increasingly framed in terms of risk. Based on the calculation of probabilities, the notion of risk has become a way to manage uncertainty in diagnosis, therapy, prognosis and judgement. This lecture traces the emergence of the risk factor in medicine, its connections to the epidemiology of chronic disease, and its broader epistemic and political consequences for medical practice and patients somatic experiences. **Thomas Schlich, Risk and medical innovation: a historical perspective, In. idem., and Ulrich Trhler (eds.,) The Risks of Medical Innovation: Risk perception and assessment in historical context, London: Routledge, 2006, pp. 1-19. (ISBN-10: 0415334810 ISBN-13: 978-0415334815) UR **A.M. Brandt, The cigarette, risk, and American culture, Daedalus 119 4(1990): 155-176. UR *Robert Aronowitz, The social construction of coronary heart disease risk factors, In idem., Making Sense of Illness: Science, Society and Disease, Cambridge: CUP, 1998, pp. 111-144. DPF *Raymond Tallis, The Coming of Age of the Youngest Science, In idem., Hippocratic Oaths: Medicine and Its Discontents, London: Atlantic Books, 2004, pp. 28-38. DPF Primary texts:
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Doll R, Hill AB. (1950) Smoking and carcinoma of the lung. Preliminary report, British Medical Journal, 2: 739-748; Doll R, Hill AB. (1954) The mortality of doctors in relation to their smoking habits. British Medical Journal, 228:1451-5; Hill AB. (1965). The environment and disease: association or causation? Proceedings of the Royal Society of Medicine, 58, 295-300. BB.

Challenging Orthodoxies
Week 8 (24, 27 November) (24 November) Homeopathy and Heterodox Medicine The making and rationalization of modern medicine has involved the displacement of numerous ways of understanding the body, health and disease. As scientific medicine became orthodox in the 19th century, medical systems and practices such as homeopathy, hydropathy, mesmerism and chiropractics were labelled heterodox. Through the 20th century, various professional, legal, and epistemological mechanisms hardened the division between orthodox and heterodox medicine. Using the case of homeopathy, this lecture explores how this boundary was created, how it has been maintained, and how it is challenged by the revival of so-called alternative or complementary medicine. Harry Collins and Trevor Pinch, Dr. Golem: How to Think about Medicine, (London: University of Chicago Press, 2005, Chapter 4. **Charles Rosenberg, Holism in Twentieth Century Medicine, In Christopher Lawrence and George Weisz, Greater than the Parts: Holism in Biomedicine, 1920-1950, pp. 335-356. UR **Ursala Sharma, Situating homeopathic knowledge: Legitimation and the cultural landscape, In S. Cant and U. Sharma, Complementary and Alternative Medicines. Knowledge in Practice London: Free Association Books, 1996, pp. 165-85. UR *Roger Cooter, Alternative Medicine, Alternative Cosmology, In Roger Cooter (ed.) Studies in the History of Alternative Medicine, (Oxford: Macmillan Press, 1988), pp. 62-77. (ISBN 033462130) DPF. *Mike Saks, Medicine and the Counter Culture, In. Roger Cooter and John Pickstone (eds.) Companion to Medicine in the Twentieth Century, London: Routledge, 2003, pp. 113-124. (27 November) Patients and the Politics of Medical Knowledge (Bresalier) Contrary to claims of their disappearance, medicalization, or objectification patients have actively participated in shaping biomedicine and its objects. The paradigmatic case is that of AIDS activists becoming lay-experts and re-defining the protocols of clinical trials. Similar forms of patient activism can be traced through polio, cancer, sick-cell anaemia, and various other diseases. In this section we situate the identity of the patient activist in the context of broader challenges to medical authority launched in the 1960s and 1970s by academics, new social movements and critics of the welfare state. Patient activism around specific diseases or conditions raises important questions about how suffering and pain are mobilized in medical and healthcare politics, the status of disease categories, medical power, scientific expertise, and the role of patients in making biomedical knowledge.
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Readings: Harry Collins and Trevor Pinch, Dr. Golem: How to Think about Medicine Chp. 7. **Steven Epstein, The Construction of Lay Expertise: AIDS Activism and the Forging of Credibility in the Reform of Clinical Trials, Science, Technology, & Human Values 20 4(1995): 408-437. (UR) *Steven Epstein, Activism, Drug Regulation, and the Politics of Therapeutic Evaluation in the AIDS era: A Case Study of ddC and the Surrogate Markers Debate, Social Studies of Science 27 5 (1997): 691-726. DPF. **Ilana Lwy, Trustworthy knowledge and desperate patients: clinical tests for new drugs from cancer to AIDS, In. M. Lock, A. Young, and A. Cambrosio (eds.), Living and working with the new medical technologies, Cambridge: Cambridge University Press, 2000, pp. 82-102. (UR). Ivan Illich, Medical Nemesis, Lancet, 11 May (1974), pp. 918-921. BB Rudolf Klein, The Crises of the Welfare States, In Roger Cooter and John Pickstone (eds.) Companion to Medicine in the Twentieth Century, London: Routledge, 2003, pp. 155-170. Week 10 (1 December) Medicine and Death (Bresalier/Carel) When does life end? When does death begin? Since the birth of the clinic in the early nineteenth century, defining death has been a fundamental epistemological and ethical problem in medicine. This lecture traces modern medicines changing conceptions of death. It concentrates on the emergence and implications of the new category of brain death in the recent history of organ transplantation. This category illuminates the ways in which the meaning and nature of death has been negotiated within biomedicine and across cultures. Readings: **Martin Pernick, Brain Death in Cultural Context: The Reconstruction of Death 1967-1981, In S.J. Youngner, R.M. Arnold and R. Schapiro, The Definition of Death: Contemporary Controversies, Baltimore: Johns Hopkins University Press, 1999, pp. 3-33. DPF **Margaret Lock, Locating the Moment of Death and Making the New Death Uniform, in Idem. Twice Dead: Organ Transplants and the Reinvention of Death, Berkeley: University of California Press, 2002, pp. 57-75; 103-126. UR *Martin Pernick, Back from the Grave: Recurring Controversies over Defining and Diagnosing Death in History, In Richard M. Zaner, Death: Beyond Whole-Brain Criteria, Dordrecht: Kluwer Academic, 1988, pp. 17-74. DPF Ruth Richardson, Fearful Symmetry: Corpses for Anatomy, Organs for Transplantation, In S.J. Youngner, R.C. Fox and L.J. OConnell, Organ Transplantation: Meanings and Realities, Madison: University of Wisconsin Press, 1996, pp. 66-100. DPF Week 11 (8 December) Conclusions Week 12 (12 January) Revision
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