Casting a realist's eye on the real world of medicine: Against Anjum's ontological relativism

Norris, David C.

doi:10.1111/jep.12689

Cited by 4 publications

(5 citation statements)

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“…In their reply, 46 Rogers and Mintzker argue that there is an overlap between these concepts, defending their typology of misclassification and maldetection overdiagnosis, and arguing that overdiagnosis involves both epistemic and ontological issues. David Norris' brief communication 47 objects not only to the arguments of Anjum and Mumford discussed above, 29 but to Anjum's work in other contexts and (by implication) the whole thrust of the CauseHealth project in analysing "the scientific norms of EBM" with reference to philosophical assumptions about causal ontology. 80 He characterizes the use of "rule-utilitarianism" as the demolition of a "straw-man" and suggests Anjum is committed to a form of "ontological relativism"-a claim we feel certain she would reject, and which Norris accepts is incompatible with the realism she "seems to profess.…”

Section: Debatesmentioning

confidence: 99%

“…David Norris' brief communication objects not only to the arguments of Anjum and Mumford discussed above, but to Anjum's work in other contexts and (by implication) the whole thrust of the CauseHealth project in analysing “the scientific norms of EBM” with reference to philosophical assumptions about causal ontology . He characterizes the use of “rule‐utilitarianism” as the demolition of a “straw‐man” and suggests Anjum is committed to a form of “ontological relativism”—a claim we feel certain she would reject, and which Norris accepts is incompatible with the realism she “seems to profess.”…”

Section: Debatesmentioning

confidence: 99%

“…In this edition, we present an array of up‐to‐date analyses of the problems of reason in practice, addressing a diverse range of healthcare contexts and methods, considering policy decisions as well as specific instances of clinical reasoning . Contributors discuss the nature of practical wisdom, the relationship between reasoning, emotion, intuition, and evidence, and the sense in which EBM is (or is not) a “modern” scientific enterprise, in the light of considerations of the relationship between science, context, and culture .…”

Section: Introductionmentioning

confidence: 99%

“…[29][30][31][32][33][34][35] The growing interest in medical and health philosophy is illustrated by the number of important texts currently being published in this area, and we present reviews of some of the most recent work in this field. [36][37][38][39][40][41][42] The edition concludes with an extensive debates section, where arguments presented in this and in previous editions are challenged by respondents, [43][44][45][46][47][48][49][50][51] in ways that we hope will further illustrate how underlying philosophical commitments can make a substantive difference to our understanding of the right ways to approach and improve practice.…”

Section: Introductionmentioning

confidence: 99%

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Reasoning, evidence, and clinical decision‐making: The great debate moves forward

Loughlin¹,

Bluhm

Buetow

et al. 2017

Evaluation Clinical Practice

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When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life.

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Section: Debatesmentioning

confidence: 99%

Section: Debatesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Reasoning, evidence, and clinical decision‐making: The great debate moves forward

Loughlin¹,

Bluhm

Buetow

et al. 2017

Evaluation Clinical Practice

View full text Add to dashboard Cite

show abstract

“…Such modifications could begin with decreasing the relaxation factor ω , but might also involve efforts to classify and predict these new DLTs, and to incorporate such new understanding explicitly into the DTA yielded by the study. Indeed, whatever philosophical challenge DTAT embodies is likely to take the form of requiring an intensified commitment to clinical judgment, in a learn-as-you-go world where the always-provisional nature of medical knowledge must frankly be acknowledged 6, 26 .…”

Section: Discussionmentioning

confidence: 99%

Dose Titration Algorithm Tuning (DTAT) should supersede ‘the’ Maximum Tolerated Dose (MTD) in oncology dose-finding trials

Norris¹

2017

F1000Res

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Abstract. Absent adaptive, individualized dose-finding in early-phase Background oncology trials, subsequent 'confirmatory' Phase III trials risk suboptimal dosing, with resulting loss of statistical power and reduced probability of technical success for the investigational therapy. While progress has been made toward explicitly adaptive dose-finding and quantitative modeling of dose-response relationships, most such work continues to be organized around a concept of 'the' maximum tolerated dose (MTD). The purpose of this paper is to demonstrate concretely how the aim of early-phase trials might be conceived, not as 'dose-finding', but as -finding. dose titration algorithm (DTA) A Phase I dosing study is simulated, for a notional cytotoxic Methods. chemotherapy drug, with neutropenia constituting the critical dose-limiting toxicity. The drug's population pharmacokinetics and myelosuppression dynamics are simulated using published parameter estimates for docetaxel. The amenability of this model to linearization is explored empirically. The properties of a simple DTA targeting neutrophil nadir of 500 cells/mm using a Newton-Raphson heuristic are explored through simulation in 25 simulated study subjects.Individual-level myelosuppression dynamics in the Results. simulation model approximately linearize under simple transformations of neutrophil concentration and drug dose. The simulated dose titration exhibits largely satisfactory convergence, with great variance in individualized optimal dosing. Some titration courses exhibit overshooting.The large Conclusions. inter-individual variability in simulated optimal dosing underscores the need to replace 'the' MTD with an individualized concept of MTD . To illustrate this principle, the simplest possible DTA capable of realizing such a concept is demonstrated. Qualitative phenomena observed in this demonstration support discussion of the notion of such algorithms. Although here illustrated tuning specifically in relation to cytotoxic chemotherapy, the DTAT principle appears similarly applicable to Phase I studies of cancer immunotherapy and molecularly targeted agents.

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Dose Titration Algorithm Tuning (DTAT) should supersede the Maximum Tolerated Dose (MTD) concept in oncology dose-finding trials

Norris¹

2017

F1000Res

Self Cite

View full text Add to dashboard Cite

Background. Absent adaptive, individualized dose-finding in early-phase oncology trials, subsequent ‘confirmatory’ Phase III trials risk suboptimal dosing, with resulting loss of statistical power and reduced probability of technical success for the investigational therapy. While progress has been made toward explicitly adaptive dose-finding and quantitative modeling of dose-response relationships, most such work continues to be organized around a concept of ‘the’ maximum tolerated dose (MTD). The purpose of this paper is to demonstrate concretely how the aim of early-phase trials might be conceived, not as ‘dose-finding’, but as dose titration algorithm (DTA)-finding. Methods. A Phase I dosing study is simulated, for a notional cytotoxic chemotherapy drug, with neutropenia constituting the critical dose-limiting toxicity. The drug’s population pharmacokinetics and myelosuppression dynamics are simulated using published parameter estimates for docetaxel. The amenability of this model to linearization is explored empirically. The properties of a simple DTA targeting neutrophil nadir of 500 cells/mm 3 using a Newton-Raphson heuristic are explored through simulation in 25 simulated study subjects. Results. Individual-level myelosuppression dynamics in the simulation model approximately linearize under simple transformations of neutrophil concentration and drug dose. The simulated dose titration exhibits largely satisfactory convergence, with great variance in individualized optimal dosing. Some titration courses exhibit overshooting. Conclusions. The large inter-individual variability in simulated optimal dosing underscores the need to replace ‘the’ MTD with an individualized concept of MTD i . To illustrate this principle, the simplest possible DTA capable of realizing such a concept is demonstrated. Qualitative phenomena observed in this demonstration support discussion of the notion of tuning such algorithms. Although here illustrated specifically in relation to cytotoxic chemotherapy, the DTAT principle appears similarly applicable to Phase I studies of cancer immunotherapy and molecularly targeted agents.

show abstract

Casting a realist's eye on the real world of medicine: Against Anjum's ontological relativism

Cited by 4 publications

References 8 publications

Reasoning, evidence, and clinical decision‐making: The great debate moves forward

Reasoning, evidence, and clinical decision‐making: The great debate moves forward

Dose Titration Algorithm Tuning (DTAT) should supersede ‘the’ Maximum Tolerated Dose (MTD) in oncology dose-finding trials

Dose Titration Algorithm Tuning (DTAT) should supersede the Maximum Tolerated Dose (MTD) concept in oncology dose-finding trials

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