Unveiling the interplay between evidence, values and cognitive biases. The case of the failure of the AstraZeneca COVID-19 vaccine

This paper depicts a Covid science case, that of the AstraZeneca Vaxzevria vaccine, with specific focus on what happened in Italy. Given that we believe acknowledging the role of non-evidential factors in medicine is an important insight into the recent philosophy of science, we illustrate how in the case of Vaxzevria, the interplay between facts, values (both epistemic and non-epistemic) and cognitive biases may have possibly led to different institutional decisions based on the same evidence. The structure of the paper is as follows. First, we provide a glossary of the relevant terms involved, that is to say, epistemic values, non-epistemic values and cognitive biases. Second, we sketch a timeline of Vaxzevria's approvals and suspensions by relevant institutional healthcare authorities with special focus on Italy and the Italian Medicines Agency. Then we show the interplay between the evidence base, epistemic as well as non-epistemic values and cognitive biases using a narrative review of political decisions along with newspaper and social media content pertaining to Vaxzevria. We briefly compare Italy with other European countries to show that different political decisions were made on the basis of the same evidence.

Positive Prostate-specific Membrane Antigen Findings: How To Interpret Them

Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) is more accurate than conventional imaging for primary staging of high-risk prostate cancer and localization of biochemical recurrence. Knowledge of PSMA expression patterns and standardized reporting facilitate accurate interpretation of positive PSMA findings. PSMA PET/CT should be adopted as part of clinical routine, as recommended in international guidelines.

Wherein is the concept of disease normative? From weak normativity to value-conscious naturalism

In this paper we focus on some new normativist positions and compare them with traditional ones. In so doing, we claim that if normative judgments are involved in determining whether a condition is a disease only in the sense identified by new normativisms, then disease is normative only in a weak sense, which must be distinguished from the strong sense advocated by traditional normativisms. Specifically, we argue that weak and strong normativity are different to the point that one 'normativist' label ceases to be appropriate for the whole range of positions. If values and norms are not explicit components of the concept of disease, but only intervene in other explanatory roles, then the concept of disease is no more value-laden than many other scientific concepts, or even any other scientific concept. We call the newly identified position "value-conscious naturalism" about disease, and point to some of its theoretical and practical advantages.

The DSM-5 introduction of the Social (Pragmatic) Communication Disorder as a new mental disorder: a philosophical review

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the Social (Pragmatic) Communication Disorder (SPCD) as a new mental disorder characterized by deficits in pragmatic abilities. Although the introduction of SPCD in the psychiatry nosography depended on a variety of reasons-including bridging a nosological gap in the macro-category of Communication Disorders-in the last few years researchers have identified major issues in such revision. For instance, the symptomatology of SPCD is notably close to that of (some forms of) Autism Spectrum Disorder (ASD). This opens up the possibility that individuals with very similar symptoms can be diagnosed differently (with either ASD or SPCD) and receive different clinical treatments and social support. The aim of this paper is to review recent debates on SPCD, particularly as regards its independence from ASD. In the first part, we outline the major aspects of the DSM-5 nosological revision involving ASD and SPCD. In the second part, we focus on the validity and reliability of SPCD. First, we analyze literature on three potential validators of SPCD, i.e., etiology, response to treatment, and measurability. Then, we turn to reliability issues connected with the introduction of the grandfather clause and the use of the concepts of spectrum and threshold in the definition of ASD. In the conclusion, we evaluate whether SPCD could play any role in contemporary psychiatry other than that of an independent mental disorder and discuss the role that non-epistemic factors could play in the delineation of the future psychiatry nosography.

COVID-19 as the underlying cause of death: disentangling facts and values

In the ongoing pandemic, death statistics influence people's feelings and government policy. But when does COVID-19 qualify as the cause of death? As philosophers of medicine interested in conceptual clarification, we address the question by analyzing the World Health Organization's rules for the certification of death. We show that for COVID-19, WHO rules take into account both facts (causal chains) and values (the importance of prevention).

The concept of disease in the time of COVID-19

Philosophers of medicine have formulated different accounts of the concept of disease. Which concept of disease one assumes has implications for what conditions count as diseases and, by extension, who may be regarded as having a disease (disease judgements) and for who may be accorded the social privileges and personal responsibilities associated with being sick (sickness judgements). In this article, we consider an ideal diagnostic test for coronavirus disease 2019 (COVID-19) infection with respect to four groups of people-positive and asymptomatic; positive and symptomatic; negative; and untested-and show how different concepts of disease impact on the disease and sickness judgements for these groups. The suggestion is that sickness judgements and social measures akin to those experienced during the current COVID-19 outbreak presuppose a concept of disease containing social (risk of) harm as a component. We indicate the problems that arise when adopting this kind of disease concept beyond a state of emergency.

A Potential Tension in DSM-5: The General Definition of Mental Disorder versus Some Specific Diagnostic Criteria

The general concept of mental disorder specified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is definitional in character: a mental disorder might be identified with a harmful dysfunction. The manual also contains the explicit claim that each individual mental disorder should meet the requirements posed by the definition. The aim of this article is two-fold. First, we shall analyze the definition of the superordinate concept of mental disorder to better understand what necessary (and sufficient) criteria actually characterize such a concept. Second, we shall consider the concepts of some individual mental disorders and show that they are in tension with the definition of the superordinate concept, taking pyromania and narcissistic personality disorder as case studies. Our main point is that an unexplained and not-operationalized dysfunction requirement that is included in the general definition, while being systematically violated by the diagnostic criteria of specific mental disorders, is a logical error. Then, either we unpack and operationalize the dysfunction requirement, and include explicit diagnostic criteria that can actually meet it, or we simply drop it.

Consensus Procedures in Oncological Imaging: The Case of Prostate Cancer

Recently, there has been increasing interest in methodological aspects of advanced imaging, including the role of guidelines, recommendations, and experts’ consensus, the practice of self-referral, and the risk of diagnostic procedure overuse. In a recent Delphi study of the European Association for Nuclear Medicine (EANM), panelists were asked to give their opinion on 47 scientific questions about imaging in prostate cancer. Nine additional questions exploring the experts’ attitudes and opinions relating to the procedure of consensus building itself were also included. The purpose was to provide insights into the mechanism of recommendation choice and consensus building as seen from the experts’ point of view. Results: Regarding the factors likely to influence the willingness to refer a patient for imaging, the most voted were incorporation into guidelines and data from scientific literature, while personal experience and personal relationship were chosen by a small minority. Regarding the recommendations more relevant to prescribe an imaging procedure, it resulted the incorporation into guidelines promoted by scientific societies (59% of votes); these guidelines also resulted the more trusted. With respect to patients’ preferences considered when prescribing an imaging procedure, the most voted was accuracy, resulted more important than easy access and time to access to the procedure. The majority of the experts expressed the opinion that there is a scarce use of imaging procedures in prostate cancer. With respect to the most relevant factor to build consensus, it resulted the transparency of the process (52% of votes), followed by multidisciplinarity of contributors. The main obstacle to incorporation of modern imaging procedures into guidelines resulted the lack of primary literature on clinical impact. Conclusions: Firstly, the panelists portray themselves as having Evidence-Based Medicine oriented and scientifically inclined attitudes and preferences. Secondly, guidelines and recommendations from scientific societies, especially clinical ones, are positively taken into account as factors influencing decisions, but panelists tend to consider their own appraisal of the scientific literature as more relevant. Thirdly, in respect of overuse, panelists do not think that advanced diagnostic procedures are overutilized in the specific case of Prostate Cancer, but rather they are underutilized.

Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the presence of distress or disability, which may be bracketed as the presence of harm, is taken to be merely usual, and thus not a necessary requirement: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for defining the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others pertaining to the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be (provisionally) maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified.