Philosophy of Medicine Roundtable 2025 (part two)

This is a brief report of some of the talks delivered on the second day of the Philosophy of Medicine Roundtable hosted by King's College London in June 2025. For a report of day one, please go here.

From the poster of the Roundtable

The second day of the event started with a presentation by Devora Shapiro on the role of EBM (evidence-based medicine) in enabling phenomena such as medical gaslighting and illness invalidation. Shapiro discussed cases where patients are told that there are no medical issues for them, because the test results come back with no indication of pathology, and yet the patient has a complaint that matters to them and is not given sufficient uptake.

A slide of Shapiro's presentation

The discussion following the presentation centred on what causes the problems of power-imbalanced relationships between doctors and patients, whether it is EBM or something else, for instance a failure to provide care or a lack of recognition that, although successful, medicine cannot tackle all human problems.

In one of the several talks by project EPIC members at the Roundtable, Elisabetta Lalumera asked why definitions matter in medicine and how linguistic labels function as operational tools. Conceptual engineering and conceptual choice may serve various goals such as diagnostic utility and inclusivity. One example of the importance of definitions is the change in the definition of pain, which has been revised in 2020 to include the sensations of those who cannot describe pain such as infants, nonverbal patients and animals.

Elisabetta Lalumera on definitions of pain

Such revision was motivated by inclusivity and ethical concerns so it was a deliberate value-laden choice. The new definition has the merit of avoiding the risk of epistemic injustice (e.g. when a patient claims to be in pain but no lesion is found) but has risks as well, being more vague, more difficult to operationalise, and likely leading to overmedicalisation of human experience.

In the next talk, Kathleen Murphy-Hollies, postdoc on project EPIC, presented a talk about what it means to give uptake to the metaphorical meaning of delusions. Murphy-Hollies started talking about the experience of entomologists being contacted by people with delusions of parasitosis claiming that they are suffering from an infestation. How should entomologists deal with these cases? To what extent should they believe the people claiming an infestation?

Each testimony has two aspects: the propositional content conveyed and the perspective conveyed in the statement. We can fail to believe what the person says and yet take their perspective seriously. Maybe delusions express metaphorical meaning that is worth trying to understand. Murphy-Hollies builds on account by Federico Bongiorno and Rosa Ritunnano to explore the metaphorical interpretation of delusional utterances.

Kathleen Murphy-Hollies on delusions

In the rest of the talk, Murphy-Hollies observed how metaphorical meaning is not just relevant to people reporting delusional beliefs, but is often conveyed in cases of reports by people who experienced trauma or have implicit knowledge. This observations lead to a new understanding of uptake which is not just believing what the person is saying but is about mutual engagement.

Dan Degerman talked about the medicalisation of silence. Silence has been seen as a cause of depression (not talking about something might lead someone to become depressed), as a symptom of depression (it appears in the criteria for depression), as a problem in the workplace (underperforming) and as a cause and symptom of depression in that context.

Dan Degerman on silence

Degerman asks why the medicalisation of silence is a worry. Silence is a diagnostic marker for depression and can be associated with distress. But by medicalising silence we represent it as a threat, we end up avoiding it, and we obscure its benefits:

• social benefits
• epistemic benefits
• medical benefits.

More important, we may override the benefits of silence for medical or health-related reasons.

As hopefully shown by these remarks on some of the talks, the second day of the Philosophy of Medicine Roundtable was very rich and addressed a variety of issues in the metaphysics, epistemology, and ethics of medicine.

Philosophy of Medicine Roundtable 2025 (part one)

The Philosophy of Medicine Roundtable was held at King's College London on 2nd and 3rd June 2025. Here is a brief account of some of the talks and posters presented on the first day of the event.

Bush House in London, conference venue

The first talk was by John Ioannidis, "Research results: the false, the fake, the useless, and the untouchables". The presentation started with the statement that "Science is the best thing that can happen to humans". Yet, Ioannidis argued that most scientific research has used non-reproducible and sub-optimal research practices.

Results can be:

• False = due to random error or bias
• Fake = not real, crafted, fabricated
• Useless = not having a meaningful purpose
• Untouchable = impossible to access or use.

John Ioannidis

Problems:

• Megajournals publish too many papers and have high acceptance rates (25-60%). Review is fast and authors pay to publish.
• Predatory journals publish poor science and have an acceptance rate of 100%.
• Extreme publishing behaviour is another threat (researchers publish 60 research articles every year) and get high citation rates in problematic ways.
• Many fake papers are generated through AI and only a few are detected and retracted.

In the rest of the presentation, Ioannidis analysed in more detail the challenges of doing science in a way that produces results that are not fake, not useless, and accessible; and suggested some ways we can improve scientific practices.

In the first break of the conference, participants were invited to look at the research posters. One of these posters was by EPIC postdoctoral researcher Jodie Russell. Russell's work is on intersectional invisibility. You can download her poster here.

Jodie Russell on intersectionality

In the afternoon,  Maria Cristina Amoretti presented a paper about the distinction between values and biases in medicine, co-authored with Elisabetta Lalumera. While values guide research priorities and clinical decision-making, biases are typically seen as distortions to be eliminated. However, this view is too simplistic: both values and biases can promote or hinder medical knowledge and patient care. 

Cristina Amoretti and... Pimpa!

Amoretti and Lalumera proposed a functional distinction: values are explicit, discussable, and justifiable judgments shaping medical aims, whereas biases are implicit tendencies influencing reasoning in ways not explicitly articulable. Values are not always beneficial, and biases are not always harmful. Instead, their roles in medical research and clinical practice need further examination.

In another talk, Elena Popa and Jay Zameska discussed the relationship between social determinants of health and various conceptions of causation. The empirical evidence linking wide social issues such as inequality or poverty to health outcomes justifies the search for interventions on these high-level phenomena. This can be a more efficient way of improving the health of a population in contrast with targeting individuals suffering from downstream health effects. 

Elena Popa presenting

But it is difficult to fit insights from population health science with biomedical approaches which focus on downstream causes and which have been preponderantly used in public health. For Pola and Zameska, overcoming the dominance of narrow biomedical models requires considering a wider range of causal concepts, particularly mechanistic and dispositional ones. The suitability of these concepts can then be assessed by analyzing the interventions resulting from them through the lens of priorities in public health

ethics.

Another break in the conference meant another look at the posters! Themistoklis Pantazakos prepared a poster on the role of biomarkers in debates about pathologization.

Themistoklis Pantazakos on biomarkers

Rebecca Brione presented on the importance of philosophy of language for doctor-patient interactions. In particular, Brione focused on failed refusals of medical treatment. Should the patient have the right to refuse treatment, and if so, under what circumstances? Little attention has been paid to the speech act of refusal itself. 

Brione argued that philosophy of language offers the resources we need to develop a more sophisticated understanding of medical refusal (and similar speech acts), in isolation and in context. These resources enable us both to conceptualise refusal as a normative act, and to understand what is required for a patient to succeed in their attempt to refuse treatment. 

Rebecca Brione on medical refusal

Brione presented a novel account of refusal as an assertion which attempts to add both a direct proposition and presupposed content about the normative landscape to the communicative common ground (the shared beliefs, knowledge and information that form the background for an assumed-collaborative conversation).

The first day of the Roundtable was very rich and thought-provoking, showcasing the variety of issues that can be tackled by philosophers of medicine.

Radical Bodily Doubt

A year ago, I was woken up at 1am by a phone call. The transplant coordinator said: ‘how would you feel about coming in for a possible match?’ By 3am my partner and I were at the hospital. At 7am it was confirmed: the surgery was going ahead.

When I woke up four days later, everything has changed. My body had new lungs in it and my immune system was highly suppressed to avoid rejection. The major surgery left me confused and in complete shock. My body unravelled in ways hitherto unbeknown to me. My recovery was hard and long, with significant complications. I spent many months in hospital, and later at home, recovering. The harsh medical complexities and their effects profoundly changed not only the boundaries, but the very texture, of my bodily experience.

Some days, I didn’t care. Other days I was too confused to understand my predicament. On still others my broken body lamented this undertaking, which seemed endless and futile. The toll on my agency, thought, self-familiarity and self-regard was so total as to force a rebirth of sorts. The restitution narratives of recovery as 'getting better’, ‘returning to how things were before’ or ‘bouncing back’ seemed naive, formulaic and barren: entirely oblivious to the painful reality of a body in total disarray. The anticipated and hotly desired ‘return’ revealed itself as no return at all. As Heraclitus said: you cannot step into the same river twice; both the water and the person are different each time.

Whilst navigating the rocky and uneven terrain of recovery during protracted months of constant, yet varied, suffering I tried over and over to reconnect with this body, which became a focal point of dread, humiliation and distrust. Nothing worked, and nothing could be expected to work without careful medical management. The easy, casual way in which we usually inhabit our body in health was destroyed by an artifice of surgery, medication, treatment protocols, and a restrictive bodily regime.

Extreme bodily trauma requires a renewed encounter with one’s self-presentation and one’s awkwardly distant, functionally dubious and existentially treacherous body. It cannot be trusted but one cannot help but put one’s trust in this flimsy excuse for the grounded, fleshly presence of the past. How else could I proceed?

This led me to go beyond the notion of ‘bodily doubt’ described in chapter four of my 2016 book, Phenomenology of Illness. Bodily doubt is the feeling of doubt in one’s body, that is not simply a cognitive or intellectual doubt, but a feeling of doubt experienced at a bodily level. It is a bodily feeling mirroring intellectual doubt: a feeling of hesitation and doubt, revealing that our sense of bodily certainty and trust are epistemically ungrounded. Bodily doubt is composed of: i. loss of trust; ii. loss of continuity; and iii. loss of faith in one's body.

I now propose a new notion: Radical bodily doubt, described in a short new paper in The Lancet. This is an extreme form of doubt experienced in liminal bodily states, such as end of life or major trauma, necessitating intensive hospital care. Primarily, it is not a state in which certainty about a particular bodily function, such as balance, vision, or digestion is lost, but a complete collapse of all certainty, continuity and faith in one’s body and its ability to persist. It is a breakdown, not of one or some bodily functions (characterising bodily doubt), but a collapse of all tacit beliefs previously held secure by one's bodily certainty.

We need to develop linguistic and other communicative modes to describe radical bodily doubt, and to incorporate liminal bodily experiences into familiar modes of speaking and orienting ourselves towards our bodies. The unspoken experiences of those who are very ill, incapacitated, incapable of speech or even unconscious must be brought into commonly available ways of speaking about illness. As Lucienne Spencer argues, our account of testimonial injustice ought to include a wider range of expressions, including non-verbal ones. We must develop more varied ways to understand and describe our embodied existence when broken or whole, in situations that are familiar or uncanny, and when selfhood is stable or disrupted to the point of implosion.

I thank my donor and their family; we remain anonymous to each other, but I am grateful for their altruism and kindness to strangers at a time of great distress.

Havi Carel is Professor of Philosophy at the University of Bristol. She currently leads a Wellcome Discovery Award, EPIC, on epistemic injustice in health care. She has previously published on the embodied experience of illness, epistemic injustice in healthcare, vulnerability, wellbeing within illness, transformative experience, death, and on the experience of respiratory illness in the Lancet, BMJ, Journal of Medicine and Philosophy, Journal of Medical Ethics, Journal of Applied Philosophy, and in edited collections.

Toxic Positivity and Epistemic Injustice

 

Toxic positivity (TP) is “the phenomenon of people being positive and optimistic to a degree that is unreasonable in a given situation, and as such makes others feel as if their own (less than positive) feelings are invalid or in some way wrong, thus having the potential to cause harm to the victim” (de Rijk 2025). For example, if one loses a loved one and tries to garner support from a friend who then tells you that you should not be sad because your loved one is in a better place, you may have fallen victim to TP. 

Features of  Toxic Positivity

TP has four features: 

1) appropriate emotion in the victim as a starting point

2) unreasonable optimism on the part of the perpetrator

3) dismissal of the victim 

4) potential harm to the victim 

Toxic Positivity and Epistemic Injustice

I have argued (de Rijk 2025) that TP is an epistemic injustice because it has the potential to undermine knowledge to which the victim ought to have a claim so wronging the victim as a knower (Fricker 2007). Further, this is a particularly sneaky kind of epistemic injustice because it often masquerades as something good, because optimism is seldom considered problematic. Knowledge might be undermined through TP in at least three ways, all of which have their root in the doubt-instigation that is caused through dismissal. 

First, TP can make a victim doubt their belief and genuinely doubting a belief means that it can no longer count as knowledge. Second, TP could make a victim lose their belief because they might think the best course of action in response to genuinely doubting their belief. Thirdly, a victim may lose self-trust, which is a precondition for acquiring and maintaining knowledge (e.g., Zagzebski 2012; Dormandy 2024), although this would only happen in the most serious cases. 

Toxic Positivity and Getting Proper Medical Help

I now argue that TP that undermines knowledge formed through negative emotional experiences related to health can prevent one from timeously seeking proper healthcare. Imagine you are suffering a serious bout of depression but remain highly functional. You confide in a friend that you think you are depressed and need help. But your friend responds by pointing out that you do not seem depressed, you are going about your life as normal and even cracking jokes with your friends and colleagues, he suggests that maybe you are just feeling stressed about an upcoming deadline and when it has passed you will feel better. 

This makes some sense to you, and you begin to seriously doubt that you really are depressed even though you continue to feel all the symptoms of depression. Nonetheless, the doubt sown by TP acts as a defeater to your belief that you are depressed. 

So, you do not seek proper treatment for your depression (because why should you seek treatment if you are not really depressed?) and eventually suffer a complete nervous breakdown. In this case, TP has prevented you from seeking timeous medical help and as a result you ended up in a far worse position than you might otherwise have been.

This is just one way that TP undermining knowledge in connection with our health can prevent one seeking healthcare. But it is sufficient to show that undermining knowledge formed through negative emotions related to health can be detrimental to taking the right steps to ensure that one receives proper medical help before one’s condition worsens. 

Shené de Rijk is a PhD candidate at the University of Johannesburg in South Africa. She is affiliated with the African Centre for Epistemology and Philosophy of Science (ACEPS). Her dissertation is centred on investigating the phenomenon of toxic positivity in the field of social epistemology. Other than toxic positivity and social epistemology (and epistemic injustice in particular), her research interests include applied ethics, especially bioethics on which she has also written.