Exposome by Elodie Giroux
Handbook of the Philosophy of Medicine, 2024
The exposome concept was introduced by Christopher Wild, a molecular epidemiologist, in 2005. He ... more The exposome concept was introduced by Christopher Wild, a molecular epidemiologist, in 2005. He defined it as the totality of life-course environmental exposures (including lifestyle factors) from the prenatal period onwards. The concept has attracted widespread attention since 2010 and is now an important political and financial driver of research into environmental health. But this ambitious holistic approach to human health exposures raises several methodological and conceptual challenges. If the multiple promises of exposome research seem to have in common the promotion of a holistic and integrative approach to environmental health, the meaning given to this holism, and the integrative and interdisciplinary approach associated with it, varies from one researcher to another, usually according to their disciplinary specialization. In fact, in the background of these variations, there remain at least three main aspects of the exposome that need to be clarified. They concern the scope (should social data be included?), the nature and degree (reductive unification, integrative pluralism, or interactive pluralism?), and the object (data? explanations? methods?) of the integration of exposures that is to be achieved via the exposome approach.
médecine/sciences
Dans un contexte post-génomique, le concept d’exposome a été introduit par Christopher Wild pour ... more Dans un contexte post-génomique, le concept d’exposome a été introduit par Christopher Wild pour proposer une approche unifiée des expositions et fédérer différents champs disciplinaires de la recherche en santé et environnement. L’approche « exposomique » se caractérise par la volonté de développer une analyse à la fois intégrative, longitudinale et plus précise des expositions, et cela principalement grâce à l’identification de biomarqueurs. L’usage du concept d’exposome, qui se révèle particulièrement plastique, constitue un terrain d’exploration privilégié des enjeux et tensions entre approches holiste et réductionniste dans les sciences de la santé. Cet article propose une analyse de ce concept, ainsi que des promesses qui lui sont associées.
Lato Sensu: Revue de la Société de philosophie des sciences
L’exposome réfère à un domaine émergent de recherche qui a pour visée de développer une science i... more L’exposome réfère à un domaine émergent de recherche qui a pour visée de développer une science intégrée de l’ensemble des expositions auxquelles est soumis un individu tout au long de sa vie et qui influencent sa santé. Deux principales orientations se font jour. L’une se concentre sur l’étude de l’exposome interne qui permettrait d’identifier l’essentiel des expositions impactant la santé en mesurant avec précision les effets au niveau de l’environnement biochimique du corps. L’autre entend intégrer les expositions sociales, écologiques et les expositions biologiques et internes, ou autrement dit, faire davantage de place à l’étude de l’exposome externe et ainsi développer un modèle holiste de la santé environnementale. À partir de l’examen de la littérature scientifique, de l’analyse de la première génération d’études exposomiques (2010-2020) et d’entretiens menés auprès d’épidémiologistes engagés dans ces recherches, cet article propose un état des lieux des promesses et réalisa...
Environnement Risques & Sante, May 1, 2013
BioSocieties
This article provides a critical and genealogical analysis of the allostatic load research framew... more This article provides a critical and genealogical analysis of the allostatic load research framework. AL research is used as a case study to analyse how the current biosocial context is articulated in the field of health inequalities research. Providing a contemporary analysis of AL studies with a genealogy of the AL concept, we show that the ambition to use biological tools to improve measurements, predictions, and ultimately public health action, is rooted in a history that predates current biosocial entanglements. We analyse the conceptual and methodological grounding of AL studies in relation to the ambitious propositions to address health inequalities they often convey. The difficulties in translating AL research findings into public health policies and the risks of biomedicalisation that could emerge through the use of AL are also addressed. While acknowledging these risks, however, we nuance the risk of depoliticisation associated with the biomedicalisation of social inequali...
Integrative Approaches in Environmental Health and Exposome Research, 2023
Encyclopedia Universalis, 2022
La science de l’exposome entend fédérer les sciences en santé-environnement par une approche glob... more La science de l’exposome entend fédérer les sciences en santé-environnement par une approche globale, à la fois simultanée et dans le temps long, de l’ensemble des expositions auxquelles est soumis un individu. Dans le même temps, l’objectif est d’augmenter la précision dans l’identification des expositions des individus pour se rapprocher de celle atteinte pour le génome. Cet article s’intéresse à la manière dont ses principaux promoteurs entendent concilier ces deux objectifs de globalité et de précision. Deux stratégies sont repérables : l’une consiste à prendre la partie pour le tout, l’autre repose sur une proposition de catégorisation de l’exposome en trois sous-types. Nous montrons que par-delà des divergences de définitions et d’orientations, la recherche exposomique s’apparente aujourd’hui davantage à un prolongement de la médecine de précision orientée vers l’individu qu’à une recherche interdisciplinaire ouvrant à une conception renouvelée des expositions et de la prévention en santé publique.
The science of the exposome intends to unite the environmental health sciences through a comprehensive approach, both simultaneous and over time, of all the exposures to which an individual is subjected. At the same time, the goal is to increase the precision in identifying the exposures of individuals to approximate that achieved for the genome. This article examines how its main promoters intend to reconcile these two objectives. Two strategies can be identified: one consists in taking the part for the whole, the other is based on a proposal to categorize the exposome into three subtypes. We show that beyond the divergences in definitions and perspectives, exposomic research is today more akin to an extension of precision medicine oriented towards the individual than to an interdisciplinary project opening up to a renewed conception of exposures and prevention in public health.
Médecine/sciences, 2021
Dans un contexte post-génomique, le concept d’exposome a été introduit par Christopher Wild pour ... more Dans un contexte post-génomique, le concept d’exposome a été introduit par Christopher Wild pour proposer une approche unifiée des expositions et fédérer différents champs disciplinaires de la recherche en santé et environnement. L'approche « exposomique » se caractérise par la volonté de développer une analyse à la fois intégrative, longitudinale et plus précise des expositions, et cela principalement grâce à l’identification de biomarqueurs. L’usage du concept d’exposome, qui se révèle particulièrement plastique, constitue un terrain d’exploration privilégié des enjeux et tensions entre approches holiste et réductionniste dans les sciences de la santé. Cet article propose une analyse de ce concept, ainsi que des promesses qui lui sont associées.
Personalized Medicine by Elodie Giroux
médecine/sciences
L’oncologie est souvent considérée par les défenseurs d’une psychiatrie scientifique comme un mod... more L’oncologie est souvent considérée par les défenseurs d’une psychiatrie scientifique comme un modèle médical à imiter. Psychiatres, oncologues et philosophes, nous proposons dans cet article une autre manière d’envisager les relations entre oncologie et psychiatrie, en promouvant l’intérêt d’un dialogue entre ces disciplines, convaincus de leur potentiel enrichissement réciproque et, en particulier, des apports possibles de la psychiatrie à l’oncologie. Nous proposons d’étudier chacune des manières de faire face aux difficultés épistémologiques et éthiques rencontrées dans l’approche des maladies. Nous pensons que psychiatrie et oncologie peuvent apprendre l’une de l’autre, dans le contexte commun de maladies chroniques qu’il s’agit de gérer plutôt que de guérir, grâce au potentiel qu’offrent le recueil de données massives et leur traitement biostatistique pour l’identification de marqueurs permettant d’individualiser les traitements, ainsi que grâce à l’attention renouvelée accordé...
"Personalized medicine″ has been subjected to numerous criticisms regarding its claim to be able ... more "Personalized medicine″ has been subjected to numerous criticisms regarding its claim to be able to personalize care. The main allegation is of a certain deceit deriving from a misunderstanding of the notion of the "person". One of the difficulties lies in the ambiguity of this notion but also of the expression "personalized medicine". To consider this issue in the context of the question of humanism in medicine, and a humanism which takes account of the social and demographic dimensions of medicine, does however reveal what personalized medicine and its personalist criticisms have in common: a focalisation on the individual which neglects the necessary and tight complementarity in medicine between public health and clinical medicine. Is it that evident that focussing on the person, whether they are considered on the basis of their genome or their psycho-social characteristics, lies at the heart of humanist medicine? Adopting a population-based perspective inspired by the "population health sciences", this article develops a criticism of the way that personalized medicine envisages the individual and the population and defends the idea that an approach that conjoins individual and population health is a basic condition of humanist medicine.
The progress of so-called "personalized medicine", in particular in the context of the developmen... more The progress of so-called "personalized medicine", in particular in the context of the development of targeted therapies in oncology, leads to more precise definitions, diagnostics and treatments of diseases. This could give rise to the constitution of ever smaller classes of diseases. Further, via an approach that aims to be both dynamic and holistic, "systems medicine" and in particular "P4 medicine" (preventive, predictive, participative, and personalized) advocates an individualization based on observation of the transition between health and disease for each individual, thanks to repeated monitoring of various genomic, clinical, psychical, environmental, and social characteristics. These different forms of individualization echo the theses of Canguihem, according to which there is no general definition of the normal and the healthy but only a universal biological normativity, which, in each biological individual, takes an individual form. That idea led Canguilhem to affirm the impossibility both of a science of the normal and the pathological and of complete objectivity with regard to these phenomena. Systems medicine, by contrast, and in particular P4 medicine, promotes both a quantification and a science of well-being. The aim of this chapter is to examine the forms of individualization of health and disease which give rise to the two principal orientations of personalized medicine-the stratified medicine, the precision medicine, already used in oncology, and the more theoretical systems medicine-and then to confront them with Canguilhem's thesis regarding health and disease. In this way, I will develop a critical analysis of the promises and pretentions of personalized medicine, and in particular P4 medicine.
La médecine dite « personnalisée » (MP) est souvent présentée comme un nouveau paradigme. Sa prom... more La médecine dite « personnalisée » (MP) est souvent présentée comme un nouveau paradigme. Sa promotion envahit le champ de l'économie et de l'industrie pharmaceutique, les institutions de santé et les agendas politiques et sociaux, et ce, aussi bien au niveau étatique qu'au niveau européen et international. Mais que recouvrent ces promesses ? Qu'est-ce que cette personnalisation a de nouveau ? Et de quelle « personne » ou « personnalisation » est-il question ? Quelles sont les valeurs et les normes sous-jacentes aux projets qui se logent derrière cette étiquette ? Par rapport à quelle autre conception de la médecine la MP introduirait-elle une rupture épistémologique ? Malgré la diversité, ces projets ont en commun de promettre un recentrement sur le niveau individuel et de s'opposer plus ou moins explicitement à une médecine « populationnelle ». Mais que signifie cette insistance sur une individualisation de l'épistémologie et de la pratique médicales ? Que devient le niveau populationnel d'analyse et d'action dans une médecine centrée sur la personne ? Il s'agit d'interroger la norme partagée par ces divers courants, par-delà la diversité des valeurs impliquées, selon laquelle toute bonne médecine doit être personnalisée et la relativisation afférente du niveau populationnel d'action.
L’Evidence-Based Medicine (EBM) et la médecine personnalisée (MP) ont une ambition commune : rédu... more L’Evidence-Based Medicine (EBM) et la médecine personnalisée (MP) ont une ambition commune : réduire l’écart entre les résultats de la recherche biomédicale et leur application en clinique. Toutefois la MP est souvent présentée comme un « nouveau paradigme » pour la médecine, comme l’avait d’ailleurs été l’EBM dans les années 1990. Elle recouvre beaucoup de projets différents mais au cœur de la plupart d’entre eux, on retrouve la prétention d’une meilleure prise en compte des spécificités individuelles que ne le permettrait l’EBM avec son approche populationnelle et statistique. Dans cet article, nous concentrons notre attention sur la MP en cancérologie : elle concerne essentiellement un ciblage des traitements à partir de caractéristiques moléculaires des patients. Ce ciblage est rendu notamment possible par la meilleure connaissance des mécanismes moléculaires des cancers. Il conduit à une stratification en sous-groupes plus restreints de patients et met en difficulté l’évaluation classique des thérapeutiques promue par l’EBM, en particulier, les essais cliniques randomisés qui reposent sur des cohortes de grande taille. Mais la meilleure connaissance des mécanismes et la plus grande précision des thérapies pourraient rendre ces essais moins nécessaires. Assistons-nous avec la MP à une revanche de la culture physiopathologique et mécaniste sur celle statistique et empiriste au sein de la recherche clinique ? Notre objectif est de mettre en évidence ce qui, pour cette MP déjà effective, conduit à des changements épistémologiques dans la manière de considérer ce qui compte comme type d’information et de preuve en médecine, en particulier dans le champ de l’évaluation thérapeutique. Nous défendons l’idée que la MP, loin de pouvoir se passer des approches statistiques et de la mise en évidence de corrélation, place en réalité l’EBM face à de nouveaux défis. Elle la conduit à renforcer l’articulation et l’intégration des données statistiques et mécanistes pour une meilleure prise en charge de chaque patient.
Evidence-Based Medicine (EBM) and Personalized Medicine (PM) share a common goal: reducing the gap between the results of biomedical research and their clinical application. PM is, however, often presented as a “new paradigm” for medicine, just as EBM was in the 1990s. It covers a wide variety of projects but the core idea that generally unites them is the ambition of better taking account of individual specificities than did EBM with its statistical and population-centred approach. In this article, I concentrate on PM in cancerology, the essence of which is to target treatments based on the molecular profile of the patient. This targeting is made possible by gaining better knowledge about the molecular mechanisms of cancers. The classification of patients as a function of their molecular profile entails the creation of patient sub-groups. This creates a problem for the traditional evaluation of therapeutic treatment promoted by EBM, in particular the use of randomized trials using sizeable cohorts. But a better understanding of the mechanisms and the greater precision of treatments could reduce the need for these trials. Does PM thus represent the revenge of a physio-pathological and mechanistic culture in clinical research against the statistical and empirical one of EBM? My objective is to show how current practices of PM leads to epistemological changes in our estimation of what count as relevant types of information and proof in medicine, in particular in the field of therapeutic evaluation. I defend the idea that PM, far from obviating the need for statistical approaches and the search for correlations, ultimately poses new challenges for EBM. PM drives EBM to strengthen the articulation and the integration of statistical and mechanistic data with a view to providing a better service for each patient.
Epidemiology by Elodie Giroux
History and Philosophy of the Life Sciences
Bulletin d’histoire et d’épistémologie des sciences de la vie, 2012
L'importance prise par l'epidemiologie dite "quantitative" dans la construction... more L'importance prise par l'epidemiologie dite "quantitative" dans la construction des savoirs sur la maladie conduit a privilegier l'affirmation d'une continuite entre le normal et le pathologique. Qu'en est-il, des lors, de la these vitaliste et holiste de Canguilhem defendant l'existence d'une difference qualitative ? Nous traitons cette question d'une maniere quelque peu detournee en partant non pas du couple continuite/discontinuite ni meme du couple qualitatif/quantitatif mais de celui tout/parties, ou plus precisement, holisme/reductionnisme. L'epidemiologie, bien que porteuse d'une modelisation continuiste, a une approche de la maladie qui echappe aux critiques de Canguilhem sur le reductionnisme. Dans le contexte d'une medecine des risques, l'alternative entre une conception continuiste ou discontinuiste des relations entre le normal et le pathologique n'est pas dissociable des objectifs pratiques et du niveau d'organisation auquel on cherche a intervenir.
Revue d'histoire des sciences, 2011
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Exposome by Elodie Giroux
The science of the exposome intends to unite the environmental health sciences through a comprehensive approach, both simultaneous and over time, of all the exposures to which an individual is subjected. At the same time, the goal is to increase the precision in identifying the exposures of individuals to approximate that achieved for the genome. This article examines how its main promoters intend to reconcile these two objectives. Two strategies can be identified: one consists in taking the part for the whole, the other is based on a proposal to categorize the exposome into three subtypes. We show that beyond the divergences in definitions and perspectives, exposomic research is today more akin to an extension of precision medicine oriented towards the individual than to an interdisciplinary project opening up to a renewed conception of exposures and prevention in public health.
Personalized Medicine by Elodie Giroux
Evidence-Based Medicine (EBM) and Personalized Medicine (PM) share a common goal: reducing the gap between the results of biomedical research and their clinical application. PM is, however, often presented as a “new paradigm” for medicine, just as EBM was in the 1990s. It covers a wide variety of projects but the core idea that generally unites them is the ambition of better taking account of individual specificities than did EBM with its statistical and population-centred approach. In this article, I concentrate on PM in cancerology, the essence of which is to target treatments based on the molecular profile of the patient. This targeting is made possible by gaining better knowledge about the molecular mechanisms of cancers. The classification of patients as a function of their molecular profile entails the creation of patient sub-groups. This creates a problem for the traditional evaluation of therapeutic treatment promoted by EBM, in particular the use of randomized trials using sizeable cohorts. But a better understanding of the mechanisms and the greater precision of treatments could reduce the need for these trials. Does PM thus represent the revenge of a physio-pathological and mechanistic culture in clinical research against the statistical and empirical one of EBM? My objective is to show how current practices of PM leads to epistemological changes in our estimation of what count as relevant types of information and proof in medicine, in particular in the field of therapeutic evaluation. I defend the idea that PM, far from obviating the need for statistical approaches and the search for correlations, ultimately poses new challenges for EBM. PM drives EBM to strengthen the articulation and the integration of statistical and mechanistic data with a view to providing a better service for each patient.
Epidemiology by Elodie Giroux
The science of the exposome intends to unite the environmental health sciences through a comprehensive approach, both simultaneous and over time, of all the exposures to which an individual is subjected. At the same time, the goal is to increase the precision in identifying the exposures of individuals to approximate that achieved for the genome. This article examines how its main promoters intend to reconcile these two objectives. Two strategies can be identified: one consists in taking the part for the whole, the other is based on a proposal to categorize the exposome into three subtypes. We show that beyond the divergences in definitions and perspectives, exposomic research is today more akin to an extension of precision medicine oriented towards the individual than to an interdisciplinary project opening up to a renewed conception of exposures and prevention in public health.
Evidence-Based Medicine (EBM) and Personalized Medicine (PM) share a common goal: reducing the gap between the results of biomedical research and their clinical application. PM is, however, often presented as a “new paradigm” for medicine, just as EBM was in the 1990s. It covers a wide variety of projects but the core idea that generally unites them is the ambition of better taking account of individual specificities than did EBM with its statistical and population-centred approach. In this article, I concentrate on PM in cancerology, the essence of which is to target treatments based on the molecular profile of the patient. This targeting is made possible by gaining better knowledge about the molecular mechanisms of cancers. The classification of patients as a function of their molecular profile entails the creation of patient sub-groups. This creates a problem for the traditional evaluation of therapeutic treatment promoted by EBM, in particular the use of randomized trials using sizeable cohorts. But a better understanding of the mechanisms and the greater precision of treatments could reduce the need for these trials. Does PM thus represent the revenge of a physio-pathological and mechanistic culture in clinical research against the statistical and empirical one of EBM? My objective is to show how current practices of PM leads to epistemological changes in our estimation of what count as relevant types of information and proof in medicine, in particular in the field of therapeutic evaluation. I defend the idea that PM, far from obviating the need for statistical approaches and the search for correlations, ultimately poses new challenges for EBM. PM drives EBM to strengthen the articulation and the integration of statistical and mechanistic data with a view to providing a better service for each patient.
In this paper I propose a historical analysis of the emergence of the risk factor concept in epidemiology with the objective of highlighting how the question of causality arose. Causal inference in epidemiology has been structured by the famous
Bradford Hill’s criteria that were developed in the context of the ‘smoking-lung cancer’ controversy in a pragmatic objective and spirit. Even if there were not analysis of the implicit concept of causation presupposed by these criteria, I will show that there are several interpretations of causation behind these criteria which are more or less assumed by epidemiologists. All this leads us to the question of pluralism or monism with regard to the nature of causality in epidemiology and more generally in biomedicine.
other contemporary cohort studies carried out in the USA and in the UK: in particular its conception as a large clinical study, its relationship to American constitutional medicine and the division of work between clinicians and statisticians.
in the decades following the Second World War, the methodological formalization and the increasingly frequent use of case-control and prospective cohort study designs played a major role in the development of etiological research in epidemiology. The history of the prospective cohort study is best known for the study of cancer epidemiology, with
this design being developed and improved in the context of an animated controversy over the causal status of cigarette smoking as a risk factor in lung cancer. In this paper, I focus on the history of this kind of study design in American cardiovascular epidemiology, and, more particularly, the Framingham heart study. This study rapidly came to be considered as the prototype and model for this method of study and an icon of its potential success in etiological research in cardiovascular epidemiology. A comparison with cancer epidemiology reveals the differences between this type of study in the context of cardiovascular disease in terms of both the approach and its origins. I shall first highlight the main
differences and specificities of the Framingham study in terms of the nature of its cohort and the follow-up. I will then show how this cohort study design has some roots both in longitudinal studies led on general populations by the epidemiologists of the United States Public Health Service at the beginning of the 20th century, and in “follow-up studies” conducted by clinicians.
Keywords: epidemiology, prospective cohort study, lung cancer, cardiovascular disease, Framingham heart study.
Methods. – This paper consists in an epistemological and historical analysis of the Framingham study that provides some of the answers to this question. In my treatment of the study’s methodology, I focus on the issue of how the study population was constituted, and the manner in which the multiple factor analyses were conducted, two issues that are now central to cohort studies and more generally to analytic epidemiology.
Results. – I show how the study population of Framingham and its long-term follow-up have contributed significantly to the interpretation of the cohort as a sort of ‘‘population-laboratory’’. The data generated by this study, which have been very widely used by epidemiologists and other researchers, are unparalleled in terms of the amount of detailed clinical information available for such a long follow-up period. Furthermore, multivariate statistical modelling, which has become a standard statistical tool for clinical as well as epidemiological studies was introduced in the context of this study to improve the identification of significant factors in the simultaneous analysis of multiple correlations. Multivariate analysis has since proved crucial in shaping the epidemiological concept of ‘‘risk factor’’ and in analyzing multifactorial diseases. Indeed, I suggest that the modern idea of multifactorial diseases depends on the adaptation of this statistical method.
Conclusion. – Thus, the Framingham study played a leading role not only in remodelling epidemiology after SecondWorldWar, in particular because of its contribution to the establishment of the cohort study as a standard method of investigation in etiological research, but also in constituting the ‘‘risk factor approach’’ to disease.
During the first half of the 20th century, the discipline of epidemiology was demarcated in terms of its differences with clinical medicine. As a public health discipline, its level of analysis was the population rather than the individual, and the vital statistics and demographical data were its main objects of analysis. During the fifties, however, a significant shift occurred. Some specific methods of etiological studies (cohort study and case-control study) on groups of individuals were further developed and a number of statistical tools derived from the new inferential statistics began to be used and adapted to the analysis of epidemiological data. Since the 1960-1970s, the identification of individual risk factors based on etiologic studies has led to the development of an individualized prevention of disease risk. Thus, the individual appears to be at the forefront of this new epidemiology and the preventive strategies. But should we consider that we are witnessing a clinical turn in epidemiology? The goal of this paper is to study aspects of the convergence between epidemiology and clinical medicine in analyzing one of the paradigmatic cohort studies of the nascent modern epidemiology, the Framingham Heart Study. Led since 1947-1948 in Framingham, this pioneering cohort study on cardiovascular disease shaped the development and diffusion of the notion of risk factor. I will argue that this study and more generally cardiovascular epidemiology as developed in the United States have their origins in both approaches and questions that pertain to clinical medicine. I will then assess whether, and if so, to what extent, a historical and methodological link can be established between the new connection between epidemiology and clinical medicine that emerges from risk factor epidemiology and what is now called “clinical epidemiology”.
Starting from the second half of the twentieth century, “modern epidemiology” or “risk-factor epidemiology” has progressively become a major source of knowledge concerning disease aetiology. Epidemiology has become an independent scientific discipline that contributes to the construction of our knowledge of health and disease. But what can we say about the specificity of its contribution as opposed to clinical and physiological research? Its definition as the study of the distribution and determinants of disease in human populations suggests that the notion of population has a central place in any characterization of this discipline. Nevertheless, this extremely complex and multi-faceted notion of population has an unclear status in epidemiology where the term remains polysemous. With an increasing interest in identifying individual risk factors, modern epidemiology seems ultimately to be more concerned with individuals than with populations. The objective of this paper is to show that the notion of “population thinking” introduced by Ernst Mayr in opposition to “typological thinking” is particularly useful and relevant for shedding light on the status and the signification of “population” in epidemiology. Firstly, this notion enables us to account for the shifts brought about by the emergence of “modern epidemiology” during the fifties and secondly, it allows us to point out the specificity of an epidemiological approach to health and disease. Thus, we supply a tentative characterization of what can be termed an epidemiological conception of health phenomena.
For around ten years now, the potential health risks of using mobile phone, and more generally of being exposed to radiofrequencies, has been a very controversial subject. The core of this debate is our insufficient knowledge concerning such low levels but widespread exposure to the electromagnetic spectrum emitted by telecommunication technologies. The analysis of the health risks from this kind of exposure is very complex; and it gives rise to opposition between the experts and activists, and even between experts themselves. In adopting both a historical and epistemological perspective, this paper shows that this controversy highlights the complexity and ambivalence of our way of dealing with the uncertainty of the environmental risk. The analysis of the institutional and political answers to this debate in France shows the shifts in expertise that follow from it. This paper argues the importance of reevaluating our view on the links between science and uncertainty in order to overcome some of the challenges which emerge from this kind of controversies.
not taken into account by BST in a satisfactory way. The article’s central contention, therefore, is that if the project of defining the theoretical concept of health is to be maintained, more importance should be accorded to the contribution made by epidemiology—alongside physiology—in defining health.
Keywords Boorse Disease Bio-statistical theory Risk-factor Epidemiology Normality
This article presents a comparative analysis between Georges Canguilhem’s Essay on Some Problems Concerning the Normal and the Pathological , published in 1943 and the English language debate that started in the 1970s between the naturalists and the normativists. Seemingly, this comparison illustrates the opposition between the French historical epistemology and the Anglo American philosophy of sciences. However, I put into perspective what is generally considered an opposition between the two traditions by analyzing certain conceptual similarities.
le problème de la démarcation entre le normal et le pathologique. Les facteurs de risque modifient et questionnent la pertinence de ces concepts. Cet article propose une analyse épistémologique de la notion de « continuité » telle qu’elle est utilisée dans le contexte de l’épidémiologie des facteurs de risque.
The fact that numerous risk factors are continuous raises the problem of the boundary between the normal and the pathological states. Moreover, a risk factor approach to disease deeply calls into question the relevance of these concepts. In this paper, I propose an epistemological analysis of the notion of “continuity” as it is used in the context of “risk factor epidemiology”.
This volume offers the first comprehensive review and critical assessment of the nature and status of naturalism in the philosophy of health. It explores the notion of biological normativity and its relevance for the philosophy of health, and it analyses the implications of the philosophical theories of health for healthcare and the debate on health enhancement.
In the first section, several contributions identify the kind of ‘naturalism’ the biostatistical theory belongs to and offer further criticisms or possible modifications, such as the concept of function that is required by this theory, and whether a comparativist approach to health is more relevant than a non-comparativist one. The second section explores natural or biological ‘normativity’ and some possible accounts of health that could be based on this concept. The third and final section focuses on the implications of naturalism in healthcare. 'Goals of Medicine’ is the first paper in which Christopher Boorse ventured toward analysing the implication of his biostatistical theory of health on the practice of medicine, the difficult issue of the goals of medicine and the boundary between treating and enhancing. Other papers in this section critically evaluate Boorse’s account and analyse the importance of a positive concept of health.
Tous les textes présentés dans ce volume ont participé de cette controverse. Ceux de la première section accordent une part importante à la composante biologique. Ceux de la seconde donnent le primat à la notion d’action. Ceux de la dernière section mettent en question l'utilité ou la possibilité même de définir les deux concepts.
Avec des textes de Ch. Boorse, G. Canguilhem, H. T. Engelhardt, G. Hesslow, D. Magnus, R.M. Nesse, L. Nordenfelt, J.C.Wakefield, K. Zadegh-Zadeh.
Paris, P.U.F, 2010
ISBN : 978-2-13-056900-8
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Le livre met en évidence les enjeux pratiques de la définition générale de la santé et de la maladie et il présente et discute les principaux apports de la philosophie contemporaine de la médecine sur ce sujet.
La définition générale de la santé et de la maladie revêt des enjeux pratiques, sociaux, économiques et politiques considérables : notamment, la décision sur l’irresponsabilité dans le domaine judiciaire mais aussi le remboursement des traitements et les orientations de recherches biomédicales. Or elle soulève d’importantes difficultés. Le concept de maladie désigne-t-il avant tout un état indésirable vécu par un sujet ? Peut-on établir un concept neutre qui légitime un usage scientifique ainsi que son extension aux animaux et aux plantes ? La santé est-elle un concept positif comme l’affirme la définition de l’O.M.S. ? Et si c’est le cas, quelles en sont les limites et comment la distinguer du bonheur ?
La philosophie a un rôle à jouer ne serait-ce que pour clarifier le sens de ces termes, particulièrement ambigus et plurivoques, analyser la part des normes et des valeurs qu’ils contiennent et, si possible, proposer des définitions. C’était la conviction du philosophe et médecin Georges Canguilhem qui, dans sa thèse de médecine publiée en 1943, défendit l’impossibilité d’une conception objective et entièrement scientifique de la santé et de la maladie à partir de la notion de normativité biologique. Depuis 1970, la philosophie de la médecine, principalement anglo-saxonne, a apporté d’importants développements sur toutes ces questions. Ce livre présente et analyse les théories de la santé de deux des principaux représentants du débat moderne entre naturalisme et normativisme : celle bio-statistique et analytique de Christopher Boorse, et celle holiste, qui repose sur la notion de capacité à agir, de Lennart Nordenfelt. Il est montré comment ces deux théories prolongent et approfondissent les analyses de Canguilhem.
Plan détaillé
Introduction
Canguilhem, Boorse et Nordenfelt : entre naturalismes et normativismes
Georges Canguilhem et la normativité biologique : un naturalisme anti-réductionniste ?
Quelques difficultés du concept de normativité biologique
Christopher Boorse : un naturalisme non réductionniste
Lennart Nordenfelt : un normativisme faible
La théorie bio-statistique de Christopher Boorse
Concepts théoriques et pratiques : une approche multi-niveaux des concepts de santé
La définition bio-statistique de la santé
Limites de la théorie bio-statistique
La théorie holistique de Lennart Nordenfelt
Capacité et circonstances acceptées
Les buts vitaux
La composante normative du concept général de santé
Les concepts de santé et de maladie : relations logiques et définitions
Avantages et limites de la théorie holistique
de l’esprit de l’EBM, d’autre part.
La science de l’exposome entend fédérer les sciences en santé-environnement par une approche globale, à la fois simultanée et dans le temps long, de l’ensemble des expositions auxquelles est soumis un individu. Dans le même temps, l’objectif est d’augmenter la précision dans l’identification des expositions des individus pour se rapprocher de celle atteinte pour le génome. Cet article s’intéresse à la manière dont ses principaux promoteurs entendent concilier ces deux objectifs de globalité et de précision. Deux stratégies sont repérables : l’une consiste à prendre la partie pour le tout, l’autre repose sur une proposition de catégorisation de l’exposome en trois sous-types. Nous montrons que par-delà des divergences de définitions et d’orientations, la recherche exposomique s’apparente aujourd’hui davantage à un prolongement de la médecine de précision orientée vers l’individu qu’à une recherche interdisciplinaire ouvrant à une conception renouvelée des expositions et de la prévention en santé publique.