Conceptual and Ethical Challenges of Evolutionary Medicine (Ethics of Science and Technology Assessment, 53) 303145765X, 9783031457654

Table of contents :
Foreword
Preface
Acknowledgments
Contents
1 Introduction
1.1 Concepts and Reality
1.2 Starting Point; the Concept of Disease and Evolution
1.3 Setting of the Problem Agenda for the Concept of Disease
1.4 The Motivation
1.5 The Structure of the Book
1.6 Dealing with Concepts of Scientific Research
1.7 Going to the Central Question; Disease
1.8 Caveat for a Conclusion
References
2 Finding Value in Concepts
2.1 Introduction
2.1.1 Significance of Thick Concepts
2.2 Evaluative and Descriptive, Why the Distinction is Hard to Grasp and Its Prevalence
2.2.1 Hume’s Guillotine, Naturalistic Fallacy and Non-cognitivists
2.2.2 Disentanglement of the Thick
2.3 The Thin and the Rest
2.3.1 The Thin and Against the Dichotomy
2.3.2 Global Evaluation and Embedded Evaluation
2.3.3 Dimensionality
2.4 Reduction
2.4.1 Reduction as Replacement
2.4.2 Reduction in the Case of Subset of Properties
2.5 Conclusion
References
3 Meaning as Definition and Meaning as Use
3.1 Introduction
3.2 Why to Talk About Meaning Within This Context in the Very First Place?
3.3 Meaning Theories
3.3.1 Meaning of What? Concepts, Sentences and Larger Linguistic Representations. A Brief Criticism of the Object of Linguistic Analysis
3.3.2 A Social-Pragmatic Approach as the Critique of Idealist Conception of Concepts
3.3.3 The Meaning of Meaning
3.3.4 Negation and Pragmatics
3.3.5 What Is Real and What Is Representation?
3.4 Conclusion
References
4 Locating the Conceptual Change in Scientific Research
4.1 Introduction
4.2 Limits of a Stable Division of Labor and the Steamship of Theseus
4.3 When Is Biological Research Complete? Difficulty Due to the Structure of Research Communities
4.3.1 Difficulty in Research, Someone’s Research Topic, Someone’s Given—Vertically Direction of Change
4.3.2 Sub-fields—Which Part of a Discipline Speaks for the Concept—Horizontal Aspect of Change
4.4 What Kind of Entities Are Concepts in Research?—Is It Simply a Linguistic Problem?—Language and Thought
4.4.1 Contradictions Between the Particular and the Abstract
4.4.2 Grasp and Use (Possessing a Concept)—Scientist Is Back into the Picture
4.5 Conclusion
References
5 The Concept of Disease in the Traditional Debates
5.1 Introduction
5.1.1 The Concept of Disease in Short, the Shadow of Logical Positivism
5.1.2 What Kind of Concept is Disease? Positioning Disease in the Context of Philosophy of Science
5.2 The Normativeness Debate—Can It Be Value Free?
5.2.1 A Solution to the Normativeness Debate
5.3 Social and Psychological Aspects; Three Part Division; Disease, Sickness and Illness
5.4 Medical Explanation
5.4.1 What Are We Explaining: What Kind of a Concept is Disease?
5.5 Contextualism and Disability Internal and External
5.6 What to Do When the Concepts Are Changing?
5.7 Individualized and Invented Disease
5.8 Conclusion
References
6 Evolution and Evolutionary Medicine in Disease
6.1 The Concept of “Evolution” in Evolutionary Medicine; General Distinctions
6.1.1 The Delphi Study of Evolutionary Medicine
6.1.2 Relevance of Evolution to Medicine
6.2 What is Evolutionary Medicine, Historical and Contemporary Accounts
6.2.1 A Brief History of Evolution and Medicine Together
6.2.2 The Cannon of Evolutionary Medicine
6.3 Are These Simply and Adaptationist Stories? Explanation in Evolutionary Medicine
6.4 How Does EM See Disease; What Can We Expect from It?
6.4.1 What is an Explanation?
6.4.2 The Primary Focus of Modern Synthesis; Genes
6.4.3 We Are not Perfect—Trade-Offs, Constraints and Disease Vulnerability
6.4.4 New Evolutionary Entities—the Units of Selection
6.5 Established—Emergent Structures Versus Continuum (Population Thinking) Mismatch for Environment
6.5.1 Other Developments in Philosophy of Biology that Are Relevant to the Debate; Everything Flows and Everything is Distributed so Shall Disease
6.6 Conclusion
References
7 New Developments in Evolutionary Theory and Evolutionary Medicine, New Frontiers for Evolutionary Medicine
7.1 Introduction
7.1.1 Epigenetics
7.1.2 The Structure of Inheritance Dynamics in Epigenetics
7.2 Limitations of Evolutionary Medicine and the Discontents
7.2.1 A Brief History of Evolutionary Theory; Ever Since Darwin
7.3 A Brief History of Inheritance and Inheritance of Inheritance
7.4 Extended Evolutionary Synthesis
7.4.1 Explanations in EES
7.4.2 Ancestral Population Individualized—Inheritance of Different Mechanisms
7.4.3 Structures Fixed and Getting Fixed
7.4.4 Another Kind of History, Individualization and Evolutionary Histories
7.4.5 Emerging Pathogens
7.5 Conclusion
References
8 Conclusion
8.1 Introduction
8.2 The Potential Futures of the Concept of Disease
8.3 Different Kinds of Injustices
8.4 The Death of the Non-Clinic
8.5 One Possible Objection—Where Does Disease End
8.6 Conclusion
References

Citation preview

Ethics of Science and Technology Assessment 53

Ozan Altinok

Conceptual and Ethical Challenges of Evolutionary Medicine

Ethics of Science and Technology Assessment Volume 53

Series Editors Carl Friedrich Gethmann, Universität Siegen, Siegen, Germany Michael Quante, Philosophisches Seminar, Westfälische Wilhelms Universität, Münster, Germany Bjoern Niehaves, Universitaet Siegen, Siegen, Germany Holger Schönherr, Department of Chemistry and Biology, Universität Siegen, Siegen, Germany

The series Ethics of Science and Technology Assessment focuses on the impact that scientific and technological advances have on individuals, their social lives, and on the natural environment. Its goal is to cover the field of Science and Technologies Studies (STS), without being limited to it. The series welcomes scientific and philosophical reviews on questions, consequences and challenges entailed by the nature and practices of science and technology, as well as original essays on the impact and role of scientific advances, technological research and research ethics. Volumes published in the series include monographs and edited books based on the results of interdisciplinary research projects. Books that are devoted to supporting education at the graduate and post-graduate levels are especially welcome.

Ozan Altinok

Conceptual and Ethical Challenges of Evolutionary Medicine

Ozan Altinok Centre for Ethics and Law in the Life Sciences (CELLS) Leibniz University Hannover Hannover, Germany

ISSN 1860-4803 ISSN 1860-4811 (electronic) Ethics of Science and Technology Assessment ISBN 978-3-031-45765-4 ISBN 978-3-031-45766-1 (eBook) https://doi.org/10.1007/978-3-031-45766-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Foreword

Our conceptions of disease are ancient and subject to constant change. Accordingly, conceptions of disease vary considerably throughout history and across cultures. In contrast, the paradigm of evolutionary theory is relatively young; however, even here there have been significant advancements within evolutionary theory (or the family of theories) in recent decades. In contrast, the emerging and developing field of evolutionary medicine is very new. Here the field of action of medicine and the dynamic theory of evolution meet. Thus, the concept of disease with its manifold dimensions also migrates into the context of evolutionary insights, explanatory models, and patterns of thought. In this study, Ozan Altan Altinok addresses the complex constellation of the concept of disease and evolutionary theory as it can be traced in the context of evolutionary medicine. The concept of disease is a thick ethical concept; by this is meant that this concept has not only evaluative but also descriptive aspects of meaning. In other words, the concept of disease can be used to formulate both descriptive and evaluative statements. In the case of thick concepts, there can be shifts in meaning on two levels. Advances in knowledge can have consequences for descriptive aspects of meaning on the one hand; changes at the level of socially shared values and norms can entail effects on evaluative aspects of meaning on the other. In his study, Altinok examines these possible effects of the advancement of evolutionary theory on our conception and conceptualization of disease. For this purpose, it is necessary to present the underlying model of conceptual meaning, especially in relation to the complexity of thick concepts. Altinok employs a pragmatist conception of meaning, according to which meaning is constituted by use. This allows us not only to capture the plurality or even diversity of factual usage, but also to show what effects changes in the context of use could or should have on meaning. Starting from “classical” conceptions of disease found in traditional debates, Altinok uses evolutionary medicine to present the new context of use in order to identify such possible changes in meaning. In doing so, the conception of disease implicit in evolutionary medicine is explicated to show why and in what ways recent developments in evolutionary theory necessitate modifications in the ethical debates v

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Foreword

in the future. Here, Altinok elaborates the tension between a population-centered perspective, traditionally associated with the viewpoint of evolutionary theory, and an individual-centered perspective. However, the latter, according to one of the central findings of the present study, not only lies in the orientation of personalized medicine, but is at the same time also capable of connecting more recent developments within evolutionary theory. Overall, Altinok’s study enters a complex and dynamic terrain that is uncharted territory for classical bioethics. In this pioneering work, fundamental dimensions of the issues at stake here are addressed and problem-opening approaches are demonstrated. As such, Altinok’s book will become a foundational contribution to a current and nascent debate. Münster, Germany

Michael Quante

Preface

This book was written in times where people were thinking a lot about health, a lot about disease, a lot about evolution of disease as well as care, isolation, and what rights and liberties we have and which responsibilities we have towards each other, as well as questions of injustice, equity, and life in general. In short, business as usual—but all in one during COVID-19. The more time is spent on thinking of the network which enabled me to write this book, the more difficult it becomes for me to have a limited understanding of interrelations of thankfulness, the reader I hope will understand that through reading the book. I am very lucky to be in a position to think of many people who have been of help, and I am very grateful to be in a position to be helped and help in return. Through the making of this book, me and my loved ones have encountered many different problems of health, in an odd way, these always gave me help and support to understand our notion of health, but more importunately reminded me of that it was “our” concept of health, and we need care of different sorts from the community, loved ones, and a better healthcare structure. Parts of this book have been presented as ideas within discussions of research training group EvoPAD (evolutionary processes in adaptation and disease) within MGSE (Münster Graduate School of Evolution) and it has been funded by the DFG (Deutsche Forschungsgemeinschaft) as well as various conferences and has been updated with conferences of philosophy, philosophy of biology, as well as evolutionary biology. Hannover, Germany

Ozan Altinok

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Acknowledgments

I am thankful to: Prof. Dr. Dres. h.c. Michael Quante, who taught me how to see the end even from the beginning, who has been of great help in understanding how a text works and how understanding is made to reflect on itself as well as all the possibilities he enabled. Prof. Dr. med. Bettina Schöne-Seifert for providing a new perspective not from far away but from within bioethics. Prof. Dr. Ulrich Krohs for always being very friendly and opening new intellectual horizons for me. Dr. Simon Derpmann for all the time he took to understand what I have been trying to do and helping me make sense of it. Prof. Dr. Matthew Sample, who as being my later advisor, has been always kind and supportive for me to carry on what I have already done with great attention and understanding towards not only what my work is, but what I can do with my work to restructure not only how I see life, but life itself. Prof. Dr. Ayhan Sol started making me into a philosopher and has been of great health and support until here I started my Ph.D. Dr. Shrey Ghandi for his hospitality and directness as a cure for loneliness. Baki Coban, Merve Coban, Dr. Med Ekin Karagöz, and Sezer Karagöz for being a community. Dr. Nina Kranke for showing me how to face a similar challenge and difficulties. Eva Tanita Kraaz, as an inspiration and helping hand for taking values seriously and actualizing them as well without hesitation. EvoPAD research training group members at large, who created an interesting environment to begin with, and to Prof. Dr. Joachim Kurtz in particular. Münster Kleingarten for all the help that is done and that is more to be done. Odak Kültürzentrum Münster for fighting the good fight despite differences, despite the need for help for its own members to raise solidarity. Leo Kneipenkollektiv Münster for having a modest, yet stubborn vision for a new world. Baris Can Altinok, who, if not anyone was guaranteed to be my audience, critique, and commentor and very enthusiastic at any case. Yasemin Gülhan Altinok, for all the care and material and mental work she has put “in the making”. Lena Bohn, for being there in ways that were of amazing help while she was also “working it”.

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Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Concepts and Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Starting Point; the Concept of Disease and Evolution . . . . . . . . . . . . 1.3 Setting of the Problem Agenda for the Concept of Disease . . . . . . . . 1.4 The Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 The Structure of the Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6 Dealing with Concepts of Scientific Research . . . . . . . . . . . . . . . . . . . 1.7 Going to the Central Question; Disease . . . . . . . . . . . . . . . . . . . . . . . . 1.8 Caveat for a Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 2 2 3 5 5 6 7 8 9

2 Finding Value in Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1 Significance of Thick Concepts . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Evaluative and Descriptive, Why the Distinction is Hard to Grasp and Its Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.1 Hume’s Guillotine, Naturalistic Fallacy and Non-cognitivists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2 Disentanglement of the Thick . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 The Thin and the Rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3.1 The Thin and Against the Dichotomy . . . . . . . . . . . . . . . . . . . 2.3.2 Global Evaluation and Embedded Evaluation . . . . . . . . . . . . 2.3.3 Dimensionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4 Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.1 Reduction as Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.2 Reduction in the Case of Subset of Properties . . . . . . . . . . . . 2.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11 13 13 16 17 21 23 24 25 28 29 29 31 32 34

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3 Meaning as Definition and Meaning as Use . . . . . . . . . . . . . . . . . . . . . . . 3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Why to Talk About Meaning Within This Context in the Very First Place? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Meaning Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.1 Meaning of What? Concepts, Sentences and Larger Linguistic Representations. A Brief Criticism of the Object of Linguistic Analysis . . . . . . . . . . . . . . . . . . . . 3.3.2 A Social-Pragmatic Approach as the Critique of Idealist Conception of Concepts . . . . . . . . . . . . . . . . . . . . . 3.3.3 The Meaning of Meaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.4 Negation and Pragmatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.5 What Is Real and What Is Representation? . . . . . . . . . . . . . . . 3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

37 38

4 Locating the Conceptual Change in Scientific Research . . . . . . . . . . . . 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Limits of a Stable Division of Labor and the Steamship of Theseus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 When Is Biological Research Complete? Difficulty Due to the Structure of Research Communities . . . . . . . . . . . . . . . . . . . . . . 4.3.1 Difficulty in Research, Someone’s Research Topic, Someone’s Given—Vertically Direction of Change . . . . . . . 4.3.2 Sub-fields—Which Part of a Discipline Speaks for the Concept—Horizontal Aspect of Change . . . . . . . . . . . 4.4 What Kind of Entities Are Concepts in Research?—Is It Simply a Linguistic Problem?—Language and Thought . . . . . . . . . . 4.4.1 Contradictions Between the Particular and the Abstract . . . . 4.4.2 Grasp and Use (Possessing a Concept)—Scientist Is Back into the Picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5 The Concept of Disease in the Traditional Debates . . . . . . . . . . . . . . . . . 5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.1 The Concept of Disease in Short, the Shadow of Logical Positivism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.2 What Kind of Concept is Disease? Positioning Disease in the Context of Philosophy of Science . . . . . . . . . . 5.2 The Normativeness Debate—Can It Be Value Free? . . . . . . . . . . . . . 5.2.1 A Solution to the Normativeness Debate . . . . . . . . . . . . . . . . . 5.3 Social and Psychological Aspects; Three Part Division; Disease, Sickness and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 Medical Explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

89 90

38 40

41 44 51 55 57 58 59

65 68 70 73 75 77 78 84 86

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Contents

5.4.1 What Are We Explaining: What Kind of a Concept is Disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Contextualism and Disability Internal and External . . . . . . . . . . . . . . 5.6 What to Do When the Concepts Are Changing? . . . . . . . . . . . . . . . . . 5.7 Individualized and Invented Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Evolution and Evolutionary Medicine in Disease . . . . . . . . . . . . . . . . . . 6.1 The Concept of “Evolution” in Evolutionary Medicine; General Distinctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1 The Delphi Study of Evolutionary Medicine . . . . . . . . . . . . . 6.1.2 Relevance of Evolution to Medicine . . . . . . . . . . . . . . . . . . . . 6.2 What is Evolutionary Medicine, Historical and Contemporary Accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.1 A Brief History of Evolution and Medicine Together . . . . . . 6.2.2 The Cannon of Evolutionary Medicine . . . . . . . . . . . . . . . . . . 6.3 Are These Simply and Adaptationist Stories? Explanation in Evolutionary Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 How Does EM See Disease; What Can We Expect from It? . . . . . . . 6.4.1 What is an Explanation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4.2 The Primary Focus of Modern Synthesis; Genes . . . . . . . . . . 6.4.3 We Are not Perfect—Trade-Offs, Constraints and Disease Vulnerability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4.4 New Evolutionary Entities—the Units of Selection . . . . . . . . 6.5 Established—Emergent Structures Versus Continuum (Population Thinking) Mismatch for Environment . . . . . . . . . . . . . . . 6.5.1 Other Developments in Philosophy of Biology that Are Relevant to the Debate; Everything Flows and Everything is Distributed so Shall Disease . . . . . . . . . . . 6.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 New Developments in Evolutionary Theory and Evolutionary Medicine, New Frontiers for Evolutionary Medicine . . . . . . . . . . . . . . . 7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1.1 Epigenetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1.2 The Structure of Inheritance Dynamics in Epigenetics . . . . . 7.2 Limitations of Evolutionary Medicine and the Discontents . . . . . . . . 7.2.1 A Brief History of Evolutionary Theory; Ever Since Darwin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3 A Brief History of Inheritance and Inheritance of Inheritance . . . . . 7.4 Extended Evolutionary Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4.1 Explanations in EES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4.2 Ancestral Population Individualized—Inheritance of Different Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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100 100 101 102 103 104 107 107 109 111 113 113 115 118 122 124 126 128 130 133

135 137 139 143 143 145 146 149 151 158 159 161 165

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7.4.3 Structures Fixed and Getting Fixed . . . . . . . . . . . . . . . . . . . . . 7.4.4 Another Kind of History, Individualization and Evolutionary Histories . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4.5 Emerging Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2 The Potential Futures of the Concept of Disease . . . . . . . . . . . . . . . . 8.3 Different Kinds of Injustices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4 The Death of the Non-Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.5 One Possible Objection—Where Does Disease End . . . . . . . . . . . . . 8.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

177 177 179 180 182 182 183 185

167 169 170 172

Chapter 1

Introduction

Abstract This book is about disease, but from a very specific perspective, namely that of evolutionary medicine. It explains evolutionary medicine in its current form, criticizes it, and tries to apply it not directly on disease instances or tokens of disease, but rather the concept of disease. Doing so, the aim of this book is to ask the question; how to build a better concept of disease? The parts of the answer to this question are answered in different chapters piece by piece, trying to give an account of a better concept first and giving an account of how to see the concept of disease grounded differently. This book is not about giving every possible account of disease, or even the major ones including the established or traditional concept. This book is not about providing a singular perspective on diseases in general, however it assumes a general orthodoxy of medicalized disease understanding.

In this book, I will defend the thesis that, when the concept of disease is seen from perspectives provided by evolutionary biology, the ontology of disease and the surrounding perspectives shall change, leading our understandings in medicine related to concept of disease and social, action guiding concepts to shift towards a more individualized and care based understanding of medicine to overcome the epistemic injustices that are done by the orthodox understanding of disease that prevails in medicine.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_1

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1.1 Concepts and Reality Scientists, like any other people, use concepts, and as they use them, they use them under the given weight of concepts both epistemically and morally.1 Sometimes they knowingly adhere to a certain meaning of the concept they use after critical reflection and sometimes they use them without knowing the consequences or the relationships of concepts to other concepts, practices and society. Although scientists use concepts very often, they are not only passive receivers in the use of concepts. Through their engaged activity in the use of concepts that they are occupied within their work, be it in conceptualization, sharing of results and experiences, grant applications, communication with their colleagues, discussing with their students etc., they knowingly or unknowingly also change the meaning of the concepts. The change in the meaning of concepts that are employed by scientific activity in general are of course not limited to the scientific domain. The change of meaning is received from different parts of society and social activity and these activities, like many other activities in society, are reciprocal in the meaning change of the concepts. Of course, their own social environment is quite nuanced, and does not refer to the possibility of having one single society. Scientific activity, when seen as a social activity that is both within the society and autonomous to other social activities in general, the meanings and the usage of different meanings of the concepts gain importance, particularly when it comes to bringing these concepts back to general usage. How do scientists engage in concepts, particularly value bearing concepts and how they are active members in the meaning change, even in cases when they work on seemingly other issues? This is one of the primary questions of this work.

1.2 Starting Point; the Concept of Disease and Evolution The concept of disease plays a crucial role in many social and socially related activities, legally, morally, socially and scientifically. Scientists, as the bearers, users and determiners of the concepts are often not aware of the exact consequences of the concepts they use due to the division of conceptual labour at play in the current status of institutionalization in the knowledge related activities. The concept of disease, distributed by its usage and in the making is a very important concept in our lives and is studied by different people working in different fields. In this work, the second, more empirical question comes from the concrete example, how the concept of disease is challenged by evolutionary medicine and the new developments in evolutionary biology. The intersection of evolutionary biology 1

The concepts that the scientists employ do not need to be always loaded epistemically and morally in every context, but it seems to be the case most often and the central concept I am dealing with in this work, disease, and the related concepts to it generally are loaded in both of these senses in many contexts.

1.3 Setting of the Problem Agenda for the Concept of Disease

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and medicine itself creates evolutionary medicine, however, the union of evolution and medicine is a very flexible and fluid union due to the richness and diversity of both fields. The difficulty talking about a stable union is also because of the fact that while evolutionary medicine itself is creating a core through solidifying a new discipline, which in turn is supposed to relate itself back to medicine and evolutionary theory as it also develops its own core more solidly as it becomes a discipline on its own right.2 This situation, that evolutionary medicine itself is claiming to become a field forces them to make certain choices that will make them frame evolution and evolutionary theory in a certain way, and while still keeping its own relation to evolutionary theory in general, it is required to be medically relevant. While addressing these issues, the central question of this work, disease, is also being studied by many different perspectives in biology and medical science. In this discussion, I favor an understanding of “evolutionary perspectives” over evolutionary medicine or evolutionary explanations in medicine. However, this does not mean that I do not deal with evolutionary explanations and evolutionary medicine in general; on the contrary, I go through the traditional discussions around evolutionary medicine to make sense of the current debate to understand their influences to the concept of disease. In a sense, the concept of disease has a presence in an old fashion marketplace, which is not only itself constantly in motion, but also the goods and the customers are also shaping and being shaped by it. These perspectives inspired by the “trading zones” framework of Gallison (2010). This work aims to capture a moment in the conceptual change in this context and in the end aims to make sense of the unknown of one discipline by the sense of the other discipline. Like in any conceptual change, capturing the moment is not easy, due to uneven and unequal growth and pace in different communities. Concretely, this means, this work aims to see how to connect the medical unknown with the evolutionary unknown but functional. In this sense, this work is ethically relevant in two folds, it starts with concepts and the centrality of value bearing concepts in human action and it ends, after empirical investigation, the ethical consequences of the possible new understanding of the concept of disease.

1.3 Setting of the Problem Agenda for the Concept of Disease Another problem, as the result of the inquiry adds up to the second aspect I touched upon above. The health-related situations which fall under healthcare in the postindustrial world are increasing rapidly. Of course, this is partly because diagnostics are getting better. However, I argue that it is not the only cause. Although there are more people who are diagnosed properly, and more people have access to healthcare, due to the lack of particular understandings of disease that shape our relationship 2

At the moment, evolutionary medicine is mostly discussed, published on and studied in departments of biology, and particularly evolutionary biology and rarely in medical science.

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to the patients, potential patients and non patients, the categorizing function of the concept of disease plays a crucial role. In a sense, the concept of disease, when it does not reflect the current possibilities of healthcare, the people who can be seen as in need of medical care are—from sometimes to often—are not given the proper healthcare for them. Our concept of disease in the West is a concept that was designed for the kinds of intervention methods that were available to the West in the nineteenth century and early twentieth century. The reason that we had the concept of disease in its current form can be speculated upon. However, from my perspective a main understanding of intervention is key to the understanding of disease. The intervention on the individual in a way that some working of the person goes differently.3 To illustrate the strength of this argument, we can think about the ongoing debates around long covid and the extent of it or look at a recent report. The report by Robert Koch Institute, Health in Germany 2015, notes that “However, many determinants of health lie outside the health sector, for example in the area of educational and labour market policy or urban planning.” The problem in the conceptualization of health lies in the fact that, although health itself is very often discussed in the social and environmental set ups and healthcare policies, public health and similar general understandings, disease is rarely the case. One Health proposal, for example, an approach which is used to extend the understanding of health to a larger domain than the organism such as the environment, animals and environment, has gained general acceptance by many health organizations such as WHO (Zinsstag et al. 2020). The social aspect of healthcare is constructed with a disease concept that is heavily medicalized in the restrictive sense of clinical interventive medicine and is rarely socialized, while health itself is seen as a more social phenomenon. My aim in this work is to socialize and historicize the disease concept by highlighting its relational status with environment by employing the understandings from evolutionary biology by investigating evolutionary medicine and new developments in evolutionary biology. The problematization of this work is mainly on the concept of disease, and unlike the traditional view that sees it very centralized, I aim to show that how it is distributed, following the ongoing debates about the extension of many central themes in philosophy (Morar & Skorburg, 2018). The central idea is thus, based on one understanding of an empirical framework, evolutionary biology, how disease could be socialized. This perspective is influenced by Karl Marx’s understanding of focusing on “unfreedom” instead of freedom to understand the human condition and Miranda Fricker’s understanding of focusing on injustice rather than justice to understand the social state of affairs that cause injustice.

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Whether different from the general population or different from her own pre-diseased make up can be seen differently in many different contexts. I do not claim to answer this question here, however regardless of its origin the usage of the concept has been going towards various directions on.

1.5 The Structure of the Book

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1.4 The Motivation Every work needs some kind of a driving force; mine found its own driving force in the making. There has been immerse criticism of the medicalization of certain kinds of “normal” behaviour and “normal” properties, and it is still actual. Liberating understandings of mental disorders, acceptance of “non-normal” body types and different kinds of behaviour and way of existence, new perspectives on disability that puts heavier emphasis on environmental contexts have been increasing at least since 70 s. I find these developments of course positive, however not enough. This work tries to look at social concerns of medicalization from the other side and it tries to see the suffering of people who have not been diagnosed, whose suffering is not caused by certain element that falls under definitions of disease, disorder, or sickness that is defined by today’s medicine and cannot get medical help, or in case they happen to get help, it is not for them but for a general, idealized model patient. The people who are not eligible for the medical help (the only kind of state or social based help that is available in many countries still), however are still in difficult health related situations that reduce their quality of life due to certain kinds of understandings of disease. What we know in particular is little when it comes to healthcare, what we know of general understanding of disease is certain—in addition, certain perhaps—the question is how to handle the unknown when we accept this epistemic problem. Bernard Williams (1985) famously made the observation that his book was about the observation of ethics and how things are seen from the looking glass of ethics, not how they should be. In the preface of his work, Ethics and Limits of Philosophy he writes “This book is about how things are in moral philosophy, not about how they might be, and since I do not think they are as they should be, some of it consists of criticism of present philosophy” (p. XV) (Williams, 1985). I start this work with a very observational perspective about how ethics is used especially when it comes to thick concepts, as well, reaching a conclusion about how things should be only at the conclusion.

1.5 The Structure of the Book The nature of this work is quite interdisciplinary, but to put it in a domain, it can be said to be metaethical. It is composed of three parts. The first part is more traditionally philosophical, working on meaning theories, concepts, and thick concepts. This work deals with a traditional metaethical theme, thick concepts in the first chapter. In the second chapter, it deals with meaning theories and the relationship between language and practice. While trying to achieve that, the second chapter aims to provide an understanding of how the values are related to scientific research activity. Starting with the perspectives that I have navigated in the second chapter, the third chapter is occupied with meaning change within science with scientifically informed concepts

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and certain perspectives on concepts that will enable conceptual change, seeing the concepts and linguistic activity as a social phenomenon. The second part of the book focuses on practice centered understanding of philosophy of science to give an account of disease within the framework of the first part to understand the conceptual changes that are brought by evolutionary understandings to the concept of disease. Although there have been discussions about the role of evolutionary understandings in medicine as a discipline, there have hardly been any perspectives on the concept of disease will change due to these new developments. On the second part, I start the fourth chapter, which is primarily occupied with the concept of disease and the traditional discussions around the concept of disease. The fifth chapter introduces evolutionary medicine and evolutionary perspectives on the phenomenon of disease, analyzing the relationship between the phenomenon of disease being seen from evolutionary perspectives. The sixth chapter deals with the application of new evolutionary developments to medicine, trying to make the disease vulnerability perspective more useful for a larger epistemic framework. The third part, conclusion, looks for an ethical result of the empirical investigation and conceptual analysis that have been put to work throughout the work. The main claim is, if the considerations—conceptual and empirical—are put to work in understanding the phenomenon of disease within the informed concept of disease, we need to have a different relationship to the healthcare which is individualized in order to stop certain kinds of epistemic injustices that are taking place in the healthcare system as it is conceived in most post-industrial countries at least.

1.6 Dealing with Concepts of Scientific Research Scientists deal with concepts very often. Although the practical aspect of their research can be seen separately from the conceptual aspect in certain cases, more often than not, we expect scientists to tell us about the “true” meaning of a concept implicitly. One rather naïve realist position—the position that takes reality of the entities on its face value—is to say that, it is that scientists will find what a GENE, DISEASE, MATTER, HEALTH is, and based on their research we can settle the concept, since it is a matter of empirical investigation. After all, we know that WATER is H2O and this is due to the efforts of chemists who have been analyzing water. This way, after years of tedious research the scientists could fix the extension of the concept, and now whenever we are in doubt, we can do empirical investigation to determine whether what we have is water. We rearrange the phenomena we have in life in a way that reflects the correct nature of water, which was found by the scientists, and when we see that the concept is used to refer to something that is not the correct extension of it, we say that that proposition is false.

1.7 Going to the Central Question; Disease

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Another, rather idealist4 position holds that, what the scientists are doing has nothing to do with the change in the meaning of concepts. Of course, they might be going to laboratories to do research on certain phenomena, yet these phenomena are detached from the concepts that we employ. However, this shall not make us think that what they are doing has to do with changing or even employing concepts. From this perspective, it can be said that the concepts we have, and use are different kind of entities that exist not in empirical inquiries but somewhere else.5 If we hold this view, the concepts we deal with can only be “found” or “discovered” and can be analyzed by rationality perhaps in order to make new concepts or find the true application of concept. The mathematicians dealing with the concepts, such as numbers do not think that the concept of number three requires re-evaluation after it is “tested” by the state of affairs in the world. The concepts they have, and employ are by definition separated from the “empirical”. I believe that both positions are applicable to a limited number of cases for only certain amounts of time and under certain circumstances, and they only depict a very limited case of conceptual change and the usage of concepts. Of course, these are the extreme/ideal positions of the debate and they do not reflect the state of the research when it comes to more intricate concepts, concepts such as disease.

1.7 Going to the Central Question; Disease It is clear that the concept of disease is exceedingly difficult to define (Cooper, 2020). The efforts that have been put to demarcate a general concept of disease have already acknowledged the difficulty of finding a single definition for the concept of disease. Although being that central to many social and scientific issues in our lives, the concept of disease being very open to be interpreted could mean two things. First, without the need to define disease, we can understand how it functions. This is the point raised by the shaplessness hypothesis when it comes to evaluative concepts by McDowell (1998).6 I will go more into detail of that in the coming chapter about the shapelessness hypothesis, but in principle, the main idea is the impossibility of defining the concepts which are both normative and evaluative in a single understanding. On top of that, medical knowledge and evolutionary knowledge are different kinds of knowledges. Due to their differences in purpose of knowing, ways of knowing and the result of knowing, although they do intersect, it is a difficult task to integrate them. 4

The idealism I mention here can vary from Platonic idealism where concepts are seen very real entities to kinds of nominalism where the concepts themselves becomes redundant since they are equated with terms or words. 5 Of course there are many different positions about where this somewhere else is, be it in some Platonic ideal world of forms, a priori knowledge, in the social domain, amongst agents. 6 McDowell’s previous discussions about the rule following aspect of evaluative concepts can be seen also in; McDowell (1979), (1981), (1987). I will not explain the argument and the discussions around it here, it will be discussed more in detail in the first chapter.

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This disunity of science, becoming rather prevalent in late 90 s raised the question of how to integrate different perspectives on the same topic (Galison & Stump eds., 1996). In this example, disease, as a concept to be seen from both medical and evolutionary perspectives, presents a difficult situation.

1.8 Caveat for a Conclusion My aim in this book is to sketch a new concept of disease, not to define it, or in short, try to point to a new location to look for when it comes to operationalizing the concepts of disease. In that regard, I aim to follow the Marxist critique of idealism. I do not claim that this approach is unique or novel, however a certain guideline to see the concept of disease, and see the ideality of the current concept. Hegel makes the predicates, the objects, autonomous, but he does this by separating them from their real autonomy, viz., their subject. The real subject subsequently appears as a result, whereas the correct approach would be to start with the real subject and then consider its objectification. The mystical substance therefore becomes the real subject, while the actual subject appears as something else, namely as moment of the mystical substance. Because Hegel starts not with an actual existent (hypokeimenon, subject) but with predicates of universal determination, and because a vehicle of these determinations must exist, the mystical Idea becomes that vehicle (EW, 80; Colletti’s Introduction, 20).

Following this dictum; like we look at concrete unfree to construct a concept of freedom, look at concrete injustice to create a concept of justice, let us look at concrete disease instances and their structuring from the individual, autonomous patients to build a concept of health. In this work, I claim that evolutionary understandings in medicine (1) Can be helpful in some cases in explaining certain diseases for the purpose of intervention. (1a)

These explanations can be clinically relevant enough to help medical intervention in certain kinds of diseases (1b) Even if they are not clinically relevant, these explanations can be helpful for patients and clinicians for other purposes, purposes such as making sense of the disease, or the feeling of relief from responsibility in the case of disease. (2) Evolutionary perspectives do not only provide explanations in the narrow sense of explanation for the clinic in the interventionist sense, but they can provide changes in the concept of disease so that the domains that use the concept, medical research, public health, structure of medical understanding of the society, can have shifts. The changing perspectives in conceptualization of disease can lead to different research programmes or different methods of intervention or non-intervention to the phenomena that are traditionally seen in the domain of clinical intervention.

References

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(3) If the conceptual changes in 2) are followed, we are supposed to change certain perspectives on healthcare to stop epistemic injustices that are manifested in the medical institutionalization, eventually causing people who are suffering not to get any kind of help from the medical field.

References Cooper, I. R. (2020). The concept of disorder revisited: Robustly value-laden despite change. Aristotelian Society Supplementary, 94(1), 141–161. https://doi.org/10.1093/arisup/akaa010 Galison, P. (2010). Trading with the enemy. In M. E. Gorman (Ed.) Trading zones and interactional expertise: Creating new kinds of collaboration. MIT Press, Cambridge MA. Galison, P., & Stump, D. J. (Eds.). (1996). Writing science. The disunity of science: Boundaries, contexts, and power. Stanford University Press. McDowell, J. H. (1979). Virtue and reason. The Monist, 62(3), 331–350. https://doi.org/10.5840/ monist197962319 McDowell, J. H. (1981). Non-cognitivism and rule-following. In S. Holtzman & C. Leich (Eds.), Wittgenstein: To follow a rule (pp. 141–162). Routledge. McDowell, J. H. (1987). Projection and truth in ethics. Lindley Lecture, University of Kansas. Reprinted in McDowell (1998). McDowell, J. H. (1998). Mind, value, and reality. Harvard University Press. Morar, N., & Skorburg, J. A. (2018). Bioethics and the hypothesis of extended health. Kennedy Institute of Ethics Journal, 28(3), 341–376. https://doi.org/10.1353/ken.2018.0020 Williams, B. (1985). Ethics and the limits of philosophy. Fontana. Collins, London. Zinsstag, J., Schelling, E., Crump, L., Whittaker, M., & Stephen, C. (Eds.) (2020). One Health: The theory and practice of integrated health approaches. CABI. https://doi.org/10.1079/978178924 2577.0000.

Chapter 2

Finding Value in Concepts

Abstract Scientists use some concepts that are socially and ethically highly relevant in their research and other kinds of scientific activities. Some of these concepts determine many things in the social domain. How these concepts are related to their practical activity, and what to make of their usage of concepts is an ongoing question, which was made explicit already (Hacking, 1975). Philosophy of science, as well as “meta science” have been dealing with the relationship of scientists to the concepts not very much, preferring to deal with the concepts themselves only. Although within philosophy of science, the “philosophy of science in practice” perspective has put forward attempts to deal with that, and at earlier accounts of Frankfurt School already as well as Science and Technology Studies, there have been perspectives to restore or restructure the relationships between public and scientists, there has not been comprehensive accounts of such study of concepts and their interrelations within the scientific activities. In this regard, the connection between the “normative” elements of concepts and their “descriptive” counterparts have been institutionalized by large, at least within philosophy by separate structures. The aim of this chapter is to introduce the general understanding of “thick concepts”, the concepts that have both descriptive and evaluative properties to start the analysis of both philosophy of science in practice, and ethics of science coordinatively.

Tritt vor: Wir hören Daß du ein guter Mann bist. Du bist nicht käuflich, aber der Blitz Der ins Haus einschlägt ist auch Nicht käuflich. Was du einmal gesagt hast, dabei bleibst du. Was hast du gesagt? Du bist ehrlich, du sagst deine Meinung. Welche Meinung? Du bist tapfer. Gegen wen?

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_2

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Du bist weise. Für wen? Du siehst nicht auf deinen Vorteil. Auf wessen denn? Du bist ein guter Freund. Auch gute Leute? So höre: Wir wissen Du bist unser Feind. Deshalb wollen wir dich Jetzt an eine Wand stellen. Aber in Anbetracht deiner Verdienste Und guten Eigenschaften An eine gute Wand und dich erschießen mit Guten Kugeln guter Gewehre und dich begraben mit Einer guten Schaufel in guter Erde. Bertolt Brecht “Verhör des Guten“ in Me-ti/Buch der Wendungen (Gesammelte Werke 12, pp. 462–463) Step forward: we hear That you are a good man. You cannot be bought, but the lightning Which strikes the house, also Cannot be bought. You hold to what you said. But what did you say? You are honest, you say your opinion. Which opinion? You are brave. Against whom? You are wise. For whom? You do not consider personal advantages. Whose advantages do you consider then? You are a good friend Are you also a good friend of the good people? Hear us then: we know You are our enemy. This is why we shall Now put you in front of a wall. But in consideration of your merits and good qualities We shall put you in front of a good wall and shoot you With a good bullet from a good gun and bury you With a good shovel in the good earth.

2.1 Introduction

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Interrogation of the good (Brecht, 1935)

2.1 Introduction Scientists use some concepts that are socially and ethically highly relevant in their research and other kinds of scientific activities. Some of these concepts determine many things in the social domain. How these concepts are related to their practical activity, and what to make of their usage of concepts is an open question, which was made explicit already (Hacking, 1975). Philosophy of science, as well as “meta science” have been dealing with the relationship of scientists to the concepts not very much, preferring to deal with the concepts themselves. Although within philosophy of science, the “philosophy of science in practice” perspective has put forward attempts to deal with that, and at earlier accounts of Frankfurt School already as well as Science and Technology Studies, there have been perspectives to restore or restructure the relationships between public and scientists, there has not been comprehensive accounts of such study of concepts and their interrelations within the scientific activities. In this regard, the connection between the “normative” elements of concepts and their “descriptive” counterparts have been institutionalized, at least within philosophy by separate structures. The aim of this chapter is to introduce a general understanding of “thick concepts”, the concepts that have both descriptive and evaluative properties to start the analysis of both philosophy of science in practice, and ethics of science coordinatively. After the introduction, I will engage in the discussions about the significance and use of thick concepts following the literature of thick concepts. Following these discussions, I will position myself in a meta ethical understanding in which I will claim that the use and meaning of thick concepts can be conceived differently through different understandings of meta ethics without picking a side, carrying the debate to the social aspect of the use of the concepts. The pluralist meta ethical understanding I will use will be helpful not in trying to figure out the exact meaning or use of thick concepts, yet it will be helpful about advocating the multiplicity of use of different kinds of thick concepts in various contexts.

2.1.1 Significance of Thick Concepts Concepts are very central to our communication, understanding and action. Not only everyday concepts, but also concepts that are used by scientists, policy makers and researchers are considered fundamentally important when it comes to evaluating certain kinds of actions and creating grounds for action. Scientists and clinicians technically evaluate a state of affairs, and decide whether a person can be considered diseased or healthy, and depending on such conceptual definitions, the way that person will be treated changes radically in certain contexts such as legal, social and

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political decision making bodies. For example a person with a certain kind of disease like Alzheimer’s disease, is taken to be exempt from certain kinds of decision making, for example about their wills. Under certain conditions, people with schizophrenia are not found legally liable for their criminal activities. In the case of Lois Althusser, the famous philosopher murdered his wife, Hélène Rytman in a case where the legal bodies ruled that—after poor investigation—he did the action “under the influence of his mental condition”. Moreover, the action guiding characteristic of concepts are already at work even— or particularly—when the users of these concepts are not reflecting on them. When it comes to distinguishing between the concepts that create reasons for action, one important debate within meta ethics is the discussions around thick concepts. For the sake of demonstration, let us consider these two sentences. The sentences, “Johannes is good” and “Johannes is just” are obviously different sentences morally. In the first one, we understand that Johannes is being evaluated by his moral properties1 —thus, becoming an object of moral philosophy—and this evaluation is done positively while in this sentence we have no clue what makes Johannes good. Is it his friendliness, generosity, fairness, boldness or courage? The answer can be all or none of them and there is no way to understand it from this sentence alone. The second sentence on the other hand, while evaluating Johannes positively, also gives us an understanding of a quality that describes him and makes him good in a certain way. Whereas the first description is considered only “evaluative”, the second description is both “evaluative” and “descriptive”. Evaluative, in this context refers to the role of the concept in seeing it from an ethical standpoint, while the descriptive is the negation of the first one, meaning that the concept does nothing to evaluate and only describes a certain state of affairs. The second sentence, in this regard, seems to contain the meaning of the first one as well, while adding a descriptive aspect to the meaning. Let us consider another kind of sentence as a control group, let us consider this one; “Johannes is short”. In this third sentence, he is only being described without any evaluative quality thus being only “descriptive”. Does ethics deal with concepts such as these—courageous, fair, and brilliant; or can it only talk about manifest ethical concepts such as good and bad is a critical question in meta-ethics due to the nature of the question demarcates the possible limitations of the domain of ethics and due the results following this distinction. The main question is, can the ethical concepts pick certain things in the world, and if so, they can be investigated ethically. Spearheaded by Williams, this distinction started to make its place in moral philosophy since 1985 when he published his book Ethics and the Limits of Philosophy (Williams 1985). Since then, the distinction between thin and thick concepts and terms began being used by not only moral philosophy, but also some other philosophers who work on aesthetics and epistemology (Kyle, 2013). For the defenders of the significance and use of thick concepts within moral 1

Although thick concepts debate is not limited to the domain of moral philosophy, it is often discussed within this context. For comparison, consider an aesthetical thick concepts such as GEORGEOUS. And of course, the concept of GOOD itself is rather demanding to give the full explanation for.

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philosophy, the concepts that are employed in the moral philosophy are generally considered to fall under these two distinct categories: thin and thick.2 Here, good in “Johannes is good” is considered to be a thin concept and the kind in “Johannes is kind” is considered to be a thick concept. Their particular interesting aspect comes from their double nature. Williams (1985, p. 140) describes the application of thick concepts as “action guiding” and “guided by the world”. Since their application depends on how the world is, and their usage guides action, whereas, he defines thin concepts only as action guiding. In this context, what is meant by purely action guiding is a concept such as GOOD, which evaluates actions, events and persons, but does not gave any element within it that makes it guided by the world. Purely guided by the world concepts on the other hand, enable us to see certain things but they have no effect while guiding our action, such as CHAIR. Following the general introduction, I will briefly introduce the proposed division between thin and thick concepts and the general suppositions that lead us to make this distinction in philosophy. My main concern is to understand the distinction in order to provide a better scheme on the meta-ethical level since I do not aim to have a general understanding at the meta ethical level about the nature of ethical concepts, but to have an understanding about how they are used. I find this important since my main aim in this work is not to provide a general analysis of thick concepts, but to understand how they are related to conceptual change in the coming chapters. I start with the importance of the distinction and then the attempts in explicating the general discussions that spiral around this division, and then, moving on to discuss the attempts to reduce the meaning of the thick terms and with the possibility of “disentanglement”, finally defending a pragmatic position in terms of meaning, which I believe to be the initial case where Williams (1985) used it in the very first place. Eventually, I will try to establish a position to accommodate the meaning change in thick concepts in science that I will use later.

2

Although I believe that the very essence of Williams’ (1985) objection to the usage of only thin concepts in ethics is in the same spirit with furthering the applicability of ethical concepts to a richer field through further meta-ethical and epistemological investigation of the issue. In addition to that, Williams’ ethical and meta- ethical objection and pursuit shall be carried out simultaneously. Receiving Williams’ objection only at the face value and not seeing it as a general approach towards philosophy will lead this division to a pseudo dualistic position quite contrary to the main spirit of Williams’ is a way of pursuing the nature of ethical concepts is resurrecting the “only evaluative” method at least in form. This would leave certain very important aspects and methods that can be employed to contribute to the subject. Regarding this topic, I believe that my position is similar to that of Kirchin (2017). Due to the formal structure of the contemporary debates, I will operationally use it as it is generally referred to in the literature.

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2.2 Evaluative and Descriptive, Why the Distinction is Hard to Grasp and Its Prevalence Purely descriptive concepts3 are generally considered to be straightforward concepts and are easy to understand and they constitute many concepts that are used in daily life and research alike. Descriptive concepts4 such as SQUARE, BOOK and PLANT, although having different definitions by different linguistic communities, still are purely descriptive in the sense that they define certain set of properties and these properties, when applied to the world, find their objects, resulting in these objects being a member of the group defined by the limitations drawn by the extension of the concept. Quite intuitively, a person can say that the concept of SQUARE does not have any evaluative component, meaning that the concept by itself is not in the moral domain. It describes certain conditions that are applicable to the objects in the world, and nothing else. On the other hand, concepts such as GOOD, WRONG or OUGHT express certain evaluations and are central to many discussions in ethics. In the traditional understanding of thick concepts, ethical concepts, this way, do not define the characteristics of any entity, but puts it simply in the moral domain.5 When the sentence “Murder is wrong”, is uttered, we do not learn anything new about the descriptive properties of murder, we simply learn that it is ethically non-permissible.6 However, why does this distinction matter in the very first place? Most people use evaluative concepts in their daily life quite frequently in the form of thick concepts and because of this reason, for them, it is quite normal for a concept to be both evaluative and descriptive, without the knowledge of the significance of such a distinction in philosophy. In most peoples’ daily lives, discussions about morality are generally about the extension or application of thick concepts. It is commonplace to argue that an act counts as LOYAL or a person is DECIETFUL while the question whether being loyal is good or bad is rarely asked. The general question about the nature of morality when it comes to meta ethical discussions in the form of “what is good and what is evil?” are not parts of daily conversations, and research institutions. On the 3

There has been a controversy about using the words terms or concepts as the best way of handling “the thick”. It seems as if there is a fundamental distinction between the two approaches. While the usage of “terms” is pushing the debate to a linguistic level in order to leave a nonlinguistic dimension to which ethical understanding still applies by the method of Väyrynen (2013). On the other hand, the focus on “concepts” meaning roughly a more general perception of the issue and handling of it in a more “indistinguishable from language” way as Kirchin (2017) does. I believe that while there is a distinction between the two approaches, this does not result in an unresolvable tension. 4 On my part, I will use capitalized letters to indicate concepts, and I take them to be more general notions which can also have relationship to nonlinguistic elements, and brackets to indicate more elucidated elements which are reserved to the language. 5 Although as it can already be seen, OUGHT and GOOD are not the same things. 6 Although we do not learn anything new about murder, we learn something descriptively new about the person who uttered the sentence bearing in mind theories of communicative action, however I do not want to go into the debates around the information conveyed in speech acts here about the speaker and addressee, I would like to thank Dr. Simon Derpmann for pointing this out.

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contrary, for some moral philosophers—mostly philosophers who develop embracing ethical system theories—as Williams criticizes (1985), morality is merely about what is GOOD and BAD.7 The grounding of the ethical is also seen as one of the most important issues in meta ethics, while the analysis of the ethical domain and the limits of the domain of ethical are not that central to the discussions within meta ethics. Therefore, the very occurrence of thick concepts and the distinction between thin and thick might be a little difficult to grasp for both parties; moral system theorists who would like to ground ethics in the first place, and people without ethical expertise who are more interested in the application of the ethical concepts, searching for instances of the particular concept alike, for their different purposes of ir- relationship to thick concepts. This is why thick concepts are working as a new domain in which moral philosophy, philosophy of language and pragmatics intersect. Although, the obvious difficulty is to say that moral philosophy deals with the “pure” ethical concepts, GOOD and BAD, leaving the possibility of discussing metaethical aspects outside in this framework. In short, thick and thin concepts derive their significance partly because they look as if they are—because they are in the conceptual and linguistic level—shared by people who are dealing with many different aspects of ethics, from its foundation to application. Based on this understanding, they are also seen as an objection to the fact value distinction, a distinction that is perhaps the most central topic of analytical moral philosophy. At the same time, for the same reason, it is also difficult to start discussing thin and thick concepts because their occurrence and significance are directly related to more general discussions in ethics, since they sit on one of the most heated fault lines of meta-ethics. Now let us turn to the elements that make this distinction important in order to understand the debate better. One of main positions is to assert the fact -value distinction and then make descriptive and evaluative elements of the concepts split into one or the other direction.

2.2.1 Hume’s Guillotine, Naturalistic Fallacy and Non-cognitivists It is possible to see ethics restricted to a smaller domain, through a limitation of ethical concepts only to GOOD and BAD, and the instances within the world falling under certain kinds of goods and bads, while leaving the analysis of the situations themselves always descriptive, by taking this approach to look for objectivity in the descriptive domain via science, conceptual analysis, reflection etc. The ethical analysis itself, being separated from the events that are happening, leaves the supposedly subjective8 ethics outside our inquiries in our daily lives, research and other similar 7

Of course, there are many moral philosophers who deal with particular concepts and what kind of events and properties they pick from the world as well. 8 From the perspective of more science minded understanding of the possibility of the distinction between “the ethical” and “non-ethical”.

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pursuits where we claim for “objective knowledge”. For this reason, distinguishing between fact and value becomes crucial at the conceptual level. The claim that there is no way to derive values from facts, and the question how the evaluative is related to the descriptive becomes pressing in many situations, particularly when scientists are using concepts that are important in the social sphere. In the non-cognitivist tradition, this issue becomes particularly severe. There certainly are differences of attitude towards the subject within the tradition, however in the most general sense; the central claims of non-cognitivists are (van Roojen, 2016): (a) Moral propositions are not truth apt since they do not describe the world in a way that can be expressed in a proposition which will be a candidate of truth and falsity of the belief, thus the moral propositions do not show us “how the world is like”.9 (b) After the claim a, there has been a position which claimed that the moral truth is not “out there” in the world, but in the mental states of the individuals. The third claim is the denial of this position, instead, saying that the moral states of the mind also fall into the non-cognitivist domain, hence having no truth aptness either. A non-cognitivist needn’t hold both claims at once and can hold one in degree in various ways. The central point here is how thick concepts create a challenge for non-cognitivists.10 Given that thick concepts describe and evaluate at the same time, accepting their significance creates a troubling environment for the non-cognitivists. The descriptive part of a thick concept describes the world in a way or various ways and by the merit of it, becomes eligible for truth or falsehood, while retaining its evaluative property, thus becoming concepts that are also morally relevant. Moreover, since non-cognitivists argue against the truth aptness of moral claims, morality being embedded in so to speak “testable” propositions via these concepts become a challenge that they need to overcome. Certain methods have been developed to overcome this problem by non-cognitivists, yet of course, the discussions are not only done by non-cognitivists but are due to general philosophical interest as well. I will discuss it further in the disentanglement and shapelessness part below. For the time being, let us continue with the root cause of the problem for non-cognitivists, the fact/value distinction, is-ought problem or Hume’s Guillotine, since the main issue is whether the concepts in ethics that we employ have to do with picking correct instances from the world or not.11 The tradition is very entrenched in philosophy. The same issue after Hume’s 9

This claim can be seen in its strongest in Ayers’s emotivism. (Ayer, 1952). As Väyrynen (2013) points out, separationists (those who claim that the descriptive and evaluative aspects of the concepts can be separated) do not need to be non-cognitivists—although often they are so, and the aim of the discussion here is not to introduce separability but to make the case for non-cognitivists to clarify the distinction since they create the biggest challenge to truth aptness. 11 There could also be a distinction between what kind of entities can be considered as thick concepts. Are they virtues, human actions such as kindness or people themselves. I think there are differences when it comes to evaluate these different things. However, for my purpose, seeing action guiding 10

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own time was addressed by Moore. Moore’s Principia Ethica (1959) [1903] also deals with this issue on the basis that ethics should give more attention to definitions, and whoever tried to define GOOD was doomed with naturalistic fallacy, since these ethical concepts should not be based on natural facts. In the crudest sense, Hume’s law (1739–1749), asserts that no ought statement can be derived from an is statement, therefore, the moral based on purely non moral premises are morally sterile. It is not possible to reach moral conclusions from them.12 The more relevant interpretation of the topic is in the discussion between Foot (1958) and Hare (1963). Foot (1958) claims13 that thick terms bridge the is-ought gap by providing sufficient properties to be in the both sides of thick-thin dichotomy. Her example on this topic is “rude” and she advocates that; the proposition O, which indicates that a certain offence is done by being disrespectful, and R, the rude behavior, have a certain, established connection. For her, any account of the concept of rudeness already includes a reference to offence. She claims, if one accepts O, then it is impossible for him to reject R, thereby an evaluative claim can be derived from a seemingly non-evaluative claim.14 From this perspective, it becomes possible to claim that some actions can only be described evaluatively. If this holds true, the idea to divide between how we categorize and conceptualize certain actions and how we evaluate them is very dependent on the value concepts we use. A simple objection to this line of thought is context based choice of thick terms. The thick terms are not universally accepted, as she already admits on her work and in different situations, being rude—albeit a little—might be the appropriate course of action under certain circumstances. The claim that thick concepts are not universally evaluative is particularly sharpened by Hare (1963). He argues against Foot about this issue. He holds that, if her general argumentative structure was to be correct, even racial slurs would fulfill the criterion. Given that we define someone as a “Kraut”,15 a racial slur against Germans, and know that “being a Kraut” is being German, although we do not appropriate the evaluative content that is embedded in aspect more important than evaluative, I do not think that there is a problem with analysing all of them together. For the pure analysis of evaluative, I think there can be differences between these. 12 There has been strong criticism against such direct interpretations of Hume’s law, claiming that Hume himself also does what Hume’s law forbids, and about the possibility of overcoming such strong barriers, I see it sufficient to note that for me, the distinction between fact and value is not as sharp as certain non-cognitivists such as Hare (1963) claim. 13 Since “thick concept” was not coined while she was writing this, she instead uses “evaluative” for concepts that were not considered to have evaluative properties traditionally by the ethicists, such as “rude”. 14 Although she creates the argument from the conclusion as she already claims that “rude” is evaluative, this is more of a reconstruction of her argument within the thin-thick dichotomy. 15 Note that one of the favorite examples of separationists is “Kraut”, simply because it was considered to be negatively evaluative during WW 1, and lost its evaluative aspect ever since. However, this can be argued against any kind of “racial slur” or “insult”, since it is practically impossible to point out a group of people—because of race, religion, gender, sexual orientation, etc.—and to expect from everyone, particularly the members of the group themselves to agree on the negative evaluation of the concept.

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Kraut, we nonetheless understand that being a Kraut is being German. The result being, although the relationship between the descriptive concept and the so called evaluative concept is known, the provider of the relationship does not guarantee that the relationship produces an evaluative result. There have been different maneuvers to solve this problem such as classifying racial slurs out of the group of thick concepts, eventually analyzing thick concepts without referring to the racial slurs (Väyrynen, 2013, Chap. 1). However, I believe that it demonstrates a certain edge of the application of thick terms and I do believe that they help us to perceive the overall picture better. The problem is about the possibility of seeing the social world of actions in a frozen, objective way which is ready for analysis and then analyzing them in the ethical domain or the inability to do so. Now that the problem is made more explicit, I will turn to the dynamics of the problem and attempts to solve it from different sides of the debate. As described by Kirchin (2010), specific positions within noncognitivism such as that of Blackburn (1984), where there are possibility of sorting evaluative concepts differently with respect to non evaluative parts so that the evaluative aspects are still held together with the aid of the nonevaluative part. However this is a relatively niche position within noncognitivists, and for my purpose here, it is not the main objection I do need to answer to since I do not aim to provide an argument against any form of noncognitivism. While explaining the importance of thick concepts, Blackburn (2010), goes back to Hume’s An Enquiry Concerning the Principles of Morals (1998) to provide that Hume has mentioned certain positive concepts such as industry, prudence etc. as concepts “whose very names force an avowal of their merit” (Hume, 1998: 126). Although Blackburn (2010) does not see thick concepts debate of importance since he does not think that they carry a particular significance in ethics (at least at the level that they claim to occupy), I think it is still possible to answer Hume. Hume does not give his own critique as a moral actor so that his own position and value system can be subjected to meta ethical investigation, particularly by philosophy of language of today since it was not a tool of philosophy of his day. Hume gives his own account not as a philosopher in the sense that he is supposed to give the critique of the concepts he employs, but as a person manifesting the virtues he holds important in this work. If we accept the social character of the concepts we use from an anthropological perspective.16

16

I use anthropology here not as the scientific discipline, but in line with Michael Quante’s (2018) Pragmatistic Anthropology project, where the social aspects of concepts are to be seen very much related to the concepts we employ dependent on our form of human existence.

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2.2.2 Disentanglement of the Thick Understanding the difference between the evaluative and descriptive characters of thick terms is quite intuitive once the “purely evaluative” is distinguished.17 Since the application of thick concepts is descriptively bounded, such as being SMART is not only about being GOOD, but also being good in a certain way, the descriptive content comes under investigation. After the intuitive contrast is clarified, one attempt was to reconstruct the thick terms and concepts in a way that they will no longer be thick, replacing seemingly evaluative and descriptive concept with a purely descriptive concept, similar to the strategy that was pursued by Hare (1963) on his ethnic slur examples. This project is important, since if it is possible to claim that these concepts can be replaced by the descriptive ones, we can claim that they are “value free”. Another possibility is the separation of the two aspects of the term and concept. If it were the case that all of the evaluative content from the “so-called thick concepts” can be separated, it would be possible not to change our general framework or the set of concepts we use in ethics. Furthermore, as Crooms (2010) describes, their central aim of non-cognitivists is to articulate, “the world as it is independent of our experience”. These two different strategies are related; however, they can be independently supported. The view that claims that thick concepts can be completely replaced by purely descriptive concepts is the Strong Reductive View, while the view, which claims that they can be merely separated without elimination, is called Weak Reductive View. Against the position that supports in principle separation of descriptive and evaluative aspects of the concept, McDowell (1981) pursues what is called “antidisentangling argument”. The argument tests the possibility of replacing the thick concept with a purely descriptive one by the means of applicability of the descriptive part of such a thick concept without losing any meaning, use or function. To test the possibility of such a replacement, he imagines an “outsider” in a community that is foreign to her.18 The outsider is like an anthropologist who studies the community, in order to be component enough to apply their concepts. The community itself is considered to be morally homogenous, meaning that everyone in the community shares the same set of beliefs and there is agreement in the application of the concepts amongst its members. The outsider observes the community and tries to grasp their evaluative perspective that is associated with a certain thick concept. He claims, without grasping the evaluative perspective, it is not possible for the outsider to understand the rules that apply to the thick concept and therefore, the outsider,

17

Although this has never been the primary aim of most moral philosophers, since it is generally taken for granted that morality is about thin evaluative concepts, and moral philosophers are quite adept at applying these concepts in various circumstances, particularly in ethical systems. I believe that this is exactly what Williams (1985) criticizes in the very first place. 18 As Kirchin (2010) notes, in order to discuss the shapelessness hypothesis, we need to accept that the “concept use is consistent across individuals in different times and if need be, across communities”.

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without the same moral perspective, cannot completely conceive the complete extension of the concept. The outsider might see individual instances of application, but the rule following structure of the concept is derived from the evaluative aspects of the concept. Without grasping the evaluative position, what she does is merely collecting examples, not including the ground that makes all these examples be the instances of the same concept. This results in inability to apply the concept in the new situations and cases as long as they are not identical to the ones she already observed. The argument is called as “disentanglement argument”19 by McDowell.20 These are very strongly related to Wittgensteinian rule following idea. The main idea about disentanglement argument is that, the surrogate of rule following is the evaluative element. To exemplify in a less evaluative way in rule following, consider the game of chess. Since the rules are set in the game, we can agree that the community of chess players is a very homogeneous community. Only the ones who know the rules can play it. Moreover, let us also consider that they are from the same school of chess, making them strategically, therefore somehow evaluatively21 homogeneous. If an outsider who doesn’t have any knowledge of chess, enters a chess club of which members are only followers of Soviet chess school, and watches the games of chess, where the audience called the good moves in the game as SMART, how likely is it for the outsider to grasp the concept without holding its evaluative aspect? If the outsider tries to group the moves that are considered to be SMART falsely, he needs to understand that the other categorization is false. For example, if he mistakenly thinks that all SMART moves are Queen’s moves, because all the SMART moves accidentally involved the Queen, how can he know that he is wrong? Probably by seeing the moves that are considered SMART that do not involve movement of the Queen. However, this still invokes the question, how does this inquiry end? Can’t he simply add the new moves token by token to his vocabulary, and even apply them correctly when he plays the game himself? Since McDowell presented this argument before the introduction of thick concepts and terms and them becoming a central topic in philosophy by the initiative of Williams (1985), it is instead aimed against non-cognitivism, and therefore it does not clearly take a position on thick concepts. The operation or maneuver of disentanglement in the case of thick concepts and terms is made clearer once seperability is introduced. Since given that our community observed by the outsider does not 19

The argument is used as disentanglement and anti-disentanglement argument at the same time within the literature, this is due to McDowell’s (1981) usage of the impossibility of disentanglement on his own behalf. Although he describes a situation of disentanglement, he also claims within that argument that this thought experiment fails, making the conclusion he reaches an”anti-disentanglement argument”. 20 There has been criticism against his conclusion, notably by Hare (1997) on the basis that the outsider can understand the rule of application of the concept by observing and reflecting on the previous examples. However, I believe that this objection is not a knock out argument against the disentanglement argument since disentanglement argument itself does not put forward the impossibility of grasping the evaluative content but only asserts the requirement of knowing the evaluative aspect in order to apply it correctly. 21 When the concept of evaluative is taken to be “guided by the world”.

2.3 The Thin and the Rest

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(or at least might not) have the direct purely descriptively (given that it is possible) equivalent of the thick that they have been using. In order to support this outcome, the concept of Descriptive Equivalence is postulated. It simply means that, in principle there is a purely descriptive concept that can be constructed (or it is already in the vocabulary) that is intelligible and has the same extension with the thick concept it corresponds to. Given that descriptive equivalence is true, descriptive and evaluative parts of the thick concept is separable, if not, they are inseparable (Väyrynen 2013, p. 12). The weak reductive view depends on the validity of separability, and separability is dependent on descriptive equivalence in the simplest sense. Therefore, the central point of this part of the debate concentrates on the possibility of descriptive equivalence.22 To this point, I made the general outlay of the debates on thick concepts understandable by sketching the general notions and their relationships to the debate. Of course, there are other aspects of thick concepts about their applicability, whether all of them are of the same nature or not, whether they differ in degree or kind, or how their descriptive and evaluative properties are related. In addition, although I have also referred to controversies in the debate from time to time, it was generally obvious which route I took—particularly on the example of non-cognitivist objections to further evaluate the significance of the thick concepts. I believe that this is important since it must be noted that the scientists, as they use the concept of DISEASE, are involved in a morally significant issue. Within this framework, meaning of thin concepts and their relationships to their usages can be the first thing to be investigated.

2.3 The Thin and the Rest I have mentioned the disentanglement argument above, and although it has been controversial to an extent and even though I am unsure about its applicability and convenience, in this part I will discuss the relationship between the thin element of the thick concept and whatever left out of the thin, as the “rest”, looking for the possibility of meaning equivalence.

22

Kirchin (2017) claims that descriptive equivalence is not necessary to discuss separability, and although I am sympathetical to this view, and understand him on the basis that within his framework, reference to descriptive equivalence is not important in order to challenge Väyrynen’s (2013) perspective, I believe that it is more useful to follow Väyrynen’s classification, that is usage of descriptive equivalence because Väyrynen’s account questions the possibility of reconstruction of the concept following the rules that created to meaning, which is better suited to observe a pragmatic conception.

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2.3.1 The Thin and Against the Dichotomy Kirchin (2017) proposes something quite novel to the general debate, namely the analysis of the thin. He claims that not every evaluative concept has the same meaning in the sense that they have differing evaluative strengths, although they all can be evaluative in the same direction, for example, positive. The understanding that the already existing thick concepts should be reduced and forced to fit in this GOOD or BAD dichotomy faces a central objection from this perspective that claims that the thin concepts themselves can be different—at least in degree—from each other. Perhaps because many moral philosophers tend to take typical thin concepts as staple tools in their inventory unchallenged or perhaps because it is more practical to enter the debate this way without everything on the move at once, this has been the general predicament of the debate around thick concepts. Kirchin (2017) notes that; Writers normally introduce thin concepts and talk of GOOD and BAD, RIGHT and WRONG, and then move quickly onto the whole run of thick concepts. It also often happens that these thin concepts are described as being evaluative only, and the thick ones are thought to be both evaluative and descriptive. But all of this is simply too quick. Compare two of our thin concepts, GOOD and RIGHT. That these concepts are different concepts is surely unarguable. For a start, philosophical and other writers normally namecheck both of them rather than use one to stand for the other. And, second, they do so because the vast majority of writers and ordinary people think there is a difference, even if, in the end, some theorists might argue that the two come together in an interesting way. The whole of modern normative ethics—and much of our everyday thought that it is supposed to reflect—makes no sense unless we assume, at least at the start, that there is a difference between GOOD and RIGHT. (Kirchin, 2017, p. 60)

The point he is raising has to do with analyzing ethics in a more general sense than simple approval and disapproval distinction. This way he makes a very clear point about the differences in our evaluation. Considering evaluation merely as PRO and CON, although in the parallel with more or less the denial of inseparability of thick concepts or at least challenging their significance,23 at the very heart of Williams’ (1985) definition of thick concepts is the presumed attention to “more of the language”. He also argues that the concepts of approval, although all of them seemingly thin, come in degrees. Concepts such as FINE, OUTSTANDING, OKAY, and ACCEPTABLE are all concepts of approval, yet they all come as different degrees of approval. Kirchin (2017) also claims that, within thick concepts, there are some sort of families that are related to each other and the relationship within the families is not clear-cut. He comes closer to Williams (1985) in the sense that rather than looking at the issue in a binary way, he introduces the diversity of action guiding aspects of language. This way he can investigate the degrees and relationships between concepts: Compare this family of concepts: KIND, CARING, COMPASSIONATE, EMPATHETIC, SYMPATHETIC, THOUGHTFUL, and CONSIDERATE. It is impossible to be precise 23

Note that the most central claim of non-cognitivism is demonstrated in the example of “Killing is wrong” does not mean more than “Booo! Killing” or “I disapprove killing”.

2.3 The Thin and the Rest

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here, but to my mind it seems obvious that KIND is thinner and more general than, say, EMPATHETIC and SYMPATHETIC. THOUGHTFUL, at least as meant as part of this family, seems to lie in the middle, it being a certain way in which one can exercise kindness, although I am prepared to be argued out of this claim. The main idea is that there is a host of different thicknesses among all those concepts classed as thick concepts. (Kirchin, 2017, p. 62)

The very existence of different families of evaluation creates a ground to believe that these concepts already have something that is shared within our ethical understanding, since categorizing concepts with respect to their common banding togetherness of evaluation is quite agreeable. I believe this shows us that thinking about moral evaluation is not a very straightforward thing to do, neither through purely evaluative thin concepts nor thick concepts. Although these families show different levels of approval, or in the example of RIGHT and GOOD evaluating in different senses, the evaluation is done quite differently in these cases, it seems as if there is more to evaluation than simply a “descriptive plus thumbs up” or “descriptive plus thumbs down” dichotomy. Furthermore, outright distinction seen as a mere dichotomy becomes hard to hold under these objections. However, it is still possible to ask whether we are employing a universal metric for evaluation when it comes to action guiding concepts.

2.3.2 Global Evaluation and Embedded Evaluation Arguing against the inseparability, Väyrynen (2013) takes a different route in his understanding of evaluation in the debate. His arguments lead to a position eventually claiming that, before even arguing about separability, thick terms do not hold distinctive evaluative significance to begin with. He holds that the evaluative aspects of the thick terms are not within the terms themselves, but are outside of them. The messages we convey with these concepts are not carried within the semantic meaning but are carried through gestures or mimics. When we say that a show is LEWD we also convey a certain kind of pragmatic element where the evaluation is, since it is possible to see it negative, natural or positive. He advocates this through making a distinction on the semantic and the pragmatic part of the concepts, eventually concluding that the evaluation of the thick concepts are for almost all thick concepts, done by nonlinguistic elements, such as the tone of voice, a nod and similar non semantic elements in communication. To undermine the semantic perspective, the distinction of descriptive content and evaluative content is crucial to his analysis, following Elstein and Hurka (2009), as global evaluation and embedded evaluation.24

24

I am emphasizing their work because seemingly, their model has been in the center of discussion about both the separability/reduction debate and the communication/dispute debate.

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2.3.2.1

2 Finding Value in Concepts

Elstein and Hurka’s Two Part Model

This model is a rather straightforward one for separation, which they claim to have general applicability to many thick concepts, therefore is more or less the standard model to separate the descriptive element from the evaluative one and afterwards reduce the vast majority of thick concepts while doing so. The model is as follows: Then ‘x is distributively just’ will mean something like ‘x is good, and there are properties X, Y, and Z (not specified) that distributions have as distributions, or in virtue of their distributive shape, such that x has X, Y, and Z, and X, Y, and Z make any distribution that has them good’” (Elstein & Hurka, 2009, p. 522).25 In this model, the GOOD at the beginning and the end are the evaluative components, while X, Y and Z are descriptive parts of the concept. They claim that this model is compatible with most thick concepts, drawing from the asserted easiness of disentangling the KRAUT example.26 In Elstein and Hurka’s (2009) model, the interchangeability of the concepts within the equation is possible due to “if and only if relation” connection between them. That is to say that the conditions that are already presented will mean the definition of the concept and will be only that totality—only the sum of all properties within the concept could make that concept up—this way, it would be possible to reconstruct the thick concept by descriptive concepts alone. The interesting aspect of this perspective is voiced by Harcourt and Thomas (2013). While there are people who are not on the same definition about one concept, how can it be possible for them to create such an equation? Different users use particular aspects of X, Y or Z while they are not in complete agreement. In cases where there is controversy about the application of a thick concept, there are generally different definitions of the concept itself. Consider the concept of DISTRIBUTIVELY JUST; different people who have an understanding of the concept can have different definitions for DISTRUBITEVLY JUST. While the desert theorist will claim that something is JUST when things are distributed according to peoples’ merit, an egalitarian will say it is JUST only when it is equally distributed.27 Moreover, even both parties have different definitions of DISTRIBUTIVELY JUST; they also understand that the other party still uses the same concept, although their definitions differ. I discuss more on the reduction part, but for the time being; let us return to the second model to make the case for Väyrynen’s (2013) pragmatic reconstruction of thick concepts.

25

“Shape” as mentioned here is—although not exactly the same thing—is very much similar to being disentanglable in McDowell’s framework. 26 There have been quite strong arguments against such a system of division, most notably by Kirchin (2017) and Harcourt and Thomas (2013). However I will not discuss it in depth here, instead pointing out only one criticism by Harcourt and Thomas (2013). 27 Note that this criticism is also applies to McDowell’s (1981) dinsentanglement argument due to his supposition of the homogeneous ethical community is challenged.

2.3 The Thin and the Rest

2.3.2.2

27

Elstein and Hurka’s Three Part Model

Elstein and Hurka (2009) claim that while most thick concepts can be explained by their two component model, there are some thick concepts which require specific attention to another model to be explained. These thick concepts seem to have a stronger significance due to difficulty in their disentanglement, possibly meaning that they are more central to our evaluation. As they claim, virtue concepts such as COURAGEOUS or KINDLY, do not fit their first analysis because they are somewhere between the thick and the thin, and closer to thin in general, while concepts such as KRAUT are very thick examples. Their second model is preserved for concepts such as INTEGRITY and as they exemplify, although “sticking to one’s ideals and projects despite temptations or distractions” defines INTEGRITY, there can be many counter examples to it. For example, the case of “someone who persists in building his beer-mat collection despite the rise of Nazism around him and the temptation to fight against it would hardly be described as acting with integrity” (Elstein & Hurka, 2009, p. 526). Here they bring in a certain context in which integrity is operational, they further build their argument on the basis that, for an act to be an act of INTEGRITY, it requires an evaluative point, namely, the embedded evaluation. So for these cases ‘act x is courageous’ can be analyzed as something like ‘x is good, and x involves an agent’s accepting harm or the risk of harm for himself for the sake of goods greater than the evil of that harm, where this property makes any act that has it good,’ and where, again, the second ‘good’ is an embedded evaluation. (Elstein & Hurka, 2009, p. 527)

As this model has three parts, the first and the last evaluative GOOD are global evaluations, which means they are independent of the previously used concepts. The GOODs used in the sentence are separable and thus the concept can be evaluation natural in this regard. However, the GOOD that is employed in the central descriptive part of the content as expressed “for the sake of goods greater than the evil of that harm” is considered embedded evaluation. This element is required to make the distinction to match the definition to the correct use of the word. As in their beermat collector example, not every act counts as an act of integrity, since there can be more important things at stake, and the certain type of behavior should “outrun” the contextual limitations to count as good.28 From this model Väyrynen (2013), reaches the conclusion that, when there is embedded evaluation within the concept, then the evaluative aspect of the concept is not too significant, since embedded evaluations show us a small framework about the applicability of the concept. The domain of usage is limited, making it not possible to be globalized. Moreover, since the concepts that require a three-part analysis are only a small fraction of the thick concepts, the significance of thick concepts as a general phenomenon is thus undermined, making them less worthy of philosophical attention. He adds on to that by claiming that the evaluative concepts are prior to and distinct from the concepts that we are working on: 28

There are such thick concepts that are difficult to outrun by a more general context, which seems as if they always have a positive meaning such as JUST or TACITFUL (Roberts, 2017).

28

2 Finding Value in Concepts For instance, even if the extension of courageous depends on what things count as goods and evils, their status as goods and evils is prior to, and independent of, what counts as courageous. (Väyrynen, 2013, p. 43)

Upon that case, he further claims that in the two-component analysis, the evaluative aspects are distinct and separable, and by their nature, these evaluative aspects are of an independent relation to thick concepts while they are being reconstructed.29 I believe that I have exemplified the strongest case for the separability claims, now I will use some other perspectives to see thick concepts differently within a framework that is more central to my case. However, before passing, I will make one other claim against the general separationist move, since I find it quite central to the debate.

2.3.3 Dimensionality I have already mentioned Kirchin’s (2017) brief objection against the simple duality of evaluative concepts and terms. While we have different concepts of approval, and the strength of thick concepts are of varying degrees, it is hard to divide our ethical understanding into merely two distinct evaluative judgements. Agreeing with Kirchin (2017) I claim that our varying degrees of approval or demise also have strong relationships with thick concepts. Let us consider an example of thick concepts: – Turkey’s action in Afrin was OUTRAGEOUS. – No, it was simply BAD Here while they are on the same negative side, but their strength differs significantly. Perhaps it might be even possible to brand OUTRAGEOUS as a thick concept if we retain the simple dichotomy because in most real life cases, this is also, what happens to the thick concepts, which tend to be “worse than bad”. I believe that it is more commonplace to say something is not simply bad, but even worse—or better—through the usage of a thick concept, “what he did was bad” is not as bad as “what he did was murder”. I believe that it makes sense to have a pluralist stance here. Some thick concepts might be following this suit, where they can be worse than the typical bad concept we have, on the other hand, it can also be the other way around. The true nature of the concept depends on the particular thick concept we are dealing with. According to the seperatabilist view, if we can separate the evaluative from the descriptive, or if our contexts can be pragmatically distinguished from the evaluative, it should be possible to reduce the thick concept to a purely descriptive concept. Now I will address that argument.

29

This also applies to the three component analysis.

2.4 Reduction

29

2.4 Reduction Separation has been an important aspect within the discussion around thick concepts in the literature. This is due to its central importance in the application and significance of thick concepts and terms. One of the expected steps taken30 after establishing that separationism is possible is to presume reduction.31 In this part, I will focus on reduction of thick concepts to the general formula [thin + descriptive content] and continue the discussion of the possibility and/or the consequences and stipulations under reduction. However, I believe that reduction of thick concepts in particular is a pressing issue. This is partially because in the literature there are at least two classes of thick concepts at least in separabilist accounts, namely the KRAUT class and the COURAGE class.32 While the former is considered thicker the latter is seen as thinner.

2.4.1 Reduction as Replacement It is one thing to say that thick concepts and terms can be separated in the form of evaluative element + descriptive element, and another thing to say that for every thick concept there exist an independent descriptive component which can be used to separate the evaluative and descriptive aspects of the thick concept. I believe that it is hard to claim the second, since the vocabulary can be missing already, and I think this is the reason why Elstein and Hurka (2009); use a multi property expression in their two component evaluation. Therefore, I believe that even separationism holds true, it is different from saying that reduction is a valid operation since even within the descriptive concept’s domain, it is difficult to replace a concept with another—they have to be synonymous for that. We can talk about two different types of reduction, one is the possibility of creating a collection of concepts which can replace the descriptive part of the thick concept (a) and the other one being a concept that is the exact match of the descriptive part of the thick concept (b) Although the two seem not too distinct from each other in principle, making this distinction is important to see the difference in the reductive strategies. A strong criticism of reduction as complete replacement (a), is presented in Harcourt and Thomas’ (2013) work. They are criticizing exactly the meaning equivalence of the descriptive part of the thick concept and the candidate of replacement. To develop this objection let us return to the trivial kind of ‘analysis’ that we hinted at earlier, brutal = bad + brutal or, as it might be, red = colored + red. Here is a more complex (but 30

And perhaps not even seeing the need to do so because the implication seems too obvious. And vice versa. 32 In the nonseparabilist side, they can be classified as the same. It is also possible to claim that there are more than two subclasses. 31

30

2 Finding Value in Concepts no less trivial) version of it: red = (is true of surfaces) + coloured + (there is some further property of surfaces such that any surface satisfies coloured in virtue of having this property). This cumbersome formulation mimics Elstein and Hurka’s two- part analyses, because its first clause simply ‘narrows the possible extension of the target concept’. However, it differs from our earlier ‘analysis’ of red in that it does not specify which property needs to be added to coloured to yield red: it just says there is one. But it will be obvious that the only property that can be a value of the property variable in our new quantified ‘analysis’ is, in fact, red itself. (Harcourt & Thomas, 2013, p. 32)

I think this criticism applies to most cases. The replacement possibility is actualized only when the exact concept is in disposition. However, there might be one possible criticism of this case, which I will exemplify. It is possible for one to claim that, RED is identical to, say a certain wavelength, does that make it possible to use another concept in the place of red? I think the answer is not a straightforward yes or no, because from its history we know that a certain spectrum of light can be observed as the color red, and the direct linkage between these concepts is only possible due to our isolation of the concept RED itself.33 We do not have color names for the colors below or above the “visible spectrum”; however, there can be certain stipulations for the visible ones. Therefore, it might be possible to say that RED = wavelength nm 70. Even so, it might be difficult to replace it with some concept34 due to the possible loss of content via connotations and the various ways in which the concept gathers different facts of the world. Hence, even if it seems possible to reduce the concept as a whole, it has many obstacles, such as the necessity to cut down the relationships and connotations it has with the previous concept. The semantic identical of a concept for the standard of synonymy seems difficult here. The more difficult to reduce example can be made from a more social domain, consider the concept of FLYOVER COUNTRY. This is a concept that is used in the USA, mostly by people living in New York or Los Angeles to refer to the states that they are flying over when they are visiting the other city. Since their lives are culturally and socially very much tied to these cities and such lifestyles, it connotes something very cultural. Which kind of states does the concept cover? If we happen to have a list of all the “red states” in the USA socio-political jargon, would they be picked up by the concept? Alternatively, although the original usage comes from somewhere else, it makes sense to ask whether Chicago, a very “city like city” in the USA counts as flyover country or not. There is a very specific community that uses it, however as Bullard (2016) claims, it is not only used pejoratively. Since the general sociopolitical lines make sense for us to understand the classification, people living in the FLYOVER COUNTRY can understand it, and use it positively, meaning that it is something to be proud of, living there.35 33

For a further discussion within the philosophy of science about the incommensurability debate, Feyerabend, For and Against Method, 1999. 34 Apart from the technical difficulties such as the dimness, exact wavelength, separating the exact wavelength under certain conditions etc. 35 In this example, I believe that we can talk about making shape of the shapelessness, if we are to tell the whole story, how different entities as extensions of the concept, under the concept come

2.4 Reduction

31

Certain BAD things are new to us especially when they are new due to the social setting; consider the practices of gaslighting. The practice became possible through popularization of internet. Our value concepts do not always simultaneously catch up with the material developments we have.

2.4.2 Reduction in the Case of Subset of Properties The other possibility for such conceptual reduction (a) is, as the instantiation of several properties to a single concept, based on the two-component model of Elstein and Hurka (2009). Consider MURDER is a thick concept; one can say that it can also be defined as BAD KILLING. However here killing is constructed in a very one dimensional way already. Let us think various instances of KILLING, like “killing time” or “killing the pain”. Although they are not the most general usages of the concept, and they can be seen as metaphors or wordplays, these expressions still use the same concept. While killing the pain is positive, killing time can be negative and killing a person is definitely negative. Therefore, does that mean that, “of all the instances of killing, the bad ones count as MURDER”? Even so, there are other instances of BAD KILLING, such as MANSLAUGHTER.36 Instead, there could be certain properties like, “ending the life of someone”, “without their consent”, or “in the peacetime”, …, + it is bad. After this analysis, the hope of the reductionists on this issue is to be able to explain all extension of the concept through these properties. Kirchin (2017) also explains the problem with this approach. In his analysis, as the incomplete list of certain properties do not create a credible ground for understanding reduction, as he claims, “an incomplete analysis is no analysis at all” (p. 84). As I will discuss more about the concepts in the coming chapter, this is similar to Hacking’s (1983) criticism to Putnam’s account of meaning, as the incomplete list is no list at all. I would like to further this claim pragmatically on larger scale. Language is a living entity, and thick concepts are not out of the general rules that apply to language in the general, more encompassing definition of the language, which also involves aspects of pragmatics. On top of this, the values, and value societies are also dynamic and non-homogeneous. As claimed by Kirchin (2017) and Väyrynen (2013), thick concepts are not completely static, that is to say, they have certain starting points in the language—or, to be more explanatory for the general understanding of the concept—and they undergo sometimes lengthy changes within their lives. Some of them completely lose their thinness, while some of them gain it, some of them move together to make meaning for the concept also in the social sense, the evaluative aspect is then dissolved to the functional element of the thick concept in question. This way, it can be possible to “rise above” the evaluative social level, and create a more general social level as in the case of an anthropologist in the case of Williams (1985). 36 It is relatively easy to see the differences between these two concepts due to intention playing a very important role in our value system; however, it is also possible to form a value system in which these two phenomena are equated.

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in the “thick-thin axis” while some of them gain some other thin property across the process of their meaning change. Some examples as discussed by both authors are, INDUSTRIOUS and LEWD. I cannot find any reason to limit this phenomenon of change in the concepts with respect to their moral and descriptive position. On the contrary, I think it is reasonable to think that all thick concepts are subject to change through time or within contexts, some uses of them we may never know of because it is only used by a subculture. Therefore, I do not think that thick concepts have set definitions at least temporally or across different communities as they exist as we know them, neither their definitions ever be completely settled easily. In addition to that, the multiplicity in meanings varying between different cultures and people as well as context create further diversity in their meanings. One such example of variation in meaning due to context, albeit in different evaluative value is given by Kirchin. Similarly, consider GOSSIP. We can talk in a variety of ways and gossiping is one of them. It is certainly more specific than COMMUNICATION, say, and something more than and different from the idea of ‘sharing information’. Furthermore, we can damn a piece of information as gossip, or revel in the loveliness of gossip, as well as enjoying the piece of gossip we have just heard. The OED has: “...idle talk; trifling or groundless rumour; tittletattle. Also, in a more favourable sense: Easy, unrestrained talk or writing, esp. about persons or social incidents.” We see here, as with MACABRE, the reliance on synonyms, and also the switch from negative to positive. There is no clear ‘good’ or ‘bad’, let alone ‘pro’ or ‘con’ mentioned, but no competent speaker of English could fail to latch on to the positive and negative associations that occur in general with the concept when it is used. (Kirchin, 2017, p. 131)

In examples such as GOSSIP and many more, the definition of the concept is rarely straightforward. Yet we can of course make sense of them under definite circumstances and certain contexts. This will lead me to another challenge to Väyrynen’s (2013) pragmatic conception of thick concepts and terms.

2.5 Conclusion In conclusion, Elstein and Hurka’s (2009) three-part model looks promising when it comes to understanding that there are various different concerns and contexts in which thick concepts can be used, particularly if the conceptual change of the scientific concepts is at play. If we accept the global evaluation of a concept to be different than that of local evaluation, that is to say, if we accept the social nature of the concepts that is defining the thickness, while still enabling it to be seen as analyzable when there are other concerns in the world that can counteract the value terms, it becomes possible to conceive the concepts that the scientists employ to be free from evaluation in their use to a certain extent and under specific conditions. Through this ability to conduct research with concepts independent of the value given to the scientists, they can work on these concepts eventually resulting in conceptual changes. Moreover, the separability without reduction position can also enable us to work with the subjective

2.5 Conclusion

33

element’s experiencing the different uses of the concept without losing its touch to social or pragmatic aspect of the concept, while still maintaining a realistic position. I believe that this position in conceptual change of thick concepts is in line with Harcourt and Alan’s (2013) understanding of elimination. Pointing out the social and community aspect of the issue; Williams (1985) asks while discussing the conversational element of thick concepts: Still, a problem remains in the method even when one grants its assumptions, and that problem may perhaps be what someone has in mind who raises the question whether the intuition it endorses are “actually correct”. The problem is who we are. In describing the theory I have referred to “a society”, and it is fairly clear what this means when we are thinking about a contractual theory that is in the very first place a theory of social justice. (1985, p. 114, his emphasis)

The community here does not necessarily reflect the speech community or the ethical community. The speech communities can be detached from the ethical “value sharing” communities in this regard, and I find it difficult to note that there is one single way to use them on one kind of realist level. Moreover, I claim that the speech communities and value communities can be non-overlaping. My own conclusion is relatively simple here, instead of focusing too much on the concepts, we should focus on the actualization of these concepts in contexts we apply them. This way it would be much easier to go into a particularistic direction. I believe that this is also in line with the social understanding of ethics.37 As I explained at the start, my aim is not to provide a solution to the “problem” of thick concepts. I do believe that they are significant, however where and how they are significant has detailed answers depending on the contexts they are used. The missing element in the semantics and pragmatics of the concepts, is seeing how it related to the social level and how the concepts we use and have at hand have action guiding qualities with respect to the social activities. In the end if we are to rely on the concept of ethics in the more general sense, in the sense that it refers to ways of acting in the social world, it becomes much easier to see the interconnection of concepts. I do believe that both semantic and pragmatic approaches can be used to understand the concept of disease; however, it should be borne in mind that my main emphasis is on the sociality and the social relationships with respect to concepts. If the required understanding of semantics and pragmatics were borne in mind, I would have no problem with working with either approach. Although I do believe that some form of contextual semantics makes more sense to me due to the social being categorized in a more concrete way in that approach rather than pragmatics being seen as the more fluid approach where the social is blended with the meaning. The main starting point of shapelessness argument relied on the concept of the insider/outsider dichotomy in which there would be different perspectives carried 37

Kirchin (2010, p. 9) also discusses about possible strategies to deal with the shapelessness in the empirical context. I am sympathetic towards his third option in taking into account both the linguistic and the empirical aspects of dealing with thick concepts. And in this work I pursue both empirical and conceptual parts.

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by different people in these ethical communities. However, the insiders are also living in a time of change, and they are hardly in a homogenous stance with respect to evaluative concepts, making them create complex concepts with respect to their relationship to the world. If the concepts we employ are incomprehensively complex, so that even the insider of the society could not understand the correct usage of such concepts, we should ask the question how do we even learn different usages of such complex concepts? One way is to go to platonic idealism and say that from a non ethical point of view, there exist such concepts such as KINDNESS and no matter how complex they are we, learn them in social relations. The other way to do is to say that these concepts are used in different contexts by different speech communities, and they also evolve. The concept of mercy killing evolved in a situation where killing could be merciful under certain circumstances for example. The question here is, how inside can the insider be? In many societies it is difficult to pinpoint one single insider ethics that applies to every case. When we use the ethical concept in a new way, we make heuristic definitions of the concepts so that they apply to the new case. However we can also have similar structures as users of concepts, for example whoever has a concept of kosher can understand concept of halal very easily. In the end, the discussion about the outsider can be put into rule following considerations of Wittgenstein in Philosophical Investigations, “if a lion could talk, we could not understand him” (2009, p. 225). The relative comfort we have at the analysis of thick concepts is, although the value communities can be different from each other, speech communities somehow share the concepts they use and apply.

References Ayer, A. J. (1952). Language, truth, and logic. Dover Publications. Blackburn, S. (1984). Spreading the word groundings in the philosophy of language. Oxford University Press. Blackburn, S. (2010). Through thick and thin. In S. Blackburn (Ed.), Practical tortoise raising (pp. 129–146). Oxford University Press. https://doi.org/10.1093/acprof:oso/9780199548057. 003.0008 Brecht, B. (1935). Die Übersetzbarkeit von Gedichten. BB, Gesammelte Werke, Bd, 19, 404. Bullard, G. (2016, March 14). The surprising origin of the phrase ‘Flyover Country’. National Geographic. https://www.nationalgeographic.com/news/2016/03/160314-flyover-cou ntry-origin-language-midwest/. Croom, A. M. (2010). Thick concepts, non-cognitivism, and wittgenstein’s rule-following considerations. South African Journal of Philosophy, 29(3), 209–232. https://doi.org/10.4314/sajpem. v29i3.59143 Elstein, D. Y., & Hurka, T. (2009). From thick to thin: Two moral reduction plans. Canadian Journal of Philosophy, 39(4), 515–535. https://doi.org/10.1353/cjp.0.0063 Foot, P. (1958). Moral arguments. Mind, LXVII(268), 502–513. https://doi.org/10.1093/mind/ LXVII.268.502 Hacking, I. (1975). Why does language matter to philosophy?. Cambridge University Press. Hacking, I. (1983). Representing and intervening: Introductory topics in the philosophy of natural science. Cambridge university press.

References

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Harcourt, E., & Thomas, A. (2013). Thick concepts, analysis, and reductionism. In S. Kirchin (Ed.), Mind association occasional series. Thick concepts (pp. 20–43). Oxford University Press. https:// doi.org/10.1093/acprof:oso/9780199672349.003.0002 Hare, R. M. (1963). Freedom and reason. Clarendon Press. Hare, R. M. (1997). Sorting out ethics. Clarendon Press. Hume, D., & Beauchamp, T. L. (Ed.). (1998). Oxford philosophical texts. An enquiry concerning the principles of morals. Oxford University Press. Kirchin, S. (2010). The shapelessness hypothesis. Philosopher’s Imprint, 10(4), 1–28. Kirchin, S. (2017). Thick evaluation. Oxford University Press. Kyle, B. G. (2013). Knowledge as a thick concept: Explaining why the Gettier problem arises. Philosophical Studies: An International Journal for Philosophy in the Analytic Tradition, 165(1), 1–27. http://www.jstor.org/stable/42920162. McDowell, J. H. (1981). Non-cognitivism and rule-following. In S. Holtzman & C. Leich (Eds.), Wittgenstein: To follow a rule (pp. 141–162). Routledge. Moore, G. E. (1959). Principia Ethica. Cambridge University Press. Quante, M. (2018). Pragmatistic anthropology. Mentis. Roberts, D. (2017). I-Depending on the thick. Aristotelian Society Supplementary, 91(1), 197–220. https://doi.org/10.1093/arisup/akx006 van Roojen, M. Moral cognitivism vs. non-cognitivism. The Stanford Encyclopedia of Philosophy (Winter 2016 Edn.), Edward N. Zalta (ed.). https://plato.stanford.edu/archives/win2016/entries/ moral-cognitivism/. Väyrynen, P. (2013). The Lewd, the Rude, and the Nasty: A study of thick concepts in ethics. Oxford University Press. Wittgenstein, L. (2009). Philosophical investigations. Wiley. Williams, B. (1985). Ethics and the limits of philosophy. Fontana. Collins, London.

Chapter 3

Meaning as Definition and Meaning as Use

“Die wissen das nicht, aber sie tun es” They do not know it, but they are doing it Karl Marx–Friedrich Engels–Werke, Band 23, “Das Kapital”, Bd. I, Erster Abschnitt, S. 88, Dietz Verlag, Berlin/DDR 1968

Abstract In this chapter, my aim is to discuss meaning theories to introduce a more social understanding of thick concepts within the debate, providing a social aspect which can work with Elstein and Hurka’s (Can J Philos 39(4):515–535, 2009) three part model. My main aim is to focus on the socio-linguistic element in the making of meaning rather than focusing on the meaning itself in the classical sense, also because I find it more important to focus on this issue due to the conceptual change I have in mind. In this chapter, I will lay out certain principles with respect to handling of thick concepts within meaning theories and concepts. The aim is not to give detailed accounts of meaning theories here, neither to find the most accurate or comprehensive meaning theory or approach to analyze thick concepts. My main point of departure in this chapter is to defend that, thick concepts are related to language and linguistic activity in many ways. I think there is reason to believe that in most cases meaning theories capture and explain certain aspects of language but fail to do so when the vast diversity of linguistic activity is considered. More generally, certain approaches to language are more suitable to analyze thick concepts for the most usages of thick concepts. When thick concepts are taken as particular phenomena of their own right within philosophy, as it has been central to the debate which approaches to concepts should be employed, it is understandable that there are many different philosophical approaches that are open for analysis. In the this chapter, I will try to employ different kind of usages of the language based not on specific definitions but meanings in their usage to understand the making of meaning. The general aim is to position concepts in general and thick concepts as tools, not only as lasting, truth corresponding elements of the language.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_3

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3.1 Introduction I have briefly covered the main debates around thick concepts in the previous chapter; in this chapter, my aim is to discuss meaning theories to introduce a more social understanding of thick concepts within the debate, providing a social aspect which can work with Elstein and Hurka’s (2009) three part model. My main aim is to focus on the socio-linguistic element in the making of meaning rather than focusing on the meaning itself in the classical sense, also because I find it more important to focus on this issue due to the conceptual change of the concept of disease. In this chapter, I will lay out certain principles with respect to handling of thick concepts within meaning theories and concepts. The aim is not to give detailed accounts of meaning theories here, neither to find the most accurate or comprehensive meaning theory or approach to analyze thick concepts. My main point of departure in this chapter is to defend that, thick concepts are related to language and linguistic activity in many ways. I think there is reason to believe that in most cases meaning theories capture and explain certain aspects of language but fail to do so when the vast diversity of linguistic activity is considered. More generally, certain approaches to language are more suitable to analyze thick concepts for the most usages of thick concepts. When thick concepts are taken as particular phenomena of their own right within philosophy, as it has been central to the debate which approaches to concepts should be employed, it is understandable that there are many different philosophical approaches that are open for analysis. In the this chapter, I will try to employ different kinds of usages of the language based not on specific definitions but meanings in their usage to understand the making of meaning. The general aim is to position concepts in general and thick concepts in particular as tools, not only as lasting, truth corresponding elements of the language.

3.2 Why to Talk About Meaning Within This Context in the Very First Place? Within philosophical analysis of thick concepts and their usage within the philosophical literature, one prevalent method of analysis is the analysis of the thick concepts through the existing understandings of semantics. As discussed in the previous chapter, the main critique of thick concepts’ significance came from Väyrynen (2013a). The concept of linguistic analysis itself is of course a very worked field and requires a lot of direct connection and loaded jargon, particularly when we are limiting the concept of language to semantics. Väyrynen (2013a, 2013b) focuses his critique on the (in) significance of thick concepts particularly by emphasizing the indifference of thick concepts compared to other descriptive concepts within the limits of semantic approaches to meaning. He finds evaluation to be mostly at the level of pragmatics, tone of voice, and gestures. I find his critique meaningful, however not enough on that. The focus of his analysis is still the concepts that are

3.2 Why to Talk About Meaning Within This Context in the Very First Place?

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seen as relatively indifferent to the speakers. As a result, he claims semantic analysis of thick concepts leads to an inconclusive specificity for thick concepts to attain any specific significance. He pushes the agenda to pragmatics of meaning to make a place for thick concepts to be operational within his account. After limiting the semantic analysis to conclude disentanglement of thick concepts, he analyzes another area of philosophy of language—pragmatics—to prove his understanding of the insignificance of thick concepts. He follows Grician (1975) speech maxims to analyze the pragmatic understandings of speech to assess meaning and thus significance1 of thick concepts. His understanding of speech maxims derived from the Grecian account is central to his pragmatic analysis of thick concepts. The maneuver relies on distinguishing pragmatics and semantics. The distinction between semantics and pragmatics of language is already an established domain; although, there are still different ways of classification of pragmatics.2 My approach, instead of putting aside issues in pragmatics as a general category is, seeing them within value communities, which is much better fitting to Elstein and Hurka’s three part model. Within this model it becomes possible to crystalize the reason of the pragmatics within those communities. It is also possible to see pragmatics of the language not limited to the traditional speech maxims, but the meaning itself is seen as an emergent kind of activity based on— among other things—semantics and traditional pragmatics. Following that perspective, it is possible to see that, contrary to his understanding of pragmatics and certain Gricean accounts of pragmatics where pragmatics is defined rather narrowly, there is more about meaning in practice. I will analyze thick concepts and their pragmatics and semantics in a broad understanding where there is no sharp distinction between semantics and pragmatics of meaning. Because leaving it in the pragmatics, although saves the semantic element to be the surrogate of meaning, leaves the social aspect undefined. This account is heavily influenced by the “meaning is use” perspective of Austin (1975) and late Wittgensteinian accounts.3

1

In his case, insignificance. This relies on the meaning theories that are already in use. 3 I do not claim that there is a very sharp distinction between Austin’s and Grice’s accounts as the original contributions. Some, like Strawson (1969) focus on similarities of the contributions to communication theories by these accounts. However, Grice’s account is systematized more by the followers of Grice under his name, eventually developing a more systematized and complete understanding of Gricieanism while Austin’s supposedly main follower Searle created a more rigorous general theory for his own name. This causes Austin’s project not to be completed easily and his own philosophy standing on its own. This is also the reason why Austin’s understanding denotes a kind of more basic and thus flexible conception of pragmatics of language. This can be both a positive and a negative quality depending on the purpose of usage. 2

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3.3 Meaning Theories Before going into various aspects of thick concepts and meaning, one rather small criticism is at issue about the traditional understanding of meaning. As criticized by Hacking (1983), many conceptions of language are limited to the perspectives where the language is construed as some sort of schism similar to “sense and reference” in the Fregean sense in his On Concept and Object (Über Begriff und Gegenstand) [1892]. In the same argument Hacking (1983) also criticizes the formulation of “elementary objects of philosophy of language” as intension and extension by the followers of logical tradition, claiming that they generally tend to overlook the complexities in human language use and representation of reality.4 When divided as such, the object in the real world, and its linguistic representation, one of the primary aims of philosophy of language is limited to find the correct match between senses and references.5 I subscribe to the program that defends “copy” or “correspondence” theories are rather limited in their scope of analysis when it comes to usage of language and the “reality” that it is assumed to represent. I believe that when thick concepts are discussed in particular, defining them in the same spirit as Williams (1985) requires distinguishing between world guidedness and action guidingness. In this respect, the world guided aspects of the concepts are more similar to the semantic aspects of the linguistic activity while action guiding aspect of the concept is related to pragmatics. However, in order to establish such a division, the pragmatics shall also be considered bearing in mind its relationship with meaning and agency.6 Earlier7 discussions in the philosophy of language are to a large extend about truth and conditions of truth and falsehood. Nevertheless, at least from the dissidents of this framework such as Putnam (1975), we have an understanding that the cases where the extension of the concept can be clearly demonstrated as true or false are relatively rare. Since in this chapter I will try to understand meaning not centralized around the truth-value of propositions and take concepts as designators within propositions, but about world guidedness and action guiding aspects of the concepts, I find 4

I think the main issue when it comes to understand meaning starting from concepts and “objects” lead us to understand the meaning in a restricted sense, taking our attention away from conceptualizing larger structures than concept, such as sentences, expressions or other representational entities of the language. I mention this in the following parts of this chapter. 5 How much of a space it occupies within philosophy of language is of course open to discussion. However, I believe that still more than needed amount of effort is put in this domain. Moreover, fuelled by certain Wittgensteinian understandings of seeing every problem in philosophy as a linguistic problem, some proponents of this perspective try to limit the entire scope of philosophy to that domain. 6 It is also possible to see the world-guided elements of thick concepts not only reserved for the semantic aspects when the distinction between semantics and pragmatics is seen more liberally. 7 By earlier I mean logical positivists and pre-pragmatics for the most part. However, introduction of pragmatics around 60s did not only create a new dimension to the existing discussions but also changed our understanding of meaning outside pragmatics as well.

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agency or subjectivity quite central to the discussion. The agency I am interested in is simply for whom the world is guiding the concepts and for whose actions are guided with the employment of these concepts. In one emotivist account that can be traced back to Hume’s Treatise of Human Nature (2003 [1740]), one can say that certain concepts—or the event that are described or carried with these concepts— invoke certain emotions, and create reasons to act. However, from a rather rationalist or cognitivist8 perspective, it is still possible to define certain actions differently and fulfill the criterion of being action guiding. One example is torture, even if a person does not have bad feelings about torture on the level of emotions, she can still be against it from a cognitivist moralist perspective which leads her to recognize a certain kind of punishment as torture and act against it.9

3.3.1 Meaning of What? Concepts, Sentences and Larger Linguistic Representations. A Brief Criticism of the Object of Linguistic Analysis Determining the meaning of concepts in general and thick concepts in particular is a notoriously difficult task. Before passing, one side note will be mentioned. Our language consists of many different entities. Apart from syntactic markers or grammatical differences, the object, which can be under investigation linguistically or philosophically, can be the concepts, sentences or even larger units of language, such as stories, paragraphs, thought systems, entire theories. From the perspective where the aim of the meaning theories to assess truth values to sentences or concepts, the limitations of the approach can be traced back to Saul Kripke’s Naming and Necessity (1980). In Kripke’s remarkable work, he had to go to great lengths to supply the reference for proper names only, leaving the non-proper names relationship to the reference not grounded.10 However even in Kripke’s formulation—although better than most descriptive theorists—he still had to subscribe to a certain form of naïve realism, where the meaning of the term is determined, although mediated by the speakers—to yield to a one to one relationship in the possible worlds. The connection between the references of proper names and proper names themselves, which seem to be much easier to assess the reference of also has seen criticism (Hacking, 1983). If this is the situation of proper names, fixing to a given reference or a class of references should be much more difficult for common names, and concepts, which are my focus here. When we pass to more general and larger linguistic representations, such as entire theories, contexts, etc. the issue becomes much more complicated. For example, to 8

Of course, cognitivism here should not be limited to truth aptness of the moral judgements. Such understandings of action guiding are not only central to Williams’ account but perhaps most importantly discussed by Charles Stevenson in his Facts and Values (1963). 10 Proper names are those names, which designate a particular object in contrast to common names, which are generally considered to be similar with abstractions or concepts. 9

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what extent the theory of evolution is “true” and what is the meaning of “truth” for an entire theory? Or what does any concept within scientific work mean? Any person working in evolutionary biology would frown upon such a question. Which particular theory of evolution, under what circumstances, for which organisms, in simulated systems or not and similar fundamental questions they would ask. Without giving a detailed understanding of other elements used to explicate the concept of truth or the theories connected to the theory of evolution, they would not make much sense. Quite obviously, one to one matching of larger knowledge systems and what they are supposed to represent and mean are very diverse and cannot be constrained easily to truth conditionals. Hacking (1983) and Cartwright (1983) have quite strong answers against consideration of scientific theories as simple truths. Hacking (1983) emphasizes the autonomy of differences in meaning in different contexts, although his focus is not on the level of truth. While for Cartwright (1983), the higher theories are hardly truth apt let alone being true. Hacking, in his Why Does Language Matter to Philosophy criticizes the entities that fall under the analysis of language; At any rate, I have one answer to the question of why language matters to philosophy now. It matters for the reason that ideas mattered in seventeenth-century philosophy, because ideas then, and sentences now, serve as the interface between the knowing subject and what is known. The sentence matters even more if we begin to dispense with the fiction of a knowing subject, and regard discourse as autonomous. Language matters to philosophy because of what knowledge has become. (Hacking, 1975, p. 112, my emphasis)

Although the “meaning” analysis can be made in several different objects, the focus here is on thick concepts, particularly the ones that are employed more by scientists but when thick concepts are considered, their world guided and action-guiding natures are highly context dependent as well. Certain thick concepts, especially the ones that are more “social”11 in the sense that they denote social categories, can be evaluated differently by different agents. These different agents generally fall under different parts of societies. We can easily think that thick concepts that denote social categories such as BOURGEOIS, FEMINIST, KANAKE and the like have positive or negative evaluations, as well as being evaluation free for certain agents,12 even when they are living in the same society or the same “linguistic community13 ”.14 11

I do not claim that it is only social categories that are more context sensitive in their description and evaluation. At least seemingly non social concepts can mean different things for different parts of society or even for different individuals. 12 They can also be and often are descriptively different. On the concept of disease, Nordby (2019) discusses the concepts of disease, illness and sickness to assert the ownership of the particular concepts. However he also does not analyze the various usages of the concepts by different kind of members of the linguistic communities. 13 The possibility of having a value free account does not invalidate the possibility of a value laden standard meaning, while the non-existence of an established standard meaning also does not stop singular agents to have their own evaluative meaning. 14 The difference can also be in the descriptive aspect of the concept. BOLD carries a meaning more similar to NAUGHTY in Irish English, while it bears similarity to BRAVE in British English for the most part, set aside the subdivisions within the same linguistic community. Although NAUGHTY

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The distinction can lead us to believe that there are—at least—two types of thick concepts, those, which are context sensitive, and those, which are not. However, I believe that this is a false dichotomy. The context can always be instrumentalized with respect to the agent’s position, and I think this is a commonplace move by moral philosophers. Although thick concepts such as DEMOCRACY, JUSTICE or HEALTH can be taken to have always positive evaluations, they can be instrumental to the purpose of the agent, when the agent distances herself from the context properly. This happens particularly when the concept is “instantiated” in case of more mathematical or logical concepts, or used in a concrete example, as in more empirically related concepts. Consider the following Cold War scenario: – Democracy in Chile is working properly and thriving! – Damn! This was exactly what we were trying to overthrow, damn this Allende!15 The hypothetical conversation assumes that the concept of DEMOCRACY can be evaluated negatively by some agents,16 when it is instrumentalized. The problem here is that the conversation that is taking place is in the same linguistic community and the social community they are members of is different from the addressee.17 However, for the most part, when dealing with moral philosophy, certain things are considered to have constant meanings since supposedly the agents have similar motivations. One does not define the concept of GOOD to mean something that does not resemble it in any means in order to achieve a certain end. World guided meaning should be taken into account on a common ground, where the context is taken to mean something stable. In the following, I will focus on the meaning of concepts while leaving out the contexts and the evaluative aspects of thick concepts. However, it shall be borne in mind that they are interrelated and confusions as well as productive investigations can result from these interrelations. As one point of note, I will once again turn to Williams to remind the limits of language in moral philosophy: Moral philosophy is one area of philosophy in which the “linguistic turn,” as it has been called, has not helped to give problems a more tractable shape. This is not to deny that moral philosophy, like other parts of philosophy, is properly concerned with reflection on what we say. Indeed, at one level it might have done better than it has if it had been more concerned with what we say. (Williams, 1985, p. 127) and BRAVE can both be positively evaluative, thinking that they evaluatively exactly the same would be quite a big mistake. (Thanks Daniel Downing for the tip). 15 This is the general formulation, how we distinguish “good guys” from “bad guys” in typical narration. The antagonists are easily detectable since they despise the evidently positive concepts that we hold as the audience. I think this is one good reason to assign significance to thick concepts, they are also remarkably important when it comes to analyze the intentions and moral positions of agents in the social and ethical communities. 16 This does not mean that there is an established semantic standard meaning. 17 Many similar examples are not very difficult to find. One can take the examples of “sharia marches” in the UK where people condemn democracy, or the “police protests” that took place in Turkey, where the police officers condemned “human rights” since they saw it as an “obstacle” against them doing their “duty”. I do not think that in such examples they are using the concepts wrong, they simply have different aims than the expected “standard” user.

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The “linguistic turn” conceived this way, might change the focus of philosophizing on morality about the moral language but not morality itself. This is the problem of instrumentalization of the evaluative I intended to emphasize. Distinguishing between which part of the analysis or critique is on the level of moral language, and which aspect is on the level of morality is thus important. Within this understanding, so far I have put forward some critiques of concept meaning. I now discuss the positive approach towards certain kinds of aspect of meaning theories that I use, they can be considered within the social understanding of meaning.

3.3.2 A Social-Pragmatic Approach as the Critique of Idealist Conception of Concepts Before passing I would like to make the distinction between speech communities and value communities. Naming the main issue, when it comes to evaluating the linguistic usage simply as pragmatics and semantics, as I have argued in the main discussion, is around in the previous chapter, might not be the best way to address the problem of the evaluative aspect. What I find more important with thick concepts is not that they are inherently, above and over the social, value bearing, but how they are related to the social domains in different ways. The importance here is that, different relationships to different communities are of great importance when it comes to see thick concepts. In order to do this analysis, I will focus on pragmatics. Pragmatism18 also was bogged down with the concept of truth alone for some time, partially due to the spirit of the twentieth century where the quest for the Truth was the most notable one in philosophy. From William James to John Dewey early philosophers working on explicit pragmatism have put truth as the focus on their notions for good reason. However, not all pragmatists had explicitly carried the label of pragmatist while working in philosophy. Philosophers such as Austin, later Wittgenstein and Grice had pragmatic notions in philosophy of language; however, they were not pragmatists in all areas of language. When it comes to concepts, it is only natural to have great diversity leading to a more complicated and patchwork understanding of them. Eventually, as we are dealing with a variety of entities in the world, “the concept” as a singular kind of entity fails to represent this diversity, and any account that tries to depict and explain all entities quite naturally loses its explanatory force. I think it is also very similar with concepts, in the sense that in the language there is a variety of different concepts and conceptual relations, for that regard one single understanding of concepts also does not have good prospects when it comes to explain all concepts and conceptual relations.

18

Pragmatism is a very loaded concept; my understanding of pragmatism here can be read as pragmaticism of Pierce (in the sense that it has an understanding of truth of sorts) and has more to do with anthropological approaches, meaning that it is more related to practice rather than purely linguistic understanding or pragmatism.

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When we distinguish between speech communities and value communities certain examples would make more sense, consider the concept of MISOGYNIST and how different kinds of feminisms try to find the extension of the concept with their own their relationship to birth control pills. While some approaches within feminism can even find the practice of prescribing birth control pills misogynistic, some would say the opposite. It is not that they lack agreement on the concept of misogyny, but the values and how they are related to the world as they pick instances seem to be different. The main problem seems to be, the conceptual aspect by cognitivists is generally at the level of looking for a general concept independently of the context, the only context in the limited understanding of ethics is left to approval or disapproval, positive or negative. However, in a more social sense, we are acting according to the ethical concepts we have. We do not evaluate people when they are rude, we act in a certain manner, we do not do something kind only for doing it for the sake of it, and we do it to certain people, for a certain purpose. The concept of disease, being so institutionalized and used in many different contexts, also is such a concept. It does not only evaluate, it guides action in a certain way.19 Although how the concepts pick different aspects of the world is open for a larger discussion, now I will lay out some traditional perspectives in how they do that.

3.3.2.1

Classical Theory of Concepts

The simplest understanding of concepts is a very non-socially related. On one extreme, there is the “classical theory” of concepts. Prevalent at least until the end of second half of the twentieth century, and represented mainly by Frege and Russell, classical theory is about the structure of the concepts, definitionally speaking, the classical theories see concepts as compositional entities.20 The definition of a concept is given by the correct “constituents” or intension of the concept. In this theory, BACHELOR = UNMARRIED + MAN makes sense to understand the composition of the concept of bachelor. Moreover, the main claim is, the meanings of concepts are rather stable and from the definition of a concept, one can understand if not all, many properties that describe the concept. The proponents of such an understanding of concepts hold that understanding and grasping of a concept is very different from the meaning of the concept itself. Most proponents of classical view find examples from mathematics where the concepts are rather definitional and scientific essentialism where the concepts are seen to be found matching with the existence of an object in the world of which properties are describable when the scientific research is over. Because of this set of exemplar, the mathematical notions have more to do with idealism and the scientific ones with certain kinds of naïve realism. Either way, the copy theory of truth is at play. The concepts we have are related to something 19

These more general understandings of ethics can also be followed in another tradition from Alain Badiou (2012). 20 For a good formulation of the modern formulation of the classical theory, see Peacocke (1992).

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essential in the world, be it reason, the set—knowable structure of the world or the like. According to this family of views, the concepts themselves and the concept usage is also considered to be separate. The main problem with this view is that, when it comes to thick concepts and concepts that are used to refer not to a so called exact reference in the world—such as H2 O—, they seem to lack a particular reference point for the concept to be fixed. How the concepts are made is out of question, they either exist independently of us, or can be fixed. Those fixed definitions do not have to be eternal. However, the place for truth holder is there. If there is a better definition for an entity in the world, it will simply replace the older one, if there is a mistake in the reasoning while creating the new concept, there will simply be better reasoning showing that the old one is not true anymore, and while doing so it does the replacement. In case such concepts are used in “false” way, the other kinds of usages such as that of the social domain, it is deemed false, since experts found the true definition already. However, from a pragmatic perspective, the definition is only one part of the meaning, and it is far from being comprehensive in understanding the concept. Moreover, the classical approach takes concepts “ready-made”; that is to say, they see concepts with a concrete definitional structure in which the making or the use of the concept is at of best secondary or tertiary importance. The general method for such a conception of concepts is best used in the philosophy of antiquity about the ideal definition of a concept. However, in my opinion, this forces us to accept that there exists such an essence of the concepts. Even though this can function for mathematical or very well defined, specific concepts that are considered to be natural kinds, and it is assumed to represent Socrates when he asks the people of Athens about their notions of bravery. The discussions around this perspective are very detailed, however, I do not want to get involved in them, since I assume that this perspective does not help much at least when it comes to rather vague and socially related concept that are disputed. Depending on different kind of concepts, some concepts might or might not be understood with classical theory. I will simply say that when it comes to action guiding or value loaded concepts such as thick concepts, it makes sense to see that these concepts are difficult to define, and their meanings are much more social than say mathematical concepts.

3.3.2.2

Prototype Theory and Conceptual Skepticism

Trying to assess a straightforward understanding like that of the classical theory of concepts has faced many challenges. Since it is more or less established that they cannot account for at least all concepts, different approaches to concepts became prominent. Against this armchair understanding of finding certain kinds of definitions of concepts, more empirical and socially21 related ways to define concepts have

21

In the sense that, focusing on various kinds of usages within the society empirically instead of one person doing conceptual analysis.

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been developed. Amongst these, more empirical minded researchers such as psychologists like Smith and Medin (1981) tried to establish concepts with fuzzier borders.22 Influenced by later Wittgenstein, they conducted their own psychological research in which they investigated how people categorize different properties that made up concepts based on different parameters. One important outcome was consideration of prototype theories.23 Osherson and Smith (1981) also proposed similar conception of concepts, in which the concepts did not have the necessary connection that is held to be in the classical view. The necessary condition, as in the case of BACHELOR did not apply to many concepts, but the objects rather had different conditions that they needed to fulfill to fall under a concept. Moreover, in some cases none of these conditions were privileged over the other. The representative of the concept determined many properties of the concept, while the concept itself did not mean much for the users of the concept. The prototype view starts from the fact that not all concepts are equal. When we are talking about ANIMAL, the representative of the concept seems to be LION rather than SPIDER. The various conditions that are out there to be filled in order to qualify for being member of a certain concept are not only numerous, but they are also of differing importance. In more radical interpretations of prototype theory, it can also mean that concepts do not even have any power of gathering different kinds of properties within themselves. This view takes the concepts not to be eternal or fundamental, the concepts look more like family resemblances, however it still does not involve any kind of concept creating activity. Moreover, while the classical theory subsumes empirical work to philosophy, the prototype theory downplays the role of “pure philosophical analysis” in the traditional sense for the sake of empirical sciences, since their meanings can be assessed experimentally through cognitive experimentation.24

3.3.2.3

Pragmatic Use Notion of Concepts and the Thick

Pragmatism with respect to concepts can be seen in the middle ground between the relatively continuous line starting from concept essentialism or conceptual Platonism through concept skepticism until concept eliminativism proposed by Machery (2009). Machery (2009) proposes that, from a psychological standpoint, talking about concepts is a project that should be abandoned, since there are many different structures of concepts. The received view of concepts, that either they are exemplars, prototypes or theories, does not help us to settle the issue of the main structure of concepts. I support the position that this is due to the concept of concept 22

It was inevitable to have fuzzier borders for concepts from this perspective since it takes differences in people’s understanding of the concepts as the true element in definition of concepts. 23 The heterodox theories of theory are also similar to them within the limitations of my purpose here. 24 There is indeed a directionality here. Starting from classical understand to a more pluralist understanding, I try to see different kind of concepts in different frameworks being explainable by multiple frameworks.

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being forced to group concepts of too many kinds. Since the kinds of concepts we use, define and modify are many (based on the manifold within reality, following Waters, 2017), the concepts have many different shapes and structures. Another critique of the classical understanding of concepts comes from the domain where people learn concepts. Against the relatively strict understanding of concepts, from education sciences, Amin and Wiser (2001) develop an understanding of concepts that sees people in different kinds of relationships to a certain concept to have different kinds of meaning structures for these concepts. In their research they reflect on students’ and teachers’ understanding of the concept of heat to see how the relationships that the students have to the concept of heat from an everyday understanding of the concept is still meaningful compared to the scientific one. From a pragmatist standpoint, the concepts we use have a certain form of existence and applications, and they are of our own creation. I think the earliest explicit “pragmatist of concepts” in this regard were Marx and Engels in their work German Ideology. The products of their brains have got out of their hands. They, the creators, have bowed down before their creations. Let us liberate them from the chimeras, the ideas, dogmas, imaginary beings under the yoke of which they are pining away. Let us revolt against this rule of concepts. (Marx & Engels, 1976 [1845], 23)25

In a way, this is an early form of the pragmatic critique of the essentialism of concepts; it can even be seen as a pre-pragmatist approach, perhaps due to the Hegelian nature of the work. We produce concepts socially in order to use them for various purposes, them being produced does not make them nonexistent but when we are using them they become quite real on the contrary to the pure constructivist assumption that can be seen in contemporary concept skepticism. In the thick concepts debate, the analysis of concepts in this regard is still at the level of earlier concepts. When scholars working on thick concepts conceptualize conversation, they tend to agree on the classical definition of concepts where the conversation takes place in an ideal environment. That is to say, the speakers have a mastery of the concepts that they are dealing with as well as having positive communicative intentions towards each other.26 The “mastery” of the concept as it is used frequently in the arguments of “disentanglement”, sprung from McDowell’s (1981) argument also assumes that there is one certain way of conceiving a concept that is ultimate, while other ways of grasping the concept different than the true way are mistakes. Of course, the “mastery of the concept” shall not be one and only method of conceiving the concept. A statement using one of these terms can be analyzed into something like “this act has such-and-such a character, and acts of that character one ought not to do.” It is essential to this account that the specific or “thick” character of these terms is given in the descriptive element. The value part is expressed, under analysis, by the all-purpose prescriptive term ought. (Williams, 1985, p. 130) 25

The second Wittgenstein of Philosophical Investigations pose a certain similarity with this approach. 26 For discussion of the positive communicative intentions; Grice (1975)

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The givenness of the elements of the concept can be strictly within the close proximity of the concept, or can be in the background assumptions, or as Grice (1989) calls it within the conversational principle, where the contribution should be “as required” and within a common ground. As in here, the reason for action does not need to be a strict ought element in this regard. The precise nature is not that thick concepts must be disentangling, but rather the analysis of the concept should account for the action guiding or ought part of the concept. Moreover, within this account it is also possible to claim that the analysis is “already there”, within the commitments of the linguistic community. Take slurs for example, when someone calls the other as “Nigger”, and this happens to be perceived, observed and carried to the court of law, the defendant cannot say that the articulator merely meant that the victim was perceived to be “of African origin and bad”. We hold concepts not only as they are but quite often we know that we are operating in a network of social and linguistic relations. When we choose to sort the world differently, we do so against the alternatives. Fricker (2007) and Mason (2018) tell us that we are entitled to a certain responsibility when we are able to categorize and choose differently amongst the available conceptions of the world. Committing an offence via the employment of thick concepts is therefore only possible when the world is “out there” to be categorized by us differently. This is the precise gate where we can be pragmatists when it comes to concepts. However, the concepts we can use differently are of social domain? I believe that there are two ways to move on from this point. One option is to assume that, although in the daily lives of people they use these thick concepts rather casually, the moral philosophers and ethicists should strive above and try to find the nature of these concepts and their descriptive and evaluative properties alike. This perspective puts the moral philosopher in a certain position to evaluate semantic, pragmatic and social aspects of the concept in question.27 When moral philosophers see a thick concept they should accommodate it with the thin and descriptive counterparts and move on with the usual ethical analysis with the core concepts of GOOD and BAD, since they already possess28 the tools of conceptual analysis. The alternative is to see that there is such a diversity in our understanding, and even though we have our “absolute” ethical verdicts such as good and bad, we should nonetheless consider other action guiding concepts not only with respect to them being GOOD or BAD but also with their specific form. The second account indicated here is simply what the more practical and moral philosophers do, while the first task is a meta ethical task. If we consider that the “concepts” or terms or thoughts are not ideal Platonic entities, we should have an understanding of them in which we are the active creating agents. Consider Rawls for example. In the introduction of his A Theory of Justice (1975), he openly argues for changing our ethical perception in the light of the social structures we have. The social structure he has in mind is liberal democracy in this case. What we need to 27

I do not object the possibility of such a position; however, I do not think that this analysis being embedded in a person as a particular task is necessary for the function of thick concepts. 28 Moreover, they have better expertise in using them.

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change is not our concepts of good and bad per se, but rather other thick concepts, like JUSTICE and FAIRNESS. As can be seen, the ethical structure we have can be put forward to accommodate the social structures we have. The meanings of the terms borrowed from the society can thus be guiding in the ethical theory making. It is an obvious enough idea that if we are going to understand how ethical concepts work, and how they change, we have to have some insight into the forms of social organization within which they work. The linguistic approach does not, at some detached level, deny this, but it does not ask any questions that help us to gain that insight or to do anything with it in philosophy if we have gained it. (Williams, 1985, p. 131)

The social domain is also not very straightforward; there is more than one way to conceive society and the role of our conceptualizing in understanding social organizations. The very conceptualization of the society can be theory laden or mistaken, but I claim that within a pragmatist perspective, since there are many aspects of our social categories, when employed by people in their daily lives or scientists alike, they have an increased chance of representing the usage and social aspects of the concepts better. Williams also works a great deal on reflection and how reflection affects the society: … the urge to reflective understanding of society and our activities goes deeper and is more widely spread in modern society than it has ever been before; and that the thicker kinds of ethical concept have less currency in modern society than they did in more traditional societies, even if their use in those societies did not guarantee, as the myth has it, communal identity, lack of conflict, and a sense of completeness. (Williams, 1985, p. 163)

He eventually concludes by saying that when there is reflection in the society, there is “no turning back”.29 I disagree on that topic. I think this only applies when we have a more classical understanding of concepts, where the concepts have meaning detached from contexts and social groups. It is certainly true that many thick concepts that we have inherited from older ages and are in circulation today are losing strength. The typical example is KRAUT, the definition served the purpose during the war, but when the war was over, there was no social function of using the concept. Longer lasting thick concepts, such as CHASTE and LEWD are also dependent on certain social arrangements, which are losing their strengths nowadays. Consider the concept of HONOR, the concept was really thick and highly regarded in the middle ages, however within our ethical system of today, has a smaller role. On the other hand, other thick concepts such as INDUSTRIOUS, ENVIRONMENTALIST, AUSTERITY and EFFICIENT have gained enormous evaluative content, all because they have better functions in the society, thus better “action guiding” relationships to the world.30 Nevertheless, this is also because they were much more useful to reach and depict a certain new domain in life, also becoming more “guided 29

Looping kinds understanding of Hacking (1995) can be read in a similar way. I think the compromise between the action guiding and world guided aspects of thick concepts is very important. More abstract value concepts such as HONOUR are very difficult to define, while AUSTERITY is much simpler. I think this has something to do with their “evaluative strength”. However, I am not sure of the nature of the relationship.

30

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by the world”. In addition, I do believe these two accounts are complementary. Now that concepts are roughly seen in the ideal, one interesting remark can be seen from Putnam’s perspective.

3.3.3 The Meaning of Meaning Talk of meaning and concepts when they are left idle, that is to say when they are seen as entities in their own right, can be limiting to this study. Traditionally, Putnam (1975) provides another perspective on understanding concepts, since he starts defining them from meaning, not the concept itself. The difference in Putnam’s definition of meaning compared to the previous attempts in analytical philosophy lies in his ability to mix different approaches when social elements are considered. He uses some form of synthesis of both the classical and prototype accounts of concepts. The main point of his position is that, there is more than intension and extension when we analyze a concept. Putnam proposes a four-part analysis of concepts as a novel understanding to the intension and extension dichotomy. He begins with syntactic markers, which are, for his typical example WATER, mass, noun and concrete. In the second part of the analysis, he includes semantic markers, being natural kind and liquid. The third part is the stereotype that involves colorless, transparent, tasteless, thirst quenching, etc.31 The fourth part is the extension of the concept, namely H2 O (give or take impurities). In his analysis, all three parts have particular importance in the making of the concept. Putnam comes from a more scientific understanding compared to linguistic understandings of philosophy, in the sense that his definition involves “relatively stable” concepts in the inquiry, leading to certain readily made concepts. The extension of the concept in his account is rather stable, the concept and the extension have relatively close relationships, water and H2 O are very commonly related. The difference between conceptual eliminativism, kinds of nominalism and prototype approach to concepts that is shared by some philosophers of psychology such as Machery (2009) in the philosophy of psychology is, the prototype32 approach sees us in the making of the concepts, albeit ideally, creating quite changeable concepts. On this account, the concepts are not related to “concrete concepts” such as H2 O, but rather to subcategories, themselves being classes that can be further divided into subgroups. We can distinguish one apple from the other and certain kinds of apples, but for most of us, all H2 O looks the same, although WATER can denote different objects. In either case, the concepts are “hanging in the air” without being used in this context.

31

He claims that stereotypes can be added as desired when we pick up something new about the nature of the concept. 32 It is also worthwhile to note that while the word stereotype is used in our daily speech to refer to things that exist outside us, prototype means something we produce.

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When talking about the concepts vaguely, we generally hold some extensions of the concept the main representative of the class. Even when someone accepts that the concept can be used more generally, they tend to feel that some certain stereotype and closeness to that stereotype define the trueness of the proposition that contains the concept of which stereotype is investigated. Under these circumstances, the stereotype becomes the determining factor of the discussion. Therefore, other instantiations of the concept, do not “support” the argument neither give the same reason for action. When someone says, “Workers deserve better pay” their typical worker in the mind of the speaker is not the CEO or a certain bureaucrat, and perhaps even not the white collar worker but only certain blue collar workers, this is the outcome from the analysis of stereotype of concepts. Therefore, the meaning of the worker indicated in the sentence is meaningful only within the sentence. The stereotype is inferred from the content and the context. I claim that in Putnam’s account, we can never have the complete picture, the complete definition of a concept. Even the account mentioned above necessarily admits it, with the dots of extension in the stereotype indicating that the definition is not complete. Putnam hopes that the dots that are filling will always converge to a certain meaning, which is a possibility, especially when we think that Putnam has two elements, which are very much established within all linguistic communities, WATER and H2 O. Anything that depicts, defines or elaborates on water will have to be filtered first by being water and H2 O. The other stereotypes, semantic and syntactic markers should be in accord, only then it becomes possible for a property to be added to the meaning of WATER. Putnam tells this quite openly. But in fact, I also think, contrary to most recent theorists, that the reference of names is rarely or almost never fixed by means of description. And by this I do not just mean what Searle says: “It’s not a single description, but rather a cluster, a family of properties that fixes the reference.” I mean that properties in this sense are not used at all. (Putnam, 1975, p. 152)

He later defends an ostensive account, we know that WATER is H2 O because we can point at it and take it to be WATER. However, there is a lot being omitted here, not all water is H2 O for example, D2 O or T2 O have unnoticeable properties from H2 O for most purposes. Water has a certain cluster of properties, all assigned under certain circumstances, etc. Putnam takes the causality one way; he thinks that being H2 O determines all the other properties what we call water has. I think a dialectical account can be helpful here, particularly when it comes to looping kinds or concepts. We fix the reference, we take the reference point to be the stereotype, then test subject for the concept to operate, and then we make further analysis on our specimen, extending the concepts, eventually to change our starting reference fixing properties. Putnam then accepts the possibility of a non-ideal property structure for concepts, since he already holds onto the ostensive relationship; The fact that a feature (e.g. stripes) is included in the stereotype associated with a word X does not mean that it is an analytic truth that all normal Xs have that feature, nor that some Xs have that feature. Three-legged tigers and albino tigers are not logically contradictory entities. (Putnam, 1975, p. 170)

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The relationship between the ideal concept and the stereotype is also curious. When we are discussing tigers for example, this may apply and work very well. However, when it comes to “less natural kinds” such as social categories, the concept becomes dubious. Is a person still HONORABLE after he breaks one single promise? There are certain negative definitions for our social concepts; however, this does not apply to the “more natural” concepts. The more important distinction that can be learned from Putnam’s account is that the meanings are supposed to be public. He considers how one uses some concepts collectively, like a steamer ship while some concepts are put to individual uses, like a hammer. However, I claim that we get to know that a meaning is public when we have a different definition of the same concept. The other option is simply to hold that the other meaning is false. In the case of “public meaning” one resorts to public meaning only when he understands that his account of a certain concept is not public, but he knows things “differently”. Consider the sentences (a) I am using this small door as the main gate33 (b) But it is not the main gate! It is just the side door for the employees. In cases like this, a can understand that he is not using the main gate, but for that he has to know that there is a “real” and “public” main gate. Thus, his usage of the concept of main gate is meaningful only when he knows that he is using it differently. I claim that we generally start to know certain concepts with very strict outer limitation as the ordinary meanings. However, as we understand the concepts better, we can go out of the “stereotype” and do many different things with the concepts we employ. Therefore, I think we start assuming that our conception of a certain concept is “essentially” something more pragmatically, it is the public usage because there is no other meaning for the concepts as these concepts are merely false. Afterwards, we have a domain to extend our usage, which is possible only when we know that the public and private can be distinguished, and we can make our own meanings. This state becomes possible only when we recognize that there is at least one public meaning of the concept.34 The problem with Putnam’s account of the linguistic division of labor is, he considers that the average user of the concept does not have the extension of the concept so that he can apply the concept in the world. Putnam has in mind rather “scientific” concepts, the concepts which are preserved with the scientific domain, such as “elements” and “molecules”, of which extensions are unknown to the average user but are assessed by the experts.35 I think this naïve realism is question begging. While the experts change their reference or extension on their research quite often, the 33

Alternatively “my main gate” in which there is no challenge to the intersubjective conceptualization of a main gate. 34 On a rather speculative note, this sense bears similarity to Hegelian notion of dialectical recognition of certain concepts. 35 For a discussion around more “natural kind” concepts, the received view is Homeostatic Property Cluster (HPC) Theory (Ereshefsky and Reydon, 2015). Hacking champions it amongst other natural kind perspectives (1991). For Boyd’s categorization, Boyd (1990, 1991).

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average user refers to the same thing for the most part. Moreover, in thick concepts, the average user’s notion is more correct in general. Putnam also talks about “possible” worlds and stereotype, as well as strength or weakness of the stereotype.36 However, I think “negative stereotype”, the things that do not apply to the concept are also important when it comes to thick concepts. One single problem in the workings of a biological system can turn that individual from HEALTHY to DISEASED. Putnam has an “assimilatory” account, in which a certain notion and conceiving of a concept is the correct one in his twin earth example. He relates this to Kripke’s concept of rigidity. The reason why Putnam’s (1975) account is problematic for me is to accept one-way definition of meaning, that is to say, “meaning determines extension”, my account is different in the sense that meaning derived from stereotype influences meaning in general, which in turn influences how the stereotype is constructed. I claim that the different concepts of DISEASE employed by different branches can and do have a great diversity in both their usage and isolated definition. The extension, also being murky as it is, involved in defining such concepts eventually leads us to derive and create new concepts out of them. We conceive concepts; we have different conceptions of concepts as Rawls (1972) puts it. However, the conceptions do not form stable entities and most often, we have different conceptions of the same concept,37 with these conceptions, we refine and create new meanings. For different social groups, concepts get to mean different things since the extra conceptual elements such as other concepts they employ in their thinking are different. A HORSE can be action guiding for King Richard III in Shakespeare’s play; the concept LADY, can be positively evaluative and thus action guiding for old-fashioned sexist, while it is a natural concept and non-action guiding for modern sexist, while for modern feminist, it is a negatively evaluative concept. Moreover, as Vargas (2018) claims, one might or might not be responsible for doing negative or positive evaluations depending on what is available to her. The modern feminist responds differently to being called a LADY depending on the agent. An anarchist has a definition of ANARCHIST for herself, however when labeled and evaluated as an ANARCHIST by the legal authorities, she can object to the conception, providing another definition in her defense. In short, we do not only have a variety of different conceptions of concepts, but we also produce concepts differently depending on our subjective position related to the context. We encounter and are engaged in different instantiations and particularities of our concepts, which do not neatly characterize or categorize the conception. We learn new things and redefine stereotypes, concepts and conceptions, but in order to do that, we have to hold them true and understand different definitions, sometimes as essential entities.

36

Strength and weakness distinction in his account points towards the ability of the stenotype to represent the concept in general. 37 This is how Rawls explains disagreement about the concepts that can be communicated.

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3.3.4 Negation and Pragmatics Väyrynen (2013a, 2013b), while defending his case for pragmatic view of thick concepts, puts a heavy emphasis on modalities, questions, negations and similar “not very straightforward usages” of thick concepts within propositions. I will focus on negations as Kirchin (2017, p. 155) does, reaching a somewhat similar yet different result. The difference in my position has to do with the use of thick concepts, not about the result itself. I think in Väyrynen’s usage as well as because of more general importance on its relation to disagreements, negations hold a more important position within his pragmatic framework than other modal propositions. His most frequently used example is in this form: (1) Madonna’s stage show is lewd. (2) Nah, Madonna’s show isn’t lewd. He claims that while for LEWD users, that is to say, people who believe that LEWD is a valid term and applies to certain cases because certain actions of overt sexual display are to be condemned, this can be a normal case because they are in disagreement about the applicability of a certain moral evaluation to a definite extension. While on the other hand, a person who denies the applicability of the concepts of LEWD, a person who does think that nothing is LEWD and overt sexual display is neither to be condemned nor praised, can still use the second expression, and can still evaluate the situation. From this, Väyrynen (2013a, 2013b), reaches to the conclusion that, the evaluative aspect of the term, while used sincerely by the LEWD users, has to be somehow understood and applied by non-LEWD users as well, eventually leading to the claim that the embedded evaluation in LEWD does not apply universally. This, together with a more meta-linguistic claim, leads him to end the argument in the conclusion; thick concepts are not of very distinctive significance, because their so-called evaluative aspect is not very strongly universalizable, since the deniers of the application of the concept can still use them. This also leads him to say that most evaluation is therefore meta-semantic and shall be pursued in pragmatics because pragmatic evaluations that are not conveyed within language, such as nods, sarcasm and tone of voice are overruling the verdict of embedded evaluation. I believe that his position about the essence of evaluation makes the difference between his understanding and that of Kirchin (2017). Due to this position, he is thus more of a universal pragmatic evaluationist. I think Väyryren’s claim is a very important one in understanding thick concepts. The very idea of being able to make “the final evaluation” should help us to engage in a more diverse understanding of evaluation and hence thick concepts. First, let us see Väyrynen’s argument in a more generalized form in the language. Let us think of an example not about morality but reality. Assume two people believe that unicorns exist and in fact, they believe that they see unicorns here and there occasionally. While they discuss whether a particular animal was unicorn or not, a third person arrives. The third person does not believe that unicorns actually exist, but can perfectly understand what people mean when they talk about unicorns. In that case, when one unicorn believer says that;

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(3) This was a unicorn. And another unicorn believer adds, (4) Nah, it was not a unicorn, it did not look like the one we have seen in the forest. We can perfectly predict that there is no problem when a unicorn denier joins the conversation and says: (5) No, it was not, there is no such thing as a unicorn in reality, it is fictional! So does his general belief system prevents him from saying so? I do not think that is the case. Nevertheless, if we extend the case, it might have different consequences. Think about a more general claim, now the first two believe that God exists and they are pointing their fingers to things and claiming that they are acts of creations of God. The third person thinks that God does not exist, but he can perfectly understand what other people mean by it. In this case, when the God believers say that X is a creation of God, the third person will say that it is not. Within the context of God believers, they will either believe that there are certain things in the world, such as perhaps things produced by people like any material constructs, which are not “created by God” which will end the discussion. Alternatively, the discussion might continue based on determining whether it was the God who created that particular thing or it was made by humans. The second option, given that they believe everything is eventually created by God, they will not understand the first case and object to the claim, leading to a controversy between them and the non-believer, in which the non-believer has to clarify his position and understanding. In the LEWD case as well, when someone denies the usage of LEWD in the daily language, this is generally due to some other moral standards, or political agendas while the denier of the concept can perfectly understand the concept and its use. I believe that the concept LEWD loses its action guiding element due to the possible actions through the application of this concept change due to changes in the society. If we place the social practice as a basis for the morality, the change in practice can be meaningful for the changes in the linguistic sphere. In his analysis of the moral language, Williams (1985) already points out ““I simply don’t like staying at good hotels” is an intelligible thing to say. This brings out the basic weakness of prescriptive accounts of the evaluative” (p. 139). I follow his advice, not to go into prescriptive accounts of the evaluative perspectives, but accept that analysing the evaluative also requires an evaluative perspective. When it comes to application of a certain concept within this framework consider this second example. Think about the meaning of a police car for a person who is immune to the legal system—at least to a certain extent—be she a monarch or a president. Even she cannot see herself as a subject who could be controlled by the police; she would understand how the justice system functions, while being above the justice system. This is how I think thick concepts can function in this framework. Whether it be a meta-reality debate as in the example of God or unicorns, or a metaethics debate in the example of LEWD, denying the particular concept in general is possible while still being able to apply the concept correctly. The explanation of this

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phenomena is given by Harcourt and Thomas (2013), as they state, metalinguistic negation can also apply to the subject, and I see no problem to agree with them. When a LEWD denier states that something is not lewd, while retaining the semantic implications, the LEWD denier denies it on the meta-linguistic grounds. It is also the same with reality, when a biologist operates in the lab, she can believe that the concept of GENE is ambiguous, and perhaps not even real—she might hold that there is a more general theory, which explains the biological phenomena without referring to the concept GENE—but still can work with the concept.38 The same applies to the discussions in ethics, we can distance ourselves from a certain moral codification in the community we live in—and probably since the society is not homogenous, there are people who already deny the usage of such a concept as a whole—and while still being able to understand how the concept applies, can be against the application of the concept in the language nevertheless. While on the other hand we can still be in the “community” and use the concept while claiming that the deniers are of some other nature.

3.3.5 What Is Real and What Is Representation? It is possible to debate the exact nature of any concept. There are many ways to define a concept and some are obviously better than others. We can be instrumentalists or skeptics when discussing the meanings of concepts, however, when it comes to their application, we need a minimum account of realism. Hacking (1983) defends this in concepts that are used by science, I think the same applies in speech acts and usage of concepts in practical aspects of life. The received view at the moment about the stability of concepts is not very diverse. While Dupré (1993) and Hacking (1991, 2007) are relatively liberal about the application of scientific concepts, the emphasis is about the making of the concepts in the general literature. And although it has received criticism (Ereshefsky & Reydon, 2015), the main idea is about the repetition of our social interests, institutions and practices and aims. Be it in Hacking’s Looping Kinds (1995), or Boyd’s “accommodation thesis” (1991), the main emphasis is on concepts’ stability on this regard. In thick concepts, when it is considered that the evaluative aspect of the thick concept can be taken apart from its meaning, the problem is, while it is detachable “in theory” it hardly translates to anything concrete in the general discourse. While thick concepts are detachable in terms of their evaluative and descriptive parts in the abstract, they are “glued” in Blackburn’s (2013) terminology by the practice. A philosopher of language can define a certain thick concept as neatly as possible to yield to certain components being explicitly put apart, but how does this “representation” match “reality”? Moreover, when the thick concept is taken out of the language, 38

For a deliberate discussion of theoretical realism, see; Hacking (1983). Especially on his example of experimentalist engaged in the same experiment in the same group while holding different beliefs about the reality of certain objects they are dealing with (pp. 271–274).

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there is an act towards the existing totality of the language. It creates a gap so that the non-existence of the concept is also meaningful by its existence. If we consider the usage of a certain concept as its total existence, its elucidation is simply a way of abstracting it to organize thought, similar to a scientific “law” or an engineering plan. However, no engineer can plan something in its totality and apply it to the world in a certain definite form.39 Even when the plan is applied to a concrete situation, the result is not that the plan is “true” but rather a certain plan, when applied to a certain situation through modifications in the plan and the environment alike, can lead to a certain result. The plan or the abstraction itself does not define the bigger picture, the practice itself. In language, the role of the elucidation is therefore similar in that regard. We can define a concept to mean something particular, devoid of its use; however, the result of it would be a large abstraction that does not have a touch to reality by itself. Take the concept of CELL for example. The common concept in circulation is assumed to come about from the similarity of the structure of what we call today biological cell and monastery cells. When Robert Hooke resembled what he saw under the microscope to the cells that the monks lived in the monastery, he decided to call the biological cells with the same name (Karp, 2009). Of course, anyone today knows that the two concepts are very different and the resemblance alone hardly means that the two concepts denote the same thing. What Hooke saw might not even be proper cells, perhaps he only saw a grid-like structure that resembled him something; structure of the sub organismic parts. Whichever way the story goes, the underlying result is this, and both concepts of CELL were very different. What established them so differently is the fact that they represent quite different parts of the world. However, this one is easy; the real trick is to distinguish between another forking of the concept, namely the prison cells and the cells that were monks’ quarters. These two cells are also remarkably different, still we do not feel the need to differentiate one from the other, they are quite different because the way we use the realities that they represent is different. They are different of course, but different in a more relatable sense.

3.4 Conclusion When the meaning of the concept is considered together with its usage, there is a greater possibility to produce an understanding that makes thick concepts more understandable. Austin (1975) distinguished between locutionary and perlocutionary acts. The simple distinguishing factor is what we do and which effect we produce while performing a speech act. One form or perlocution is creating meaning; however, it can also be an unintended result of the speech act. We pick a part of the world,

39

Although in principle it can be possible, the current division of labour of current understanding of projects do not allow it.

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we take it for our purpose and bend it as much as we can to fill our purpose,40 we use it and we create a result. At the moment of our usage, it has to be solidified into something that can be put to use, it has to be something socially valid in the linguistic community, even though this linguistic community is not uniform or partial. After the usage, we can “tend” our concept fortifying a certain meaning of it, make willing adjustments, or the adjustment occurs through our usage. One usage can prevail over the other, changing the extension or the intension of the concept depending on which part of it we are using for whichever purpose. However, we do not do it as it pleases us in any way. The parts of the concept, vectors in Putnam’s account, such as the determining factors, change due to our ability to hold them non essentially in their usage, the concepts are changing. The “real” exists second to representation in Hacking’s (1983) account, he claims that humans first created representations of things, and then we had to choose “real” or “true” representations amongst them. For thick concepts, I think a similar model is helpful to understand the conceptual analysis and conceptual usage, as well as agent’s dynamic relation to both. When we consider Hacking’s understanding of meaning in relation to action and making, we reach both a closer account to that of Williams, and also make sense of the meaning change; Epistemology so-called begins when it becomes recognized that knowledge is public, and is not merely a mode of existence of ‘human nature’, ‘understanding’, or ‘reason’. Epistemology needs an object; its object is knowledge; knowledge was not conceived of as an autonomous object until quite recently. In presenting the heyday of ideas in Chapters 2 to 5,[…] I harped on the negative theme that in those days no one cared about meanings. By meanings, I meant what Frege called Sinn, objects whose existence he postulated to explain the common store of human thoughts transmitted from generation to generation.” (Hacking, 1975, p. 166, my emphasis)

When the use of the concept is embedded in the making of the concept; now let us turn to how the concepts are made in the scientific domain. Now I will proceed to sketch how the change of meaning happens in the scientific activity. The concept of disease, is probably not a natural kind and it is under many different kinds of influences, however my aim is to go towards how scientists conceive of concepts in general.

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Moreover, of course, as it is bent, the functions it can perform are subject to change.

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Rawls, J. (1972). A theory of justice. Clarendon Press. Smith, E. E., & Medin, D. L. (1981). Categories and concepts. Harvard University Press. Stevenson, C. L. (1963). Facts and values: Studies in ethical analysis. Yale University Press. Strawson, P. F. (1969). “Meaning and Truth”. In Proceedings of the British Academy. Oxford: Oxford University Press. Vargas, M. R. (2018). The social constitution of agency and responsibility: Oppression, politics, and moral ecology. In K. Hutchison, C. Mackenzie, & M. Oshana (Eds.), Social dimensions of moral responsibility (pp. 110–136). Oxford University Press. Väyrynen, P. (2013a). The lewd, the Rude, and the Nasty: A study of thick concepts in ethics. Oxford University Press. Väyrynen, P. (2013b). Thick concepts and underdetermination. In P. Väyrynen (Ed.), Lewd, the rude, and the nasty: A study of thick concepts in ethics (pp. 159–185). Oxford University Press. Waters, C. K. (2017). No general structure. In M. Slater & Z. Yudell (Eds.), Metaphysics and the philosophy of science (pp. 81–108). Oxford University Press. https://doi.org/10.1093/acprof: oso/9780199363209.003.0005 Williams, B. (1985). Ethics and the limits of philosophy (London: Fontana/Collins).

Chapter 4

Locating the Conceptual Change in Scientific Research

Abstract The debates around the conceptual change of scientific terms and concepts have traditionally held correspondence theory of truth as the main truth criterion. Be it Kuhnian “paradigms” (Kuhn, The structure of scientific revolutions. University of Chicago Press, 1962), and the proposed solution to this problem with the reference of scientific concepts (Devitt, 1979; Scheffler in Bobbs-Merrill, 1967). I am more sympathetic towards a Lakatosian account of theory change as a larger framework within philosophy of science here, and the implied pluralism in his framework. The more nuanced approaches such as that of Brigandt (2020) and Brigandt and Rosario (2020) are more relevant, yet not the same to my understanding of conceptual change due to changes in research agendas. Here I take a pluralist stance, refusing the incommensurability thesis, following the practice-oriented understandings of concept usage in science, following Hacking (1983) and Cartwright (1983, 1999), which enables scientists to have greater autonomy in making of meaning. I believe that if we carry our focus in meaning to the practice and individual scientist and departmental distinctions shaping their making of meaning following different epistemic goals of making of inferential part of the meaning, we can have a more accurate understanding of conceptual change.

4.1 Introduction We use many concepts that are used differently by other people. With some concepts, our relationship with them is of a different nature than the relationships that certain experts have with them. When we are writing about the concept of GENE, what do we know and what does a biologist knows can be radically different from each other. This chapter is about the division of labour in the usage of concepts, and how scientific activity is distributed in the making, use, and change of the concepts employed in science. In the previous chapter, after discussing various perspectives on the composition and the general structure of concepts I concluded that most of the time words that are

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_4

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used by the scientists are rather “like a steamship”, but not “like a hammer” similar to Putnam’s (1975a) account.1 In his traditional model, his main criticism is focused on how concepts as with the traditional accounts that were the received view so far, are seen to be used by one single individual, like a hammer, while some words are of a different nature, they are like steamships that should be operated by multiple people.2 I can find no reason why thick concepts are no exceptions to linguistic division of labour; on the contrary, they are perhaps the best examples of linguistic division of labour in the level of concepts within meaning, since their evaluative part is very social in many occasions. In addition to that, the usage of thick concepts particularly the ones that are thicker, that have stronger evaluative aspects, are monitored by their usage. Such an understanding of concepts emphasizes the social determination of the meanings of the concepts against other externalist accounts.3 Here I will argue for the distinction between different epistemic goals of branching out disciplines, and the diversity in the conceptual usage of different parts of biology. The debates around the conceptual change of scientific terms and concepts have traditionally held correspondence theory of truth as the main truth maker. Be it Kuhnian “paradigms” (1962), and the proposed solution to this problem with the reference of scientific concepts (Devitt, 1979; Scheffler, 1967). I am more sympathetic towards a Lakatosian account of theory change as a larger framework within philosophy of science here, and the implied pluralism in his framework. The more nuanced approaches such as that of Brigandt (2020) and Brigandt and Rosario (2020) are more relevant, yet not the same to my understanding of conceptual change due to changes in research agendas. Here I take a pluralist stance, refusing the incommensurability thesis, following the practice-oriented understandings of concept usage in science, following Hacking (1983) and Cartwright (1983, 1999), which enables scientists to have greater autonomy in making of meaning.4 I believe that if we carry our focus in meaning to the practice and individual scientist and departmental distinctions shaping their making of meaning following different epistemic goals of making of inferential part of the meaning, we can have a more accurate understanding of conceptual change. 1

Putnam (1975a) does not distinguish between words and concepts and writes about words only, however the way he uses the concept word that is also sensical in a structure that is based on concepts rather than words. 2 “We may summarize this discussion by pointing out that there are two sorts of tools in the world: there are tools like a hammer or a screwdriver, which can be used by one person; and there are tools like a steamship which require the cooperative activity of a number of persons to use. Words have been thought of too much on the model of the first sort of tool.” (Putnam, 1975a, p. 706). 3 This perspective takes the nature of concepts as mental entities and uses them as representational categories rather than tools we use to interact with the world. However, I think subscribing to a meaning as use view does not disrupt the work on concepts as representational entities that can be further used. 4 Olsson and Westlund (2006), coming from a more formal epistemological perspective discuss the importance of individual researcher’s agenda in meaning change. Although I believe that it is similar to the autonomy I mention here, their analysis is in relative formal epistemological understanding, not focusing on the research structures.

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Moreover, this can allow us to have an understanding of the main drivers of conceptual change in science.

4.2 Limits of a Stable Division of Labor and the Steamship of Theseus Similar to Putnam’s (1975a) original example of WATER, there are also many other concepts that are employed by scientists within the scientific communities and the general public alike.5 On such concepts as well, there is usually a division of labour.6 There is no single use or mastery of concepts that is invested in a singular individual scientist, but rather there are various aspects of concepts, which only through diverse activities amount to the application of the concept, making meaning a social issue in the greater structure.7 I claim that this perspective, although has great benefits when it comes to understand the workings of the stable concepts in general, does not give a specific understanding of the perspectives of scientists about these concepts. This does not necessarily mean that this perspective is limited to the concepts being employed by science, but scientific plurality being more of the norm rather than the exception in research, applies easier to concepts that undergo such changes, which I believe are most concepts within scientific research. This is due to the focus of Putnam’s linguistic division of labour being attached to a theory of truth that has the expectation of truth convergence in the very first place.8 As a result of this perspective of realism, in Putnam’s initial account the roles of the different users of the concept are given in a unified way. By a unified way I mean that, the set division of labour is there to stay, the individual tasks are in a given scheme and this division of labour is always made in a harmonious fashion where the tasks for scientists, communicators and the general public are predetermined. Some people within the division of labour is tasked to do only certain kinds of activities with concepts, for example determining the extension, while others are responsible with 5

Moreno (2016) distinguishes between the reference changes in Putnam and Kripke’s accounts. Kripke’s account has speaker reference and semantic reference. In Kripke’s (1977) account there is a further distinction between speaker referent and semantic referent. Although the meaning change I imply here is not only reference change, it is important to see that there are other accounts that give speaker a certain autonomy with respect to meaning. 6 One important point Putnam does not consider is the production, invention or alteration of concepts in the division of labor. He writes about the usage of the concepts, which are already in the circulation in the division of labor but not in the making of the concepts. 7 Norby (2019) goes so far to discuss the ownership of concepts within the division of labour. 8 There is a special account of Kitcher, namely the “mode of reference” where he discusses about the tokenings of a term reference being fixed in different ways, which is granting subjective autonomy in the creating or redefining of the concept (Kitcher, 1978, 1982). However, his accounts could not become the received view, and they are rather idealistic in the sense that they to not refer to the conditions in which the concepts take shape. Brigandt (2010) criticizes his model of not being rational although I agree with his criticism, I think he uses rational in a restrictive sense. I criticize Kitcher’s model for being not tied to institutions or scientific activity.

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finding examples. Moreover, although Putnam’s account on division of linguistic labour explains how the concepts are used through different tasks being fulfilled by various parts of the users of the concept, it gives no account of change in the meaning of the concepts, or in the structure of concepts. Standard meaning of concepts is possible only in the personal understanding of meaning. In addition to that, Putnam’s account of division of linguistic labour does not allow any kind of pluralism about the truth of the meaning, or anything external that can have effects on the usage or the making of the concept.9 In his account, some users of the concept of GOLD know how to recognize it, some, how to work it, and some, how to value it etc. This stable structure can be realistic in some areas of established science in some sciences for a certain time, or for some scientists working strictly on one designated area of science or for a science student. However, with the growth of subfields, when various new disciplines and the disputes among these disciplines as well as pluralistic understanding of some concepts within a discipline “that is to be born” are considered, it is not easy to accept this scheme for application of every linguistic division of labour. Since the conception of concepts in their rigid form of the classical concepts do not make it possible to study conceptual change, one prime difficulty when it comes to conceptual change is its location, whether in semantic, cognitive or social level. Scholars working on different senses of conceptual change worked on different places to locate conceptual change.10 For some, the concept change occurs on the individual level,11 through the creative activity of the individual. It is more of a personal cognitive change since the concept is possessed by the individual. Whereas for Nersessian (1984) as well as most philosophers of science such as Feyerabend, Hacking and Cartwright, who have been involved in the debates around scientific realism in the 80s, concept change has to do with meaning networks and how the individual scientist can see the meaning of the concept change as the scientist works on different concepts and different networks. The older, rather Kuhnian12 account sees the process of conceptual change both on the social and individual level; however, the relationship between the individual level and the social level is not given in a detailed account in Kuhnian perspectives. 9

Putnam (1975b) uses the benefit of doubt on the certainty of the references of concepts, which might not be easy to settle in the progressing and newly developing sciences; however, it should not be confused with pluralism as it is understood in the classical philosophy of science. 10 Most of the meaning change debate was about scientific terms and the debate that revolved around incommensurability of scientific terms. This is understandable within the framework of scientific realism debate, since the proponents of scientific realism took theories to be true, or at least getting closer to truth, therefore they tried to address this issue within scientific realism in which the language was to be arranged with respect to the assumed scientific reality. I do not take part in this debate, but would shortly note that I follow more practical oriented approaches in scientific pluralism, which holds that although there are different theories and networks of knowledge, the scientists can understand the same concept being applied in different theories, and be instrumentalists about their entities. 11 Individual level here applies both to experts and non-experts. 12 Sankey (2000) defends that in scientific revolutions, the main change is the Kuhnian alterations in the meaning schemes in a realist manner.

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From a historical perspective on scientific concepts in particular and concepts in general, one thing is certain, conceptual change when it comes to many concepts employed in science is the norm, not the exception. Some philosophers, particularly the philosophers working on the newly developing field of conceptual engineering, like Sawyer (2018) take conceptual change itself as a given,13 and use this fact to work on conceptual engineering.14 Chalmers (2020) defines conceptual engineering as “as the design, implementation, and evaluation of concepts” (p. 1). Although accounts, which work on conceptual engineering often require a semantic externalist understanding of meaning that relies causal theory of reference (Koch, 2018), a division of linguistic labour model can also accommodate understandings that are more pragmatic. Conceptual engineering becoming so prominent recently is already waving the flag that for at least some concepts, the communities of research are rather eager and ready to see concepts not only corresponding to a passive reality out there. Although it is not easily possible to account for one general formula for meaning change of concepts, it is possible to describe the locations of conceptual change in a general way. I believe that there can be used a three-part structure to account for the conceptual change, these three parts being; cognitive/individual, semantic/mediating and social/general levels and claim that this threefold structure can explain how conceptual change in biology takes place. This structure follows Putnam’s (1975a) understanding of meaning through some alterations in the linguistic division of labour due to the difficulty in assessing the division in the biological research, as well as looking at the practical aspects of the concepts in their usage in the experiments and research. This account will be more helpful to understand the conceptual change since it does not rely on the general externalist understanding of concepts and the copy theory of truth where there are usually two aspects that determine meaning. I will employ this three-part model by acknowledging the relative autonomy of the scientists in the conceptual change, and enabling the outside factors that determine the meaning of a concept to enter the division of labour to understand this change.15

13

It makes sense for conceptual engineering to assess the change of meaning as a very “natural” character of concepts in general to establish a more interventionist perspective. 14 It is interesting to see that recent philosophy of concepts is branching out from conceptual analysis, that is the backward looking analysis of concepts in hindsight, to a future looking design of concepts in the recent couple of years. Conceptual engineering looks like a promising approach towards openly talking about the kinds of concepts we need and use. 15 As Rusanen (2014) defends, I also think that one single understanding of conceptual change fails to capture the general phenomenon taken to be the conceptual change. However, within a given discipline, when certain requirements are met, we can have an explanatory model in conceptual change in evolutionary biology.

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4.3 When Is Biological Research Complete? Difficulty Due to the Structure of Research Communities Defining a biological concept at first seems like an easy task when we ask for the intension of any concept.16 On top of that, most proposed structures of concepts end division of linguistic labour is mostly about “mature” or “finished” concepts, and supposedly concepts employed in biology should be falling under those. After all, biological concepts are supposed to be scientific, undergoing relentless revision and being used very often by the scientists for very precise experimental and theoretical purposes, yet still when it comes to ask a biologist about the possibility of a definition it seems difficult. Following a scientific realist understanding, the result is expected to be simple. It seems like looking at a relevant biological textbook could help us to understand what that concept means, and how it is related to other concepts. Observing how the scientists use the concept that is investigated also can be helpful to conceive the meaning of the term eventually they are expected to be leading to the same direction at least. However, as long as we accept that the concepts are open to change in biology, we have to distinguish between how they are written in the textbooks in their final form, and how they are actually used and related to the scientific activity by the scientists. Following Cartwright’s (1983) and Hacking’s (1983) understandings about the difference between practical and theoretical aspects of the concepts that are used in science, Still, there is a large gap when it comes to distinguishing between the usage of a concept in research and how it is codified in a given textbook or manual. Take the concept of GENE for example. In any textbook it is possible to find a definition of a gene, and although there has been increasing diversity in the usage of the concept, it is still used within the context of a progressive research programme. I claim that a better way to understand conceptual change can emerge from the investigation of research activity in its complete, rather than looking at particular elements, be them extensions, intensions or epistemic goals of the concepts. When we look at the usage of a concept by a scientist we can also see the scientist working on different usages of the concept. During personal relationship as well, she first takes the exact definition as it is. Afterwards applies it in a modified way to her specific study or discipline. In the professional scientific set up probably she needs to see the epistemic goals and intensions taken to be different in other branches, or within the same branch as well, due to varying research agendas. And if she looks at the other 16

Here, instead of an exclusivist account of meanings, I will rely on all the different aspects of concepts. I will hold true the cognitive picture as well as the traditional picture and will try to develop a structure to explain how different parts of the scientific concepts might be connected to different parts of scientific, linguistic and everyday practices. The scheme that I will offer will not be final or all inclusionary, it will mainly be based on my observations in the various laboratory groups of IEB and EvoPAD in Münster. Due to that, I will be closer to the concepts that the scientists working on the recent developments in evolutionary biology are studying and it will not reflect the scientific concepts in general. I will consider not only a pluralistic stance, but also a position where the individual scientist’s cognition and practice also takes part in the concept formation, use, policing and change.

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works of other scientists working in the field albeit using the concept differently, she can end up using it in a pluralistic way afterwards. After recognizing this she might reach another conclusion, and go back to redefine the concept in the end. However, these tasks are also often distributed amongst the different parts of the scientific communities quite often given the size of the communities themselves.17 Consider the diversity of scientists who are using the concept of cell, parasite or health. These concepts undercut even the traditional disciplines, let alone the differences within these disciplines. When it comes to such “spread out” concepts in particular, trying to find an exact intension will be problematic, since it will not only disallow other usages by different disciplines but it will also make the individual modification of the concept, and individual research agendas impossible. To make this process more conceivable it makes sense to start from a student’s position looking at a textbook. However, this starting point does not mark the end for looking for the semantic truth value of these concepts. I claim that the classical theory of meaning, which is explained in the previous chapter, is closer to what we have as meaning of concepts in the textbooks of science. That is to say, at first, every scientist learns a concept in the very essentialist and stable manner. In this perspective, an entity has a certain set of properties, and as these properties fall under a concept, eventually they make that concept up. Although scientists can employ the classical schema of concept structure during various parts of the scientific inquiry also when the given definitions of concepts are different, when we look at the complete process of scientific inquiry, it becomes impossible to hold onto the classical schema of concepts through the scientific work at least for certain concepts. The space where the classical definitions do not apply—given there are differences in meaning— are particularly necessary for the research purposes (Nersessian, 1985), since the standard set of definitions—given that they are pluralistic—need a place where it should be possible to switch among different definitions. Yet since biology is a very large discipline, even the idea of a single textbook presenting all concepts that are relevant in the field is quite difficult to attain. Of course, there are introductory books to biology and in addition to them introduction books to specific biological domains and even introduction books to more specific subdomains and there are research groups which are working with a particular meaning of a concept. Such textbooks make it look like even if there is no strict quest for one single definition that is objectively true, there can at least be some kind of agreement amongst the scientific community in the sense of a trade-off or negotiation. However even the last set of books or even lab manuals in their respectable domain can be a bit—or by large—far away from how the concepts are employed in the laboratories by the scientists who are doing research.18

17

This first dual distinction, as it is already discussed in philosophy of science, marks the borderline between the context of discovery and the context of justification. 18 Moreover, although the general concept in the introductory level might be true, it might lose its explanatory use due to generalizations from very different fields.

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So far I argued within the framework, eventually the scientific research would lead to a conceptual consensus, by stating that in the end the scientific community will redefine the concept.19 Although whether it is possible to reach a unified concept or not depends on the individual concept that is under inquiry, there are many pluralists when it comes to key concepts of biology such as SPECIES (Dupré, 1993; Ereschefsky 2001), or GENE (Burian, 2004; Dupré, 2004). I do believe that as the concept reaches more generality and such is used by more subbranches that have differing research programmes or research agendas, the more pluralistic they have to be, due to extension, intension and also the social elements are prone to change with respect to the comparison concept. In addition to this “laboratory of division of labour”, the social aspect of the concept within the linguistic division of labour is also prone to be detached under some circumstances, As put by Hacking; ‘The distribution of electrons is 50 per cent spin-up, 50 per cent spin-down’ has no standard use outside some version of the quantum theory. It has no truth conditions apart from the theory, and hence, on a simplistic version of the Fregean account, no meaning either. (Hacking, 1975, p. 123)

The limitations of truth dependencies of concepts under very specific circumstances make sense to conceptualize the possibility of a concept being used even in predicates with truth conditions make it understandable that, there will always be at least certain kinds of pluralisms when it comes to scientific concepts due to their specificity. Moreover, even within a single domain in biology, as long as there is ongoing research for the entities that fall under a certain concept, during research this concept will be used differently, given that the research is continuous,20 and the research programs are plural. Therefore, in biology it is not easy to expect a single definition of a concept that will prevail over the others after lengthy discussions and discovery processes, due to the structure of the research communities themselves. Putnam’s model of steamship, being very durable and concrete in its nature, is not answering the concepts that are in use by biology, not the concepts that matter within research at least. Therefore, we can start talking about not a regular steamship, but the Steamship of Theseus.

4.3.1 Difficulty in Research, Someone’s Research Topic, Someone’s Given—Vertically Direction of Change One challenge that needs to be addressed when it comes to arrange the relationships between various scientists and scientific communities that, at least on the façade, seem to be working on the same topic is the difficulty about which aspect of the 19 20

The scientific consensus can be localized or pluralistic at least in practice as well. Or progressive research programmes in Lakatosian sense.

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concept is worked on and which direction their research leads. While some scientists are doing research in a particular topic where the concepts are strictly defined and well-guarded,21 some others are doing research in the periphery of the concept.22 This research process eventually contributes to different parts of the meaning of the concept at least in a particular field or number of fields sometimes even developing new fields related to the classical field that the original concept is originated from. While the ones who are working on topics established around the traditional definition of the concept are strengthening the orthodox usage of the term by holding the definition true by application of it in many domains, other groups can be revisionary in the usage of the concept. Moreover, it quite often is the case that, while some scientists are using a concept in a very strict definition, others are using it through an even stricter textbook definition, yet a different one. This situation brings about a particular problem since while in one discipline the research might stabilize the concepts, at the same time in another it might start to become vaguer or can start to have a different meaning. This means for some scientists working on a single part of biology, a concept might be a constitutive element something close to an a priori principle to be able to conduct research (Stump, 2015). While for another biologist, the exact same concept is an open question and multiple theories, and hypothesis are at play about the same concept when they are dealing with the same referent of the concept.23 This issue becomes particularly pressing when it comes to theoretical and empirical parts of the research, which are usually conducted by different people, groups and even sometimes departments, or in the case of biology, when one sub-discipline has or a couple of sub-disciplines have a higher authority in deciding on the theory (Gould & Lewontin, 1979).24 ,25 This can also be the case when they are following different research programs, in which the concepts are used to solve different problems, changing the explanatory task of the concept in question (Brigandt, 2010). This way, the stable identity of the concept can be retained in one discipline since the epistemic function of the concept remains constant in one branch while for the other it changes slowly. Thagard (1990) also describes this slow pace of meaning change in concepts where the concepts also have degrees of change, such as adding weak 21

Guarding of the concept can be seen in a Lakatosian way of hardcores within research programmes (Lakatos, 1980). 22 For example, research on certain properties of an entity rather than explaining the entity in general. One might think about research on virulence, without doing direct research on a certain virus or a disease, some scientists take virulence to be an issue, which is related to the concept of microbe however, it is not by itself at issue. 23 This can also be seen similarly to concept learning. While the concept learning perspectives are often connected to the understandings that have more to do with students and not “experts”, when it comes to particular fields within sciences, I believe that seeing them similar to students’ concept learning perspectives is a better way to make sense of the conceptual pluralism particularly when it comes to communications amongst scientists. This perspectives sees the methods and definitions always in possibility of revision, enabling scientists to “teach” to and “learn” from each other. 24 Spandrels of San Marco discusses this issue in evolutionary biology. 25 Bishop and Downes (2002) call this kind of situations as division of cognitive labour in science.

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instances, weak or strong rules to them when it comes to their application. Moreover, usually there is no higher authority which tells us what will happen to the meaning of the concepts eventually.26 The revisionary27 case is exemplified by Arabatzis. The stable identity of a concept can be explained in two ways: first, by the retention of a core of properties attributed to its referent (for details, see Arabatzis 2007); and, second, by the continuity of the epistemic function of a concept, that is, the preservation of a core of problems (e.g., explanatory tasks), which continue to be addressed in terms of the concept in question (cf. Brigand 2010). (Arabatzis, 2019, p. 93).

I claim that during conceptual change, the stable identity of a concept can be eroded in two different ways described by Arabatzis (2019). It is possible for a scientific concept’s referent to lose or gain “core properties” of the entity. After all, the widely accepted function of a science is to learn more about the entities in the world, and as we know new properties of the given object, they add up and occasionally they are subject to change due to revision of beliefs. Given that different branches of science are occupied with using the same concept for their own explanatory tasks, it would be only natural for the concept in question to retain, gain or lose some properties depending on its usage. This is connected to the second possibility; the epistemic function of the concept might be changing due to more fundamental changes in the discipline, such as branching out of the discipline itself or development of different research questions, methods, paradigms or programs. The particularly important aspect when it comes to meaning pluralism in branching new disciplines within an established science is its relative independence from the stem discipline that it branches from. This situation occurs when there are new scientists who are specified in working on new set of questions, which were not considered within the discipline previously at all or seen as not very important in the original discipline.28 Furthermore, it might be practically difficult or even sometimes impossible for the parent discipline to have the kind of epistemic goals with the branching out discipline due to the conceptual limitations imposed by the concept they employ. I name such changes in the new coming branches as the vertical shifts. Although there is a shift with respect to the new discipline, the parent discipline can stay the same with respect to its epistemic goals, concept definitions, research communities and the like, continuing its own research activities. It can even be expected for the parent discipline to go “backwards” since some of the shared research agenda has left, or at leased ceased to become central due to the creatin of the new discipline. From a pragmatic perspective, it is sensible to expect a form of diversity as new areas of study are opening for research, and creating new domains where the concept is supposed to be used differently. 26

Of course this is true when we consider the possibility of staying within the borders of scientific communities. If we consider research programmes, departments, etc. it might be possible to expect a certain outcome in the meaning of a concept at the end of the scientific inquiry. 27 In contrast to the more traditional “revolutionary” account that is generally attributed to Kuhn. 28 The distinction can be traced back to Lakatos’s (1980) protective belts and hard cores. In general, the development of a new discipline is the production of a new hard core sometimes inside the protective belt of the existing discipline and sometimes completely far from it.

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Consider having a department of parasitology under a more general biological discipline. Since they are dealing with various kinds of parasites as life forms with a rather theoretical understanding of the parasitic relationship, this discipline includes the study on viruses, bacteria, worms, etc. However, in the department of virology, where the focus is on the research on viruses, the concept parasite fulfils another function. On the façade, it seems as if they both are using the same unique biological concept of parasite. However, as the class of entities that fall under both disciplines also differ, the research programs and epistemic goals are divergent, this eventually leads us to have another concept of parasite in virology, and a different one in parasitology. The list of relevant disciplines can go further in number in medical science, bacteriology etc. The result is, the more productive the parent disciplines, the disciplines that create new branches that are first under them, have to face this dilemma about the multiplicity of concepts since the scientific communities also start to differ on this vertical level.

4.3.2 Sub-fields—Which Part of a Discipline Speaks for the Concept—Horizontal Aspect of Change Apart from the vertical aspect of the conceptual change, we can also talk about the horizontal aspect. That is the interrelation between two related disciplines that do not have a primary but rather secondary relationship or weaker relationship with each other. An example can be the relationship between virology and ecology. In biology, it is also often the case that the people who are doing their own part in the linguistic division of labour are not unified in the research activities that they are involved in. Scientific communities, since institutions are diverse, and they can be quite conservative, in come cases, they need to be conservative about certain concepts to maintain their disciplinary integrity when there are many other disciplines close enough to them which are around them. Although many communities are tasked to use the concept for a specific purpose due to their overall linguistic activity in using a concept, they can use it differently to fulfil different tasks; moreover, scientists who are supposed to decide which use is the correct one might not come to a unanimous decision. That is to say, usually there are many different scientists who are working on different aspects of the concept at issue, and most often than not, there is no high authority at the level of decision makers of the intension and even when there are, they are still not united in the definition of the intension.29 Furthermore, even in the subfields and among colleagues, it is commonplace to subscribe to different meanings of the concept, although communication between colleagues and even

29

Of course, it can be claimed that the parent discipline has a certain authority to fix the meaning. However, I find this position not very convincing by itself due to institutionalization structures, however some form of trade off can be seen in the overall structure.

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working together in the same project is still possible on the practical level (Hacking, 1983).30 The difficulty in establishing the meaning of a certain concept through explication is due to the concept having different meanings although they are in the same field albeit having different uses by different communities. This issue is particularly pressing when the scientific communities are working on the same domain. In some cases, it might be easy to distinguish through disambiguation. When the disciplines are substantially far apart, it is easy to say that a certain concept is different from its namesake, since it is surrounded with completely different auxiliary concepts and usages and is within very different epistemic frameworks and research programmes. Hacking (1983) uses the example of phenomenology in such disambiguation as meaning pluralism, where in quantum physics, there are also phenomenologists working in the experimental set ups, and the concept is originating from the same stem as philosophical phenomenology. However, when it comes to concepts which are still relatively closely related, such as the concept of acid, the issue becomes more complex. Since there are already—at least—two different scientific definitions of acid, each being applicable for specific purposes, and the general concept of acid still retaining its function, this is also a likely possibility for concepts to diverge in meaning within a given discipline. Moreover, in the example of acid, we have also seen that it is possible to have people from different research groups using the concept pragmatically depending on what they are dealing with. In such situations, even deferring other aspects or uses of the term are required for the concept to be useful (Nersessian, 1984). This is understandable since without changing certain functions of the concepts reaching other activities might be difficult or even impossible due to the limitations that are enforced by these concepts.31 Again, following the social aspect of meaning perspective resulting in the objection to the copy theory of truth by Hacking (1975, p. 76), it is possible to see that the “sense” of the terms needs an objective public to attach itself to its truth-value. Against the pluralistic possibility, Rusanen and Pöyhönen (2013) argue about the possibility of a correct answer within a scientific community. The difficulty is, in research, it is usual to have cases where there are only few other scientists and research groups working in the field who can police the truth or falsity of the current research, particularly when the domain already has abundant alternatives for truth. Establishing meaning for concepts that are more general in scope but divided much further in research activities is even more difficult to assess at the research level. Of course, a horizontal distinction does not mean that the concept is being left for disambiguation for good. 30

The question whether there should be a unity or not in concept understanding is not at question here. I believe that although there is pluralism at the conceptual level, practical level can be fully operational. Although this is the case within science at practice, when it comes to thick concepts, the emergence of a certain kind of meaning gains importance, since the result has direct social consequences. 31 It is also possible for the discipline to come up with a new concept. However in order to make it relatable or relevant to the general epistemological framework, it needs to relate itself in a way that in the end it creates a certain kind of meaning change in the earlier concept.

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However, it means that, when it comes to ongoing research on scientific concepts, which are also used publicly, it is indeed very difficult to assess a higher authority due to the research communities being structured in the way they currently are. In addition, this way of structuring the division of linguistic labour in the horizontal divisions of meaning in research seems to be here to stay at least in the active sciences.32 After seeing the disciplinary distinctions creating differing research agendas, epistemic goals and the individual scientists autonomy in the framing of the epistemic framework. I would like to visit the main issue in the discussion of scientific realism because it can as well be claimed that, although linguistically they are dealing with different entities, factually it can be claimed that they are still working on the same phenomena even the scientists can have individual differences in their agendas and disciplines diverge.

4.4 What Kind of Entities Are Concepts in Research?—Is It Simply a Linguistic Problem?—Language and Thought In part 3.1, I demonstrated two variants when it comes to the direction of change in scientific concepts. These two variants of different divisions are namely the horizontal and vertical aspects. In order to counter social aspects of concepts, there has been an important move in differentiating the linguistic and conceptual parts of the terms. Sawyer (2018) distinguishes between terms and concepts to save the copy theory of truth. On this account, while linguistic entities—terms—can be matters of convention where what matters is not even the expertise about settling the meaning, the concepts expressed by these terms can be separated from the linguistic structures that they are expressed through, and thus can be objective—freed (or at least autonomous) from the social aspects of the linguistic process. This distinction is particularly valuable. We can see the divide between terms and concepts, the former being linguistic, and the latter being thought related as an important fault line in philosophy. Working on the first part would amount to working on semantics while the other would be more about cognitive science and psychology. Burge (1986) makes the distinction between thought and language, we can also see this distinction as early as Fodor (1975) while he coins cognitive science and expects it to work on the mental, rather than conceptual issues. If this distinction holds about the linguistic division of labour, the objectivity and the reference fixation of the concepts can be saved, since it will enable us to talk about the social part—the term—as linguistic, and the conceptual part completely as a relationship between the

32

We can read this parallel to the general understanding of nonexistence of the crucial experiments in science.

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mental and the world.33 The main idea is rather straightforward in the making of this distinction, if thought is supposed to be about the reality, perhaps it can be possible to stop talking about the linguistic problems and focus on scientific entities. Although this strategy can be possible for more natural kind34 concepts, when it comes to terms, which are expressing entities that are more abstract where the constitution of the concept is also dependent on what is included due to the ontological status of such concepts, the situation becomes much more difficult. The difficulty arises firstly due to the fact that finding natural kinds are difficult particularly when it comes to biological research (Nicholson & Duprè, 2018). In the inquiries revolving around the supposed natural kinds philosophers often use examples such as chemical formulas (H2 O, Aluminium etc.) or biological species (Whales, humans and the like). Even for such concepts, there have been objections (Chang, 2012; Dupré, 2004; Hacking, 1999) about their natural kindness. However, the concepts which are more of interest to us are even more difficult to fit in to the ideal understanding of natural kinds. When it comes to more categorical terms such as disease, protein, organism and similar terms, the difficulty is obvious because these terms do not denote single kind of entities because they are more general categories and their intension—let alone epistemic goal—are very diverse with respect to diversity in different subfields and rivalling theoretical structures.35 The entities require a Kripkean baptism of which applicability is also often limited to proper names, natural kinds and logical constructs and these general more abstract concepts are very unlike proper names in this regard. The kinds of concepts that are called into question in this debate also take a different form under this light. Many high level36 concepts that scientists use are not natural kinds or an object in its own right, but rather concepts that categorize many different kind of entities, in the sense that the already known and defined process or entity becomes part of a bigger concept that makes sense of the process. Examples for these can be concepts such as DISEASE, EVOLUTION and GENE.37 There are certain entity concepts such as HEART, TABLE and WING. These second kind of concepts seem to be closer to the supposed natural kind concepts and therefore it is much easier for them to have definitive and exhaustive descriptions of them. However, concepts such as DISEASE or SPECIES, which are very difficult to define due to the numerous instances falling under them, are closer to Wittgensteinian family resemblances. Moreover, unlike the often-used WHALE example in meaning change debate, where they were supposed to be fish yet after discovering more about 33

Interestingly, in discussions regarding thick concepts this distinction is seldom made. Väyrynen (2013) takes this distinction to be even unimportant. This might be due to general idealistic understanding of concepts, which are generally followed while discussing thick concepts, which does not easily make it possible to work on conceptual change on this subject. 34 Or closer to natural kind, more causally connected like in the examples of Boydian accounts. 35 Of course it is possible to argue against the nonexistence of natural kinds, however I will not pursue it here, my general position with respect to natural kinds debate is somewhere between Duprè’s (1993) promiscuous realism and Hacking’s (1999) universal constructivism. 36 With “high level”, I mean more abstract, rather ideal concepts. 37 In GENE, when the definition is given in a structural manner, it becomes difficult to mitigate the structural and functional definitions, for detailed discussion see (Greslehner, 2020).

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whales there has been a conceptual change about the intension of the concept, more abstract concepts do not seem to follow this suit. Unlike “whale-fish” where the extension remains constant since the whales are concrete entities, in categories such as “evolution” or “disease” it becomes much more difficult to fix intension since the concepts at play are already very abstract and many different entities with various properties fall under them and the extension changes together with the intension of the concept. Moreover, linguistically, societies also govern the extension of the term indirectly when the concept is action guiding. This situation is also holding true for the concepts that Sawyer (2018) uses as examples which are purely descriptive concepts. However, contrary to the presuppositions of the above discussion, it is also possible for a concept to be retained by the scientist on a rather psychological level or retained by a certain group of scientists on a more social level even when the general scientific community accepts a new definition.

4.4.1 Contradictions Between the Particular and the Abstract In the literature of philosophy of science, there are different ways to distinguish different kinds of entities. Apart from the above-distinguished natural kind, nonnatural kind distinction, often the entities around which the realism debate is centered are distinguished as “manifest entities” and “unobserved entities”, although this distinction, partially due to efforts of Van Fraassen (1980) and Hacking (1983), was weakened on different grounds. In contrast to the traditional way to distinguish between different kinds of entities within research—manifest and unobservable—, some philosophers of science developed another way within their particular frameworks to make sense of different kinds of entities within research. This other way to distinguish entities is about their reality and their relationship to research activities (Cartwright, 1999; Galison, 1987). Unlike the general category concepts which are discussed above, most of the day to day scientific research is usually about the particular, while the conceptual work and canonization of the concept in the semantic and the social level are conceptual. When a scientist conducts research, the research question itself can be general, such as the evolutionary advantage of diseases; however the scientific methodology requires a level of certainty that can be only attained when the limiting conditions are present which can result to research on a particular response of a certain microorganism under controlled environments. This creates the problem of doing research for such large level concepts The second kind of research activity amounts to knowledge about the particular disease, through a particular mechanism of evolution, in a particular environment etc. Because of this specificity, it is almost impossible to attain the answer to such general level questions on the level of practical research activity. However, there is another activity that, although not all scientists have to do, some scientists and some philosophers are more involved in. This is the theory and concept building activity that in turn yields to the more general concepts’ meaning

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shifts “when the research is complete”. Due to this specific nature of the research activities oftentimes, the scientists can be both at the liberty to choose their different understanding in the general theory to an extent, and that also means that one single research programme or group is almost never tasked to do research for such an answer for a single conceptual question. The scientific field in this sense, is distributed.

4.4.2 Grasp and Use (Possessing a Concept)—Scientist Is Back into the Picture So far, I have pointed out various difficulties in research, particularly in biology when it comes to representing different concepts in single conceptual structures and the necessity of certain kinds of cleavages in meaning. Of course, it is possible to find new structures that create different kinds of pluralisms and I do not claim that I have by any means exhausted the pluralism that exists within scientific communities. The importance and prevalence of differences in research communities and the differences in their usages of these concepts as well as their particular importance when it comes to analyse concepts should be made clear by now. In this part, I would like to point out how different scientists relate themselves to these concepts and how the individual scientists can possess different conceptions for the same concept and employ them as different tools while entertaining many of them at the same time. This, in turn, will be the third aspect in the making of the meaning, the subjective/individual element. Many scholars working on conceptual change within conceptual learning such as Caravita and Hallden (1994), Vosniadou (2003) and Hatano and Inagaki (1994) do it as far as it is taking place for schoolchildren ranging from primary school pupils to university students. Although many scientists spend the vast majority of their time learning concepts which can be considered very similar to that of young students, there are also a couple of different elements relatively unique to scientific research activity when it comes to conceptual change. (1) Scientists usually work in pluralistic networks of knowledge through most of their research at least about some of the concepts they employ. (2) Scientific activity is also a creative activity, which involves not only grasping a concept, but also requires scientists to develop their own concepts, be they for ad hoc purposes or for the purposes of explanation and also use them in ways which are not defined by the concept itself38 (Nersessian, 1984). This process means that through the scientific activity, the scientists are often involved in different vertical parts of the linguistic division of labour in scientific communities. Moreover, from other parts of the scientific community they can also have access to other usages of the concepts that they employ. This can enable the 38

Unlike children creating their own concepts, which is generally seen as false application of the concept, scientists have certain amount of authority to claim that their concepts can be truer than the widespread usage or one of the widespread usages of the concept at question.

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scientist to learn from the horizontal distinction, since the other sub-disciplines are also available to them. From this point, we can look at the more psychological/individual level of the concept use and grasp. Regarding the awareness of the multiplicity of the usages of the concepts in their own disciplines, more psychologically oriented approaches like that of Machery (2009) tell us that it is natural to possess many different concepts for a single category, be it in the scientific or the public level. The concepts we use are already existent and employed in one or multiple linguistic communities for most of the time unless we create them for a particular purpose similar to Kripkean baptisms. However, the general meaning of the concept is rarely sufficient to understand the concept use. Like in any kind of tool use, concepts also need to be grasped or grasped more accurately through better mastery of the concept. Machery (2009) tells us about various parts of the concepts which can be grasped in different ways, and the concepts can be seen in different ways by individuals, I think there is no reason to think that scientists are different with respect to their relationships with concepts.39 While the classical, rather idealistic view claims that, there is one “correct” use of the concept; this perspective does not allow us to see the meaning changes of the concepts in a dynamical way in the research. The possession of a certain concept, much like any other “object” starts a change in the very concept’s meaning. The “possession” literature, also supported by Arabatzis (2019) helps us to understand that the scientists can also distance themselves from the meaning network that they are operating in. Moreover, from earlier work of Lakatos (1980) and Feyerabend (2020) [1975] we have ground to believe that scientists also can possess different meanings for the same concept, even when they are embedded different theories and theoretical structures. Therefore, it is not only that there are various usages of concepts, but scientists can be made aware (internal or external to the scientific activity) of these various usages.40

4.4.2.1

Parts of the Concepts—Where to Grasp?

After discussing different relationships that scientists have and can have with concepts and different kinds of concepts, we must ask again, how does it all come together again? Returning to Putnam’s (1975a) account of meaning, we can see that it has four elements for every concept: syntactic markers, semantic markers, stereotype and extension. I believe that when it comes to more general concepts 39

It can be argued that although the individual scientists’ understanding can be more psychological, the overall scientific activity follows a more “rational” path. I believe that in such an understanding, viewing the larger scientific activity with respect to research programmes rather than incommensurable paradigms also answer the same question. I believe that the purpose should be at creating levels, not the exact location of levels at this stage. 40 This approach might resemble reverse engineering in the sense that, I first take the domain and activity pluralism as the main issue, and then when it is seen as a given, the scientist is being positioned as the carrier of the change through her own individual position with respect to the research activity.

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such as DISEASE or EVOLUTION, unlike H2 0, it is difficult to find matching parts for all four. The extension branches out due to many sub disciplines working on the concept in question. In addition to that, the subdisciplines use different stereotypes of the concept they have in common due to their different epistemic frameworks. In Machery’s (2009) understanding of possession of multiple concepts on the psychological level, we have three distinct types of concepts; exemplars, theories and stereotypes. He claims that these distinctions are not due to some linguistic division of labour but structures that are embedded in the cognitive processes of individuals. When we see that the division of labour in Putnam’s sense is further divided into Machery’s structures, and the scientist’s ability to partake in different parts in the division of labour, I think we have a much more liberal and open understanding of concepts which is easier to make sense of the conceptual change. However, are these different parts of the division of labour autonomous when it comes to thick concepts? After all, they are supposed to be action guiding and unified by their usage in the social level, this is the central point of McDowell’s disentanglement argument.41 Most concepts that are used in science such as DISEASE become a property of the particular instance of the concept that the scientist is working on. This way, such properties impose certain restrictions to the possibilities for the given entity. Since the particular disease, say malaria, has the property of being a disease, it shall do harm to example. Moreover, the positive instances where malaria has health benefits that fall under the research activity on malaria are swiped away from the meaning in order to “save the phenomena”. Against the mentioned problem, in the cases of research, a likely possibility is the retention of the everyday use, or at least an early scientific use of the concept in the scientific linguistic community. For example, when biologists refer to PARASITE, they have a vague concept in their minds.42 The ones who are working in parasitology have a much more explicated concept of parasite; however, they are also aware of the everyday concept. On the other hand, ecologists have a somewhat similar, yet not exactly same concept of a parasite compared to that of parasitologists, of which stereotype is at least partially different from the parasitologist. As a result,43

41

Although it can be claimed that McDowell expects the thick concepts to impossible to be disentangled only when there is a unified understanding in their application, which might not be the case for the particular concepts, it is not my exact argumentation here, therefore I do not see an exact problem with this argument. 42 When a biologist does research on a particular parasite, the organism in question’s behaviour in investigated. If the organism is not really much known of, it is possible for the biologist to call the organism not a parasite, but a commensalist (living together without doing harm). However, a time tested parasite, when researched might be seen to be not harming certain organisms, and perhaps even benefiting some during some phases. This obliges us to have a relational definition of parasitism, as well as a temporal one. The parasitism of the organism becomes dependent on certain conditions, and the organism is no longer always a parasite. However, I can still claim that the parasitic relationship remains, and it is always negative, this making the thick concept stay as a cognitive and conceptual relationship although the concrete examples not fulfilling the requirements. 43 Or perhaps as a cause.

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the extensions of these concepts in different disciplines are also different.44 Due to this reason, scientists can play with their concepts in multiple ways since the concepts they use are cognitively in a different place, semantically distinct, and the research communities where the division of labour occurs is flexible and the scientist is possible to move through them. In this sense, when it comes to thick concepts, I believe that the matter at hand is not that they are creating “unsurpassable” boundaries. Although the boundaries are there to be recognized, or to be played with, completely accepting boundaries and using the three part model of Elstein and Hurka by the scientists to create a level of subjectivity is possible. Let me now discuss more on other kinds of autonomy of the scientist in making of the concept.

4.4.2.2

Practice Above Theory—Independence of the Scientists from the Research Activity

There are also discussions in philosophy of science that go towards the direction of the importance of theory against the importance of experiments. Starting from the 80s with Cartwright (1983), Hacking (1983), Nersessian (1984) and later Gallison (1995) have put high emphasis on the practice of scientists and the independence or at least autonomy of the experimental works of the scientists from the theoretical constructs they deal with, such as theoretical entities, concepts, lines of force, processes etc. Combined with the tradition of sociologists of science, of which beginning is generally marked with Latour and Woolgar (1979), a comprehensive and assertive discipline of “philosophy of science in practice” was born. Although there are significant differences between many philosophers, sociologists and scientists on various parts of their thinking about what means to be practical and how it is related to theory, the main element is the importance of practice in science over theory in the general sense. Some, such as Gallison (1995) claim that “the experiments have lives of their own” outside theoretical structures and limitations. This is to mean that the scientist is partially autonomous in the decision-making through the experiments, and is not dictated by the theoretical and conceptual grounds through research. If the autonomy of experiment over theory is taken for granted in many parts of scientific activity, not only in the epistemic sense but also in the conceptual level seriously, it becomes possible to see the benefit in the reconstruction of the concept. Since while during research the scientist can remain independent of the conceptual limitations, at the same time they can contribute to the meaning of the concepts through the end result of their work when it comes to rearrange the concepts. This way, the scientist can be claimed to be independent of the concepts they work with to a certain extent, both in the descriptive and evaluative aspects when the required conditions are met. This argument allows us to be able to, after the end of 44

Similar examples are abundant in biology, particularly when the concept is not “thick” such as in the concept of GENE. Since the early scientific concept is built without many different tools, methods, etc. in scientific inquiry, the new domains, which are opened up constantly, come up with alterations of the concept.

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research activities, reconstruct concepts that are employed in science that is in line with the social understanding as well.

4.4.2.3

Pluralism and Thick Concepts

So far, my position with respect to conceptual change relied on the pluralism on the field, the autonomy of the scientists and the structure of the concepts. What to do with these concepts is another question to be asked. Competence pluralism as advocated by Komatsu (1992) claims that for different tasks45 to be done on a class of objects, there can be different object categories. This clearly indicates a problem of categorizing the particulars in a unified way by a single concept while employing different methods to unify them. Eventually these different methods result in different concepts. The entities referred by these terms will be in or out of the term’s extension due to this multiplicity. An examplication of Kamatsu’s (1992) pluralism in biology can be seen in Ereshefsky’s (2001) mention on how biologists use concepts such as SPECIES and GENE differently in different contexts. In professional discussion, they use a clear-cut concept of GENE, and as such, the concept itself becomes unnecessary since the definition as such is out there, be it in textbooks or as a shared belief within the particular scientific community. However, when they are engaged in public discussions or more general debates, they use the concept rather easily. He also claims that this is the same when it comes to terms of HEALTH and DISEASE (Ereshefsky, 2009).46 Yet, there is another ground for pluralism in the scientific research, that is based on the multitude of thick concepts and action guiding elements that are already embedded to the research activity. It is not only one single thick concept that scientists employ has action guiding elements they have in mind, but other thick concepts, aims, protocols, other definitions of the thick concept they employ are also within their reach and even in many cases obligatory to their research activity. This enables the scientist to gain “freedom” or at least autonomy from the normative aspect of the concept in question, perhaps similar to the case of a racial slur being used differently in different contexts by different social communities, through which an understanding of the concept as being socially constructed to fulfil a certain task becomes possible. The scientist can also be pluralist about the normative character of the concept. Consider the concept of DISEASE, just like the scientists being able to understand that there are several definitions and concepts of disease, having different descriptive parts; the scientists can also conceive a pluralistic normative understanding of the concept. It is possible for the scientist to attain the positive normative character of the concept of disease although at the global level it is negatively evaluative. As 45

These tasks are considered to be tasks on the conceptual level such as classification, deduction etc. 46 However, when it comes to thick concepts, I think the issue is much more difficult to maintain a simple form of pluralism, since eventually the concepts we refer to are action guiding, and what kind of action to be guided and towards which direction are always pressing questions. Under these circumstances, it might be much more difficult to maintain a pluralistic attitude in most cases.

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already discussed in the first chapter that when we have a pragmatic approach to the normative character of concepts, the normativity of the concept in question can also be ambiguous and can come in degrees. The pluralistic normative understanding of the concept can also be in degrees,47 or it can be very much context dependent and simply have something to do about the positive or negative evaluation of the concept.48 The scientist can be relatively “value free” when conducting research due to other concerns that she acquired in research, which can downplay the other values, which are considered in the public use of the concept. In Elstein and Hurka’s (2009) three-part model of disentanglement, they mention the possibility of disentangling normative aspect of thick concepts from their descriptive aspects in the case of having a context in which there is a global evaluative aspect that can underscore the embedded evaluative aspect in the concept. Since scientists in different disciplines work not only with various concepts, but these concepts are different value concepts, they can see one value concept that they employ to be globally evaluated negatively while being positively evaluated locally, such as the concept of MALARIA from an evolutionary biologist’s perspective, the concept of MALARIA is outrun by the concept of fitness.49 Pluralism about the normative character of the concept in categorizing various entities in science helps the scientist to become value autonomous due to having many different value bearing concepts becoming outrunning each other in different contexts. This can also be done historically; this is what the normativists do when they deal with the “false” categorizations of diseases such as homosexuality and drapemonia, and eventually building a complete value laden understanding from them. Following this argumentation, I claim that the pluralism in the descriptive character of the concept, combined with pluralism at the normative level allows us to see individual scientist to exert the autonomy to design concepts in ways that enable her to organize the concepts and engineer them. The branched uses of the concept at hand can be expressed by the parent term when certain adjustments are made. However, this is a difficult question, since on one hand we can leave it relatively free for the concepts at question to be determined partially by their usage, leaving terms to be ambiguous to a certain extent. On the other hand, certain parts of the descriptive aspect of the concept might simply diverge from each other. In the end, the concept of VIRUS is diverged from our understanding of pathogen, since research has showed it to be a particular kind of pathogen, apart from bacteria. This manoeuvre had descriptive aspect of the concept developing to a certain level that allowed the scientists to become value free on the general research level. Alternatively, as another option we can loosen the limits of the concepts at question. Since the concepts we are dealing with, due to their particular normative aspects, remain related to the public usage, I believe it makes more sense to talk about 47

As in Kirchin’s (2017) example about the differences between GOOD, OKAY and AWESOME. Consider the example “INDUSTRIOUS”. 49 I discuss the particular situation of outrunning when discussing evolutionary medicine in Chap. 5. 48

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the refinement for the general concept as a description of what is expected from it to be fulfilled. However, as the scientists are “giving the concept back to public” after adjusting the descriptive element of the concept, they should be mindful of how the concept can be used once the concept get out of their hands, as it reaches the public discourse. This recognition of the public usage of the concept is another issue at play, although this leaves the scientists autonomous from the value judgements within the community, it does not tell us about the direction of change about the normative character of the concept. I think that question can be better answered at other levels than the semantic one alone.

4.5 Conclusion The location of the conceptual change is, not in the mind of a scientist and not in the scientific community level neither in the semantic level. I claim that the creative conceptual change occurs in the totality of these domains, when the scientist can understand the concept in her own domain, perceives the social and semantic ones, and produces another concept to understand the developments in the field. This creates a particular difficulty in predicting the direction of conceptual change. Following Nersessian (1984), in the three different part of the scientific research where the new concepts are used as heuristic guides, elobrational and philosophical parts, there is a possibility for the scientist to conceive the concepts differently. The obvious difficulty is, they are at different levels for different kinds of scientists working on close disciplines. This structure gives the scientist the autonomy that is required to create scientific concepts while at the same time relating it to pre-existing structures. I relied on three features of linguistic division of labour in meaning to accommodate meaning change. (a) The social use of the concept is dependent on how societies authorize particular strength to certain groups who have an impact on the concept. For the purpose of my own research topic, those people are scientists who can have an upper hand. However, the social aspect, coming from the normative dimension of the concepts in question can override the scientists’ understanding of such cluster concepts and descriptive meanings. This perspective is partially in line with Burge’s (1979) understanding of specialists’ role in the linguistic division of labour. Burge (1979) gives an account of social meaning where the social is distributed amongst different parts of society. In his account, the set of affairs in the world are also given in a very rigid sense. The social aspects of the concepts do not change the given tokens in the world. The categorization and limitations of “real” concepts is lacking in his analysis. In his project, while exemplifying different kinds of incomplete understanding about the joint set of beliefs, Burge (1979, p. 80) also mentions how the concepts that are mainly used by specialists—including scientists—are used incompletely by the laypeople.

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However, if we take more abstract concepts that are used to achieve certain tasks by laypeople to belong to the specialists, there is another problem in the meaning of the concept. The meaning in the “specialist first” understanding downplays the role of the layperson and her usage in the overall working of the concept and also dismisses specialist disagreement. This is not the position I would like to hold, since according to his perspective, specialist understanding is always more complete than the laypeople’s’ understanding of the concept. Although from the historical accounts we can see that the experts in DISEASE concept (medical doctors, researchers etc.) are influenced by the popular usage via the infiltration of these concepts by social scientists when it comes to particular disease but also more abstract concepts as well. The problem in this account has to do with the concept of linguistic community. Burge (1979) makes distinction between various linguistic communities, albeit he still holds that the linguistic community has a relationship to the “correct” meaning of the concept. My objection is, in research communities as well as scientists working on different branches, the “true” meaning of the concept also is being eroded. This means, the laypeople’s community understanding of meaning has many different “reals” that it can match with. The tension here is about the possibility of an exact mastery of the concept.50 As an alternative to the status quo (a), the other possibilities I can think of about the direction of conceptual change is in this form. (b) The scientist as an individual can have cognitive freedom to entertain various possibilities for the concept’s different parts instead of simply applying her own task in the linguistic division of labour and is in a privileged position to give accounts of meaning. In this solution instead of the expertise itself, the individual expert, in this case scientist or people who are interested in the development of concepts takes the role to design a concept. However, the distinction is between designing a concept for the general, “true” purpose or a specialized “local” purpose. As a reply to absolute mastery of concepts, Peacocke (1992, p. 29) distinguishes between possession conditions and attribution conditions to concepts. According to him, someone needs the “full mastery” of the concept in order to possess it while she can51 fulfil the attribution conditions in the form of “x believes that red” when there are true occasions of the expression. However, in the scientific research I believe that it is not very easy to find the examples following this structure. What is more likely to be found within this activity is, there is hardly any mastery given that the field is often very pluralistic, following my argumentations through the chapter. (c) The relationship of the scientists to the concepts they employ can be thus pluralistic (following b) since the scientists are indirectly related to these concepts due to manifold of understandings that they are involved in during scientific activity. The difficulty for the experts to design a general concept is relatively 50

Glick (1996) also questions the extent of the mastery of the concept eventually arguing that an absolute mastery of concept is a problematic expectation. 51 In a Burgean way.

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obvious. Moreover, experts should have partial knowledge to a certain extent in order to make place of that particular phenomenon for their own understanding of realism in some cases, since it is impossible at times for the researches to be impartial in order to conduct experiments or devise theory. The possible options to rebuild concepts after being used in diverse ways seem to give use two options; either keeping them separate or creating new concepts and uniting them. Both seem to have problems of their own. If we keep multiple concepts distinct from each other this could mean that, we will always have a divided understanding of a concept which is united in the daily language to fulfil a certain purpose. However, if we try to have a unifying concept, this can still be dangerous since it is unlikely that we will have any meaningful concept properties attached after being so general to be able to include all uses that fall under—when possible. The question is how this widening of the descriptive account creates a change in the public understanding of the concept. Therefore, it seems in many cases, the relationship of the normative element of the thick concept to the spread-out descriptive uses of the thick concept seems very important to decide on this trade-off. The conclusion for my purposes here is to note that, the absolute mastery of the concept cannot be thought of its function, particularly in the social domain, and the location of conceptual change is as well very much distributed within different kinds of scientific activity and can only be seen as an emergent situation. After discussing this distributed understanding of concept meaning and the division of labour in that within conceptual change of no mastery, now I move on to the second part of the book, the concept of DISEASE and the analysis of the concept of disease from this perspective.

References Arabatzis, T. (2019). What are scientific concepts? In K. McCain & K. Kampourakis (Eds.), What is scientific knowledge? An introduction to contemporary epistemology of science (pp. 85–99). New York: Routledge. Bishop, M. A., & Downes, S. M. (2002). The theory theory thrice over: The child as scientist, superscientist or social institution? Studies in History and Philosophy of Science Part A, 33(1), 117–132. https://doi.org/10.1016/S0039-3681(01)00029-2 Brigandt, I. (2010). The epistemic goal of a concept: Accounting for the rationality of semantic change and variation. Synthese, 177(1), 19–40. https://doi.org/10.1007/s11229-009-9623-8 Brigandt, I. (2020). How are biology concepts used and transformed. Philosophy of science for biologists, 79–101. Brigandt, I. & Rosario, E. (2020). Strategic conceptual engineering for epistemic and social aims. In A. Burges, H. Cappelen, & D. Plunkett (Eds.), Conceptual engineering and conceptual ethics (pp. 100–124). Oxford University Press. Burge, T. (1979). Individualism and the mental. Midwest Studies in Philosophy, 4, 73–121. https:// doi.org/10.1111/j.1475-4975.1979.tb00374.x Burge, T. (1986). Intellectual norms and foundations of mind. The Journal of Philosophy, 83(12), 697–720. https://doi.org/10.2307/2026694

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Burian, R. M. (2004). Molecular epigenesis, molecular pleiotropy, and molecular gene definitions. History and Philosophy of the Life Sciences, 26(1), 59–80. https://doi.org/10.1080/039197104 12331341641 Caravita, S., & Halldén, O. (1994). Re-framing the problem of conceptual change. Learning and Instruction, 4(1), 89–111. https://doi.org/10.1016/0959-4752(94)90020-5 Cartwright, N. (1983). How the laws of physics lie. New York, NY: Clarendon Press. Cartwright, N. (1999). The dappled world: A study of the boundaries of science. Cambridge University Press. Chalmers, D. J. (2020). What is conceptual engineering and what should it be? Inquiry, 1–18. https:// doi.org/10.1080/0020174X.2020.1817141 Chang, H. (2012). Is water H 2 O?: Evidence, realism and pluralism (Vol. 293). Springer Science & Business Media. Devitt, M. (1979). Against incommensurability, Australasian. Journal of Philosophy, 57(1), 29–50. https://doi.org/10.1080/00048407912341021 Dupré, J. A. (1993). The disorder of things: Metaphysical foundations of the disunity of science. Harvard University Press. Dupré, J. (2004). Understanding contemporary genomics. Perspectives on Science, 12(3), 320–338. Elstein, D., & Hurka, T. (2009). ‘From thick to thin: Two moral reduction plans.’ Canadian Journal of Philosophy, 39, 515–536. Ereshefsky, M. (2001). The poverty of the Linnaean hierarchy: A philosophical study of biological taxonomy. Cambridge University Press. Ereshefsky, M. (2009). Defining ‘health’ and ‘disease’. Studies in History and Philosophy of Biological and Biomedical Sciences, 40(3). https://doi.org/10.1016/j.shpsc.2009.06.005 Feyerabend, P. (2020). Against method: Outline of an anarchistic theory of knowledge. Verso Books. Fodor, J. A. (1975). The language of thought (Vol. 5). Harvard University Press. Galison, P. L. (1987). How experiments end (Vol. 88). Chicago: University of Chicago Press. Glick, D. J. (1996). Possessing a concept. Theory & Psychology, 6(2), 349–352. Gould, S. J., & Lewontin, R. C. (1979). The spandrels of San Marco and the Panglossian paradigm: A critique of the adaptationist programme. Proceedings of the Royal Society of London. Series B, Biological Sciences, 205(1161), 581–598. https://doi.org/10.1098/rspb.1979.0086 Greslehner, G. P. (2020). Not by structures alone: Can the immune system recognize microbial functions? Studies in History and Philosophy of Biological and Biomedical Sciences, 84, 101336. https://doi.org/10.1016/j.shpsc.2020.101336 Hacking, I. (1975). Why does language matter to philosophy?. Cambridge University Press. Hacking, I. (1983). Representing and intervening: Introductory topics in the philosophy of natural science. Cambridge University Press. Hacking, I. (1999). The social construction of what? Harvard University Press. Hatano, G., & Inagaki, K. (1994). Young children’s naive theory of biology. Cognition, 50(1), 171–188. https://doi.org/10.1016/0010-0277(94)90027-2 Kirchin, S. (2017). Thick evaluation. Oxford University Press. Kitcher, P. (1978). Theories, theorists and theoretical change. The Philosophical Review, 87(4), 519–547. https://doi.org/10.2307/2184458 Kitcher, P. (1982). Genes. The British Journal for the Philosophy of Science, 33(4), 337–359. Koch, S. (2018). The externalist challenge to conceptual engineering. Synthese, 1–22. Komatsu, L. K. (1992). Recent views of conceptual structure. Psychological Bulletin, 112(3), 500– 526. https://doi.org/10.1037/0033-2909.112.3.500 Kripke, S. (1977). Speaker’s reference and semantic reference. In P. A. Frenc, T. E. Uehling Jr., & H. K. Wettstein (Eds.), Contemporary perspectives in the philosophy of language (pp. 255–276). University of Minnesota Press. Kuhn, T. S. (1962). The structure of scientific revolutions. University of Chicago Press. Lakatos, I. (1980). The methodology of scientific research programmes (Vol. 1). Cambridge University Press. https://doi.org/10.1017/CBO9780511621123 Latour, B., & Woolgar, S. (1979). Laboratory life: The construction of scientific facts. Sage.

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Machery, E. (2009). Doing without concepts. Oxford University Press. Moreno, L. F. (2016). Putnam’s view on reference change is different from that of Kripke’s. Organon F, 23(3), 367–383. Nersessian, N. J. (1984). Faraday to Einstein: Constructing meaning in scientific theories. Science and philosophy. Brill-Nijhoff. Nersessian, N. J. (1985). Faraday’s field concept. In D. Gooding & F. A. J. L. James (Eds.), Faraday rediscovered: Essays on the life and work of Michael Faraday, (1791–1867/pp. 175–187). Macmillan. Nicholson, D. J., & Dupré, J. (Eds.). (2018). Everything flows: Towards a processual philosophy of biology. Oxford University Press. Nordby, H. (2019). Who are the rightful owners of the concepts disease, illness and sickness? A pluralistic analysis of basic health concepts. Open Journal of Philosophy, 09(04), 470–492. https://doi.org/10.4236/ojpp.2019.94029 Olsson, E. J., & Westlund, D. (2006). On the role of the research agenda in epistemic change. Erkenntnis, 65(2), 165–183. https://doi.org/10.1007/s10670-006-9001-6 Peacocke, C. (1992). A study of concepts. MIT Press. Putnam, H. (1975a). The meaning of “meaning.” University of Minnesota Press. Putnam, H. (1975b). Language and reality. In H. Putnam (Ed.), Philosophical papers: Volume 2: Mind, language and reality (pp. 272–290). Cambridge University Press. Rusanen, A.-M. (2014). Towards to an explanation for conceptual change: A mechanistic alternative. Science & Education, 23(7), 1413–1425. https://doi.org/10.1007/s11191-013-9656-8 Rusanen, A.-M., & Pöyhönen, S. (2013). Concepts in change. Science & Education, 22(6), 1389– 1403. https://doi.org/10.1007/s11191-012-9489-x Sankey, H. (2000). The language of science: Meaning variance and theory comparison. Language Sciences, 22(2), 117–136. https://doi.org/10.1016/S0388-0001(99)00008-X Sawyer, S. (2018). VI—The importance of concepts. Proceedings of the Aristotelian Society, 118(2), 127–147. https://doi.org/10.1093/arisoc/aoy008 Scheffler, I. (1967). Science and subjectivity. Bobbs-Merrill. Stump, D. J. (2015). Conceptual change and the philosophy of science: Alternative interpretations of the a priori. Routledge. Thagard, P. (1990). Concepts and conceptual change. Synthese, 82(2), 255–274. van Fraassen, B. C. (1980). The scientific image. Oxford University Press. https://doi.org/10.1093/ 0198244274.001.0001 Väyrynen, P. (2013). The Lewd, the Rude, and the Nasty: A study of thick concepts in ethics. Oxford University Press. Vosniadou, S. (2003). Exploring the relationship between conceptual change in intentional learning. In G. M. Sinatra & P. R. Pintrich (Eds.), Intentional conceptual change (pp. 377–406). L. Erlbaum.

Chapter 5

The Concept of Disease in the Traditional Debates

Abstract In 1851, American physician Samuel A. Cartwright observed that the slaves were trying to escape captivity. Based on this observation, he tried to understand the reason why this was the case. Looking for causes of events from a biological and medical perspective of his day alone, the answer he found was a very straightforward one. The slaves who tried to run away were suffering from a mental illness, drapetomania (White in Annual Review of Genetics 38:681–707 2008). This mental illness was the cause they tried to run away. Much later, as an unrelated event, in 1973, American Psychiatric Association, decided by 58% of the votes that homosexuality should be removed from Diagnostic and Statistical Manual of Mental Disorders [DSM] (Australian and New Zealand Journal of Psychiatry 37(6):678–683, 2003) (They did not use a vocabulary or a conceptual framework that distinguished gender identity, orientation or behavior. What they meant was more similar to what we can call as sexual orientation now.). This would mean that homosexuality could not be “treated” by psychologists and psychiatrists anymore, since it was no longer a disease in their repertoire. Although they had to tools to “treat” homosexuality, they were not allowed to, since the intervention that they were aiming at was being aimed at a false “disease”. What do examples like these mean, or rather, what to make of these events? Is the concept of disease some kind of normative concept that is used to control and pathologize certain behaviours or traits without any kind of solid scientific grounding as some radical interpretations of constructivism claim? Alternatively, as the extreme counter position to that, are they merely anecdotal examples of the occasional misuse of science that does not even belong to this century due to the proclaimed immerse advancements in science as some naturalists claim? This chapter does not aim to answer this question directly. This chapter does not give a general concept of disease or analyse how the concept of disease have been used either. Instead, this chapter tries to lay out different elements effecting the concept of disease while discussing certain central issues in the discussion of the concept of disease, eventually arguing “Detskaya Bolezn’ "Levizny" v Kommunizme” [Left Communism, an Infantile Disorder] Book by Lenin „aus der Krankheit eine Waffe” “Turn illness into a weapon” Headline of a text by SPK (Sozialistisches Patientenkollektiv) [Socialist Patients Collective]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_5

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around the intersection of social aspects in its usage and the biological aspects of the disease concept. I will use a pragmatic approach towards philosophy of science to understand the different aspects of the concept.

5.1 Introduction In the previous part through three chapters, I have discussed the idea of conceptual change and normativity in general terms. In this second part, starting with this chapter I will go towards the analysis of a particular concept; disease and how it can be reconceived by evolutionary medicine of today, and how other perspectives that are evolutionary or evolutionarily relevant will change the concept of disease. I believe that the previous part has created a more general and abstract scheme for conceptual change and pragmatics of concepts, in this sense, this part will be about the application and demonstration of that framework in the particularity of disease concept. This chapter aims to give a brief outlook of the concept of disease and the main discussions revolving around the concept of disease in philosophy. While doing that, I aim to look at one of the most discussed issues about philosophy of disease concept, namely the normativeness of the concept. After that, I aim to discuss the concept of disease in relation to other similar concepts with respect to its usages in social or patient-based understandings, namely sickness and illness, and explain the orthodox characterization of the tripartite distinction of disease—sickness and illness model is constructed. The idea is to conclude that, although several discussions around the concept of disease are quite useful, they have a certain kind of idealism in common in the standard structure which is a problem in philosophy of medicine. I will briefly discuss the models of disease to see the relationship between the disease concept and the surrounding normative usages of the disease concept. As an alternative to the standard models of disease, I will introduce perspectives from disability to reconstruct an understanding of disease, which I will support by the new developments in evolutionary biology and evolutionary medicine in the coming two chapters.

5.1.1 The Concept of Disease in Short, the Shadow of Logical Positivism It is not very easy to pinpoint the exact location of disease discussion because philosophy of medicine itself is an emerging field. Philosophy’s relationship to the medical was not particularly investigated until 70s (Lemoine, 2016). Although within medicine, certain topics such as medical ethics and epistemology of medicine has been areas that fell under philosophy of science, medicine itself, at least by the mainstream understanding of analytical philosophy has not been seen either due to the reductionist programme already trying to ground biology and waiting to call

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medicine applied biology when it has achieved that goal, or simply seeing it too chaotic to be engaged with, was not in the target of philosophy.1 One crucial concept to medicine, disease, has been studied by philosophers of science mostly. Due to this historical baggage, disease was not defined or tried to be defined by philosophers for a long while by philosophers. This rather rarely defined concept, disease, according to the famous WHO (World Health Organization) definition of “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (Preamble of the constitution of the WHO, 1948 p. 459) with reference to health. Until 1973, the medical experts did not see a great need to define the concept of disease (Spitzer & Endicott, 1978). This was due to the pressing concern of declassifying homosexuality as a disease in that year (Stroller et al., 1973) Apart from that, in any widely accepted manner, definition of disease as a concept is difficult to find. Although there have been important attempts to give intension like criteria for the concept of disease, perhaps most importantly by Spitzer and Endicott (1978) particularly for mental disorders,2 the concept of disease seems to be very broad to explain with certain number of criteria by intension alone. The main problem is, in my opinion the multitude of different kinds of disease. Since it is a very general concept that is employed by different parts of medical, psychological, social and biological disciplines, the easier it becomes to find counter examples to any kind of set criteria. Albeit, the general understanding of disease is a normative one, something must be going wrong for an entity to count for disease for most, although there are disease without any symptoms, and there are people who are asymptomatic carries of diseases. The general unpleasantness of diseased condition, although can be helpful in starting to understand the concept of disease, rarely is the end result of the inquiry. Moreover, although it can be seen as harmful, the question whether it is harmful to a certain individual, or an idealized system is on the table. The fact that the concept of disease is widely used in daily life and by experts while being so undefined is quite an interesting aspect of the concept of disease. Moreover, few people need to come out with a general disease concept, and there is no single branch nor institution that deals with the concept of disease at the moment. However, it was not always the case. In the early twentieth century until the criticism of positivism in philosophy of

1

Following a positivistic spirit, it makes sense to expect medicine to develop its own ideas and correct its own mistakes without questioning its central assumptions. I believe that only through a critique of Vienna Circle positivism it became possible to talk about the limits of a field itself. Although such critiques of positivism have always been in the discourse, it took a while for them to have their place certain in the mainstream philosophy of science discourse. 2 In the literature, disorder, disease, condition, and similar situations are used not with clear cut definitions. Since already defining even one of them is a difficult task, although it is possible to draw distinctions between them, the task might not worth it. Certain limited cases, such as wounds or injuries are more difficult to define, which do not fall under the concept of disease. Here I am in favor of using them interchangeably since all of them are very broad concepts and further definition and contextualization of the concept is always needed.

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science, following the general trust towards science by the mainstream understandings of science, the concept has been at the hands of medical experts and clinicians. The diagnostic manuals that the medical doctors and clinicians used were the guides for certain diseases that they could use to diagnose and intervene to the diseases. Since the negative aspect of disease went without question, it was simply a matter of correct diagnosis of and correct intervention to an unpleasant situation. Starting around 1970s, following the research perspective that can be epitomized with Michael Foucault’s Birth of the Clinic (2012) [1973] being an influence in the English speaking World, the idea that the medical knowledge, much like any other scientific or science related knowledge, does not follow a linear, accumulative manner, but it develops through different epistemes gained wider acceptance, the correct conception of medical knowledge has been seen at least critically by different scholars in philosophy of science.3 Following this route, Margolis (1976), draws an analogy from legal positivism to medical science to see that, both medical and legal theories deal with deviance and maladaptation. The analysis on this line of thought typically sees disease as a concept that is used to mark certain states as deviated, undesirable, abnormal or in similar ways, negative. On this account, the concept of disease as it is used by the institutionalized medical knowledge, is key to structure and form the society in a certain manner. The main criticism to a purely objective concept of disease was clear. Scientists were using these kind of institutionalized categories in a normative way. The clinicians were using categories that were developed by pathologists (Feinstein, 1967). The pathologists were using value judgements because these categories were constructed to fulfil an institutional function to diagnose patients in ways which made sense to them, enabling a certain kind of pathology—normatively negative—within the patient. One of the main issues is of course, the diversity of the ways in which we relate ourselves to diseases. For some diseases, control of certain social groups can be easier to mark—such as the case of drapetomania, while some seem to be negative for all, and seem like it is harmless to intervene in these kinds of diseases, such as the common cold.

5.1.2 What Kind of Concept is Disease? Positioning Disease in the Context of Philosophy of Science What kind of concept is disease? This question can be answered from several different perspectives. Discussions around kinds, be it natural kinds or other kinds of scientific categories has been very central to philosophy of science (Ereshefsky & Reydon, 3

I will not go into detail about the general challenge against the linear accumulation of scientific knowledge. Discussing this issue at this generality is not helpful, what I can say for my position is simply, there are certain kind of things that accumulate and certain kind of things that do not. However, I find it important to note that I do not subscribe to understandings that employ incommensurability thesis at least in its simple form.

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2015). Since I have already mentioned the natural kinds discussion in the previous chapter, I do not want to argue further on that regard, all I would like to say would be that, although it can be possible to discuss the natural kindness of certain diseases, discussing the concept of disease in general in this regard is not very helpful. Moreover, defining the concept of disease within a given kind of concept, say natural kind, would also limit the kind of phenomena which would fall into the category of disease. Within this discussion, the main breaking point is about how normative, or in which way the concept of disease is normative, or seen from the other side of the debate, can the concept of disease be naturalized.

5.2 The Normativeness Debate—Can It Be Value Free? With concept of disease being challenged as a construct by looking at the examples where certain disease have been made up like to fulfil certain social regulations and certain situations becoming medicalized such as homosexuality, the main worry was how to construct—if possible a value free concept of disease. I do not aim to go into detail about the constructivism versus naturalism debate, I will highlight a couple of points to mention the traditional debate and then position myself in the debate similar to my position in the previous chapter, namely normative character has to do with the division of labour and the group activity. The traditional debate around the concepts of disease and illness started with Boorse’s seminal papers (Boorse, 1975, 1977). In this account Boorse distinguishes between illness and disease, in which he defines illness with respect to personal experience of a disease situation and disease itself falls into a naturalist account. One understanding to define the concept of disease comes from psychology, that is harmful dysfunction. Murphy and Woolworth (2000) also see this within the terms of harm to the individual herself. However, I think the main problem with approaches trying to claim that the concepts of disease can be value free comes from a particular understanding of value. On the other side, the idea that they are value laden also does not help much and carries similarities with the Science Wars of 90s, where social construction concept was used to mean that a certain social domain had nothing to do with the biological domain, and the categorization of biology was arbitrary.4 Boorse’s naturalism is based on the idea that bodily malfunction criterion can be objectively constructed with reference to the normal functions of the bodily organs.5 In his definition he takes evolutionary design of human related organs as a 4

For a detailed discussion of this perspective; Ian Hacking; Social Construction of What (2002). The “traditional debate” includes many other accounts Nordenfelt (1986, 2001) for a more general account of wellbeing, Wakefield (1992) for a relatively hybrid account of psychological disease, alswao Mililkan (1989), Neander (1991). For a prominent version of biostatistical account; Swartz (2007). For the necessity of normativeness in the definition; Kingma (2007, 2010). For the recent discussion of selected effect account, Griffiths and Matthewson (2018).

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species specific property to fulfil certain functions. Naturalist understandings generally come in two ways, based on evolutionary functions, and based on biostatistics. The “selected effect account”, the idea that the normal functioning of organs can be understood and naturalized with respect to evolutionary understandings has been put forwards in different versions by many.6 While restrictive definitions of disease for the naturalist accounts can be helpful in certain domains in research to understand the specific phenomenon of disease within their own research programmes, they have always been under various criticisms. Griffiths and Matthewson (2018) criticize even the best possible theory for them, that is the selected effect account, although they still believe that it is the best account available. Cooper (2020) holds that in near future, there will not be any purely biological account of disease. On the other side of the constructivist spectrum, one worry is making the concept of disease too open for interpretation, too much that there are not enough require criteria to define the concept of disease. The ideal concept of disease from this perspective should allow us to us to find what is there to treat, making healthcare about disease and disease alone. The task for the naturalist is relatively simple in principle. Find an intentional definition of the concept of disease which is defined without any reference to any thick concepts that also includes all particular disease examples that are already known in the extension. And this is done by another discipline mostly, medicine. Because they miss the point about how the concept is used, and moreover how the epistemic and social goals of the concept are important in the making and definition of the concept, wait for counter examples from the extension. This again, is based on the reliance of a naïve copy theory of truth. Doing medical research with a naturalist concept, such as that of evolutionary malfunction would be difficult because many evolutionary malfunction situations might not have much to do with the undesirable condition of the patient. There has been certain evolutionary definitions of disease as well, I would use evolutionary understandings to create an approach towards disease, rather than seeking evolutionary medicine to give a naturalized definition of disease, which I find rather contradictory to certain other developments in evolutionary biology in the coming chapters. Amongst these definitions, although Griffiths and Matthewson (2018) argue that, they are in line with Nesse (2001a, 2007) as the leading figure of evolutionary medicine, that they favor a selected effect perspective of evolution in the naturalization of the concept of disease, I think their definition of naturalization isolates individual in another level, namely at the level of the organism. I believe that for a singular intension of the concept of disease to be successful, it has to come with a single epistemic goal. That is to say, if evolutionary accounts of disease were to be successful, it should be the only research agenda for the scientific discovery, which I find not promising, due to the fact that also within evolutionary biology there are multiple epistemic agendas. I believe that instead of this kind of a

6

For rather recent views for the selected effect; Millikan (1989), Neander (1991).

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clear-cut distinction for the professions, the level of reflection and interdisciplinarity is more important.7 Another criticism to knock out naturalism is based on the argument that, since the disease concept is seen as normative by naturalist understanding often in a very simple understanding of the concept of normativity. I think that if we try to extend the idea or normativity, and instead of discussing whether the concept is normative or not, try to answer what does this normativeness mean in the context of disease, we could reach a much more productive research agenda. Since, following Williams, if we see the issue not stuck into the normativeness debate, but lift it to the level of action guidingness, how the actions are guided together with the concept of disease will be various and can be quite helpful in understanding the purpose of the debate around normativeness. Although these debates are trying to build on an understanding of these concepts, be them disorder, disease or malfunction, they share the same assumption; namely the possibility of one singular value judgement attached to these concepts. Based on my analysis in the first part and particularly on the second chapter, I believe that trying to find out one singular understanding of normativity in this perspective is difficult and it does not the reality of how these concepts are used.

5.2.1 A Solution to the Normativeness Debate The previous discussion is my contextualization of the traditional debate, although there are other positions as well, beyond normative—naturalist accounts, most importantly by Broadbent (2019) where he conceptualizes a two to two matrix in which normativeness is only one aspect of categorization, the other being the reality of the disease. I find this categorization very agreeable and I do believe that in the evolutionary understanding the relationship is similar, in the sense that evolutionary medicine deals with disease vulnerability, not disease itself, making disease secondary in this categorization. However, when it comes to locate the normativeness, one interesting account of discussions around disease is by Spitzer and Endicott (1978). They claim that disease categories are “calls to action”. According to their definition, “Implicitly there is a call for action on the part of the person who has the condition, the medical or its allied professions, and society” (p. 15) Coming from a psychiatry background, they claim that when a person is diagnosed as diseased, this means that there is a call to action and various kinds of intervention to the patient, be it on the biological, psychological or the social domain. This understanding is very much in line with action guiding understanding of Williams, since being a thick concept and action guiding, disease calls us to action to do a certain kind of action to the patient. Now I will turn 7

In the coming chapters, I also claim that, not only at the conceptual level, but at the empirical level as well there are theoretical shifts happening, creating a different result than the discussions around the normativity of disease concept.

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to this aspect of the disease, mentioning it normative part, with the possibility of disentanglement on certain different levels when the researchers are working on this concept. The problem with their account is, although they see that diseased person is in need of help, the epistemic definition of disease is not personalized. That is to say, they take diagnostics itself to be the call to action within the given limitations of generalized diagnostics. In addition, who is called to action and how should also be discussed. Should that be particular medical professionals or the medical research is an open question. Although I believe the most sensible interpretation is that of an objective medical classification, they make no room for the medical understanding as well. When we apply Elstein and Hurka’s three part model (2009) again here to check the local and global evaluations of the concept of disease, we are to see that, and define disease in a situation of survival or individual wellbeing, we can state the same global evaluation versus embedded evaluation here. The result of this enquiry is obviously a form or pragmatism, however bearing in mind that the value making structures shall not be overlooked. The different concerns and value making characters of different medical practices and different institutional structures. Following a pragmatistic understanding of normativity of concepts in different contexts in mind, it makes sense to reach for a more nuanced understanding of normativity of disease concept. That is to say, instead of reaching the conclusion that the disease concept can be value free once and for all, we should look at the particular diseases in particular contexts or particular usages of the disease concept by different speech and moral communities.

5.3 Social and Psychological Aspects; Three Part Division; Disease, Sickness and Illness From the perspective of medicine, the normativeness question seems to be distributed to different concepts and structures to be resolved. Although there are certain normative components of the concept of disease that cannot be naturalized and have to be social, there is another kind of attempt to reunite these perspectives. Since the different concerns with respect to the relatively restrictive medical understanding of early twentieth century has been challenged, there has been attempts to introduce social and psychological and individual aspects of the diseases to the disease concept. Moreover, there has been entire disciplines that are built to investigate different aspects of medicine, such as history of medicine, sociology of medicine, medical anthropology and certain related disciplines (Hofmann, 2002). The social and individual aspects of the phenomenon of disease are included to the general theory in this generalized way. I find the medical perspective in which instead of analysing the single concept of disease, creating a framework that includes the concept due to the concerns that has been put forward by social and individual aspects a good point to start a more pragmatistic study on the concept. In this sense,

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my claim is, the concept of disease is meaningful in this discussion with relation to the other similar concepts, since its use is also very socially embedded. Although this model, a relatively accepted model of disease and related concepts, sickness and illness, make a good division between the relationships of each domain, the decision here seems to be rather stable. That is to say, in this model, the concepts or perhaps domains of disease illness and sickness seem to be there to stay. Although this model provides the social aspects in relationship to disease, I find it problematic to give a general structure rather than having a more nuanced understanding for individual disease types without any possibility of seeing them differently. This tripartite division mostly relies on an older account of conceptualization of disease, namely Biopsychosocial Model of George Engel. the much-celebrated biopsychosocial model, was first introduced by George Engel in the 1970s (Engel, 1977, 1980). The objection to the so called biophysiological model from psychology made psychological and social aspects of disease more prominent in disease ontology, diagnostics, and treatment. The purely physical level of intervention was put to question in clinic, and more social and psychological aspects of explanation, intervention and care was in focus. Although it was progressive for its time and now is the established view on disease for many purposes, as I will criticise it in the following chapter, the general perspective was still too rigid and was not very open for new diseases. Practically every disease has relationship to these social, psychological and social domains, and the structures that they are in without looking at the particular disease. Due to this generality of the framework, it is generally criticised to have little explanatory power and cannot be good ground for intervention. Against this criticism, Bolton and Gillett (2019) argue that the biophysical model is not taken to be a literal model, which has explanatory and predictable power in medicine. Instead, this model has to do with establishing a general framework to approach disease. I believe that this works well with the more particularist understanding of disease in which we can much more easily see modifications with respect to particular disease or disease structures. In general, I am sympathetic towards and understanding which involves the social and psychological aspects of the disease related phenomena, however as argued by Bolton and Gillett (2019), I believe that it still leaves room for explanation and particular diseases. Now in order to see what is required for explanation, I will turn to medical explanation.

5.4 Medical Explanation There has been a long debate about the nature of scientific explanations in general. The main discussion can be traced back to Deductive Nomological model of explanations in science, which was influenced by, among others, Popper (1935), Nagel (1961), Hempel and Oppenheim (1948) and Hempel (1942). Although the concept of scientific explanation has been broadened by many different accounts in the second half of twentieth century and in the early twenty first century through the critique of

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general structure of explanations for example through the introduction of pragmatics of explanation (van Fraaseen, 1980), the traditional understanding of explanation created a general structure, based on physics for the most part, about explanations in science. The contemporary account of explanations is rather pluralistic, taking into account many different elements, pragmatics, the specificity of the discipline etc. The specificity of the explanatory framework to the discipline shows itself in the discussions of medicine as well. Due to the possibility of domain specific explanations in a pluralist manner, there has been a debate whether these kinds of explanations are suitable for medicine, or whether medicine a science is in the explanatory standards of traditional structures of explanation. Despite the ongoing debate about different kinds of medical explanations, there has been not very much effort put to work to understand medical explanations.8 Amongst the earliest works on medical explanations, Schaffner (1993) argues that many explanations in medicine are inductive—statistical (IS) explanations. Due to the large groups of sampling and variation and complexity of biological processes it makes sense to use statistical approaches to understand medical phenomena in a statistical understanding.9 The large group of medical explanations take this form, however the problem for the traditional explanatory framework is, since the statistical explanations already provide a blanket like probability for the event, they do not directly explain the process how a certain medicine works in a mechanistic manner. Following this structure, Salmon (2006) argues that statistical-relevance (S-R) model of explanation is more suitable for medical cases since it creates a relevant class of cases that are to be explained. This model adds statistical relevance as a factor to the correlation/causation making. The problem with this model is, which class of events should be chosen over the others to provide a good medical explanation are not given in Salmon’s (2006) understanding or in the S-R model in general. Although there was been various explanatory strategies put forward to explain medical phenomena, the recent view such as that of Lemoine (2016) is that, they are usually very pragmatic and context specific. My main aim here is not to provide a general model for medical explanation, let alone a disease explanation. However, I would like to indicate the difference between clinical explanations, research explanations, public health explanations and within each different kind of them. Psychiatric explanations of certain sorts can be radically different from a certain explanation of somatic disorder. In addition to that, as Cooper (2020) argues, explaining an aspect of disease also has to do with our aim of intervention. Whether we cant to change

8

This might have to do with the fact that, medical explanations are so diverse and medical intervention can take so many different shapes that creating a model for such a wide discipline is very difficult if not impossible in the very first place. 9 In Chapter Six I argue how statistical approaches can be employed by evolutionary medicine to a larger extend so that the explanation of medical phenomena can be more compatible with the evolutionary explanations. In addition to that, in Chapter Five, I argue that the population genetics understanding of evolution already provides similarities with the statistical understandings of explanation.

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the social aspect that is causing the disease, or treat the disease structure is an open question, based on our expectations from the explanation. In addition to the previous distinction, I would like to make the following distinction when it comes to medical explanations; the field of medicine, the explanations within medicine, medically relevant explanations and clinically relevant explanations are all different areas of knowledge.10 Although they intersect very often, it is indeed difficult to have an understanding that will fit them all. Talking about explanations is of course important, but the question, what is to be explained is sometimes neglected in this discussion when the explanatory models of philosophy of science are directly trying to be integrated to the medical field, even with alterations. Because even when the explanatory models are fit for the purpose, the purpose being defined not based on the available important element in mind but for the availability of containment of these models, these models tend to explain in the direction that they are built for. In medicine, this is generally the biological phenomena since as I discussed earlier in this part, this understanding of explanation is rooted in the reductionist model in which the relationship between the causes and entities are designed to create an understanding that prioritizes biology. Now, I will investigate the models of disease to see the kind of entities or events that they are trying to explain in order to find what do they explain. Courneya (2018) makes a list of the qualities that he expects from medical explanation on the causal basis since he claims that mechanical explanations are kind of explanations that make disease intelligible. However, since he models his medical explanation in the shape of clinical explanation, this model misses some important points of the generality and the possibilities of explanations in medicine in general. There have already been objections to the classical understanding of causal explanation in the medical field (Anjum et al., 2020). This book, Rethinking Causality, Complexity and Evidence for the Unique Patient: A CauseHealth Resource for Healthcare Professionals and the Clinical Encounter various philosophers, clinicians and a patient work together to provide a framework for individualized medicine, in individualized causation. I believe that the expectation of strict medical causation and medical explanation that is embedded to the traditional understanding of disease generalism and orthodox clinical interventionism is on the weakening side. How question is difficult to answer at the moment, however new epistemic strategies are being developed to fill the individualization perspectives. In addition to that, emergency roomization of disease—centering disease ontology around emergency -, and strict interventionism gaining prevalence in the disease concept, also made direct medical intervention as we know it the stereotype of medical intervention. Being such, the explanations for medicine have been constructed to reflect such issues that had more to do with the explanation of such acute diseases and the concept of disease is taken to have a stereotype of this kind. This creates a problem of overlooking the other kinds of diseases and disease locations.

10

These distinctions are not only limited to the distinctions in explanation. As domains, they also are different fields of study, areas of inquiry and are relevant to different kinds of interests.

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In this regard, I would like to change the discourse of medical explanations a bit by putting them in context. Since different kinds of medical explanations explain different parts of the disease processes (such as genetic element, social element, behavioural element etc.) it is nor easy neither productive to limit explanations of disease to a certain understanding of biology. Since most of the disease processes are interacting with different biopsychosocial domains, statistical explanation has been gaining ground as a general model for disease explanations.

5.4.1 What Are We Explaining: What Kind of a Concept is Disease? A relevant question following the discussion in the main section, then becomes, what kind of an entity disease is. If it happens to be a natural kind or similar very strictly realistic concept, that will mean that the issue surrounding the construction of the disease concept. In this regard, the diseases can be seen as various kinds of entities. However, instead of going to a pluralist path in the particular disease phenomena, I would like to argue briefly that the concept of disease itself can hardly be seen as a natural kind concept. The research on conceptual change has been focused on the change in the extension of the concept for quite some time (Brigandt, 2010). This created a “discovery” minded way of understanding in the philosophy of language, ending up in a philosophy of language that is still highly under the influence of logical positivism. I do not want to argue for long here about the intensionality or extensionality of the conceptual change. I rather follow the sociosemantic account that I drew in chapter three. My claim is that disease is not a natural kind concept, which also argues against the problems that can be evoked by reductionism and physicalism.

5.5 Contextualism and Disability Internal and External One interesting account of disease comes from disability studies. In Garland— Thomson’s (2011) account of disability, instead of seeing the disabled situation something inherent to the disabled person, disability is seen as relational and emergent property. From this line of study it is easy to see the difficulty in categorizing a situation as disabled intrinsically to the individual. In Cooper’s (2020) critique, she highlights differences of internal—external distinction; Garland-Thomson (2011) suggests that disability is often best regarded as a misfit between an individual’s body or psychology and the environment. She takes this to show that disability is relational. As she puts it, ‘The problem with a misfit, then, inheres not in either of the two things but rather in their juxtaposition, the awkward attempt to fit them together’ (GarlandThomson, 2011, p. 593). She goes on: ‘The relational and contingent quality of misfitting and fitting, then, places vulnerability in the fit, not in the body’ (2011, p. 600). However, if

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we are looking for a descriptive account of disorder, we do currently distinguish between disorders, which are located ‘within’ individuals, and social and environmental problems, which are located without. (Boorse, 1977 and Wakefield 1992 also claim that disorders have to be internal.) Consider how we would regard the following cases: (i) Petite woman struggles to use tools designed for big men. (ii) Left-handed person struggles to use tools designed for righthanded people. (iii) Wheelchair user struggles to get around a town without ramps. (iv) Person who requires artificial respirator struggles to breathe without it. In all these cases, the difficulties can be dealt with either by altering the individual or by altering the environment; the problems are in a sense relational. However, we tend to think of the location of the problem differently depending on whether we think the individual or the environment should be altered.” (Cooper, 2020, p. 155–156)

I see this critique quite important about the limits of internal and external, and how socially influenced the distinction is. I would like to answer the claim that, the difference of internal and external that is challenged by disability studies is supported by the recent research in biology—as I will discuss in the coming two chapters—that blur the line between internal and external. Of course, that does not mean that we need to see every difficulty belonging to the concept of medical, however this shows us that medical, social and political interventions are often intersecting. Which path to choose within this, should be left to the “patients”, but also the framing of the problem should be made openly about how the environment—individual distinction is fluid. For different medical—or socio medical—cases, there would be different directions, also depending on the social structures and social organizations. In the coming chapter, I will argue that the environment—non environment dichotomy is not a very good one from evolutionary perspectives, since the making of the organisms consists of going through evolutionary processes that creates the organism. The mechanisms of organism in many ways are shaped by the environmental elements, be it selection or other evolutionary factors, and they are inherited.

5.6 What to Do When the Concepts Are Changing? The concept of disease and how it sits in the general research agenda of medical research and practice has been changing for quite some time. In this regard, Thagard (1996) compares Hippocratic and nineteenth century concepts of disease to understand the important changes in the concept of disease. He claims that the main driving force of the conceptual change about the changes in the causal theories of diseases. When we would like to investigate the research limits of the established paradigm which was criticized by the contextual understanding of disability studies, we see a concept of disease that is shaped by strict biologism. This reflects itself also in the understanding of causality. When we look into the lens of disease from causality that took the shape of the causality in strict biologism of twentieth century which was based on a reductionist conception of biological causation, following the famous

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reductionist attempts of causation in biology such as that of Smart (1959) (ontologically), Nagel (1961) (in theory and modelling), Oppenheim and Putnam (1958) (methodologically) this seems like an expected conclusion.11 However, if we instead take another route against this understanding of reductionism, the way we see and individuate diseases is different than how would it be when we see disease in a different causality network. So far I have distinguished between different kinds of disease debates, Cooper (2020) sees that these debates are not easy to settle with the current knowledge we have. In Chapter Three I explain certain elements and mechanisms of conceptual change. Seeing that the concept of disease is particularly open to conceptual shifts, Cooper (2020) talks about different kinds of normative strategies to follow during the conceptual changes of the concept of disease.12 She lays out three different accounts at the face of conceptual change: How, then, can philosophical work proceed? I first discuss two options that are already being pursued by others in the philosophy of medicine, (1) give up, and (2) go revisionary; I then introduce a third option, (3) seek to ‘belt and brace’ conceptual claims. (p. 149)

She favors the third option amongst these since she claims that both the normative function is important and in near future, it will not be possible to provide a purely biological concept of disease. I agree with her on that regard, although our concept of disease will not be final, reflecting on it with what we have, precisely because it an action guiding concept and socially very embedded is, we should for the time being at least try to be more reflective and instead of looking for reductionist or final definitions of the concept, be more investigative in the general usage of the concept’s intension.

5.7 Individualized and Invented Disease Although most of the critique of only conceptual analysis of the disease concept has been challenged by different ways (Cooper, 2020), I would like to criticize it on the individualization of disease as a general critique of the research programme of disease as well. Whitbeck (1977) and Carter (2017) claim that disease as an abstract kind that is realized in different ways. I find this approach generally positive since it emphasizes that disease cannot only be seen as an etiological agent. However, if we take a step further, it can be also seen in line with Hacking (1983) that we are inventing the phenomena that we are investigating. 11

I do not claim that all philosophy of biology was based on a reductionist understanding, however, I claim that it has been the mainstream understanding to build explanations at least in analytical philosophy. 12 Although Cooper (2020) writes about the concept of DISORDER instead of DISEASE, she uses it in the same way that disease is used in the literature.

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On this account, I would like to distinguish between disease generalism, and disease particularism. What I mean by disease generalism is to expect every particular disease to have the same model or function and every disease in particular to be isolated to make similar effects on the patient. With particularism in disease, the particular disease mechanism is related to the particular patient in a way, creating a different outcome. If we take the particular to be our focus in investigating disease, I believe that we will be able to reach more accurate conclusions if our aim is not to fit the patient in a disease structure but to help the patient. As Cooper (2020) argues; “On the ‘medical model’, the disorder lies within the body of the wheelchair user. On the social model of disability, the problem is located within the environment.” (p. 156). This leaves the concept of disease to be an emergent property that is realized within a certain interaction. Similar to this line of understanding in medicine, Broadbent (2019) argues that health and disease are secondary properties. This disease anti realist attitude is exactly in line with disease vulnerability view of evolutionary medicine. The secondary characteristic comes from them being dependent on other properties and causes. I believe that there is a great possibility of disease particularism and invention of individualized disease from there contexts. In addition to that, Morar and Skorburg (2018) focus on distribution of the concept of health out of the organism, as they put it; “… develops and defends the Hypothesis of Extended Health (HEH), which denies the claim that health and disease states are predicated solely on the internal functioning of an organism. If this is correct, then the targets of medical invention and ethical concern are wider and more diverse than is usually assumed.” (p. 341). They base their study on the various accounts of distributed understandings of cognitive science, social and personal psychology, neuroscience and microbiology. I believe that this distribution while creating a good framework, can also be supported by evolutionary biology. My aim is to give an understanding of such embeddedness of disease from the evolutionary perspectives. However, focusing on disease rather than health in the distributed and individualized character of the health phenomena is also another concern that I do have here.

5.8 Conclusion In the end, finding a general principle for naturalization is difficult since it needs to refer to certain kinds of other thick concepts, be it normality, harm etc. However calling them normative also does not explain much, since the normativity in question can be related to the values in many ways. Now I will try to give an account of evolutionary understandings about disease to be able to conceptualize the diseased condition in which there are no strong boundaries and different values. Finding normality as an ultimate element in medical field is difficult. In the following chapter, I will discuss it within the meaning network of biological researchers to understand the problem and propose a solution to the normativity problem through including multiple values.

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The mainstream, normative component of disease for the health professionals and general public alike, at the moment is that of helping and care, following the developments of personal autonomy, the importance of individual in the decision making. However, is there a matching descriptive content filling this gap at the moment? I believe the medical science of today has done little in this domain, yet evolutionary perspectives can be much helpful for us to fulfil this gap in the descriptive part of the project. On the other hand, the naturalist side in the traditional debate around the concept of disease assumes to define the concept of disease from an evolutionary naturalized perspective. The traditional naturalist strategy is to say that the concept of disease can be naturalized, and give certain criteria and claim that they are value free for certain reasons. I believe that instead of trying to find such knock out arguments, finding the concept specificity of value freeness makes more sense. Without limiting ourselves to the traditional structure of disease in the evolutionary understanding, I claim, we should strive for a definition of disease not from the medical part of evolutionary medicine but from the evolutionary part of it. This could change the structure of evolutionary medicine radically. This chapter gave the outlook that the concept of disease can be seen through social and psychological aspects, since the phenomenon of disease can be modelled based on certain explanatory and interventive criteria in these domains. The coming two chapters will lay out the perspectives from evolutionary medicine and elaborate the perspectives of evolutionary medicine to say that, with the new empirical developments in evolutionary related fields, disease is ontologically in a different categorization in which inclusion of social and psychological is not necessary only, but distinguishing them from the biological is not possible. In a sense, the positions I hold in this chapter will be elaborated and argued for on empirical grounds in the following two chapters. Since disease concept, at least in the Western societies for the most part is taken to be a concept more related to care nowadays, as a call for action and medical aid, the previous concerns of normativity shall be taken accordingly. And finally, I have argued that, in parallel with HEH, we have to duel the dichotomy of disease/healthy, since as I will argue in the next chapter, variation is the norm, and the interaction between the variant traits and the varying environment of individuals active choosing is creating conditions in which diseased or healthy statuses can emerge within the perspective of evolutionary understandings. I believe that this can be empirically realized and be supported by evolutionary medicine, and evolutionary research.

References Anjum, R. L., Copeland, S., & Rocca, E. (2020). Rethinking Causality, Complexity and Evidence for the Unique Patient: A CauseHealth Resource for Healthcare Professionals and the Clinical Encounter. Springer International Publishing.

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Morar, N., & Skorburg, J. A. (2018). Bioethics and the hypothesis of extended health. Kennedy Institute of Ethics Journal, 28(3), 341–376. https://doi.org/10.1353/ken.2018.0020 Murphy, D., & Woolfolk, R. L. (2000). The harmful dysfunction analysis of mental disorder. Philosophy, Psychiatry, & Psychology, 7(4), 241–252. Nagel, E. (1961). The Structure of Science: Problems in the Logic of Scientific Explanation. Harcourt. Neander, K. (1991). Functions as selected effects: The conceptual analyst’s defense. Philosophy of Science, 58(2), 168–184. https://doi.org/10.1086/289610 Nesse, R. M. (2001). On the difficulty of defining disease: A Darwinian perspective. Medicine, Health Care and Philosophy, 4(1), 37–46. Oppenheim, P., & Putnam, H. (1958). The unity of sciences as a working hypothesis. In G. Maxwell, H. Feigl, & M. Scriven (Eds.), Concepts, theories, and the mind-body problem (pp. 3–36). Minnesota University Press. Popper, K. R. (1935). Logik der Forschung: zur Erkenntnistheorie der moderner Naturwissenschaft. Verlag von Julius Springer. Salmon, W. C. (2006). Four Decades of Scientific Explanation. University of Pittsburgh Press. Schaffner, K. F. (1993). Discovery and Explanation in Biology and Medicine. University of Chicago Press. Spitzer, R. L., & Endicott, J. (1978). Medical and mental disorders: Proposed definitions and criteria. In R. L. Spitzer & D. F. Klein (Eds.), Critical Issues in Psychiatric Diagnosis (pp. 15–29). Raven Press. Stoller, R. J., Marmor, J., Bieber, I., Gold, R., Socarides, C. W., Green, R., & Spitzer, R. L. (1973). A symposium: Should homosexuality be in the APA nomenclature? The American Journal of Psychiatry, 130(11), 1207–1216. https://doi.org/10.1176/ajp.130.11.1207 Thagard, P. (1996). The concept of disease: Structure and change. Communication and Cognition, 29, 445–478. van Fraassen, B. C. (1980). The Scientific Image. Oxford University Press. https://doi.org/10.1093/ 0198244274.001.0001 Whitbeck, C. (1977). Causation in medicine: The disease entity model. Philosophy of Science, 44(4), 619–637. http://www.jstor.org/stable/186942 White, K. (2008). An introduction to the sociology of health and illness. SAGE; Wickner, R. B., Edskes, H. K., Ross, E. D., Pierce, M. M., Baxa, U., Brachmann, A., & Shewmaker, F. (2004). Prion genetics: New rules for a new kind of gene. Annual Review of Genetics, 38, 681–707. https://doi.org/10.1146/annurev.genet.38.072902.092200

Chapter 6

Evolution and Evolutionary Medicine in Disease

“The answers you get depend on the questions you ask” Thomas Kuhn.

Abstract Evolution has a very strict definition and is very central to evolutionary biology itself when the canonized evolutionary understandings of population genetics is at work, which is as strict as “any change in the frequency of alleles within a population from one generation to the next” (Millstein and Skipper, 207, p. 26) in terms of microevolution, or any kind of “process that results in changes in the genetic material of a population over time”. However, when it comes to philosophical and everyday circles, it is difficult to point out the exact meaning of evolution. It can be used as gradual transformation, change in general or a certain kind of progress within public usage. In a sense, it can be said that evolution cannot be defined, but can be shown due to its many connections to other concepts within fields of biology. On the other hand, “evolutionary” has a particular meaning within the scientific community as well as public with respect to the contrast group, non-evolutionary. The contrast class of evolutionary within biology is generally seen as concept of stable from one perspective, and the concept of revolutionary from the other perspective. In this chapter, my usage of evolution and evolutionary are in line with the usages within the scientific community. In the beginning of discussion of evolutionary medicine, it makes sense to clarify the concept of evolutionary first, since medicine itself is a very broad area, towards which evolutionary understandings, perspectives and methods are directed by evolutionary medicine to explain medical phenomena.

6.1 The Concept of “Evolution” in Evolutionary Medicine; General Distinctions Evolution has a very strict definition and is very central to evolutionary biology itself when the canonized evolutionary understandings of population genetics is at work, which is as strict as “any change in the frequency of alleles within a population from one generation to the next” (Millstein and Skipper, 207, p. 26) in terms of

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_6

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microevolution,1 or any kind of “process that results in changes in the genetic material of a population over time”. However, when it comes to philosophical and everyday circles, it is difficult to point out exact meaning of evolution. It can be used as gradual transformation, change in general or a certain kind of progress within the public usage. In a sense, it can be said that evolution cannot be defined, but can be shown due to its many connections to other concepts fields within biology. On the other hand, “evolutionary” has a particular meaning within the scientific community as well as public with respect to the contrast group, non-evolutionary. The contrast class of evolutionary within biology is generally seen as concept of stable from one perspective, and the concept of revolutionary from the other perspective. In this chapter, my usage of evolution and evolutionary are in line with the usages within the scientific community.2 When it comes to Evolutionary Medicine [EM], evolutionary is used to mean application of evolutionary tools and understandings to medicine compared to the non-evolutionary tools and ideas.3 I generally use the first one, which creates a good basis to work with when it comes how the medical phenomena are related to the biology in a more general perspective. Evolution itself is a difficult concept to clarify even in strictly scientific communities. Similar with many scientific theories, there are various kinds of pluralisms in evolutionary theory particularly when it comes to register meanings of certain terms (Sterenly, 1996). The first distinction to be made is the one between evolution itself and evolution of an entity. While evolutionary theory itself marks a set of theories, approaches and ideas, evolution of a particular organism, a species and a kind of

1

It is possible to defend an account of microevolution that is based on traditional understanding of population genetics and explain macro evolutionary processes such as evolution of a species based on that account. However, it is not necessary to rely solely on these kinds of micro evolutionary explanations within the population genetics framework as well. 2 Although various scientific communities use the concept of evolution and evolutionary differently, I believe that the common elements within the usages of scientific communities bear more similarities compared to the public or political usages of the term. 3 Within the general perspective of this chapter, I do not believe that it is possible to give a clear-cut account of evolutionary and non-evolutionary tools. However, evolutionary tools of thinking and evolutionary understandings make sense for the biologists in a common sense manner. For example employment of evolutionary histories of a species to explain a certain disease, for example hernia due to human bipedalism and spine structure would be considered employment of evolutionary tools as in the example used by McArdle (1997). The contrast class to evolutionary explanations in medicine are of a manifold; those explanations can be not evolutionary due to their non-historicity, their reliance of organism-environment relationship, individual life stories that are based on noninheritable characters etc. There are certain attempts to formalize certain kinds of evolutionary explanations in which evolutionary explanation is taken to be “the ultimate explanation” compared to the “proximal explanation”, following mainly Mayr’s Cause and Effect in Biology (1961), in which he claims that both kinds of explanations are necessary to understand biological phenomena, evolutionary ones denote the ultimate ones, answering why questions. Even this is the case, within the chapter and particularly in the following; I debate against this perspective, trying to defend a perspective in which the distinction between evolutionary and non-evolutionary explanations, tools, approaches and methods are not that easy to make.

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entity is about the evolutionary history of that entity, adding many other accounts to the “evolution proper” while explaining this history. The concept of evolution when used as an adjective in the form of “evolution of x” marks the evolutionary history of an entity, evolutionary “laws” or a contrast class for the non- evolutionary in biological research and can be analyzed at least to three distinct parts as concept, theory and object (Toepfer, 2013). The importance of various evolutionary mechanisms also varies amongst researchers when it comes to understand a particular evolutionary process as well as the general importance of a certain law, mechanism of process also varying greatly (Laland et al., 2014). With more institutions and researchers, working on evolution as a general theme having different research goals and independent starting principles, trying to integrate evolution to medicine as a general concept of analysis becomes even more difficult. However, although the perspectives differ and some approaches within evolutionary biology define the contrast group of non-evolutionary within their own research that includes central elements of other self-defined evolutionary approaches; evolutionary biology is a connected network of research. At least, the researchers acknowledge that they are working in the same field and occasionally discuss their respective perspectives (Ahouse, 1998). This enables us to see evolution as a vague yet interconnected concept at work in science.

6.1.1 The Delphi Study of Evolutionary Medicine This difficulty to define evolution is not unique to the philosophers, evolutionary biologists as well, at times, are finding it difficult to give a strict account of evolutionary and non- evolutionary principles, particularly when it comes to choose which principles within evolutionary biology are applicable to medicine. The Delphi study amongst scientists and scholars working on evolutionary medicine aimed at framing evolutionary medicine as a derivation of general evolutionary understandings for this very reason (Grunspan et al., 2018). During this study, when it comes to integrate evolution to medicine, several questions are in order. As seen in the Delphi study done in 2018 amongst 56 expert panelists of evolutionary medicine, there has been varied consensus on which principles should be applied to medicine. This means that, while evolutionary medicine tries to establish itself as an individual discipline, there are already discontents and experts of medicine and evolutionary biology who believe that different forms of evolutionarizing medicine are possible. If we define evolutionary medicine as the “application of evolutionary principles to medicine” as it is commonly defined by the contemporary forerunners of the field such as Nesse (1995, 2019), Trevathan (2018), Alvergne et al. (2016), the practice of evolutionary medicine will always be broader than the discipline.

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EM itself. Thus, it makes sense to expect evolutionary theory and evolutionary thinking having different kinds of effects to medicine in time and even following different traditions.4 Medicine on the other hand, as the traditional categorization goes, is a very practical discipline that employs various different tools, concepts and theories from diverse fields to reach practical goals, the most frequent of these goals being curing a disease.5 Although both are very interdisciplinary fields, evolutionary biology is generally considered a very theoretical and thus unrelated discipline to medicine (Nesse, 1995). I will not deal with the concept of medicine and not even the compatibility of medicine and evolution by large here. My emphasis is the medical characterization of disease, that being said; of course, it is impossible not to acknowledge a certain level of pluralism in the categorization of disease in medicine. However, since medicine is a strictly socially controlled and institutionalized practice due to its immediate effects, the agreement on medical concepts, at least when we investigate particular diseases is relatively simpler compared to the evolutionary biology. Despite such strict standardization on the level or particular diseases, the medical perspectives themselves do not give an easy answer on the concept of disease. The traditional World Health Organization (WHO) definition starts with defining health as “a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” (WHO, 1946). In this model, health is defined with the help of absence of disease while disease is not defined at all. Instead of looking at a particular definition of a general disease concept, we can try to see how the different working definitions of disease created a history for the disease concept in medicine. “However, medical classification underwent a dramatic shift. As historians of medicine (Gelfand 1980; Cunningham and Williams 1992; Hannaway and LaBerge 1998) generally say, modern medicine arose with the rise of clinical medicine in the late eighteenth century (even though there are many raging controversies regarding the relative importance of certain authors, geographic center’s periods: the mideighteenth century Edinburgh school of medicine, the nineteenth century Paris “Ecole clinique”, etc.—see e.g. Ackerknecht 1967; Foucault 1963; Keel 2001). The traditional historical view states that the main focus switched from diseases as entities— as “species” or “essences” which were related to each other in a table or system that medical theory had to discover (the “nosological medicine” of early modernity) towards the diseased patient with a dysfunctional body (Jewson 1976), whose lesions or dysfunctions had to be traced back to specific symptoms. Whatever the historical value of this received view, it still implies that the importance of classification (nosography or taxonomy) decreased with the emergence of clinical medicine, anatomo-clinical medicine (namely, clinical medicine that tied the identification of 4

This point is similar to the general conception of how a concept can have multiple uses and effects to a field when it is employed by different kinds of scientific research as discussed in Chapter III. 5 In the traditional debate, evolution is mainly taken to be evolutionary theory or principles. This also limits the possible approaches from evolutionary fields to medicine. I will discuss the more detailed perspective of problems of theory centrism in classification of evolution in Chapter V.

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diseases to the data of pathological anatomy), and then contemporary medicine, which starts with the laboratory (i.e. with biology)—as Claude Bernard accurately put it.” (Huneman et al, 2015, pp. xiii-xiv) (My italics). Although the starting point of contemporary medicine is considered as biology here, it is not the theoretical or evolutionary biology, but molecular biology and cellular biology where there are multiple tools of intervention to the patient or to the disease. As it can be seen from the history of medicine, the emphasis is on dysfunction and pathological anatomy have been very central to the disease concept in medicine, since in its mainstream it aims at an ideal to match when the patient recovers. The medical concept of disease is relatively more tangible mostly because it is a very central concept to medicine, while for evolutionary biologists, it was used to be a minor, related concept to the evolutionary theory, but on the conceptual level they were not working on disease concept, but individual diseases to explain them within an evolutionary framework. The general view is that evolutionary perspectives will take diseases and explain them away. On the other hand, there can be diseases (or at least oddities) for evolution, which are normal cases for medicine. The concept of disease does not belong to the field of evolution. Evolutionary biologists rather talk about maladaptation, tradeoffs and decreased fitness when talking about the function of a trait. The task to relate evolutionary theory to disease is still ongoing, and the first order of business for people working on evolutionary medicine is to claim that evolutionary theory can be related to medicine in principle and also in practice and even further develop medical understanding.

6.1.2 Relevance of Evolution to Medicine When writing about evolutionary medicine in contrast to physiological medicine for example, the first step is to establish the presumably already existing potential of evolutionary theory and evolutionary thinking in medical field. Another method is directly to do it. As of 2022, there is a very important journal Evolution, Medicine & Public Health started by some of the forerunners of the EM. Their approach is focused on “doing” evolutionary medicine, that is to say, using evolutionary understanding and evolutionary theory to understand certain diseases. Their studies deal with various kinds of research, spreading from the effect of fish consumption on children’s school performance to (Lehner et al., 2020), origins of Mycobacterium bovis, a bacterium that cause tuberculosis in the livestock (Chloé Loiseau et al., 2020). More “real life” evolutionary perspectives being applied to ethical aspects of research are also being done (Gati et al., 2021). Such approaches directly link “medical phenomena” to evolutionary biology. In these kind of examples, the relevance is already easy to follow, since they link particular medical phenomena to concrete evolutionary understandings. The other important task is to assess the importance of evolutionary biology by establishing EM as a discipline, which is itself an important approach in medicine.

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The focus of this part is to discuss this aspect, namely the assessment of evolutionary medicine to disease. The relevance and potential of evolution to medicine is a heated discussion (Bentley, 2016; Perlman, 2013; Trevathan et al., 2008). The first reaction to “defend” medicine from evolutionary explanations or evolutionary perspectives is to claim the irrelevance of evolution to medicine. The differences at first sight such as being highly theoretical versus practical—as discussed above—look very obvious and prominent. This problem is accelerated due to the currently limited toolbox of EM. One principle problem of EM when it comes to show its relevance to the medical field is the limitation in its own tools. Since it is still in a very early stage where it builds disciplinary barriers and tries to give relevant examples, evolutionary medicine is trying to show its own relevance to the medical so that it can get more attention and research done it to show more relevance. In order to prove this relevance one main activity is to introduce it to medical doctors and biologists by publishing books and journals, which try to point out the relevance of evolutionary thinking to medicine.6 The obvious question to ask in this regard when faced with a very practical discipline where the aim is to provide very practical output is of course, “what can a book do?”. In a field like medicine, the proof of the pudding is in eating, since evolutionary biologists are not working on curing diseases, the most relevant to medicine they can get is explaining diseases, in this respect, often they are non-interventionists. Moreover, people working on evolutionary medicine are hardly getting the funding they demand to conduct the experiments that they see necessary to assess the clinical results for the use of evolutionary medicine (Nesse, et al., 1995). Another problem of trying to emphasize the importance of evolution to medicine is a bit paradoxical. As EM gets more relevant to medicine through its successes in explaining diseases, evolutionary perspectives that are applied become a part of existing medical perspectives and medical practice. Stearns (2012) has an insight, saying that. When at some future date evolutionary insights have been accepted and integrated into the training of doctors, epidemiologists, nurses and veterinarians, they will then be so familiar that the term ‘evolutionary medicine’ will disappear from use. (p. 4305). (My italics)

This position requires a body of knowledge known to be evolutionary biology to “infiltrate” into the medical field, make its place there, and eventually be parts of the regular toolkit of medicine. This also means that, while EM becomes more relevant, it is no longer called EM, it is simply medicine. When it comes to relate “what is left of EM” after different insights are integrated into medicine and are no longer called EM but medicine proper, EM loses some body of knowledge within itself, waiting to be integrated, and regarded as a separate discipline.7 Due to this problem, EM faces 6

This kind of relevance does not mean that it ist he most important or the main kind of relavance of these two fields, however it ist he most frequent way it is done within the literature. 7 This is a very central dilemma of the EM. On one hand, its practice makes it seem more relevant, on the other hand, if its practice is successful, it becomes part of the medical discipline. Deciding on a separate strategy when it comes to asses EM separately of not is an important question that EM needs to answer.

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the difficulty of showing itself as a discipline or body of knowledge that is capable of explaining things on its own. Although in principle, given the vast diversity of meaning of the concept of “evolutionary” and the manifold of sub-fields within evolutionary biology, making the parts of evolutionary perspectives and theoretical frameworks is possible in many ways, the study here will focus on the traditional field, which is called evolutionary medicine since 90 s.8

6.2 What is Evolutionary Medicine, Historical and Contemporary Accounts As Trevathan (2018) puts it, “Evolutionary medicine is defined as the application of principles of evolutionary theory to medical practice and research.” (p. 1). Defined as such it is very broad and diverse, here I will discuss the general developments in introduction of evolution to medicine, and eventually will sketch the modern canonical EM.

6.2.1 A Brief History of Evolution and Medicine Together The grandfather of Charles Darwin, Erasmus Darwin, is generally considered the first figure to investigate disease in an evolutionary understanding. He was a very well known medical doctor, is known to base his ideas of evolution in medicine. He was also one of the biggest influences to Charles Darwin. In Charles Darwin’s works, it is very clear that he has problematized the phenomenon of disease itself. Particularly, when it comes to hereditary diseases, he used to see them as an oddity in a sense—since it was not selected against—and a phenomenon that helped to support his view on variation within populations. Since something that has such a selective disadvantage, being prevalent in the populations is obvious; this brought further validation to his understanding that there is a variation amongst traits within a population. After Darwin, there was a great interest in applying evolution and evolutionary understandings to various related fields. This was also because in nineteenth century, there was not as strong as a disciplinary distinction within sciences as it is now, and not the disciplinary policing that we have now. When it comes to follow the general trajectory between evolution and medicine, it is possible to divide the whole history in two phases (Zampieri, 2009). In a quantitative analysis, it is possible to make this distinction, following Zamperi’s method. He divides to history of relationship between evolution and medicine into two through a frequency research on the terms 8

For a further discussion of what can be used within the evolutionary framework to understand disease, chapter V will be informative.

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“Darwin”, “Darwinism”, “evolution” and “evolutionism” on the two main weekly medical journals; The British Medical Journal and the Journal of the American Medical Association (Zampieri, 2009). He calls the first phase between 1880 and 1940 Medical Darwinism, and the second phase, mainly starting in 1990s, Darwinian Medicine. The end of interest in Darwinism in medicine came at 1940, when eugenics research came to a stop during the WW II, when the public was aware of the extent— even for their standards in 1940—to which certain ways of Darwinism can end up with racially motivated crimes against humanity (Tracy, 1992).9 There are two historical periods in which medicine and evolutionary biology cooperated to build evolutionary theories of disease that were eventually applicable to the curing of sick individuals—two periods in which Darwinism was sometimes an applied science and medicine a theoretical system, in which Darwinism became a science of individuality and medicine a theory of populations, and in which a network of schools and ideas existed whose complexity counted in favour of, rather than against, the fecundity of this approach (Zampieri, 2009, p. 334). In the first period, Medical Darwinism, the concepts within evolutionary biology were not well defined. Evolutionary theory—from today’s standards—used very vague concepts, the theory itself was not canonized and the application of evolutionary understanding to different fields did not come to an end. The conflict between Mendelans and biometrics for example, was still ongoing on how to unify these two different fields in a compatible way to the evolutionary understanding of the time. The Modern Synthesis of evolutionary theory—which is still referred to as the orthodox understanding of evolutionary—started to take shape only by Huxley’s Modern Synthesis (1942). Before the Modern Synthesis, Zampieri (2009) finds essentialism during Classical Darwinism (1860–1920) phase where evolutionary processes created types such as species, varieties and races. He tells us that it was a typological approach in which there are essences that are being shaped by evolution.10 In this phase of relating evolution and disease, although there have been some attempts to understand certain kinds of diseases, such as hereditary diseases, it was not a very successful attempt due to its essentialism and its early end. Relatively new union of Evolutionary Medicine of today is something rather novel. The relationship between evolutionary biology and medicine recently created the branch of Evolutionary Medicine. EM itself is very recently trying to be canonized by the efforts of scholars working in the fields arranging commissions such as that of the Delphi Study in 2018 (Grunspan et al., 2018). The evolutionary biology itself changing constantly, it became an area of evolutionary approaches to medical field, with these evolutionary approaches being what is understood from the concept evolution by those scientists. “Smoke detector principle”—a principle to explain how

9

Zampieri (2009) also notes that the old Darwinian Medicine was more of a British phenomenon, while contemporary evolutionary medicine is stronger in the USA. 10 Nesse’s understanding of “capacities” in Good Reasons for Bad Feelings (2018) is similar.

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costly warning mechanisms have evolved—for example, is a relatively recent principle put forward by Nesse (2019). While the issue is by itself a competing ground for scientists, there has been few philosophical approaches in the field of EM. Buller (2007) also looks at evolutionary psychology to comment that evolutionary medicine is “a loose confederation of research programs that differ significantly in theoretical and methodological claims” (p. 255).

6.2.2 The Cannon of Evolutionary Medicine During 1990s, there has been an increasing interest in using evolutionary theory and evolutionary insights in medicine. The framing of Darwinian Medicine in its current usage happened in 1991 through the article The Dawn of Darwinian Medicine by Williams and Nesse in the Quarterly Review of Biology (Williams and Nesse, 1991).11 Although Nesse (2007b) tried to use the concept of Darwinian Medicine to highlight the importance of natural selection when it comes to apply evolution to medicine in 2007, in the Delphi Study, as well as his later work (Nesse, 2019), his position has changed to broaden this concept to EM again. The new trend was renamed as the term took the shape of Darwinian medicine at first; it was eventually replaced by the name Evolutionary Medicine (Alcock, 2012).12 This new approach used new tools while dealing with disease, partially due to developments in evolutionary biology that clarified certain concepts such as gene centric evolution (also popularized by Dawkins as he calls it Gene’s Eye View (Dawkins, 2016 [1976]). This perspective was based on the works of population geneticists’ work, mainly those of Fisher and Williams (Fisher, 1930; Williams, 1966). The body is a bit like an epiphenomenon in evolutionary medicine because the evolutionary processes acting on the body are of a different nature. Genes carry the blueprints that will create the body, and the focus of research in evolutionary biology in the orthodox sense are genes. This led to a meaningful distinction between the previous approaches in application of evolutionary theory and understandings in medicine, and Darwinian Medicine. The conceptual changes happening in the evolutionary theory itself changed the general understanding of evolution which could be now applied to diseases and the medical field differently. Since the concepts in evolutionary theory were explicated, the theory itself mathematized, institutions mainly working on evolutionary biology were funded, and there was the possibility to create an orthodox understanding of evolution. In this sense, it was possible for evolutionary biologists to create a common framework, despite the dissidents. 11

It is important to note that most of the works in evolutionary medicine were published in journals of biology before they started to circulate their own journals, and today as well, most of the publications are in biology journals rather than medical journals. 12 There were also differences in the approaches in what is evolutionary when it came to see evolutionarize medicine in many different approaches and the difference is not only in terminology. The EM also developed standard Darwinian Medicine also in scope and tools.

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On the level of its own achievements, the movement gained an unpresented success compared to the previous attempts in evolutionary understandings in medicine. The main starting point as a self-standing book, Why We Get Sick (1994), written by Williams and Nesse, has been translated to every major language, was on the cover of Bild in Germany, and was targeted at a very broad audience (Zampieri, 2006). Williams’s article on senescence (Williams, 1957) started the collaboration between Williams and Nesse (Nesse, 2007a, 2007b). Williams’s article was a milestone in the sense that it advocated the idea that natural selection operated for the reproductive success of the genes but not for the benefit, health or happiness of the organism.13 On this diversity of the framework, Nesse even quoted Margie Profet (1991), an immunologist who worked on the adaptive function of allergies in the making of his own perspective. (Zampieri, 2009). This new movement, which is being canonized as EM has gathered the scholars working on various fields who believe that they are a part of the EM community to create a plan in 2018. One of the aims of this Delphi Study was to solidify the principles of EM so that it can be studied within the medical curriculum, can be advocated as a set of rules and studied as research topics. The agreed principles of the Delphi Study of 2018 is as follows; Grunspan et al., (2018, p. 17), show the agreed principles.14

As they note in the Delphi study (Grunspan et al., 2018, p. 13), “evolutionary medicine is a young field, so this list of core principles will likely change as the field develops further”. The principles they have developed and collected are principles that hold useful for the current understanding of evolution and evolutionary medicine as well as creating a canon that can be thought at universities15 and defended when it comes to ask for research grants. There have been even guidelines for medical teaching on how to include evolutionary medicine (Nesse et al., 2010). This way they could have a unified understanding to put forward and support. In their own words, “a current impediment is the lack of consensus on core principles that unite the field” (Gluckman et al., 2018, p. 14). However, the Delphi Study of 2018 already shows that there is not an easy agreement on most of the principles. Some principles, such as the Smoke Detector principle, a principle that is not within the traditional evolutionary understanding but a rather new phenomenon put forwards by Nesse (2007a, 2019), could not meet the popular support. As discussed earlier as the negotiation process within the Delphi study, this shows that, within the EM community, there is a level of disagreement on some of the principles that they have decided on. Even within the agreed principles, Grunspan et al., (2018, p. 20) not every principle that is accepted as a core principle has the same agreement strength as it is shown in the study.

13

It is indeed interesting to note that evolutionary biology starts from refusing the concept of disease within its own framework, in a sense, not considering health and disease in the first analysis is the trademark of EM. 14 I will discuss the main conceptual framework of EM within this chapter later. 15 For many people working on EM, one of the main issues is to add EM to medical curriculum.

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The disagreement is understandable also because evolutionary biology is related to medicine already through many common concepts, be it disease, health, senescence, reproduction, environment etc. The richness of this conceptual toolkit enables different kind of evolutionary biologists working on different aspects of evolutionary biology to assess their own conceptual framework more important within the entire evolutionary field when it comes to relate to medicine than the other evolutionary biologists who are focused on different concepts. For the multitude of concepts at work when it comes to discuss evolution, we can use the analysis made by Zampieri in Darwinian Medicine. “Evolutionary concepts of relevance to the health sciences are: natural selection, genetic drift, adaptation, coevolution, host-parasite arms race, defense and the “smoke detector principle,” traits balanced between costs and benefits via trade-offs, genetic quirks, reproductive advantage at the expense of individual maintenance and survival, constraints, evolutionary legacy, and mismatches to the modern environment (Williams and Nesse, 1991; Ewald 1993; Nesse and Williams 1994; McGuire and Troisi 1998; Stearns 1999; Trevathan et al. 1999, 2007; Stearns and Koella 2008)”. (Zampieri, 2009, 348). As a result of the varieties this diverse trying to be canonized into one single type of EM, it is natural to have a divide between evolutionary biology and evolutionary medicine. Since some of the thoughts, approaches and methods of the evolutionary biologists and aspects of evolutionary biology will be excluded from evolutionary biology, evolutionary biology itself will be kept out of evolutionary medicine proper, and the crystallization of the EM in its current form will create discontents who will try to evolutionarize medicine through different principles of evolutionary theory and evolutionary understandings. After the description of the main cannon, now I will turn to the main discontents of EM in particular and scholars who do not believe that neither evolutionary biology nor the EM has much to offer to medicine. The first objection comes from the testability of evolutionary theory and hypothesis as well as explanations coming from the evolutionary domain. This seen as one of the main problems of evolutionary biology since a field as practical as medicine—as it is claimed—needs testable small scale hypotheses and methods.16 More general critics of evolutionary medicine such as Cournoyea (2018), put aside, even strong supports and leading figures working on EM think that EM needs more research that is experimental. Two leading figures in EM, Gluckman and Bergstorm (2011) go back to the testability of evolutionary hypothesis through empirical research. In addition, they demand more empirical studies to be done for EM. However, the objection to EM strikes directly to this point. Are the explanations of EM useful, or are they stories that are not only not interventionist, but are not even true, because there is no possibility to test their truth? 16

The discussion between lower levels of explanation, and the debate between explanation and reality can be found in Hacking’s (1984) as well as Cartwright’s (1999) works, and whether evolutionary biology can be seen as a general theory or lower level mechanisms is a very large discussion that I aim not to get involved in this part, however in Chapter V, I briefly discuss the structure of contemporary evolutionary explanations and claim that they tend to be more mechanistic lover level explanations.

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In other words is the discipline that is being canonized capable of helping medicine at all? My answer to the second question comes in different kinds of answers, depends on whether we are talking about clinical medicine or medicine as a general field.

6.3 Are These Simply and Adaptationist Stories? Explanation in Evolutionary Medicine The discussion, whether explanations of EM are useful for medicine or not is a new issue, since the discipline itself is trying to gain its legitimacy while still working on its own foundation. The most notable work in the field about medical explanations in evolutionary medicine is done by Cournoyea in a philosophy PhD dissertation (2018). He (2018, Chap. 1) evaluates EM within the framework of evolutionary explanations.17 Although the issue looks recent,18 there has been a very central debate within evolutionary explanations since at least 1979. Since the publication of Spandrels of San Marco (Gould and Lewontin, 1979), adaptationism—rightfully—became the most shunned word in evolutionary explanations if not in complete evolutionary biology. Briefly, Gould & Lewontin criticized what they called “the adaptationist programme” in evolutionary biology, an approach based on using few evolutionary principles—sometimes only one, as natural selection perfecting each and every trait—to explain evolution of individual traits of an organism. The main critique become central as a method to deflect evolutionary explanations which did not have much explanatory relevance to the trait to be explained, or when these evolutionary explanations were used against other rivaling explanations from other fields. However, Spandrels certainly affected evolutionary research a lot, and recently most evolutionary biologists do not subscribe to at least a simple version of the adaptationist programme. Adaptationism is not limited to adaptationist programme only, as a general research method. Godfrey-Smith (2001) distinguishes three kinds of adaptationism from each other; explanatory, methological and empirical. Tim Lewens (2009) elaborates these three kinds to seven different kinds of adaptationism, and while doing so, he advocates that there are non- adaptationist programmes in the developmental biology.19 Within the EM framework, different kinds of adaptationism are employed to give different answers. In many works of EM, one question is addressed at the beginning 17

I will not be dealing with whether evolutionary explanations themselves are another type of explanations or whether they are historical or mechanistic explanations, however I find these issues also very important when it comes to discuss evolution. 18 Moreover, Cournoyea (2018) correctly observes that EM literature did not address this debate on explanation, however, I think this by no means mean that in the conceptual level there will not be changes when it comes to assess disease. 19 He also mentions the positivity of the developmental biology’s evolutionary research programme; I mention this in chapter V.

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of the discussion; why our bodies are left vulnerable to disease. This is almost universally true for evolutionary medicine textbooks and needed for explanation for EM. It is as if they are constantly subscribed to the belief that evolution amounts to perfection in its expected form, and disease itself is a surprising phenomenon, given that evolutionary processes should be amounting to perfection of a system. Many other aspects, such as aging, the prevalence of parasites, infertility follow the same suit. The standard view in the evolutionary understanding is the adaptationist story. EM tries to explain the individual disease when all the remaining issues are remained constant, as if there is one ideal environment and there is no interrelation in the development of new traits, the new traits simply emerge out of thin air. The main structure is very simple; there was an ancestry population in which the trait in question has evolved. This trait in question, which was adaptive at the time of its emergence20 in the evolutionary history becomes maladaptive in certain circumstances, and it is not selected against, due to that, it is still prevalent in the population. The question for the evolutionary biologist starts here, how can a trait that was beneficial and selected for at a certain time can be maladaptive and harmful under these circumstances. These kinds of diseases are called diseases of civilization. The diseases of civilization are used in EM to explain diseases that occurred due to a mismatch between when human body’s21 adaptions took shape during the Pleistocene epoch (about two and a half million years ago22 to ten thousand years ago, when agriculture started) and the modern environments.23 When traced to its origins, this understanding of an original environment can be found in a psychologist’s John Bolwby’s, work (1969), where he framed the period as environment of evolutionary adaptedness (EEA). Some evolutionary explanations of some diseases can always be adaptationist stories; however, it is not a necessary condition for evolutionary explanations in disease. Moreover, evolutionary explanation of a particular disease is also different from an evolutionary perspective that is brought in by EM on the concept of disease and how disease should be treated. The brief structure of adaptationist explanations in EM can be structured mainly this way; 1. A disease of concern is taken from the medical context, as defined by medicine. 2. Since it should be selected for (due to the adaptationist understanding) in the evolutionary history of the species, the condition under which that trait (which is

20

Emergence is a very loaded concept, I am using it here in the most general sense. Note it idealistic, typological understanding of the “human body” instead of the population approach that embraces variation within a population. 22 The beginning of the epoch is also based on the genetic evidence of the first appearance of humans. 23 Here the idea of a modern environment is also in an idealized form. Generally, with modern environment what is meant is a post industrialist society for a middle class average citizen. 21

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maladaptive not and causing disease) might increase the fitness24 of the organism is investigated. 3. The conditions under which this trait is selected for is researched with the tools available to evolutionary biology and other auxiliary sciences. 4. Or they see it possibly beneficial in different conditions at different times. All leads up to some kind of an adaptationist story. There are many different examples of this kind of explanation of disease. This kind of explanations range from early ejaculation of men; considered not to be a disease in evolutionary terms, but a disease in medical terms (Apostolu, 2015) to child abuse (Nesse and Williams, 1994, pp. 223–224). The main problem with such adaptationist explanations is, they do now provide an effective nor reliable explanation for the phenomena they claim to explain. Since medicine is a field of intervention and is in need of reliability, holding the criticism that the evolutionary explanations are “just so stories” due to the criticism of adaptationsim, the evolutionary explanations coming from EM are not helpful—if not harmful—to the medical field since they are made up stories. It is not very surprising to see the adaptationist dynamic in explanations of EM. Since they have a tendency to apply Darwinism and natural selection to different subjects, sometimes under the etiquette of Generalized Darwinism, or Universalized Darwinism. Nesse, for example expects Darwinism to be helpful in many different domains; “Help from Darwinism does not end at the boundary between the medical and the social or educational. Darwinism is relevant to all aspects of human life, not just medicine” (Nesse, 2019, pp. 182-183)

Here it is possible to see that, also the distinction between the medical and nonmedical diminishes due seeing phenomena without disciplinary boundaries yet only through the lens of natural selectionism in EM. Stearns (2012) made a table to demonstrate how different evolutionary branches can help with various kinds of medical issues that deal with diseases that fall under respected disciplines.

When it comes to explanations of EM, Cournoyea and Kennedy (2014) on the benefit of causal explanatory pluralism in the diagnostic workup and clinical management. They hold that; A mechanistic explanation is nearly always more fundamental than a topological or structural one and as such is considered the gold standard of medical diagnoses. (Cournoyea and Kennedy, 2014, p. 930)

From this perspective, even when the evolutionary explanations are not complete made up stories, and even when they hold true, they do not provide any explanatory power when it comes to medical diagnostics. According to this perspective,

24

Evolutionary biologists are not interested in health or disease per se, their focus is the fitness of the organism – or depending on different evolutionary understandings, gene, kin, or species.

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that compares evolutionary explanations with respect to their diagnostic value, evolutionary explanations do not help at all in medicine.25 Apart from the general objection Cournoyea (2018); takes “ultimate causation” and “importance of natural selection” to be trademarks of EM. (p. 20). In his characterization, he also puts forward; “These assumptions privilege natural selection over other evolutionary forces in the evolution of human anatomy, physiological, sociality and health” (p. 20).26 Evolutionary medicine, it is claimed, is using “why questions” when it comes to disease. After all, one of the most central books in the field is called Why We Get Sick? However while doing so they always kept using the disease concept or set of concepts which already existed.27 The two pressing concerns are as follows; 1. EM explains disease through an understanding that is focused too much on natural selection. 2. The explanations it provides are either inadequate or unrelated. My main objection will be against the first concern in the end; the second concern(s) are more of empirical nature, and dependent on the state of the research on EM although I deal with the natural selection playing a different kind of role in different kinds of evolutionary entities here and in chapter V, I also deal with different 25

One note here is about another role of explanations, namely; explaining for the patient. Most of the discussions around “scientific explanation” revolves around the idea of the explanation for the purpose of further research. The explanations are supposed to be made by the scientists and for the scientists. Although it is possible for scientific explanations to be made for the general public, the main element in the mainstream philosophy of science focuses on the accuracy of the nature of explanation to provide a good ground for the scientists in their future work. Medical explanations of clinic are of a different nature than them. In the clinic, the physician does not only explain for interventionist purposes, but also explains for the sake of informing the patient, be it on the grounds of acquiring consent, or providing relief for the patient or both. On that point Kainz (2003) discusses the possibilities diverse ways of explaining certain diseases to patients. I believe that traditional evolutionary explanations in the clinic, due to their nature of framing the patient itself as a product of historical evolutionary processes, and always under the influence of these historical contingencies, having to face certain constraints, the patient finds herself in a position to be able to “solve”, “fix” or “live with” a problem that is not of her own creating. I believe that this is a liberating experience for most of the patients. One of the most promoted ideas of what to do with the cannon of evolutionary medicine Why We Get Sick, advises the reader to buy one copy for herself and one for her clinician, not only on the interventionist purposes but also for the purposes that these kinds of explanations are the kinds of explanations that the patients would be not only happier with, but this very psychology can be helpful for the mindset of the patient in the process of healing. I believe that they can be particularly helpful about diseases which are treatable but not curable or not even treatable. Of course it might be possible for the patient to have a negative consequence of “destined to be sick”, this decision shall be left for the medical ethics in principle and to the clinician-patient interaction in practice. 26 I deal with other possible evolutionary understandings, which also have a critique of the centrality of natural selection in chapter V. 27 This means, there should be certain structures that create the disease which are themselves are not of negative outcome. However, ultimate causation gives the biologists liberty when it comes to understand disease in a natural framework instead of using a loaded concept.

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kinds of evolutionary mechanisms. Most importantly, claiming that all EM does is trying to explain particular diseases is not doing justice to EM, since it also broadens our conceptual framework of the disease concept while it is at work.

6.4 How Does EM See Disease; What Can We Expect from It? Against the general critique of explanations of EM, EM develops its own perspective from an evolutionary background to understand the medical phenomena such as diseases, which make it meaningful within an evolutionary framework. However, this does not mean that they do not enlarge the vocabulary of evolution to engage in medical phenomena. In Good Reasons for Bad Feelings (2019), Nesse asks, what if we categorized cough as a disease, instead of the diseases that create cough symptoms as diseases. Obviously, that would create a very bad research programme. We would have to categorize unrelated disease that have cough as symptoms under the same type, the same disease. This is a bold claim within EM. The idea is to put evolutionary understanding as a central theme, so central that the categorizations and explanations made by medical science are not better than the evolutionary thinking’s results from its own inquiry.28 The discussion around EM was mainly focused on evolutionary explanations. The individual explanations that could explain a certain disease. However, if we see the principles of evolutionary medicine at play to define disease rather than explain it, the picture will be different. This would create another function for EM. In How We get Sick, the conclusion states the general paradigm of problematization of EM. They ask; “Why isn’t the body more reliable? Why is there disease at all? … First there are genes that make us vulnerable to disease. Some … are defectives continually arising from new mutations but kept scarce by natural selection. Other genes cannot be eliminated because they cause no disadvantages until it is too late in life for them to affect fitness. Most deleterious genetics effects, however, are actively maintained by selection because they have unappreciated benefits that outweigh their costs. Second, disease results from exposure to novel factors that were not present in the environment in which we evolved.” (Nesse and Williams 1995, p. 236)

Williams and Nesse (1995) ask this question mainly to evolutionary biologists while concluding, the ones who are most prone to adaptationist explanations, and have a greater tendency than medical doctors have to see evolutionary processes eliminating diseases. However, apart from explanations, they also have another perspective to offer, in the shape of a research and education programme, as well as healthcare policy. When 28

It can be discussed that; this understanding has to do with more theoretical “purer” sciences having explanatory priority over the lower level mechanisms and laws. I do not want to get into this debate; however, I would like to note that I do not agree with that perspective, although Nesse’s point here is well made to look for better explanatory frameworks.

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they are discussing about the healthcare policy and prevention of disease; “While not pretending to offer solutions, we observe that the many participants in this debate don’t even agree on what disease is. They know disease is bad but differ widely on where it comes from and the extent to which it can be prevented or relieved.” (Nesse et al., 1995, p. 248, my italics).29 From an evolutionary perspective, it makes sense to see how things are “going wrong” instead of simply seeing that they are going wrong. The different units of selection understanding also means that different elements or parts within human body, or within a human organ or on overall developmental processes have reasons to go wrong due to the conflicting nature within the biological systems. Whereas, in the traditional picture of medicine, disease is generally seen as something going wrong on an otherwise working system due to the physiological perspective of clinical medicine. Evolutionary understanding here helps us to make sense of the things that are not working properly under certain circumstances. When it comes to the conceptual level, it is difficult to define a single concept of disease in EM. No evolutionary textbook makes a clear definition of it. After all, even one of the most central books of EM; Principles of Evolutionary Medicine by Gluckman et al. (2016), they do not give an explicit definition of, and only spend half a page to deal with the question. Although Gluckman et al. (2016) do not give a definition of disease even in their chapter of What is a Disease? they describe how they see diseases. The issue of interest for the evolutionary biologist is how disease is possible at all. Many evolutionary biologists are puzzled by the idea that some adaptations could be diseases.30 In their perspective, evolutionary processes were supposed to optimize traits, behaviours, structures or at least be trade-offs. The other explanation could be that they were broken some way. However, the adaptations themselves becoming diseases is very striking for them. I think this is the best perspective about thickness of the concept of disease in EM. Since the same entity (a trait here for example) can be both positive and negative for the organism depending on the circumstances,31 the thick concept itself loses its global evaluation. The advantage of evolutionary thinking within EM when it comes to discuss disease is, it does not have a disease concept of its own. EM is instrumentalist about disease while in most of the medicine the researchers are disease realists. In medicine, it makes sense to find a particular disease for a particular sickness under particular circumstances. EM does not need a general disease concept to conduct research as well. In the linguistic division of labour, EM simply goes with the diseases picked by medicine. This way EM can develop its understanding of adaptation and evolutionary mechanisms to understand that there can be a possible benefit in everything. However, although EM starts without having a diseases concept of its own, while explaining 29

It is worth noting that they also use the thickness of the disease concept here. Based on observations within EvoPAD, Münster. 31 In thick concepts literature, it is similar to Foot’s (1958) example of RUDE, when it sometimes makes sense to be rude under certain circumstances. 30

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the particular disease it creates one through modification of the already existing disease concept by means of framing the diseases within different contexts.

6.4.1 What is an Explanation? There is good reason to expect the explanation of specific individual diseases from EM as long as they are helpful in intervention, even when we can categorically say that most of them will not be helpful. In the end, this is what we expect to be translated to medical field, finding remedies for the diseases we already have. The easiest demonstration of the success of evolutionary understandings in medicine comes from the examples of hereditary diseases. As discussed before, hereditary diseases have surprised evolutionary biologists starting with Darwin. However, this analysis is not reserved only for history. Today the screening for hereditary diseases became commonplace when people want to bear children, sickle cell naemia was demonstrated as an example of evolutionary theory itself where natural selection selected for a trait that is harmful to the individual at first sight, but also protective on other respects (Haldane, 1949). Explaining disease concept within evolutionary theory through explaining particular diseases has been one of the main issues of Modern Synthesis (MS), due to selection, eventually leading to an area called fitness landscapes within evolutionary theory (Smith, et al., 2002). However, what they aim to explain does not seem to be only diseases. Nesse claims that; While our main focus in this book is on how evolutionary ideas can help to explain and prevent or cure specific medical diseases, here and in the next chapter we broaden our view somewhat to encompass emotional and behavioral problems that may or may not be considered medical disorders. (Nesse and Williams, 1995, p. 182) (my italics).32

The “explanatory worry” of the traditional medicine for the explanations coming from EM was, they were going to “explain away” the phenomena of medicine, being not only not helpful all, but also obstructive of other kinds of (mostly medical) explanations within medicine. However, instead of “saving the phenomena” in the sense that, the phenomena being explained away by an adaptationist story, the aim of EM seems to be reorganize what is to be explained.33 Moreover, as they explain more diseases this way, they tend to create a greater understanding of the general concept of disease in their own framework. The individual explanations, where the diseases, together with non-disease conditions are explained within the framework of EM, the concept of disease is altered. The more diseases, explainable and treatable with the understanding of EM, the more the concept of disease will shift and create new relationships with the bordering concepts in the both medical and public meaning of the concept. In this sense, explaining in this regard is like defining a concept. If 32

Also note that, they mention putting diseases together with non-disease phenomena to create a common explanatory framework to understanding a new “disease vulnerability” concept. 33 For a general discussion about “saving the phenomena” see; Hacking (1984).

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the explanation holds true, this adds, alters or cancels certain properties of the given concept. If the evolutionary explanations are meaningful, these will also affect the whatness of the given disease. However, it can be problematic that a new concept of disease, created through the standards of EM since it will be competing against the medical concept of disease in general. One single kind of evolutionary explanation replacing all other kinds of evolutionary explanations in medicine is also a source of worry. While discussing the general medical explanations and their pluralism Cournoyea & Kennedy note that; As Kellert et al. [21], p. xiv]noted in their description of the pluralistic stance, inquiry ‘typically represents some aspects of the world at the cost of obscuring, or perhaps distorting, other aspects.’ Helen Longino [22] likewise advocated for pluralism in explanations of behaviour, where different approaches yield partial knowledges that compose ‘a nonunifiable plurality’(p. 111). Explanatory pluralism is not merely a pragmatic compromise when complex cases defy explanation; such pluralism allows us to understand why more adequately, efficiently and accurately in each relevant context with the ultimate aim of discovering causal explanations. (2014, p. 932)

Therefore, the main concern becomes the possibility of the evolutionary conception and explanation taking over the medical pluralist understanding. Most people in EM note that they are advocating EM to only to help medicine but not replace it (Nesse & Williams 1995, Gluckman et al. 2018). However, they do not provide a set framework with which they describe how to do that. This situation is also question begging, because the way they categorize diseases also seem different and incompatible with explanations in clinical medicine. Here, note that the causal explanations that are needed in medicine are of pluralistic kind; however, EM does not try to be the single one at that.34 Moreover, there has been studies on contrastive explanations from genetics when it comes to explaining evolutionary phenomena, including disease, importantly from Woodward (2003), Schaffer (2005) Raerinne and Baedke (2015). In contrastive explanation, genetic causes. are not seen as singular causes of event, but with respect to the likelihood they increase compared to the contrast group. Explanations in evolutionary medicine, when they are more reliant on genetic explanations are sometimes of this type. Contrastive explanations of EM can be very good at explaining phenomena on that regard. They are often used together with models of population genetics, and due to that they have a limitation in their explanation. However, I believe that this is the basic pluralism of the explanations from EM, they are not of a singular type, but they employ different regimes of causation and explanation from their connected disciplines. And although limiting EM to adaptationist stories can be helpful to understand them, and the representation of explanations of EM are generally of those to which EM can give a very certain causal answer to, this is not always the 34

I believe that within a linguistic division of labour understanding, when we see the meaning of the concept of disease distributed amongst many different domains, it makes sense not to have a plan for the general structure of a disease concept by the EM. As they simply exert a force to change the meaning towards a direction instead of giving a general definition.

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case that they provide causal mechanistic explanations. After the discussion about explanation, now let us turn to what is doing the explanation, namely genes.

6.4.2 The Primary Focus of Modern Synthesis; Genes The idea of an ultimate explanation in evolutionary thinking is not new. For some it has been the main explanatory strength of the evolutionary theory over other parts of biology and other kinds of biological explanations. Although it can be argued that the traditional evolutionary theory did not distinguish between them in the early days after Darwin, it is generally considered that the orthodox evolutionary biology after sixties was heavily influenced by this distinction (Laland et al., 2013). Mayr (1961) was the first person to distinguish between ultimate and proximal causes explicitly.35 The explanations that follow from these kinds of causations are the ultimate and proximate explanations. The ultimate, when compared to the proximal explanation is supposed to answer why questions differently. While Mayr (1961) does not distinguish between two different kinds of causes in priority, the general environment of the late twentieth century in science, when it came to explanations in science, was prioritizing ultimate over the proximal explanations and laws (Galison and Stump, 1996, Cartwright, 1999). The proximal questions give us short ranging, local explanations, while the ultimate questions provide us with ultimate explanations. The ultimate explanation of aging for example, relies on the disposable soma theory, (Schächter et al, 1993), research on the ultimate explanation of aging, in which the energy invested in the maintenance of body decreases through time, since the reproductive success of the organism is reduced in the later age. The proximal explanation of aging is radically different from this kind of explanation. In a proximal explanation, how the body functions deteriorate in time is being researched and how this can be used to stop the aging process is investigated, hopefully, ending with new tools of intervention.36 Within this perspective, the surrogate for ultimate causes became genes in the modern synthesis of evolutionary theory. Modern Synthesis (MS) is the framework in evolutionary theory that most of the EM is based on at its core. It is still considered the main paradigm of evolutionary theory. The orthodox narrative of history of evolutionary thinking starts often in a period, much later than Darwin, where there exist two parties that are claiming to be true approaches towards evolution before the modern synthesis, namely Medalians and biometricians, which eventually fused into population genetics (Dietrich, 2006). The trend eventually developed into the central tenet of what is called the Modern Synthesis (MS), making it possible to use population genetics to explain many evolutionary phenomena such as allopatric 35

Ultimate and proximal are also very loaded concepts, and can be thick concepts in explanation. From this perspective, it seems like there is not much sense in trying to understand the ultimate causation in medicine, however as mentioned before, the causation can also direct our research apart from being single explanations.

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speciation (Mayr, 1942) and genetic polymorphism (Ford, 1949) which were, before the synthesis, actually used as refutations against the evolutionary thinking due to its lack of explanation in these fields. In addition to that, MS was related to the more general biological phenomena such as mutation and was reaching fields such as ecology. Thus, the central premises of evolutionary theory were set in the shape of population genetics. Since then, although there has been a lot of controversy about the relationship between MS and the other disciplines within biology and there has been many dissidents, mostly causing alterations in MS, it was held as the main evolutionary cannon, and it was probably the closest thing that was held to a scientific theory for evolution by setting up a strict and counterintuitive to non-experts’ definition changes in the allele frequencies in populations. MS provides us with the general perspective, in which the units of selection (the elements that are selected for in evolutionary processes) are essential units, which are in this case the genes (Crick, 1970). The early work of Nesse and Williams (1995) show that they had strong confidence for gene centered approaches. As they write, “the instructions for making a human body are contained in molecules of DNA, twisted into twenty-three pairs of chromosomes.” (p. 93). And through the book they use genetic to refer to hereditary diseases, expecting to find solution to genetic diseases by unrevealing the DNA code of humans. Despite the commitment to gene centered understandings, they already admit that there is a “vast sea of ignorance in which there are scattered islands of understanding” when it comes to account for “how can even an enormously long sequence of only four chemical symbols manage to code for a complete human being?” (Nesse and Williams, 1995, p. 95). In the end, towards the later works (Nesse, 2019), the focus is shifted from gene centered approaches to a general capacity based explanations. Using the suggestion of Williams and Nesse (1991), based principally on the population biologists’ work such as Fisher (1930) and Williams (1966) who were perhaps the most influential figures in the field of evolution on the twentieth century, created a framework that accepted genes as the unit of selection. That meant that the evolutionary processes (mainly headed by natural selection) changed genetic frequencies of the individuals. In the evolutionary medical literature, it is still used as a very prevalent paradigm. Kwon & Guate (2000), for example, use “candidate gene approach” to understand the genetic basis for alcoholism. The main idea of a gene centred approach is simple, if we can find the gene that causes the disease, we can intervene with methods that work on the genetic level, so that the disease will not occur. If certain enzymes produced due to a gene are stopped, we stop the disease at its root cause. Of course, this perspective is pure evolutionary biology, however, it was the main point of EM, and they claim that evolutionary understandings can be helpful to medicine, without overtaking their own role in explaining and intervening on their own levels.

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These kinds of explanations are good for particularly hereditary diseases, and diseases, which are based on one gene.37 From the evolutionary perspective though, it seemed also to evolutionary biologists that they could not explain everything only through recessive alleles, which dodged natural selection, they needed a better explanation to explain the prevalence of diseases in a framework (the framework of early MS) where the natural selection could not always optimize the traits (Altinok, 2022).

6.4.3 We Are not Perfect—Trade-Offs, Constraints and Disease Vulnerability The main objection to MS came from Spandrels of San Marco in 1979. As already mentioned, the main idea was simple; natural selection could not perfect certain traits—possibly most of them. They based this claim on two main reasons. The first reason was it countered the possibility of natural selection being able to perfect each individual trait due to trade-offs, the second instance was about constraints. They open the possibility for disease vulnerability, since through trade-offs it becomes possible to understand that, from an orthodox MS perspective, why our traits are not perfected. For every adaptation, there was a cost. Some adaptations were even evolving antagonistically. Even the harshest supporters of a selectionist understanding such as Dawkins (2016 [1976]) did not have a problem with balancing the adaptive benefit of running fast for a cheetah and the possibility of hurting its own bone and muscle structure if it evolves to have faster and longer legs. One interesting example is Brett and Niermeyer’s (1999) study on bilirubin levels and baby development. While in adults bilirubin is seen as poisonous, they claim that from an evolutionary perspective, the increased amount of bilirubin in new-borns is normal since it stops radicals that might harm the baby in the younger age. Upon this analysis, they propose new methods to measure and interfere with bilirubin levels to the babies, since the pressure for the radicals have changed in our modern environment. Similar to trade-offs, parasitology and evolutionary ecology also employ a tradeoff like understanding of natural selection when it comes to systems with more than one organism. In order to explain the mutual evolution of more than one species in close proximity (such as hosts and parasites) Van Valen (1977), put forward the Red Queen Hypothesis. Red Queen Hypothesis is based on the adventures of Alice when she encounters the queen in Lewis Carroll’s Through the Looking Glass. Similar to the story, hosts and parasites had to evolve, even to stay where they are. From this perspective too, since evolutionary structures interactive systems, the fact that they evolved did not guarantee that they had increased fitness overall. Conflict and tradeoff theory is employed even in the baby mother relationships, making the womb, a 37

Although the general hope of finding one gene for one disease is not fulfilled, and the paradigm within evolutionary biology is shifting from gene centred approaches, there is no reason to deny outright the possibility of finding diseases, which can be linked to single genes.

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battleground for father’s and mother’s genetic investment if we keep a gene centric position on the issue. (Haig, 1993). Evolutionary trade-offs are an important concept also in evolutionary medicine because they allow us to see the antagonistic elements in the evolutionary processes. This way, different traits, organs, properties have been evolving in an antagonistic process, and when one selection pressure eliminated for one aspect of the trait, the other can be medically more relevant particularly when it comes to surgeries, operations etc.38 The other challenge to the adaptationist programme was constraints. Constraints are important in evolutionary processes particularly when it came to strongly natural selectionist understandings of evolution, since they create a crack on the multiplicity in population genetics based mathematical understanding of evolution. This way the evolutionary theory is forced to enrich its tools to go beyond its own orthodox theory. Simply put, as in Spandrels of San Marco (1979), not every trait or product is selected for in the evolutionary history. Similar to spandrels of a building, they can be simple by-products and necessary compromises. Certain traits, organs or structures can even be not selected for at all, or even can limit the further evolution of a trait. These constraints can be history of the organism, a certain structure or the like. This understanding is embedded well in EM, since the focus of EM is not the evolution of diseases but disease vulnerabilities as it is repeatedly argued by Nesse (2019, 2001). The constraints perspective of the MS when applied to EM can give us many hints to understand the weaknesses of human body. On the conceptual level, it directs us more towards a disease vulnerability research program on disease concept because the human body can have certain constraints through the evolutionary history that it never could eliminate, and even become bigger burdens in time. One important aspect of the structure of the organism constructed through evolutionary processes and the relationship they have to external elements is within the evolutionary history of the individual. On this regard I would like to take the vulnerability idea more seriously. That is to say, it becomes possible to see disease as an emergent structure that is realized in a particular relationship between the individual’s certain kind of systems and another element, be it the environment in the crude sense, another system, another evolutionary entity etc. Fodor (1974), defends an understanding of multiple realizability of phenomena on the basis that they can emerge within different relationships of different kinds of entities. When we carry this understanding to the structure of disease, we are confronted with an emergent understanding of disease. In line with Broadbent (2019), the conclusion can be that, disease itself is a secondary property of the organismic activity and relationship. This is a very central idea of evolutionary medicine that the diseases are in this regard secondary in their activity since the main explanans is the disease vulnerability in EM. That is to say, the historical making of the vulnerability towards disease (in the acute sense), is embedded in the previous history of the species, group or individual. The previous history of the species being, and part of the species, systems, organs etc. 38

Consider the evolution of digestion with hunting, in case that the hunting pressure is dropped, the digestive system problems might be solved through different nutrition techniques.

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can be seen to be embedded in the vulnerability structure. This perspective allows us to see disease as having a function on the organism that is multiply realizable by different elements. Once we take vulnerability to disease as the main ground to see disease, and apply multiple realizability of disease phenomena to individuals, we are so see the argument leading to an individualized disease understanding. That is to say, instead of having a disease explanation, an explanation for a concrete disease structure, we end up with seeing particular diseases emerging with respect to the vulnerability to disease that has been evolving. In this sense, emergent disease idea should be made explicit and clear for each and every case. Of course it sounds funny to talk about emergent diseases particularly when it comes to talk about hereditary diseases due to their causality being centered in the genes and are seen to be more closed structures, or diseases which are structured in a more closed circuits, such as cardiovascular diseases. In this sense, the discussion can be carried to looping kinds within different kinds of evolutionary entities, yet I am not willing to go there for this discussion. However, when the structures within the organism are considered, and the concept of environment is recreated for every individual entity, it makes sense to see that a certain gene creating disease through its interaction with the complete system. This is a question of general ontology, in which it is possible to see all diseases within the same framework. This also allows us to see disease as a more distributed concept, since disease vulnerability enables disease, and the organism or the parts of the organism, through its evolutionary history or histories, take part in the making of the disease. When it comes to how questions, I think from an EM perspective we can say that we are still asking how questions, but of a different kind. This kind of how questions have to do with the nature of disease as an entity. How can I intervene, based on this disease understanding? This disease framework can be made much more productive with its relationship to the environment as well. The adaptationist programme in that regard could be only helpful in a limited sense since it has a very rigid framework of explanation. Now let us turn to aspects of EM that are not part of the adaptationist programme.

6.4.4 New Evolutionary Entities—the Units of Selection To this point, what was meant as “evolutionary” was the evolutionary history and constitution of an individual, species, gene or a trait. It was contextualized within a general framework in which the disease is an outcome of the evolutionary process when the evolutionary process itself was seen as a part of the life history. However, evolutionary theory and thinking in EM is not only applied to the individual or a species. It is also applied to other biological processes. In this part, the general perspective is still one that is criticized of being heavily reliant on natural selection only. The idea that natural selection is the major force in evolution, however, does not mean that there is an adaptationist programme about the organism.

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The main difference here is an important one, since from a purely medical perspective it makes sense to conceptualize organism as a holistic system, physiology and the organs are functioning for the whole, however evolutionary understanding enable us to make any target within the organism, or encompasses the organism completely or partially a Darwinian Individual. Darwinian Individual is a concept that is put forward by Godfrey-Smith to argue for the possibility of application of evolutionary theory, structure and mechanisms to whatever applicable entity (2013). The main idea is to see different kinds of entities, unities, relationships with their relationship to evolutionary theory. That is to say, as long as the variation and selection are applicable to the entity in question, that entity can be called a Darwinian Individual. In his analysis it is possible to find how biological individuals can be different from Darwinian individuals, which is quite counterintuitive to the medical discipline. The evolution or the diversity of certain systems or non-systemic relationships such as energy networks, cognitive networks, inheritance systems etc. being selected for and active influencers of any phase is, although understandable for evolutionary biology, is not to be researched in medical research. Although even before him, application of evolutionary understanding to various, the biggest example should be Dawkins (2016 [1976]), where he argues for genes to be the only active and main causal elements in the evolutionary processes. Here, I will discuss two of example cases within the framework of natural selection centered approaches in evolution; cancer and holobiont, although in principle they can be many other structures, since the conceptualization methods of evolution can be applied to many different entities.

6.4.4.1

Cancer

The target of the diseased, especially when it comes to pathogenicity and cancer, are to be evolved. For cancer, there has been research on the evolutionary character of cancer development. Nowell (1976), Merlo et al. (2006), Greaves & Miley (2012), with some even looking at cancer stem cells as units of selection (Greaves, 2013). For pathology, there has been also a tradition of seeing pathogen evolution in these terms perhaps starting with the trade-off between virulence and transmission (Fenner 1983; Alizon et al. 2009). And how the vaccination process can be hazardous for the host, effecting the evolutionary processes of pathogens, (Gandon et al. 2001; Mackinnon et al. 2004, 2008). This disease understanding is radically different than the traditional disease understanding in medicine when it comes to cancer (Stearns, 2012). Consider evolutionary approaches to cancer. While standard medical explanation seeks to explain and treat cancer through means it does in many traditional disease structures (by eliminating them as a threat to the otherwise perfectly functioning organism, evolutionary medicine helps us to see how the individual cell at that level (due to the unit of selection applying at the cell level historically) can work against the organism very often, and based on that, tries to assess a new strategy to treat cancer, with not selecting the particularly aggressive ones through non treatment.

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The Darwinian and natural selectionist understanding on these levels, such as at the cellular level give us radically different results than the results of Darwinian fitness measure in other fields.39 There are a lot of new developments particularly on the more nuanced understandings of cancer and evolution.40

6.4.4.2

Holobionts and Hologenomes

The holobiont is defined as host plus its microorganisms (Doolittle and Booth, 2017). This concept is getting increasingly central to studies in evolution and ecology. Studying host organisms together with their respective microorganisms has also gained ground in research investigating different levels of biological organization such as genomes and proteomes. Hologenome, a newer concept, is from the same stem as holobiont, and used as a way to extend the notion of individual. Hologenome is defined as the total genome of the holobiont. This conception, seen in static, may look like it is simply the genetic analysis of holobiont, however, it also defines how we construct the individual given the methods used for the two concepts (Robbins et al., 2016). In most cases, holobiont and hologenome are considered functional wholes in the evolutionary biology. Indeed, it is very convenient to see them as such in many cases, particularly in the cases where the host and its microbiome are not co-transmitted. However, even when seen within a less strict interpretation of individuality, the limits of such a strong expansion of individuality, particularly due to difference in the degrees of association and permanency of relationship between different organisms and their respective microbiome, is questioned on the functional basis, based on the differences of etiology and systematicity. (Catania et al., 2017). The functional account is of course very important within this picture. However, hologenome, when the function of the genes that are present within the holobiont at any given time, is considered, the species or the evolutionary background of the species of microbiota no longer create an obstacle for etiological function because of their discontinuity from the host, in terms of physical proximity or co-inheritance. Co-inheritance of the function is already a necessity in some microbiota given that the host and its microbiota already have a functional relationship and the function of the related genome of the microbiota remains stable (Rosenberg and Zilber-Rosenberg, 2018). In this case, even when there is no co-inheritance on a one-to-one species basis, it is possible to use an extended notion of individuality based on hologenome, and such a definition can affect the development of probiotics, responses to pandemics and epidemics, and ethical discussions related to those topics (Destoumieux-Garzón et al. 2018).

39

In a sense, it can be claimed that, the strength of EM comes from is lack of disease concept, since both diseased and health processes should be explained by the same basic principles. 40 For a recent study of evolution and cancer, Thomas et al. (2020)

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Suarez Diaz (2019) sees holobionts as units of selection, a recent entity in the unit of selection debate.41 Within this understanding, the traditional principles of evolutionary biology becomes applicable to a new unit of selection, in which bacteriology and virology are important. Pitlik and Koren (2017) discuss the possibility of seeing holobionts being able to get sick, in the sense that they are also entities that are functional and can be harmed. This creates a new entity to be diseased, not an organ, not an individual but a new unit, the holobiont. Another problem is also taking the human organism as the sole evolutionary entity in the EM debate. When microbiology, holobiont research, evolutionary ecology are also providing us with various evolutionary entities, it becomes much more obvious that the evolutionary perspectives will play a larger role when it comes to human health. These relationships, such as the microbial relationships to humans, provide a relevance relationship between evolution and human health.

6.5 Established—Emergent Structures Versus Continuum (Population Thinking) Mismatch for Environment The aim of this part is to give an understanding of the entities that are commonly used within clinical medicine through the looking glass of evolutionary medicine, eventually trying to assess the difference between typological medical understandings and evolutionary understandings. The structures that are shaped by evolutionary processes are generally taken as very strong and rigid structures that had a certain “historical weight” in them. It was the main idea of studying evolutionary understanding of diseases. When they are seen as more stable, the more fluctuating and fluid part becomes the environment. This is the basis of the understanding of environmental mismatch and the diseases of civilization. Evolutionary biologist asks; why there is iron in the blood in the very first place? Such a question would make no sense to the clinician and almost no sense to anyone in medical domain. For medicine, there is iron in blood to fulfil a certain function and it has always been a part of the system. The general understanding of defining disease concept differently based on a vulnerability perspective with population thinking is also demonstrated in lactose intolerance example. This example is central to the purpose of this book, because Western medical textbooks often define the inability to absorb lactose as a metabolic disorder—adult hypolactasia—but from an evolutionary point of view this man’s inability to digest lactose is normal and is shared with 70% of the world’s population. It has only become manifest in an environment distinct from that to which he is adapted. (Gluckman et al., 2016, p. 5) 41

Unit of selection debate is very central to philosophy of evolution. Shortly, the debate is around what kind of entities in evolutionary biology are to be applied the evolutionary processes and forces. For a good and mature discussion; Okasha (2006), for the original conceptualization, Lewontin (1970)

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This shows a challenge to the medical understanding of disease, since if we are strict disease realists, this means that we have to accept any condition as a disease given that if can effect even the smallest proportion of the global human population. While medicine often is occupied with a smaller group of individuals, in a given country for example, evolutionary biology works regardless off culture, race or population.42 In this regard, evolutionary medicine focuses more to the environment, since it takes the individual make up of the organism as something constant, a product of natural selection, and the diseases is likely to be the result of a mismatch.43 Pollard (2008) also draws on classical EM to account for the development of “western diseases” such as diabetes, heart disease and the like, which are also called “diseases of civilization” based on the mismatch between the human organismic builtup due to evolutionary processes that led us to the assumed stone age conditions and the current western cultures. She also provides an anthropological and social account in which the public health policy shall be followed differently by different countries due to the specificity of the environmental conditions that they are in. Autoimmune deficiencies also fall within this mismatch example. Main idea is that the human immune system has also developed in an ancestral population where the standards were not hygienic and people had many parasitic infections (Dunne and Cooke, 2005). When the parasites are removed from our modern environments, the immune system is faced with problems that it did not encounter before. Due to this problem, some autoimmune disorders are more prevalent in the post-industrial countries than they are in developing countries. Another problem with evolutionary phenomena fitting in the medical model is although the evolutionary medicine emphasizes the importance of established structures heavily, the evolutionary understanding also focuses on continuous traits. Variation is not only normal, but given within a population, and what is meant by variation is not only about continuous traits, it is also about different types and typologies. Chung (2003) discusses in detail how Mayr’s understanding of species has changed from typological to population-based approach. Population approach instead of typological approach of Darwinism sees the evolutionary entities not as goals or certain shapes that are reached by the evolutionary processes, but as variations (Mayr, 1953). When the variation within the population is seen as the norm, not as a deviation, there is no “ideal” constitution of any organismic entity, there are always diversions.44 In 42

It is a bold claim to say that evolutionary biology can be a tool for “decolonization” of medical practice. I do not claim this outright, yet I have an intuition for that. 43 Of course, it is also dangerous to leave disease realism because then, the palette of healthcare covered issues shrinks, leaving some patients not to be getting the medical help they need. The boundaries between the medical help and social help is shrinking, can also be seen in welfare, health distinction. 44 While in medical perspectives too it is possible to employ population thinking, still the population thinking has very strict barriers. While in evolutionary understanding, populations are also dynamic. Therefore, the variation within the population itself is dynamic. While in medicine, the diseases are to be found and noted as particular diseases effecting a particular person or a group, in evolutionary medicine, due to generalized understanding, we can only talk about vulnerabilities in certain conditions.

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typological approach, every individual is unique (note that this is the Darwinian idea of variation, another Darwinian perspective, selection towards a certain function works against such general structures and variation within populations). In a sense, it can be said that this population thinking has already penetrated the medical field, making variation non-problematic.45 The dream of an ancestral population is very much alive in EM. However in a very different from. Instead of a singular understanding of monotonous tasks for traits and the like, in modern EM, the ancestral population is not stuck to a particular time and space. On the contrary, due to the general understanding of capacities and the usage of these capacities in particular environments, EM creates a very pluralistic understanding of disease on this account as well. This way EM shifts the focus of the disease vulnerability to the environment rather than focusing on the individual. In the end, what we have been evolved was for having a palette for biological responses to environmental situations. This increases the environmental aspect of explanation.

6.5.1 Other Developments in Philosophy of Biology that Are Relevant to the Debate; Everything Flows and Everything is Distributed so Shall Disease Here my claim is not to lay out every other novel perspective within philosophy of biology, but to mention relatively relevant ones that would help me to conceptualize against strict definitions of disease that are woven around disease realism and disease universalism. Against the common understanding of stabilizing disease functions one argument comes from philosophy of immunology. Thomas Pradeu (2011) argues that, against the mainstream opinion, immune system does not try to stop any kind of influence coming from the environment. The immune system, instead, selects the kinds of influence that are going to be accepted by the organism and selectively and actively makes certain parts of its environment its own self while keeping certain parts outside. This supports the general claim that, the boundaries of the organism are not easy to asses, since even the maker of the self and non self—immune system according to Pradeu—is not doing a very strict gatekeeping activity. In addition to that, following Dupré and Nicholson (2018), and the new developments in the processual view of organisms and organismic entities becoming more relevant in evolutionary thinking, enables us to see disease as a processual entity, some form of becoming rather than a stable structure. I think it also makes sense to see disease within this context. That is to say, the emergent entity of disease can be seen to be starting and ending without strict boundaries to the organism. How to make sense of the individualized diseased process is an open question, but the range 45

Perhaps EES can take the second step and talk about variation in another level, variation of variability, variation of certain mechanisms etc.

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of stability of the structures and the expected disease processes also explains the standardisation of disease structures. This stability owes much of it to the evolutionary development. In this sense, evolutionary, as seen in the second chapter requires us to use a broader understanding of evolutionary entities. This might also be seen in a way with reference to individualized bauplans and within species diversity and individual developmental history. If the effect of evolution to medicine is not seen as a simple explanation but the general evolutionary perspectives becoming more prominent in medical sciences, we can conclude that seeing the organism together with the environment as in the evolutionary theory, could be very helpful. Following Sultan (2015), the organism—environment relations seen as fluid and evolutionary relevant effects, this can also increase the influence of environment in the hereditary characters of the individual. The new concept of disease in evolutionary medicine sees the disease element with relation to its lacking features, not only as a form of malfunction but as separate systems not being able to work in a given environment (niche construction, theory- match/mismatch idea). Heras-Escribano and Pinedo Garcia (2018) already challenge the nature—culture dichotomy on the grounds of niche construction theory where the niche can be seen in the ecological landscape perspective both as nature and culturally created structures. From this perspective, based on affordance landscape theory, human evolution does not distinguish between the cultural or the natural, while overcoming the distinction they see that it makes more sense to apply it to organismic activity and its affordances. Disease, when seen as an emergent entity for a particular organism under certain conditions can also have an effect on our evolutionary understanding. From the emergentist understanding, disease type can also be different from the same disease manifested in another organism. From here, disease for evolutionary medicine can be seen as a negative emergent process that effects the bauplan of the individual organism negatively, and it is multiply realizable. As put by Laland et al.; “Developmental processes, operating through developmental bias, inclusive inheritance and niche construction share responsibility for the direction and rate of evolution, the origin of character variation and organism–environment complementarity” (Laland et al. 2015: 8)

The classical evolutionary understandings can be supported by evolutionary relevant research on these domains. These perspectives bear similarity, and provide support to Extended Health discussion of Morar and Skorburg (2018). However, I to take a position based on evolutionary biology and evolutionary relevant disciplines instead of other kinds of distributed ontologies. I believe that these understandings are complementary in understanding this issue.

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6.6 Conclusion In the examples and discussions within this chapter, natural selection remained the single, constant evolutionary force when it came to shape diseases. Even when it is only natural selection that shapes traits, we can see a diversity in the kinds of explanation and categorization in disease. In the end if we follow the general understanding of emergence of the disease, the general continuum and the capacities, disease has to be evaluated individually from the perspective of evolutionary medicine. Even if nothing holds, this is always a strong position. A nice summary of the classical understanding of EM can be seen in the following citation; Nesse and Stearns proposed a scheme for the categories of evolutionary questions and objects of explanation (2008:32). There are two kinds of evolutionary questions—one related to phylogeny (history and relationship), and the other related to adaptive significance (selection and drift). Each of these can be applied to one of five kinds of objects of explanation: human traits, human genes, pathogen traits, pathogen genes, and cell lines. Evolutionary explanations of disease can be ordered into several categories. First, the main distinction is between disease and disease vulnerability (I discuss the population concept of vulnerability below). According to Williams and Nesse, the Darwinian approach can be useful only if applied to vulnerability rather than to disease itself because, setting aside some exceptions, natural selection does not shape disease. Natural selection shapes structures and functions that, being imperfect, are vulnerable to dysfunction or disease. This does not mean, however, that evolutionary medicine has worked only with this perspective. (Zampieri, 2009, p. 348)

I agree with Zampieri that evolutionary medicine has much to offer out of the explanation debate as well. Evolutionary medicine correctly sees its own potential, however defending the validity of such a potential is another job, that I will not do here in its full sense, and I think it is also a very tedious task to defend evolutionary medicine’s relevance in its full and all its explanations in one place. In this regard, we should look at concepts as ideas against the explanation only view, which holds that concepts are epistemic or general tools alone. EM does not simply try to explain away diseases; it also creates its own lower level theories and additional explanations, such as mismatch theory, so that it enriches evolutionary theory in the explanations. This way it also distances itself from the adaptionist programme this way, while still keeping the natural selection as the main driving factor.46 In the end, EM has very concrete goals to help the human health by emphasizing the importance of “the history of the complaint itself; the developmental history of that individual; and his or her evolutionary history” (Gluckman et al., 2016, p. x). However, for now it does not have enough tools to accomplish this goal that it has set forth. Still, it shows the important aspects and the directions of conceptualizing disease on these lines. 46

A discussion of whether lower level laws are more explanatory in EM might be interesting, but I am not sure.

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In this sense, EM directs our epistemic understanding towards a different direction. I claim that the main descriptive aspect of change in the canonical understanding of EM is its leading us to the research direction of environment when it comes to disease rather than the organism itself. In this sense, EM detaches organism from the environment, looks at the evolutionary history of the traits, and then tries to rematch it to the environment that it has been and could have been. This gives EM a unique liberty compared to medicine to see disease as an emergent entity, and it directs the research towards the environment although it sounds paradoxical. In EM, environment and organism are decoupled but only to be matched again to make sense of the disease. A condition can lead to disease under certain environments, and the obvious benefit is that, there is no distinction between social and biological environments in evolution. From this rather environmental perspective, EM makes healthcare policy and public health and preventive medicine under focus. Cournoyea (2018, p. 20) tells us that, “We are frequently concerned with how we get sick that we often neglect to ask why we get sick.” That is very true in the general sense, however from another perspective; it is also possible to say that, in research, we are excessively often concerned why we get sick that, we tend to overlook what implications it has to explain why we get sick. When explanations are not seen only with respect to their truth values, explanatory relevance per se or their use in intervention, but seen as the general framework they produce, research programmes they put forward or the focus they have, we have a rather different picture. Therefore, due to the constant variation within the evolutionary understanding, the classical deviation from the norm ceases to be a ground for being an element in deciding the diseases situation being negatively evaluative in the global sense. And since there is another value embedded in evolution—survival and reproduction—being the global value of the discipline, there is an ethical decoupling for the evolutionary biologist for the concept of disease. So far, I have outlined the general understanding of the evolutionary biologist with respect to the concept of disease. On the question of the existence of disease, evolutionary theory sees disease as a secondary entity built in relationship to the organism. Disease, in this regard from an evolutionary perspective has to be seen processual and emergent due to the views on disease vulnerability. In this sense, the strength of evolutionary medicine does not come from its closeness to the medical phenomena, it is the contrary. Because traditional evolutionary biology uses a very different ontology in its explanatory structures, the explanations it can provide can jump over the medical phenomena. I believe that this can be particularly useful in certain areas of medicine such as building research programmes. With the change of perspective at the conceptual level, evolutionary medicine changes our disease ontology with respect to the previous understandings. When it comes to the normativeness of question of disease, evolutionary understandings due to their differing values and their involvement of the globally evaluative fitness concept, the disease concept can be seen as locally evaluative. This enables localized value free concepts. In this sense, value free local understandings of disease concept if possible for the evolutionary biologists in the research. However, bringing concept back to the social understanding should also to take the overrun concept in

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the by the evolutionary biologists back to public discourse. Scientists, when dealing with particular diseases link their disease to the disease concept of their own choice. This allows the scientists to subscribe to different concepts of disease, but when they are doing that they should show epistemic openness to the concepts so that the other meanings of the disease concept shall not be excluded. Evolutionary medicine focuses on the outcome of disease, how the individual is related to the disease phenomenon. Since evolutionary understandings put the organism—or other entities—at the center of the study from its birth to death, they enable us to see the effect of the disease to the individual as the normative element. This means there is more possibility for the individualization of the disease concept, since while a condition might not fall into the abnormal for the medical context, I can very well fit into the abnormal context of the evolutionary understanding, since the measure of the individual is only itself in static and the average outcome of the population at the behavioral level from an evolutionary perspective. So far, I have discussed EM within the framework of a natural selectionist understanding, which is the orthodox view in evolutionary biology. However, this view is recently being challenged much harsher than it was challenged before. Now I will turn to new perspectives in evolution that can be used to evolutionarize medicine and the disease concept in a different way.

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Nesse, R. M. (2019). Good reasons for bad feelings: Insights from the frontier of evolutionary psychiatry. Penguin. Nesse, R. M., Williams, G. C., & Mysterud, I. (1995). Why we get sick. Trends in Ecology and Evolution, 10(7), 300–301 Nowell, P. C. (1976). The clonal evolution of tumor cell populations. Science, 194(4260), 23–28. https://doi.org/10.1126/science.959840 Okasha, S. (2006). Evolution and the levels of selection. Oxford University Press. Perlman, R. (2013). Evolution and medicine. Oxford University Press Pitlik, S. D., & Koren, O. (2017). How holobionts get sick-toward a unifying scheme of disease. Microbiome, 5(1), 64. https://doi.org/10.1186/s40168-017-0281-7 Pollard, T. M. (2008). Western diseases: An evolutionary perspective (Vol. 54). Cambridge University Press Pradeu, T. (2011). The limits of the self: Immunology and biological identity. Oxford University Press Preamble of the Constitution of the World Health Organisation as adopted by the International Health Conference: 1948, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the WHO, No. 2, p. 100) and entered into force on 7 April 1948 Raerinne, J., & Baedke, J. (2015). Exclusions, explanations, and exceptions: On the causal and lawlike status of the competitive exclusion principle. Philosophy and Theory in Biology, 7. Rosenberg, E., & Zilber-Rosenberg, I. (2018). The hologenome concept of evolution after 10 years. Microbiome, 6(1), 78. https://doi.org/10.1186/s40168-018-0457-9 Schächter, F., Cohen, D., & Kirkwood, T. (1993). Prospects for the genetics of human longevity. Human Genetics, 91(6), 519–526. https://doi.org/10.1007/bf00205074 Smith, T., Husbands, P., Layzell, P., & O’Shea, M. (2002). Fitness landscapes and evolvability. Evolutionary Computation, 10(1), 1–34. https://doi.org/10.1162/106365602317301754 Stearns, S. C. (2012). Evolutionary medicine: Its scope, interest and potential. Proceedings Biological Sciences, 279(1746), 4305–4321. https://doi.org/10.1098/rspb.2012.1326 Suarez Diaz, J. (2019). The hologenome concept of evolution: A philosophical and biological study (Doctoral Dissertation). Sultan, S. E. (2015). Organism and environment: Ecological development, niche construction, and adaptation. Oxford University Press Thomas, F., Roche, B., Giraudeau, M., Hamede, R., & Ujvari, B. (2020). The interface between ecology, evolution and cancer: More than ever a relevant research direction for both oncologists and ecologists. Evolutionary Applications, 00, 1–5 Toepfer, G. (2013). Evolution: Grundwissen Philosophie. Reclam Tracy, S. W. (1992). George draper and American constitutional medicine, 1916–1946: Reinventing sick man. Bulletin of the History of Medicine, 66(1), 53–89 Trevathan, W. R., Smith, E. O., & McKenna, J. J. 1. (2008). Evolutionary medicine and health: New perspectives. Oxford University Press Trevathan, W. (2018). Evolutionary Medicine. In Trevathan W. (Ed.), The International Encyclopedia of Biological Anthropology pp. 1–4. Wiley Blackwell van Valen, L. (1977). The Red Queen. The American Naturalist, 111(980), 809–810. https://doi. org/10.1086/283213 Williams, G. C. (1957). Pleiotropy, natural selection, and the evolution of senescence Williams, G. C. (1966). Adaptation and natural selection: A critique of some current evolutionary thought. OCLC Williams, G. C., & Nesse, R. M. (1991). The dawn of Darwinian medicine. The Quarterly Review of Biology, 66(1), 1–22. https://doi.org/10.1086/417048 Woodward, J. (2003). Making things happen: A theory of causal explanation. Oxford University Press Zampieri, F. (2009). Medicine, evolution, and natural selection: An historical overview. The Quarterly Review of Biology, 84(4), 333–355. https://doi.org/10.1086/648122 Zampieri, F. (2006). Storia e origini della medicina darwiniana. Mattioli 1885.

Chapter 7

New Developments in Evolutionary Theory and Evolutionary Medicine, New Frontiers for Evolutionary Medicine

Abstract The central idea of the chapter is, how new developments in evolutionary biology make us see inheritance in new ways, and these new ways create new possibilities to use them how to use them in medicine. The canonical understanding of evolutionary medicine as discussed so far, does two different things; it uses Environment of Evolutionary Adaptiveness (EEA) concept to define matches and mismatches through the evolutionary history of organisms firstly, and secondly it uses evolutionary perspectives to understand the behaviours of non-organismic entities such as cancer cells and hologenomes. EEA concept will be employed to account for an individualized and specified understanding of disease when it comes to diagnostics and intervention. From that point, I will further assess an understanding of the frontiers of evolutionary medicine and its new capabilities. The central idea is a very simple one; the theories and the tools we use to understand evolution are changing and in return, the general perspective in evolutionary medicine—if it is taken in the broad sense instead of the canonized vision—will change. Eventually, I claim that the new developments in evolutionary biology lead us to see disease in a way in which we must count in the environmental elements and see the concept of disease in an individualized way. This individualization comes in two counts, first as epistemic individualization of the explanation (connected to token character of medical explanations), and second, metaphysical individualization of disease.

I still have my health, at least that’s what they tell me If wellness is this, what in Hell’s name is sickness? But business is business and business runs in the family. Amanda Palmer, Runs in the Family.

7.1 Introduction During the Second World War, occupied Netherlands, like many other countries at war or tangent to the war, has suffered lack of resources. In the Dutch case, this lack of resources lead to an immense famine. The famine, called Hongerwinter

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_7

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[Hunger Winter] by the locals, intensified towards the end of the war, and peaked during the winter of 1944–45. The children of the women who were pregnant during these difficult times had often significant health problems when they grew up such as diabetes, obesity, cardiovascular disease, microalbuminuria (Lumey, et al., 1993). The health problems that were experienced by the children after difficult pregnancies such as malnutrition or chronic stress were already known cases. Moreover, certain mechanisms that were affecting the health of the babies after difficult pregnancies were already well researched within medical science. Since it was already a muchknown general phenomenon and conditions during pregnancy affecting the health conditions of the children who are born from these pregnancies are known even better at the moment, therefore why to do research on this topic now? Stein and Lumey (2000) have researched the relationship between maternal and offspring birth weights after maternal prenatal famine exposure. The babies were smaller, which was not a big surprise bearing in mind that pregnancies affect the health of the new-borns. The striking result was, when they grew up and started their own families, it was observed that they also had children who were smaller than average. Unlike the general understanding in which the inherited characters were tied to the genes and the phenotype was, although an interaction of genotype and the environment, mainly inherited by the genetic structures, which were not effected in the germ line, there seemed to be certain inheritable changes that were acquired. This observation led people to indicate certain inheritable changes being acquired by the new generation. Possibility of integration of these kinds of epigenetic changes being heritable mechanisms within evolutionary processes to evolutionary medicine’s perspective is key to this chapter. That is to say, first I will explain it on the empirical grounds, and then will try to put forward its benefits to the EM. The central idea is, how new developments in evolutionary biology make us see inheritance in new ways, and these new ways create new possibilities to use them how to use them in medicine. The canonical understanding of evolutionary medicine as discussed so far, does two different things1 ; it uses Environment of Evolutionary Adaptiveness (EEA) concept to define matches and mismatches through the evolutionary history of organisms firstly, and secondly it uses evolutionary perspectives to understand the behaviours of non-organismic entities such as cancer cells and hologenomes. Here, EEA concept will be employed to account for an individualized and specified understanding of disease when it comes to diagnostics and intervention. In addition to that, the conceptual change that guides towards a disease particularism will be grounded. Besides that, the main perspective of this chapter is to find an understanding of evolutionary theory in general and the integration of these new developments in evolutionary biology to evolutionary medicine. From that point, I will further assess an understanding of the frontiers of evolutionary medicine and its new capabilities. The central idea is a very simple one; the theories and the tools we use to understand evolution are changing and in return, the general perspective 1

Of course, these are things that it does overtly only. In the background as the main claim of this work, the idea is that these moves shift our understanding of disease and shapes our perspectives to see disease.

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in evolutionary medicine—if it is taken in the broad sense instead of the canonized vision—will change. Eventually, I claim that the new developments in evolutionary biology lead us to see disease in a way in which we must count in the environmental elements and see the concept of disease in an individualized way. This individualization comes in two counts, first as epistemic individualization of the explanation (connected to token character of medical explanations), and second, metaphysical individualization of disease.

7.1.1 Epigenetics First put forward by Conrad Hal Waddington in 1942, epigenetics is the study of inheritable non genetic factors (Waddington, 2012). Since in his day the mechanisms of DNA was not known, he proposed it mainly as a non testable conceptual framework to understand the development of organisms, particularly the transformation of totipotent2 cells. After the foundation of Central Dogma, and the gene centric views that see the genes and particularly nucleotide sequences within DNA as the main elements of inheritance, the presumably less frequent changes within the make up of the DNA were categorized under the concept of epigenetics. Today this concept refers to many kinds of things but mainly it refers to the study of heritable changes without the alteration of the DNA sequence of the germ line. Two of the most prominent defenders and people who popularized epigenetics, Jablonka and Raz (2009) distinguish between Epigenetics and epigenetic inheritance mechanisms, in this distinction, they take epigenetics to be “the study of the processes that underlie developmental plasticity and canalization and that bring about persistent developmental effects in both prokaryotes and eukaryotes. …” (p. 132) while they define epigenetics inheritance as “a component of epigenetics. It occurs when phenotypic variations that do not stem from variations in DNA base sequences are transmitted to subsequent generations of cells or organisms.) (p. 132). Therefore, this is a broad definition, everything that is not caused by difference in the DNA sequence is taken to be epigenetic inheritance.3 In this distinction, it is possible to see that while there is the inheritable element in epigenetics, epigenetics itself marks a field rather than a certain mechanism of inheritance. They build the concept of “Epigenetic Inheritance Systems” to refer to any system of inheritance that is creating variation in the offspring as an epigenetic mechanism. I believe that this distinction is of particular importance since similar to EM’s view on disease, there is an emergent process of variation that comes about due to the non-genetic mechanisms within the cell. 2

The cells of an organism, which have the ability to transform into cells of different tissues of the same organisms, that are generally compose more of the organism in the embryonic phase. 3 This makes us primarily focus on the DNA, however focusing on the DNA as the starting point makes sense since DNA based cellular mechanisms of inheritance are much better known than the non-DNA based ones, creating an epistemic advantage to explanations when they are linked to the DNA based or related mechanisms.

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Baedke (2018) also claims that epigenetics is a Wittgensteinian family resemblance concept. According to him, the concept itself has been used very inflationary due to the domain getting larger very fast. With the new research domains and groups working on these domains involved, it is only natural that as a “negative concept” that marks a field by exemption of genetics, many different approaches starting from the same initial claim to create different conceptual frameworks and finding different biological mechanisms. Instead of trying to define and give clear cut borders to the concept of epigenetics here I will try to give certain examples of mechanisms of inheritance in epigenetics that I will later use to integrate to EM.

7.1.2 The Structure of Inheritance Dynamics in Epigenetics From the perspective of EM, what matters here of epigenetics is the general understanding of Environment of Evolutionary Adaptiveness (EEA) concept. In the standard EM, the main idea is to establish a certain typology for the organism to evolve, which is long enough for certain structures of inheritance to stabilize. However, when we have an inheritance dynamic which responds much quicker to changing environments, unlike the mutation—which is random and due to that taking a lot of time to be stabilized—and selection process—which are seen as blind processes in MS, therefore also taking more time to create a stable biological mechanism— attributed to the standard EM, there is much more sense to talk about the possibility of creating these kind of localized EEAs with respect to the mechanism or the structure we choose to employ. The main claim of this part is simple, EEA relied on these biological assumptions; variation was random and selection was blind and unbiased. The result of these assumptions was, adaptation took a very long time and is eventually imprinted heavily to the genetic code of the organisms, which are there to be manifested.4 EEA concept is very useful for EM because it creates an understanding in which all humans have evolved more or less under the same circumstances.5 However if we allow localized EEAs, this means that the explanation and the context that we need to deal with should be localized. Now let’s try to see if such mechanisms of localized EEAs at least have theoretical possibility due to certain empirical results.

7.1.2.1

Epigenetic Mechanisms and Inheritance

The main point is very simple; the inheritance mechanisms are many and diverse. The inheritance of any kind of biological system that will end up in a process through 4

In the most radical interpretations of this biological understanding (Dawkins’ Selfish Gene for example) the genes were acting “for themselves” even in a sense. 5 Of course, there are certain employments of EEA that try to explain sex differences, which stops them from universal explanation for all humans.

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interaction with the environment leading to the emergence of a disease contradicts the general understanding of EEA while creating the possibility to construct various different kinds of EEAs. In the literature of epigenetics there is a distinction between the short-term inheritance and long term inheritance mechanisms of epigenetics. One rather simple kind of epigenetics mechanism for the short term is the one that functions through diluted cell products. The cell product that was effective in a cell is carried over to the daughter cells through cell division in generations; however, this is a short-term system. The cell products get “thinner” as the new generations pass, eventually eliminating the acquired “Lamarckian” characteristic. (Zacharioudakis et al., 2007)6 This kind of a mechanism does not have its influence directly over genetic inheritance systems. Moreover, they can work only for a single generation for the organisms that have germ line, somatic line distinction,7 like humans. Such research can be helpful to understand very quick changes in the family history and heritability of certain acquired characteristic in one generation in the studies of disease.8 On the other hand, Epigenetic Inheritance Systems (EIS) put by Maynard Smith (1990), sees the mechanisms within epigenetics in a broader sense so that the mechanisms that enable inheritance mechanics to be operational and variation to have a stable point of reference that is fixed. Within this conceptual framework, it becomes possible to see epigenetic mechanisms having influence on genetic inheritance systems by adjusting them. That is to say, epigenetic mechanisms of this sort work like on, off switches or controllers for already known inheritance systems within genetics, mainly based on DNA. In addition to cellular product based approaches, there are also Self-Sustaining feedback loops that create heritable variation. Within epigenetic research, it is also shown that there are metabolic circuits through which different patterns of activity can be maintained, resulting in alternative heritable cell phenotypes (Laurent et al., 2005). This study shows that when inducer concentrations are low genetically identical cells can generate two alternative true-breeding stable phenotypes. Many studies are done to examine the mechanisms underlying these processes (Dubnau & Losick, 2006; Malagnac & Silar, 2006; Smits et al., 2006). These loops can happen not only through transcriptional regulation but also in the post-translation stage. Studied by Wickner et al. (2004), protein-modifying proteins can affect their own structure and function without being in contact with other elements within the cellular processes. These are also very stable processes of inheritance that are capable of producing heritable variation through generations. Another aspect of epigenetic inheritance is structural inheritance through spatial templating. This aspect of inheritance relies on the three dimensional structure of 6

Some of those mechanisms depend on such rather straightforward Lamarckian use and disuse paradigms (Veigl, 2017, 2019). 7 This distinction refers to the distinction between the cell lines that can be transferred to the next generations and the ones who are of bodily make up of the organism and cannot be transferred to the next generations. 8 Although calling such short lasting effects as evolutionary effects might be a bit difficult.

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various sub- cellular elements such as chromatin or proteins. The study on chromatin structures have shown that This kind of inheritance systems are not limited to more traditional patterns of inheritance, but they can be found also in mitochondrial and cellular membrane structures where inheritance is possible between generations (Cavalier-Smith, 2004).9 These structures can be as important as the genetic imprinting of cellular mechanisms. In addition to those, there is also a lot of work done in the field of epigenetics on DNA methylation, the patterns that make certain regions of the DNA active, inactive, relevant etc. when it comes to transcription. The methylation dynamics of DNA make the function of DNA in cases are also inherited through generations, being more flexible and persistent at the same time (Brink, 1973; Chandler, 2007).10 Although there are, various kinds of empirical work done and is being done in this domain, in order to legitimize the frequent employment of epigenetic explanations in medicine we need to know how strong the explanatory power of epigenetics is. With a higher explanatory power it can be expected that the more phenomena will be able to be explained, due to a larger domain that the explanations will be able to work, and second the explanations coming from epigenetics will be better explanations than the rivalling explanations coming from MS or standard EM or the medical explanations alike. As Jablonka & Lamb (2007) put it, “How common is epigenetic inheritance? This question is often raised, and the answer, based upon the data we have accumulated, is that it may be ubiquitous. We believe that epigenetic variants in every locus in the eukaryotic genome can be inherited, but in what manner, for how long, and under what conditions has yet to be qualified.” (p. 138). Following their perspective, it can be claimed that the prevalence and relevance of the epigenetic systems of inheritance can only be dealt with on a case-by-case basis. The main issue here is the negligence of potential epigenetic inheritance in the manifest image of inheritance mechanisms amongst generations in the MS. I cannot make a conclusive claim about the issue here, also because the scientific community itself is also divided about the explanatory power and frequency of these systems, however this perspective being neglected within EM is certain, and there is obviously a good potential, the extent of which is yet unknown. Baedke tells us about the standoff situation in evolutionary biology; Recently, in evolutionary biology a number of ‘standoff situations’ between opposing EES and SET explanations have occurred, in which each explanation addresses the same (or very similar) phenomena with seemingly equal evidential support. Such standoffs have led to contrary interpretations of the same developmental phenomena (e.g., Laland et al., 2014a, 2014b; Wray et al. 2014; see Kovaka 2019). For instance, niche construction has been dismissed as nothing but an ‘extended phenotype’ (Scott-Phillips et al. 2014) or described as a causal starting point of evolutionary trajectories (Laland et al. 2005). Developmental plasticity has been explained as merely an adaptation to environmental variation or as facilitating and directing evolutionary processes (reviewed in Sultan 2017; Uller & Laland, 2019). Finally, epigenetic inheritance has been accounted for as under genetic control (Dickins and 9

Which creates yet another entity that can be studied by evolutionary approaches. For a thorough review of mechanisms of epigenetic inheritance, (Jablonka & Lamb, 2007) where they collect and categorize many different mechanisms of epigenetic inheritance.

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Rahman 2012) or as an additional and (partly) independent source of variation (Jablonka 2017). (Baedke et al, 2020, p. 20).

The main issue about epigenetic inheritance within the perspective of evolutionary medicine thus come in two folds. What is inherited is variation. Certain epigenetic mechanisms are capable of adjusting the “hard inheritance” of genetic mechanisms. If we take this position, the localized EEAs can be causally easier to defend due to their connection to harder inheritance mechanisms which are more commonly accepted. If we see the epigenetic mechanisms themselves as the source of phenotypic variation without any connection to the DNA based mechanisms, a whole different domain for localized inheritance dynamics that can be affected in many different timespans become possible to research, enabling many different EEAs. From these two conclusions, the relationship between different inheritance mechanisms and their own properties and processes being intertwined also allows us to see the dynamics of inheritance and the stability of inherited characters in a very diverse way, which can be researched on a case by case basis. This in turn, means that the evolutionary explanations with reference to many different mechanisms which cannot easily be categorized easily as proximate or ultimate to have roles in the evolutionary explanations. I think in this part, it shows that (also with the addition of EES becoming a stronger research programme within evolutionary biology) there are at least certain biological processes that can be explained by much shorter-term adaptations and evolutionary processes. Now let us try to see the framework of explanations within EES.

7.2 Limitations of Evolutionary Medicine and the Discontents When talking about EM, we have to keep the two aspects of EM separately. One is the theoretical evolutionary understandings that it holds onto, and the other its integration methods of these methods and understandings to clinical medicine. In this part I will investigate, and advocate for the possibility of change on the first aspect. The evolutionary theory is developing and changing, and we should look into new developments in evolutionary biology to understand how new approaches will look like for EM. In the previous chapter the criticisms on EM about the explanatory power and the possibility of integration of kinds of explanations coming from EM to clinical medicine to the EM were based on the criticisms that were already out there in the literature of evolutionary biology. These criticisms were aimed at the evolutionary understanding that took shape relatively early in the twentieth century, namely the Modern Synthesis. This understanding, a theory of evolution that is mainly focused on population genetics and the explanatory structures following mathematical modelling

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mainly, has faced certain criticisms rather early, even at the beginning of the modern synthesis (Dietrich 2006, Chap. 1). Starting from 70 s (Gould & Lewontin, 1979) the criticism has gained ground even on the mainstream understandings of evolutionary theory. The evolutionary understanding that EM expects to apply to clinic is based mainly on this general understanding.11 However, as EM is applying a theoretical understanding that is previously established and seen as the orthodoxy to the medical field, therefore it is expected that the new developments are not only against the canonization of the discipline and then not easily welcome.12 There is also the issue of knowledge transfer from different areas of biology since these new perspectives come not from developments in population genetics but from other evolutionary relevant fields in biology. In this section, I will briefly discuss the developments in the evolutionary theory and the central tenets that are being challenged recently which will have an impact in disease understanding. The new developments in the evolutionary relevant biological fields13 became a very important concern particularly after the developments on epigenetics when it comes to healthcare. The most studied domain that contributed to this challenge is epigenetics however, it is not limited to this domain. They also include the studies on niche construction, developmental bias, developmental plasticity and inclusive inheritance.14 Among the dissident disciplines, epigenetics became such a large field in biology that, a philosopher, Jan Baedke (2018) wrote an entire book in philosophy on the possibility of and strategies of philosophy of epigenetics. This section largely builds on a discussion on his understanding of philosophy of epigenetics and how it can be integrated to evolutionary medicine and the results following this integration. In this section, I will analyse the new developments in evolutionary biology, epigenetics and philosophy of epigenetics as well as following an interpretation of the change of perspectives in the structure of evolutionary theory.

11

On a side note, Nesse writes about how he was expecting fierce criticism on his perspective on EM from Gould, probably the biggest critic of adaptationism, on a conference and the criticism of Gould was generally very positive (Nesse and Williams, 1996). 12 Such excluding character or EM while forming the discipline can also be seen in the analysis of the Delphi Study of 2018 in the previous chapter. 13 I intentionally differentiate between evolutionary relevant fields from evolutionary theory itself due to the branching out of biology. Such branching out into ecology and developmental biology particularly have strong evolutionary connections, however they are not “the” evolutionary theory. On a side note, it can be claimed that similar to Gallison’s (1995) observation in physics, in biology also theoretical and practical aspects of biology are being differentiated. This differentiation is not only at the level of institutions, but also at the level of research groups, disciplines and research activities and possibly at other levels. This particular fault line about the production and formulation of biological knowledge can be seen throughout the sections I criticize traditional evolutionary biology. 14 Danchin et al. (2011) amongst many other scientists working on the field, take epigenetics within inclusive inheritance.

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7.2.1 A Brief History of Evolutionary Theory; Ever Since Darwin The history of any thought or theory can be written in various ways, and the evolutionary theory is no exception to that; however, there is a very strong orthodoxy when it comes to the history of established evolutionary theory.15 The orthodox narrative about the history of evolutionary theory16 states that, the most prominent contribution of Darwinian evolution with respect to other evolutionary theories or perspectives in his day was his mechanistic explanation of the evolutionary process by means of natural selection. Although there is some truth in this narrative, which can also be understood through Malthus’ Essay on the Principle of Population (1992 [1798]) and its’ effect on Darwin, the so called orthodoxy that is held today is claimed to turn the blind eye to other approaches on evolution at least since then, until the so called epigenetic turn in the twenty-first century. Although there has been some work on evolution and its mechanisms other than natural selection even before and certainly after Darwin, they were generally seen as exceptions, unscientific claims, or simply wrong theories—sometimes with good reason. The orthodox narrative of history of evolutionary thinking starts often in a period, much later than Darwin, where there exist two parties that are claiming to be true approaches towards evolution before the modern synthesis, namely Medalians and biometricians, which eventually. fused into population genetics (Dietrich, 2006). The trend eventually developed into the central tenet of what is called the Modern Synthesis (MS),17 making it possible to use population genetics to explain many evolutionary phenomena such as allopatric speciation (Mayr, 1942) and genetic polymorphism (Ford, 1949) which were, before the synthesis, actually used as refutations against the evolutionary thinking due to evolutionary theory’s lack of explanation in these fields.18 In addition to that, MS was related to the more general biological phenomena such as mutation and was able to explain relatively disconnected fields such as ecology. Due to its success in explanation and the celebration of mathematical models in the spirit of twentieth century science and philosophy of science alike, the central premises

15

I will not discuss here whether it is the theory that made scientist directed at a gene centric perspective in explanations or the practical tools and methodologies which directed them towards embracing a gene centric ontology besides epistemic tools they developed while doing the research. 16 Although calling all the evolutionary understandings before the birth of Extended Evolutionary Synthesis (EES) as a programme does not reflect the reality in the field, it is certainly something that held a strong orthodox position in evolutionary theory. After all, although differing accounts of evolution was possible, the standard orthodoxy was always a very canonical and well kept theory that was formulated and transferred for decades. 17 Also categorized as Standard Evolutionary Theory (SET), or evolutionary orthodoxy depending on the context. 18 It is an interesting observation that evolutionary medicine of today, by its critics, it not seen to have the explanatory power to explain medical phenomena today.

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of evolutionary theory were set in the shape of population genetics.19 Since then, although there has been a lot of controversy about the relationship between MS and the other related disciplines within biology, it was held as “the evolutionary theory”, and it was probably the closest thing that was held to a scientific theory for evolution by setting up a strict and counterintuitive to non-experts’ definition “changes in the allele frequencies in populations”.,20 ,21 The main difference of today’s inclusive inheritance from the initial criticism of Gould and Lewontin (1979) and criticisms coming from that direction is in its ability to explain these criticisms empirically. In other words, in the critique of Gould and Lewontin it was conceptual, now the same claims are seen empirically valid by the biologists in the ways that they would understand not only the critiques but also they could be put forward to provide alternatives.

7.2.1.1

Standard Evolutionary Theory and Four Force Matrix

The general perspective of MS and how it came about was discussed in the previous chapter. Apart from disciplinary critiques, here I will briefly describe the main elements as the drivers of evolutionary change in the MS. What I would like to point out here is the gene centrism of orthodox evolutionary theory, which follows the paradigm that the important changes in evolution can only be followed through this the changes in allele frequencies. One common history starts with saying that MS was mainly based on a particular branch of biology, namely population genetics. Within this framework, evolution was understood as “change in the allele frequencies in a population”22 (Magnus, 1998). This understanding does not give any idea about the individual organism in its current form and the evolutionary processes can only be observed within the populations. Of course, this does not mean that the individuals as well as the populations do not undergo evolutionary processes, however “evolution” in its restrictive sense is defined with respect to that. When the limits of the concept of evolution within the scientific context is stabilized in that sense, the question is; what causes this change in allele frequencies? Although in general there can be many different processes and mechanisms, orthodox evolutionary biology has limited them to four. These four main mechanisms that act 19

In addition to that, the “unity of science” idea, which focused on theoretical unification of different parts of related sciences, was very prominent throughout most of the twentieth century, for further discussion (Galison & Stump, 1996). 20 Of course, the meaning and the constraints of this formulation consisted of many other claims such as the central dogma, one gene one trait approach, two alleles hypothesis etc., the change of which eventually became the highest force that made MS challenged. 21 It is also important to say that such formulation was very much in spirit with the increasing emphasis on mathematical models and simulations during the thirties and forties, which was more or less the gold standard for being scientific in the day, again for discussion; (Galison & Stump, 1996). 22 As it can be seen in many textbooks and other resources.

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upon the allele frequencies in a given population are natural selection, mutation, genetic drift and gene flow.23 All of these forces act upon populations and more correctly about the allele frequency of the genetic make-up of the populations.24 That is to say that they do not give us any understanding of life history evolution of an individual or a species, they are purely theoretical models. The concentration and unification of evolutionary “laws” was not always there within evolutionary thinking, however it was a trend that led to the MS. Gould (2002, p. 13) dates this “hardening of the synthesis” (implying the modern synthesis) to 1959, during the centennial celebrations of the Origin of the Species. Dietrich (2006), writing on evolutionary theory on a modern reference book, starts the discussion about the history of the evolutionary theory by focusing on evolutionary genetics in the first place. The general reductionist programme that takes microevolution in this four-force matrix to be the main indicator of any evolutionary process is still the main orthodoxy when it comes to the evolutionary theory. Only when the four-force matrix is constructed other kinds of phenomena and ad hoc hypothesis are brought to explain processes in evolution. In this four-force matrix, like the MS in general most of the evolutionary biology, health, disease and other possible health related value concepts are omitted, if not overlooked since the primary aim of evolutionary biology is not to explain health or disease. Evolutionary biology goes to this level of abstraction to be able to create more simplistic models for entities such as genes that are employed in the evolutionary theory. From these general mathematical models in abstract, covering laws to explain various phenomena are made possible. These covering law models of explanation have been very popular in early twentieth century within science. They were based on a particular understanding of physics of early twentieth century, and were very popular in philosophy of science in its modern beginnings such as in Hempel (1942) and Carnap (1962) (Reck, 2013). In addition to the covering law model, trying to understand nature reduced to a number of fundamental laws of physics and explaining biology (among other sciences) within this framework similar to that of what they had engineering in mind was quite common (Smart, 1959).,25 ,26 When the main micro mechanisms of evolution that are centered around the genetic understanding of variation and the four forces applied to them are seen as the main mechanisms, and the local evolutionary theoretical models such as red queen hypothesis or the arms race are not seen as central to evolutionary explanation, 23

Due to the gene centrism of the framework, more “natural” biological events such as migration are seen in terms of genes again and fall under gene flow. 24 In a way, the contradiction between the defenders of MS and EES can be seen about the role of higher versus lower level theories and on the same line between the mathematical and tidy understanding of MS and more biological and diverse understanding of EES. 25 Of course, heuristically the four forces matrix can still be operational, see Baedke (2018, chp. 3) for different kinds of epigenetics and their relationship to the general understandings of inheritance. In addition to that the four forces can be employed without any problem within the framework of population genetics for certain purposes. 26 Here, the higher-level laws and lower level laws can be discussed in detail. Look at the construction of the phenomena and the Dappled World (Cartwright, 1999).

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this level of abstraction faces difficulties to explain the medical phenomena which are supposed to explain phenomena that is distributed to a smaller timespan. In the end, it boils down to adaptationist stories because the explanatory power within these adaptationist stories are expected to be in the high theory,27 namely the mathematical models within the evolutionary theory. Of course, this is not an argument against EM per se; it has more to do with focusing the aspects of explanation. This is why I think Courneoya (2018) overlooks the value of adaptationist explanations, however why it is the case that adaptationist explanations are seen redundant or not helpful is the focus on the explanatory role of high theoretical parts within the explanation. If we instead tend to focus on the particular explanation and the role of ad hoc or at least local parts of the evolutionary explanations, they will most certainly look different. In a sense, Standard Evolutionary Theory (SET) overlooks the kinds of events and histories that are considered within the life histories of organisms because it is on the theoretical level due to the level of abstraction required for that. These “omitted” domains are core of the explanatory domain of the Extended Evolutionary Synthesis (EES) framework that I will go into detail in 6.3). Niche constructions and epigenetics mechanisms, although they can have an effect for a short period of time in this perspective, occasionally resisting certain changes within the evolutionary history in general, do not mean much in the grand scheme of things, when being looked from a SET perspective. One gene frequency increasing in the population having certain results is not very central to the understandings of SET or MS, while for the developmental biologists studying the life history evolution of a particular species, it can be of particular importance. This is the exact problem of explanations in clinical explanations, where supposedly the ultimate explanations are useless that EM should oppose when it comes to healthcare related explanations and interventions in medicine. Since these short-lived effective mechanisms of inheritance—or are not even inherited characteristics –, have crucial effects on people when it comes to explain and intervene. A certain disposition towards having higher blood sugar for two generations is what we are trying to solve in the medical perspective, while the mechanisms that led to the evolution of this disposition are seen as the ultimate causes in this framework. In other words, the main problem of explanation within evolutionary biology can be seen as a problem of explanandum and explananda together. The things to be explained are selectively entering the framework of evolutionary biology since what is seen as evolutionary is expected to be relevant with ultimate explanation. This created a kind of a vicious circle which also protected the research programme from external influences since it was creating a questions it needed to solve, and because the problems it solved were nor very practical problems, this enabled the distinction of proximate and ultimate to be persistent in the research activities.

27

High theory is used here in Nancy Cartwright’s (1983) sense of more abstract and general formulations of theoretical models compared to explanatory models that are aimed at explaining smaller structures.

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The Main Aim of the Critique; Against the Proximate—Ultimate Distinction

I have mentioned ultimate explanations are very central to modern synthesis at 5.2, however I did not explain its importance and its contrast group within explanation, namely the proximate causes. Since ultimate causes are seen as the more important elements and all other biological causation that had effect on the evolutionary history of any species, regardless of their differences were put into the general category of proximate causation. In this part, I will focus on the distinction between ultimate and proximate causes in biology in the construction of evolutionary biology and its function, eventually defending a position that allows us to see proximate—ultimate distinction in evolutionary biology a pragmatic distinction that can be arranged according to our explanatory aims in evolutionary biology, and I will advocate a weak distinction enables us to employ more explanations coming from evolutionary biology to medicine. The main text that put forward this distinction in 1961 by Ernest Mayr was a text that was published in one of the major scientific journals, Science. Although Mayr himself was not a philosopher and in this rather short text, he did not use many philosophical references, he employed mainly Ernest Nagel’s works as the philosophical background of his perspective.28 In his vocabulary, he distinguishes between two kinds of biology; namely Functional Biology and Evolutionary Biology. In this distinction, he claims that the evolutionary biologist deals with the history of any biological phenomenon. Interestingly in his example to demonstrate the difference between the proximal and ultimate causes of the migration of a bird, he uses both environmental (the temperature changes) and intrinsic causes (about survival) of the migration as the ultimate causes. This parallel in the distinction between the intrinsic and extrinsic, and proximate and ultimate also interestingly tells about things that he sees more central and stronger in explanation and things he sees environmental and not constant. In his view, the main distinction between these two causes is based on their historicity. Although he does not directly argue for the embeddedness of the effector of these causes to DNA, he follows the effect of ultimate causation through the information embedded in the DNA as he claims; “… immediate factors of the environment while ultimate causes are responsible for the evolution of the particular DNA code of information with which every individual of every species is endowed.” (Mayr, 1961, p. 1503). These two arguments; argument for the distinguishing proximate and ultimate causation in principle and argument for the embeddedness of ultimate causes to the DNA of the individual create the base line for the explanations that depend on EEA. Since the main cause of any biological mechanism is embedded in the DNA of the individual, and the other mechanisms are shaped by evolution for many years, the legitimacy of the general EEA to explain diseases

28

In retrospect, it looks confusing how such a philosophically little informed work (only 4 of 14 total references can be considered within philosophy of science in today’s standards) could create such a big debate in philosophy of biology. However, it is probably the case due to Mayr being a very influential figure in the development of biological theory.

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within an evolutionary framework looks very easy to asses to the evolutionary biologist as long as she follows these lines.

Against Mayr, Scholl and Pigluicci (2015) and Laland et al., (2011, 2013) claim that this distinction between proximate and ultimate causation is no longer very easy to make neither useful for biology, which is going to be discussed in the following part. As claimed by these three works, Mayr’s understanding created a paradigm in evolutionary biology that protected it from change for a while, however it is about time that this paradigm needs to be changed.29 The main critique against proximate and ultimate causation distinction comes from the observation that, many biological traits affect each other through evolutionary history. Laland et al. (2011) claim that reciprocal causation is much more common in evolutionary histories of trait adaptation than it was predicted and exemplified by Mayr. Some, such as West-Eberhard (2003), Laland et al. (2008), Jablonka and Lamb (2005) and Griffiths et al. (2001) claim that the distinction of causes in biology as proximate and ultimate also hindered research activities in this domain. Of course, not all epigenetics is against the proximate—ultimate distinction (Baedke, 2018, pp. 83–84)), however the proponents of EES are. The two main different trends, one being developmental epigenetics based on stem cell search, most famously by Sui Huang and the more Lamarckian perspectives of molecular epigenetic inheritance, most famously by Eva Jablonka.30 I do have a pragmatic stance when it comes to proximate—ultimate distinction, like many critics of this distinction. This distinction is meaningful depending on our epistemic aims and the traits that we are trying to explain. When the scientists want to build a general theory to understand the abstract evolutionary entities, such as genes, it makes sense to have the ultimate explanation. However, for the purposes of evolutionary biology again, when it comes to explain a particular species or life history, so called proximate explanations become important within the evolutionary biology and they have explanatory priority. In the context of evolutionary medicine, when this distinction is blurred, ad hoc evolutionary mechanisms and phenomena are much more useful for clinical medicine, since they are much closer to the proximate explanations. The Smoke Detector Principle that I mentioned in the previous chapter, put forward by Nesse (2019), is one of these locally applicable principles. This distinction is important for MS, because it can easily build disciplinary distinctions, different areas for different biologists and a different history for evolutionary entities. Since the built of our organismic make up is determined through the environment of evolutionary adaptiveness this should be the time to have the optimally adapted human form to this particular environment and our task should be thinking about the human relationship of which body make up is evolved in 29

What Laland et al. (2011), and many other texts written by evolutionary biologists on this issue use the concept of paradigm while most of the time what they mean has more similarity to Lakatosian research programmes. 30 Amongst other work, Eva Jablonka was probably the main figure who made epigenetic research in the late 20th and early twenty-first century again a discipline of concern to evolutionary biologists through many of her work.

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the prehistoric conditions, to the current environment, and look for mismatches in the current environments. Evolutionary medicine relied on a very particular understanding of Environment of Evolutionary Adaptiveness as I discussed in the last chapter. The main idea is that humans have evolved in the conditions where many things held stable as the environmental conditions, and the evolutionary processes were imprinted in the DNA of the individuals, assuming that it is the main mechanism of inheritance. The biological mechanisms, seen from the framework of the Mayrian distinction (1961) also tended to fall into two distinct categories.31 Cournoyea (2018), the main critic of EM also argues that EM usually uses proximal—ultimate distinction when it comes to its explanations.32 I do agree with his criticism that certain traditional explanations within EM are of this type, however if we take the causation in biology more liberally and try to see causation in a more general framework not to fit it in the already existing theories and models of causation, this also means that the evolutionary entities that emerged through various evolutionary processes can also have different kinds of evolutionary causal powers. From this perspective, the smaller mechanisms and phenomena of evolution, for example the causes that lead to the Red Queen Hypothesis (van Valen, 1977), a hypothesis that is used to explain the coevolution of hosts and parasites, and see the phenomena as such and create ad-hoc laws, causation and models of explanation, this can create a new understanding of causality in evolutionary biology. This can also mean that in the evolutionary terms, disease can be evolutionary relevant and even explanatory in certain senses. This also makes disease itself an active participator in the evolutionary processes. For example, although they are still trying to find a genetic basis for it, Kurtz, et al. (2016), look at the field of evolutionary biology to see how diverse the species are that can be explained by the Red Queen Hypothesis to see that it is a very general field in which different organisms within the host—parasite relationship could be coevolved following this more localized understanding. In Mayr’s time, it was perhaps commonplace to have different kinds of biologists, e.g. physiologists and evolutionary biologists who are asking two different questions, how and why. However, in contemporary biology due to its much finer grained and structured distinctions on the level of research groups but interdisciplinarity at the working environment, why question of a microbiologist can be the how question of a physiologist. The howness and the whyness of the questions are also pragmatically determined. The ecologists, depending on the aim of their work, can see proximate 31 Mayr (1961) did not only limit evolutionary explanations to ultimate explanations with this manoeuvre, he also limited evolutionary biology to deal with the ultimate explanations instead of dealing with the general complexity and evolutionary history of organisms. Due to this manoeuvre, the departments of evolutionary biology had focused on these kind of explanations as their primary epistemic goals, and had a success criteria for themselves only with respect to the connection to the ultimate explanation in the individual cases. I have discussed it in the disciplinary distinctions in the previous chapter. 32 Although, following Scholl and Pigluicci (2015) and Laland et al. (2011, 2013) he agrees that this distinction is not as stringent as it used to be in evolution, he concludes that the explanations from EES are not sufficiently established enough to provide a counterpoint, I do not agree with this position and try to point out different perspectives within EES to show that EES can be both explanatorily relevant and metaphysically convincing.

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explanations differently than evolutionary biologists since the evolutionary biologist might be looking for explaining a life history of millions of years, therefore taking a causation as proximate, while for the ecologist, seeking to explain a more short term effect, can see this explanation ultimate in her domain. After the main conceptual issue is discussed, now I will turn to the new research programme that has a different conceptual framework and can be capable of explaining differently than traditional EM. The new research programme that is defended by the dissidents of proximate—ultimate distinction in biological causality is called Extended Evolutionary Synthesis (EES).33 However in order to make sense of it first I will look into the idea of inheritance from different biological perspectives.

7.3 A Brief History of Inheritance and Inheritance of Inheritance Previous part was used to discuss the most important element the dogma of ultimateproximate distinction in biological causation and its relationship to gene centrism of evolutionary frameworks. Since the main idea is the stability of the genetic material as the plan of the organism, and hence the main ideas of EM depend on it, it is central, in this part; I will first give an outline of different frameworks of the new understandings of evolution and then give empirical argumentation for them. The distinction between what is evolutionary and what is non-evolutionary in the very first place marked a distinction of what is constant and what is changing as the biological mechanisms. In general, this distinction, evolutionary biologists’ vocabulary also marks the distinction between what is plastic and what is non-plastic (Pigliucci, 2001). According to him, developmental plasticity was the key concept for biologists to go beyond the nature nurture dichotomy for decades. In a sense, the whole idea of evolutionary understandings is that they provide us something constant. They have been evolved in a certain way, moulded by the evolutionary forces and processes. The assumption is that these forces stayed constant for a long enough time and afterwards there was no chance for the other mechanisms to evolve in reply to them. However, if we see it differently, from a perspective that allows new mechanisms of inheritance, we could have a different perspective on the evolution of other entities as well. This part deals not only explanation but also conceptual horizons of inheritance. The recent empirical research on evolutionary biology allows us to see inheritance in a different way that is biologically more encompassing and can be used to conceptualize evolutionary medicine in a broader way. Through this understanding, I claim that instead of directly applying whatever they have to the evolutionary related branches 33

Although the critique takes shape in EES, most central ideas come from epigenetics within my work, since they have better mechanical objections to the standard theory of inheritance. The other processes are also important, yet the general paradigm of MS or SET rely on the gene centrism in inheritance that creates the important objection to the traditional EM.

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to explanation of the medical phenomena perhaps for epigenetics it is better to “take a step back” makes itself unrelated to evolution and show the limits of MS, use the unexplained as its own evidence against the central dogma. In that regard the main idea is that, the mechanisms of inheritance themselves are subject to different inheritance and selection regimes. Although this has not been used as a genuine biological argument, the selection regimes of different inheritance dynamics have been debated through partial mechanisms as it will be discussed in 6.3.1.1, the conceptual understanding in this fashion has not been put forward. The issue is most often this issue is not discussed under inheritance but under the topic of evolution of evolvability such as the study of Wagner and Altenberg (1996) or Dawkins (2003). However if we see the issue as the inheritance of inheritability, the perspectives we can get can be seen more similar to EEA perspectives of EM.

7.4 Extended Evolutionary Synthesis EES is a movement or a loosely knit research programme amongst evolutionary biologists that aims to explain certain phenomena of biology within evolutionary biology. In addition to that, EES has a different theoretical framework than the MS, employs concepts differently and has a differing research aim than the MS. I will not go into details about every aspect of EES or try to give out an analysis of the completely theoretical change neither I will try to advocate that it is convincing and will ultimately replace MS. What I would like to point out first is its relative importance when it comes to assess EEAs. Although MS had discontents not late after its conception, they could not so far develop into a theory or a movement that was strong enough to openly challenge it with a manifesto. Although there have been individual scientists or research groups who challenged the MS, EES, for the first time at large, tries to do it in a well- organized research programme. The success of EES can be measured by the influence it brought to one of the—if not the—prestigious journals for biologists, Nature in 2014 (Laland et al., 2014a, 2014b). This is an important milestone in the establishment of the new programme because now not only small groups of biologists, single authors or certain philosophers of biology were pushing this challenge towards MS, but it was accepted as a valid disagreement of opinion within the scientific community itself. In this discussion, evolutionary biologists of opposing sides, the ones who would like to keep MS without major alterations, and the ones who demand relatively radical changes within the theoretical structures, concepts and explanatory aims of evolutionary theory, wrote their positions about the future of evolutionary biology. Although the format itself shows that, the criticisms and the framework of EES is not established as orthodoxy, nevertheless it became a fundamental issue at the decision making of scientists on these theories and it certainly became at least a rivalling research programme. This means that the demands of EES is at least seen as serious demands.

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Calling EES as a single programme is nevertheless rather difficult. The main reason for this difficulty is the diversity of the origins of the critiques of MS. Although they do not include every dissident of MS such as Craig (2010), they still built a relatively large group of dissidents and created networks to connect different kinds of research that could challenge MS. When it comes to the constitution of EM, the main theoretical objection to the core assumption of MS—gene centrism—came from the field of epigenetics, which is a categorization at the level of inheritance systems, while when it comes to the disciplinary distinctions, most criticism was from evolutionary developmental biology (EvoDevo). Apart from other conceptual tools, the relatively new domain of niche construction—mostly based in behavioural biology—also added certain conceptual shifts to the MS. They explain their predictions in comparison to the traditional predictions of evolutionary biology on this table in their website. As it can be seen from their web site, the differences that the EES claim to have from the SET are radically different in some domains. For example, environmental induction of any kind of variation has been side- lined and was seen as trivial by most of the MS, although EES claims that it can be particularly important in certain evolutionary processes. Or the main issue on which natural selection operates, variation, has been seen not as a given or a random process, but a process in which there are certain kinds of biases, and these biases can be even studied, understood, modelled and even intervened.34 These create very different predictions than we traditionally hold in evolutionary biology. The central element in these differences is how, instead of a very strict developmental plan written in the genetic material of the individual, they see evolutionary processes being heavily influenced (depending on the cases) by the environment. Some of their claims are hard claims, such as genes being followers of evolutionary processes and soft claims can be environmental elements having a certain kind of influence in natural selection.35 In many cases, the explanation can depend on the individual case, individual trait, or the context. I would propose here also a rather pragmatic approach to science, instead of looking for a one fundamental explanation to the general theory, it makes more sense to think that for different traits—or even for the same trait—there can be different mechanisms of selection. Now let us turn to the central element of the critique by the EES to the MS, epigenetics.

34

In a sense, I believe that most issues that are voiced by the EES that they claim were not explained in evolutionary biology has to do with the temporality of evolutionary processes. MS deals with phenomena that are meaningful to be modelled in millions of years of evolutionary history. Because MS focuses on that level to construct its own models, environmental effects or mechanisms that create huge variation does not mean much for them. However, if our aim is to understand the kind of variation that is supposed to explain differences, inclinations and variation that takes place in vivo or in the history of a couple to a couple of hundred generations for some organisms, such models of evolution can explain better these events. 35 Here hard claims refer to more radical and more unorthodox claims within evolutionary biology.

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7.4.1 Explanations in EES Since the critique of EM follows the main argument that tries to strive off its explanatory relevance in the clinical medicine context by criticizing its irrelevance to the medical explanations, we should now try to assess whether explanations coming from EES and particularly epigenetics would be different or not. Although the research guiding elements and public health focus is also important in discussing the effects new evolutionary understandings to EM, I will limit the effects of EES to EM to explanations here. In this part, I will look at the kinds of explanation in EES and their differences with the MS explanations to be able to advocate for the explanatory relevance of an EM that integrate explanations from EES. Baedke et al. (2020) writing about different kinds of explanations between the EES and SET; “They are more sensitive to changes in background conditions and changes to values of explanans variables (i.e., in developmental processes). Conversely, a less precise and more idealized SET explanation is more stable in that it enables inferences to more counterfactual situations without breaking the dependency relation.” (p. 20). In this sense, EES’s integrative ability to medicine comes from its flexibility in adjusting the background conditions for explanation. One example for this can be seen in Harper (2005) where, in psychological domain, such as in the example of temperamental variation, epigenetic inheritance started to be used to explain individual behaviour. This was made possible by the ability of background conditions and the theory that is used to explain the phenomena being able to include diverse elements within.

7.4.1.1

Future Looking; Will the Debate Solved in the Empirical Grounds Alone?

Before talking about integrating new explanations coming from EES to orthodox evolutionary biology, one question can be asked, in case of conflicting accounts of explanation, what should the biologists do? In short, are the evolutionary explanations coming from EES better than the explanations coming from SET? In case that the issue can be resolved in empirical grounds, there is not much work needed to be done for philosophers to integrate new evolutionary developments to EM. Since already, the proponents of EES see that theoretical integration is difficult (Laland et al., 2013) there has been hope for certain conceptual attempts to integrate different perspectives to the central idea. There has been proposed centralized formulations of the theory, most famously by Laland et al. (2015). On the defenders’ side Jablonka and Raz (2009) and Wray at. al. (2014) claim that an empirical inquiry will prove which explanations are better, EES or SET. And although certain proponents support that the issue can be resolved on empirical grounds, they do not explain how the ultimate structure will look like. On the opposing side, Baedke et al. (2020) object the possibility of the issue being solved on empirical grounds alone. In their article, they also do not formulate

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a unified framework and advocate a rather minimalist understanding that claims that this work will enable a possible understanding for evolutionary biology in which it can be unified. I believe that a general unified framework itself is not necessary for evolutionary biology neither for science in general. Following Cartwright (1999), I am more sympathetic towards lower level explanations, and from the perspective of Hacking (1984), I believe that a general explanatory unity is difficult and uncertain to be desirable. I do believe that it is possible for EES to contain MS. However, in order to do that they need to expand their own framework to include a more diverse ontology when it comes to what they do explain. However, I will not argue for it in a strong sense here and it is tangential to my discussion here because my main aim is about integration of evolutionary thinking to medicine. For that goal, being one simple kind of evolutionary theory, different kinds of thinking etc. are not of importance, and probably the more plural it is, the more diverse likelihood there are to integrate it to medicine in many different ways. Although this pluralism would make canonization of a single type of EM concentrated in an institution or discipline to be integrated to medicine, as I discussed in the previous chapter, due to the paradox of EM getting closer to medicine being absorbed by medicine, I do not believe that having one single EM is a necessity for the success of the project in general if we regard the project as employment of evolutionary approaches to medicine. The new epigenetic perspectives and their integration is also questioned by Baedke (2018). As he puts it, “The integration of epigenetics into the theoretical framework of modern biology in general and of evolutionary biology in particular faces several conceptual and methodological challenges.” (2018, p. 88). However, he still optimistic, posing two questions to be answered; “First, how can molecular epigenetic explanations that are based on highly artificial experimental setups address evolutionary explananda? Second, how can epigenetic explanations that focus on developmental proximate causes rather than on ultimate causes address evolutionary explananda?” (p. 88). When these new perspectives hold water, this would mean that we would have to re- evolutionarize the evolutionary medicine in a way for new kinds of evolutionary explanations as well as provide a new conceptual framework for evolutionary medicine. However, for them to hold water, let us look at the criticisms and disputed aspects first. However, regardless of a unified scheme for evolutionary theory being possible or not, different kinds of explanations coming from EES can be helpful for medicine, when the concept of medicine is constructed to include public health policy and medical research. Public health itself uses statistical explanation also very often, and in that regard, is much closer to fit the distinction that Baedke (2018) already makes. In this sense, the “disputed” part of EES that is causally more difficult to integrate to EM becomes the more easily relatable element to medicine.

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Critiques of Epigenetics

Now I would like to make a small distinction between epigenetic variation and the heritable epigenetic variation. While as discussed earlier, there are various mechanisms of epigenetic variation, how much of it is inheritable and to what extent the epigenetic mechanisms are variation making are open questions and can be partially empirically, partially conceptually be resolved. The heritability of the epigenetic variation through epigenetic mechanisms is also called into question by Baedke, (2018, pp. 43–44) on the empirical level. The questions arising from the fidelity of heritability of epigenetic variation is due to unstable states and high mutation rates (J.Dawkins, 2004; Deichmann, 2016; Hall, 1998; Pál & Hurst, 2004; Walsh, 1996). Although there are criticism in this direction, my expectation from epigenetic stability is not as high as assumed genetic stability, on which the core assumptions of EEA are based on. Since my aim here is to provide more localized and temporally shorter understandings of EEAs, different levels of variation in the mutation rate in which phenotypic variation is made possible supports a more pluralistic position. That is to say, if certain variations are to happen in ten generations, an approach that sees something within a couple of centuries makes more sense to understand the event, if it is for two generations, certain social events and subcultures and interactions at this level would make more sense. Due to the variation at the mutation rates and the level of stability of epigenetic change over generations, I believe that evolutionary understandings of EES have a more advantageous position to have explanatory relevance in this context. To support the possibility of pluralism in the coming research Baedke et al. (2020) draw exact quotations from Uller and Laland (2019), Müller and Pigliucci (2010), Laland et al. (2015), Müller (2017) and Müller and Pigliucci (2010), claim that many proponents of EES advocate that EES stands for increased pluralism and extended explanatory power of the EES over MS.

7.4.1.3

Critiques of Explanatory Integration

Another challenge of epigenetics to become relevant to evolutionary biology is at the difficulty in connecting causal explanations of molecular biologists and statistical explanations of ecologists and evolutionary biologists (Baedke, 2018, p. 45). Baedke’s conclusion follows the observations of meetings of population geneticists and developmental epigenecitists (Richards et al. 2010a), philosophers of science (Griesemer, 2011a, 2011b), and plant scientists (Latzel et al., 2013). Moreover, there are also issues when it comes to connect observational studies in novel fields of ecological and evolutionary epigenetics and the causal reasoning in experimental molecular epigenetics (Baedke, 2018). The observational studies that he mentions are focused on the newly built perspectives on ecological epigenetics, which are general guidelines rather than research (Bossdorf & Zhang, 2011), study of epigenetic variation as an inheritance mechanism to be investigated (Richards et al. 2010b). These two studies also indicate the emergence of a new field and the

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work that is required to be done to integrate these two different domains. I think it is getting closer to be achieved, although this is not a necessity for my general project. The main idea is that molecular biologists’ explanations rely heavily on mechanistic view on causation while ecologists and epidemiologists36 use statistical models37 for their own explanations (Baedke, 2018). As a for the unificationist case, Baedke (2018, Chap. 2) speaks from the framework of a general unification of epigenetics and evolutionary biology. I believe that this is a high standard to look for when different kinds of evolutionary relevant theories and hypothesis are going to be used in disease and health related interventions, be they in clinical practice or public health. In addition to that, I do not feel that I am required to prove the centrality of explanations in epigenetics or EES to be completely integrated nor central to evolutionary medicine. If anything, I believe that the relative smaller scale case-by-case explanations to the medical field are better at times to understand disease processes and disease making mechanisms. The lesson from the previous chapter kept in mind (the organism’s relationships to the environment and their ability to endure and select various environments in mind), the epigenetic and EES explanations do not need to be based on the traditional EM. After following the conceptual understanding of orthodox EM, evolutionary understandings that follow non- orthodox explanations coming from epigenetics or EES can be used in a helpful way in clinical medicine or public health. There are also other developments for the unification of statistical models and epigenetic mechanisms. Herrera and Bazaga (2011) build the link between molecular epigenetics’ mechanistic models and statistical models of ecological and evolutionary epigenetics on their natural experiment on southern Spanish plant Viola cazorlensis. In this experiment, they could conclude that these explanations can be used together to explain at least certain phenomena (Baedke, 2018, pp. 48–53). On a similar line, the integration of Gene Regulatory Networks and cell differentiation in systems biology with other studies in evolutionary and developmental biology is a difficult task, however there seem to be methods to overcome the difficulties (Green et al., 2015, O’Malley et al. 2015). However, these models are for very complex and interactive systems, they aim to give a complete structure of causal understanding of genetic and epigenetic factors within the biological causation. The “problem” with epigenetics explanations is the difficulty of controllability and thus the standardization of the experimental structures. As put by Baedke; Instead, the field seems to be heading in the right direction by going out of the lab and, at the same time, developing research methodologies that are heuristically useful because 36

The evolutionary medicine, when using explanations that are closer to statistical explanations are in fact closer to epidemiologists, therefore, ecological epigenetics, epidemiology and public health. The possibility of using the same framework for causation between ecological epigenetics and health sciences is promising. 37 Statistical models are mathematical models that are based on certain kind of statistical assumptions to explain (often) the distribution of certain kinds of data. As a contrast group, causal models are the models in which there is a direct connection between different kinds of structures. For discussion between causal and statistical models of explanation; Glymour (2009).

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they allow the development of reciprocal transparent models in ecological epigenetics and molecular biology. In addition, even at this early stage, the results of epigenetic field studies offer sufficient causal information to, by themselves, guide further research—even across disciplinary boundaries—on phenomena under study. (Baedke, 2018, p. 54)

The interrelation and integration of causal, interventive mechanisms can be seen here, as a reply to the statistical understanding of evolution. Instead of causation, evolutionary biology also should be seen mainly as a matter of statistics.38 This demonstration does not only show that epigenetic mechanisms can be useful for evolutionary explanations mechanistically; it also gives us a better understanding of evolutionary understandings of disease and evolutionary medicine. Because of that, the above understanding is of extreme importance. When it comes to the issue integration, Green et al. (2015) calls systems biologists to act in a similar fashion with Tolstoy in Isaac Berlin’s short story “The hedgehog and the fox”. In the story, the fox knows many things; the intricate details of a system—the detailed regulatory mechanisms in their example—but does not believe in a general theory while the hedgehog only knows one thing—the overarching theory. However, even when a single system biologist does not go this route, I think the combined efforts of the scientists in the general framework still add up to that. When we add clinical to the discussion, the matter becomes more complicated and easier to resolve at the same time. Evolutionary biologist asks; why there is iron in the blood in the very first place. This makes no sense to the clinician. Because of that, the clinician does not make sense of that side of evolutionary explanation, but the research is again another issue. However, from my perspective, integration is not necessary. Evolutionary understandings, without creating unified or general structures can still by individual attempts explain the medical phenomena and diseases.

7.4.2 Ancestral Population Individualized—Inheritance of Different Mechanisms So far, I have argued for two main things; (1) Inheritance mechanisms are of a manifold. (2) The inheritance mechanisms being a manifold are shaped differently unlike the general claim of Environment of Evolutionary Adaptiveness39 (EEA). When they are combined, we can construct different environments of evolutionary adaptiveness, depending on the population, individual and the environment. Moreover, this is made possible by the discovery of different mechanisms of inheritance such as the mechanisms that are briefly sketched in the mechanisms of epigenetic inheritance. 38 39

Especially when it comes to more proximate mechanisms and processes. Chapter IV discusses the idea in general.

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I have discussed that the heritable mechanisms that are put forward by research on epigenetics indicate that these mechanisms are creating variations that are vary from very short term (in the timespan of one generation sometimes), to relatively longer term. Moreover, there are a manifold of these mechanisms (Jablonka & Lamb 2007). There is research to be done until we can have sufficient knowledge of the extent of such mechanisms that can be reliable guides to make us analyse the localized EEAs. In this sense, it can be said that the whole “baggage” of one singular image of EEA can be replaced by many different and well researched programmes. In a sense, it can be said that, the EES creates an ancestral population where the “ancient”—the preserved or resistant structures to environment are different from that of genes. Through this perspective, EES’s understanding of history itself is different from that of the MS. The discussed mechanism of inheritance that I have discussed earlier also mean that it is possible to create new, localized EEAs and based on that, reconceptualising environment in a way that can create new kinds of match, mismatches. Already at a central text of EM, Nesse (2001b), mentions the importance of individualization of disease in the sense that it shall be very context dependent when it comes to relationship between concepts and the individual behaviour. If we combine the evolutionary understandings’ indifference towards natural and human made, making the nature—culture dichotomy obsolete with respect to the selection pressure effects and shaping of the organism in this regard, we can see the localized EEAs in context to create explanatory networks. There has been an increasing understanding when it comes to see localized EEAs in the history of human groups, without referring to evolutionary history already, perhaps most notably by DeGruy Leary in her Post Traumatic Slave Syndrome: America’s Legacy of Enduring Injury and Healing (PTSS) (2005), where she discusses the epigenetic changes that create enduring psychological effects due to inherited characteristics that are shaped in a few previous generations. On this line, Yehuda and Lehrner (2018) discuss the epigenetic mechanisms underlying the possibility of trauma being transmitted to the new generations. The extent in which this can be assured is an open question. However, as a general research perspective, it would be helpful to account for the new, short term inheritance mechanisms. When it comes to immune system inheritance, Kurtz (2005) have been working on how the individual immunity is dependent on the priming experiences of the previous generations of Tribolium castaneum (Red Flour Beetle) in order to understand the inheritance of immune characteristics. The interesting point about this research is that, even in organisms with relatively simple immune systems compared to mammals for example humans; it is possible to have inheritable mechanisms within immune systems. This experiment and the others following from Kurtz group show us that not only it is possible to have different organismic make ups that make organisms more or less vulnerable to certain diseases, but also show that certain kinds of EEAs are possible depending on the stability of the environment of the organism. Of course, the mechanisms and the stability of environment and their interrelation is still under research, however short term EEAs and the structures of mismatches that can be modelled specifically for a certain kind of disease vulnerability seems possible.

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7.4.3 Structures Fixed and Getting Fixed Some structures have longer evolutionary histories, while some have rather short. The aspects which are discussed in EES are the ones with shorter, and sometimes more relevant histories. Especially the explanatory strategies that are coming from “causes without mechanisms”. As Baedke describes them; In short, this explanatory strategy in epigenetics can be labelled “causes without mechanisms.” This means that although the genetic basis of epigenetic phenomena is not neglected, genes no longer carry with them a special causal and explanatory weight. (Baedke, 2018, p. 204)

This means that the ancestral mechanisms and traits to be stabilized do not come from the EEA framework, but more individualized (or socialized) understandings of evolution are at play. When it comes to compare different histories in this regard, it also becomes possible to overlook certain kinds of singular EEAs in this framework, freeing from the baggage of EEA. From this perspective, it can be said the idealization in clinical medicine’s integration to EM is constructed either from a certain kind of physiology or from an understanding of evolutionary ideal, be it with trade-offs or not. However, epigenetic understandings of inheritance provide us with a multiplicity of shapes and structures that can lead to making up of individual physiology and individual variation. Because of this difference, epigenetic understanding of medicine builds the theory from the particular to the general, not vice versa like the standard understanding of clinical medicine. Moreover the strength of which kind of explanation—singular gene based ancestral or local, recent, not genetic in the traditional way or something in between is a topic for research at each individual case. This is not because epigenetics starts from the individual per se, but the conceptual scheme of epigenetics allows different inheritance and inheritance making mechanisms to come together to explain the individual making up of one single organism. Since these mechanisms are also inheritable, it gives them better stability and explanatory power. These structures, with the knowledge of different kind of inheritance mechanisms and their relationships to the interaction of the organism with the environment can be helpful to develop such localized EEAs. Bolhuis et al. (2011) call for similar revisions in evolutionary psychology, in the sense that more nuanced understandings of evolutionary history should be borne in mind when it comes to explanations in evolutionary psychology.

7.4.4 Another Kind of History, Individualization and Evolutionary Histories Diseases of civilization in the environment of evolutionary adaptedness are seen very important in EM when it comes to recreate the evolutionary history. However, with the new challenges brought by niche construction, epigenetic inheritance and new

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kinds of units of selection, creating a unified history seems even if possible, very vague and not informative. In traditional EM’s evolutionary history, we all share a common species history that made us vulnerable to particular kind of diseases. We share many commonalities amongst us humans, since our environment for evolutionary adaptation was the same. However, when we consider the rapid evolutionary processes and mechanisms, the ones in the EES for example, we would have a much different understanding of history. This history is different on two counts. First, certain diseases and traits, the branching out of history will be different depending on the dominant evolutionary processes and mechanisms at play for that particular disease. This can also mean that some disease will be also family, culture specific even. Second, due to horizontal processes rather than vertical in hereditary mechanisms, evolutionary history itself will mean something different, instead of a linear structure, it can have a branching out and in structure. Of course, it is possible to think of evolutionary biology’s perspectives simply as environmental conditions, or other elements in medicine. However, evolution gives us something else, the evolutionary mechanisms in the discussion of organism when it comes to health; create durable structures that remained stable. This even includes perspectives to say that the structures that enable evolvability; structures such as DNA, chaperons, or translation. This understanding creates a distinction from the traditional concept of the environment, and this way, makes us able to distinguish different environmental elements and act accordingly. Sterling (2020), a neuroscientist who works on the evolutionary understanding of health in brain sciences, points out that, health has to do with the responsiveness of the organism to the environment but it is not a state. These dynamical interactions with the organism and environment can also be seen within the history of the individual, this would also help us to create individualized disease understandings. The problem with classical naturalistic approaches to disease is, they find their reference class to compare the diseased form from the healthy form within the population. From an evolutionary perspective we already know that variation is the norm, but moreover, the individuals functioning can also be determined positively or negatively with respect to the individual. Nesse (2001a) uses this as an argument for naturalization of the concept of disease, however the problem is, he has to use the already existing concepts as set of diseases to explain this situation. From a broader evolutionary perspective, individual’s ability to behave in various environments can be the only way we can start to define the particular disease for that individual. This is the main difference between personalized understanding of disease and one health or similar normative approaches. The normative approaches, although accept in general that the disease concept is context sensitive, do not expect new diseases, personalized diseases or “non discovered” disease concepts to be employed by disease understanding. I believe it is the most crucial aspect in the normative understanding the concept of disease because only this way we are able to deal the dualisms of health and disease in healthcare.

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7.4.5 Emerging Pathogens Let me now try to paint how it looks from a particular kind of disease class, namely pathogens to demonstrate the localized understanding of evolutionary processes in action in the definition of a partial disease concept. I believe that this is a good example of how disease perspectives can be enriched by evolutionary understandings. A subclass of diseases makers, pathogens have been under investigation in their essential properties. In Pathogenicity and Virulence: Another View (1988), Isenberg claims that the concept of PATHOGEN (also a thick concept, carrying negative evaluation) was taken to be an essential character of microorganisms starting at least from Koch’s Postulates. The evolutionary understanding of the disease making properties of the non-human elements on the human body are not new, as early as 1938, there were evolutionary views such as Smith’s on parasitism as a “universal biological process that evolved from the predatory struggle for food and, therefore, represents the normal interdependence of all living things” was out there in the scholarly circles. Smith established a non-medical and proecological/evolutionary relationship out of parasitism as a purely descriptive definition. He defines infection and disease in terms of introduction of a foreign element to the system and the disruption of balance between the host and the microorganisms while distinguishing between accidental harmful attributes to the organisms in the form of endotoxins, where normal and the usual is defined as the temporal general function of the organism. He highlights certain relationships between the host and the microorganisms in the form of the relationships between cell walls, motion etc. to account for the dual responsibility in the occurrence of pathogenicity. Smith uses a rather old balance understanding in health while trying to assess disease. In short, Isenberg’s research emphasizes the following; He describes the status quo and how well established and strict the concepts of pathogenicity, virulence and parasitism are and even goes forward to note that, anyone who asks the meaning of these terms to be regarded as a “heretic” in the scientific community. The “human” specimen which is susceptible to disease has changed drastically due to our capability and effort in curing the “external”, our relationship to the pathogens changed drastically due to the change in our relationships with the environment in the postindustrial societies. Pathogen was used to be defined as the cause of infection at first, however “hospital diseases”, and the infections which are caused by the non-pathogenic agents are creating anomalies to this framework. The need to readjust our concept of pathogen comes from ecology: the orthodox view was “one disease has one cause”, while the more recent and more accurate one that includes environmental and social factors in the “outcome and progression of disease”. A pathogen causes an infection which in turn causes the disease in the traditional view, however it does rarely hold true, the causal insufficiency of the agent can occur in each phase. Our technological limitations led us to consider only external factors that could be handpicked in the early twentieth century, however, new with the recent developments, we can see the process which leads to disease in which microorganisms and host are equally contributories. His objections against essentialism in Koch’s postulates include; examples of animal studies which

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show that the portal of entry is important in pathogenesis; lab studies are insufficient in showing the actual properties, because some organisms gain or lose pathogenicity under lab conditions; the negligence of effective dose, although dose is important in disease formation; 11 polymicrobial diseases where, in many natural cases the microbes are codependent in the formation of disease; the niches of the microbes which are also crucial to their disease forming behaviors, when they change niche due to surgical or other means, they might cause infection; the condition of the host as well as the historical background are also important factors in the coming about of pathogenicity; the disruption and through new coming microbes are also essential to the disease forming potential, since certain microorganisms only form disease when they are in the process of establishing themselves in the host. He further asserts our anthropocentrism in the issue. “The study of microbial etiological agents suited the simplistic approaches that reflected primitive technology, nurtured by philosophical anthropocentric attitudes. The primitive technology which still represents the majority of our activities in the clinical laboratory is now in the process of yielding to modern approaches in the analysis of the microbial participants and is beginning to permit at least an appreciation of the hosts’ contributions.” (Isenberg, 1988, p. 45) Since then, a lot of work is done in the same direction and now scientists such as Casadevall and Pirofski (2014) suggest the biologist not to use the concept pathogen at all, suggesting instead usage of concepts such as pathogenesis and pathogenicity, which they see as more accurate depictions of emergent processes that result from the interactions of microbes and their hosts, while Méthot & Alizon (2014) focus on how research in genomics and pathogenomics fostered a new understanding of agent-host relations but also tended to blur the distinction between pathogen and non-pathogen (Méthot, 2011). In the same rationale, the biological mechanisms of a person, when investigated with the diversity of the underlying bio-chemical processes, the more study directs our research towards a diseaseogenesis perspective when it comes to the genetic background, chronic diseases etc. As it seems, pathogen, started as a thick concept with reference to human health—as it is defined directly as disease forming or harm inducing organism—loses its evaluative aspect because it’s strict isolated ontological definition, since the process of formation of disease and pathogenesis is rather complicated and involves many different agents. When the definition is loaded to the external element, further research on it enables us to see different interactions, which might not cause disease. The “burden” of disease shifts from external elements to a more dynamic process with this understanding.

7.5 Conclusion Chapter 5 is about how the evolutionary medicine changes our understanding of disease causality and individual’s relationship to disease. In order to achieve that they direct the disease and healthcare towards the direction of public health in the protective level of the individual. Chapter 6 gives the possibility of interventive

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accounts of potential evolutionary medicine if it uses the developments in evolutionary theory, EES and particularly epigenetics and sees the concept of intervention and the medical together. The two main answers that I wanted to develop here are as follows; First kind is about the explanatory power and the possibility of integration of EM to medicine, making it more relevant to medicine; (a) With the employment of perspectives within EES and the new developments related to evolutionary theory, EM has a stronger explanatory power about disease related phenomena. (b) The new mechanisms within evolutionary biology tend to blur the line between proximate and ultimate mechanisms, which make EM easier to integrate to clinical medicine. (c) The explanatory framework and epistemic structure of epigenetics allow us to add statistical understandings to EM, which are already at use by medicine. This way, following the new evolutionary understandings, the explanatory methods that EM employs are already in line with medical understandings. On the conceptual level, the result is; (a) The mechanisms that are understood to take part in inheritance processes of individuals enable us to see the concept of disease in a more individualized way, instead of disease generalism. Of course that is to say it should be complementary to particular diseases and disease structures, without overlooking the importance of individualized cases. Following Cournoyea’s (2018) critique, Obviously Dobzhansky quote of 1973 “Nothing in biology makes sense except in the light of evolution” is false,40 but we can make it true by reframing evolutionary biology and its role taken seriously in conceptualizing disease. In addition, when it comes to EES, we see that the patient histories mean different things due to epigenetic research (Baedke, 2018, Jablonka & Lamb, 2014). Before ending the chapter, I have to give a warning still, the misuse of epigenetics on the other hand in disease could be problematic (Baedke & Delgado, 2019). In this work, Baedke and Delgado show that the usage of old racial categories can end up in using archaic understandings of races due to their prominence. However, there should be made a distinction between the biological and the conceptual on that level. While assuming that epigenetic changes are always a possibility, it should be borne in mind that the epigenetic changes are never a necessity for a certain kind of categorization, e.g. racially based. Moreover, although misuse of these categories is possible, not using them can also create epistemic injustices if they are at play, yet they are not researched. Now I will turn to the ethical conclusions that are coming from this situation of epistemic novelty. Ethics and individualization, the social dimension of healthcare should be constructed taking the ideas in account which create the conditions. 40

Also when the issue of the “invisibility of EM in medicine argument” is borne in mind.

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Scholl, R., & Pigliucci, M. (2015). The proximate–ultimate distinction and evolutionary developmental biology: Causal irrelevance versus explanatory abstraction. Biology & Philosophy, 30(5), 653–670. Smart, J. J. (1959). Sensations and brain processes. The Philosophical Review, 68(2), 141–156. Smits, W. K., Kuipers, O. P., & Veening, J.-W. (2006). Phenotypic variation in bacteria: The role of feedback regulation. Nature Reviews. Microbiology, 4(4), 259–271. https://doi.org/10.1038/ nrmicro1381 Stein, A. D., & Lumey, L. H. (2000). The relationship between maternal and offspring birth weights after maternal prenatal famine exposure: The Dutch famine birth cohort study. Human Biology, 72(4), 641–654. Sterling, P. (2020). What is health? MIT Press. Uller, T., Feiner, N., Radersma, R., Jackson, I. S. C., & Rago, A. (2020). Developmental plasticity and evolutionary explanations. Evolution & Development, 22(1–2), 47–55. https://doi.org/10. 1111/ede.12314 Uller T., & Laland K. (Eds.) (2019). Evolutionary causation: biological and philosophical reflections. MIT Press, Cambridge van Valen, L. (1977). The red queen. The American Naturalist, 111(980), 809–810. https://doi.org/ 10.1086/283213 Veigl, S. J. (2017). Use/disuse paradigms are ubiquitous concepts in characterizing the process of inheritance. RNA Biology, 14(12), 1700–1704. https://doi.org/10.1080/15476286.2017.136 2531 Veigl, S. J. (2019). A use/disuse paradigm for CRISPR-Cas systems. Biology & Philosophy, 34(1), 13. https://doi.org/10.1007/s10539-018-9661-z Waddington, C. H. (2012). The epigenotype. International Journal of Epidemiology, 41(1), 10–13. https://doi.org/10.1093/ije/dyr184 Wagner, G. P., & Altenberg, L. (1996). Perspective: Complex adaptations and the evolution of evolvability. Evolution, 50(3), 967–976. https://doi.org/10.1111/j.1558-5646.1996.tb02339.x Walsh, J. B. (1996). The emperor’s new genes. Evolution, 50(5), 2115–2118. West-Eberhard, M. J. (2003). Developmental plasticity and evolution. Oxford University Press. Wickner, R. B., Edskes, H. K., Ross, E. D., Pierce, M. M., Baxa, U., Brachmann, A., & Shewmaker, F. (2004). Prion genetics: New rules for a new kind of gene. Annual Review of Genetics, 38, 681–707. https://doi.org/10.1146/annurev.genet.38.072902.092200 Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. World psychiatry, 17(3), 243–257. Zacharioudakis, I., Gligoris, T., & Tzamarias, D. (2007). A yeast catabolic enzyme controls transcriptional memory. Current Biology: CB, 17(23), 2041–2046. https://doi.org/10.1016/j.cub. 2007.10.044

Chapter 8

Conclusion

Abstract Although our health-related concepts such as disease are strongly value bearing and action guiding, we seem to direct these actions towards one singular direction in a very crude sense in general. This singular direction in the contemporary West is the direction of health care. Although what we hold dear as health, and what we try to avoid as disease make a lot of meaning in our lives, the care we need rarely comes and even rarely comes in the form we want from healthcare. One particular problem that I have addressed throughout the work was the generality of disease concept and the diagnostics of the disease model that we have, which focuses on finding and curing particular diseases. There have been enormous developments that has been challenging the limited system of the organism that sees the boundaries as continuous rather than dichotomous. I have advocated for an evolutionary understanding which conceptualizes disease in a way that enables them to see it with reference to organism’s relationship to environment.

Ideology is strong exactly because it is no longer experienced as ideology… we feel free because we lack the very language to articulate our unfreedom. Slavoj Zizek, In Defense of Lost Causes

8.1 Introduction In most Abrahamic religions, Job is seen to be encountering a disease. When he asks Yahweh about his disease, trying to make sense of his own diseased condition, he is refused an answer, not only a cure, but making sense of the disease itself. Making sense of the disease, and how the value laden concept of disease can be researched and how evolutionary understandings frame it in a different way was the central question of this work. In this part, I will conclude with the potentials of building up ethical frameworks around contextualized disease understandings around EM. Although our health-related concepts such as disease are strongly value bearing and action guiding, we seem to direct these actions in one singular direction in a very crude sense in general. This singular direction in the contemporary West is the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 O. Altinok, Conceptual and Ethical Challenges of Evolutionary Medicine, Ethics of Science and Technology Assessment 53, https://doi.org/10.1007/978-3-031-45766-1_8

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direction of health care. And although what we hold dear as health, and what we try to avoid as disease make a lot of meaning in our lives, the care we need rarely comes and even rarely comes in the form we want from healthcare. One problem that I have addressed throughout the work was the generality of disease concept and the diagnostics of the disease model that we have, which focuses on finding and curing particular diseases. There have been enormous developments that has been challenging the particular limited system of the organism that sees the boundaries as continuous rather than dichotomous. I have advocated for an evolutionary understanding which conceptualizes disease in a way that enables them to see it with reference to organism’s relationship to environment. Does it increase fitness or decrease it, does it have to do with survival? These are the questions the evolutionary biologist asks, as Nesse (2001a) puts it; Thus, there is no ideal type to use as a benchmark for comparison to determine what is normal and what is not. It does not make sense to ask if sickle cell allele is normal or not; it is just an allele that give an advantage in certain circumstances, namely, when paired with a normal hemoglobin allele in an environment where malaria is prevalent. Sickle cell disease is a disease even if the sickle cell allele is selected for. (p. 44)

However, this is only the perspective of the evolutionary biologist. When the concept returns to decision making bodies, the patients, the clinic or research the question should rather be how can we increase the relationship of the individual to the environment. Therefore, it makes sense to follow the analysis made in the second chapter that concludes that value is context dependent on the multiplicity of scientific disciplines. The problem with naturalist accounts, also those with an evolutionary perspective is that they miss the division of labour in the making of a particular disease. First the clinical medicine collects certain kinds of “abnormalities” be they statistical deviation or any other way, and makes it a disease. Then it becomes possible for evolutionary understandings to “naturalize”1 the disease since it can be not harmful or even beneficial in certain contexts, or in the evolutionary past. The problem with this approach is, they do not think how the concept of disease is used, they talk only about particular disease, although evolutionary understandings might one day explain every particular disease, as long as we stay skeptical towards absolute disease realism, there will be new diseases coming up and certain explanations will lose their explanatory power in the face of rivaling explanations. The problem with naturalization via evolutionary modeling is placed at the missing part of seeing the division of labor and contextualization of the concept. Although they conceptualize the phenomenon of a particular disease with respect to environments, the concept of disease and the making of it remains outside of their understanding.

1

I am making a distinction here between naturalization of a certain disease and having the concept of disease as a natural concept. Thanks a lot to Prof. Dr. Ulrich Krohs for pointing out that for EM the concept is already naturalized.

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8.2 The Potential Futures of the Concept of Disease Through the book, I have tried to “catch up” with the ongoing research on disease and evolutionary medicine. In the meantime, I have been arguing about how different contexts give different meanings to concepts. Based on that observation, the concept of disease, as a reply to the current research due to different lines of research and research institutions might also divide. Similar to different kinds of diseases such as microbial infections, and hereditary diseases, there might be evolutionary diseases as a kind of disease category. However, this approach of intentionally further dividing the disease categories might not be very promising because the evolutionary explanations of disease cuts through many traditional distinctions as well as evolutionary understanding becoming more and more related to the discipline, eventually becoming redundant. Of course, it is easy to say that disease is a Wittgensteinian family resemblance concept, and say that diseases are so diverse that the concept of disease should not be defined and cannot be used in a general set up. The problem with this view is two folds: (1) Engineering of the concepts should be done justly. If we leave the concepts of to be evaluated by certain kinds of experts who are supposed to design the particular disease concept as it is suiting to their own research dynamics and structures, we close the possibility of large publics to use the evaluative element of the concept, and thus disfranchise the public from evaluating the concept. The concept of disease should be constructed so that it can help people in need. This can only be done with the critical evaluation of the disease concept that encompasses different understandings of disease and does not do underdiagnoses. Consider the following situations; (a)

A person does not have an easy life, cannot wake up at a certain time easily and loses his job. He goes to seek medical help. The clinician tells him that he is suffering from thiamine deficiency a condition that emerges due to thiamine (Vitamin B1) deficiency as the name indicates, possibly leading to chronic condition called beriberi, decreasing physical activity. The patient then takes the required medication, shifts his diet and hopefully recovers. (b) A person with similar conditions to the example in a seeks medical help, however although most the conditions look the same, the problem is psychiatric, not non-psychiatric problems, having insomnia that reduces the productivity of the patient. The patient then seeks required kinds of physical therapy, changes his life style and eventually “recovers”. (c) A person with similar conditions with the examples seeks medical help, however non- psychological approaches cannot diagnose the person, moreover, the psychological and psychiatrically approaches cannot find a diagnosis as well. Psychologists seek to help the person by the approaches that are available to them, using different approaches of therapy, however the condition of the person does not change. The person is discharged.

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If we happen to see the concept of disease not with clear cut boundaries in disease generalism’s sense, but without the strict dichotomy of cultural and environmental as new developments in evolutionary understandings usually show, we are to see the concept of disease with the unknown and undiagnosed diseases differently. I have argued for disease particularism epistemically based on EM. Now I will turn to various aspects of laying out the ground work for ethical discussions around these epistemic results.

8.3 Different Kinds of Injustices Ian Hacking in his Autistic Autobiographies (2009) discusses the importance of the narrative making of the patients with autism. He sees the autistic autobiographies shaping the language around autism, forging our general understanding of autism from the perspectives of the patients. I believe that this can be a good starting point in the discussion of many diseases, however, the structure of diagnosis and the general structure of medical institutions of today see many sick people as not diseased, and even if they contextualize sick people as diseased, they hardly try to understand the sick person’s condition to an epistemic diseased situation, using a generalized understanding of disease. If we hold that the epigenetic makeup of the organism can be various and can be inherited to make up certain kinds of responses that are not mechanically explained yet, and also the importance of evolutionary processes leading to disease vulnerabilities that create the diseased conditions through the match-mismatch hypothesis, we are led to conclude that most of the diseased conditions we explain and can explain for now and perhaps for good, need a radical shift from the generalized disease realism that is the mainstream understanding now. I think such frameworks, The clinical understanding of disease therefore limits our disease understanding, causing epistemic injustices. In this example, epistemic injustice comes in two distinct shapes. Once because the patient is not diagnosed, second because the very framework that sees patient only as a small element in the decision-making, leading to hermeneutical injustice. Instead of trying to fit the patient into a large framework, if we happen to fit the disease understanding to the patient by providing the disease understanding with the required knowledge from the patient, the epistemic injustices can be overcome. From this perspective it is possible to say that, many people with reduced wellbeing are underdiagnosed or misdiagnosed from a generalist understanding.2 The concept of disease, seen not as a deviation from a norm but a reason to care, therefore should be seen as a vector concept. How it should guide our action should not be dependent on whether or not a patient fits our model for a particular disease, but the question should be how we can change our concepts 2

For a detailed discussions on epistemic injustice perspectives through which I am operating in; Miranda Fricker (2007) Epistemic Injustice, Power & Ethics of Knowing . Of course, it is possible to say that since evolutionary biology is generally dealing with the concept of fitness which, within an adaptationist framework, is limitless to the level of perfection, making all situations that do not fall under the concept of disease.

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of disease (in the sense of particular disease) so that it can be helpful to a greater number of patients. The care based concept of disease should then be individualized to fit each person’s own biology, experiencing of life, expectations and life fulfilment. I think this is the only way to design the concept of disease for the purpose of caring. In a sense, when we use evolutionary understandings, that is to say, by bypassing medical concepts of disease, we can be able to look at the individual’s reaction to the various kinds of environments that she finds herself in. This way, the conceptual necessity of looking for the just way of treatment can be, in a pluralistic way, up to the patient. Of course, I do not claim that every disease should be individualized to the level of the patient alone. The idea of this work is that it comes in degrees, some disease allowing systems of human constitution are very closed and standardized systems, such as certain generalist microbial diseases, since they have been coevolving with us (and with other organisms and environmental conditions) for a long enough time, the working mechanisms of them and human physiology on that level has developed into a foreseeable level of similarity. However, what I believe that is certain is, our stereotype of disease comes with many assumptions, including the generality of disease, and due to that, there has been different kinds of injustices. One question here can be whether the “non-scientific” claims of the patients could be used to refer something that is seen very scientific, objective and medical. I think I have laid out the general understandings of localized understandings of disease to show that what patients in this state suffer also fall in the domain of medical research. Usage of uncertainty in this regard should favour the patient and not the medical system due to the power asymmetries within the system. Because of that I do not think that any illness shall be considered sickness, the “fear” of malpractice of this kind of framework does not look likely. The best option seems to be to equip the patients, classifying their own selves, with equipping them with the possible conceptual tools. That is to say, if the patient is taken to be in the place of deciding the normativity of the disease, which can be given to the patient via providing the patient with a larger perspective about the diseased situations, they can be in place to decide whether they would like to change the conditions that they are in or the environment they are in, be it through political change, organization or simply by a change of environment in the sense of choosing another path of life. I do believe that as discussed in Chapter V, this is also a very important aspect of relieving the patient through evolutionary understandings of disease, where they are entitled to see disease as an emergent entity that is within their lives, instead of seeing it as normatively negatively. In this regard, increasing the autonomy of the patient shall not only be at the level of enabling the patient the treatment and explaining the consequences, but should be also within the framework of enabling the patient to conceptualize disease in different, context dependent ways with attributing disease responsibility to different interacting aspects.

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8.4 The Death of the Non-Clinic Although medical care has been in varying degrees social before modernity, the concept of medical care has been limited to clinic in most of the modern understanding. The main idea is that, medical profession and modern medical instuitions are seen to be responsible for very rigid concepts and their understanding is limited to given definitions of diseases and those kinds of interventions. The main issue is to look at the material conditions of pre-modern understanding of disease, and how social and psychological in the material sense has been omitted from the general healthcare understandings. I believe that evolutionary understandings, due to their relationship with the environment and their understandings of the complex structuring of the organism-environment relationship, provide us with a framework in which our concept of disease is changing, an understanding within the conceptualization of evolutionary biology will be a great help. In a sense, the whole point of evolution is a way to understand how the nature shaped the organism historically and how and to what extent these mechanisms are important. The more we know about them, the more we see organisms as relatively open systems, especially when we see organisms are intergenerational entities and if not organisms, evolutionary structures as argues within the book. I argued at the end of chapter four, the dichotomy of health and diseased is not useful if we are to have a care based One Health approach towards disease. In that case, healthcare should be occupied with assessing the health condition of the patient with respect to the patient and the wellbeing of the patient. That is to say, the care aspect of healthcare should be also in the form of a continuous network rather than healthy/ diseased, intervention/non-intervention dichotomies. Different kinds of support, be them in the dietary, life style, interventive medical, social, psychological and other possible middle grounds should be assed within the healthcare system. And from that point we should go back to medical care instead of going into the direction of medicine alone, this point can be summarized in; bringing care back to healthcare, or more provocatively as; more care, less medicine.

8.5 One Possible Objection—Where Does Disease End From the evolutionary perspectives that I have depicted so far, it can be said that almost every condition that somehow means that the organism is coping to adapt and thrive in a condition or situation it occupies falls under the concept of disease. I do understand seen this way, and the possible problem of difficulties of categorizing the diseased condition from the healthy condition through an overdetermination of disease concept. Spitzer and Endicott (1978, p. 16) discuss the need to define disease in their own framework as follows;

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We believe that the definition offered here helps clarify the goals of medical classification. It helps delineate the areas of responsibility of the medical system from those of other societal systems which also have as their purpose improving or otherwise changing human functioning, such as the educational or criminal justice systems.

As it can be seen from their framework, they see the medical system as a part of a larger category of “social systems” which are aimed at “improving or otherwise changing human functioning”. Although it is important to not expect the “call for action” from the medical field for things that do not belong to the medical domain, however, delineation of these domains is not very easy all the time on certain issues (expand) and on some other issues, there is no need to delineate, since I believe that EM offers a framework for the medical to operate that is different from that of the past. However, in a rather Rawlsian way, in the sense that he tried to create a theory of justice in a society that operated in liberal democracy, given that we are living in a society where we try to create solidarity networks for the people in need, it makes sense to see that in medical epistemology as well, the knowledge should be used to create benefits for the most vulnerable and the condition of vulnerability should be started to be analysed from the individual not from a general theory which decides the conditions that are seen of deserving medical help. Of course, it can be said that some of these conditions are not medical, and cannot be solved in medical terms, however, medicine being one of the (if not the) institution and institutionalized knowledge that regulates the care of individuals in most societies and the reasons for suffering mostly seen to be coming from situations that are categorized under medicine, broadening the concept of medicine can be much more helpful than, say using a more social approach in the non-medical understanding due to the current value structure around medical conditions and of disease. Ideally (also following evolutionary biology), the gap and barriers that protect this gap between what is medical and what is social should be non existent, so that the care networks for the individuals can be created for the individuals’ particular need and vulnerability.

8.6 Conclusion Zizek, in his In Defence of Lost Causes says; “Ideology is strong exactly because it is no longer experienced as ideology… we feel free because we lack the very language to articulate our unfreedom.” I think we can apply this to the lack of framing within medical understanding of disease, which can be considered within heuristic injustice framework. We think we are healthy because we lack the very concepts to define the diseased situation. Individualized medicine understanding can be constructed upon the epistemic understanding of individualized disease, and the frameworks that are related to that understanding. This way it would be possible to overcome epistemic injustices around the patient. It can be argued that, a good understanding of sickness,

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and the patient’s needs being heard should be sufficient instead of a disease particularist understanding against disease generalism. Although medical doctors necessarily structure diseases as they manifest themselves differently at each patient, my agenda is to turn the general epistemic structure around for disease particularism, and construct a framework in which the “symptoms” or manifestations of disease on the individual should be seen as the main element of not only diagnosis but also of conceptualization of disease. This is the practical epistemic consequence that we end up having an individualized understanding of disease. I hope that I have provided another understanding to conceptualized disease from evolutionary perspectives that does not try to evade the concept of disease or explain it away but creates a research programme that will allow to have an understanding of personalized disease that can be helpful to many people. The general processual concept of disease due to the understanding of disease vulnerability also allows us to see individualized loss of function and coping problemed situations disease themselves, this way creating a better understanding that blurs the traditional line between prevention and curing, which I find to be the approach that can lead to justice when dealing with disease at the individual level. One question to be asked is, disease concept, a concept which has been with us for all written history at least, why should be individualized just now? I think it has to do with the modern understanding of disease and healthcare. In other words, it has to do with what medicine and the medical care has become together with the social changes. This work aims to create an understanding of disease which can provide perspectives as a reply to the limited understanding of medicine and medical care at the stage of advanced capitalism and the social changes brought about by it. The ethical, action guiding, aspect of disease is now ripe to provide a positive care based, individualized understanding of disease, and the object of care and object of intervention in this sense, when the empirical developments, particularly in evolutionary biology are followed, shall be much more diverse, and without any reference to ideal models of disease, but they shall be starting from the individual patient. On this note, prioritizing the scientific epistemic goal of the concept of disease over its social use is problematic. Since when the concept in the semantic sense is carried to refer to instances that were useful in the social domain through the extensions of the concept which are found to be useful to the social sphere are fallen out of the concept leads to understandings leaves these cases not to be acted upon in a similar way. The problem is, the causal theory of reference is still valued very highly in the general understanding in the everyday life concepts. The expectation is that the scientists to find the true set of references to unite them under one reference for a given concept. This is not only a wrong expectation from a pragmatist view, it also creates injustices. In the end, this also has to do with the role of medicine and medical care. Following the old Aristotelian tradition, if we happen to observe nature, instead of trying to dictate the concepts we have about nature onto them, we can reach a much more productive result. Unfortunately, at the moment the division of labor when it comes to create concepts of disease, apply them, and change them are quite distributed, and the ones who are makers of the concepts are less related to observation of the individual

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