The Fundamental Antagonism: Science and Commerce in Medical Epistemology

I consider the claims made by medical ethicists that funding by pharmaceutical companies threaten the integrity of medical research and the claims of philosophers of science that evidence-based medicine can provide a sound epistemic foundation on which to base medical treatment decisions. Drawing on both game theory and medical history, I argue that both medical ethicists and philosophers of science have missed crucial aspects of medical research. I show that both veritistic and commercial aims are enduring and entrenched aspects of medical research. Because these two drives are perpetually pulling medical research in different directions, I identify the resultant conflict as the fundamental antagonism The primary task of the dissertation is to provide a framework that incorporates both drivers of medical research. Specifically, I argue that medical research is best conceived of as an asymmetric arms race. Such a dynamic is typified by a series of moves and countermoves between competing parties who are adjusting to one another's behavior, in this case between those who seek to make medical practice more responsive to good evidence and those whose primary motivations are instead commercial in character. Such a model presents three challenges to standard evidential hierarchies which equate epistemic reliability with methodological rigor. The first is to show that reliability and rigor can (and do) come apart as a result of the countermeasures employed by manufactures. This fact suggests that in considering policy proposals to improve epistemic reliability, it is robustness (i.e. resistance to manipulation) that should be the crucial desideratum. The second consequence is a reorientation of medical epistemology. One of the primary strategies that manufacturers have employed is to manipulate the dissemination of information. A focus on an isolated knower obscures the impact that industry has in shaping what information is available. To address these problems medical knowledge must be understood from a social epistemological framework. Finally, and most importantly, the arms race account suggests that the goal of identifying the perfect experimental design or inference pattern is chimerical. There is no final resolution to the fundamental antagonism between commercial and scientific forces. There is only a next move