A Philosophy of Nursing Forum
Friday, October 02, 2009

This last week's discussion about science and epistemology has impressed me. I gather that the class is quite diverse in terms of how much philosophy the participants have taken, but folks appear to be picking up on many important concepts and ideas right out of the starting gate. Good job!

Let me suggest something further to think about. Caveat: what I am about to say is opinionated and contentious, and would not necessarily meet with widespread agreement by “paid up” philosophers of science. Still it might get the discussion rolling in useful directions.

ONE way to think about the big issues in philosophy of science is to organize the discussion around “realism” versus “anti-realism”, and see how that relates to the empiricism versus rationalism versus pragmatism debate. When we organize our thinking in that way, at least initially, we find an argument going on about the status of “theoretical” entities and forces which we cannot see. Take electrons as a simple example. We don't “see” electrons (or do we?). We take eggs to be “real” because we see them, hold them, eat them, etc. But we don't see, hold, taste or eat electrons in the same way. So why take them to be real?

And, why stop with electrons? What about “causes”? Logical positivists read Hume, famously, as being dubious about any claim of the sort “putting poison in his wife's tea caused her death”. Ayer and the positivists thought Hume would allow that we observed the act of putting poison in the tea, and that we observed the death of the little missus thereafter. He would allow that this same sequence of events has been observed many times in the past. He would allow that, so far, this sequence has been “exceptionless”, that is, that every time we have seen poison put in tea, death has followed on the part of the person drinking the tea. He would allow that we expect that death will follow putting poison in the tea if we do that tomorrow. Moreover, he would allow that expecting death to follow poisoning is perfectly natural on our part. It is a “habit of thought”. But that is ALL he (Hume) would allow, because what we see is the events; we don't SEE the cause. Note, please, that not everyone reads Hume this way. Strawson, Craig and Blackburn offer alternate readings. But, for this discussion, let's stick with the “Hume a la Ayer” version, because it is illustrative.

Illustrative, because we can use it to see what was bugging empiricists “back in the day”, and why empiricism classically can lead to anti-realism in science. “Empiricism” writ large is just the idea that “sense experience is the ultimate source of all our concepts and knowledge”, as contrasted with “rationalism”, which holds that “there are significant ways in which our concepts and knowledge are gained independently of sense experience.” As regards “causes”, or “electrons,” the classical empiricist position might be that, since we never actually see them, there is no reason to treat them as “real”.

Kant thought that, at least as to concepts like “cause”, he had put an end to the debate, arguing that “cause” was a “category of understanding”, a sort of operation that the human mind performed upon experience, thereby constructing the “phenomenal world”. We know, then, that putting poison in the tea causes death, but this is knowledge of the phenomenal world, not knowledge of the “noumenal” world, that is, the world not comprehended through the categories of human understanding. De Pierris and Friedman put it this way: “Kant agrees with Hume that neither the relation of cause and effect nor the idea of necessary connection is given in our sensory perceptions; both, in an important sense, are contributed by our mind. For Kant, however, the concepts of both causality and necessity arise from precisely the operations of our understanding—and, indeed, they arise entirely a priori as pure concepts or categories of the understanding.”

Not everyone agrees that Kant succeeded here, or even what all of that meant, exactly. But, even if he did succeed when it comes to “cause”, where does that leave “electrons”, or germs, or...? THEY aren't “categories” or “operations of the mind,” but rather, according to realists, putative “objects”, or things that (allegedly) exist whether there is any “experience” going on or not. So how does Kant have anything to do with this? How does this HELP? Let's take a brief detour through a bit of medical history and and then return to the question. Much of what follows is inspired by Dr. Marc Lange's article “Salience, Supervenience, and Layer Cakes in Sellars's Scientific Realism, McDowell's Moral Realism, and the Philosophy of Mind”, in Volume 101, Numbers 2-3, of Philosophical Studies. However, he might not agree with some, or much, of this, so don't blame him.

Consider Dr. Semmelweis, the Viennese obstetrician who was horrified to discover that, in the Doctors ward of the hospital, women were dying like flies of Puerperal fever, whereas, over in the nurse midwife ward, women got Puerperal fever less than half as often. And, he wasn't the only one to notice. Here in the good old USA, poet and physician Dr. Oliver Wendell Holmes, Sr. (Justice Holmes' father – a distinguished family) had noticed too. He wrote, years before Semmelwies, that
“. . . in my own family, I had rather that those I esteemed the most should be delivered unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease."

Folks back then understood that diseases could be spread from person to person. They also presumed that bacteria existed, since Antony Van Leeuwenhoek's 1674 observations of “animalcules” through a microscope had been repeated many times for over 150 years. Some even guessed that “disease” could inhere, somehow, on physical objects like blankets, thus giving General Jeffrey Amherst the bright idea of giving native Americans blankets that had been used by small pox victims. Charming. No one, though, thought that “animalcules” could kill you, since they were so tiny. Thus, there was no “germ” theory of disease.

Semmelweis had before him a classic researchers' problem – discover why two groups, “Doctors' patients” versus “Nurses' patients” had different rates of death due to Puerperal fever. So he made Baconian “observations.” Observations of the organs of someone who had died of "cadaverous fever”; observations of the organs of women who had died of Puerperal fever; observations of Nun midwifes and what they did; observations of Doctors and what they did; observations about ward location, temperature, population and crowding; ton-o-observations, in other words, and he wrote these down methodically. Let's call what he wrote down “observation level” statements.

Not everything he observed, though, had anything to do with Puerperal fever. Semmelweis needed to figure out which observations were clues. He needed for some observations to “stand out”. Salience, per cognitive scientist Dr. Laurent Itti is that “which makes some items in the world stand out from their neighbors.”

In the event, the “right” observations were made “salient” for Semmelweis; that is, the right ones “stood out” for him, for the most part, and he ignored those observation level statements of his that didn't matter. What stood out for him were things like “the nuns wash their hands before and after touching the sick,” “the nuns don't go from cutting up corpses to examining women in labor,” “the nuns have clean clothes on that haven't been in contact with rotting corpses,” “the internal organs of people who have died of cadaverous fever look like the organs of women who die of Puerperal fever,” etc. Equally important was what didn't stand out – things like the color of the nuns' habit, the color of the doctors' trousers, the prayers the nuns said, the temperature in the ward.

What made some observation statements salient and others not? How about the THEORETICAL statements (thoughts, conceptual schemes?) in Semmelweis's noggin? His THEORIES, in other words. Note that they weren't the best of all possible theories. In fact, they were pretty much WRONG, consisting as they did of mostly of the stuff he had been taught – the “wisdom” of his day. The theoretical entities in his noggin were things like “miasmas”, and “vapors”, neither of which, in fact, exist. Still, they were good enough, close enough to how things are, to make the RIGHT observations salient for him, after postulating the existence of a new “theoretical entity”, the “cadaverous particle,” which, while not exactly a bacteria, is a step closer than a “miasma”. Based on his theories, he was able to utilize his observations to formulate some “laws of obstetrical ward hygiene”, which are, roughly, the same ones we subscribe to these days.

These laws of obstetrical ward hygiene can be expressed entirely in the terms used in Semmelweis's “observation level” statements. The only “terms” we need are soap, water, hands, wash, etc. So, once we have them, and we confirm the laws inductively – new moms don't get Puerperal fever when we adhere to them – what else is needed? Wouldn't the right thing for nurses to have done back then be to reason as follows: “we nurses will follow the 'laws of obstetrical ward hygiene' as long as they are inductively confirmed, but we will remain agnostics about vapors, miasmas, and cadaverous particles”?

At first glance that SEEMS right – agnosticism would keep researchers from refusing to look at better theories when they came along, like a theory that substitutes pathogenic “animalcules,” or bacteria, for “cadaverous particles”, say. Viewing science historically, with the benefit of hindsight, agnosticism might look sound. There are even respected philosophers of science who counsel something like this attitude today. Constructive empiricists, for example, allow that one can USE theorizing in order to formulate hypotheses and “observation statement” type laws, but are still of the opinion that it is okay to be skeptical, or at least agnostic, about entities and forces which cannot be directly observed by the senses. Perhaps, they say, today's “electron” is tomorrow's “miasma”, and anyone who is not at least open to that possibility is a pig-headed, lab-coated intellectual fascist.

Plausible as this seems, there are problems with it. For one thing, it assumes that there is some principled distinction between that which is “seen” with the naked eye, and that which is “seen” with a microscope, or by means of some other method which augments our senses. Harvard philosopher John Hall finds this highly suspect. It would mean, for example, that some tiny creature that can “see” a bacteria should “believe” in them, whereas we should be agnostic about them because we need microscopes to spot the little rascals. Or what about the moons orbiting the outer planets? Does this mean that we can be agnostic about them as long as we only “see” them through telescopes, but we can “believe” in them after astronauts “see” them through the spaceship's window?

A second problem is this: absent an assumption concerning the truth of our theories, how do we arrive at explanations? We want good laws of obstetrical hygiene, of course, but we also want an explanation for why they “work”. The philosopher Willfrid Sellars used the example of Boyle's law. Why does the equation P=VT work? BECAUSE (theory) heat = molecular motion, and (theory) gases are itty bitty moving particles. If confined, then, as they heat up they move faster, so they bump in to each other more often, so they exert more force on the confining vessel, so pressure rises. COOL!

A true theory, aided by an ASSUMPTION that the fundamental laws of the universe will be the same tomorrow as they are today, permits us to stop relying on inductions from observational statements, and start actually “deducing” things, as J. S. Mill noticed a while back. When our deductions don't work in terms of the observations we make, we go back and revise the theory, expecting (reasonably enough) that it will EXPLAIN not only the observations we do make, but why the old theory SEEMED to work as well as it did.

The miasma theory of disease is a good example to use here. According to that theory, disease was spread by noxious, vaporous things called “miasmas”, which contained tiny bits of rotting stuff called “miasmatas”, and this was the standard theory of disease in the mid 1800's. Nightingale accepted it, for example, at least at the beginning of her career. Accepting it as true lead to changes in public behavior. People started washing stuff that smelled bad (including themselves, thank God), covering sewers, inventing toilets and digging outhouses, and draining swamps so that the bad stinky air wouldn't blow in to town (eliminating the mal aria, in Latin. Isn't that an interesting tidbit?)

The miasma theory wasn't all that great, but it seemed to work. Malaria, for example, virtually ceased to exist in many parts of the industrial world. Public health visibly, measurably, improved. Observations seemed to confirm the theory. It began to be modified/abandoned only when anomalous phenomena were observed, and/or its explanatory power proved inadequate. And, our newer theories of disease explain the successes the miasmatic theory did enjoy. Drained swaps don't harbor mosquitoes, and so malaria disappears. Washed bodies are far less at risk for septicemia than unwashed ones are, due to a lower bacteria count. Cholera is less frequent when people stop throwing poop in to gutters, where it washes in to streams and shallow wells, because fewer vibro cholerae are getting in to the drinking water. In fact, one can go so far as to say that we wouldn't ACCEPT the germ theory of disease if it COULD NOT explain the successes of the miasmatic theory.

So where does this leave us? I think it ought to leave us back with Kant, at least in spirit, if not in detail. Nick Fearn and others have suggested that we think of Kant's BIG idea about categories of understanding as analogous to eyeglasses that we cannot take off, operations that the mind automatically and unceasingly performs on the information it receives, and indispensable to us, since without them we could not THINK at all. Similarly, we might think of theories and the entities and forces they postulate as indispensable eyeglasses which render certain observations salient. Without them, and the presumption that they characterize reality accurately, we cannot proceed.

The late and very much missed philosopher Jay Rosenberg put it much better than I ever could:

“...stories that postulate “theoretical entities” are not merely manageable second-class surrogates for more complicated and unwieldy stories about entities that we have good, i.e., observational, reasons to believe actually exist. Theoretical entities, rather, are those entities we warrantedly believe to exist for good and sufficient theoretical reasons. On this understanding, scientific theories explanatorily “save the appearances” precisely by characterizing the reality of which the appearances are appearances.”

So, don't forget to wash you hands, empiricists. They REALLY have animalcules on them.
Another way of carving up the debate would be to consider it in terms of a
dispute between moralism and ethics. Understanding moralism as that which wants
to preserve a guarantee for one's knowledge (I'm right) and ethics which
concerns one's constitution in the act. The latter is probably closer to
nursing's traditional handling of the problem. Nursing seems far more concerned
with the act than the knowledge, it is even reflected in the fact that we refer
to our field through a word that has adverbial and verbal qualities "nursing" (a
bit like "running" :-)) - different from doctors who refer to their domain as
medicine (not doctoring).

We can see it in the work of the early modern nurses. Nightingale and her
theology (or theodike) of the active life and her regular denunciation of 'mere
memory work', conscience, and reports as impediments to proper action. Through
to Lavinia Dock's marvellous "Ethics or code of ethics" in which she puts it
bluntly - codes of ethics are for those who don't have them. As Lacan points out
in his "Ethics of psychoanalysis" we tend to use the terms moral and ethics
interchangeable but we can make a choice between them. Hegel in his
"Phenomenology of mind(or spirit)" draws a distinction between Ethics and
Morality. Hegel seems to draw a distinction between ethics as a decisive act not
subject to pre-judgment – not indecision but being-in-the-decision - and
morality as an act subject to prior reflection and social expectations.

Often the debate about theory has a moralistic tone. More about the correct way
one needs to formulate a problem. Your example of theory as being what allows
the making of further useful deductions can be recast a little. Is it really
about having the correct knowledge or is it more about the fact that one takes
up a knowledge that gives one latitude for action. Taking Miasma theory as an
example. A number of historians of epidemiology are inclined to point out that
the public health measures that emerged form miasma theory had a far greater
impact on the decline of mortality rates in western culture than anything
contributed by germ theory. Miasma theory tends towards recommendations that
operate at large environmental and social levels than germ theory, the modern
variant of which can embrace these larger domains but all to frequently
degenerates in to the treatment of individual cases. Nightingales exasperation
with germ theorists can be couched in these terms. In a letter to Galton over
the agenda for a meeting on the handling of an epidemic she writes

"God forbid that the Buck's sanitary conference should come to the conclusion
that typhoid fever, diphtheria, etc. of which they have had a good deal, are the
direct consequences of bacillus F, bacillus D, instead of bad drainage,
cesspools instead of dry earth closets, fouled water supply, etc."

To put it another way does nursing want 'plausible' theories those which couch
ones actions in terms of current prejudices (one way of reading Hegel's term
'moral') or looser ones which allow a space for the act. Much modern philosophy
finds the notion of an act without prior reflection abhorrent, how can one act
without a reason, but this presumes that conscious knowledge precedes the act
rather than the act being the seed of the knowledge. In nursing we see this in
Nightingale "Nursing=Training" and the the work of Benner when she tries to come
to grips with the experienced nurses "intuition". I wonder whether nursing
should cast its intellectual net a little further than Kant and the usual
suspects for its inspiration (or perhaps more fairly the dominant reading of
these suspects).

To recapitulate, following Hegel's distinction between morality and ethics, is
nursing utopic (moral) or atopic (ethical). At an intellectual level we may have
negotiate epistemology and ontology - because these are the forms in which our
activities are censored and have to be socially justified - but perhaps we
should not put too much stead in them.
Hi Bob and Gary, Kay Lundy here. Our students are blogging under the original post, will pick up here. More later, welcome back home Bob.
I am not familiar with Dock's comment that a code of ethics is for 'those who do not have them.' Bob, after your first board of nursing hearing, would like to hear your take on this. We discussed the various definitions of nursing in the last physical class, categorizing of course since that is what we do best. I will not even pretend that I know nursing theory but it does seem that are concepts of nursing fall into either 'acting' or 'being' (doing vs knowing?). Nurs-ing is a positive, cuddly feely word and doctoring conjures up deviant, unethical acts. There is also the acted 'upon' that interests me, when one nurses something, it is usually a person, puppy or I suppose a drink, most often it is a helpless, needed 'something'. Doctoring is most often associated with an object, as in 'doctoring the books or election results.'
I am reminded of a t shirt seen this week "Just because you don't believe in God, Richard Dawkins, doesn't mean HE doesn't believe in you." Dawkins was coincidentally on Bill Maher last evening, commenting on the latest finding of "Ardi" --the fossil of yet another Eve which debunks the long held theory connecting homo sapiens to chimps (this Eve is APPROXIMATELY 4.4 million yrs old, maybe her Adam got the poisoned tea!).
Dawkins --with tongue in cheek--supported his usual atheist position by pointing out that any God who needed to 'rest' on Sunday, was not much of a deity.

I am feeling pretty young this am, off to hear some blues and forget that I am really over a half century old. And I will wash my hands and make a priori judgements about how clean the cooks are as they smoke the ribs.

Good Morning! Yes, we do speak of things that are microscopic and deny those things which cannot be seen. For example, one of the strongest powers known to man, Love, cannot be seen or touched. However, one has only to look around to see the forces of love (or all too often, the lack of it.) Bertrand Russell made it possible for philosophers to speak of things that do not exist. His theory of definite descriptions held that any statement that is a conjunction of propositions is false if any one of the conjuncts is false. Furthermore, he followed Hume’s belief that there is no necessary connection between two occurring events but only a habit which expects that the occurrence of A (giving the wife the tea) will lead to B (her demise.) Ultimately, Russell asked if there is any reason to belief in the uniformity of nature. His principle of induction follows:
When a thing of a certain sort A has been found to be associated with a thing of a certain other sort B, and has never been found dissociated from a thing of the sort B, the greater the number of cases in which A and B have been associated, the greater is the probability that they will be associated in a fresh case in which one of them is known to be present. Thus, we form probabilities, but cannot rule out that that they will always be reliable.
The difference between morality and ethics is the most interesting question. Philosophy helps decide which questions to ask and also forces us to look at our own limitations. The morality of what we do with science is the major question. Morals define an individual’s personal character, but ethics speak more to the way in which an individual complies with codes of behavior expected by the group. Gary’s post, To put it another way does nursing want 'plausible' theories those which couch ones actions in terms of current prejudices (one way of reading Hegel's term 'moral') or looser ones which allow a space for the act is very interesting. When reading this, I first answer that nurses want theories which will support what they believe to be ethically sound. Ethics of course are decided by the society in which we live. Thus, like Kuhn believed, scientists often look for answers which support what they are already doing. If nursing instead wishes to address the moral question of bioethical issues which confront us, they will embrace the research of uncomfortable issues such as the nursing implications of assisted suicide, or the issues of domestic abuse. How can we support the fact that in the U.S. there are currently more shelters for stray animals than there are for battered women? The current debate about health care is also perplexing. If one takes into account that medical errors rank as the country’s eighth leading cause of death is it of the utmost importance that everyone have the opportunity to have insurance and as the saints say,” be in that number?” Or, are they perhaps better off without the hospital system? The essence of how we learn is critical, but the way in which we utilize the knowledge is most important. Dr. Lundy’s observation that nursing is oriented to what we do is most important. We are first appreciated because we are there. The hospital business exists because nurses are there. Physicians treat charts, nurses treat patients. Nurses know what to do from the simplest motor skill (holding a hand) to the more complex action of identifying when a patient “Is just not looking right.” and preempting emergency interventions. Should we not be focusing less on labels and more on leading the way? (The way of course, being the philosophical way where we question everything and never jump to conclusions.)
Louanne Friend
Theory and reality lock horns on a daily basis.
To quote from Dr. Newsom's blog posting, "Empiricism” writ large is just the idea that “sense experience is the ultimate source of all our concepts and knowledge”, as contrasted with “rationalism”, which holds that “there are significant ways in which our concepts and knowledge are gained independently of sense experience.”"
Take this as an of a combo of empiricism with rationalism:
I was watching TV yesterday and this commercial appeared ...a 'coroner' was standing over an open dead body on the autopsy table and he drops the taco he is eating into the body...he proceeds to pick up the taco and continue eating...the commercial continues to promote a product totally unrelated to food or the previous autopsy scene.
Talk about 'cadaverous particles' and realism--this was an example of shock 'realism' that would grab the attention (Senses) of the average TV viewer! It seems that basic 'germ theory' is accepted by the general public. People seem to realize the unseen is somewhat real because they have been 'educated' and believe it to be truth (rational).
Now if only the general public could grasp the concept of lice (animacules!) being able to jump, maybe the ongoing lice epidemic among school age children would abate.
I agree with what Dr. Newsom said about Nightingale and the miasmas theory, "accepting it as true leads to changes in public behavior".
I think a philosopher once said, "Trust your instincts for they will lead to the truth."
Have a nice day ;)
I am the worst person in the world to comment on any Hegelian distinction, as I am no Hegel scholar. But MAYBE the distinction is one that is similar to the distinction between theory and practice, and I suppose nursing has historically been more concerned with practice.

I'll say more about ethics versus morality below, but first let's turn to Nightingale's remarks about germ theory. I think that quote is interesting, since what she meant EXACTLY matters greatly. If she is simply denying that bacteria are direct causes of the diseases mentioned, that is, that their presence in a human body is a necessary and (c. paribus) sufficient condition for suffering from a particular illness, then she is simply WRONG (and not for the first time - she rejected evolutionary theory as well, for example). On the other hand, if her concern was that the FACT of the TRUTH of the germ theory might somehow blind public health officials to the importance of sanitary measures, I suppose the fear was understandable, but needless. After all, discovery of germ theory did not result in the REPEAL of public health measures - "foul water supplies" did not suddenly become "okay to have." Germ theories give us even better reasons for avoiding "foul waters" than miasma theories do.

Epidemiologists are correct, then, in saying that the miasma theory led to the adoption of important beneficial practices. However, the germ theory of disease explains the success of these practices every bit as well as the miasma theory does, and then some. It was germ theory that got doctors to start washing their hands. An analagous case is the science of ballistics. Newtonian principles are used to derive ballistics tables, and these tables are extremely precise. Thanks to them, we are able kill people in Afghanistan at truly impressive distances. This does not, however, render newtonian physics "true", and quantum physics "false." In fact, quantum physics PREDICTS the accuracy of newtonian ballistics tables, our success at blowing people's brains out, here on the surface of the earth and utilizing 70 gr. objects moving at non-relativistic speeds, with stunning precision. That is to say, it is a better theory than Newton's, and it possesses the virtues it does BECAUSE we live in a quantum universe, not a newtonian one.

Now, as to Dr. Saucy Lundy's writing prompt about ethics versus morality. I have always viewed morality in terms of a "code of conduct" - that is, a code regarding what is, and is not, "okay to do." Such codes can be informal, and consist of social norms (chaps pass the Port to the LEFT, if they've been properly brought up), or be formalized in some way, like written codes of conduct or Board of Nursing "rules". Ethics, for me, is that area of intellectual inquiry into what "morals" should BE. What SHOULD be "okay to do?" Example: suppose the narcotics box count has "missed" the Dilaudid tablet lying loose at the bottom of the box for a week. Is taking it "okay to do?" Board of Nursing rules, not to mention the United Sates Code and the General Statutes of North Carolina, say "NO, that is NOT okay to do". Still, the question remains, should that be the rule? Isn't this a G.E. Moore "open question?" How to answer that question is, to me, the subject matter of ethics.

Thus, when someone opines that "codes" are needed only by those who don't have "ethics", or that "rules are for fools", I object. Such views reflect a deep seated CONCEPTUAL confusion about the moral dimension of our lives.
I'm still not convinced that your account of germ theory is as clear cut as your presentation would indicate. I think at Nightingale's time the implication of germ theory was precisely to roll back public health measures and to introduce cheaper less socially disruptive solutions like vaccination. It was only as the result of a considerable political struggle that germ theory became more receptive to public health measures.

A good example of this is another one of Nightingale's 'misjudgments' her misgivings about vaccination programs. If one simply reads her objections from the point of view of whether she held views similar to the dominant prejudice of our day than her views are quite embarrassing. But a far more philosophically interesting exercise is to explore her objections and these are sharply reasoned and still valid. One of her objections was about the safety of the vaccine - in her day to inoculate against smallpox you found some one with cowpox and inoculated others from the pustules - the effect of taking some poor sick individual in a work house and using their pustules to inoculate others could have been a public health disaster given all the other diseases and conditions prevalent in the work house.

The other and much more interesting objection was epidemiological. Nightingale was a pioneer in the use of statistical epidemiology and she had noted that in regions that had instituted vaccination programs one often got a decline in the mortality for that particular disease but it's numbers were soon made up for by other diseases. That is one might suppress small pox but at the population level the over all death rates remained the same. In healthy populations who benefit from the public infrastructure introduced by miasma theorists :-) immunisation might be a viable strategy but in impoverished populations it would be futile - though not a popular topic I think you could argue this is still true - did the eradication of small pox improve the mortality rates of the world poor or did other diseases (e.g. HIV) make up the numbers? From Nightingale's perspective the obsession with particular disease entities misdirects ones efforts, and one is simply cooking the books if one points out the decline in specific diseases.

The focus on the treatment of specific diseases even undermines some of germ theories own successes such as antibiotics. Tuberculosis is a favourite of epidemiologists because it demonstrates this point elegantly. About 30% of the world's population carry the TB bug of these there is a 1 in 10 chance of clinically developing the disease. So whilst the TB bug might be necessary to develop TB it only accounts for 10% of the explanation of the prevalence of the disease. In well immunised poor populations the rate of TB rises with the neglect of public infrastructure, and some epidemiologists have argued that the rise of antibiotic resistant strains of TB correlate with the use of antibiotics to treat people in impoverished environments (no doubt the use of antibiotics here is seen as a relatively cheap non-socially disruptive solution).

In my own field (respiratory medicine) these points are amply demonstrated in Cystic Fibrosis. The bugs that undermine CF patients are not exotic but one's most of us carry and give us no trouble. During an exacerbation of CF we have to treat it with ABs (intensive physio is just as important) but we are being forced to use more dangerous ABs as we get a rise in resistance.
I over ran the word limit on my las post :-). SO just some additional remarks about morality and ethics.

I'm with you on Hegel, I'm not a Hegel specialist - when I stumbled across his distinction I clung to it because it manages to open the debate a little. After my last post I went back to the passages I was thinking of and it is even more useful to my position about the act proceeding the thought than I imagined. Hegel with his privileging of consciousness and thought would seem particularly unfavourable terrain for my position but writing about ethics and morality he argues that action divides spirit into substance and consciousness of the substance - and this leads to the ethical act. Morality emerges later after one has acted ethically. I think I was a little unfair to Hegel when I simply characterised Morality as the social order - it might be but only as a larger realisation of the ethical act. In other words from Hegel's position one cannot arrive at morality by studying and categorising it but through the effect that one's actions have on the formation of ones consciousness.

The Buddhist inspired critique of the western cogito from some of the philosophically literate Japanese thinkers is quite valuable here (Nishida, Ichikawa (as rendered by Nagatomo)).
A few final points to make here.

First, I am not sure how to link Nigtingale's concern with vaccination safety to germ theory, as vaccination began before germ theory became accepted. Vaccine safety is an issue no matter what the theoretical basis for the practice might be.

Second, I am not sure what we learn when we discover that people, when not dying of smallpox, die of something else instead. Maybe we just learn that there are lots of diseases that kill people, that everyone dies sooner or later, and sooner rather than later if they live in a dump. Seriously, though, if Nightingale's point was that vaccination is a tempest in a teapot as long as broad and effective public health measures remain un-executed, she was right, but this is no embarrassment to germ theory, as that is EXACTLY what a mature germ theory would predict.

TB is another interesting case. I am one of those people who tests positive, thanks to nursing, but without active disease, so I have studied TB with an intensity driven by paranoia. From what I understand A lot of mistakes have gone in to producing the current TB crisis, in the US and elsewhere, including the far slower than necessary maturation of germ theory due to the neglect of basic research. Another factor might be a misplaced reliance on apparent and immediate cost-effectiveness in health care decision making at national and international levels. This, too, is a topic better left for another day, and one that is under-discussed.

I think it is interesting to note how easy it is to drift into a sort of neo-pragmatism, a la Rorty, when we begin to discuss Truth in this context. Rorty, I think, would have read this discussion and felt that his point was being made for him. Instead of asking "which is true, the germ theory or the miasma theory", Rorty would have urged us to ask "which is GOOD for us to believe?" And, he would likely have said, Gary has shown that the answer to that last question is not so clear. Rather than fooling around with questions like the "truth" of theories, then, shouldn't we focus instead on "practices" that effectuate sparkling new health utopias?

I think the answer to Rorty is a resounding NO, and that might make for a really good next post. More to come.
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