At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms

Abstract

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.

Evidence-based or person-centered? An ontological debate

“…This assumption can also be seen in EBM, where we often start from the perspective of homogeneity [24]. For instance, we could imagine a pair of identical twins who lived exactly the same life, so that all the biological, social and psychological factors would be the same for both.…”

“…On this ontology, one should not expect that there is a standard way to express a disease [24]. Since no two patients will have exactly the same genetics, life-style, values, history, etc., any assumption of homogeneity is an abstraction from reality.…”

“…In addition, the need for multifactorial causation seems acknowledged. Still, holism remains a problem, since genuine complexity cannot be inferred from a number of separate studies testing biological, psychological and social factors [23,24].…”

What's ‘difficult’? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms

“…somatisation disorder, somatoform disorder, abnormal illness behaviour or functional symptoms [2]- [7]. The terminological heterogeneity not only mirrors the fact that such conditions often fall between specialities [8], but also reflects the lack of agreement about the conceptual basis of this phenomenon [9]- [11]. This is especially the case regarding questions about mind-body interaction [12].…”

“…[41] (p. 336), "MUS are challenging to treat and can be frustrating for primary care physicians to address and manage" [5] (p. 664), and "there are a number of characteristic features of MUS that make them particularly difficult to handle scientifically." [9] (p. 2).…”