keeping score for causal claims: causal contextualism applied to a medical case

Keeping Score for Causal Claims: Causal Contextualismapplied to a Medical Case

CEI MASLEN

ABSTRACT This article investigates how Causal Contextualism applies in a medical context.It is shown how the correct interpretation of some medical causal claims depends on relevantalternatives and then argued that these relevant alternatives are determined by standards ofpractice and practical limitations (of equipment, personnel, expertise, cost), amongst otherfactors. Causal Contextualism has recently been defended by a number of philosophers; howeverdetails of the relevant factors determining content in different contexts have been lacking. It seemsto me that establishing such details of Causal Contextualism goes a long way towards makingthe view plausible, and is also necessary for discovering some important consequences of CausalContextualism.

1. Introduction

This article investigates how Causal Contextualism applies in a medical context.Although Causal Contextualism has recently been defended by a number of philoso-phers, the view has never been developed in a lot of detail. Before introducing the viewI begin with a brief discussion of Epistemic Contextualism, as this is more likely to befamiliar to readers and will be helpful in introducing some features of contextualistviews.

Epistemic Contextualism is the view that the word ‘know’ contributes an element ofcontext dependence to expressions in which it occurs (in addition to any context-dependence arising from tense and other context-dependent vocabulary in the expres-sions). For example, truth conditions of statements of the form ‘S knows that P’ and ‘Sdoes not know that P’ involve facts about the context in which those statements occur,such as the interests of the speaker.This view has risen in popularity over the past twentyyears. Defenders have elaborated it in detail, and drawn surprising conclusions, anddetractors have subjected it to vigorous attack.1

Epistemic Contextualism is a general view, but here is a simple version of how thismight work. In a high stakes context (that is, a situation in which the costs of being wrongare high) the claim ‘S knows that P’ expresses the proposition that S’s belief that P is atleast strongly justified; while in a low stakes context, the claim ‘S knows that P’ expressesthe proposition that S’s belief that P is at least weakly justified. For example, suppose thatin the course of an idle discussion I say ‘Fred knows that this is the way to the hospital’.In this context, ‘Fred knows that this is the way to the hospital’ expresses the propositionthat Fred has at least weak justification for his belief that this is the way to the hospital.But suppose now that someone’s life is at stake and we are counting on Fred to get himto the hospital. In this second context, ‘Fred knows that this is the way to the hospital’

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expresses the proposition that Fred has at least strong justification for his belief that thisis the way to the hospital. Suppose that in fact Fred only has moderate justification forhis belief. Then it follows from this view that the very same knowledge claim is true inthe first context but false in the second context.

It is possible to define a parallel view about causation: Causal Contextualism is theview that the word ‘cause’ contributes an element of context dependence to expressionsin which it occurs (in addition to any context-dependence arising from tense and othercontext-dependent vocabulary in the expressions). For example, truth conditions ofstatements of the form ‘c is a cause of e’ and ‘c is not a cause of e’ involve facts about thecontext in which those statements occur, such as the standards or interests of thespeaker. Who would hold such a view of causation and why? Causal Contextualism hasnot yet enjoyed the same popularity or even unpopularity that Epistemic Contextualismhas; it has simply remained relatively unknown until recently. Versions of Causal Con-textualism were first presented over a decade ago with compelling presentations byHitchcock (1996), Holland (1986), and Horgan (1989), for example.2 More recently,interest has been increasing with developments from Menzies (2004), Price (2007),Schaffer (2005a),Woodward (2003) and others.3 The examples and arguments that canbe used to argue for Causal Contextualism are similar to those used by epistemiccontextualists.

In Section 2, I describe a medical example in some detail and argue that CausalContextualism applies to it. This is not intended to give a full defence of CausalContextualism. For that I refer the reader to the writings just mentioned, which I take toalready have made a strong case for Causal Contextualism. Rather the example isintended to illustrate one plausible detailed medical application of Causal Contextual-ism. In Sections 3–5, using the same medical example, I investigate some mechanisms bywhich the truth of causal claims is fixed by context. This task has been neglected bycausal contextualists. However, much has been written by epistemic contextualists onthe parallel task of describing mechanisms by which the truth conditions of knowledgeattributions are said to be fixed by context, and it will be helpful to use these as acomparison in developing a picture for causation.

Finally, in Section 6, I address one general question about Causal Contextualism.Thisis the question of whether the state of knowledge or ignorance of the speaker preventshim or her from making meaningful causal claims. I will argue that it does not, usingwhat we have learned about how context determines alternatives.

2. A Medical Example4

Suppose that a patient comes to a small public hospital in New Zealand with a non-malignant tumour blocking the left side of her bowel. The patient will not survive longwithout treatment, so the surgeon recommends immediate bowel resection (removalof the diseased portion of the intestine and suturing of the healthy ends together).The patient consents and the surgeon successfully performs this operation to removethe tumour. Unfortunately, the patient dies several days later from complications of thesurgery (leakage from the reconnection of the intestine).

Was the decision to perform bowel resection a cause of this patient’s death? As we shallsee, the correct answer to this question may depend upon the context of enquiry.

Keeping Score for Causal Claims 13

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Suppose that the surgical team’s internal audit finds that the decision to performbowel resection was not a contributing factor to the death, on the grounds that bowelresection was at least as good as available alternative procedures. Although the death didarise from complications of this procedure, the decision to perform bowel resection inparticular was not a contributing factor; it was not at fault, and the level of care provideddid meet existing standards.

Let us suppose that the only alternative procedure that the surgical team consideredrelevant in their audit was the standard alternative procedure of colostomy (removalof the diseased portion of the intestine and connecting it through the abdominalwall to an external bag). Suppose that randomised controlled trials have found colos-tomy to have a mortality rate of 20% compared to a mortality rate of 12.5% frombowel resection without colostomy. If they had decided to perform colostomy instead,then the chance of death would have been even higher. This does seem to indicatethat the decision to perform bowel resection was not a contributing factor to thedeath.

However, in a different context of enquiry another procedure may also be consideredrelevant. Suppose that a medical researcher comes across this case while collecting datafor her research aimed at designing international standards. In judging the causes ofdeath in the very same case she may take a wider range of procedures into account.Standard procedure for treating acute bowel obstructions in Europe and the UnitedStates is endoscopic placement of a self-expanding metal stent (SEMS). EndoscopicSEMS placement is a relatively new procedure, and SEMSs are very expensive, butrecent studies have shown endoscopic SEMS placement to have considerably lowermortality rates as compared with bowel resection or colostomy. Citing these lowerrates, the medical researcher comes to a seemingly conflicting conclusion about thevery same New Zealand case. She concludes that the bowel resection was a cause ofthe death on the grounds that it was greatly inferior to the alternative procedure ofendoscopic SEMS placement.

Note that endoscopic SEMS placement would not have been an available alter-native in the small New Zealand hospital for two main reasons. Firstly, no surgeonsin that hospital had the training and expertise to perform this operation, and trans-porting the patient to a tertiary centre would not have been possible in time. Secondly,SEMSs are not kept in stock at small hospitals in New Zealand. They need to bepre-ordered and this would not have been possible in time. Given these practicallimitations and the standard alternatives, the finding of the surgical team in theirinternal audit does seem to be justified. Yet, the medical researcher also seems to bejustified in taking another procedure into account, and justified in her subsequentfinding.

The two investigations reached apparently conflicting conclusions about the very samecase. So, which is correct? The Causal Contextualist can say that both investigations arecorrect, and explain why the disagreement is only apparent. The different conclusionsreflect a difference in perspective, not a difference in facts. Bowel resection was not acause of death, relative to the only other available standard procedure, colostomy.However, bowel resection was a cause of death, relative to a wider range of knownprocedures including endoscopic SEMS placement. One range of alternatives wasrelevant in the first context while a different range of alternatives was relevant in thesecond context.

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3. The Standard Counterfactual Approach to Causation and a WorkingContextualist Analysis

Standard analyses of causation are not contextualist.They do not allow for both medicalinvestigations to be correct, or for the truth of causal claims to be relative to alternativeprocedures. At the end of this section I will present a simple contextual analysis ofcausation that does allow these claims to be true.This involves only a small modificationto a standard analysis of causation.

One of the most popular approaches to analysing causation is in terms of counterfac-tuals, that is, subjunctive conditionals. The basic idea of this approach is that a cause isanything that if it had not occurred then the effect would not have occurred. Lawyerssometimes use this approach and call a cause a sine qua non — that without which theeffect would not have occurred.5 A simple probabilistic version of this requires only thatif the cause had not occurred then the probability of the effect would have been muchlower.6 Applying this standard analysis to our example, the decision to perform bowelresection was a cause of death if and only if had the decision to perform bowel resectionnot occurred then the probability of death would have been much lower. Which alter-native procedure is relevant here? The answer is that it is the alternative procedure thatwould have been chosen otherwise — the second-choice procedure, as I will say. Anassumption of the standard analysis is that that there is always a unique second-choiceprocedure and that it does not depend on context.7

Our example shows the standard analysis to be unsatisfactory on at least two counts:in not allowing for context-dependence, and in its crucial dependence on the second-choice procedure. Firstly, let’s suppose (plausibly) that had the doctors in question notchosen to perform bowel resection, then the alternative procedure they would havechosen is colostomy (with a higher probability of death). The standard analysis thenyields the result that the decision to perform bowel resection is not a cause of death, asit did not raise the probability of death relative to the second-choice procedure. Thisworks for the first context, but yields a counterintuitive result for the context of themedical researcher, for the standard analysis also judges that the decision to performbowel resection is not a cause of death in this second context. The second-choiceprocedure is the procedure that the New Zealand doctors would have chosen if they hadnot made their actual choice, and this is the same regardless of whether it is an internalaudit investigating the question or an independent medical researcher. So the standardanalysis does not account for the context dependence in our example.

Secondly, suppose that, as it happens, had the decision to perform bowel resection notbeen made, then the doctors in question would have chosen not to operate on thispatient at all — they would have made a negligent decision. The standard analysisimplausibly implies that this fact about the second-choice procedure is relevant to thequestion of whether or not the actual procedure is a cause of death. (It is hard to imaginehow we would find firm evidence for such a fact about the psychologies of these doctors.Evidence might be the consultant later confessing that he was on the verge of a mentalbreakdown that day, and was close to making the negligent decision. Though it is notunreasonable to think that in many other cases there is no determinate fact of the matteras to the second choice.)

On the supposition that the second-choice procedure was to choose not to operate,the standard analysis again yields the judgment that the bowel resection was not a



cause of death, which is an intuitive end result in the context of the internal audit.However, a variation on our original example quickly shows that this dependence onsecond-choice procedure is unsatisfactory. As a variation, relocate the example to ahospital in America where endoscopic SEMS placement is an available procedure.Again the doctors made the actual choice of bowel resection and the patient died. If wesuppose the second-choice procedure to be endoscopic SEMS placement, then thestandard approach yields the judgment that the actual choice was a cause of death (asit raised the probability of death relative to endoscopic SEMS placement). On theother hand, if we suppose the second-choice procedure to be not to operate, then thestandard analysis judges that the actual choice was not a cause of death (as it loweredthe probability of death relative to the alternative of no operation). What a peculiarresult! It seems that mentally choosing a worse second-choice procedure (no operation)can make a difference as to whether or not something is a cause of death. Also, if inthe case of a second-choice not to operate the doctors are no longer implicated in thecause of death, the standard approach to causation has the consequence that mentallychoosing a worse second-choice procedure can make all the difference as to whethersomeone is to blame for a crime. I think this is an unsatisfactory consequence of thestandard analysis to causation.

We have concluded that the answer to the question of which alternative procedurewould have been chosen otherwise (even supposing that there is a determinate answer tothis question) is sometimes completely irrelevant. One possible lesson to draw from ourexample is that causation depends on what should have happened otherwise, rather thanon what would have happened otherwise. ‘Should have happened otherwise’ can beunderstood as ‘should have happened, subject to the aims, availability and norms in thatcontext’, and even if there is some widest sense of ‘should have ideally’, this sense is notnormally relevant. Although ‘should have happened otherwise’ does seem to capture thecontextual shifts in our example that ‘would have happened otherwise’ fails to capture,we will see in the next section that we need to allow for a dependence on an even widerrange of alternative procedures.

We can easily modify the standard analysis given above in order to fit our contextualconclusions. Unlike the standard analysis, we will not assume that the appropriatealternative to the cause depends on a determinate answer to the question ‘What wouldhave happened without the cause?’ Instead our analysis will explicitly state a dependenceon a set of alternatives implicit in the context.8 A number of contextual featuresdetermine this set, as we shall see later: assumptions, goals, plans, limitations, andstandards — all of which may be partly pragmatic. I expect that the set is frequently onlypartly determined by the context — it is left vague — and that this indeterminacy onlyoccasionally leads to miscommunication.

Here is the analysis:9

Where C* is the set of relevant alternatives to the cause in context C: ‘c is a causeof e’ is true in context C iff, for every c*i in C*, had c not occurred and c*i hadoccurred instead, then the probability of e would have been much lower.

Note that implicit alternatives to the effect can also vary. For example, with the medicalexample given, the obvious contrast with dying is staying alive. However, in othercases, the alternative of never having existed could be a relevant contrast with dying.10

In the main example used throughout this article, alternatives to the effect do not seem

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to be relevant, so, for the purposes of this article, I have not stated a more general analysisincorporating alternatives to the effect.11

This may be a good place to distinguish some closely related concepts. Singularcausation is causation in a single case, for example where smoking causes cancer in aparticular patient; general causation does not concern a particular case, for example,smoking also causes cancer in general.We have been concentrating on singular causationwith our medical example, and we shall put questions of general causation asidethroughout this article. A second important distinction may be less familiar. This is thedistinction from Hitchcock between component cause along a causal route and net cause.12

A component cause along a causal route is something that contributes to an intermediatestep in one of the pathways to the effect, while a net cause is something that makes anoverall difference to the effect. For example, the surgery contributed to the leakage,which in turn contributed to the infection, which in turn contributed to the death. Hencebowel resection is undeniably a component cause along a causal route to the death andthis is true in both contexts described above. I agree with Hitchcock that the word ‘cause’may be commonly used to mean either of these concepts.We will restrict ourselves to netcausation here, unless otherwise stated.

4. Causal Contextualism and Relevant Alternatives

What determined the relevant alternatives in the different contexts of our medicalexample? In the first context (the clinical audit of the surgical team in the small NewZealand hospital) there seems to be a restriction to procedures that conform to NewZealand professional standards. This first restriction arises naturally from the acceptedgoal of this type of audit, which is to review the quality of surgical care by comparingrecent past practice with recognised standards and criteria. The professional standardshere are related to legal requirements and to typical surgical practice in this country. InNew Zealand, some legal criteria for hospitals are stated by the Ministry of Health andthe local district health boards, and legal requirements on doctors also depend on typicalrecent surgical practice in New Zealand, because legal cases may appeal to a panel ofexperts describing their own practices.

There also seems to be an implicit restriction to available surgical procedures in thesense of the procedures that the surgical team had the ability to carry out at that time andin those circumstances.That is, for the purposes of this audit, the surgical team seems toaccept as fixed the limitations of personnel, technical expertise and equipment that theyhad to work with at the time and place that the patient presented.13 Although the surgicalteam may have some influence over attainment of more equipment, training and per-sonnel for a later date, this would not be relevant in this first context. This secondrestriction also arises naturally from the accepted goal of this specific type of audit, whichis only to review the surgical team’s own past performance and judge whether they hadprovided the best surgical care that they could in the circumstances, or at least whetherthey had provided adequate surgical care in the circumstances.

In the second context (of the medical researcher), a wider range of alternative proce-dures was relevant but there are still implicit restrictions in place. Given norms ofevidence for medical research and the explicitly stated goal of designing internationalstandards, the contrast class was limited (roughly) to those procedures that have been



used in the past for treating the condition, whose results have been investigated bywell-run studies. Some careful researchers may explicitly state their selection criteria foralternative procedures, for example a limitation to procedures whose results have beenpublished in certain peer-reviewed medical journals.

In conclusion, we have found that relevant alternative procedures were determined bya number of factors: aims, abilities, professional and legal standards, epistemologicalnorms, and availability of equipment, personnel and expertise.We can group this answerinto three main groups: aims, availability of alternatives, and norms.

5. Conversational Score and Conversational Salience

In the previous section, we looked at contextual factors that determine relevant alter-natives for Causal Contextualism. This was the main goal of this article, but it is a taskthat other causal contextualists have set aside, perhaps thinking it is a tedious linguis-tics task with not much philosophical import, or perhaps suspicious that such factorsneed to be derived from more general and fundamental linguistic principles. We havestated a general analysis for Causal Contextualism that relies on an intuitive notion ofrelevant alternatives. But it seems to me that we need to see the details of how CausalContextualism applies to real cases, before we can evaluate Causal Contextualism,or to investigate its consequences. I also think that discovering the details of howrelevant alternatives can be found in the context is helpful for understanding howcausation can depend on context, and for dispelling some mystery that surroundsCausal Contextualism.

Lewis was one of the first to see the need for such detailed discussion of contextualfeatures in the case of Epistemic Contextualism, and we will look at this soon.14 Healso introduced the notion of conversational score, which can help us to fit our projectinto a more general linguistic framework.15 Lewis suggests that it is often helpful tothink of a conversation as a language game in which there are features analogousto the components of the score of the game. Just as a baseball game has a scoreboardto keep tally of innings, runs, strikes, outs etc., well-run conversations have featuressuch as presuppositions, standards of precision, and salient objects which can bethought of as components of an abstract scoreboard. These components persist orchange in an orderly manner as the conversation progresses: as things are said andevents occur. Lewis’s Epistemic Contextualism depends on the notion of a relevantpossibility, which is another component of conversational score. Similarly, our relevantalternatives to the cause function as a component of conversational score in Lewis’ssense. They persist throughout a conversation while goals, standards and other limi-tations persist, and later in this section we will also see how they depend on what issaid in a conversation.

As I said, in a later paper Lewis goes beyond these general comments on EpistemicContextualism and scorekeeping to investigate the details of how knowledge claimsdepend on context.16 The most important rule he introduces is a rule of conversationalsalience, and for the remainder of this section I want to focus on versions of this rule andhow they might apply to Causal Contextualism. As we shall see, conversational salienceplays a part in Causal Contextualism too, but I will argue that it is not the primary factor,in medical contexts at least.

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Conversational Salience

In the case of Epistemic Contextualism, ‘The salience rule — or something like it — isthe most common tool of contextualists’.17 This is the rule that an alternative that issalient in a conversational context thereby becomes a relevant alternative for thepurposes of interpreting the contextual claim. An alternative may be salient becausesomeone recently mentioned it in the conversation, or perhaps because the speakersimply had it in mind. Lewis states the salience rule for Epistemic Contextualism likethis: ‘No matter how far-fetched a certain possibility may be, no matter how properly wemight have ignored it in some other context, if in this context we are not in fact ignoringit but attending to it, then for us now it is a relevant alternative.’18 (This is his ‘Rule ofAttention’.) For example, suppose someone says, ‘I know that this is a zebra’, but thatsame person has recently mentioned or thought of the possibility that the animal in frontof him is a cleverly painted mule.Then it follows from the Rule of Attention that he doesnot know that it is a zebra unless he can rule out that alternative. The mere thought orexplicit mention of the alternative makes it a relevant alternative that cannot be properlyignored. Other epistemic contextualists agree with Lewis, though the formulations of therule are quite varied.19

A parallel principle for Causal Contextualism would be a principle that explicitlymentioning an alternative ensures that it is a relevant alternative in that context. Doessuch a principle hold for the medical example we looked at? Suppose that an additionalalternative is explicitly mentioned during the surgical team’s audit meeting — say, thealternative of endoscopic SEMS placement.Would that be enough to make it a relevantalternative? If it were enough, then after explicit mention were made the team would beforced to conclude that the decision to perform bowel resection was a cause of death, andthat adequate care had not been given. But, on the contrary, endoscopic SEMS place-ment would still be irrelevant, for the same reasons we examined above — because it wasnot an available alternative, and was not required by the standards in place. Simplymentioning it as an alternative, or even seriously entertaining it as an alternative, is notenough to make it relevant to evaluating the current outcome here.

Turning now to the second context we discussed above — the medical researcherconstructing a meta-analysis — it seems that this context has more flexibility forconstructing and modifying standards and goals by explicit mention. Would explicitlymentioning an additional alternative procedure be enough to make it relevant in thiscontext? I think it would, provided that it doesn’t contradict other explicitly statedselection criteria for alternative procedures. (If the explicitly mentioned procedure isunusual enough — say based on a new religious ritual with no data as yet on its success— that would certainly serve to reduce the quality of the study. However, unless itcontradicts other explicit selection criteria for alternative procedures, interpretation ofthe causal claim would still unambiguously include it and the causal claim may evenhappen to be true, though lacking in evidence.)

Conversational salience is the primary rule for epistemic contextualists not justbecause it is their most common tool, but also because they claim it to be a factor thattrumps all other factors. For example, if one of Lewis’s other rules entails that apossibility is not relevant, but his salience rule (the Rule of Attention) entails that it isrelevant, the salience rule always has priority. For example, one application of Lewis’sRule of Reliability entails that possibilities involving hallucination are not relevant



(on the grounds that our process of perception is normally reliable). However, ifsomeone explicitly mentions the possibility that we are merely hallucinating that there isa zebra in front of us, then according to Lewis that automatically becomes a relevantpossibility that must be ruled out in order for knowledge to obtain.

In the case of Causal Contextualism, this is not so. In our first context, even explicitmention of an alternative was not enough to make it relevant, when it was neitheravailable nor required by medical standards. Hence, in the case of Causal Contextual-ism, dependence on aims, standards and availability can trump conversational salience.

Note that a dependence on norms and availability of alternatives does not fit withsome understandings of how contextualist views should work. In particular, it involvesa departure from what Stanley calls the intention-based view. This is the view that thepragmatic features of the context that determine the proposition expressed are thereferential intentions of the attributor.20 In other words, it is the idea that any con-text shifts in the meanings of words must arise somehow from the speaker himselfintending the meaning to shift. A simple contextualist view based only on conversa-tional salience fits this idea well. So, if I intend alternative A to be the one relevantalternative for my utterance of ‘c caused e’, then the meaning of my utterance is ‘ccaused e, relative to alternative A’. This is the simplest caricature of contextualism,but some still wish to saddle contextualism with it. However, I see no reason whyCausal Contextualism should be limited by the intention-based view. A registrarpresenting the surgical audit may intend her causal claims to be relative to a widerange of surgical procedures, but this is not enough to make the appropriate inter-pretation of her claims relative to these procedures, for that is determined by otherconsiderations.

Vetoes

Epistemic contextualists are divided on whether alternatives can be made salient in a waythat makes it clear that they are not relevant. This could happen when someone finallysays, ‘Forget cleverly painted mules for now, okay?’ and thereby makes it the case that thepossibility that it is a cleverly painted mule is not a relevant alternative. DeRose considerssomething like this when; he talks about ‘veto power’ and the ‘Aw, come on!’ response tothe mentioning of a sceptical hypothesis.21

I think that this type of conversational salience does play a role in Causal Contextu-alism. Causal claims arise commonly in a wide range of medical contexts and thus far wehave only looked at two contexts. Let us consider briefly just one further context — aninformal conversation between medical experts about the very same case in NewZealand that we have looked at throughout. Suppose that the conversation takes place inthe tea-room, outside of any formal meeting or enquiry. One expert says, ‘The bowelresection decision wasn’t the cause of death. You know if they had used endoscopicSEMS placement like we do back home, then the patient would have stood a goodchance.’ The second expert then replies, ‘That’s beside the point.You know that wasn’tgoing to happen here.’

It seems to me that in this context, the content of the first expert’s claim is determinedin part by the second expert’s rebuff. The second expert did not agree to the relevanceof the proposed alternative, so the first expert’s mention of it did not succeed in makingit relevant.

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We have now looked at causal claims occurring in several different contexts aboutthe same medical case. I’m not claiming to have listed all the contextual factorsthat determine relevant alternatives for Causal Contextualism.22 However, from thefactors we have looked at, it may be puzzling that we have ended up with so manyfactors that eliminate relevant alternatives (limitations, standards, vetoes), and onlyone factor (conversational salience) that generates relevant alternatives. In cases whereno alternatives are conversationally salient to begin with, aren’t we always going tobe left with no alternatives? This is not a problem for epistemic contextualistsbecause of their primary emphasis on conversational salience, which generates relevantpossibilities.

I am unsure what the best answer to this question is. One promising suggestion for ananswer is that as a default, interpretation of a causal claim is always relative to the widestpossible range of alternatives, which is then narrowed down by other contextual factors.So with our medical example, a default interpretation of the claim ‘the actual procedureis a cause of death’ is to interpret it as relative to all possible alternative procedures to theactual procedure.23

6. Do We Have to Know What We’re Talking About?

It has been suggested to me that it doesn’t seem right that the truth of a causal claim maydepend on the state of ignorance or knowledge of the speaker.24 Carroll also suggests thatthere may be contexts where no suitable alternatives to a cause are salient and a causalutterance fails to be true as a result. He calls these contexts impoverished contexts.25

For example, we may worry that a patient with very little medical knowledge will beunable to successfully make meaningful medical causal claims. Certainly someone whoaccepted the intention-based view might expect this. If the patient is not familiar withany alternative procedures then she may not be able to have appropriate referentialintentions, and hence her causal utterances may count as false or meaningless. Note thatwhat is in question here is not whether such a patient can know that a medical causalclaim is true or meaningful, but whether it can even be true or meaningful coming fromher mouth.

Returning to the same medical example, suppose that our patient (prior to death) hadpredicted that bowel resection would cause her death, but that she had no medicalknowledge of alternative procedures.What are the appropriate relevant alternatives withwhich to interpret her claim, and would her causal claim be automatically meaninglessor false due to her lack of knowledge?

There are several reasons why it does not follow from Causal Contextualism that anignorant speaker is unable to utter true causal claims. Admittedly, when we don’t knowwhat we’re talking about we may be unable to make salient some more esoteric alter-natives. But our causal claims can still be interpreted straightforwardly and simply andmay still be true. My answer to the question has several parts, for I think the appropriateinterpretation of the patient’s claim does depend on her intentions.

The first part of the answer is that even the most ignorant patient is aware of the ‘donothing’ option.With the ‘do nothing’ option as the only relevant alternative the patient’sprediction that bowel resection would cause her death is false, as doing nothing had ahigher chance of death than the actual procedure. But at least her causal claim is not



meaningless.26 Now it may be that the ‘do nothing’ option is salient in this context, asthe patient has presupposed it or even explicitly mentioned it. However, this is not theonly possibility.

The second part of the answer is that the relevant alternative for the patient’s utterancemay be determined by what was salient to a particular doctor when the patient discussedit with him. The patient may have a referential intention to defer to her own doctor,or simply ‘to the experts’. This is one way in which the relevant alternative can be aprocedure that she has never heard of.

The third part of the answer is that the relevant alternatives may be determined not byconversational salience but by natural limitations of the case, just as it was in the firstcontext we considered (the context of the surgical audit).We begin as a default with thewidest possible range of alternative procedures, and then narrow this down by limitationsof the availability of alternatives. The result is that in the absence of specific referentialintentions of the patient, the relevant range of alternative procedures is all of thealternatives to the actual procedure that were available in the circumstances. This thirdpart of the answer seems to me to most likely to give the appropriate interpretation ofher claim.

In this article, we have investigated the contextual factors that affect interpretation ofmedical causal claims, by looking at one medical example in several different contexts.The story we have discovered is a complicated one: we have found a dependence not juston explicitly mentioned alternatives and explicitly vetoed alternatives, but also on alter-natives determined by goals, standards, availability and other limitations. We have alsobriefly looked at the interaction of different contextual factors. We have found thatconversational salience can be trumped by limiting factors such as professional stand-ards. Finally, we have used some of our conclusions in order to explain why CausalContextualism does not entail that a speaker ignorant of alternative procedures is unableto make true or meaningful causal claims.27

Cei Maslen, Philosophy Programme, School of History, Philosophy, Political Science andInternational Relations, Victoria University ofWellington, PO Box 600, Wellington 6140, NewZealand. [email protected]

NOTES

1 For defences see, for example, Stewart Cohen, ‘How to be a fallibilist’, Philosophical Perspectives 2 (1988):91–123; K. DeRose, ‘Contextualism and knowledge attribution’, Philosophy and Phenomenological Research52,4 (1992): 913–929; D. Lewis, ‘Elusive knowledge’, Australasian Journal of Philosophy 74,4 (1996):549–67; Ram Neta, ‘S knows that P’, Noûs 36,4 (2002): 663–81. For attacks see, for example, PatrickRysiew, ‘Contesting contextualism’, Grazer Philosophische Studien 69 (2005): 51–70; S. Schiffer, ‘Contextu-alist solutions to skepticism’, Proceedings of the Aristotelian Society 96 (1996): 317–333; J. Stanley, Knowledgeand Practical Interests, (Oxford: Clarendon Press, 2005); P. Yourgrau, ‘Knowledge and relevant alternatives’,Synthese 55,2 (1983): 175–91; Timothy Williamson, ‘Contextualism, subject-sensitive invariantism andknowledge of knowledge’, Philosophical Quarterly 55, 219 (2005): 213–35.

2 C. R. Hitchcock, ‘Farewell to binary causation’, Canadian Journal of Philosophy 26,2 (1996): 267–82;P. Holland, ‘Statistics and causal inference’, Journal of the American Statistical Association 81 (1986): 945–60;T. Horgan, ‘Mental quausation’, Philosophical Perspectives 3 (1989): 47–76.

3 P. Menzies, ‘Difference-making in context’ in J. Collins, E. Hall & L. A. Paul (eds) Causation and Counter-factuals (Cambridge, MA: MIT Press, 2004), pp. 139–80; H. Price, ‘Causal perspectivalism’, in H. Price &R. Corry (eds) Causation, Physics and the Constitution of Reality: Russell’s Republic Revisited, (Oxford: Oxford

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University Press, 2007), pp. 250–92; J. Schaffer, ‘Contrastive causation’, The Philosophical Review 114(2005a): 297–328; J. Woodward, Making Things Happen, (New York: Oxford University Press, 2003).

4 I want to stress that this is a description of a plausible scenario, not a real case study.5 See, for example, H. L. A. Hart & Tony Honore, Causation in the Law (Oxford: Oxford University Press,

1959).6 For example, Lewis (1996 op. cit.) proposes a slightly modified version of this.7 Counterfactuals themselves are often acknowledged to be context-dependent, so if the standard counter-

factual approach to causation is correct one might expect this context-dependence to carry over tocausation. A famous example of the context-dependence of counterfactuals is from Quine. He observedthat the following counterfactuals both seem to be true yet conflict with each other:

If Caesar were in command in Korea, then he would have used catapults.If Caesar were in command in Korea, then he would not have used catapults – he would have usedthe atom bomb.

However, this feature of counterfactuals has usually been ignored by defenders of the counterfactualapproach to causation. An exception is Lewis, the foremost defender of the counterfactual analysis ofcausation, who did observe in his first paper on causation that, ‘The vagueness of similarity does infectcausation and no correct analysis can deny it’ (D. Lewis, ‘Causation’, Journal of Philosophy 70 (1973):556–67). However, he did not expect this element of context-dependence to ever be important in practice(1996, personal conversation). Another exception is Carroll (J. Carroll, ‘Making exclusion matter less’,Manuscript (2004)) who defends a contextualist approach to causation and suggests the context-dependence of counterfactuals as the source of the context-dependence of causal claims. However, I thinkthat the context-dependence of causal claims goes beyond any context-dependence in counterfactuals. (AsI argue later in this section, it can be legitimate to contrast with alternative procedures that should havehappened if the cause had been absent, or indeed more generally with a range of options that might haveoccurred if the cause had been absent.)

8 Alternatives may also be explicitly stated in the context, for example, with claims such as ‘Taking medica-tion1 rather than medication2 was a cause of her recovery’.

9 Note that the standard analysis fails to account for preemption and overdetermination, a problem which hasoften been considered to be of the first importance. I think that Causal Contextualism can provide asatisfactory treatment of preemption and overdetermination. However, I do not have space to argue for thisclaim here, so such cases are not discussed. For discussions of Causal Contextualism and preemption andoverdetermination, see Woodward, op. cit. and C. R. Hitchcock, ‘Prevention, preemption, and the principleof sufficient reason’, The Philosophical Review 116,4 (2007): 495–531.

10 Woodward and Hitchcock suggest this as a contrast when discussing another example. (Woodward mentionsa remark from Hitchcock about a case where the contrast with never having existed is relevant (J. Woodward,‘Sensitive and insensitive causation’, Philosophical Review 115,1 (2006): 19, footnote 13).This is a case wherewriting a letter of recommendation leads to taking a job, moving city, the conception of a baby, andeventually the baby’s death many years later.)

11 A dependence on alternatives to the effect could easily be incorporated into an analysis if a more generalaccount is needed For example: c, relative to a set of contrast events {c*i}, is a cause of e, relative to a set ofcontrasts {e*i}, iff for every c*i in { c*i } there is an e*i in { e*i } such that if c*i had happened then e*i wouldhave happened.’

12 See C. R. Hitchcock, ‘A tale of two effects’, Philosophical Review 110,3 (2001): 361–96.13 Note that limitations of technical expertise do not just play a part in limiting relevant available procedures,

but also play an important part in the assessment of risk. (Thanks to John Matthewson for pointing this outto me.) The surgeon’s personal success rate for this kind of operation will be more indicative of theprobabilities relevant to the causal analysis than nationwide statistics. For example, endoscopic SEMSplacement in inexperienced hands will have a lower success rate than the same procedure performed by anexpert, and so bowel resection, relative to inexperienced endoscopic SEMS placement, will not count as acause of death on our analysis. Given this dependence on technical expertise already comes into the causalanalysis by influencing probabilities, it may be unnecessary to also include limitations of technical expertiseon relevant alternative procedures.

14 See Lewis 1996 op cit.15 D. Lewis, ‘Scorekeeping in a language game’, Journal of Philosophical Logic 8 (1979): 339–59.16 Lewis 1996 op cit.



17 J. Hawthorne, Knowledge and Lotteries (Oxford: Oxford University Press, 2004).18 Lewis 1996 op cit.19 For example, Hawthorne argues that serious worrying is required. As he says, merely watching The Matrix

doesn’t rob one of the knowledge that one is at the movie theatre. ‘Entertaining or attending to a state ofaffairs is one thing. Taking seriously the idea that things may be actually that way is quite another . . . ’(Hawthorne op. cit., p. 64).

20 See Stanley op. cit., p. 25.21 See K. DeRose, The Case for Contextualism (Oxford: Oxford University Press, 2009), chapter 4).

Note that the standard answer the epistemic contextualist gives to the sceptic depends on it being harderto raise standards (e.g. rule out alternatives by mentioning them) than to lower standards (e.g. to makealternatives relevant by mentioning them). I think this is one reason that this second type of rule of attentionis rarely mentioned, despite its plausibility.

22 For example, there may also be a probability threshold rule, similar to the rule suggested for EpistemicContextualism A suggestion is as follows: an alternative that is very improbable, or below a threshold that issalient in the context, is not relevant. For example, if expert 2 were to say (sarcastically) ‘Yeah, right. Likethat was really going to happen’ this seems to be both fixing a threshold for how probable an alternative mustbe in order to count and implying that it does not meet this threshold. This seems to involve a Rule ofProbability working together with an explicit veto.

This is similar to the main mechanism that Cohen (op. cit.) postulates in his version of EpistemicContextualism. Collins (J. Collins, ‘Preemptive prevention’, in J. Collins, N. Hall & L. A. Paul (eds)Causation and Counterfactuals (Cambridge, MA: MIT Press, 2004), pp. 107–18) seems to have somethinglike this in mind, although he does not advertise his account as a version of Causal Contextualism.

23 I realise that the phrase ‘all possible alternatives to the cause’ has not been made precise. It will take somefurther work to state rigorously what is involved in an event being an alternative to the cause. In some cases,‘possible’ may mean physically possible and in other cases it may mean logically possible. Perhaps there arealso cases in which logically impossible alternatives are relevant, either because they have been explicitlymentioned, or because there are no logically possible alternatives to the cause. I have in mind in particularclaims of mental causation but I will not explore such cases in this article. For now, we can let the phrase ‘allpossible alternatives to the cause’ be captured by the might-counterfactual: ‘all the situations that might havebeen present if the cause had been absent.’

24 Maurice Goldsmith expressed this worry to me.25 Carroll op. cit.26 There is not always such an obvious alternative as ‘do nothing’. Suppose that someone ignorant of

neuroscience is claiming that the firing of neuron535 was a cause of some action.That person may very wellbe unable to make any neuroscientific events salient alternatives to the firing of neuron535, either byexplicitly stating them or by having secret neuroscientific thoughts.

27 Thanks to John Carroll for letting me quote his unpublished work here.Thanks also toTom Crisp, Josh Gertand John Matthewson for helpful comments on early drafts of this article and toYasser Salama for surgicalbackground (although he should not be held responsible for any errors). Thanks also to two anonymousreferees for this journal for helpful comments.

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keeping score for causal claims: causal contextualism applied to a medical case

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