Explanation and Ontological Reasoning

Philosophical work on explanation has focused on the following two topics: theories of explanation, intended to enumerate necessary and sufficient conditions for explanation, and inference to the best explanation as the strongest form of justification for ontological or metaphysical claims. I critically examine the most important philosophical work in both of these areas and defend my own conclusions about the connections between explanation and ontology. I argue that all of our inferences about the nature of the world, in ontology or metaphysics, presuppose criteria for acceptable explanation. I first examine the metaphysics of Plato, Aristotle, and Leibniz, arguing that their metaphysical reasoning was guided by assumptions about the nature of explanation. I also survey some recent work in ontology and find inference to the best explanation offered as the strongest available method of defending existence claims. To conclude this discussion, I offer an original argument for the thesis that all reasoning about existence claims, being nondeductive, presupposes some criteria for acceptable explanations, or a theory of explanation. Carl Hempel and Wesley Salmon have been two of the most influential philosophers offering theories of explanation, and I examine their work with the intention of discovering ontological or metaphysical assumptions shaping their theories of explanation. I argue that Hempel's theory rests on deterministic assumptions, and I argue the Salmon's theory of causality, which he admits supports his theory of explanation, is subject to empiricist criticisms. Theories of explanation typically rest on assumptions about the nature of the world, I argue, and I explain why this is so with an original theory of explanation connecting it to the psychological phenomenon of understanding. We rely on understanding in the identification of explanations, and understanding requires establishing a metaphysical context for an explanandum-event. I end by indicating the possibility of generating vicious justificatory circles through the reciprocal relationship of support between explanation and ontology, and I argue that vicious circles can be avoided only by grounding all ontological reasoning in a fundamental explanatory task of giving order to experience through a system of categorie

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used