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Review Article
Epidemiology and Causation
Jungwon Kim
Kosin Medical Journal 2013;28(2):87-97.
Published online: January 19, 2013

Deparment of Occupational & Environmental Medicine, College of Medicine, Kosin University, Busan

Corresponding author: Jungwon Kim, Deparment of Occupational & Environmental Medicine, College of Medicine, Kosin University, 34 Amnamdong, Seo-gu, Busan, 602-702, Korea TEL: +82-51-990-6368 FAX: +82-51-990-6694 E-mail:
• Received: May 27, 2013   • Accepted: November 9, 2013

Copyright © 2013 Kosin University School of Medicine Proceedings

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • In medicine and public health areas, it is essential for researchers and clinicians to investigate causal relationships dealing with the terms of cause, causation and causality. In treating a patient, the treatment will be given based on the assumption that that treatment will cause an improvement or cure of the patient. For diagnosis, we need a causation concept to associate diseases with etiologic factors such as genetic, environmental, occupational and other components. The prevention and intervention of a disease involve the selecting process of probable causal factors too.
    The causal problem is one of main issues in philosophy since ancient Greek. Aristotle theorized material, formal, efficient, and formal causes. Francis Bacon and Descartes mainly used induction and deduction, respectively. Hume denied the capacity of inductive methodologies to find truth. Among philosophers of science, the debates whether we can find objective truth or not will be continued. This causation can be two subsets, ontological and epistemological (or methodological). Traditional philosophical approaches mainly focus on ontological problems, such as what is causation?; are there causal laws? In general, scientific or epidemiological approaches are dealing with the epistemological dimension, i.e, causation criteria; test for a causal hypothesis.
    For clinicians and researchers in medical and public health, it would be a good chance to review and re-think the notions of cause, causation and causality. Also there will be helpful understanding of more detail informations about the methodology such as causal inference, Hill’s criteria and Rothman’s causal pie model.
Fig. 1.
(A) A necessary cause, (B) A sufficient cause, (C) A necessary and sufficient cause, (D) Most of causes.
Fig. 2.
Concept Diagram of Causal pie model.
Fig. 3.
Depiction of the constellation of component causes that constitute a sufficient cause, and U represents all of the other unspecified event, conditions.
Fig. 4.
A causal pie model for the oral cancer.
Table 1.
Definitions of causation and their criticism from the epidemiological literature
Definition Main criticism
A cause is something that produces or create an effect. Tautological because “production” and “creation” synonyms of “causation”
A cause is a condition without which the effect cannot occur. Only few diseases could then have a cause
A cause is a condition with which the effect must occur. Again, few diseases could then have a cause
A cause is made up of several components, no single one of which is sufficient of its own, which taken together must led to the effect. Introduces unnecessary complexity in cases of simple dose response and in cases of interaction between components
A cause is a condition that increases the probability of occurrence of the effect. Dose not distinguish between an association and a “cause”c
A cause is a condition that, if present, makes a difference in (the probability of) the outcome. Is, in the strict sense, unprovable because there is only one world and one cannot observe it twice-once with and once without the condition
Table 2.
Hill‘s criteria and their problems
Criterion Problems of Criterion
1. Strength Strength depends on the prevalence of other causes; it is not a biologic characteristic and can be confounded.
2. Consistency Causal relations have exceptions that are understood best with hindsight.
3. Specificity A cause can have many effects.
4. Temporality It may be difficult to establish the temporal sequence between cause and effect.
5. Biologic gradient It can be confounded; threshold phenomena would not show a progressive relation.
6. Plausibility Too subjective
7. Coherence How does it differ from consistency or plausibility?
8. Experimental evidence Not always available
9. Analogy Analogies abound.
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      Kosin Med J. 2013;28(2):87-97.   Published online January 19, 2013
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