The role of counterfactual theory in causal reasoning

In this commentary I review the fundamentals of counterfactual theory and its role in causal reasoning in epidemiology. I consider if counterfactual theory dictates that causal questions must be framed in terms of well-defined interventions. I conclude that it does not. I hypothesize that the interventionist approach to causal inference in epidemiology stems from elevating the randomized trial design to the gold standard for thinking about causal inference. I suggest that instead the gold standard we should use for thinking about causal inference in epidemiology is the thought experiment that, for example, compares an actual disease frequency under one exposure level with a counterfactual disease frequency under a different exposure level (as discussed in Greenland and Robins (1986) and Maldonado and Greenland (2002)). I also remind us that no method should be termed “causal” unless it addresses the effect of other biases in addition to the problem of confounding.