I recently read Stein et al (2024), “Philosophy of psychiatry: Theoretical advances and clinical implications." This review article has the double merit of including some of the most prominent names in philosophy of psychiatry among its co-authors and of appearing in a psychiatry journal, World Psychiatry, thus promoting the relevance of philosophy to mental health professionals and researchers. As with any review article, breadth comes at the expense of depth, and, as with any review article, I find myself tempted to criticize it for its omissions rather than its inclusions. Yet despite its attempt to serve as a non-technical introduction to the subject, the paper deliberately advances several core positions in the debates it covers.
The authors select three thematic areas: 1) the nature of
disorder; 2) pluralism in psychiatry (ontological, explanatory, axiological);
and 3) enactivism or the “4E” framework as an integrative approach. I am going
to focus here on the first of these. A review article cannot contribute a novel
or even a nuanced answer to a philosophical question, but it can help map the
space of debate in a useful way. That is what I think this article does.
Consider the following argument: the fundamental question of
philosophy of medicine concerns the nature of disease and health. Insofar as
philosophy of psychiatry is a branch of philosophy of medicine, these questions
are also fundamental to it. Now, I am not sure the premises of this argument
are true, but the argument is certainly deductively valid. Judging from
scholarly output, it also seems to be popular. Indeed, Wilkinson’s textbook of
philosophy of psychiatry, which I have had occasion before to treat as a
barometer, starts with the question of what mental illness is and how it is to
be differentiated from mental health. Flagging these sorts of questions as
fundamental also brings philosophy of psychiatry into communion with standard
non-specialist concerns—such as popular concerns about whether mental illness “really”
is illness or whether specific conditions, such as alcoholism, should be treated
as diseases or as moral failings.
Very roughly, the debate goes like this: some people think
that what makes something a disease or disorder is purely an objective matter. Other
people think that the question can only be answered by taking values into
consideration. Stein et al call the first camp “naturalists” and the second camp
“normativists.” Other writers use slightly different labels. Of course, the
space of debate is actually much more complicated than this.
I admit, though, that I have a certain aversion to these
questions as such. Having given the philosophical debate a cursory once-over, I
have tended to think that the different parties are talking past each other—are
answering different questions. I have also tended to think that much of the disagreement
rests on the perceived implications of the different positions—especially the
implications for questions about moral responsibility, public policy and
allocation of scarce resources, or the conceptualization of specific conditions
(again, think substance use disorders). But I would venture that the real
action lies downstream. Figuring out what makes something a disease and what is
and is not a disorder does not really solve, in my view, the question of where
the boundaries of moral responsibility lie. So, in short, I have taken until
now a rather deflationary attitude to the question of what health consists of
or what makes something a disorder or a disease. My view up to now has been
something like this: When we ask about how to define disease, disorder, and health—I
am talking about real definition here, not nominal definitions—what we are really
asking about is a whole bundle of other smaller questions that do not admit of
any single global answer. There is no “wholesale” answer to these questions; we
cannot avoid doing the real “retail” philosophical work to answer them (to
borrow a metaphor from Brandom).
Stein et al convinced me to test these prejudices out. It
would take me too long to say why, but in a nutshell I have come to think that
the questions I have been exploring up to now about classification and the
ontological status of diagnostic categories depend on more fundamental questions
about what disorder and health consist of. In the coming weeks, I want to use
the Stein et al bibliography to go through the debate in philosophy of medicine
and philosophy of psychiatry about disease and health. This is a daunting task
because the relevant literature—limiting myself just to the contemporary
Anglophone debate growing out of Christopher Boorse’s work in the 1960s and
1970s—is so large. I will need a guide, so I will also use the Stein et al
mapping of the debate, which they helpfully present in Table 1 (p. 217):
The table presents a menu of answers to four questions: 1) “Are
there biological and behavioral states that can be characterized as dysfunctional
or malfunctional in objective terms independent of human interests?”; 2) “Is
there an essence that is shared by all dysfunctions?”; 3) “Is ‘dysfunction’
necessary for disorder status?”; and 4) “What are the relevant human interests
[to judgments of disorder status]?”
There are a few things to note about this mapping. First,
the concept of disorder usually takes precedence over disease in
these discussions, and rightly so. Most of the relevant writers treat “disorder”
as having a much wider extension than “disease,” so that all diseases would be
disorders but not vice versa. I will honor this focus going forward while
bearing in mind that “sick,” “disease,” and “ill” are much more common words in
everyday discussions of these topics.
Second, the questions make it clear that the concept of dysfunction
plays a central important role here. Many, but not all, of the positions in
the table proceed from the premise that disorder involves dysfunction, which in
turn raises questions about what makes a state of affairs dysfunctional—and whether
we need to have a theory of functioning well to answer such questions. Thinking
in terms of dysfunction is also deeply embedded in the DSM-5 introduction and
in the ubiquitous “causes clinically significant distress or impairment”
criterion appended to most sets of diagnostic criteria in the manual.
Finally, the question of relevant human interests indicates
just how varied the normativist answer can turn out to be. In fact, I think the
range of relevant concerns and interests is far broader than what is included
here, and I wish the writers had paid attention to Quill Kukla’s recent work on
the pragmatics of illness ascriptions. Perhaps I will move in that direction:
from Boorse’s naturalism to Kukla’s pragmatism. I cannot promise, though, that
I will stay on topic!
Comments
Post a Comment