Sunday, November 24, 2013
I recently published a short commentary piece in the American Journal of Bioethics about the use of anti-love biotechnology. The paper is entitled "The Vice of In-Principlism and the Harmfulness of Love". It offers some critical remarks on Earp et al's target article "If I could just stop loving you: The ethics of a chemical break-up".
You can access the final version of the paper directly from AJOB (subscription required), or a pre-print version here. To understand it in full, you should really read Earp et al's target article, which is luckily available open access on the AJOB website.
Saturday, November 23, 2013
(Part One, Part Two)
This is the third part in a series on the philosophy of mental illness. The series is looking at the long-standing debate about the legitimacy of mental illness. It covers some of the classic contributions to the literature. For example, in part one, we considered Thomas Szasz’s infamous arguments for the “myth” of mental illness. And in part two, we considered Robert Kendell’s attempted defence of the legitimacy of mental illness, as well as Bill Fulford’s account of the logical geography of illness concepts.
In this, the final, part we will do two further things. First, we will step back from the particular arguments for and against the legitimacy of mental illness, and focus on Neil Pickering’s meta-philosophical diagnosis of the problems inherent in the debate. Then, having sharpened our appreciation for the meta-philosophical issues, we will consider what is probably the most recent and widely-discussed attempt to define “illness” in such a way that it (properly) includes mental illnesses: Jerome Wakefield’s Harmful Dysfunction analysis.
As mentioned in previous entries, this series is based heavily on chapter one of Tim Thornton’s book Essential Philosophy of Psychiatry, though, as ever, I will feel free to critically expand upon what it says.
1. The Likeness Argument and its Flaws…
Disagreement about the legitimacy of mental illness persists despite decades of debate. This is not too surprising: philosophical disagreements have a remarkable knack for persistence. Nevertheless, every now and then, philosophers who are fed up with the endless argumentative back-and-forth associated with these disagreements, like to take a step back and offer a diagnosis. That’s exactly what Neil Pickering did with the mental illness debate in his 2006 book The Metaphor of Mental Illness.
According to Pickering, the major problem with the current debate is that it relies on something he calls the Likeness Argument. The Likeness Argument tries to determine the legitimacy of mental illness by comparing it to a paradigm case. In other words, it takes a condition or illness that everyone agrees is an illness, and tries to argue that mental illnesses are sufficiently like (or not like) that paradigm case. This is usually done by abstracting the essential properties of that paradigm case and applying them to mental illnesses. In the case of Szasz and Kendell the paradigm illness is either some specific physical illness (e.g. hypertension) or the general class of physical illnesses.
The following is a more formalised version of the Likeness Argument template:
- (1) A paradigm case of illness properly-so-called has properties P1….Pn
- (2) Mental illnesses share a sufficient number of these properties.
- (3) Therefore, probably, mental illnesses are illnesses properly-so-called.
The Likeness Argument is, in effect, an argument from analogy and so suffers from the associated logical shortcomings. It is not formally valid: the conclusion does not really follow the premises. The similarity between the two cases gives us, at best, a probabilistic, defeasible reason for endorsing the conclusion.
Typically, disputants in the mental illness debate will argue about the premises of the likeness argument. Thus, they’ll offer different accounts of the essential properties of the paradigm case, and different accounts of the similarities between the paradigm case and the case of mental illness. Pickering’s goal is to show how hidden assumptions undermine these arguments.
In particular, his goal is to highlight two hidden assumptions that make the Likeness Argument work. They are:
Hidden Assumption 1: That there are necessary and sufficient conditions that determine category membership for things like illnesses.
Hidden Assumption 2: That a putative mental illness such as schizophrenia is describable in terms of its properties without that description presupposing which category it belongs to.
The first hidden assumption plagues many philosophical debates. Consequently, it is difficult to say whether or not it is truly problematic, without engaging in a much wider debate. Philosophical analysis of concepts and phenomena often proceeds on the assumption that there are objective conditions that determine why X is one thing and not another. To some extent, this is just good old-fashioned commonsense: surely it is true that the cup upon my table is distinct from the saucer? And surely this distinction is determined by the properties they both exemplify? The concern is that the game of philosophical analysis, whereby ever-finer distinctions between concepts and categories are drawn, ends up with arbitrary and stipulative conditions for category membership. If it does, then the claim that mental illnesses, or indeed illnesses more generally, have some objective essence that determines whether or not they belong to the category of illnesses properly-so-called might be undermined. But this is a big debate, not one that can be settled here.
The second assumption is rather more interesting, and it is the one that Pickering thinks is particularly problematic in the mental illness debate. As he sees it, people like Szasz and Kendell work from the assumption that category membership is determined from the bottom up. In other words, that first you identify the properties associated with a particular condition (e.g. hypertension or schizophrenia) and then you work out which category it belongs to (illness/not an illness). Pickering argues that the relationship between property description and category membership is more holistic than that. Oftentimes, assumptions about category membership determine how we describe a phenomenon. The process is more top-down than we may realise.
He illustrates this by using the example of addiction. Let’s say there are two categories to which this phenomenon could belong: (i) it could be a blameworthy moral defect; or (ii) it could be a blameless mental illness. Pickering’s point is that hidden assumptions about which category it belongs to will affect how we describe it. So, if we think it is a moral defect we will describe an addict’s behaviour in terms of “choice”, “autonomy”, “vice”, “weakness of the will” and so on. On the other hand, if we think it is an illness, we will describe their behaviour in terms of “chemical dependency”, “helplessness”, “addiction” and so forth. I have tried to illustrate this in the diagram below.
What Pickering is pointing out here is the theory-ladenness of observation, something which has long been recognised in the philosophy of science. The point is that data doesn’t simply present itself to us in an objective, category-neutral fashion. We need to make theoretical assumptions before we can even make sense of the data and distinguish it from the background noise.
I have no doubt that observations are theory-laden. But is this a major problem? Does it undermine any attempt to argue rationally about the status of mental illness? I’m not so sure. It’s true that we have to start from somewhere — i.e. with some set of theoretical assumptions — but that doesn’t mean we are forever wedded to those assumptions. I could start out believing that addiction was a moral defect, but gradually adjust my view — through a process of reflective equilibrium — to the belief that it is a mental illness. I’m not sure I would be irrational in so doing: my readjustment could be driven by sound reasoning and argumentation. Furthermore, as Thornton points out, we can accept the epistemic-dependence between theory and description, without thereby needing to accept their ontological-dependence. In other words, we can accept that we would not be able to know the properties of a particular condition without also knowing its overall classification; but that doesn’t mean that we must accept that our judgments about those properties are constituted by the overall classification.
2. Jerome Wakefield’s Harmful Dysfunction Analysis
With that meta-philosophical point out of the way, we can proceed to consider one final attempt to define illnesses in a way that mental illnesses are (properly) included within their scope. The attempt comes from Jerome Wakefield, and it is probably the most widely-debated and discussed analysis of illness in recent times. (Terminological note: Wakefield uses the term “disorder” instead of illness, as he thinks it is the broader term. I’m going to stick with “illness” since I have used it throughout this series. This should not lead to confusion. For the purposes of this discussion, the terms “illness”, “disease” and “disorder” can all be taken to refer to the same kind of thing: a condition that is a legitimate subject of medical scrutiny and treatment).
Wakefield thinks that the major challenge for psychiatry is to show why the so-called illnesses (or disorders) are different from other mental traits. After all, the challenge raised by the likes of Szasz is that all mental illnesses are really just socially deviant or disvalued forms of thought and behaviour, and therefore shouldn’t be subject to excessive control or treatment from the psychiatric profession. This is probably the main weapon with which the anti-psychiatrists attack the legitimacy of psychiatry. Wakefield agrees that there is a problem here. As he sees it, the legitimacy of psychiatry depends on having a definition of mental illness that distinguishes true mental illnesses (like the various forms of psychosis and depression) from other socially undesirable traits (e.g. illiteracy, aggression, infidelity, lack of skill etc.).
He thinks this can be done by first accepting that all definitions of illness include a value judgment that is linked to social norms, and then by adding to that a value-free element that distinguishes illness from other forms of norm-violation. This is exactly what the Harmful Dysfunction analysis tries to do. It says that any illness properly-so-called will include the following two elements:
Harm Element: The condition will be harmful.
Dysfunction Element: The condition will involve the divergence of a biological/mental mechanism from its natural function.
The harm element incorporates the value judgment, with harm being measured in relation to social standards (e.g. harm = setback to interests). So things like illiteracy, infidelity, aggression, addiction, psychosis, depression, anxiety and so forth will all match this criterion. What distinguishes the latter from the former, however, is the dysfunction element.
There’s quite a bit of philosophy/science underlying the dysfunction element. According to Wakefield, dysfunction is determined in relation to the selected-for function(s) of a particular biological or mental mechanism. In this manner, his account of illness is explicitly evolutionary in nature. Natural function is equivalent to selected-for function. To give an example, the heart is a biological mechanism that performs certain functions. Its selected-for function is the function that explains why it has continued to exist over evolutionary time. Wakefield suggests that the selected-for function of a heart is its ability to pump blood around the body. It was this function that increased the inclusive fitness of the organisms that had a heart. (To be clear: a single organ or mechanism can have many selected-for functions). Heart disease then is any harmful condition that prevents the heart from fulfilling its selected-for function.
Wakefield argues that the harmful dysfunction analysis can apply just as well to mental illnesses. The brain/mind is made up of a variety of mental mechanisms: perceptual, cognitive and emotional. These mechanisms perform many different functions, some of which were selected-for over evolutionary time. A mental illness is simply any harmful condition that prevents a mental mechanism from fulfilling its selected-for function(s). For example, schizophrenia is a mental illness because it is harmful and because it prevents our visual, auditory and cognitive mechanisms from performing their selected-for functions.
This gives us Wakefield’s paradigm argument for the legitimacy of mental illness:
- (4) A condition X is an illness properly-so-called if it is (a) harmful and (b) involves the divergence of a biological/mental mechanism from its natural (read: selected-for) function(s).
- (5) At least some mental illnesses fulfill both of these criteria.
- (6) Therefore, at least some mental illnesses are illnesses properly-so-called.
Wakefield’s analysis is certainly interesting, and to be fair to the guy, there’s a lot more detail to it than I have been able to cover in this discussion. Nevertheless, there are some obvious problems that are worth mentioning here.
The first is that Wakefield’s attempt to have a value-free element in his definition of disease is doubtful. Some would argue that the concept of a dysfunction, even if it is related to Darwinian natural selection, involves a value judgment of some kind. The idea is that function depends on the purpose or telos of the organism, and that the purpose or telos of an organism is a value-laden thing. I’m not too enamoured with this critique. I think evolutionary purposes might be a good deal more objective than other kinds of purpose; and I also think the whole desire to have a value-free element in the definition of illness is misguided. I don’t think the legitimacy of psychiatry depends on this: what matters is whether it is guided by the right value judgments.
A bigger problem with Wakefield’s definition is that, in many cases, it can be difficult to identify the selected-for functions of a particular mechanism. Take language as an example. Has the brain evolved, in part, to allow us to learn and speak a language? Was that one of the selected-for functions of the brain? Some people argue yes (e.g. Pinker), others argue that language acquisition is a by-product of other selected-for functions. The same is true for many other mental mechanisms. Some are viewed as clear adaptations, others as by-products, with lots of arguments about these classifications. The evidence is complex and nuanced, and yet if Wakefield’s definition were to be followed it would make a big difference whether something was classified as an adaptation or a by-product. If it’s the former, then an inability to perform that function might lead to a diagnosis of illness; it it’s the latter, it would not.
Tied to this is the fact that some people — indeed, some psychiatrists — argue that certain classic mental illnesses like depression are in fact evolutionary adaptations. If they are right (and they may well not be), then depression shouldn’t be classified as a mental illness. Of course, this isn’t necessarily a problem: it could be that depression doesn’t deserve to classified as a mental illness. Furthermore, Wakefield is clear that certain psychiatric diagnoses are insufficiently attentive to the question of natural function at the moment. This is a basis on which the diagnostic criteria can be revised. Still, if one his goals is to defend the legitimacy of mental illness, then it is possible that his definition will incentivise psychiatrists to ignore or call a halt to any attempt to explain mental illness in terms of evolutionary adaptation.
Finally, there is the concern that the definition is under-inclusive. It’s possible that functions for which we were biologically selected are harmful in modern environments (e.g. having a sweet tooth). Does this mean that their harmful manifestations should not be classified as illnesses or disorders?
In the end, I feel like the classification of illness is largely (and perhaps appropriately) driven by pragmatic, treatment-oriented factors: if it can be treated by medical means, then it is a illness; if not, it's not. Of course, I recognise that even this definition assumes that the concept of “medical treatment” is more stable than it really is.
Friday, November 22, 2013
This is the second post in a brief series looking at the philosophy of mental illness. As noted in part one, some people are suspicious about the concept of mental “illness”. To call something an illness is to deem it worthy of medical scrutiny and treatment. This makes sense — so they argue — when dealing with things like broken bones, viruses, clotted arteries, bacterial infections, cancerous tumours and so forth. They all involve clear, objectively assessable physical effects and causes. Mental illness is not the same: it involves more nebulous, less tractable effects and causes, ones that are not always open to the same level of objective assessment. In part one, the mouthpiece for these suspicions was Thomas Szasz, a trained psychiatrist who has repeatedly challenged the legitimacy of his own profession.
The suspicions of Szasz seem to have been confirmed by a series of controversial experiments on the reliability of psychiatric diagnosis. Perhaps the most infamous of all these “experiments” comes from the work of David Rosenhan. In the early 1970s, Rosenhan recruited seven “pseudopatients”, each of whom was perfectly sane and had no prior history of mental illness. The patients (along with Rosenhan himself) presented themselves to different psychiatric institutions, complaining of (vague) auditory hallucinations. Apart from this they acted normally. In all cases, the patients were admitted to the psychiatric institution, and often forced to stay there for extended periods (two months in Rosenhan’s case). They were also diagnosed with different mental illnesses, schizophrenia in most cases, bipolar disorder in one.
Experiments like this — and there have been others since, particularly ones casting into doubt the reliability of diagnoses between different psychiatrists — add fuel to the fire of anti-psychiatry. If psychiatrists can’t correctly distinguish the sane from the insane, or even agree on the diagnoses among themselves, then surely theirs is not an objective, value-free form of medical practice? Rather it is, as Szasz has argued, a value-laden enterprise, concerned with labelling and identifying socially deviant thought and behaviour.
Maybe, but in many cases the results of experiments like these are never properly contrasted with the reliability of other medical diagnoses. What little research I have done on the matter, suggests that the inter-rater reliability of psychiatric diagnoses is at least comparable to, and sometimes better than, the reliability of other medical diagnoses. For example, Pies (2007) highlights the fact that the reliability of ischemic stroke diagnoses by neurologists lags significantly behind the reliability of schizophrenia diagnoses, and yet no one calls into the question the classification of ischemic stroke as a medical condition.
This raises two interesting issues, each of which will be explored in the remainder of this post. The first is that the distinction between mental and physical illness, which Szasz was so keen upon, may be more elusive than we first thought. There may instead be important commonalities between both kinds of illness that need to recognised in our conception of “illness”. The second is that this may force us to address the value-laden nature of all medical diagnoses.
We will look at both of these issues. The first by examining Robert Kendell’s account of illness; the second by considering Fulford’s “logical geography” of medical diagnoses.
1. Kendell’s Biological Disadvantage Model of Illness
In the mid-1970s, Robert Kendell offered a definition of illness in general, and mental illness in particular. The definition addressed the concerns originally raised by Thomas Szasz. As we learned in part one, Szasz thought that the problem with mental illnesses was that they involved deviations from social/psychological norms, not harms to the physical structures of the human body (like other medical illnesses).
As Kendell saw it, this approach relied too heavily on an outmoded “lesion”-based theory of disease, i.e. on the view that illnesses and diseases were linked to particular, discrete physical causes. This approach was, in Kendell’s words, “outmoded beyond redemption”, but nothing had yet been erected in its place.
This is where he came in. In place of the lesion-theory, Kendell proposed a complex statistically-based, biological definition of illness. For present purposes, we can call this the Biologically Disadvantageous Deviation from the Norm (BDDN) account of illness:
Biologically Disadvantageous Deviation from the Norm (BDDN) - Account: For any condition X, X is an illness properly so-called if X:
(a) involves the deviation in one or more parameters from a statistical norm;(b) is biologically disadvantageous to the person with the condition.
As you can see, the BDDN-account requires that two conditions be met before something counts as a medical illness. The first condition is the deviation of some parameter from a statistical norm. The term “parameter” is deliberately vague, and can cover any discernible sign or phenomenon. In the case of something like, say, blood pressure, the parameter in question is the measure of systolic blood pressure relative to diastolic blood pressure. When these measures are taken from a sufficiently broad sample, we can establish a statistical norm for blood pressure. A deviation from that statistical norm would meet the first condition of the BDDN-account. In the case of mental illnesses, the parameters in question would be things like thought patterns, moods, appetite, sleep, affect and so forth. It may be more difficult to establish statistical norms for those parameters.
The main problem with the first condition is that, if left on its own, it would render our definition of illness horribly over-inclusive. If all it took for something to count as a disease was that it involved a deviation from a statistical norm, then someone could be classified as having an illness if they were excessively tall, or had very large feet, or a high IQ. That’s why the second condition is included: the deviations in question must also be biologically disadvantageous. Unfortunately, Kendell was not clear what he meant by this concept, though one can infer from what he said that it related to Darwinian notions of survival and reproduction. In other words, X was biologically disadvantageous if it reduced life expectancy or fertility.
Kendell claimed that this definition could restore the concept of mental illness to legitimacy. His argument worked like this:
- (1) In order for something to be an illness properly so-called, it must (a) involve a deviation from a statistical norm and (b) be biologically disadvantageous. (The BDDN-account)
- (2) At least some of the classic mental illnesses (schizophrenia etc.) meet both conditions.
- (3) Therefore, at least some of the classic mental illnesses are illnesses properly so-called.
How strong is this argument? Well, Kendell himself is modest about it. As you can see from the phrasing of premise (2), the claim is not that everything that is or has been classified as mental illness will be covered. As he puts it:
Schizophrenia, manic depressive illness, and also some sexual disorders and forms of drug dependence, carry with them an intrinsic biological disadvantage, and on these grounds are justifiably regarded as illness; but it is not clear whether the same is true of neurotic illness and the ill-defined territory of personality disorder.
Maybe that’s fair enough. Maybe we should be guided by a principled definition here, not by what has, as a matter of fact, be classified as a mental illness. Those historical classifications could be wrong after all. This suggests that when it comes to the assessment of Kendell’s argument, attention should focus on premise (1), not premise (2), for that is what provides us with our principled classification.
So what can be said in favour of premise (1) and the BDDN-account? In his discussion, Thornton singles out two major virtues. First, the account is general, and so not biased in favour of the physical or mental. Second, it offers a purely factual test for whether or not something counts as a disease: does it increase mortality or reduce fertility? This might be thought to satisfy the yearning for “objectivity” among some participants to this debate.
Still, the BDDN faces significant hurdles. One major problem is that the addition of the biological disadvantage condition may render the definition under-inclusive. That is to say, it may exclude things that are diseases properly so-called. For example, minor infections might be properly included within the remit of medical attention and scrutiny, but may not actually reduce fertility or increase mortality. The other problem is that, far from being objective and neutral, the definition may simply sneak controversial evaluations in by the back door. It could do so both in the way in which it measures norms and determines what counts as a sufficiently significant deviation from a norm, and also in how it singles out biological disadvantage as being the appropriate target for disease concepts.
2. Fulford’s Logical Geography of Medical Illness
All of which leads rather nicely to Bill Fulford’s discussion of illness. One of the purposes of Fulford’s discussion is to uncover the logical geography of disease concepts, and to expose the value-laden judgments that go into them. He does this by bringing a good dose of Oxford-style ordinary language philosophy to bear on the debate. But we won’t hold that against him since some of his ideas are pretty interesting.
As Fulford sees it, the odd thing about the debate between Szasz and Kendell is not so much what they disagree about, but what they agree about. In particular, the fact that they both seem to agree that the concept of physical illness is unproblematic. Physical illness is objective and uncontroversial; the concept of medical illness is the one that is subjective and contested. But why should this be? If you think about it, the concept of physical illness is just as value-laden as the concept of mental illness. Implicitly, judgments about physical illness are made relative to some ideal of health, well-being or proper functioning. All of these things can be controversial.
For example, many people would say that old age is not an illness or disease; that it is a natural and inevitable part of human life. In saying this they make a value judgment about what is an acceptable course for a life to take. In recent years, several philosophers and transhumanists have called this value judgment into question. They have tried to reorient our perspective on ageing. According to them, it might be better if we viewed old age as an illness. At least then we might be motivated to find a “cure” for the great suffering it causes.
What Fulford wants to know is why do so many people not see the inherently value-laden nature of physical illness concepts? To answer that question he appeals to R.M. Hare’s account of value judgments in Language of Morals (here’s where the ordinary language philosophy comes in). Take a simple statement lie ”this is a good strawberry”. In this statement, the value judgment is transparent: we are using the word “good” after all. But how is goodness typically determined? Hare argues that goodness typically gets cashed out in terms of purely descriptive or factual criteria. Thus, a “good” strawberry is one that is, say, “sweet” and “grub free”. Over time, as agreement about the descriptive criteria for being a good strawberry spreads among the population, talk about those criteria replaces the value-laden talk. In other words, the statement “this is a sweet and grub-free strawberry” replaces the statement “this is a good strawberry”. The result is that the value-laden nature of certain concepts is masked or hidden by our discourse. This is depicted in the diagram below.
Fulford’s claim is that, roughly speaking, this is what has happened in the case of many physical illnesses. In other words, the concept of physical illness starts life as an inherently value-laden one: you are physically ill if you fail to live up to some norm or ideal of good health or well-being. This gets cashed out in terms of descriptive or factual criteria. There is widespread agreement about those criteria. So in the end, the value-laden nature of the concept is masked by the discourse. The same thing has not happened in the case of mental illness, because there has been less agreement about the descriptive/factual criteria over time.
This is a neat idea, and I think it does reveal something important about how value judgments can become masked in everyday discourse. Nevertheless, I think there are a couple of problems. First, it assumes too readily that there is widespread agreement about the descriptive/factual criteria for all physical illnesses. I can’t say for sure, but I imagine that this is not entirely true. There may be many physical illnesses for which it is true, but I suspect there are some that are highly contested. Second, it assumes too readily that there is widespread disagreement about the descriptive/factual criteria for all mental illnesses. This is certainly true in some cases, but the descriptive criteria for some mental illnesses (e.g. schizophrenia) have been pretty stable for some time (as far as I am aware).
Fulford goes on to offer his own definition of illness:
The Agency-Failure Account: For any condition X, X is an illness properly so-called if it involves a “failure of ordinary doing”.
This is an interesting account of illness. It is inherently value-laden (illness= a failure) and it links the concept of a disease to what an agent would like to be doing. There is a question to be asked about what is and what is not a failure of ordinary doing. Fulford draws upon J.L. Austin's account (I did say there was a good dose of Oxford ordinary language philosophy involved…) which concerned being able to get on with things without too much effort.
As I say, this is interesting, but also laden with problems of over and under-inclusiveness. Nevertheless, one thing I will say in its favour is that it is matches up nicely with liberal political values. What I mean is that within a liberal system, impediments to ordinary doing are of considerable importance. And it seems consistent with the core principles of liberalism to try to help people restore the powers of ordinary doing. But of course this illustrates how closely entwined political values can be with concepts of disease and illness. Some people would be uncomfortable with that entwining.
I’ll end on that intriguing thought. In the final part of this series, I’ll look at some more meta-theoretical issues in this debate, before closing out by examining Jerome Wakefield’s attempt to define what medical illness in terms of biological function.
Tuesday, November 12, 2013
It may be a push, but I think it is fair to say that no branch of modern medicine faces the same existential challenges as psychiatry. To give a sense of the problem, a quick browse through Amazon reveals a plethora of books, many published within the past ten years, that either directly challenge the legitimacy of mental illness, call into question the medicalisation of the mind, or dispute the unholy alliance between “pharma” and psychiatry. This is to say nothing of the organisations and religious groups (most famously the scientologists) who critique modern psychiatry and try to dismantle its apparatuses.
None of this to suggest that other areas of medicine are free from existential challenge. Far from it. There are plenty of AIDs and cancer denialists out there too, and their critiques often follow a similar pattern. Nevertheless, I would submit that those forms of denialism are more obviously “fringe”, and their arguments more easily refuted, than those which relate to psychiatry and mental illness.
Part of the reason for this is philosophical. The attempt to identify, diagnose and treat mental illness seems to bring the mind within the scope of biomedical science: to “reduce” mental phenomena to scientifically tractable, manipulable and treatable “disorders”. This cuts to the core of one of the central projects in modern philosophy: the reconciliation project. This project tries to determine the appropriate relationship between the world as it seems to be to us (the manifest image) and the world as it seems to be when viewed through the lens of modern science (the scientific image).
As such, the topic of mental illness — what it is and how it should be treated — is one that is particularly ripe for philosophical analysis and debate. The purpose of this series of posts is to look at some aspects of this analysis and debate. Specifically, to look at various attempts to determine what an “illness” or “disease” really is, and at arguments for or against the legitimacy of “mental illness”. In the process, we’ll take in some of the key contributions to the literature, from Thomas Szasz’s infamous “mental illness is a myth”-argument, to Jerome Wakefield’s “harmful dysfunction” analysis of mental disorders. As ever, much of the discussion will be shaped by my reading of a particular book or article, in this case Tim Thornton’s Essential Philosophy of Psychiatry. I shall, however, feel free to deviate from, expand upon, or critique Thornton’s work at several points.
In the remainder of this post, I’ll start the ball rolling by looking at some arguments from Thomas Szasz.
1. Szasz and the Myth of Mental Illness
Although anti-psychiatry has a long pedigree, and although exponents of the view can be found in many walks of life, Thomas Szasz’s contribution to this field is particularly noteworthy. Szasz is a trained psychiatrist who, in the 1960s, penned a famous and influential critique of his own profession. Let’s first look at a short video in which he outlines some of his basic positions.
What are we to make of this? The video is short, carefully edited, and the arguments pithy and provocative. It captures in one place, several themes and ideas that Szasz has developed more fully and more carefully elsewhere. Indeed, one thing that is noticeable about Szasz’s work is that it is slightly more nuanced, and slightly less declaratory in its academic presentations than in its public ones.
To take one example of this, Szasz’s discussion of drapetomania and ADHD in the above video is somewhat misleading. Although it is indeed true that drapetomania was a diagnosis at the time of slavery, it is a mistake to presume that it was widely accepted. On the contrary, it was ridiculed in the (US) North at the time. Acceptance seemed to split along political lines. The same does not appear to be true of ADHD.
Still, there is an important point being made here. What counts as a mental illness seems to be at least somewhat dependent on political and cultural factors. Homosexuality, for instance, was once classified as a mental illness in the psychiatric bible — the Diagnostics and Statistical Manual — before eventually being removed in 1980. This seems to have been driven to political and cultural acceptance of homosexuality. We don’t see the same kind of dependency when it comes to TB or polio or cancer. It would be odd for these diseases to be politically constructed. They are supposed to be objective, not culturally relative. Aren’t they? Why should mental illnesses be any different?
It is exactly this point that Szasz tries to make in his work. He tries to argue that there is something deeply wrong with the notion of “mental illness” and with any claim that it can be treated through medical means. We’ll look at three arguments he makes to this effect. The first rejects any attempts to subsume mental illness within the class of brain illnesses; the second casts a suspicious eye over the diagnosis and definition of mental illnesses; and the third, and most important, presents a general account of illness and medical treatment, and tries to show how mental illness falls outside of its scope.
2. Mental Illnesses are not Brain Illnesses
There are such things as brain illnesses. That much is uncontroversial. If I have a tumour in a particular region of my brain, or if I have a virus that affects certain parts of my brain, or if I have a degenerative brain disease like MS or ALS, then I can be rightly and fairly said to have an illness that needs medical care and attention. But if that’s right, then what’s the big deal about mental illness? The mind is a product of the brain. So why can’t all mental illnesses simply be subsumed into the category of brain illnesses?
To state this argument more formally:
- (1) Brain illnesses are real illnesses.
- (2) The mind is constituted by the brain.
- (3) Therefore, all mental illnesses are brain illnesses (from 2).
- (4) Therefore, mental illnesses are real illnesses.
Is this argument any good? Let’s take it premise-by-premise.
The first premise is problematic in two respects: (i) the nature of the general class of brain illnesses is unclear; and (ii) the sense in which the word “real” is being used is unclear. The former is a problem insofar as the argument may over-rely on obvious cases of brain illness and assume that all cases are as uncontroversial as these. The latter is a problem that plagues this entire debate. For now, we can simply assume that “real” means that there is widespread, intersubjective agreement about when the illness is present or not. But if we accept that, then it’s no longer clear that mental illnesses are “unreal”.
The second premise assumes a strong form of mind-body monism. That will be objectionable to some people. And the thing is, the strong form is needed if the rest of the argument is to work. If you accepted that the mind was dependent on the brain in certain respects, then you might be able to account for some mental illnesses in terms of the brain, but not all.
That said, even if you accepted mind-body monism, there might still be problems. This is where Szasz’s original critique comes into play. He points out that the ability to account for mental illnesses in strictly neurological terms is limited. The relationship between the brain and the mind is a complex on. Even if we accept that mind and body are made of the same stuff, it does not follow that talk of mental illnesses can be reduced to talk of brain illnesses.
Now, Szasz thinks that there is a deeper reason for this: one that links to how mental illnesses are defined and diagnosed. We’ll get to that later. In the meantime, I’d be willing to agree with the gist of his critique. In other words, I would be willing to question the inference from premise (2) to (3). Although we know much more about the mechanics of the brain, and the connection between the mental and neurophysiological, than we did when Szasz penned his original critique, I still agree that we are a long way from replacing mind-talk with brain-talk.
More generally, I would object to the basic strategy underlying this argument. I don’t think we have to analogise mental illness to brain illness in order to determine whether it is real or not. (This is something that will come up several times in this series.)
3. The Reification-Causation Argument
Typically, diseases and illnesses are diagnosed by means of symptoms. The symptoms are externally observable and testable indicators of the underlying disease. For example, a rash with itchy red blotches on the skin is a classic symptom of chicken pox (a viral infection). The illness is the underlying cause of the symptoms. It is by treating these causes that medicine earns its bread.
Szasz’s second argument claims that this relationship between symptom and disease is subverted in the case of mental illnesses. In other words, that a mental illness is simply a descriptive label we apply to a collection of symptoms, not an underlying cause of those symptoms. Take depression as an example. This is diagnosed by means of symptoms: low mood, anxiety, sleep disturbance, poor appetite, loss of energy etc. If you exhibit a sufficient number of these symptoms, you are diagnosed with “depression”. But depression is not the name for an underlying illness or cause of the symptoms — we don’t know what the underlying mechanism is — rather “depression” is a label for those symptoms.
The problem then, as Szasz sees it, is that this label becomes “reified”. That is to say, we are tricked into thinking that the label is itself a “thing” with causal powers. This leads us to believe that it is a illness much like any other; that it is something toward which we can direct our medical interventions. The reality is quite different.
You may well wonder whether this is a significant problem. After all, it sounds like something we do all the time, even in relation to other illnesses, without thereby undermining the legitimacy of research into that descriptively defined category, or the plausibility of crafting medical interventions to address the symptoms.
What might be going on here is that Szasz is trying to highlight the absurdity of treating mental illnesses through medical means, and that he thinks the reification of a descriptive label is one way in which this absurdity manifests itself. If so, his argument is problematic. This becomes clear once we look at his main argument against the legitimacy of mental illness.
4. Szasz’s Central Argument
Szasz’s main argument against the legitimacy of mental illness works from a general account of the nature of disease and medical treatment, and then purports to show that mental illness falls outside the scope of that account.
The starting point is a norm-based account of “illness”. As Szasz sees it, an illness is a deviation from some kind of norm. In the case of medical illnesses properly-so-called, the norms in question are biological and physiological. There is some pathological tissue (e.g. a tumour) or pathogenic organism (e.g. HIV), whose presence disrupts the normal biological structure and functioning of the body. Pathological disturbances of this sort are objectively discernible, and capable of being treated through pharmacological or other medical means.
Medical Illnesses Properly-so-called: X is a medical illness, properly-so-called, if it involves the deviation from a biological or physiological norm of the human body. (The appellation “properly-so-called” is added to indicate that it is properly an object of medical diagnosis and treatment).
The problem is that mental illnesses do not involve normative deviations of this sort. Though we have searched for some underlying mechanism for many mental illnesses, they remain elusive and dimly understood. Indeed, the literature is overflowing with multiple proposed pathological explanations for “illnesses” like schizophrenia, depression and psychopathy. Szasz thinks that the main reason for this is that mental illnesses are primarily defined in terms of social or political norms, not biological/physical ones. In other words, that a person is classed as a “schizophrenic”, “depressive” or “psychopath” because their thoughts and behaviours do not conform with socially acceptable standards. This is why mental illnesses are so politicised: their very essence is determined by reference to politicised norms.
Hence, mental illnesses are not medical illnesses, and it is absurd to treat them as such:
Since medical interventions are designed to remedy only medical problems, it is logically absurd to expect that they will help to solve problems whose very existence have been defined and established on non-medical grounds.
To distill all of this into a formal argument:
- (5) Medical illnesses (i.e. those properly diagnosed and treated through medical means) involve the deviation from some biological or physiological norm of the human body.
- (6) Mental illnesses involve deviations from social/political/ethical norms, not biological or physiological ones.
- (7) It would be absurd to treat deviations from one set of norms with the tools for treating deviations from another set of norms.
- (8) Therefore, mental illnesses are not medical illnesses and it would be absurd to treat them as if they were.
Once the logic of the argument is exposed in this manner, its flaws become pretty obvious. For starters, it relies on a contentious, and arguably outmoded characterisation of “medical” illness. Apart from its convenience for Szasz’s argument, is there any reason to think that medical illnesses (or, indeed, medical interventions) must be restricted to biological or physiological norms? Not particularly. Even if it was true that medicine has its historical origins in such standards, there is no strong reason to think it must remain restricted to them.
That said, there are difficult issues here relating to the philosophy of categorisation and the boundaries between different disciplines and concepts. We’ll touch on these later in this series, but for now I would simply note that even though many agree that Szasz’s definition of “medical” illness is outmoded, they often do so by way of defending an alternative, biologically-grounded, definition of illness. Thus, biological and physiological norms continue to play a role in the categorisation of mental illness.
That brings me to the second major problem with Szasz’s argument. The implicit assumption underlying both premise (6) and (7) is that mental illnesses are either one thing or the other; that they are either deviations from socio-political norms, or deviations from bio-physiological norms. But why couldn’t they be both? If mind-body dependence of any type is true, then it is quite possible that deviations of the former type could involve deviations of the latter type. Furthermore, if mind-body dependence of any type is true, then it is quite possible that treatments designed to affect the latter type of deviations could be effective against deviations of the former type.
The result of this would seem to be that Szasz’s argument fails. But where does that leave us? Well, with an obvious question: if Szasz’s account of medical illness is flawed, is there a more persuasive alternative? And would mental illnesses be medical illnesses properly-so-called under the terms of that alternative account? These are questions we shall pursue the next day.
Monday, November 4, 2013
Life expectancy increased dramatically over the course of the 20th century. In the UK and US — to take two obvious examples — it increased by approximately 30 years. Further increases are projected in the future. In addition to this, advances in medical technology are hoped by many, and demanded by some, to dramatically increase lifespan (a subtly different concept from life expectancy) in the coming century. It may soon come to pass that lifespans of 120 to 150 years are no longer confined to the realms of science fiction.
These increases in lifespan raise interesting issues of distributive justice. The typical life is a sequence of events, strung together under a (usually) common personal narrative. This sequence is broken down into a series of stages. Jaques famous “Seven Ages of Man” speech from As you like it nicely illustrates the idea. Each of these stages is associated with certain goods and opportunities. And a good life is the one that has access to the full suite of these goods and opportunities. In other words, the good life is one in which the goods and opportunities are justly distributed over the course of one’s life.
The problem is that increases in life expectancy and lifespan threaten the just distribution of these goods and opportunities. This has long been recognised. Increasingly aging populations put pressures on the traditional welfare system, and these pressures may have to be paid-off by the younger generation. This means that different age groups will have differential access to goods and opportunities. Is it just/fair for different age groups to be treated in this way?
The purpose of this post is to investigate this question. It does so in three parts. First, I talk generally about the concept of intergenerational justice, and the specific form of intergenerational justice that is at stake here. Second, I talk a bit more about the distributional problem that arises from increases in (life) expectancy and span. Third, I consider possible solutions to the problem, drawn from the pre-existing literature on distributive justice.
A couple of interpretive notes before we start in earnest. This post is inspired by Roberto Mordacci’s article “Intergenerational Justice and Lifespan Extension”, which appears in the book Enhancing Human Capacities. “Inspired” is the operative word here: I found the article quite confusing and so I’ll deviate from it a bit. In addition to this, readers should be aware that the topics of radical life extension and negligible senescence are not necessarily enjoined by this analysis. The distributional issues I discuss arise at relatively modest levels of lifespan extension.
1. Intergenerational Justice
One useful aspect of Mordacci’s article is the way in which he distinguishes between different concepts of intergenerational justice. Obviously, the concept of intergenerational justice is intended to refer to justice between different groups of people, where these groups are determined by diachronic as opposed to contemporaneous relations. The problem is that the notion of a “generation” vague.
In the interests of clarity, we could speak to three different concepts of intergenerational justice:
Justice Between Non-Coexisting Peoples: In other words, justice between persons who are currently alive, and future, currently non-existent, persons.
Justice Between Birth Cohorts: A “birth cohort” is defined as a group of persons born in the same time period, where this time period is more-or-less arbitrarily determined. For example, the “baby boom generation” is a birth cohort consisting of all those born between 1946 and 1964. Likewise, “generation X” is a birth cohort consisting of all those born between the mid-1960s and the early-1980s. (I believe I’m classified as a Generation Y-er or “Millenial”)
Justice Between Age Groups: An “age group” is defined as a group of persons all around the same age. For example, people aged 15-29, or 25-49 and so on. This is distinct from the notion of a birth cohort because people move through different age groups during the course of a single lifetime, whereas they always remain part of the same birth cohort.
Each concept of intergenerational justice raises different issues, some of which are relevant to the life extension debate, some of which are not.
The first concept — that of justice between non-coexisting generation — is perhaps the “classic” sense of intergenerational justice, often associated with environmental ethics. It raises many interesting philosophical puzzles, such as: Can we have duties towards non-existing persons? Are currently non-existing persons ethically “harmed” by our actions in the present? That said, it doesn’t raise any novel issues in relation to life extension. The question of whether we owe future persons a decent life remains roughly the same, regardless of how long that life is going to be.
The second concept is more relevant to the topic of life extension, and indeed we see hints of its relevance already. Debates about the pressures being placed on systems of social welfare often raise issues of justice between birth cohorts. Typically, the concern is that the younger generations (e.g. the Millenials) are being burdened with the costs of the older generations’ (the boomers) healthcare and retirement packages. This is thought to be unfair because it can limit the opportunities available to the younger generations. (Personal Note: I’m sceptical of this claim.)
Despite all this, it is probably the third concept that is of most interest to the life extension debate. For it is this concept of justice which focuses not just on the distributions made available to groups of persons, but to the distributions made over the course of an individual lifetime. We’ll talk about this in more detail now.
2. Stretching out the goods of life?
As mentioned in the introduction, the typical life can be broken down into a series of stages, each of which is associated with a distinct set of goods and opportunities. The ethical question we are concerned with has to do with the distribution of those goods and opportunities across the various life stages.
Of course, the precise characterisation of life stages will always be problematic and contentious. Some people will argue that any proposed division will be arbitrary and culture-specific, or that even if it is broadly true, there are many individual lives that fall outside its scope. Nevertheless, it is worth starting out with some sort of framework, even if we end up rejecting it for sound ethical and empirical reasons.
So we’ll start out with Mordacci’s suggestion that, at least within Western societies, the typical life consists of four stages: (i) the rearing/educational stage; (ii) the professional (and possibly) family creating stage; (iii) the mature/expert stage; and (iv) the retired/reduced activity stage. The kinds of goods and opportunities associated with the first stage relate primarily to leisure and education; with the second stage relate primarily to relationships and employment; with the third stage relate to personal and career fulfillment; and with the fourth stage to leisure once again. Common to all stages are the basic needs for survival (food, shelter, healthcare etc.) and other goods (friendship, knowledge etc.). That said, there is some variance both in how we think those needs ought to be met, and in terms of the volume of need, across the stages. Thus, for example, the middle two stages are often viewed as the “productive” ones, during which people are expected to meet at least some of their own basic needs, and to contribute to the basic needs of others. Similarly, demands on healthcare are typically greater during the fourth stage.
How are these stages, and their associated goods and opportunities currently distributed between the age groups? The diagram below gives a rough idea.
With this diagram in mind, and assuming we are happy with the current distribution, an obvious solution to the distributive problem presents itself. To address the problem posed by life extension, we should simply extend or “stretch out” the stages of life. Thus, instead of covering the first 25 years of life, the rearing and education stage might cover the first 35 years of life, and so on across the other stages. To some extent, we see this happening already, with an increasing number of people not entering full-time employment until their late twenties, and with compulsory retirement ages creeping gradually upwards.
But there is some reason to be skeptical of this “stretching out”-solution to the problem. For one thing, it may not be practicable. To give an example, reproductive opportunities for women — despite ongoing developments in fertility medicine — are predominantly distributed to those in their 20s and 30s. For another thing, “stretching out” lacks a clear ethical or normative foundation. We should at least consider the relevant ethical principles, and the different possibilities they raise, before we opt for this most obvious of solutions.
3. Distributive Principles and Lifespan Extension
Broadly speaking, distributive problems can be approached from one of three ethical perspectives: egalitarianism, libertarianism, and utilitarianism. Egalitarianism tries to achieve equality of some property or set of properties (e.g. goods/opportunities); libertarianism tries to protect individual liberty; and utilitarianism tries to maximise some property or set of properties. We’ll briefly consider the implications of each for the lifespan problem, though we shall spend most of our time on egalitarianism.
Before doing that, however, I want to reiterate something I said earlier about the nature of the distributive problem. When focusing on justice between age groups, the immediate concern is not necessarily with the distribution across different persons, but rather with the distribution across an average lifespan. Of course, the latter will affect the former, but it will do so in an indirect fashion.
With that in mind, let’s look at egalitarianism. There are many different schools of egalitarianism, usually varying in terms of what is they wish to equalise. If the concern is that everyone gets a equal share of certain goods (e.g. employment, health, family life, leisure time), then we have in egalitarianism a natural ally of the stretching out solution. We maintain the discrete life stages, with their distinctive set of goods, and just give everyone a slightly longer run at each stage.
One problem with this kind of egalitarianism is that it seems to impose a certain view of the good life on the individual. In other words, it smacks of us saying that the only good life is the one that involves education, professional life, family creation, mastery of career, and retirement. Many egalitarians, particularly those with liberal sentiments, are squeamish about imposing such a conception of the good life on individuals. Instead of seeking to equalise goods across the lifespan, they might prefer to equalise opportunities across a lifespan.
But what does that really mean and how can it be justified? Mordacci offers a Rawlsian approach. Rawls, as many people will know, addressed distributive problems with a creative thought experiment. Instead of assessing who should get what from our current position in the world, we should abstract away from that to something Rawls calls the “original position”. In the original position, people make distributive decisions from behind a “veil of ignorance” (i.e. unaware of the social role they will end up occupying). To solve our distributive problem, Mordacci suggests adding age-blindness to the veil of ignorance. In other words, the decision-makers are made aware of the ordinary lifespan, but not of the stage they will be at when the proposed distributive scheme is implemented.
Where would that lead us? Mordacci suggests it would lead us to a “keeping the options open”-principle. In other words, we would ensure that people are not closed off from certain opportunities at the different life stages. Inexplicably, Mordacci thinks that this would still warrant something close to the stretching out solution. He does so because he thinks this principle:
...suggests that the options which need to be open for different age groups can indeed be quite different and that therefore we have to elaborate on an image of each stage of life in terms of specific needs and opportunities.
(Mordacci, 2013, p. 418)
I fail to see why this must be the case. Specificity of needs might be fair enough, but opportunities as well? Surely, a rational decision-maker, who is unaware of what their actual age, would not wish to foreclose opportunities simply because they are old? As I see it, the keeping the options open principle mandates something much closer to a libertarian ideal, where choice and freedom are maximised through all stages of life.
Of course, an extreme version of this ideal may not be practicable — there would still need to be an initial rearing/education stage and perhaps some reduced activity/retirement stage — but perhaps something like a biased stretching out solution could work? If we think about the four-stage model given above, the middle two stages are usually those associated with the maximum degrees of freedom and opportunity: with an education in place, you can choose from a full range of life and career options. I think if I were forced to pick a distributive scheme from behind a veil of (age) ignorance, I would like that phase of life to be as long as possible.
Just to be clear, endorsing this libertarian solution does not, necessarily, lead us to endorse libertarianism as a whole. Remember, the focus is on distributions across an average lifespan, not across groups of currently existing peoples. One could (maybe) embrace a libertarian solution to lifespan distributions while at the same time accepting a more egalitarian approach to other distributive problems. (I haven’t taken the time to work this out, but it seems prima facie possible).
What then of utilitarian solutions? They will somewhat similar in that they will focus on the distribution of goods and opportunities that maximise some property. They could also justify biased forms of stretching out. For instance, if it turns out that childhood is the happiest time of life, a utilitarian might favour extending that life stage as much as possible. Or if it turns out that the maximum degree of preference satisfaction takes place during retirement, then that stage should be extended.
Of course, any form of biased stretching out solution will need to confront practical difficulties. I won’t address those right now. Instead, I’ll just conclude with the general point: biased stretching out might be an ethically preferable solution to the distribution problem posed by lifespan extension.