This paper criticizes Jerome Wakefield’s harmful dysfunction analysis of disorder by arguing that the conceptual linkage it establishes between the medical concepts of health and disorder and the prudential notions of well-being and harm makes the account inapplicable to nonsentient organisms, such as plants, fungi, and many invertebrate animals. Drawing on a previous formulation of this criticism by Christopher Boorse, and noting that Wakefield could avoid it if he adopted a partly biofunction-based account of interests like that often advocated in (...) the field of environmental ethics, I argue that integrating such an account of interests into the HDA would generate serious concerns. Specifically, it would make dysfunction sufficient for disorder and so reestablish between dysfunction and disorder precisely the kind of sufficiency relation that harm-requiring accounts of disorder strive to avoid; blur the line between the HDA’s dysfunction and harm components and, in so doing, deprive the HDA of its alleged main advantage over monistic dysfunction-based accounts of disorders like Boorse’s; and tie the HDA to an understanding of harm that is in itself problematic. I argue that these three concerns, and the dilemmas they generate, rob the HDA of much of its prima facie appeal, ultimately indicating that a satisfactory account of disorder should most likely eschew all references to prudential notions of well-being and harm. (shrink)

Despite the longstanding debate on definitions of health and disease concepts, and the multitude of accounts that have been developed, no consensus has been reached. This is problematic, as the way we define health and disease has far-reaching practical consequences. In recent contributions it is proposed to view health and disease as practical- and plural concepts. Instead of searching for a general definition, it is proposed to stipulate context-specific definitions. However, it is not clear how this should be realized. In (...) this paper, we review recent contributions to the debate, and examine the importance of context-specific definitions. In particular, we explore the usefulness of analyzing the relation between the practical function of a definition and the context it is deployed in. We demonstrate that the variety of functions that health and disease concepts need to serve makes the formulation of monistic definitions not only problematic but also undesirable. We conclude that the analysis of the practical function in relation to the context is key when formulating context-specific definitions for health and disease. At last, we discuss challenges for the pluralist stance and make recommendations for future research. (shrink)

Jonathan Y. Tsou examines and defends positions on central issues in philosophy of psychiatry. The positions defended assume a naturalistic and realist perspective and are framed against skeptical perspectives on biological psychiatry. Issues addressed include the reality of mental disorders; mechanistic and disease explanations of abnormal behavior; definitions of mental disorder; natural and artificial kinds in psychiatry; biological essentialism and the projectability of psychiatric categories; looping effects and the stability of mental disorders; psychiatric classification; and the validity of the DSM's (...) diagnostic categories. The main argument defended by Tsou is that genuine mental disorders are biological kinds with harmful effects. This argument opposes the dogma that mental disorders are necessarily diseases that result from biological dysfunction. Tsou contends that the broader ideal of biological kinds offers a more promising and empirically ascertainable naturalistic standard for assessing the reality of mental disorders and the validity of psychiatric categories. (shrink)

The concept of disease remains hotly contested. In light of problems with existing accounts, some theorists argue that the disease concept ought to be eliminated. We answer this skeptical challenge by reframing the discussion in terms of the role that the disease concept plays in the complex network of health-care institutions in which it is deployed. We argue that while prevailing accounts do not suffer from the particular defects that critics have identified, they do suffer from other deficits, and this (...) leads us to propose a new account that satisfies the desiderata for a concept of disease in human medicine. (shrink)

‘Gender disappointment’ is the feeling of sadness when a parent’s strong desire for a child of a certain sex is not realised. It is frequently mentioned as a reason behind parents’ pursuit of sex selection for social reasons. It also tends to be framed as a mental disorder on a range of platforms including the media, sex selection forums and among parents who have been interviewed about sex selection. Our aim in this paper is to investigate whether ‘gender disappointment’ represents (...) a unique diagnosis. We argue that ‘gender disappointment’ does not account for a unique, distinct category of mental illness, with distinct symptoms or therapy. That said, we recognise that parents’ distress is real and requires psychological treatment. We observe that this distress is rooted in gender essentialism, which can be addressed at both the individual and societal level. (shrink)

This paper presents the interpersonal variability of harm challenge to Jerome Wakefield’s harmful-dysfunction account (HDA) of disorder. This challenge stems from the seeming fact that what promotes well-being or is harmful to someone varies much more across individuals than what is intuitively healthy or disordered. This makes it at least prima facie difficult to see how judgments about health and disorder could, as harm-requiring accounts of disorder like the HDA maintain, be based on, or closely linked to, judgments about well-being (...) and harm. This interpersonal variability of harm challenge is made salient by the difficulty faced by harm-requiring accounts of disorder in dealing satisfactorily with cases of intuitively disordered conditions that seem harmless because they do not deprive the individuals that they affect of anything that they value (e.g., desired infertility). I argue that this challenge is made more serious for the HDA by some clarifications Wakefield has recently made on harm. In recent publications, Wakefield dissociates himself from the sheer cultural-relativist view of harm attributed to him by some critics based on his linkage of harm to social values, and adopts a more qualified social-values-based view of harm that leaves room for criticism of the values endorsed by members of a cultural group at a given time. I show how Wakefield’s qualified view makes it more difficult for the HDA to deal with the interpersonal variability of harm challenge, at least when applied to a Western cultural context where a high value is placed on autonomy and individual choice. (shrink)

In this article, I side with those who argue that the debate about the definition of “disease” should be reoriented from the question “what is disease” to the question of what it should be. However, I ground my argument on the rejection of the naturalist approach to define disease and the adoption of a normativist approach, according to which the concept of disease is normative and value-laden. Based on this normativist approach, I defend two main theses: (1) that conceptual analysis (...) is not the right method to define disease and that conceptual engineering should be the preferred method and (2) that the method of conceptual engineering should be implemented following the principles of Alexandrova’s account of social objectivity in the context of the definition of disease. (shrink)

The recurring claim that the construct of psychopathy is value laden often is not qualified in enough detail. The chapters in this part of the volume, instead, investigate in depth the role and significance of values in different aspects of the construct of psychopathy. Following these chapters, but also by offering a background to them, we show how certain values are involved in the characterisation of psychopathy, inform societal needs satisfied by this construct, and have a central role in determining (...) whether psychopathy is a mental disorder. Moreover, we relate this description to our criticism of the view that the entrenchment of the notion of psychopathy with values in principle renders it irreconcilable with sound psychiatric theory and practice. However, we also recognize that the value-ladenness of psychopathy leaves open other important challenges. Meeting them needs addressing interdisciplinary interrelated issues that have empirical, normative, and theoretical dimensions. (shrink)

In ‘Rethinking Disease’, Powell and Scarffe1 propose what in effect is a modification of Jerome Wakefield’s2 3 harmful dysfunction analysis (HDA) of medical (including mental) disorder. The HDA maintains that ‘disorder’ (or ‘disease’ in Powell and Scarffe’s terminology) is a hybrid factual and value concept requiring that a biological dysfunction, understood as a failure of some feature to perform a naturally selected function, causes harm to the individual as evaluated by social values. Powell and Scarffe accept both the HDA’s evolutionary (...) biological function component and its incorporation of a value component. Their proposed ‘new twist’ is to revise the value component: ‘Our proposed definition of disease is as follows: a biomedical state is a disease only if it implicates a biological dysfunction that is, or would be, properly disvalued’. So, they propose that a disorder is a ‘properly disvalued dysfunction’ rather than a ‘harmful dysfunction’, an approach they term ‘thickly normative’ in contrast to the thin normative approach of the HDA. There has been a surge of interest recently in better understanding the ‘harm’ component of the HDA. Powell and Scarffe’s analysis is a helpful contribution to this discussion. We focus here exclusively on their proposal regarding the analysis of the concept of disorder and ignore many important related issues that the authors address, ranging from prioritising resource allocation between disorders and non-disorders to whether the concept of disorder should be replaced by a generic welfarist concept. The resolution of these additional issues depends on first understanding ‘disorder’. The authors’ proposed changes to the HDA also deserve evaluation because the HDA, which has been endorsed by leading nosologists,4 plays an influential role in nosological debate across categories of disorder ranging, for example, from sexual paraphilias5 to psychopathy.6 A basic problem is that Powell and Scarffe misinterpret …. (shrink)

In this paper, my goal is to use an epistemic injustice framework to extend an existing normative analysis of over-medicalization to psychiatry and thus draw attention to overlooked injustices. Kaczmarek has developed a promising bioethical and pragmatic approach to over-medicalization, which consists of four guiding questions covering issues related to the harms and benefits of medicalization. In a nutshell, if we answer “yes” to all proposed questions, then it is a case of over-medicalization. Building on an epistemic injustice framework, I (...) will argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to answer the four questions, and I will import the conceptual resources of epistemic injustice to guide our thinking on these issues. This will lead me to defend more inclusive decision-making procedures regarding medicalization in the DSM. Kaczmarek’s account complemented with an epistemic injustice framework can help us achieve better forms of medicalization. I will then use a contested case of medicalization, the creation of Premenstrual Dysphoric Disorder in the DSM-5 to illustrate how the epistemic injustice framework can help to shed light on these issues and to show its relevance to distinguish good and bad forms of medicalization. (shrink)

In this paper I argue that the value attributed to coral reefs drives the characterisation of evidence for their regeneration or degradation. I observe that regeneration and degradation depend on an understanding of what an ecosystem looks like when undegraded (a baseline), and that many mutually exclusive baselines can be given for any single case. Consequently, facts about ecological processes are insufficient to usefully and non-arbitrarily characterise changes to ecosystems. By examining how baselines and the value of reefs interact in (...) coral and algal reef examples, I argue that considering the value of an ecosystem is a necessity when describing processes like regeneration and degradation. This connects value as studied in socio-ecological and economic research with values as discussed in the philosophy of science literature. It also explains why such a broad range of processes may be considered regenerative, including those which introduce significant novelty, as well as pointing towards ways to mediate related debates, such as those surrounding novel and ‘pristine’ ecosystems. (shrink)

The notion of harm has been a recurring and a significant notion in the characterization of mental disorder. It is present in eminent diagnostic manuals such as DSM and ICD, as well as in the discussion on mental disorders in philosophy of psychiatry. Recent demotion of harm in the definition of mental disorders in DSM-5 shows a general trend towards reducing the significance of harm when thinking about the nature of mental disorders. In this paper, we defend the relevance of (...) the notion of harm in the characterization of mental disorder against some of these attacks. We approach this issue by using the method of conceptual explication pioneered by Rudolf Carnap. Within this framework, we argue that keeping the notion of harm not only helps to discriminate what is pathological from the nonpathological but also prevents potential misuses of psychiatric authority. (shrink)

In this short commentary, I reflect on the new definition of disease proposed by Powell and Scarffe. I suggest that the method they appeal to as objective, namely, rational justification, is open to several criticisms, which I outline and discuss.

Science and technology have vastly expanded the realm of medicine. The numbers of and knowledge about diseases has greatly increased, and we can help more people in many more ways than ever before. At the same time, the extensive expansion has also augmented harms, professional responsibility, and ethical concerns. While these challenges have been studied from a wide range of perspectives, the problems prevail. This article adds value to previous analyses by identifying how the moral imperative of medicine has expanded (...) in three ways: (1) from targeting experienced phenomena, such as pain and suffering, to non-experienced phenomena (paraclinical signs and indicators); (2) from addressing present pain to potential future suffering; and (3) from reducing negative wellbeing (pain and suffering) to promoting positive wellbeing. These expansions create and aggravate problems in medicine: medicalization, overdiagnosis, overtreatment, risk aversion, stigmatization, and healthism. Moreover, they threaten to infringe ethical principles, to distract attention and responsibility from other competent agents and institutions, to enhance the power and responsibility of professionals, and to change the professional-beneficiary relationship. In order to find ways to manage the moral expansion of medicine, four traditional ways of setting limits are analyzed and dismissed. However, basic asymmetries in ethics suggest that it is more justified to address people’s negative wellbeing (pain and suffering) than their positive wellbeing. Moreover, differences in epistemology, indicate that it is less uncertain to address present pain and suffering than future wellbeing and happiness. Based on these insights the article concludes that the moral imperative of medicine has a gradient from pain and suffering to wellbeing and happiness, and from the present to the future. Hence, in general present pain and suffering have normative priority over future positive wellbeing. (shrink)

The development of gene therapy has always come with the expectation that it will offer a cure for various disorders, of which hemophilia is a paradigm example. However, although the term is used regularly, it is unclear what exactly is meant with “cure”. Therefore, the aim of this paper is to analyse how the concept of cure is used in practice and evaluate which of the interpretations is most suitable in discussions surrounding gene therapy. We analysed how cure is used (...) in four different medical fields where the concept raises discussion. We show that cure can be used in three different ways: cure as normalization of the body, cure as obtaining a normal life, or cure as a change in identity. We argue that since cure is a practical term, its interpretation should be context-specific and the various uses can exist simultaneously, as long as their use is suitable to the function the notion of cure plays in each of the settings. We end by highlighting three different settings in the domain of hemophilia gene therapy in which the term cure is used and explore the function(s) it serves in each setting. We conclude that in the clinical application of gene therapy, it could be better to abandon the term cure, whereas more modest and specified definitions of cure are required in the context of health resource allocation decisions and decisions on research funding. (shrink)

This paper addresses the Harmful Dysfunction Analysis of mental disorder. We argue that some mental conditions meet both of its criteria —the dysfunction criterion and the harm criterion— and yet should not count as mental disorders because of their value. We contend that the harm criterion, by taking harm as a proxy for disvalue, is an inadequate normative criterion in these cases. Therefore, further ethical considerations should be included as a normative criterion. To illustrate our view, we draw on the (...) experience and reflections of Jean Améry, a philosopher and Holocaust survivor who resisted the diagnosis of KZ-Syndrom. (shrink)

Russell Powell and Eric Scarffe1 are pluralists about disease. They offer their thickly normative account to meet the needs of doctors, but they allow that a different concept of disease might work better for zoologists. In this commentary, I grant that Powell and Scarffe’s thickly normative evaluation of biological dysfunction works well in many medicinal contexts. Powell and Scarffe respond effectively to eliminativists—we should retain the concept of disease. But the paper’s pluralism and focus on the specific needs of institutions (...) should permit us to eliminate the notion of disease from domains for which the historical grounding of their selected effects account of function are contrary to therapeutic goals. One such domain is mental health. I found Powell and Scarffe’s rejection of Boorse’s dispositional account of biological function persuasive—the selected effects account of function is a superior fit for biologists’ use of the term. But the historical nature of this concept is, at best, a distraction from the task of morally evaluating the many ways in which …. (shrink)

Psychiatric involvement in patient morality is controversial. If psychiatrists are tasked with shaping patient morality, the coercive potential of psychiatry is increased, treatment may be unfairly administered on the basis of patients’ moral beliefs rather than medical need, moral disputes could damage the therapeutic relationship and, in any case, we are often uncertain or conflicted about what is morally right. Yet, there is also a strong case for the view that psychiatry often works through improving patient morality and, therefore, should (...) aim to do so. Our goal is to offer a practical and ethical path through this conflict. We argue that the default psychiatric approach to patient morality should be procedural, whereby patients are helped to express their own moral beliefs. Such a procedural approach avoids the brunt of objections to psychiatric involvement in patient morality. However, in a small subset of cases where patients’ moral beliefs are sufficiently distorted or underdeveloped, we claim that psychiatrists should move to a substantive approach and shape thecontentof those beliefs when they are relevant to psychiatric outcomes. The substantive approach is prone to the above objections but we argue it is nevertheless justified in this subset of cases. (shrink)

The articles in this issue direct our attention to the role of concepts in medical ethics. The issue includes research that defines a concept,1 research that applies concepts to illuminate the moral aspects of various elements of medicine,2 3 and research investigating the appropriate set of concepts to teach medical students.4 In their in-depth exploration of the concept of disease in this issue, Powell and Scarffe argue that our understanding of a concept should be ‘tailored to the role that the (...) concept plays in the institutional settings in which it is deployed’.1 Their methodology takes seriously the institutional context in which a concept operates. This approach to thinking about concepts is potentially applicable very broadly in medical ethics. What is the institutional role that a concept plays? What is the work that we need the concept to do? The feature article by Powell and Scarffe proposes a new definition of a foundational concept in medicine, that of disease. On their view, ‘a biomedical state is a disease only if it implicates a biological dysfunction that is, or would be, properly disvalued’.1 They describe their definition as involving both a moral criterion (of being ‘properly disvalued’) and a biological criterion (of biological dysfunction). A number of commentators engage with Powell and Scarffe’s proposal. Tekin focuses on the moral criterion, through the example of grief and depression. …. (shrink)