According to a common philosophical intuition, the deep nature of things is hidden from us, and the world as we know it through perception and science is somehow shallow and lacking in reality. For all we knwo, the intuition goes, we could be living in a cave facing shadows, in a dream or even in a computer simulation, This “intuition of unreality” clashes with a strong, but perhaps more naive, intuition to the effect that the world as we know it (...) seems perfectly real. Shadows, dreams, or informational structures appear too unreal to be identical to the world as we know it! This clash between the two intuitions forms the basis of the "problem of reality." At the turn of the nineteenth century psychiatrists encountered patients they referred to as “metaphysician doubters” who constantly questioned the reality of the world. This essay draws on the study of these patients to reject, and indeed diagnose, the intuition of unreality and recent metaphysical doctrines drawing on it, such as structuralism, digitalism, and virtual realism. (shrink)

Social ontology focuses on questions about the reality of human categories. The typical examples are gender and race. Common questions about them are: Do they exist? What is their nature? Do they exist in the best possible way? Meanwhile, the philosophy of psychiatry has been discussing the reality of psychopathology, what is the best way to classify mental disorders, and whether it is possible to define them without normative vocabulary. I think there is something not only strange but inadequate about (...) these discussions being held apart. Particularly, I hold that by being held separately these discussions are philosophically incomplete. In this paper, I argue that these debates are parallel in crucial aspects, but more importantly that they can benefit from each other if they start a dialogue. I suggest some paths we can take to start fruitful discussions and offer examples of the kind of outcomes we can expect. However, my main contribution is to sketch a common framework to map current discussions, make comparisons between them, and, more importantly, guide new research. (shrink)

In this paper, I defend a version of the medical model of disability, which defines disability as an enduring biological dysfunction that causes its bearer a significant degree of impairment. We should accept the medical model, I argue, because it succeeds in capturing our judgments about what conditions do and do not qualify as disabilities, because it offers a compelling explanation for what makes a condition count as a disability, and because it justifies why the federal government should spend hundreds (...) of billions of dollars, annually, on aid and accommodations for disabled people. After responding to a pair of objections Elizabeth Barnes has raised against the medical model, I contrast it with Guy Kahane and Julian Savulescu's welfarist account of disability, and with Barnes's own mere-difference view. Both of these accounts face serious challenges, although elements of Barnes's view can—and, in my opinion, should—be adopted by proponents of the medical model. (shrink)

The status of risk factors and disease remains a disputed question in the theory and practice of medicine and healthcare, and so does the related question of delineating disease boundaries. I present a framework based on Bernard Lonergan’s account of emergent probability for differentiating (1) generically distinct levels of systematic function within organisms and between organisms and their environments and (2) the methods of functional, genetic, and statistical investigation. I then argue on this basis that it is possible to understand (...) disease in terms of biological or higher intra-level dysfunction, risk factors—including genetic risk factors—in terms of statistical inter-level conditioning of a given stage or developmental sequence of systematic functioning, and the empirical boundaries of disease in terms of the limits of both functional categorization (from an epistemic standpoint) and upper-level integration of lower-level processes and events (from an ontological standpoint). (shrink)

Philosophers of medicine have formulated different accounts of the concept of disease. Which concept of disease one assumes has implications for what conditions count as diseases and, by extension, who may be regarded as having a disease and for who may be accorded the social privileges and personal responsibilities associated with being sick. In this article, we consider an ideal diagnostic test for coronavirus disease 2019 infection with respect to four groups of people—positive and asymptomatic; positive and symptomatic; negative; and (...) untested—and show how different concepts of disease impact on the disease and sickness judgements for these groups. The suggestion is that sickness judgements and social measures akin to those experienced during the current COVID-19 outbreak presuppose a concept of disease containing social harm as a component. We indicate the problems that arise when adopting this kind of disease concept beyond a state of emergency. (shrink)

This paper explores the impact that developments in the field of neuroprosthetics will have on the ethical viability of healthy limb amputation, specifically in cases of Body Integrity Identity Dis...

In this paper, I argue for a new way to understand the integration of facts and values in the concept of mental disorder that has the potential to avoid the flaws of previous hybrid approaches. I import conceptual tools from the account of procedural objectivity defended by Helen Longino to resolve the controversy over the definition of mental disorder. My argument is threefold: I first sketch the history of the debate opposing objectivists and constructivists and focus on the criticisms that (...) led to the emergence of the debate. Second, I offer a reconstruction of the “Natural Function Approach” argument to make explicit an unsound assumption underlying this approach. The reconstruction will allow me to show that the NFO’s argument depends on the ideal of value-free science that I will criticize. Then I propose an alternative ideal for psychiatry: social objectivity. I argue that the concept of mental health should be seen as “socially objective” rather than value-free, moving the debate towards the social procedures by which the definition is produced rather than the normative and factual content of its definition. (shrink)

In recent years both philosophers and scientists have asked whether or not our current kinds of mental disorder—e.g., schizophrenia, depression, bipolar disorder—are natural kinds; and, moreover, whether or not the search for natural kinds of mental disorder is a realistic desideratum for psychiatry. In this dissertation I clarify the sense in which a kind can be said to be “natural” or “real” and argue that, despite a few notable exceptions, kinds of mental disorder cannot be considered natural kinds. Furthermore, I (...) contend that psychopathological phenomena do not cluster together into kinds in the way that paradigmatic natural kinds (e.g., chemical kinds and species) do; and, in light of this fact, I conclude that the normative ideal of natural classification—i.e. classifying real or natural kinds—is not appropriate as a general strategy for psychiatry. In the conclusion to this dissertation I propose an alternative way forward. Rather than assuming a priori that psychopathological phenomena cluster together into kinds, a more tractable and theoretically promising approach would be to first explain how particular kinds of experiences and behaviours—e.g, hallucinations, delusions, disorganized thinking, mania, low mood, etc.—are produced. (shrink)

Despite several decades of debate, the concept of disease remains hotly contested. The debate is typically cast as one between naturalism and normativism, with a hybrid view that combines elements of each staked out in between. In light of a number of widely discussed problems with existing accounts, some theorists argue that the concept of disease is beyond repair and thus recommend eliminating it in a wide range of practical medical contexts. Any attempt to reframe the ‘disease’ discussion should answer (...) the more basic sceptical challenge, and should include a meta-methodological critique guided by our pragmatic expectations of what the disease concept ought to do given that medical diagnosis is woven into a complex network of healthcare institutions. In this paper, we attempt such a reframing, arguing that while prevailing accounts do not suffer from the particular defects that prominent critics have identified, they do suffer from other deficits—and this leads us to propose an amended hybrid view that places objectivist approaches to disease on stronger theoretical footing, and satisfies the institutional-ethicaldesiderataof a concept of disease in human medicine. Nevertheless, we do not advocate a procrustean approach to ‘disease’. Instead, we recommend disease concept pluralism between medical and biological sciences to allow the concept to serve the different epistemic and institutional goals of these respective disciplines. (shrink)

RésuméCet article examine la manière dont Michel Foucault se rapporte à la psychologie et à la psychopathologie phénoménologiques dans les années 1950, à la lumière des nouvelles sources documentaires que nous avons aujourd’hui à notre disposition. Notre contribution se concentre en particulier sur le manuscrit inédit de l’un des cours donnés par Foucault à l’université de Lille entre 1952 et 1954 : le cours sur « Binswanger et la phénoménologie ». L’analyse de ce cours, conçu par Foucault dans le contexte (...) d’une réflexion philosophique sur le problème anthropologique de la psychopathologie, nous permettra enfin de restituer à Foucault la place qui lui revient dans le domaine de la « philosophie de la psychiatrie ». (shrink)

There is a conceptual crisis in the biomedical sciences that is particularly salient in psychopathology research. Underlying the crisis is a controversy that pertains to the current medical model of disease that largely draws from causal-mechanistic explanations. The bedrock of this model is the analysis of biological part-dysfunctions that aims at unequivocally defining a pathological condition and demarcating it from its neighboring entities. This endeavor has led to a quest for physiological, biochemical, and genetic signatures. Yet, so far there is (...) little evidence for reliable biomarkers for any mental disorder. The contemporary biomedical paradigm largely ignores historical, dynamic, and system-level aspects—a view that has contributed much to the conceptual disjunction of the patient as a person from his/her disease. Notwithstanding the impressive progress in the biomedical sciences, increasingly more critics question whether the constituting framework is sufficient to convey a comprehensive understanding of illnesses, especially mental illnesses. Thus, the medical model urgently requires an update. But rather than revamping it by methodological advancements, it will be necessary to critically review its philosophical roots. The most problematic issues that require reworking are: the preponderance of the biostatistical theory; the undue decoupling of physiological from evolutionary explanations of function; the clinging to the Modern Synthesis ; and the neglect of dynamic and system-level properties. The proposed overhaul requires the heeding of historical explanations that draw from the Extended Evolutionary Synthesis as well as systems biology approaches for tackling multilevel and dynamic phenomena of complex systems. (shrink)

In this paper I discuss the scientific respectability of delusion as a psychiatric category. First, I present the essentialist objection to the natural kindhood of psychiatric categories, as well as non-essentialism about natural kinds as a response to that objection. Second, I present a nuanced classification of kinds of kinds. Third, drawing on the claim that the attribution of delusion relies on a folk psychological underpinning, I present the mind-dependence objection to the natural kind status of delusion. Finally, I argue (...) that even if delusion as a generic kind stands little chance of being vindicated as a non-essentialist natural kind, we stand to gain from a natural kind methodology regarding subtypes of delusion for which there is evidence of genuine causal signatures and mechanisms. (shrink)

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. Addiction is currently classified as a medical disorder in DSM-5 and ICD-10. It is further labeled a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Lewis argues that the changes result instead from normal neuroplasticity (...) and learning in response to the intense rewards provided by addictive substances, thus that addiction is not a brain disease and by implication not a medical disorder at all. I argue that even if one accepts Lewis’s reinterpretation of the brain evidence, his conclusions do not follow. Relying on my harmful-dysfunction analysis of medical disorder, I defend the view that substance addiction is in fact a medical disorder and a brain disorder. In Part 1, I identify five arguments Lewis puts forward against the brain-disease view and evaluate them as arguments that addiction is not a disorder: Addiction is not a chronic, relapsing condition; There is no clear boundary between addiction and other strong desires; Negative consequences are not unique to disorders; The brain disease model does not account for behavioral addictions; and, Addiction is like love. I argue that Lewis’s arguments are invalid because they fail to take account of the context of addiction and its relation to biological design. (shrink)

This paper addresses philosophical issues concerning whether mental disorders are natural kinds and how the DSM should classify mental disorders. I argue that some mental disorders (e.g., schizophrenia, depression) are natural kinds in the sense that they are natural classes constituted by a set of stable biological mechanisms. I subsequently argue that a theoretical and causal approach to classification would provide a superior method for classifying natural kinds than the purely descriptive approach adopted by the DSM since DSM-III. My argument (...) suggests that the DSM should classify natural kinds in order to provide predictively useful (i.e., projectable) diagnostic categories and that a causal approach to classification would provide a more promising method for formulating valid diagnostic categories. (shrink)

I argue that ductal carcinoma in situ (DCIS), the tumor most commonly diagnosed by breast mammography, cannot be confidently classified as cancer, that is, as pathological. This is because there may not be dysfunction present in DCIS—as I argue based on its high prevalence and the small amount of risk it conveys—and thus DCIS may not count as a disease by dysfunction-requiring approaches, such as Boorse’s biostatistical theory and Wakefield’s harmful dysfunction account. Patients should decide about treatment for DCIS based (...) on the risks it poses and the risks and benefits of treatment, not on its disease status. (shrink)

Christopher Boorse’s biostatistical theory of medical disorder claims that biological part-dysfunction (i.e., failure of an internal mechanism to perform its biological function), a factual criterion, is both necessary and sufficient for disorder. Jerome Wakefield’s harmful dysfunction analysis of medical disorder agrees that part-dysfunction is necessary but rejects the sufficiency claim, maintaining that disorder also requires that the part-dysfunction causes harm to the individual, a value criterion. In this paper, I present two considerations against the sufficiency claim. First, I analyze Boorse’s (...) central argument for the sufficiency claim, the “pathologist argument,” which takes pathologists’ intuitions about pathology as determinative of medical disorder and conclude that it begs the question and fails to support the sufficiency claim. Second, I present four counterexamples from the medical literature in which salient part-dysfunctions are considered nondisorders, including healthy disease carriers, HIV-positive status, benign mutations, and situs inversus totalis, thus falsifying the sufficiency claim and supporting the harm criterion. (shrink)

This paper examines what it is for a condition to be a disease. It falls into two sections. In the first I examine the best existing account of disease (as proposed by Christopher Boorse) and argue that it must be rejected. In the second I outline a more acceptable account of disease. According to this account, by disease we mean a condition that it is a bad thing to have, that is such that we consider the afflicted person to have (...) been unlucky, and that can potentially be medically treated. All three criteria must be fulfilled for a condition to be a disease. The criterion that for a condition to be a disease it must be a bad thing is required to distinguish the biologically different from the diseased. The claim that the sufferer must be unlucky is needed to distinguish diseases from conditions that are unpleasant but normal, for example teething. Finally, the claim that for a condition to be a disease it must be potentially medically treatable is needed to distinguish diseases from other types of misfortune, for example economic problems and legal problems. (shrink)

Use of medication for treatment of ADHD (or its historical precursors) has been debated for more than forty years. Reasons for the ongoing differences of opinion are analyzed by exploring some of the arguments for and against considering ADHD a mental disorder. Relative to two important DSM criteria — that a mental disorder causes some sort of harm to the individual and that a mental disorder is the manifestation of a dysfunction in the individual — ADHD’s classification as a mental (...) disorder is found to be contentiously value-laden. The disagreements spill over to reasoning regarding appropriate management, because justification for a drug prescription is in part predicated on the idea that the drugs manage mental disorders. These debates do not appear to be nearing resolution, so individuals offering advice, or trying to decide whether ADHD drugs are appropriate for themselves or their children, may find it helpful to compare the values underlying various perspectives with their own. (shrink)

Conceptual analysis of health and disease is portrayed as consisting in the confrontation of a set of criteria—a “definition”—with a set of cases, called instances of either “health” or “ disease.” Apart from logical counter-arguments, there is no other way to refute an opponent’s definition than by providing counter-cases. As resorting to intensional stipulation is not forbidden, several contenders can therefore be deemed to have succeeded. This implies that conceptual analysis alone is not likely to decide between naturalism and normativism. (...) An alternative to this approach would be to examine whether the concept of disease can be naturalized. (shrink)

In view of the publication of the DSM-V researchers were asked to discuss the theoretical implications of the definition of mental disorders. The reasons for the use, in the DSM-III, of the term disorder instead of disease are considered. The analysis of these reasons clarifies the distinction between the general definition of disorder and its implicit, technical meaning which arises from concrete use in DSM disorders. The characteristics and limits of this technical meaning are discussed and contrasted to alternative definitions, (...) like Wakefield’s harmful/dysfunction analysis. It is shown that Wakefield’s analysis faces internal theoretical problems in addition to practical limits for its acceptance in the DSM-V. In particular, it is shown that: a) the term dysfunction is not purely factual but intrinsically normative/evaluative; b) it is difficult to clarify what dysfunctions are in the psychiatric context (the dysfunctional mechanism involved being unknown in most cases and the use of evolutionary theory being even more problematic); c) the use of conceptual analysis and commonsense intuition to define dysfunctions leaves unsatisfied empiricists; d) it is unlikely that the authors of the DSM-V will accept Wakefield’s suggestion to revise the diagnostic criteria of any single DSM disorder in accordance with his analysis, because this is an excessively extensive change and also because this would probably reduce DSM reliability. In conclusion, it is pointed up in which sense DSM mental disorders have to be conceived as constructs, and that this undermines the realistic search for a clear-cut demarcation criterion between what is disorder and what is not. (shrink)

Although the definition of a mental disorder has remained essentially the same from Diagnostic and Statistical Manual of Mental Disorder, Third Edition, Revised (DSM-III-R) through DSM-IV to DSM-IV-TR, the account of the paraphilias has changed continually. Although the definition in all the DSMs explicitly rules out deviant sexual behavior as sufficient for labeling someone as having a mental disorder, deviant sexual behavior counts as sufficient for all the paraphilias in DSM-III-R. In DSM-IV, the account of all the paraphilias is made (...) consistent with the definition. In DSM-IV-TR, mere deviant sexual behavior is not sufficient for being classified as having a paraphilia, but immoral deviant sexual behavior is. Thus, in DSM-IV-TR, only those paraphilias that involve immoral deviant sexual behavior are inconsistent with the definition, but deviant sexual behavior by itself does not count as a mental disorder. (shrink)

Current symptom-based DSM and ICD diagnostic criteria for mental disorders are prone to yielding false positives because they ignore the context of symptoms. This is often seen as a benign flaw because problems of living and emotional suffering, even if not true disorders, may benefit from support and treatment. However, diagnosis of a disorder in our society has many ramifications not only for treatment choice but for broader social reactions to the diagnosed individual. In particular, mental disorders impose a sick (...) role on individuals and place a burden upon them to change; thus, disorders decrease the level of respect and acceptance generally accorded to those with even annoying normal variations in traits and features. Thus, minimizing false positives is important to a pluralistic society. The harmful dysfunction analysis of disorder is used to diagnose the sources of likely false positives, and propose potential remedies to the current weaknesses in the validity of diagnostic criteria. (shrink)

Accounts of the concepts of function and dysfunction have not adequately explained what factors determine the line between low‐normal function and dysfunction. I call the challenge of doing so the line‐drawing problem. Previous approaches emphasize facts involving the action of natural selection (Wakefield 1992a, 1999a, 1999b) or the statistical distribution of levels of functioning in the current population (Boorse 1977, 1997). I point out limitations of these two approaches and present a solution to the line‐drawing problem that builds on the (...) second one. (shrink)

. Current debates concerning the concept of mental disorder involve many different philosophical issues. However, it is not always clear from these discussions how, or whether, these issues relate to one another, or in exactly what way they are important for the definition of disorder. This article aims to sort through some of the philosophical issues that arise in the current literature and provide a clarification of how these issues are related to one another and whether they are necessary for (...) defining disorder. I argue that the main concern in defining disorder, namely demarcation, is obscured by a number of these other philosophical issues and that a focus on demarcation gives us a means of placing these other issues in a clarifying context. (shrink)

If ecological systems are functionally organised, they can possess functions or malfunctions. Natural function would provide justification for conservationists to act for the protection of current ecological arrangements and control the presence of populations that create ecosystem malfunctions. Invasive species are often thought to be malfunctional for ecosystems, so functional arrangement would provide an objective reason for their control. Unfortunately for this prospect, I argue no theory of function, which can support such normative conclusions, can be applied to large scale (...) ecosystems. Instead ecological systems have causal structure, with small clusters of populations achieving functional arrangement. This, however, does not leave us without reason to control invasive species. We can look at the causal arrangement of ecological systems for populations that support ecological features that we should preserve. Populations that play a causal role in reducing biodiversity should be controlled, because biodiversity is a good all prudent agents should want to preserve. (shrink)

This article investigates five kinds of vagueness in medicine: disciplinary, ontological, conceptual, epistemic, and vagueness with respect to descriptive-prescriptive connections. First, medicine is a discipline with unclear borders, as it builds on a wide range of other disciplines and subjects. Second, medicine deals with many indistinct phenomena resulting in borderline cases. Third, medicine uses a variety of vague concepts, making it unclear which situations, conditions, and processes that fall under them. Fourth, medicine is based on and produces uncertain knowledge and (...) evidence. Fifth, vagueness emerges in medicine as a result of a wide range of fact-value-interactions. The various kinds of vagueness in medicine can explain many of the basic challenges of modern medicine, such as overdiagnosis, underdiagnosis, and medicalization. Even more, it illustrates how complex and challenging the field of medicine is, but also how important contributions from the philosophy can be for the practice of medicine. By clarifying and, where possible, reducing or limiting vagueness, philosophy can help improving care. Reducing the various types of vagueness can improve clinical decision-making, informing individuals, and health policy making. (shrink)

Normativism holds that there is a close conceptual link between disease and disvalue. We challenge normativism by advancing an argument against a popular normativist theory, Jerome Wakefield’s harmful dysfunction account. Wakefield maintains that medical disorders are breakdowns in evolved mechanisms that cause significant harm to the organism. We argue that Wakefield’s account is not a promising way to distinguish between disease and health because being harmful is neither necessary nor sufficient for a dysfunction to be a disorder. Counterexamples to the (...) harmful dysfunction account are considered, such as mild infections, perceptual deficits, and beneficial illnesses. Then we consider two ways of amending the harmful dysfunction account to address these cases and argue that the proposed amendments raise even more serious problems for this account. These problems apply generally to any normativist theory and raise doubts about the entire normative approach to the philosophy of health and disease. (shrink)

There is a conceptual crisis in the biomedical sciences that is particularly salient in psychopathology research. Underlying the crisis is a controversy that pertains to the current medical model of disease that largely draws from causal-mechanistic explanations. The bedrock of this model is the analysis of biological part-dysfunctions that aims at unequivocally defining a pathological condition and demarcating it from its neighboring entities. This endeavor has led to a quest for physiological, biochemical, and genetic signatures. Yet, so far there is (...) little evidence for reliable biomarkers for any mental disorder. The contemporary biomedical paradigm largely ignores historical, dynamic, and system-level aspects—a view that has contributed much to the conceptual disjunction of the patient as a person from his/her disease. Notwithstanding the impressive progress in the biomedical sciences, increasingly more critics question whether the constituting framework is sufficient to convey a comprehensive understanding of illnesses, especially mental illnesses. Thus, the medical model urgently requires an update. But rather than revamping it by methodological advancements, it will be necessary to critically review its philosophical roots. The most problematic issues that require reworking are: the preponderance of the biostatistical theory; the undue decoupling of physiological from evolutionary explanations of function; the clinging to the Modern Synthesis ; and the neglect of dynamic and system-level properties. The proposed overhaul requires the heeding of historical explanations that draw from the Extended Evolutionary Synthesis as well as systems biology approaches for tackling multilevel and dynamic phenomena of complex systems. (shrink)

New technologies facilitate the enhancement of a wide range of human dispositions, capacities, or abilities. While it is argued that we need to set limits to human enhancement, it is unclear where we should find resources to set such limits. Traditional routes for setting limits, such as referring to nature, the therapy-enhancement distinction, and the health-disease distinction, turn out to have some shortcomings. However, upon closer scrutiny the concept of enhancement is based on vague conceptions of what is to be (...) enhanced. Explaining why it is better to become older, stronger, and more intelligent presupposes a clear conception of goodness, which is seldom provided. In particular, the qualitative better is frequently confused with the quantitative more. We may therefore not need “external” measures for setting its limits – they are available in the concept of enhancement itself. While there may be shortcomings in traditional sources of limit setting to human enhancement, such as nature, therapy, and disease, such approaches may not be necessary. The specification-of-betterment problem inherent in the conception of human enhancement itself provides means to restrict its unwarranted proliferation. We only need to demand clear, sustainable, obtainable goals for enhancement that are based on evidence, and not on lofty speculations, hypes, analogies, or weak associations. Human enhancements that specify what will become better, and provide adequate evidence, are good and should be pursued. Others should not be accepted. (shrink)

This essay defends the controversial and indeed counterintuitive claim that there is a good argument to be made from a Lockean perspective for government action to guarantee access to health care. The essay maintains that this argument is in some regards more robust than the well-known argument in defense of universal health care spelled out by Norman Daniels, which this essay also examines in some detail. Locke's view that government should protect people's lives, property, and freedom–where freedom is understood as (...) independence and self-determination–justifies government action to ensure access to health care, because (roughly), just as individuals cannot protect themselves from crime and foreign invasion, so individuals are unable to provide for their own health care. Defense from disease is as important as defense from crime, and–although this is arguable–government action to guarantee access to health care does not itself undermine freedom. (shrink)

Although delusion is one of the central concepts of psychopathology, it stills eludes precise conceptualization. In this paper, I present certain basic issues concerning the classification and definition of delusion, as well as its ontological status. By examining these issues, I aim to shed light on the ambiguity of the clinical term ‘delusion’ and its extension, as well as provide clues as to why philosophers are increasingly joining the ranks of psychiatrists, psychologists, and neuroscientists in the effort to come to (...) a comprehensive understanding of delusion. (shrink)

This paper tests the predictions of an epistemological model that considered the DSM psychiatric classification (in the neopositivist and neo-Kraepelinian shape introduced by the DSM-III) as a scientific paradigm in crisis. As predicted, the DSM-5 did not include revolutionary proposals in its basic structure. In particular, the possibility of a dimensional revolution has not occurred and early proposals of etiopathogenic diagnoses were not implemented due to lack of specific knowledge in that field. However, conceiving the DSM-5 as a bridge between (...) the present phenomenally based operational diagnostic criteria and the neuro-cognitively based RDoC criteria introduces an internal tension into the system. It is expected that a liberalization of the research criteria will occur, the DSM operational criteria being only one possible way to select research subjects. (shrink)

Disability studies have been successfully focusing on individuals' lived experiences, the personalization of goals, and the constitution of the individual in defining disease and restructuring public understandings of disability. Although they had a strong influence in the policy making and medical modeling of disease, their framework has not been translated to traditional naturalistic accounts of disease. I will argue that, using new developments in evolutionary biology (Extended Evolutionary Synthesis [EES] about questions of proper function) and behavioral ecology (Niche conformance and (...) construction about the questions of reference classes in biostatistics accounts), the main elements of the framework of disability studies can be used to represent life histories at the conceptual level of the two main “non-normative” accounts of disease. I chose these accounts since they are related to medicine in a more descriptive way. The success of the practical aspects of disability studies this way will be communicated without causing injustice to the individual since they will represent the individuality of the patient in two main naturalistic accounts of disease: the biostatistical account and the evolutionary functional account. Although most accounts criticizing the concept of disease as value-laden do not supply a positive element, disability studies can supply a good point for descriptive extension of the concept through inclusion of epistemic agency. (shrink)

This is a review article of Elizabeth Barnes’ new book, Health Problems. In this article, I try to offer a sense of where this exciting sub-discipline of philosophy of medicine has got to. I do that in three ways. First, I make a few comments on the general idea that there are theories of health competing in the field of philosophy of medicine; second, I offer specific comments on the phenomenological approach; and finally, I comment on Barnes’ claim that health (...) is messy. I do not provide an overview of the book but a response to some of its themes. (shrink)

In this article, I compare and evaluate R. D. Laing and A. Esterson’s account of schizophrenia as developed in Sanity, Madness and the Family, social models of disability, and accounts of extended mental disorder. These accounts claim that some putative disorders should not be thought of as reflecting biological or psychological dysfunction within the afflicted individual, but instead as external problems. In this article, I consider the grounds on which such claims might be supported. I argue that problems should not (...) be located within an individual putative patient in cases where there is some acceptable test environment in which there is no problem. A number of cases where such an argument can show that there is no internal disorder are discussed. I argue, however, that Laing and Esterson’s argument—that schizophrenia is not within diagnosed patients—does not work. The problem with their argument is that they fail to show that the diagnosed women in their study function adequately in any environment. (shrink)

Biological dysfunction is regarded, in many accounts, as necessary and perhaps sufficient for disease. But although disease is conceptualized as all-or-nothing, biological functions often differ by degree. A tension is created by attempting to use a continuous variable as the basis for a categorical definition, raising questions about how we are to pinpoint the boundary between health and disease. This is the line-drawing problem. In this paper, we show how the line-drawing problem arises within “dysfunction-requiring” accounts of disease, such as (...) those of Christopher Boorse and Jerome Wakefield. We then provide several detailed examples to establish that biological dysfunction cannot provide a boundary. We examine potential ways of resolving the line-drawing problem, either by dropping one of the claims that generates it, or by appealing to additional criteria. We argue that two of these options are plausible, and that each of these can be applied with regard to different diseases. (shrink)

Obesity has generated significant worries amongst health policy makers and has obtained increased attention in health care. Obesity is unanimously defined as a disease in the health care and health policy literature. However, there are pragmatic and not principled reasons for this. This warrants an analysis of obesity according to standard conceptions of disease in the literature of philosophy of medicine. According to theories and definitions of disease referring to internal processes, obesity is not a disease. Obesity undoubtedly can result (...) in disease, making it a risk factor for disease, but not a disease per se. According to several social conceptions of disease, however, obesity clearly is a disease. Obesity can conflict with aesthetic, moral, or other social norms. Making obesity a “social disease” may very well be a wise health policy, assuring and improving population health, especially if we address the social determinants of obesity, such as the food supply and marketing system. However, applying biomedical solutions to social problems may also have severe side effects. It can result in medicalization and enhance stigmatization and discrimination of persons based on appearance or behavior. Approaching social problems with biomedical means may also serve commercial and professionals’ interests more than the health and welfare of individuals; it may make quick fix medical solutions halt more sustainable structural solutions. This urges health insurers, health care professionals, and health policy makers to be cautious. Especially if we want to help and respect persons that we classify and treat as obese. (shrink)

Minimizing the costs that others impose upon oneself and upon those in whom one has a fitness stake, such as kin and allies, is a key adaptive problem for many organisms. Our ancestors regularly faced such adaptive problems (including homicide, bodily harm, theft, mate poaching, cuckoldry, reputational damage, sexual aggression, and the infliction of these costs on one's offspring, mates, coalition partners, or friends). One solution to this problem is to impose retaliatory costs on an aggressor so that the aggressor (...) and other observers will lower their estimates of the net benefits to be gained from exploiting the retaliator in the future. We posit that humans have an evolved cognitive system that implements this strategy – deterrence – which we conceptualize as a revenge system. The revenge system produces a second adaptive problem: losing downstream gains from the individual on whom retaliatory costs have been imposed. We posit, consequently, a subsidiary computational system designed to restore particular relationships after cost-imposing interactions by inhibiting revenge and motivating behaviors that signal benevolence for the harmdoer. The operation of these systems depends on estimating the risk of future exploitation by the harmdoer and the expected future value of the relationship with the harmdoer. We review empirical evidence regarding the operation of these systems, discuss the causes of cultural and individual differences in their outputs, and sketch their computational architecture. (shrink)

Data indicate the ubiquity and rapid increase of depression wherever war, want and social upheaval are found. The goal of this paper is to clarify such claims and draw conceptual distinctions separating the depressive states that are pathological from those that are normal and normative responses to misfortune. I do so by appeal to early modern writing on melancholy by Robert Burton, where the inchoate and boundless nature of melancholy symptoms are emphasized; universal suffering is separated from the disease states (...) known as melancholy or melancholia, and normal temperamental variation is placed in contrast to such disease states. In Burton's time these distinctions and characterizations could be secured by the anchoring tenets of humoral theory. Without such anchoring, and in light of the findings and assumptions of today's biological diagnostic psychiatry, we must re-visit each of them. My goals here are to show the need for analytic foundations when claims are made about depression such as those cited above, and to draw attention to some contemporary attempts that may help provide those foundations, particularly, attempts to define disorder or disease. With adjustments, one of these (Cooper 2002) is shown to take us some way toward that goal. (shrink)

In this paper I will argue that Aristotelian accounts of disease cannot provide us with an adequate descriptive account of our concept of disease. In other words, they fail to classify conditions as either diseases, or non-diseases, in a way that is consistent with commonplace intuitions. This being said, Aristotelian accounts of disease are not worthless. Aristotelian approaches cannot offer a decent descriptive account of our concept of disease, but they do offer resources for improving on the ways in which (...) we think about the harms that afflict human beings. While they cannot offer an account of ‘disease' they can offer an account of ‘harm'—and this it turns out, is ultimately of greater importance. (shrink)

The central hypothesis of this book, Delusions and Beliefs: A Philosophical Inquiry (Routledge, 2019), is that delusions are malfunctional beliefs (Chapter 1); they belong to the category of belief (Chapter 2) but, unlike mundane false or irrational beliefs, they fail to perform some functions of belief (Chapter 3). More precisely, delusions directly or indirectly involve some malfunctioning cognitive mechanisms, which is empirically supported by the two-factor account of delusion formation (Chapter 4).

If a human subject knows they are being measured, this knowledge may affect their attitudes and behaviour to such an extent that it affects the measurement results as well. This broad range of effects is shared under the term ‘reactivity’. Although reactivity is often seen by methodologists as a problem to overcome, in this paper I argue that some quite extreme reactive changes may be legitimate, as long as we are measuring phenomena that are not simple biological regularities. Legitimate reactivity (...) is reactivity which does not undermine the accuracy of a measure; I show that if such reactivity were corrected for, this would unjustifiably ignore the authority of the research subject. Applying this argument to the measurement of depression, I show that under the most commonly accepted models of depression there is room for legitimate reactivity. In the first part of the paper, I provide an inventory of the different types of reactivity that exist in the literature, as well as the different types of phenomena that one could measure. In the second part, I apply my argument to the measurement of depression with the PHQ-9 survey. I argue that depending on what kind of phenomenon we consider depression to be, we will accept different kinds of reactivity. I show that both under the harmful dysfunction model and the practical kinds model, certain reactive changes in measuring depression are best seen as legitimate recharacterizations of the underlying phenomenon, and define what legitimate means in this context. I conclude that in both models, biological aspects constrain characterization, but the models are not so strict that only one concept is acceptable, leaving room for reactivity. (shrink)

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease (...) as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization. (shrink)

The phenomenological method has been fruitfully used to study the experience of illness in recent years. However, the role of illness is not merely that of a passive object for phenomenological scrutiny. I propose that illness, and pathology more generally, can be developed into a phenomenological method in their own right. I claim that studying cases of pathology, breakdown, and illness offer illumination not only of these experiences, but also of normal function and the tacit background that underpins it. In (...) particular, I claim that the study of embodiment can be greatly enhanced, and indeed would be incomplete, without attending to bodily breakdown and what I term bodily doubt. I offer an analogy between illness and Husserl’s epoché, suggesting that both are a source of distancing, and therefore motivate a reflective stance. (shrink)

Social Constructivism about the disease concept has generally been taken to ignore the fundamental biological reality underlying diseases, as well as to fall foul of several apparently compelling objections. In this paper, I explain how the metaphysical relation of grounding can be used to tie a socially constructed account of diseases and their classification to their underlying biological and behavioural states. I then generalize the position by disambiguating several varieties of normativism, including a particularly strong ‘placeholder’ version of social constructivism, (...) and showing that the grounding approach is available to each. I go on to provide what I believe to be the first attempt at a full semantics for disease-talk and disagreement, before using the placeholder to demonstrate on that basis that the most troublesome objections to normativism can be avoided even by very strong versions of the position. (shrink)

Synthetic biology promises to eliminate the distinction between biology and engineering by delivering a philosophically interesting new kind of entity: a biological organism that is wholly designed and constructed by humans. The possibility of such organisms raises interesting questions in three domains: the analysis of (1) biological functions, (2) engineering functions, and (3) health and disease. This paper identifies and systematically answers these questions. This does not only establish how we should think about functions and health and disease in synthetic (...) biological organisms, but it also reveals insights that are of broader relevance: (1) aetiological accounts of biological function need to omit or reinterpret reference to natural selection. This results in complete continuity between aetiological analyses of function in engineering and philosophy; (2) considering synthetic biology prompts interesting further questions about heritability, ancestry, and biological individuals; and (3) accounts of disease as biological dysfunction do not straightforwardly map onto our intuitive health and disease judgments regarding non‐human animals. In response to the latter point I examine three possible avenues, and tentatively defend one on behalf of the ‘disease as dysfunction’ theorist. (shrink)