Much research in the philosophy of psychiatry has been devoted to the characterization of the normal and the pathological. In this article, we identify and deconstruct two postulates that have held sway in the philosophy of psychiatry. The first postulate concerns the belief that clinicians would benefit from conceiving of psychiatric disorders as stable entities with clear boundaries. By relying on a symptom-based approach, we support a conception of psychiatric disorders whose symptoms are the products of many activated mechanisms in (...) mutual interactions. The second postulate concerns the way in which the philosophy of psychiatry has approached the question of harm. We posit that clinicians perceive harms primarily through networks of clinical manifestations. The identification and deconstruction of these two postulates leads us to propose a practical definition of a psychiatric disorder that is useful for the clinician, while adopting a principle of prudential conservatism that does not exclude other theoretical definitions of psychiatric disorder that are useful as an epistemic hub. Thus, we propose the following definition of a psychiatric disorder that is relevant to clinical practice: “a set of clinical manifestations belonging to the prototypical central core of psychiatry, organized in a causal network, involving at least one harm, and whose set of harms exceeds the traditional threshold of significance for a given psychiatric disorder, directly related to an activated mechanism. Such a network composed of clinical manifestations is frozen in a state that is unable to allow the deactivation of these manifestations spontaneously without a therapeutic intervention”. (shrink)

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)

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)

Jerome Wakefield criticizes my biostatistical analysis of the pathological—as statistically subnormal biological part-functional ability relative to species, sex, and age—for its lack of a harm clause. He first charges me with ignoring two general distinctions: biological versus medical pathology, and disease of a part versus disease of a whole organism. He then offers 10 counterexamples that, he says, are harmless dysfunctions but not medical disorders. Wakefield ends by arguing that we need a harm clause to explain American psychiatry’s 1973 decision (...) to declassify homosexuality. I reply, first, that his two distinctions are philosophic fantasies alien to medical usage, invented only to save his own harmful-dysfunction analysis (HDA) from a host of obvious counterexamples. In any case, they do not coincide with the harmless/harmful distinction. In reality, medicine admits countless chronic diseases that are, contrary to Wakefield, subclinical for most of their course, as well as many kinds of typically harmless skin pathology. As for his 10 counterexamples, no medical source he cites describes them as he does. I argue that none of his examples contradicts the biostatistical analysis: all either are not part-dysfunctions (situs inversus, incompetent sperm, normal-flora infection) or are indeed classified as medical disorders (donated kidney, Typhoid Mary’s carrier status, latent tuberculosis or HIV, cherry angiomas). And if Wakefield’s HDA fits psychiatry, the fact that it does not fit medicine casts doubt on psychiatry’s status as a medical specialty. (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)

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)

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)

Although Boorse’s and Wakefield’s accounts of health are generally regarded as competing ones, they are in fact so only if they are aimed at the same concept. Some remarks made by Boorse and Wakefield, however, leave it unclear whether they are. On one possible interpretation, Boorse’s account aims at analysing a theoreticalconcept of abnormality, which ought to be distinguished from a more clinicalor therapeuticconcept, whereas Wakefield’s account aims at analysing a clinicalor therapeuticconcept. The debate between Boorse and Wakefield would then (...) either be merely terminological, or would boil down to whether Boorse is correct to assert the existence of a theoreticalconcept of abnormality which ought to be distinguished from a clinicalor therapeuticone. This paper aims to clarify what is at stake between Boorse and Wakefield, by maintaining that their accounts are most plausibly interpreted as both being aimed towards a theoreticalconcept of abnormality. (shrink)