We Call Upon The Author To Explain

American Philosophical Association

2009-11-12T20:33:00.003-05:00

After several years of ambivalance, I decided this year to not renew my dues to the APA. I'm not on the job market, I don't plan to go any APA meetings, and it provides no other useful services for me. As a department chair, I could do with plenty of help on the creation of outcomes assessment for philosophy courses, but so far as I can tell, the APA has done nothing useful on this front. I prefer to spend my money on other things.

Nevertheless, it makes me feel a little further removed from the mainstream of philosophy. I imagine I'll return to the fold in a few years.

Neuroethics at ASBH

2009-10-09T09:58:00.002-04:00

Here's the program for Neuroethics at the ASBH meeting this year.

Neuroethics Affinity Group Agenda for October 16:

11:45 AM Welcome and Introductions

11:50 AM Announcements
NIH update - Chen
Brain Matters - Krahn
Penn Update - Powers
CBS Update - Ford
Other updates

12:10 PM Mini Presentations
Jayna Bonfini, Carnegie Mellon University, "Alice in Wonderland: Ethical and Social Implications of Adults with Autism in the Legal System."

John Z. Sadler, M.D., University of Texas Southwestern Medical Center, "Neuroethics and the Philosophy of Psychiatry - A Natural Affinity."

12:20 PM Future Directions and Networking

12:40 PM Wrap-up

ASBH 2009
Neuroethics Sessions

Thursday, October 15

2:45 – 3:45 The President’s Council on Bioethics Panel Session (103)
“White Paper on Determining Death”: Where Does it Leave Us?

2:45 – 3:45 Severe Brain Injury and Sexuality Panel Session (104)

4:00 – 5:30 Vulnerability, Moral Experience and Paper Session (108)
Decision-Making: Clinical Ethics through the lens of Open-Uterine
Surgery to Repair Spina Bifida

Friday, October 16

11:45-12:45 Neuroethics Affinity Group (221)

1:00 – 2:30 Perspectives on Mental Illness Paper Session (226)
Understanding Suffering in Mental Illness: Sarah Kane’s 4.48 Psychosis

1:00 – 2:30 Molecules, Mind, and the Law: Workshop Session (227)
The Intersection of Free Will, Biologic Determinism, and Criminal Responsibility

1:00 – 2:30 Empirical Approaches to Morality Paper Session (229)
· Cognitive Science and the Myth of the Standard Body: Some Epistemological and Ethical Considerations
· Translating our Differences: Can Empirical Moral Psychology Help Us Understand (and Eventually Address) Our Normative Differences?
· Sexing the Brain: Gender and Autism
· Functional Neuroimaging, Free Will, and Privacy

2:45 – 3:45 Translating “Brain Death”: An American Philosophical Association Committee on Philosophy and Medicine Panel Panel Session (232)

2:45 – 3:45 Discourse on Enhancement and Disability Panel Session (233) Cognitive Enhancement: The Promise, the Perils, and the role of Medicine

8:00-10:00 Film: The English Surgeon (ES6) (About a brain surgeon in the Ukraine)

Sunday, October 18

11:00-12:00 Moral Responsibility and the Panel Session (419)
Neuroscience of Self-Governance

I'm especially interested in that last session on self-governance. Here's the line up for it.

Hilary Bok, PhD, Johns Hopkins Berman Institute of Bioethics,
Baltimore, MD
Alisa Carse, PhD, Georgetown University, Washington, DC
Martha Farah, PhD, University of Pennsylvania, Philadelphia, PA
Jordan Grafman, PhD, National Institute of Neurological Disorders and
Stroke, Bethesda, MD

With 4 speakers in an hour, it promises to be compressed.

I wish I could go. But the $400 registration plus travel and hotel costs is too rich for me.

“Madness and Literature” 1ST INTERNATIONAL HEALTH HUMANITIES CONFERENCE 2010

2009-10-03T21:04:00.001-04:00

CFP: Madness & Literature
1ST INTERNATIONAL HEALTH HUMANITIES CONFERENCE 2010
“Madness and Literature”
The Institute of Mental Health is hosting The 1st International Health Humanities Conference at The University of Nottingham, UK from Friday 6th to Sunday 8th AUGUST 2010.
More details at
http://www.medhumanities.org/2009/10/cfp-madness-literature.html

Kant on mental disorder

2009-08-28T11:15:00.002-04:00

Patrick Frierson
Kant on mental disorder. Part 1: An overview
History of Psychiatry 2009 20: 267-289
Kant on mental disorder. Part 2: Philosophical implications of Kant’s account
History of Psychiatry 2009 20: 290-310

http://hpy.sagepub.com/content/vol20/issue3/

I didn't even know that Kant had written anything directly on mental illness, so this pair of papers is especially welcome.

Review of Scanlon's Moral Dimensions: Permissibility, Meaning, Blame

2009-08-19T22:09:00.002-04:00

Forthcoming in Philosophy in Review. Vol. 29 no. 4. Pages 58-60.

T. M. Scanlon Moral Dimensions: Permissibility, Meaning, Blame. Cambridge, MA: Harvard University Press 2008. Pp. 227. US$29.95 (cloth ISBN-13: 978-0-674-03178-4).

Following in the steps of What We Owe to Each Other (Harvard University Press 1999), this new, slimmer volume will garner plenty of attention in moral philosophy. It consists of four interconnected chapters, the last, on blame, substantially longer than the others, and an especially substantial contribution to the literature.

The first chapter criticizes the doctrine of double effect, arguing that it rests on a mistake about the role of intention in the permissibility of actions. The doctrine makes the following sort of contrast: in wartime, while it would be wrong to bomb an enemy with the intention of killing civilians in order to demoralize the populace in order to bring about a swifter end to the war, it would be morally permissible to bomb a military target such as a munitions factory, knowing that doing so would result in the deaths of an equal number of civilians. The contrast is between what we intend to achieve and what results from the foreseen but unintended effects of our actions. Scanlon holds that while the agent’s intentions may be relevant to the moral assessment of some actions, they are not directly relevant. Scanlon’s first criticism of the doctrine is that it is implausible to hold that the moral permissibility of a decision to bomb a munitions factory and thereby kill a number of civilians depends on one’s intentions. He argues that it is not the intention that matters directly in central cases, but rather what one does and whether one’s actions violate moral principles. He makes this argument by drawing a distinction between the deliberative use of a principle to decide whether an action is ethically permissible, and its critical use to assess how the agent made his or her decision. It is possible that a person’s (or organization’s) intentions will have an effect on how they carry out their actions, and how they would react in the case of changing circumstances. But when the action itself is fixed, and the effects of the action are known, then in assessing its morality, we need to look at the moral principles that apply. The distinction between intended effects and unintended but foreseen effects has no direct relevance, according to Scanlon.

The arguments in this first chapter are hardly conclusive, as they rest largely on unargued intuitions. Scanlon’s opponents can insist that how we understand what an agent did crucially depends on what her intentions were. Scanlon has not provided enough analysis of the concept of an action, or indeed of the sources of moral responsibility, to show his opponents’ view is incoherent. The main value of this first chapter lies in its statement of an alternative view, and Scanlon is right in saying that once one adopts that view, the claims of the doctrine of double effect look ‘bizarre’ when applied to familiar cases of trolley problems and of sacrificing one person to harvest her organs to save the lives of five other people. However, we also have strong intuitions that one’s intentions are relevant in assessing the permissibility of one’s actions, and Scanlon needs to show that his view has a place for these intuitions, in order to avoid having his own view look bizarre too.

The second chapter goes further in setting out an argument for his position. Scanlon agrees that intentions are indeed central in determining what action a person has performed, but he insists that it is the action and not the agent’s intent or understanding of morality that is crucial to the action’s permissibility. Scanlon provides an array of cases where he agrees that a person’s intentions make a difference, such as when a person who apparently does good is actually acting out of selfish or dishonorable motives. However, he argues that these cases can be explained by considering what he calls the ‘meaning’ of the actions. The meaning of an action does depend on the reason the agent did it, but it is not the same thing as the reason. One action can have different meanings for different people, but Scanlon emphasizes his view that the meaning is not purely subjective. People can be mistaken about the meaning of an action for them; they are not fixed by a person's emotions or beliefs, but instead depend on context. For example, Angela may regard Tom's action as a betrayal, but the actual meaning of Tom's action for Angela may in fact be different. To help explain his specialized conception of meaning here, Scanlon gives plenty of examples. Whether he succeeds in clarifying his concept of meaning is debatable.
The third chapter attempts to understand the idea that we should not treat people merely as a means to an end. Scanlon endorses a sense in which treating a person as an end can be used as a general criterion of moral rightness, but shows that this is different from the sense in which we generally mean that it is wrong to use people. He makes a strong case for this, and the chapter will be especially useful to those who work on the morality of using people.

The final chapter, on blame, draws on some distinctions from the prior chapters, but it largely stands alone. It not only has the most innovative and interesting claims of the book, but is also much clearer and supplies a stronger more sustained argument. On his view, blame is not simply an evaluative attitude or an emotion; rather, when one blames another, one judges her blameworthy and, crucially, takes one’s relationship with her to be impaired; one’s attitudes towards the blamed person change. To blame a person is not the converse of praising them; rather, it is closer to the converse of being grateful to another person. It follows, with some further argument, that it is reasonable to blame people for actions even in cases where they could not have done otherwise.

Paradigms of blaming on this account will be in cases where the blamer has a close personal relationship with the person she blames, and Scanlon focuses on blame in friendships and families. He spells out what dispositions are required for people in a good moral relationship. Yet it is possible to blame someone whom one has not met personally. To explain this fact, Scanlon holds that one has a relationship with everyone. Naturally, since one does not have a personal relationship with that person, the impairment in the relationship is different from the blame that occurs between close friends.

Scanlon argues that his account of blame explains several features. (a) Not every wrong action is blameworthy. For example, lack of ambition is a fault of character, but is not blameworthy in itself. (b) The blameworthiness of an action does directly depend on the intentions with which the action was performed, because the agent’s reasons constitute his attitude towards others. (c) We apply blame to young children differently, because of the inequality of the relationship between adults and children, in which adults are teaching the children to become good. Scanlon’s approach to blameworthiness is distinctive in focusing on the relationship between people, and particular actions are relevant insofar as they bear on those relationships. Indeed, blame can be independent of any particular blameworthy action. He acknowledges that this may be in tension with some common understanding of blame, but he argues that our ordinary intuitions are mixed, so no coherent theory can match them all.
People do not normally choose their characters, but since on Scanlon’s view our relationships with them are largely based on their character, this lack of choice does not mean that we should not blame them. The fact that a callous killer had a terrible childhood may alter the way we treat her, but it does not make her exempt from blame. Scanlon considers arguments that we should not hold people morally responsible for their actions when they lack choice about their nature, but maintains that such views rest on the idea that there is a real self that would be uncovered under the right circumstances, and he can make little sense of this. He emphasizes that we have to base our relationships with people on how they actually are, not how they might have been under different circumstances. Whatever the causes of their current attitudes, those are the ones that constitute their relations with other people.

One could retain many of Scanlon's insights about blaming but reject his claim that the change in relationship is partially constitutive; instead one could say that blaming expresses an evaluative attitude towards a person’s action that causes changes in our relationship with her.

Nevertheless, the great value of his proposal is his emphasis on the importance of relationships in understanding blaming. This brings ethics closer to addressing our everyday interactions with colleagues, friends and family. Scanlon’s writing style can make it difficult to pin down exactly how his arguments are meant to go or how they relate to other, well-known positions in this area, since he does not give much discussion of the relevant literature. Nevertheless, this book, and especially the chapter on blame, deserves and will repay careful study.

Christian Perring
Dowling College

Recent popular media

2009-07-30T08:49:00.004-04:00

This week there was an excellent show on BBC Radio 4 in their Mind Changers series, hosted by Claudia Hammond on David Rosenhan's famous Pseudo-Patient Study reported in "Being Sane in Insane Places." It features interviews with his colleagues and discussion about the implications and validity of the experiment.
http://www.bbc.co.uk/programmes/b00lny48

I see next week there is a Radio 4 show on DSM-V, which promises to be interesting.
http://www.bbc.co.uk/programmes/b00kf117

While on the topic of Radio 4, it's worth mentioning that All in the Mind remains the best (and maybe only) radio show about mental health in either the USA or the UK.
http://www.bbc.co.uk/programmes/b006qxx9

As the debate over the secrecy of the process of creating DSM-V heats up, Christopher Lane's recent piece in Slate, Bitterness, Compulsive Shopping, and Internet Addiction: The diagnostic madness of DSM-V, gives a quick summary.
http://slate.com/id/2223479/

If you search blogs and news for 'dsm-v' you'll find plenty of commentary. The Psychiatric Times blog has lots of helpful info.
http://psychiatrictimes.blogspot.com/

Ethics and Values in Contemporary Psychiatry

2009-06-15T11:39:00.003-04:00

This one passed me by, but I just stumbled on it.

Ethics and Values in Contemporary Psychiatry
Harvard Review of Psychiatry, Volume 16 Issue 6 2008
http://www.informaworld.com/smpp/title~db=all~content=g906687978

Interesting ToC: in particular, I noted:
The Use of Palliative Sedation for Existential Distress: A Psychiatric Perspective Zev Schuman-Olivier; David H. Brendel; Marshall Forstein; Bruce H. Price Pages 339 – 351
Character Virtues in Psychiatric Practice Jennifer Radden; John Z. Sadler Pages 373 – 380
Off the Radar: Truth Telling in Psychiatry Nancy Nyquist Potter Pages 381 – 387

I look forward to reading the papers: unfortunately my college library only gets access to them when they are a year old, so I'll have to wait.

APA NEWSLETTER ON PHILOSOPHY AND MEDICINE

2009-06-03T18:47:00.002-04:00

2 new articles in the APA NEWSLETTER ON PHILOSOPHY AND MEDICINE of particular interest:

"Classifying Dysthymia," by Jennifer Radden

"Nosologic Validity and the Intuitively Accessible View of Natural Kinds," by Claire Pouncey

Volume 08, Number 2 Spring 2009
Available online at http://www.apaonline.org/documents/publications/v08n2_Medicine.pdf

Recent publications

2009-05-08T10:14:00.002-04:00

An article and a journal issue:

A role for ownership and authorship in the analysis of thought insertion
Lisa Bortolotti and Matthew Broome
Phenomenology and the Cognitive Sciences
Volume 8, Number 2 / June, 2009
Abstract Philosophers are interested in the phenomenon of thought insertion because it challenges the common assumption that one can ascribe to oneself the thoughts that one can access first-personally. In the standard philosophical analysis of thought insertion, the subject owns the ‘inserted’ thought but lacks a sense of agency towards it. In this paper we want to provide an alternative analysis of the condition, according to which subjects typically lack both ownership and authorship of the ‘inserted’ thoughts. We argue that by appealing to a failure of ownership and authorship we can describe more accurately the phenomenology of thought insertion, and distinguish it from that of non-delusional beliefs that have not been deliberated about, and of other delusions of passivity. We can also start developing a more psychologically realistic account of the relation between intentionality, rationality and self knowledge in normal and abnormal cognition.
http://www.springerlink.com/content/145j2111842wpv7h/

And another issue of PPP: that's 3 in 2 months.

Philosophy, Psychiatry, & Psychology
Volume 15, Number 4, December 2008
http://muse.jhu.edu/journals/philosophy_psychiatry_and_psychology/toc/ppp.15.4.html

Target articles:
Delusions, Certainty, and the Background
John Rhodes and Richard G. T. Gipps
pp. 295-310
with commentaries by Giovanni Stanghellini and S. Nassir Ghaemi

The Concept of Mental Disorder: A Proposal
Alfredo Gaete
pp. 327-339
with commentary by Richard G. T. Gipps

New Art

2009-04-30T17:33:00.003-04:00

A relatively rare non-philosophy post.

I wandered around some Chelsea galleries yesterday, as I regularly do, before going to Pat Kitcher's talk on Kant on theoretical and practical reasoning at CUNY (which didn't inspire me to go and read more Kant).

The previous times I've been around the galleries this year, I was uninspired. But for some reason, this time, there were several exhibits that impressed me a great deal, so I thought I'd mention them.

At Margaret Thatcher Projects (not the British ex-PM) there was another showing of Robert Sagerman's work. This one had the title "On and On: Inquiries into Indeterminacy." (In fact it starts today, but I saw it up. I had seen his work there previously, and I'd liked it a great deal then. Looking at his work on the web, his works look rather dull, but when you see them close up, the thick three dimensional use of paint is stunning. You can see it better on the Marcia Wood Gallery page.

It was fun to see John Water's Rear Projection show at the Marianne Boesky Gallery. Nothing very stunning there, but it was refreshingly silly.

The piece The Sound of Silence by Alfredo Jaar at Galerie Lelong was, in sharp contrast, very depressing. The main work was a sculpture and film installation. The 8-minute film was about famine, South African aparteid, the suicide of a photojournalist, and the ownership of images by one of Bill Gates' companies. There's an interview with the artist in the latest issue of The Brooklyn Rail.

At P-P-O-W there was quite a strange installation: Bill Smith's Intuitive Visualization of the Unseen. You walk through a black curtain into a room with hanging sculptures. There's a sign saying that the way to experience the main item, "an epidemiological model of the perfect infectious disease (evolved growth system)," is to lie on the floor and look up, but I chickened out of that. But it was a very intriguing network of wires in spherical form, and then the lights went down, to show that the joints were luminous. It was both surprising and amazing as a visual effect, completely changing the experience of the object. It felt a bit like being Jodi Forster during her trip to another galaxy in Contact: well, just a little. It was certainly on the psycedelic side.

The highlight of the afternoon was Dustin Yellin's Dust in the Brain Attic at Robert Miller. His website is at http://www.dustinyellin.com/ but I had trouble viewing it: I found Opera worked a little better, but still with problems. The gallery website works fine though. There are biological themes, as with Bill Smith's work, but this reminded me more of the Bodies exhibit in New York (I realize there is controversy about the morality of the possible use of the cadavers of Chinese political prisoners there). The works by Yellin included anatomical depictions of the human body using paint in layers of glass fused together, based on CAT scans and magnetic resonance imaging. They were visually fascinating, and I loved the artistic use of science, raising the questions of the meanings of the information we get from modern scanning. These works were also quite playful, with, for example, an extraterrestial landscape. I especially liked that while the images looked three dimensional from the front, they gradually disappeared as you moved to the side, showing empty glass.

2 Posts at King's College London

2009-04-27T07:49:00.001-04:00

WELLCOME CENTRE FOR THE HUMANITIES AND HEALTH, KING'S COLLEGE LONDON

RESEARCH STUDENTSHIP
http://www.kcl.ac.uk/graduate/funding/database/view/280/

RESEARCH FELLOWSHIP
http://www.kcl.ac.uk/depsta/pertra/vacancy/external/pers_detail.php?jobindex=7790

Review of Rachel Cooper: Psychiatry and Philosophy of Science

2009-04-25T09:38:00.001-04:00

Forthcoming in Philosophy in Review. Volume XXIX no. 2 (April 2009). Pages 19-21.

Rachel Cooper Psychiatry and Philosophy of Science. McGill-Queen’s University Press 2007. Pp. 240. US$90.00 (cloth ISBN-13: 978-0-7735-3386-8); US$27.95 (paper ISBN-13: 978-0-7735-3387-5).

This book surveys four main issues: the nature of mental illness, psychiatric explanation, relations between different psychiatric theories, and the role of values in psychiatric theory and practice. Each of these issues has two chapters devoted to them, and this provides readers with an overview of how central theoretical questions in psychiatry are approached in philosophy of science, broadly construed. Inevitably in such a book, Cooper devotes single chapters to topics on which others have written whole books, and so she often goes quickly, not pausing for details. Yet at some points she does take the trouble to spell out the arguments in some detail, and she often presents her own perspectives and occasionally presents original research. Her writing is consistently clear and straightforward, and chapters are structured logically. This is a rich and much needed book that will serve as an introduction to one side of philosophy of psychiatry, which amply demonstrates how its debates are deeply connected with those in related areas, and how interesting the area is. It would be appropriate for upper level undergraduate courses, graduate courses, and will be helpful to professional philosophers and mental health care professionals wanting to orient themselves in the current literature.
Cooper starts out, as many others do, by addressing anti-psychiatry, with a survey of Foucault, R. D. Laing and Thomas Szasz. While she defends the view that mental illness is real and psychiatry is a legitimate enterprise, she is surprisingly sympathetic to many of the claims of its critics, and suggests that there is much of value in their work, and that they are not as radical as they often seem to be. Her characterization of early Foucault as ‘W. V. Quine plus history’ is indeed helpful, and Cooper shows that a historical perspective on psychiatry is important in understanding the field, even though most current philosophy tends to be ahistorical in its approach to psychiatry.
The next chapter compares Boorse’s biological account, Fulford’s action-based account, and Aristotelian accounts of disorder. She argues that none of these is successful on its own, but that a ‘messy’ account that combines different theories could do the trick. She cites her own previous suggestion that takes elements from the Aristotelian approach that a disorder must be a harm for a person in some sense, and adds that the sufferer both could reasonably have expected to be better off and could in principle be treated medically, if not at present, then at some point in the future of medicine. She also cites Reznek’s claim that a condition is pathological ‘if and only if it is an abnormal bodily/mental condition that requires medical intervention and that harms standard members of the species in standard conditions’ (40). Both these ideas face the challenge of providing a non-circular definition of ‘medicine’, in non-ad hoc ways that justify the special status of medical disorders in our society.
The chapter on natural kinds argues that mental disorders can be scientific kinds, even if they do not have essences. She summarizes much of the literature and focuses Hacking’s objections; she argues that the concept of natural kind is broad enough to include the phenomena he describes of temporally transient disorders and looping effects in the relation between the medical description of disorders and people having those disorders. Cooper resists the worries of Dupré that categorizing people and their problems will lead to conservative politics by saying that ethics cannot drive metaphysics. She does not address some pragmatist approaches that do precisely that, viz. allow ethics to influence our decisions about how to conceptualize human problems. Given that pragmatist approaches to categorization have gained a good deal of support in recent years, this is an unfortunate omission.
One of the most original chapters makes an argument that individual case histories can be explanatorily helpful because they help us simulate other case histories by providing us with scaffolding. Cooper sketches a portion of simulation theory and explains her suggestion with some examples. This is an interesting idea that deserves further attention given the importance of narratives in clinical psychology and the tendency of those who support the ‘scientific approach’ to dismiss narratives as secondary to a scientific understanding.
In the first chapter on relations between theories, Cooper argues that in the psychological sciences there are different paradigms competing at the same time, and although Kuhn said that different paradigms are incommensurable, it is possible to achieve genuine communication between different approaches if enough effort is made. The second chapter in this section asks if reductionist theories are incompatible with our ordinary understanding of people. Cooper examines dualism, identity theory, functionalism and anomalous monism and concludes that most psychiatric explanation is largely independent of these theories. Only eliminative materialism is genuinely incompatible with standard psychiatric explanation involving propositional attitudes. Both these chapters are rather quick and rough in their arguments, but the conclusions are plausible.
The final two chapters address the role of ethics. The first of these spells out the ways in which psychiatric science can be value-laden, and it does so very effectively by using the example of how race was treated in the American Journal of Psychiatry between 1844 and 1962. From this, Cooper shows how values shape the scientific project from start to finish. She proceeds to critically evaluate suggestions for how to avoid the problems of bad values infecting science, including making science value-neutral, making sure science is laden with good values, and adopting standpoint epistemology. She finds each of these proposals limited, and suggests that the best bet is to get a diverse body of researchers and to encourage debate about the science. The second chapter is far more specialized, addressing recent problems for psychiatry and medicine generally in the conduct of randomized controlled trials of new treatments. Cooper argues that large corporations have become so involved in these trials that the public has lost its trust in psychiatry, especially with regard to medication. She argues that the methods for policing scientific testimony have broken down, and in order to repair them, new regulations and initiatives need to be introduced. Again, as with most of the rest of this book, Cooper’s arguments here are interesting and plausible.

Recent Papers Relevant to Philosophy of Psychiatry

2009-04-23T20:20:00.008-04:00

"From Descartes to Desipramine: Psychopharmacology and the Self"
Ian Gold, McGill University and Lauren Olin, McGill University
Abstract:
Despite the remarkably widespread use of the new generation of antidepressants, almost everything we know about their effects comes from animal studies and clinical trials in which the sole parameter of interest is depressive symptomatology. Almost nothing is known about the effects that antidepressants have on cognition, affect, or motivation when used over a period of months or years. Nor do we understand what effects, if any, antidepressants have on what we think of as the self. In this article, we argue that neither psychiatry nor philosophy, in their current state, are well equipped to think about these issues. In order to explore this idea, we consider the neurobiology of romantic love and its relation to antidepressant neurochemistry. This case study, we suggest, supports the view that antidepressants are very likely to have significant effects on personhood as well as the suggestion that we are in need of new ways of thinking about the self and its pathologies.
Key Words: antidepressants • DSM-IV • philosophy • self • SSRIs
Transcultural Psychiatry, Vol. 46, No. 1, 38-59 (2009)
http://tps.sagepub.com/cgi/content/abstract/46/1/38

and, at the more empirical side,

"Pedophilia, Hebephilia, and the DSM-V"
Ray Blanchard, Amy D. Lykins, Diane Wherrett, Michael E. Kuban, James M. Cantor, Thomas Blak, Robert Dickey and Philip E. Klassen
Abstract
The term pedophilia denotes the erotic preference for prepubescent children. The term hebephilia has been proposed to denote the erotic preference for pubescent children (roughly, ages 11 or 12–14), but it has not become widely used. The present study sought to validate the concept of hebephilia by examining the agreement between self-reported sexual interests and objectively recorded penile responses in the laboratory. The participants were 881 men who were referred for clinical assessment because of paraphilic, criminal, or otherwise problematic sexual behavior. Within-group comparisons showed that men who verbally reported maximum sexual attraction to pubescent children had greater penile responses to depictions of pubescent children than to depictions of younger or older persons. Between-groups comparisons showed that penile responding distinguished such men from those who reported maximum attraction to prepubescent children and from those who reported maximum attraction to fully grown persons. These results indicated that hebephilia exists as a discriminable erotic age-preference. The authors recommend various ways in which the DSM might be altered to accommodate the present findings. One possibility would be to replace the diagnosis of Pedophilia with Pedohebephilia and allow the clinician to specify one of three subtypes: Sexually Attracted to Children Younger than 11 (Pedophilic Type), Sexually Attracted to Children Age 11–14 (Hebephilic Type), or Sexually Attracted to Both (Pedohebephilic Type). We further recommend that the DSM-V encourage users to record the typical age of children who most attract the patient sexually as well as the gender of children who most attract the patient sexually.
Keywords DSM-V - Ephebophilia - Hebephilia - Paraphilia - Pedophilia - Penile plethysmography - Phallometry - Sexual offending - Sexual orientation - Teleiophilia http://www.springerlink.com/content/7j127536573h5q8t/
with 7 letters from various others and a reply from Ray Blanchard

There's also an editorial in the January 2009 issue of the American Journal of Psychiatry, "Child Psychiatry Growin’ Up" by Daniel S. Pine, M.D., and Robert Freedman, M.D. that is important but causes me some concern.
http://ajp.psychiatryonline.org/cgi/content/full/166/1/4
They discuss recent research, and especially fMRIs done on children, and conclude:

"These findings support the hypothesis that children’s relative lack of neural response to adverse or fearful stimuli predicts deviant adult behavioral profiles. Eventually, this information may be used to predict long-term outcomes and to tailor treatments individually targeted toward underlying neural dysfunction associated with different forms of behavior disorders. The consonance of the imaging findings in children with those from laboratory animals may provide models for discovery of new neurobiological treatments."

The assumption that neurological studies mandate neurobiological treatments strikes me as problematic.

And there's yet another new issue of PPP out. It's a special issue, on "Phenomenology, Behaviorism, and the Nature of Mental Disorders: Voices from Spain," edited by Marino Pérez-Álvarez and Louis A. Sass. Table of Contents at
http://muse.jhu.edu/journals/philosophy_psychiatry_and_psychology/toc/ppp.15.3.html

News items

2009-04-13T10:00:00.002-04:00

A few things came to my inbox in the last week.

From the latest issue of Medicine, Health Care and Philosophy Volume 12, Number 2 / May, 2009

The ethics of self-change: becoming oneself by way of antidepressants or psychotherapy?
Fredrik Svenaeus

and

Should or should not forensic psychiatrists think about free will?
Gerben Meynen

A very fancy website using the Adobe Flash Player for the
12th International Conference for Philosophy & Psychiatry 2009
on the generic topic of "Understanding Mental Disorders." October 22-24, 2009, Lisbon, Portugal.
(Personally I am not a fan of sites that make it impossible to copy their text.)
The deadline for abstracts is very late: 30 August 2009. Presumably this means that that notification of acceptance of abstracts is also very late. I'd normally expect to book airline tickets and make hotel reservations in August for an October conference. Maybe it is a safe bet that most abstracts will be accepted.

And finally, a call for papers:
Vol. 4, No. 1: IJFAB Special Issue: Feminist Perspectives on Ethics in Psychiatry
Guest Editors: Jennifer Hansen, Nancy Potter and Jennifer Radden
Deadline for Submission: March 1, 2010
I'll skip the rather long text, and just give the contact info:
For more information, please contact Jennifer Hansen: jhansen@gettysburg.edu

Another new issue of PPP

2009-04-02T08:28:00.005-04:00

The issues of PPP are coming fast and furious now. Hot on the heels of the last, I just received 15(2), June 2008. At this rate, the journal dates will start to match the calendar dates. This one is so new, it is not yet listed on the PPP website at Project Muse.

It is a special issue devoted to the toic of "Values-Based Medicine, Evidence-Based Medicine." It's good to see PPP occasionally delve into the broader area of Philosophy of Medicine. It makes sense then that the editors (Wifstad, Falkum, Ayob and Thornton) are European, where the tradition of philosophy of medicine is strong. I have only browsed the issue, but one notable feature is that it breaks from the standard format, with one section on values-based medicine with five papers, another on evidence-based medicine with four papers, and then four commentaries that address general themes rather than single papers. There are no replies to the commentaries. Given my comments in the previous post on the inherent limitations of the peer commentary approach (which is especially apparent in the American Journal of Bioethics), it is good to see the PPP editors mixing it up and trying new ideas.

PPP Issue on Vice and Disorder

2009-04-01T19:22:00.001-04:00

In the latest issue of PPP, John Sadler has put together a "philosophical case conference" on vice and the classification of mental disorders, which will be a great resource for future discussion of the area.
His target piece features discussion of some of the issues of classifying vice, by which he means criminal behavior and immoral attitudes. He sets out three cases. The first is a 12-year-old boy who is disobedient and troublesome, defying authority and lying. He gets diagnosed with conduct disorder. The second is of a mother who presents her mother who presents her child as ill and having breathing difficulties. It turns out that the mother smothered her child. She has a complicated case history, with a troubled past. The third case is Jeffrey Dahmer, who received diagnoses of Asperger's, paraphilias, alcohol abuse, depressive disorder not otherwise specified, and personality disorder not otherwise specified. The rest of the paper sets out some of the issues in dealing with the vice-mental disorder relationship in DSM-UV-TR, under the headings of "Inconsistencies in How Wrongful Conduct is Classified," "Impoverishment of Some Criteria Sets for Vice-Laden Disorders," "Hierarchical and Comorbidity Issues," and "Metaphysical Ambiguities." The main theme is that DSM-IV-TR is not consistent and is not clearly formulated when it comes to the relation between vices and disorders. The paper does not set out a theory of what this relation should be.

There is an unusual number of peer commentators for this target paper:
Jeffrey Geller (U Mass Medical School)
Gwen Adshead
Nancy Nyquist Potter and Peter Zachar
Christopher Heginbotham, University of Central Lancashire
Michael First
Christopher Williams
Lloyd Wells (Mayo Clinic)
Stephen Morse
It is a diverse collection of responses. I'm a little disappointed that there was not more discussion of the cases. Geller writes about some of the history of the topic. Adhead expands on the discussion of Case 2, which was her example in the first place. Potter and Zachar give a rather general discussion. Heginbotham gives a brief discussion of the cases and proposes an approach rooted in the social model of disability. First gives a more extensive discussion of the topic and the cases, allowing that vices can also be indicative of disorders. Williams sketches some issues in identifying the causes of behavior. Wells endorses an approach that mixes medicalization and moralization, and discusses this in several cases of his own. Morse emphasizes the difficulty of examining the issues in the absence of quite well developed theories of what counts as a mental disorder and a theory of morality.

Adshead complains about the "muddling" of social, psychological, and legal discourses, as if it were possible to keep them separate, but she is open to the possibility that vice and disorder need not be mutually exclusive. Yet even here, she seems to think that the mental disorder itself could not explain violence to others completely, and that one needs other elements in the explanation. She is especially sensitive to the danger that explaining an action with a diagnosis would take away a person's sense of agency. Adshead gives the impression that she needs a more fully fledged theory of action and mental disorder in order to avoid conceptual problems. Most of the other authors embrace the fact that the moral and the medical overlap, and that people can responsible for their symptomatic behavior even when they have mental illness.

With this and all the other commentaries, it is clearly impossible for them to set out a detailed view about such a complex area. So they are able to raise a few points but one does not get a strong sense of deep engagement with issues raised by the target article, and none of the authors sets out anything like the robust theories that Morse says are needed. This is all to the good, meaning that there is still plenty of work to be done in this area. Sadler ends with the suggestion that it might be possible to do without some theories, by taking a pragmatic stance. This is an idea that I'm sympathetic with, but I'm not sure that it is possible to bypass the theories altogether, and justifying the pragmatic stance without the theory is going to take lots of discussion, if not theorizing.

Channel 4 and Mental Illness

2009-03-23T06:49:00.003-04:00

While on my trip to the UK, I took advantage of Channel 4's on demand service 4oD (which is only available in the UK).

I had been keen to see the Channel 4 production of Claire Allan's novel Poppy Shakespeare, which I reviewed in Metapsychology in 2007. The 2008 90-minute TV version was broadcast in 2008, with Naomie Harris as Poppy and an especially strong performance by Anna Maxwell Martin as N. It is true to the book, but with more fantasy scenes and playing up the absurdity of the patients' behavior. They have been institutionalized and it isn't clear if they really need help or are just milking the system. When there are cuts in services, the patients are ejected from the day ward, and they complain loudly. The mental health administrators are really only concerned with themselves and use administrative nonsense language to justify their decisions. It adds up to 1984 meeting One Flew Over the Cuckoo's Nest, with a strong dose of DaDa absurdism added. As such, it has something to offend everybody, but it makes for a robust drama. I wish it were more widely available.

I also stumbled across the Channel 4 series Psychos, which had 6 episodes, broadcast in 1999. It is set in a Glasgow psychiatric ward, and shows the daily struggles of the doctors, nurses, and patients. The lead character is Dr. Danny Nash, an unconventional but compassionate and insightful psychiatrist, who, it turns out, is also struggling with bipolar disorder. Nash is played by Douglas Henshall, whose website has a page devoted to the series. The series won some acclaim and awards, but also suffered serious criticism for its title, which was seen as stigmatizing, and also its portrayal of mental illness. Apparently there was also an offensive publicity campaign for the show at the time, with the tagline "It will blow your mind." A UK watchdog organization also condemned the trivialization of a sexual encounter between Nash and one of his patients. Despite initial plans for a second series, this criticism led to it being canceled.

The title of the series was clearly a major mistake -- what were they thinking? Yet viewing the 6 episodes makes it clear both how difficult it is to set a TV series in a psychiatric ward without succumbing to stereotypes and how much dramatic potential the idea has. There are moments here that are really interesting, with quandaries about how to help patients, working out what a doctor's responsibilities are, and when psychiatric power is being abused. In the last episode, a university mathematician patient starts quoting Thomas Szasz to the psychiatrists and questions their status in labeling him. A series such as this could serve a valuable role in educating the public on current psychiatric treatment and the experience of mentally ill people. However, the requirements of making it dramatically gripping and the worry about condemnation by advocacy groups for the mentally ill explain why it is unlikely that there will be any similar series in the UK or the USA in the near future.

Catching Up

2009-03-20T07:12:00.003-04:00

My trip to the UK went well. The seminar at Newcastle University Policy, Ethics and Life Sciences Research Centre (PEALS) was interesting especially because a number of mental health service users came and gave helpful feedback on my presentation on the language of madness. Several supported what I was saying with their own experience: they found being called "clients" or "service users" patronizing, and they prefered language that was closer to their usage. One woman said she had a written contract with her doctor to allow him to tell her she was acting "crazy" or to use similar language when she going through an active phase of her mental illness, since she did not understand more polite neutral language at those times.

The workshop at Warwick University Medical School on Mental Disorder was well attended with about 40 people. The room was full to capacity, and we went from 10am to 6pm with a few short breaks. It was a strong collection of papers, and there were good exchanges during questions. Joan Busfield strongly expressed her dislike of the idea of relationship disorders in response to my discussion of the topic, and the sources of her disapproval became clearer in her talk -- it was a suspicion of psychiatry and a concern that psychiatric solutions tend to preclude more social solutions to people's problems. Derek Bolton pressed her on this in questions, emphasizing that there's no reason why psychiatric solutions cannot be combined with other approaches.

It was good to learn of the recent work on definining mental disorder: some people expanded on ideas they have presented elsewhere, but other papers presented work that was new (to me at least) -- I'm looking forward to learning more about Lisa Bortolotti's project on delusions. But one feature of the Warwick workshop I especially liked was the mix of philosophers with people from other departments, and I was glad to hear Liz Barry's paper on Samuel Beckett and Mental Disorder. I've been thinking about teaching my course on The Culture of Madness again soon, and it would be a very useful paper to include.

At Lancaster University Department of Philosophy, the workshop on Vices and Disorders had a good range of papers. Chris Megone expanded on his neo-Aristotelian view and his dialog with Rachel Cooper on whether it can successfully distinguish between disorders and moral failings. Havi Carel had a new project on eating disorders; she surveyed some of the literature and discussed how the line between moral judgment and medical judgment is drawn with anorexia and bulimia. It's an interesting project.

Talking with people while I was in the UK, they agreed that there are more events in philosophy of psychiatry this year than usual. It's an encourage trend, so I hope it continues.

Talks and Conference

2009-02-22T15:40:00.002-05:00

I've got a busy few weeks coming up. I'll be in the UK, giving a seminar at Newcastle and participating in a couple of workshops at Warwick and Lancaster.

On Wednesday, February 25, I'm doing a Policy, Ethics and Life Sciences Research Center seminar at the University of Newcastle, on "The Language of Madness: Medicalization and Counter-Narratives." There's info here.

On Friday March 6, I'll be participating in the the AHRC Mental Disorder workshop at the University of Warwick Medical School.

On Friday March 13, I'll be participating in the Vices and Disorders workshop at the University of Lancaster.

There's info about both these latter events here.

Then on May 16 & 17, there's the annual AAPP conference I've co-organized, on Philosophical Issues in Child and Adolescent Psychiatry, in San Francisco. There's a full program listed here.

2 new journals

2009-02-12T09:49:00.003-05:00

This week, I found two new journals have come into existence in the last few years, both of which have strong connections to philosophy of psychiatry and mental health.

One is The Journal of Ethics in Mental Health. It is an online journal, with free content. Articles are short and accessible to a diverse readership. Hosted by McMaster University, it started in 2006, and publishes twice a year. It looks like it would be especially useful as a teaching resource for courses in mental health ethics.

The other is BioSocieties. It is edtied by Professor Anne Harrington, Harvard University, USA, Professor Nikolas Rose, London School of Economics, UK, Dr Ilina Singh, London School of Economics, UK. Rose and Singh are core members of the BIOS center at the LSE. The journal started in 2006 and is published quarterly by Cambridge University Press. I haven't been able to read any of the articles because my college library does not have the appropriate subscription (and in the current economic climate, I doubt that we will get access to it) but the table of contents certainly looks interesting. It is interdisciplinary and critical, and promises to show the what can be achieved by bringing together work by people from different perspectives and trainings.

AAPP Bulletin

2009-01-27T18:02:00.003-05:00

At the request of James Phillips, the editor of the AAPP Bulletin, I've put the 4 most recent issues online. They are at http://alien.dowling.edu/~cperring/aappbulletins.html

There is excellent work in there:

in Vol 13(1), there is a Symposium on “Toward a Philosophical Structure for Psychiatry,” by Kenneth S. Kendler, M.D., with several commentaries and a reply to each by Kendler.
in Vol 14(1), there is a Symposium entitled "Philosophy and Psychiatry: Reading and Writing from One Side of the Divide—Or the Other," with a target piece by Jennifer Hansen, several responses, and the replies by Hansen.
in Vol 15(1), there is a Symposium on "Psychiatric Disorders: A Conceptual Taxonomy" by Peter Zachar, Ph.D., and Kenneth S. Kendler, M.D., with several commentaries and a reply to each by Zachar and Kendler.

Hopefully now that they are available online the work here will get wider exposure and can be useful to other researchers and teachers.

As an aside, it is worth emphasizing that membership of AAPP gets you a subscription to PPP and helps to support the main international organization devoted to scholarship in philosophy and psychiatry.

Philosophy and Psychiatry in the Media

2009-01-22T08:45:00.001-05:00

I forgot that I had these up online: 4 of my columns for the AAPP Bulletin on "Philosophy and Psychiatry in the Media", from 1999 to 2001.

Here they are.

BBC Radio 4: State of Mind

2009-01-21T21:43:00.005-05:00

State of Mind is a series on BBC Radio 4 that traces the history of mental health treatment in the UK since the 1950s. There have been three episodes so far: Total Institution, Altered States, and Community Care? I was particularly impressed by the second show, Altered States, which in its discussion of antipsychiatry and critical psychiatry. There were clips from an old intereviewith R.D. Laing, and then it had an interview with Phil Thomas, (pictured), co-author of Postpsychiatry, and he talked about his involvement with Sharing Voices (Bradford). Radio 4 already has one long running show that focuses on mental health issues, All in the Mind, and its Science section has in recent years had many other programs that focus on psychology and mental health. It also has programs that address medical ethics: Inside the Ethics Committee is nearly all medical ethics and The Moral Maze often looks at medical/psychological issues. Many other programs on Radio 4 give a reasonably thorough discussion of controversies in psychiatry and psychology.

Apart from admiration for the work of Radio 4, this also highlights the lack of thorough and sustained investigation of such issues by radio stations in the USA. NPR and affiliated companies like American Public Radio pale in comparison with their coverage of these issues. The bulk of their coverage is in short items on their daily news shows, and then interviews (and phone-ins) with authors promoting their new books. It is disappointing that there isn't more room for coverage of new developments in psychology and mental health on public radio. The main show that addressed these issues was The Infinite Mind, which seems to be on hiatus now -- and I have never lived in an area where the public radio stations actually broadcast it.

New work on moral responsibility and psychopaths

2009-01-19T16:32:00.004-05:00

Doing some reading on moral responsibility and following some leads has uncovered a few couple of recent papers relating to psychopathy.

Paul J. Litton. Responsibility Status of the Psychopath: On Moral Reasoning and Rational Self-Governance, Symposium: Living on the Edge: The Margins of Legal Personhood, 39 RUTGERS LAW JOURNAL 349 (2008). Available Online

Absent, Full and Partial Responsibility of the Psychopaths
ZAVALIY, ANDREI G.
Journal for the Theory of Social Behaviour, Volume 38, Number 1, March 2008 , pp. 87-103(17)

I just read "Moral Address, Moral Responsibility, and the Boundaries of the Moral Community" by David Shoemaker at Bowling Green State University. Ethics 118 (October 2007): 70-108.

Shoemaker is interested in what criterion we should use to demarcate our moral community, and he takes as his starting point the work of Peter Strawson and R. Jay Wallace on the participant reactive attitudes. He calls their approach the "Moral Reasons-Based Theory" and summarizes its basic claim as follows:

MRBT VERSION 1:
One is a member of the moral community, a moral agent eligible for moral responsibility and interpersonal relationships,if and only if (a) one has the capacity to recognize and apply moral reasons and (b) one has the capacity to control one's behavior in light of such reasons.

He considers a number of cases of people who are possibly at the borders of our moral community: people with psychopathy, moral fetishism, autism, and mild mental retardation. After each case, he amends the MRBT theory, and by the end he reaches

MRBT VERSION 5: One is a member of the moral community, a moral agent eligible for moral responsibility and interpersonal relationships, if and only if (a) one has the capacity to recognize and apply second-personal moral reasons one is capable of discovering via identifying empathy with either the affected party (or parties) of one's behavior or an appropriate representative, regardless of the method of identification and (b) one is capable of being motivated by those second-personal moral reasons because one is capable of caring about their source (viz., the affected party/parties or an appropriate representative), insofar as one is susceptible to being moved to identifying empathy with that source by the moral address expressible via the reactive attitudes in both its reason-based and emotional aspects.

It's an interesting paper, but I have to say that I found the method of argument especially flawed because of its crude approach to the borderline cases. Shoemaker's discussion of psychopathy is a good one with which to make my point. He starts off, quite sensibly, saying "we need to get clear on just what the nature of psychopathy is." Fair enough. Then he proceeds to lump it together with sociopathy under the DSM-IV disagnostic catetory for antisocial personality disorder. Astonishingly, in making this reference, he cites the Answers.com website, rather than the DSM itself. In a footnote mentioning some disagreements on how to understand psychopathy, his source is Wikipedia (and he refers to the same source again later for more information about psychopaths). Shoemaker argues that psychopaths are able to recognize and follow moral rules, and he cites some philosophers (Jeffrey Murphy, Anthony Duff, Herbert Fingarette) to support his claim, and then he brings in his further evidence: fictional psychopaths, including Hannibal Lecter, Alex Delarge from A Clockwork Orange, and Eric Cartman from South Park.

It becomes clear that Shoemaker is not really interested in psychopathy as a real phenomenon, but rather whatever conceptually possible condition that will serve his purposes for his argument. Of course, he is assuming that psychopaths are not part of our moral community, which is a rather shakey assumption in real life, and is completely unsupported as a claim about his idealized concept of psychopathy that serves as his counterexample.

I find it surprising that anyone would use Wikipedia as a source of information for a scholarly paper, and especially troubling in this case because it leads to a great oversimplification and a neglect of scholarly discussion that is precisely relevant to the whole point of the paper, viz, how to understand psychopathy. It's only through understanding the psychiatric controversies over the nature of psychopathy and the responsibility of psychopaths, (as well as recent discussion in philosophy of psychiatry and neuroethics) that psychopathy can serve as a useful example for such discussion of moral responsibility.

Reciprocal Relations with Mentally Ill People

2009-01-09T15:15:00.007-05:00

I just read Jeanette Kennett's paper "Mental Disorder, Moral Agency, and the Self" in the Oxford Handbook of Bioethics, edited by Bonnie Steinbock, Oxford University Press, 2007. (Incidentally, it is the first time I've read a whole article through Google books -- it saved me a few weeks, since I didn't have to get a copy through Inter Library Loan. Very useful.)

Kennett (pictured) here is discussing an issue I have been thinking about myself recently -- the apparent dilemma that one either treats mentally ill people as autonomous and thus subject to blame for when they are hurful and inconsiderate, or else treats them as nonautonomous, than thus as objects rather than ends-in-themselves. Either way, mentally ill people are in a bad position.

Her approach is rich, even if seems a little rambling. Her main example is Anne Deveson's son Jonathan, who she describes in her memoir Tell Me I'm Here. Jonathan had schizophrenia. Kennett says, using R. Jay Wallace, that on the standard account of moral agency, which requires that an agent be able to step back from his or her desires and examine them in the light of moral principles. She argues that Jonathan did not have that capacity. However, she gives contradictory evidence, since she points out that Deveson found notes written by Jonathan to himself saying "Don't hurt Anne," suggesting that he did regret his actions. It seems that Jonathan was able to assess his own actions at other times, but he was far less able to stop doing them. It is not so clear why Jonathan got so angry with Anne, but it does seem that he at least sometimes regretted his harmful actions. Kennett says that on standard accounts Jonathan cannout count as a responsible moral agent, but it's not so clear to me that this is true.

Kennett also talks about the visibility of the self. At first I thought this was a weak and unnecessary part of the paper, but on reflection it seems the richest part, because it is a new attempt to voice the difficult of people with mental disorders becoming objectified and invisible. She discusses Strawson's idea of participant attitudes, and the difficulties that people with serious mental illness have at being participants, as well as in planning for the future, and forming friendships. In these says, mentally ill people can become invisible. Kennett, quite rightly I think, argues that there is no neat seperation between the mentally ill person and their illness, when their illness has come to shape their identity. Obviously, she is concerned that mentally ill people can retain visibility.

The most philosophically interesting claim of the paper is that Strawson is wrong that we must take an objective stance towards people with chronic and severe mental illnesses. She says that it is not clear that there is a strong conceptual connection between occupying the participant stance and attributing responsible agency to people like Jonathan. She also points out that the participant stance is elastic. It might be available to some degree.

Kennett also focuses on the question whether a participant stance requires attributions of responsibility. She points out that one can have rich participant relationships with children -- not taking the objective stance towards them -- without holding them responsible for their actions. Using these sorts of analogies, she argues that we are not forced toward an objective stance toward the mentally ill. So the bottom line is that even if we do not hold mentally ill pepole responsible, we can still have rich interpersonal relationships with them, even if they are not a rich as with mentally well people.

The view taken by Kennett here is very appealing, and she makes a reasonable case for it. Maybe the conclusion is not very surprising to people who spend a great deal of time with mentally ill people, and Strawson's rather black and white position is quite an oversimplification. But I also think that Kennett's position is a little simplistic. Even with people with chronic severe mental illness, it may be possible for some people to have relationships with them where some mutual attitudes of holding each other responsible is possible. We can also hold people responsible for some things but not others. This is pretty clear with children and teens: they gradually grow into full responsibility. So we need to revise, or at least use with greater flexibility, the standard criterion of moral responsibility to take into account the complexities of life.

Masters Degrees in Philosophy of Psychiatry thriving in the UK

2009-01-04T11:23:00.004-05:00

The MSc in Philosophy of Mental Disorder at King's College London has been running successfully for over 10 years now. The MA / MSc in Philosophy and Ethics of Mental Health at Warwick University (now houses in their Medical School) is still running. Now the University of Central Lancashire has a masters program in Philosophy and Mental Health.

Yet here in the USA, there are no such programs, and there's little prospect of any starting in the near future. It's disappointing that the North American educational system is so conservative, and innovation is so difficult here. My main hope is that one of the current masters programs in bioethics will start to allow for specialization in mental health issues, or possibly that the rush of interest in neuroethics will translate into new masters programs in that area.

Review of Dominic Murphy: Psychiatry in the Scientific Image

2008-12-30T17:33:00.004-05:00

This review is forthcoming in Philosophy in Review, Vol. 28 no. 6.

Dominic Murphy. Psychiatry in the Scientific Image.
Cambridge, MA: MIT Press 2006. Pp. 410.
US$36.00 (cloth ISBN-13: 978-0-262-134355-2).

There are many approaches to understanding mental illness; contemporary psychiatry builds on a medical approach. Murphy defends a particular version of scientific psychiatry, with a focus on how it theorizes mental illness, rather than on how it tries to help people. So his book is about the reality of mental disorders, their explanation, and classification. He explores the definition of mental illness, and discusses what a scientific psychiatric theory should and should not aim to achieve. Murphy ends with an extensive discussion of the objectivity of psychiatric classification. For most topics, he illustrates his points by discussing how they apply to one or more kinds of mental illness. Throughout he gives the reader helpful signposts as to what he has argued so far, what he is about to argue, and how that fits in with the overall structure of the book. This will be especially useful for those readers who are not planning to read the whole work, or who will read different parts at different times. This is a dense, scholarly work of over 400 pages that refers to current work in both psychiatry and philosophy, including philosophy of medicine, philosophy of mind, general philosophy of science, and philosophy of biology. There is a short, very incomplete index.

Murphy argues for a revised view of the medical model of psychiatry, which is not tied strongly to existing mental concepts. Especially since Murphy has been a student of, and co-author with, Stephen Stich, it is illuminating to see traces of eliminativism here. Murphy is quite ready to move on from old concepts when necessary, and does not take the primary task of philosophy to be conceptual analysis. He is thoroughly wedded to a scientific approach to understanding mental illness, and he is especially impressed with the success of the cognitive neurosciences. When our ordinary language or standard practice is in conflict with scientific knowledge, he argues for revising our concepts and practices. Thus, for example, he argues that our standard ways of demarcating mental illness from other illnesses and disorders cannot be rationally justified, and so we should embrace a new, initially counterintuitive understanding of mental illness that would, among other disorders, include at least some forms of blindness. In a related vein, he argues that we should abolish the distinction between psychiatry and clinical neuroscience, because cognitive neuroscience is the best science we have to understand mental illness. However, Murphy is not arguing for an extremely reductionist approach to the mind; rather, he embraces a version of the biopsychosocial model that allows different levels of explanation. At the end of the book, he argues for classification of mental disorders based on causal explanation, as found in much of the rest of medicine, but rejected by the widely used manuals of psychiatric classification. He argues that such an approach is both scientifically preferable and pragmatically more useful.

The book’s ambitious and occasionally perplexing middle section attempts to provide a theory of psychiatric explanation. It draws on philosophical discussion of explanation in cognitive psychology and in biomedicine. In Chapter 5, Murphy explores to what extent factual elements can be isolated to ground psychiatric explanation, and to what extent the explanation of mental disorder requires evaluative assumptions about what is normal or rational. He concludes that in much of psychiatry norms will run through the whole explanatory process, so that the prospects for a mechanistic program of the cognitive neuroscience of mental illness are dim. This causes considerable trouble for the scientific project since there is little prospect of getting intersubjective agreement on epistemic or moral norms. He considers in some detail the cases of delusion, addiction, and psychopathy, and in each case, finds that it is impossible to eliminate norms from the explanation of the phenomenon.

These conclusions seem to entail that Murphy’s earlier confidence in the medical model should be rather diminished. Yet he goes on, in a manner reminiscent of Hume in the case of the missing shade of blue, as if these problems are minor and do not create a problem for the whole project. His attitude seems to be that psychiatric explanation will sometimes be slightly incomplete or patchy, with no possibility of a full account of the mechanisms involved in the production of the phenomena of psychopathology, but that the scientific/medical approach is still the best one available. In Chapter 6, Murphy gives an account of causal psychiatric explanation. He coins the notion of an exemplar, which he describes as the idealized theoretical representation of a disorder — its typical course and symptoms. The explanation works by ‘displaying the causal relations among pathogenic processes that produce the symptoms’ (212). He proceeds to sketch how psychiatric explanation can proceed in some fairly simple cases and then in schizophrenia. In the next chapter, he sets out how social factors can enter into the explanation. In
Chapter 8, Murphy addresses the role of evolutionary theory in psychiatric explanation, arguing that many recent attempts at evolutionary explanation of psychopathology are unsuccessful. His analysis of the failures points to what a successful approach to evolutionary explanation should look like.

Together, the chapters in this middle section give a reasonably detailed picture of how Murphy envisions psychiatric explanation. He carries out a difficult project well: his aim is not to make strong empirical claims about which explanations are more successful, but rather to make a philosophical point about the feasible forms of psychiatric explanation. In the setting out
of his ideas, he addresses many particular controversies and debates in theoretical psychiatry and cognitive science. Owing to the nature of the subject of philosophy of psychiatry, which defies neat categorization and exceptionless generalizations, it is very difficult to arrive at one comprehensive theory or to make straightforward, unequivocal claims. Murphy’s discussion is a case study of how many qualifications and diversions are required by an even moderately thorough approach.

The final two chapters are relatively simple by comparison, because their task is simpler. Murphy covers familiar ground in his criticisms of the classification scheme used by most recent edition of the DSM (the Diagnostic and Statistical Manual of Mental Disorders). His advocacy for the merits of a causal taxonomy is powerful. He acknowledges that the lack of corroborated
theories about the causes of mental disorders will place major limits on to what extent a causal taxonomy can be carried out, but urges that it is still possible to make some progress even in the absence of a fully worked out theory. He gives some indication of how the classification would go using exemplars, and he argues that this would be useful not just for research purposes but also clinically.

Murphy’s book is a landmark achievement in the philosophy of psychiatry. Its claims are often plausible and interesting, and the arguments for them are carefully made. It is certainly the most philosophically sophisticated defense of the medical model of psychiatry that has been made to date. It is a challenging book to grasp as a whole, and there are many places where the argument could be clearer or is vulnerable to criticism, yet it deserves attention from philosophers of science and philosophers of psychology.

SEP: Murphy on Concepts of Disease and Health

2008-12-30T14:04:00.003-05:00

Dominic Murphy (now at the Unit for History and Philosophy of Science, University of Sydney) has has an entry on Concepts of Disease and Health published in the Stanford Encyclopedia of Philosophy.

It's an excellent survey of the issues, and it discusses some issues related to psychiatry, which is inevitable given that most of the controversial cases are to do with mental illness. He sets up the debate by making the distinction between Objectivist views and Constructivist views of disease. On this divide, Boorse is an objectivist and most other people (such as Cooper, Wakefield, and Reznek) are constructivists. I'm not a fan of the terminology: I think that it is more helpful to distinguish between those who think that the concept of disease is intrinsically value-laden and those who don't. It also lumps together people who have quite different views, but that's just about inevitable in an encyclopedia article. Murphy's article is strong in its bringing together the issue with the philosophy of biology, some discussion of the nature of functions, and the problems faced by the two sides.

On Murphy's view, the main problem faced by the Objectivists is in providing a scientific basis for the distinction between normal and abnormal. For Constructivists, the main problem is in justifying any significant distinction between medical and other forms of undesirable conditions. It seems relatively clear that it would be hard to provide any general justification for our present conception of what counts as diseases or medical condition, and if we were to make our conceptual scheme with regard to medicine more rational, we would have to redraw our existing conceptions of disease.

NYT on DSM-V

2008-12-18T18:45:00.005-05:00

An article on the coming debates over DSM-V in the New York Times. Over at the Neuroethics & Law blog, Peter Reiner (pictured) emphasizes his worries about the influence of money on the decision-making process, and urges that all conflicts of interest should be avoided. Quite right too.

However, I don't envy the architects of DSM-V. They really have an impossible task. How to categorize all those disorders in the absence of any good causal theories? In the NYT article, Edward Shorter grumbles about the process, and he bemoaned the expansion of the DSM and the increase of the number of diagnostic categories over the years. But his solution is to restrict mental disorders to the severe cases of mood disorder and schizophrenia, and if DSM followed his recommendations, many people who currently get treatment for mental disorder would no longer be eligible for it, unless they were ready to pay out of pocket. The DSM architects are in a bind: they are meant to make their manual usable by clinicians, scientifically respectable, and also a tool to help people get help. They are also subject to a great deal of pressure from interested groups. The NYT article mentions parents of children diagnosed with bipolar disorder and sensory processing disorder, who have strong opinions about this. Of course, there are some scientific facts to help make the decisions, but much of the work is political. Whatever decisions the architects make, many people will say they got it all wrong and caved in to the other side. At the same time, it is hard to feel too much sympathy for those poor architects, given that they have insulated themselves from public scrutiny. With even Robert Spitzer outraged at their secrecy, they have given themselves a huge public relations disadvantage.

From a philosophical point of view, it is disappointing that the DSM-V people seem to be distancing themeselves from the intense philosophically informed discussion over DSM that has been doing good work for that last couple of decades. None of the major names in the philosophy of psychiatry seems to have been included in the DSM-V Task Force or Work Groups. Very few of the people in these groups has even entered any dialog with philosophers -- Ken Kendler on the Mood Disorders Work Group) being a notable exception. Of course, the DSM people might be able to put together a rationally coherent manual without the help of philosophers, but they would have benefitted from more philosophical input. Kendler et al argued that there should be a Conceptual Issues Work Group, but so far, it seems that their advice has been ignored.

What is a 'new' philosophy of psychiatry and why do we need it?

2008-12-17T09:39:00.005-05:00

A new review article, just 3 pages long, on "What is a ’new’ philosophy of psychiatry and why do we need it?" in Volume 11 Number 4 of Medicine, Health Care and Philosophy, by Michael Quante (pictured). It reviews many recent books in the OUP International Perspectives in Philosophy & Psychiatry series. I've only seen the preview, but it starts off in a positive tone.

Neuroscience in Context

2008-12-17T08:31:00.004-05:00

Neuroscience in Context

This group is new to me, and looks like it is doing interesting work. They have a conference at UCLA on Critical Neuroscience on January 30. They have held a few very interesting workshops already. It's another sign of the rise of neuroethics, and more evidence that philosophy of psychiatry needs to be building bridges to neuroethics.

Weakness of Will and Responsibility for Action

2008-12-16T12:17:00.006-05:00

Sarah Stroud has written a helpful summary of the literature on Weakness of Will for the Stanford Encyclopedia of Philosophy, published in May 2008. She sets out the basic philosophical problem -- how is weakness of will possible? -- then sets out Davidson's solution, and some problems with Davidson's view. She moves on to the question of whether weakness of will is always bad, paying attention to Nomy Arpaly's arguments that it can be rational. She concludes with a brief discussion of Richard Holton's refiguring of the debate, where he argues that weakness of will is not acting against one's values, but rather a too easy changing of one's mind and giving up one's resolutions, followed by Alison McIntyre's recent suggestion that when one is weak-willed and acting against one's values, it is better to be clear that is what one is doing, rather than to rationalize one's actions.

Holton (pictured) has extended his work on weakness of will and strength in his forthcoming book, Willing, Wanting, Waiting, (available in pre-print on his home page). His work is wonderfully clear, and is backed up by recent work in social psychology, such as the research by Roy Baumeister on self-control and ego-depletion. In a recent paper, Holton, with Stephen Shute, applies his ideas to a legal context, arguing that loss of self control needs to be taken seriously as a criminal defense. ("Self-Control in the Modern Provocation Defence")

Holton's work here has already given rise to other published discussions. The journal Criminal Law and Philosophy has a couple of accepted articles related to this: Stephen Garvey has a paper on "Dealing with Wayward Desire," and Vera Bergelson has a reply to Garvey, "The Case of Weak Will and Wayward Desire." Garvey, following Holton, argues in favor of the idea that sometimes people are unable to exercise self-control and this should be a valid legal excuse for criminal action, while Bergelson argues that such sympathy for the offender has no place in the criminal law.

Buss on Autonomy in SEP

2008-12-12T20:53:00.004-05:00

The entry by Sarah Buss (pictured) on Personal Autonomy in the Stanford Encyclopedia of Philosophy (updated September, 2008) does a very nice job at mapping out different theories and their relation to each other, although you have to read the notes carefull to work out which philosophers hold which theories.) She has a pessimistic and somewhat puzzling conclusion:

Agents can be deprived of their autonomy by brainwashing, depression, anxiety, fatigue; they can succumb to compulsions and addictions. To what, exactly, are we calling attention when we say that, under these conditions, an agent does not govern herself, even if she acts as she does because she thinks she has sufficient reason to do so, even if she has (thorougly) considered the pros and cons of her options, and has endorsed her behavior on this basis, and even if she would have acted differently if there had been stronger reason to do so? Most agents who are capable of asking this question are confident that they are the authors of most of their actions, and are thus accountable for what they do. Nonetheless, as this brief survey indicates, the self-relation they thereby attribute to themselves is extremely difficult to pin down.

How can we be so confident about our own autonomy if we have not worked out the details of our theory of autonomy? More to the point, in the case of people with addictions, compulsions, and even delusions, how can we be sure that they lack autonomy if we haven't worked out our theory of autonomy? The answer must be that there are broad features of autonomous action that we can identify even if we haven't worked out the theoretical details. We can tell if a car is working well or broken down even if we don't know how the engine works.

But aren't the broad features all we need then for a satisfactory theory of autonomy for it to make the distinctions we need it to make, at least with regard to working out who is autonomous and who is not? Do we need to sort out the details of the debates between coherentists and externalists, or how agents authorize their desires, it sorting this out does not help us make the distinctions we want to make? Even further, can't we conclude that whatever these debates achieve, they don't really tell us more about what autonomy is. We might use the car example: we can understand the concept of a functioning car without knowing how the engine works, and furthermore, knowing how the engine works does not add anything to our concept of a functioning car. To be sure, it is useful for other purposes, but not in the basic use of the concept of functioning car. So with autonomy, the sophisticated debates about self-relations are interesting in their own terms, but they don't tell us more about what we mean by autonomy.

I'm not sure I accept this conclusion, but it certainly is tempting.

Neuroethics special issue on psychopathy and responsibility

2008-12-11T08:12:00.003-05:00

Neuroethics Volume 1, Number 3 / October, 2008

Moral Responsibility and the Psychopath
Walter Glannon

Psychopathy and Criminal Responsibility
Stephen J. Morse

Psychopathy Without (the Language of) Disorder
Marga Reimer

Responsibility, Dysfunction and Capacity
Nicole A Vincent

The Cognitive Neuroscience of Psychopathy and Implications for Judgments of Responsibility
R. J. R. Blair

The Mad, the Bad, and the Psychopath
Heidi L. Maibom

On the one hand, I'm thrilled that there's a whole issue on this topic. On the other hand, I wonder when I'm going to have time to read all of these! It's the price of one's area of research becoming popular.

The Philosophy of Mental Illness: What's New?

2008-12-05T07:41:00.003-05:00

It is time for me to update my entry in the Stanford Encyclopedia of Philosophy on Mental Illness. I wrote it originally in 2001, and I did some updates in the bibliography in 2005.

It has 3 main sections:

1. Does Mental Illness Exist?
2. Is There an Objective Way to Classify Mental Illnesses?
3. When are People with Mental Illnesses Responsible for Symptomatic Behavior?

I am reluctant to cut these, but it's clear that I could add many topics, and I would want to update the existing sections. But how to prioritize? One of the most obvious missing topics is on making sense of psychosis and delusions; another is on the relation between psychiatry and cognitive neuroscience. But what else?

I'd appreciate suggestions from others on this. One thing to keep on mind is that the topic is philosophy of mental illness rather than the philosophy of psychiatry, and the original idea behind this was that it was a narrower topic, although thinking about it now, it is not so clear to me why this should be so.

Psychiatric Coercion Not Evidence-Based

2008-12-04T14:02:00.002-05:00

A survey of the literature reveals a lack of study and evidence regarding medicating psychiatric patients against their will.

"Coerced medication in psychiatric inpatient care: literature review"
Manuela Jarrett, Len Bowers & Alan Simpson
Journal of Advanced Nursing 64(6), 538–548
http://www3.interscience.wiley.com/cgi-bin/fulltext/121428227/PDFSTART

The BBC reported this as "Psychiatric drugs force queried" which isn't really what the article does. Bowers has written defending psychiatric practices, in his book The Social Nature of Mental Illness. Noting the lack of study of coerced medication and calling for more study is not the same as doubting whether it should be done at all. Doubtless it is an awful experience for the person being drugged, especially at a time when they are feeling vulnerable and possibly paranoid. One of the central issues would be what alternatives are available to health care providers, especially when drugs are relatively cheap and individual attention is expensive.

All in the Mind on Mental Health Blogging

2008-12-04T13:46:00.002-05:00

There was a nice piece in the BBC Radio 4 show All in the Mind, Tuesday, Dec 2, 2008, about mental health blogging, with an interview with a couple of bloggers with psychiatric diagnoses.

One of the blogs was http://thesecretlifeofamanicdepressive.wordpress.com/

It has a great list of links to other blogs too. Worth checking out.

New Issue of Disability and Society

2008-12-04T13:10:00.003-05:00

At least two articles that particularly interest me in the latest issue of Disability & Society.

"Controlling behaviour using neuroleptic drugs: the role of the Mental capacity act 2005 in protecting the liberty of people with dementia"
Geraldine Boyle
http://www.informaworld.com/smpp/content~content=a906327424
Abstract:
The use of neuroleptic drugs to mediate the behaviour of people with dementia living in care homes can lead to them being deprived of their liberty. Whilst regulation has been successful in reducing neuroleptic prescribing in the USA, policy guidance has been unsuccessful in reducing the use of these drugs in the UK. Yet the Mental capacity act 2005 aimed to protect the liberty of people lacking capacity and provided safeguards to ensure that they are not inappropriately deprived of their liberty in institutions. This article highlights the potential for using this law to identify when neuroleptic prescribing in care homes would deprive people with dementia of their liberty and, in turn, to act as a check on prescribing levels. However, the extent to which the Act can promote and protect the right to liberty of people with dementia is constrained by a lack of access to social rights.

and

"The meaning of autism: beyond disorder"
Sara O'Neil
http://www.informaworld.com/smpp/content~content=a906324659
Abstract
The incidence of autism spectrum disorders has increased dramatically over the past two decades, yet these disorders are still poorly understood. By considering the viewpoints of autistics themselves, together with evidence from the scientific literature, it becomes clear that autism spectrum disorders are not always the debilitating conditions that they are sometimes portrayed as. In fact, they are often associated with a number of strengths. With a focus on the areas of intelligence, communication, social skills and stereotyped/repetitive behaviours, this article calls into question the idea that autism is a traditional disorder and argues that a new inclusive dialogue on the meaning of autism should be considered.

It's more evidence that great work is being done in disability studies that should be included in both psychiatric ethics and philosophy of medicine. Oh disciplinary walls, how I want to knock you down!

Young People and Personality Disorders

2008-12-01T17:40:00.004-05:00

It is strange what the press picks up on. In the latest issue of Archives of General Psychiatry is the following article: "Mental Health of College Students and Their Non-College-Attending Peers: Results From the National Epidemiologic Study on Alcohol and Related Conditions," by Carlos Blanco; Mayumi Okuda; Crystal Wright; Deborah S. Hasin; Bridget F. Grant; Shang-Min Liu; Mark Olfson. The abstract of the article concludes: "Psychiatric disorders, particularly alcohol use disorders, are common in the college-aged population. Although treatment rates varied across disorders, overall fewer than 25% of individuals with a mental disorder sought treatment in the year prior to the survey. These findings underscore the importance of treatment and prevention interventions among college-aged individuals." There's nothing very surprising here. I probably would not have looked at it, but for the headline from the Associated Press on Yahoo News: "1 in 5 young adults has personality disorder." 20%? Good grief!

US News and World Report has a more measured summary. "Among college students, the most common disorders were alcohol use (20.4 percent) and personality disorders (17.7 percent). The most common disorders among young adults not in college were personality disorders (21.6 percent) and nicotine dependence (20.7 percent)." Still, the incidence of personality disorders is very high here, and without having looked at the article itself, and not being familiar with the literature, I can't say if they are using an over-expansive definition. However, this points to the suspicion that the DSM-IV criteria of personality must be too broad, or being applies in too broad a way.

Of course, the media are right in picking out the most surprising feature of the article, which isn't even mentioned in the abstract. And the overall message, that nearly half of college-aged students experience psychiatric disorders, while only one quarter get treatment, is still alarming even if it isn't surprising.

Swiss voters approve of heroin prescription plan

2008-11-30T18:40:00.000-05:00

Apparently the experimental program for medical providers to prescribe heroin to heroin addicts as part of their treatment has been so successful in the last 10 years in Switzerland that voters approved it on a permanent basis. (Source) The scheme has been successful in getting drug users off the street, and people were impressed by that.

It is hard to imagine such a scheme being approved in the USA, because the symbolism of doctors prescribing heroin is perceived as so dangerous -- medically sanctioned addiction. In Switzerland, it seems that heroin has become less cool at least partly because of this scheme -- heroin is less romantic for young people now, and heroin addiction is more obviously a medical problem. I wonder when such an initiative would have hope of being tried in the USA, where pandering to public opinion gets in the way of effective policy.

Blog on Teaching Philosophy of Psychiatry & Mental Health.

2008-11-26T07:14:00.000-05:00

I've created a blog on Teaching Philosophy of Psychiatry & Mental Health.
It is at http://teachingppp.blogspot.com/

It is primarily a place to put up syllabi for courses. It is possibleto comment on the syllabi -- all comments are moderated.If you know of, or have, a syllabus in an area closely related tophilosophy of psychiatry you would like to be up on this blog, pleasesend it to me. If you know of a syllabus already online that I could link to, please send me the link.

I'm willing to take an inclusive approach, including many differentkinds of courses that raise philosophical and ethical questions aboutclinical psychology and abnormal psychology. So, for example, I would include history of psychology courses that include some considerations of mental illness and raise philosophical questions. I'm also looking for published articles on teaching philosphical issuesin psychiatry and mental health.

Why Don't People with Mental Illnesses Embrace Disability Identity?

2008-11-22T22:23:00.001-05:00

I've only ever been to one disability studies conference, and I should go to more. I gave this paper at the 16th Annual Meeting of the Society for Disability Studies, "Disability and Dissent: Public Cultures, Public Spaces, " held at the Bethesda Hyatt Hotel, June 12-15, 2003. It was different from most other conferences I've been to. I remain interested in the relation between people with mental illness and disability movements.

Why Don't People with Mental Illnesses Embrace Disability Identity?

Abstract
There are legal and financial benefits from identifying as disabled such as protection under the ADA and disability benefits, but despite these, people with mental illness are hesitant about identifying as disabled. This reluctance is especially clear among those with mental illnesses who manage to hold jobs and sustain relationships with significant others. Little empirical work has been done to examine this, so this presentation is speculative in addressing what might explain this phenomenon. Most obviously, people may wrongly believe that the term disability is restricted to those with physical impairments. Furthermore, they may believe that if they are able to hold a job, then they cannot count as disabled. But there may be more subtle reasons. The category of "disabled" may seem disempowering, since it often carries a connotation of being powerless. The Social Model of disability is specifically designed to be empowering, laying the responsibility for disability on society, and portraying people with physical and mental impairments as merely different. There are striking parallels between the Social Model and the antipsychiatry movement of the 1960s and 1970s, which also argued against a medical model. Now antipsychiatry has been largely rejected, and the mentally ill today tend to embrace the medical model, which is promoted heavily by pharmaceutical companies and which seems to reduce the stigma of mental illness. So even the Social Model of disability may not be appealing to people with mental illnesses. If the people with mental illnesses are to be fully included in the disability community, these concerns need to be addressed.

Identifying as Disabled

My first assumption in this paper is that people with mental illnesses are reluctant to embrace a disability identity. I should explain what I mean by this and provide some justification.
Maybe the most obvious way one can identify as disabled is in a rather superficial sense. One can claim financial benefit and get both medical and social services (at least in some countries) by proving that one fits with the official definitions of disability. Parents can sometimes get extra educational resources for their children if they show them to have physical or cognitive disabilities. One can also try to claim legal protection against discrimination through legislation such as the Americans with Disabilities Act.

Whether a significant proportion of people with mental illnesses who could qualify for various forms of disability benefits but do not claim such benefits is a matter for research. Of course, one might claim such benefits without any deeper psychological identification as a disabled person. What kinds of psychological identification are available? One may call oneself disabled and explain one's lifestyle to other people by reference to a disability. One may identify oneself as a member of a group of disabled people who communicate with each other and meet on a regular basis. The group could take on a public role, raising awareness in the rest of society about the nature of disability and the experience of people with disabilities. The group could also take on a political role, lobbying governmental organizations and defending the rights of group members. The group can engage in academic discussion and studies of issues relevant to its disability. An individual participating as a member of the group is at least likely to identify with the group in different ways corresponding to these different activities.

A final way in which one might identify as disabled is in perceiving a commonality between oneself or one's group with other people or groups with other disabilities. It is worth adding here a comment about the social model of disability. On this view, people with disabilities may have physical or mental differences from "normal" or "abled" people but the cause of the disability is understood as society, and on this view one may identify with other oppressed groups such as minorities or women who are disabled by the attitudes and practices of the rest of society.
People with mental illnesses do generally acknowledge that they have those illnesses, although there are of course studies suggesting that many people with psychological disorders either do not acknowledge their problems or else do not seek treatment for them. Some groups exist for people with major mental illness for them to share information with each other about their disorders and ways to get help for their problems. These include formal groups with membership requirements, recovery groups that often insist on anonymity, and many Internet groups that are open to anyone. There are national advocacy groups such as NAMI in the US and MIND in the UK which are especially focused on major mental illnesses which are often chronic.

What is striking is that both individuals and groups of people with mental illness rarely describe themselves as people with disabilities. Sometimes people who are unable to work due to chronic mental illness describe themselves as "on disability" but even in such cases, they often have little inclination to identify as disabled in a stronger sense. People whose mental illnesses make it difficult for them to sustain friendships or loving relationships with others may see themselves as disabled in some ways. For people with mental illnesses who are able to maintain themselves in work and love, it is much easier to "pass" as someone without a mental illness, and such people are rather less likely to identify as disabled.

Why Don't the Mentally Ill Identify as Disabled?
Having clarified to some extent what I mean by saying that people with mental illnesses do not identify as disabled, I now turn to the next aim in this paper, to set out possible reasons why such people are reluctant to identify as disabled.

One of the first concerns may be the widely shared misconception that disability must be due to a physical impairment. While the popular understanding of disability is mainly based on physical impairments such as blindness, paralysis or lack of limbs, or deafness, there's no reason to restrict the category disability to such cases. Indeed, there is probably widespread agreement that severe mental retardation should count as a disability, and since mental retardation concerns intelligence, it is a paradigm of a psychological problem. Of course, mental retardation may well have physical causes -- they are often genetic -- but the effects are mental as well as social. The etiology of serious mental disorders such as manic depression, schizophrenia or unipolar depression is still under investigation, but there is a good chance that they are at least partly physical. So this concern provides no reason to prevent seeing mental illness as a disability.

The second sort of reason that could be a factor is the belief that an illness cannot count as a disability. This in turn may be based on different possible ideas. One source may be that it is thought that disability is a static condition while an illness is a process. The central idea behind this seems right -- short-term illnesses and maladies do not seem to count as disabilities even if they are serious. A person with a broken arm may be temporarily disabled, but it would be odd to apply the label of "disabled person" or "person with a disability" to her. But as has been argued by Susan Wendell,[1] it is a mistake to exclude chronic illness from the category of disability. Paradigm disabilities are not always static but in fact can develop and change with time. Furthermore, chronic illnesses can be relatively static and permanent conditions. So this sort of concern provides no real barrier to understanding many mental illnesses as disabilities.
Some may think illnesses cannot be disabilities because illnesses are not serious enough in their effects. However, as a strict universal claim, this is obviously false -- one need only look at the suicide rates associated with mood disorders and schizophrenia. Such a consideration might be worth considering seriously is if we restrict our focus to cases of illnesses with which people can still work and have long-term relationships with other people. Indeed, this sort of reason seems right to exclude many minor illnesses and maladies from the category of disability. But even this restriction is implausible, since many people with paradigm disabilities such as blindness or deafness are able to both work and love while still remaining in the category of the disabled. So we might move to a second, greater restriction: maybe the central idea here is plausible in the case of people who with treatment or technological aids is able to compensate completely for their illness. For example, people with manic depression (in ideal cases) may be able to keep their condition under complete control through the use of medication and psychotherapy. Would this in itself mean that they are not disabled? Again, this is implausible. For example, if a person who is missing a limb has a prosthetic limb that is fully functional, would this mean that person was no longer disabled? This is not clear, and opinions or intuitions may differ. The US Supreme Court has in several decisions apparently concluded that such people do not count as protected by the Americans with Disabilities Act.[2] So maybe there is some plausibility to this view, with this major restriction, but it deserves further discussion, for which I do not have time. Since the second restriction does not apply in most cases of major mental illness, I will set this point aside.

The final reason people with mental illnesses might have for being reluctant to identify as disabled is not so much conceptual as emotional. They might feel that the stigma of mental illness is enough in itself, and they do not want to take on the extra burden of risking the stigma of disability. I can illustrate this with an example from Lucy Johnstone's Users and Abusers of Psychiatry.[3] She describes the case of a person who calls himself John Baptist, from an episode of a 1995 BBC documentary series called Minders. John is a black man who believes he was born white, that he is descended from the British royal family, and that his sister has been cannibalized. He does not believe he has a mental illness and does not want psychiatric treatment, because he has had unpleasant and unproductive encounters with psychiatry in the past. However, the authorities go to a tribunal and assert that he is "angry, irritable, shouting at people, verbally aggressive" and has inappropriate beliefs. He is forced to take medication, which he hates, and this changes him to a sad and hopeless man, although he never abandons his unusual beliefs. In one of the final scenes of the documentary, one of his treatment team encourages John to sign a form to confirm that he is "permanently and substantially disabled" by mental illness, in return for a bus pass. Johnstone uses the example to illustrate her claim that young black people are highly suspicious of mental health services, but it also shows how identifying as disabled can be a blow to one's self-confidence. This is not to say that this is always or even often the case, and of course it should not be the case. Naturally, there should be no stigma attached to mental illness per se, nor to disability per se.

The Relation between the Social Model of Disability and Antipsychiatry
Now that we have some grasp on possible reasons why people with mental illnesses may be reluctant to identify as disabled, we can move on to ask how it could be helpful to make this identification. The most straightforward reason is that it can entitle one to financial benefits, subsidized or free medical care, and social services, as well as legal protection against employment discrimination. These are important benefits that should be conferred by enlightened societies.

However, there are other sorts of benefits. First, there could be benefits from joining groups of people with disabilities in sharing information and learning from other people how they negotiate a rather hostile world. Second, identification as disabled could have benefits of reducing a sense of isolation both through solidarity with others and increasing possibilities of friendships with other people. Third, being part of a group of disability studies can expand ways of understanding mental illness. In the remainder of this paper, I want to discuss the relation between debates over the conceptualization of disability in disabilities studies and the debates over the conceptualization of mental illness.

In the US, people with severe and chronic mental illnesses are in many ways some of the most disenfranchised members of society. People with schizophrenia and manic depression are not well organized into political groups. There is a very familiar stigma attached to mental disorder and the rights of the mentally ill are often under attack when they are portrayed as potentially dangerous and a menace to society. Over the last quarter of a century at least, it has been thought that the most effective way to combat stigma has been to insist that mental illness is as real as physical illness, and indeed, it has been thought politically important to argue that mental illness is at root a physical illness. (For example, NAMI and parity.) It is striking how the situation has changed since the 1960s and 1970s there was a very active movement inspired by the work of thinkers such as R.D. Laing, Thomas Szasz, Michel Foucault and a number of feminist theorists such as Phyllis Chessler and Kate Millett, which argued against a medical model for mental illness. This view has to a large extent ceased to play a significant role in contemporary debates. It is plausible that there are important parallels between this movement, loosely collected under the term "antipsychiatry" and the current social model of disability. So there may be lessons to be learned on both sides from seeing the connections between these two approaches.

Those who have been called antipsychiatric theorists have held a wide variety of different views, and it is problematic to lump them all together. In this presentation, I do not have the time to make careful distinctions between the different strands of thought within the movement, but it is at least worth setting out some of the basic ideas. All these theorists shared a deep suspicion of the use of psychiatric technology and power to make individuals conform to the values of society, through enforced treatment and hospitalization. Works such as Erving Goffman's Asylums showed the shocking conditions in which thousands of long-term patients in state mental hospitals were kept. Movies such as One Flew Over the Cukoo's Nest and Ken Loach's Family Life brought such views to a wide audience, and these ideas fit well with a wider distrust of the uses of the power of the state to crush other points of view that was especially prevalent in the 1960s and 1970s with the rise of the civil rights movement, the anti-war movement, women's liberation, rock music and the growth of the recreational use of drugs.

One strand of antipsychiatry has been set out by the libertarian Thomas Szasz. He argues that mental illness does not exist because the very idea is a conceptual mistake. He has argued consistently that not only does the state infringe on the rights of people when it forces treatment on them, but also that people diagnosed with mental illness should receive no special status or protection from the law. He places responsibility for coping with the world on the individual and criticizes all forms of state help for the mentally ill.

An opposing strand of thought within antipsychiatry is maybe most closely associated with R.D. Laing. Laing was influenced by a rather more sophisticated understanding of existentialist philosophy than Szasz's individualist libertarianism. Laing argued that people with mental illnesses such as schizophrenia were genuinely suffering and were in need of help. However, he was very critical of the medical solutions that were in use in the 1950s and 1960s, and he linked the suffering of individuals to both their dysfunctional families and the broader alienation inherent in modern society. He experimented with various attempts to provide people with psychological problems with more tolerant living conditions, although these experiments had little success.

The social model of disability has been set out by such theorists as Constantina Safilios-Rothschild, Gerben DeJong, Deborah Stone, Wolf Wolfensberger, Paul Abberly and currently advocated by well-known activists such as Colin Barnes and Tom Shakespeare. It is surprising to me, as a relative outsider to the field of disabilities studies, that the histories of the field pay almost no attention to antipsychiatric thinkers or even to the wider cultural movement associated with the criticism of psychiatry.

The most obvious parallels between a Laingian antipsychiatry and a social model of disability lie in the placing responsibility on society for its failure to accommodate itself to the needs to people with physical or psychological differences from the norm. In some interpretations of Laing, it is society or parts of society that in fact cause the psychological problems in the first place. A familiar example today of this sort of view would be the social valorizing of thinness causing young people to become anorexic. Another potential example would be if the alienation of modern capitalist societies cause depression and schizophrenia, as some interpreters of cross-cultural studies have suggested is the case. But the causal claim is not essential to the social model of disability. Whatever the original cause of the differences in the individual, on this model, society causes the disability in the sense of making it impossible for the individual to function as well as normal people. For example, a person who needs a wheelchair is prohibited from fully participating in society if public buildings are inaccessible to people in wheelchairs. When it comes to mental illnesses, it can be pointed out that more rural and more mystical societies are able to find a place for people who hear voices and who are not able to engage in normal social relationships. For example, they might be revered as having special mystical abilities, or they might be integrated into society despite their differences, rather than being locked away in hospitals or medicated with powerful tranquilizers. Our society, with its strong emphasis on the need to work in a conventional job and conform to rigid social norms, has no place for people whose behavior is unconventional or bizarre according to its standards.

A second, related parallel between some forms of antipsychiatry and the social model of disability concerns the medical status of the individual in question. In at least some forms, the social model denies that the differences of the individual need medical treatment. Similarly, in some of its extreme forms, antipsychiatry has denied that there is any such thing as mental illness or that the individuals in question need psychiatric treatment. It is probably this aspect of both approaches which causes most controversy -- whether it be the claim that deafness is simply another way of being in the world or that schizophrenia is not a disease but is rather a psychospiritual crisis.

While there are some people who still defend antipsychiatry in its most extreme forms, it is a movement that has basically died. In its wake are left two rather disparate groups. On the one hand there are academics who defend "critical psychiatry," which tends to be more sophisticated in its criticisms of traditional psychiatry, suspicious of its individualism, sexism, classism, racism, its medicalization of normal conditions, its alliance with the interests of the multinational pharmaceutical corporations, and critical of society for not making a place for people with mental illness. On the other hand, there are groups of patients, ex-patients and "survivors" of the psychiatric system which tend to advocate conspiracy theories, and condemn psychiatry wholesale. These groups have proliferated with the advent of the Internet. Neither group holds much appeal to the majority of people with mental disorders: the "critical psychiatry" movement is at a rather too abstract and academic level to be accessible to members of the general public, and the conspiracy theorists tend to be too far on the fringe and have nothing in terms of substantial help to offer. Furthermore, now with direct-to-consumer advertising and sponsorship of groups such as the National Alliance for the Mentally Ill in the US, the pharmaceutical companies have a powerful grip on the popular thinking about mental illness, and most people are led to believe that it has been scientifically proven beyond reasonable doubt that mental illnesses are disorders of the brain. Many conclude from this, with the implicit encouragement of the pharmaceutical companies, that the best treatment for the illness is medication. It is generally thought, with no good evidential support, that this approach will help to reduce the stigma associated with mental illness.

Given this situation, there is a great deal of room for a modest revival of an antipsychiatric approach taking its inspiration from the social model of disability. It seems to be a major error to insist that there is no such thing as mental illness, not so much because it is an indisputable fact that mental illness exists , but more because such a denial is going to alienate many people who would otherwise be sympathetic to some form of antipsychiatry. The real value of an antipsychiatric approach is to emphasize the responsibility of society to accommodate people with psychological differences and problems and integrate them into the fabric of everyday life. We can debate whether we should try to eliminate mental illness or to value it, and this is certainly an interesting question, but the current state of treatment is so far from curing mental illness that this debate will be of only peripheral concern to most people with mental illnesses. The best we can do these days is help to reduce some symptoms without causing terrible side-effects, and hope for spontaneous remission of the illness.

Thus, my final proposal is that there is a clear benefit for people with mental illnesses to identify as disabled in a political sense of adopting a social model of disability, and to see their problems as caused by society. The next step is to develop a clear understanding of what it would be to have a society that treated people with mental illnesses in a non-disabling way.

[1] Susan Wendell, The Rejected Body (Routledge, 1996) and her article "Unhealthy Disabled: Treating Chronic Illnesses as Disabilities" (Hypatia 16(4) 2001, pp. 17-33).
[2] See for example, Toyota Motor Manufacturing, Kentucky, Inc v. Williams, 120S. Ct. 681 (2002) concerning carpal tunnel syndrome, Bragdon v Abbott, 524 U.S. 624 (1998) concerning HIV-positive status. Excellent discussion of these issues is in Part B of Americans with Disabilities edited by Leslie Pickering Fancis and Anita Silvers (Routledge, 2000.)
[3] Lucy Johnstone, Users and Abusers of Psychiatry. Second edition (Routledge, 2000, pp. 231-2).

The Limits of Philosophical Knowledge: Implications for Philosophical Counseling

2008-11-21T17:28:00.000-05:00

Another philosophical counseling conference paper.

THE NORTH AMERICAN CONFERENCE ON PHILOSOPHICAL COUNSELLING
Morals and Ethics in Philosophical Counselling
Saint Paul University, 223 Main Street, Ottawa, Ontario, Canada K1S 1C4
Date: November 1-3, 2002

It was quite a nice conferece, although I recall people were annoyed with me for not being sufficiently enthusiastic or optimistic about philosophical counseling.

The Limits of Philosophical Knowledge: Implications for Philosophical Counseling

Abstract

The goal of philosophical counseling is to help individuals or groups sort through problems they face in their everyday lives. These problems can be ethical, epistemological, existential, metaphysical or conceptual. There are two central difficulties for the project of philosophical counseling. The first difficulty derives from the open-ended nature of philosophical debate. It is part of the very nature of philosophy that it focuses on areas of disagreement and controversy, and it is extremely rare for philosophers to achieve consensus on any issue. If no philosophical theory is generally accepted, then no philosophical theory will be very helpful to people trying to work out what they should do when facing a real life problem, because we cannot know which philosophical theory is the right one with any degree of assurance. The second difficulty is that of deriving recommendations from philosophical theories. Even if we restrict our attention to a single philosophical theory, one generally finds that when considering real life cases, it is very difficult to derive a substantive implication from the theory concerning the case. This problem has been discussed extensively in the literature on the foundations of medical ethics in the debate between principlism, rule-based approaches, and casuistry. I argue that these two difficulties exist also for anyone attempting to teach a course in "applied philosophy," and I discuss my own experience in attempting to design and teach courses that make philosophy helpful to students. I conclude that philosophers should be very careful in their claims that philosophy can be useful in decision-making when facing everyday problems. The most they should claim is that philosophy can help people to inspect the range of choices available to them, to understand the different points of view on the choices they face, to justify their choices once they start from their assumptions, and to be aware of the contingency of their own choice.

The goal of a great deal of philosophical counseling is to help individuals or groups sort through problems they face in their everyday lives.[1] These problems can be ethical, epistemological, existential, metaphysical or conceptual. There are two central difficulties for the project of philosophical counseling that the literature on the subject has neglected. The first difficulty derives from the open-ended nature of philosophical debate, due to nature of which issues cannot normally be settled by empirical observation or scientific experiment. It is characteristic of most of philosophy that it focuses on areas of disagreement and controversy, and it is extremely rare for philosophers to achieve consensus on any issue. If no philosophical theory is generally accepted, then there is a serious danger that no philosophical theory will be very helpful to people trying to work out what they should do when facing a real life problem, because we cannot know which philosophical theory is the right one with any degree of assurance.

Indeed, even where philosophers have reached a good deal of consensus, the general public may well be reluctant to adopt the view recommended by philosophers. The clearest example of this concerns the metaphysical issue of the nature of the mind. Most participants in the current debate in the philosophy of mind agree that substance dualism associated with Rene Descartes is highly implausible, largely because the suggestion that the mind is composed of a non-physical substance has very little explanatory value and leaves unexplained crucual questions such as the nature of the interaction between mind and body, the justification in our beliefs in other minds, and why there should be one and only one mind associated with each human body. Nevertheless, substance dualism remains a popular theory among the general public, for whom it often associated with religious beliefs about life after death. The philosophical worries about substance dualism make very little difference to ordinary people. When it comes to most other issues, the philosophical debate continues and consensus about central issues is rarely achieved. The foundations of epistemology, ethics, metaphysics, and political philosophy remain disputed, and indeed, the very method by which philosophers should set about solving problems is a matter of deep disagreement. Even listing the five most important philosophers of the twentieth century can lead to fierce disputes. Maybe the only matter on which philosophers and the general public could all agree is that there is the deep disagreement about the fundamentals in philosophical debate.

If people are facing particular problems in their everyday lives, they generally need to come to a decision in a limited amount of time. Then a central question, if philosophy is to be useful to people in such circumstances, is how people can make a decision when faced with such a lack of resolution about the right perspective or theory. A further worry facing both philosophical counselors and teachers of philosophy as applied to the real world, especially when dealing with time constraints, is how to present a balanced and fair picture of the philosophical views on the issues in question, and to what extent it is problematic to openly or implicitly to favor one view over others.[2]

The second difficulty I want to discuss here is that of deriving recommendations from philosophical theories. Even if we restrict our attention to a single philosophical theory, one generally finds that when considering real life hard cases, it is very difficult to derive a substantive implication from the theory concerning the case. This problem has been discussed extensively in the literature on the foundations of medical ethics in the debate between principlism, rule-based approaches, and casuistry. There is in the medical ethics literature a thriving discussion of to what extent it is possible to derive concrete conclusions from general ethical schemes when dealing with the complexities of particular cases. Real life cases typically bring with them a daunting complexity of issues, and many ethical considerations come into play. There is certainly no algorithm that will provide concrete recommendations from very general considerations, and some have expressed doubts whether general ethical theories have the ability to provide concrete answers to real life controversies. (For recent discussions of this topic, see the Iltis (2000), chapters 1 and 9 of Beauchamp and Childress (2001), and chapters 7 and 8 of Toulmin (2001).)

My aim here is to discuss how these features of moral philosophy can be dealt with in teaching courses of “applied ethics” to undergraduates, and to explore the extent to which they could be dealt with in philosophical counseling. It is worth noting the extent of my interest and expertise in philosophical counseling: I have over ten years experience teaching courses in ethics and applied ethics, and I have a strong research interest in philosophical issues in clinical psychology; I have attended various conferences on philosophical counseling and have written on the topic (Perring 1998, Perring 2000, Perring, 2001, Perring forthcoming), but I have no experience of working as a philosophical counselor. Indeed, while I wholeheartedly endorse the aim of using philosophical skills and knowledge to help people, I have concerns about the very project of philosophical counseling. As in much of my other writing on the topic, my goal here is to suggest that the problems faced by philosophical counselors have already been worked through in other areas of philosophy, and philosophical counselors would do well to learn from what has gone before. But here my focus is on the lessons learned in the classroom, and philosophers have rarely discussed in print the problems faced by teachers trying to show the ways that philosophy can help people in their everyday lives. So I will turn to my own experience in the classroom.
I have taught undergraduate classes on medical ethics, death and dying, philosophy of psychiatry, genetic ethics, general ethics, critical thinking, and many courses of introductory philosophy organized both by philosophical topic and by historical period. My aim in teaching is to provide students with an understanding of the philosophical debates about the topics on hand, and with skills to express their understanding in debate and in writing, and to form their own opinions on those topics. When a topic has clear relevance to everyday life, I emphasize the process of decision-making and suggest that philosophical training can enable more rational decisions.

Of course, students rarely sign up for such courses in order to help them with immediate problems in their personal lives. They generally take them because they have a prior interest in philosophy or they are required to take them as ways of fulfilling degree requirements. They frequently start out with an assumption that philosophy has little relevance to the “real world” and have very little conception of how a focus on philosophy could help them either professionally or personally. Although I hope that they benefit from taking my courses, and sometimes receive positive feedback from students, I have no solid evidence that these courses do actually improve my students’ decision-making abilities. Indeed, I know of no attempt to measure the beneficial effects of philosophy courses on students, nor of any attempt to measure the effects of philosophical counseling.

Nevertheless, an experience shared by many teachers is that exposing students to a variety of perspectives on controversial issues together with the main approaches to ethical theory can often lead to student confusion and even bewilderment; far from helping them to form opinions, exposure to philosophy can lead to greater indecisiveness. This is an unsatisfactory result for students, although it is probably a good thing to induce greater epistemic humility in some students who previous had strong convictions but little justification for their beliefs, one hopes using philosophy to help students to enable them to come to some decision.

Therefore, when teaching such courses, it is important to address the fact that rational and informed people will come to different conclusions and will form different decisions. There is a strong element of contingency in ethical decision-making, and while this should be a fact that leads to further discussion and investigation to pinpoint the sources of differences and the rational evaluation of each person’s decisions, it does not vitiate the whole decision-making process. Or at least, since the contingency of ethical decision-making is a feature shared by almost all approaches to ethics and seems to be an inescapable feature, only those inclined to skepticism about the possibility of ethical knowledge will find this contingency a highly problematic feature.[3]

It is striking that in the few available descriptions of philosophical counseling, little or no mention is made of the problem of the uncertainty of moral and philosophical knowledge and the contingency of ethical decision-making. For example, Lou Marinoff and Shlomit Schuster both discuss their approaches to problems with clients and give the impression that the application of philosophy to real problems is a relatively simple affair. In Plato, Not Prozac!, Marinoff (1999) outlines his PEACE process, which has the following stages:
1. Identify the problem
2. Take stock of the emotions provoked by the problem.
3. Analyze the available options for solving the problem.
4. Contemplate the entire situation
5. Reach equilibrium.

Marinoff gives very little discussion of the move from stage 4 to stage 5, or of the uncertainties that bedevil difficult decisions. Furthermore, from the clinical vignettes offered in the book, one has strong reason to doubt that clients were offered a comprehensive survey of philosophical discussion that might be relevant to their problems. Often the conclusions the clients reached seem somewhat arbitrary; the main effect of philosophical counseling seems to be the conferring of an arguably bogus sense of justification concerning the conclusion reached. Certainly, it is clear that if a teacher offered such one-side approaches in the context of a philosophy course, the approach would be highly problematic in its incompleteness and possibly biased approach.[4]

It is worth illustrating my point with an example. Marinoff describes a case of a client named Sean (seen by the philosophical counselor Richard Dance). (Marinoff, 1999, p. 106). Sean was concerned whether he should marry his fiancé Patricia: “his underlying themes were having strong opinions, seeing the world in black-and-white, and seeking control. He also tended to overanalyze things yet not quite trust his own decisions (taking, as just one example, the eight-year trial period he found necessary before deciding that Patricia was the woman for him).” (p. 107). In counseling, he learned a meditation technique where the client replays a recent event in which strong feelings occurred, and to look on the event without emotion, analysis, or judgment. Sean learned to restrain himself from expressing strong opinions and criticizing Patricia. The counselor also recommended that Sean evaluate whether his experience bore out the wisdom of Lao Tzu and Heraclitus about the coincidences of opposites, who held that opposites are interconnected, relying on one another to complement their mutual existence. Apparently this assignment was very helpful to Sean in coming to terms with his relationship and reduced the number of arguments the couple engaged in. Setting aside possible reservations about whether there was anything particularly philosophical about the form of counseling provided here, it’s clear that the counselor was extremely selective in his choice of which philosophers to mention in his counseling. From Marinoff’s telling of the exchange, it seems to be a particularly one-sided approach. Philosophy was used in getting the client to become more settled in his choice and happier in his relationship, but one wonders about the application of the idea of the complementarity of opposites to this sort of case. Nothing in the telling of the case assures that reader that the counseling included discussion of the limits of this approach or any evaluation of its rationality. It did seem to provide the client, Sean, with a new way of looking at the world and his relationship, and this apparently was helpful, although one may well wonder whether it wasn’t the effect of pronouncement of the names of some ancient philosophers and the ring of appealing “words of wisdom” that had the beneficial effect rather than Sean’s learning anything new. There’s no question that philosophical counseling may leave some customers pleased with their encounter: my concern is that in passing over the uncertainty of the claims made, the counselor risks misleading the client and offering radically incomplete understanding.

At this stage, I can briefly address a potential objection that may be raised by some philosophical counselors, who insist that philosophical counseling is very different from teaching philosophy. For example, Peter Raabe has surveyed the views on this topic, coming to the conclusion that, “the philosophical counseling relationship may be substantively didactic but that it is not procedurally pedagogic” (2001, p. 24). It is clear that it may be inappropriate in counseling to assign the client reading of philosophical texts, to demand that she write essays or take tests, or to lecture to the client for substantial periods of time. But these differences between classroom teaching and philosophical counseling are irrelevant to my point here. The uncertainty of philosophical knowledge and the difficulty of applying abstract principles to the complex details of real life remain important considerations whenever one is trying to apply philosophy to everyday life, regardless of whether one is using traditional pedagogic methodologies or innovative counseling approaches. Indeed, the problems I am focusing on may be even more pertinent to the morality of philosophical counseling as compared to teaching philosophy. A standard course in philosophy in a north American college involves at least 30 hours in the classroom, with an expectation that students will spend at least another 20 or 30 hours outside the classroom working on homework and preparing assignments. This sustained exposure to philosophical debate nearly always has the effect of driving home the difficulty of fully justifying one’s point of view, and showing students the epistemic problems inherent in the field. But if a philosophical counselor sees a client for only a few sessions, as apparently is typical, there will be far less time to fully explore more any philosophical ideas, and there is far more danger that the client will grasp onto one suggestion or idea mentioned by the counselor and adopt it because it seems to make sense at the time.

The problem I am highlighting has a clear solution. Teachers and counselors should never promise or hint that philosophy can provide certainty or definitive answers to difficult problems. There may be some cases where philosophers manage to substantially agree on answers to philosophical problems, but there is no reason to think this is a general rule. Philosophers should be very careful in their claims that philosophy can be useful in decision-making when facing everyday problems. The most they should claim is that philosophy can help people to inspect the range of choices available to them, to increase sensitivity and understanding of the different points of view on the choices they face, to justify their choices once they start from their assumptions, and to be aware of the contingency of their own choice. This may disappoint some prospective students and clients, but it is necessary if philosophers are to give an honest assessment of what they can provide to the general public.

I want to finish by comparing philosophical counseling with psychotherapy. One might ask whether I am holding philosophical counseling up to a higher standard than psychotherapy normally requires of itself. For it can very plausibly argued that the theories underlying the practice of psychotherapy are in a far sorrier state than philosophical theories, and there is very little good evidence that psychotherapy is more effective in helping people who do not have major mental illness than talking with someone with no specific training or knowledge of psychotherapy. The controversies over the scientific status of psychoanalysis are well known, and other major psychotherapeutic theories have equally problematic foundations. Even for approaches that seem to have the best evidence of effectiveness, such as cognitive behavioral, one might argue that there is limited evidence that the approach will be helpful for a particular individual. Yet psychotherapists do not agonize about the uncertainty of their claims to understand their clients or their suggestions for clients about how to solve their problems. It follows from my arguments that psychotherapists should more openly acknowledge in the therapy that they don’t have strong evidence for the effectiveness of their discipline. An obvious concern this raises is that such a declaration of uncertainty might undermine the therapeutic bond and make the therapy less helpful. That is to say, the client’s belief in the psychotherapist, while maybe not a necessary condition, is at least an enhancement for the beneficial effect of the therapy.[5] However, this concern raises obvious ethical problems: it is a commonplace in medical ethics that patients should always give their informed consent to any medical procedure, and I see no reason why this should not apply equally to psychotherapy. This requires being open about the known efficacy of the treatment, or lack of it. It is also worth entertaining the possibility that one of the reasons that psychotherapy is sometimes viewed with some suspicion by the general public and medical professionals is not so much the weak foundations of psychotherapeutic theory as the fact that psychotherapists have been reluctant to be open and honest about the certainty of their claims to be able to help people. Indeed, being open with a client about the limitations of the evidence for the beneficial effects of therapy might not undermine the therapeutic project, since a great deal may depend on the manner in which this information is conveyed. Indeed, openness and honesty could inspire greater trust in the therapist on the part of the client.

Similar points can be made about honesty within the relationship between philosophical counselors and their clients. If counselors are straightforward with clients about the fragility of philosophical knowledge, then far from undermining the enterprise, this could enhance the relationship. Finally, an open humility about the experimental nature of the burgeoning profession of philosophical counseling would, I suggest, be likely to win it more allies among professional academic philosophers.

References
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. Fifth Edition. New York: Oxford University Press, 2001.
Iltis, Ana Smith (editor). “Specification, Specified Principlism and Casuistry.” The Journal of Medicine and Philosophy. 2000: 25:3.
Jopling, David A. “‘First do no harm’: Over-Philosophizing and Pseudo-Philosophizing in Philosophical Counselling”. Inquiry: Critical Thinking Across the Disciplines, Vol.XVII, No.3 (Spring, 1998) pp.100-112.
Kymlicka, Will. “Moral Philosophy and Public Policy: The Case of New Reproductive
Technologies,” in L. W. Sumner, (ed) Philosophical Perspectives on Bioethics. Toronto: University of Toronto Press, 1996.
Luborsky, Lester et al. Who Will Benefit from Pschotherapy? Predicting Therapeutic Outcomes. New York: Basic Books, 1988.
Marinoff, Lou. Plato, Not Prozac! Applying Philosophy to Everyday Problems. New York: HarperCollins, 1999.
Marinoff, Lou. Philosophical Practice. San Diego: Academic Press, 2001.
Perring, Christian. Reviews of Essays on Philosophical Counseling, edited by Ran Lahav and Maria da Venza Tillmanns, in Perspectives: A Mental Health Magazine, Vol. 2. Issue 4, September - October, 1997. Available Online at http://mentalhelp.net/poc/view_doc.php?type=doc&&id=336
Perring, Christian. Review of Lou Marinoff, Plato, Not Prozac! Applying Philosophy to Everyday Problems, Metapsychology Online Review, August 1999. Available Online at http://mentalhelp.net/books/books.php?type=de&id=119
Perring, Christian. Review of Schlomit Schuster, Philosophy Practice. Metapsychology Online Review, June 2000. Available Online at http://mentalhelp.net/books/books.php?type=de&id=292
Perring, Christian. Review of Lou Marinoff, Philosophical Practice. Journal of Mind and Behavior (forthcoming)
Perring, Christian and Lou Marinoff. "Debate: Who Can Counsel?," The Philosophers’ Magazine, Summer 2002, pp. 23-26.
Raabe, Peter B. Philosophical Counseling: Theory and Practice. Westport, CT: Praeger, 2001.
Schuster, Shlomit. Philosophy Practice: An Alternative to Counseling and Psychotherapy. Westport, CT: Praeger, 1999.
Younger, Stuart J. and Robert M. Arnold. “Philosophical Debates About the Definition of Death: Who Cares?” Journal of Medicine and Philosophy. 2001. 26:5, pp. 527-537.

[1] Peter Raabe (2001, Chapter 1) notes that some philosophical counseling is focused on the interpretation of world views rather than solving concrete problems.
[2] It is worth noting that some philosophers have voiced doubts concerning the usefulness of sophisticated philosophy in formulating policy on controversial issues in medicine (see, for example, Younger and Arnold (2001) and Kymlicka (1996)).
[3] For example, Beauchamp and Childress (2001) write, “Even conscientious and reasonable moral agents who work diligently at moral reasoning sometimes disagree with other equally conscientious persons…. Such disagreement does not indicate moral ignorance or moral defect. We simply lack a single, entirely reliable way to resolve all disagreements” (p, 21).
[4] David Jopling notes these sorts of concerns in his paper on the topic.
[5] Note that I am not saying that psychotherapy proceeds merely by a placebo effect, although I am also not ruling out that possibility. I am not very familiar with the scientific literature on the measurement of the beneficial effects of psychotherapy and I don’t know whether any attempt has been made to measure what difference it makes whether or not a client has a belief in the therapeutic process. Common sense would say it would, if only because without such belief, a client will be unlikely to cooperate fully with the therapist’s suggestions or even to continue in the therapy, especially when the therapy starts to delve into emotionally painful parts of the client’s life. Maybe a useful starting place for investigating these issues is Luborsky et al (1988).

What is it like to be a heteronomist?

2008-11-21T17:14:00.000-05:00

Here's a conference paper I gave in 2001. To be honest, I wasn't very happy with it at the time, but I've thought about it since giving it, and there's something here worth developing. I was thinking about the reactive attitudes at the time, and some claims by Strawon in Freedom and Resentment.

What is it like to be a heteronomist?

Philosophy and the Emotions: The Royal Institute of Philosophy Conference 2001
University of Manchester: 11-13 July 2001

Abstract:
Heteronomists believe that humans lack freedom of thought or action. In this paper I examine the moral psychology this commits them to which they there by commit themselves, and in particular, what account they can give of the rationality of emotions. I argue that the practices of praise, blame, the emotions of pride, shame, and resentment normally assume that people are free. Heteronomists are pushed towards giving an instrumental justification of these practices and emotions: they have to say that they are useful as ways of manipulating other people and oneself. There is a tension in the thought of heteronomists between denying freewill and asserting that it possible to affect one’s own behavior, and I pursue this tension by examining what account a heteronomist can give of the practical deliberation. What is the point of deliberating about what to do if the future is not genuinely open? Heteronomists can argue that deliberation is a matter of finding out what one will do. Thus heteronomists can reconstruct an account of the rationality of emotions, and so they don’t need to have a radically different world-view from believers in freedom.

Introduction
I use the term "heteronomist" to mean a person who does not believe in free will or free action. The doctrines of physical, biological, psychological, social or metaphysical determinism hold that the future is determined. Those who do not believe in freedom of will or action generally say that determinism is true, and that determinism is incompatible with freedom. Note that a "heteronomist" in the sense I am using the term may not hold that every action and event is completely determined in advance. What is essential to the heteronomist's doctrine is that people do not think or act with freedom. This doctrine applies to all agents. I will assume that a heteronomists accept that there are agents; i.e., people do perform actions, but they do not do so freely, and people make choices, but again, their choices are not free.

Some heteronomists may hold their views for other reasons than the argument from determinism. For instance, they may hold that the very concept of freedom is confused in some way. They may have theological reasons for their beliefs. Or they may simply be heteronomists because they find the view pleasing. For my purposes here, I am not concerned with the philosophical justification of a belief in heteronomy.

What I am concerned to explore is how a belief in heteronomy would affect one's view of life and one's practices. I believe that philosophers have neglected to examine the implications of philosophy for everyday life, and that the rise of philosophical counseling is leading us to think more about such implications.

I should explain at the start of this paper that I am not a heteronomist, and indeed, the doctrine strikes me as bizarre, largely because I find it extremely hard to imagine what it is like to a heteronomist. I suspect that our ordinary practices presuppose that people can act freely, and thus, that a heteronomist would have to abandon many ordinary practices. The purpose of this paper is to explore these suspicions of mine. Through this exploration, I hope even to discover an argument against the heteronomist.

"It makes no difference."
First I want to examine the view that heteronomists are just like everyone else, except that they hold a different philosophical view. This position would claim that all of one's ordinary moral psychology can remain independent of one's lack of belief in freedom. This view would say that praising, blaming, loving, liking, hating, pride, guilt, and of course, resentment do not depend on any assumption of freedom--either the other person's freedom or one's own freedom. This view might say that one praises a person when she does something good, one feels guilt when one does something bad, and one resents another person when she does something harmful to oneself, without ever assuming that any of the actions involved are done freely.

This "no difference" view has its attractions. For example, it is plausible that pets and children can like, dislike, hate, love, trust and fear others without any beliefs about freedom. Sometimes we even say that young children and pets look guilty when they have done something they know we will chastise them for, and we imagine that they feel guilty too. But this is far more speculative.

When it comes to praising and blaming, it is hard to see how these practices could be independent of an understanding of freedom and self-control. If I praise a student for writing a good philosophy paper, I assume that the student has tried hard and has stretched herself. She has not been lazy, and she has taken her assignment seriously. Furthermore, I assume she could have done otherwise, but that she freely chose to put the effort into the paper.

To take Peter Strawson's example of resentment, it seems to me that he is right that our attitude of resentment assumes that a person could have done otherwise. For example, if I resent a cat for scratching me, this seems to be irrational, precisely because the attitude of resentment assumes that the person resented could have done otherwise, but chose to act maliciously. Resenting a cat attributes too much to the cat. However, we normally that resenting the actions of another person is a practice that makes sense. If a woman resents her husband for having an affair, she believes that he could have done otherwise. If I am right, then believing that there is no such thing as human freedom should then make a difference to how one lives one's life.

Attitudes towards others
How then should heteronomists regard other people? It is tempting to suppose that they have to view other people as I might regard a cat or a small child. Of course, it would be unfair to heteronomists the belief that people are childlike or animal life. Clearly, heteronomists can accept that adults have greater intelligence and a greater range of emotions than babies and animals. Nevertheless, it seems that they are rationally compelled to say that it is as irrational to resent another person for her actions as it is to resent a cat.

Heteronomists can give an account of praise and blame. The account is instrumental: one praises a person not because she could have done otherwise but didn't, but instead in order to encourage and promote the good behavior of the person. Praising and blaming are means of manipulating other people. It is an empirical fact that people respond to praise and blame; they like praise and they dislike blame, and so one can influence other people's behavior if they can expect to be praised or blamed for their actions.

To expand this a little, one can even praise the actions of people who will never know they were praised, as a way of influencing third parties. I may praise the actions of long-dead saints as a way of getting other people to try to emulate the behavior of those saints. A heteronomist may rationally publicly blame political figures for their actions even if she knows that the politicians will never learn of this act of blame. The blame might be a way of influencing the opinion of other voters in future elections.

It is also possible to justify private praise and blame, where no one else learns of the act of praise or blame, because it may influence the praiser or blamer. It has been suggested to me that private praise or blame may help to maintain one's own values. For example, if one is watching the news on one's own and condemns the behavior of the president, one helps to remind oneself of one's own values. If one watches the news dispassionately when watching a report of the president's wrongdoing, then one's values may fade. Private praise and blame of others can be a way of manipulating oneself. I'm not sure how true this is of the general population -- it isn't true of me, I suspect, although I do find myself blaming politicians even when nobody else is listening.

Attitudes towards oneself
This last case raises the issue of attitudes towards oneself. The philosophical literature has focused on the cases of pride and shame. One is proud of one's own accomplishments when one has done well, and more tellingly, one is ashamed of one's actions when one has done something one should not have, and, at least arguably, when one could have done otherwise. Certainly it makes no sense to be ashamed of suffering misfortune if one did not bring it on oneself, as it makes no sense to be ashamed of falling ill, and if one had no free choice in doing what one did, then it seems hard to understand how one could be disappointed in oneself.

Perhaps one way for a heteronomist to understand self-disappointment is by using an analogy with disappointment with a material object. One might buy a car with high hopes for it running trouble-free for several years, only to have it break down after a couple of months. One would then naturally be disappointed with the car without believing that it had any freedom. Similarly one could be disappointed in oneself, because one has discovered that one is not as skilled or strong as one had hoped. This view replaces a metaphysically open future with an epistemologically open future. The heteronomist can still believe that we are ignorant about ourselves and that we gradually discover more about ourselves, and this process of discovery can have its pleasant surprises and its disappointments.

Furthermore, there may be a purpose for the heteronomist in self-praise and self-blame. One can praise and blame oneself as a form of self-manipulation. We might equate self-praise with "pride" and self-blame with "shame," although this is more of a substitution than a convincing conceptual analysis. The central idea is that one can affect one’s own behavior as one affects that of other people. One views oneself from a third-person perspective.

There is something suspect about this idea, however. It sounds like it is an attempt of the heteronomist to smuggle in the possibility of self-control (which for my rather crude purposes here, I will equate with autonomy) in the back door. There is a potential logical conflict between asserting that one has no freedom and yet that one can control oneself.

The examined life
I want to pursue this problem by asking what is the point, for the heteronomist, of scrutinizing oneself and one’s life. Indeed, what is the role in one’s life of any practical deliberation?

The obvious purpose of practical deliberation is to decide what to do. A heteronomist can clearly agree that agents deliberate and that this is essential in a person making a decision. What the heteronomist denies is that the deliberation is free. The question immediately arises though, why deliberate if one has no free choice? Isn’t the idea of an open future essential to practical deliberation?

A heteronomist could reply that while the future may be metaphysically determined, the agent still does not know what she is going to do until she has deliberated, so the future is epistemologically open. Maybe this is enough to explain the ordinary sense that one has freedom in making a choice, but it implies that this sense of freedom is an illusion. It seems hard to avoid the conclusion that if the heteronomist is right, then it is futile to try to control one's own life, because one's future is not under one's control.

But we must be careful here. I stipulated at the start of this paper that the heteronomist agrees that people perform actions, and that their actions have effects on the world. Am I not now falling into the trap of accusing the heteronomist of saying that there is no agency at all, and that we are no more than machines or puppets?

In order to avoid this trap, we can say that on the heteronomist world view, the agency involved is not the same as we normally believe we have. Deliberation on this view does not require a genuinely open future. Examining one's life does not mean narrowing down one's options, because one has no genuine alternatives open to one. Rather, deliberation is a matter of finding out what one will do.

Shifts of worldview.
One might regard a move to becoming a heteronomist as one in a series of historical shifts in perspective. Consider this list:
· Theism to Atheism
· Ptolemaic to Copernican astronomy
· A belief in an immaterial soul to materialism.
Each of these is a shift to a more scientific worldview. Maybe one of the great attractions of heteronomy is that it can claim that freedom is a myth of a pre-scientific era, and that while progress may entail abandoning our previously favored myths, it is a move for the better. For those who cling to old conceptions of action and our role in the world, the heteronomist's view seems pale and anemic. But the same is probably true of the shift in the concept of self from a belief in the soul to materialism. Now that we are acclimatized to a materialist worldview, the baggage of the dualist view seems (to most) utterly unnecessary.

So how major is the shift involved in becoming a heteronomist? If it what Kuhnians would call a "paradigm shift" or is it merely a slight shift in perspective? How great a change in our practices does the shift require?

It is fairly clear that heteronomists can engage in the same kinds of goals and projects as ordinary people: they can work in business, plan their careers, go on dates, form families, watch TV, and enjoy nature in similar ways to the rest of us. Their views may not be compatible with some religions, but generally religious debates over freedom (such as in the problem of evil) are part of specialized theology, and one can belong to a religion without worrying about the details of its theology. As I have already suggested, belief in heteronomy probably fits best with atheism -- and certainly all the heteronomists I have met have been atheists.

One might expect that heteronomists would be gloomy people. After all, they don't believe in what is generally held to be one of the most important aspects of our lives -- our freedom. Without any belief in freedom, one could become gloomy, and being a gloomy person in the first place could make one predisposed to the gloomy doctrine of heteronomy. However, this association seems simplistic: one might equally find the doctrine of heteronomy comforting -- after all, Sartre, whose early existentialism is the direct opposite of heteronomy, said that we are "condemned" to freedom. Anyway, there's not much evidence to support a connection between a philosopher's views and her mood. For example, it is implausible to suggest that atheists are more gloomy or even selfish people than other people. A world without a deity promising to punish the guilty and reward the good may seem more tragic and harsh to some, but only to those who believe or used to believe that there is such a deity.

However, to see whether a heteronomist is markedly different from other people, we must still look to her emotional life, and particularly her relationships with other people and herself. We have already examined these attitudes in earlier sections, and we can see that the shift in becoming a heteronomist would be subtle rather than major. So I conclude that the practices of the heteronomist would not have to be radically different from those of other people.

Conclusion
Emotions are central to thinking about everyday life, and one of the central implications of belief in heteronomy concerns emotions. The issue of how free we are is vital in understanding how to live our lives, and thus the doctrine of heteronomy needs full exploration. In this paper I hope that I have managed to set out, if sketchily, some important implications for living one's life of a belief in heteronomy. I do not pretend to be the first person to do this; indeed, Stoic philosophers were for the most naturalists and determinists, and they are famous for exploring the emotional consequences of their metaphysics, and for their focus on integrating philosophy ideas with ordinary life more than most other philosophical schools of thought. For a range of reasons, there has in the last decade been a revival of the idea that philosophy can be a guide to everyday living. This goes hand-in-hand with the longer-standing rise in applied ethics and feminism, which has brought to attention issues such as abortion rights, the right to die, sexual harassment, affirmative action, and the judgment of repellent practices in other cultures. It is notable that the theory that we have no freedom, as with theism vs. atheism, and belief in an immaterial soul vs. materialism, is a metaphysical doctrine with clear implications for our attitude to life. Thus it helps to support a more general idea that when examining the importance of philosophy to life, we need to look as much to metaphysics as to ethics.

Human volition: towards a neuroscience of will

2008-11-21T10:23:00.000-05:00

Nature Reviews Neuroscience 9, 934-946 (December 2008)
Human volition: towards a neuroscience of will
Patrick Haggard, Institute of Cognitive Neuroscience
http://www.nature.com/nrn/journal/v9/n12/abs/nrn2497.html?lang=en

Here's the abstract:
The capacity for voluntary action is seen as essential to human nature. Yet neuroscience and behaviourist psychology have traditionally dismissed the topic as unscientific, perhaps because the mechanisms that cause actions have long been unclear. However, new research has identified networks of brain areas, including the pre-supplementary motor area, the anterior prefrontal cortex and the parietal cortex, that underlie voluntary action. These areas generate information for forthcoming actions, and also cause the distinctive conscious experience of intending to act and then controlling one's own actions. Volition consists of a series of decisions regarding whether to act, what action to perform and when to perform it. Neuroscientific accounts of voluntary action may inform debates about the nature of individual responsibility.

I always get a bit nervous when scientists and especially neuroscientists start talking about the will and responsibility, because they so often start making big claims -- such as Libet denying free will. I also am skeptical that neuroscientists can tell us anything of moral or philosophical significance regarding free will. I've often liked the work of Stephen J. Morse at PennLaw who has cast doubt on the helpfulness of neuroscience in understanding criminal responsibility.

Nevertheless, I haven't yet found any a priori arguments that neuroscience must be useless in understanding free will and responsibility, and I can imagine that when used in conjunction with a sophisticated philosophical theory, the work of neuroscience would actually be very illuminating. The work of other psychologists, such as Roy Baumeister on ego depletion, has been used to great effect by Richard Holton and Neil Levy, has been used to illuminate our understanding of weakness of will, to give just one recent example. So I'm looking forward to reading Haggard's article.

Report on the NEH Summer Institute on Mind, Self, and Psychopathology

2008-11-17T13:25:00.000-05:00

Patricia Ross (also a member of the Executive Council of AAPP) and I were both participants in the 1998 NEH Summer Institute on Mind, Self, and Psychopathology. After it, we were interested in reflecting on the experience, so we wrote a report, but didn't make any great efforts to publish it.

Patricia Ross is a Research Associate at the Minnesota Center for Philosophy of Science at the University of Minnesota.

Report on the NEH Summer Institute on Mind, Self, and Psychopathology, led by Jennifer Whiting and Louis Sass, Cornell University, Ithaca, NY 1998

Abstract

We relate out experience as participants at the 1998 NEH Summer Institute on Mind, Self, and Psychopathology, and our reflections on the lessons to be learned. This seminar was an important attempt to generate discussion of the connections between Anglo-American philosophy and psychiatry. It brought together participants from many different realms with experts in both philosophy and psychiatry. We discuss the strengths and weaknesses of the Institute. We focus especially on the difficulty in achieving productive dialog between researchers from widely disparate fields, because of a lack of mutual agreement about both methodology and also what has been shown empirically in psychiatry. We suggest that it would be helpful for future such seminars to narrow their focus of study or else for participants to discuss directly what methodological procedures would be best for the group as a whole.

I. The Purpose of the Institute
In the summer of 1998, a diverse group of individuals came together at Cornell University to learn about and discuss issues at the nexus of philosophy, psychiatry and psychology. We were among the approximately twenty-six participants in this NEH Summer Institute. Our intention here is to share with you our impressions of this interdisciplinary venture, our thoughts concerning the particular questions that were addressed and what reservations we have regarding this type of work.

At the time of application, the institute was described to us as an attempt bring together Anglo-American psychiatry and psychology on the one hand and analytic philosophy on the other, in order to promote "the sort of dialogue recommended by [Karl] Jaspers but sadly lacking in our [Anglo-American] tradition". We were thereby selected to "engage with a variety of experts representing a wide range of views and approaches in addition to our own". Specifically, the hope was to enable productive interaction between Anglo-American psychiatry, often characterized by its anti-theoretical bent, and the dominant form of philosophy in the US, i.e. that in the Anglo-American tradition, often labeled “analytic.” The format of the institute was to have two different guests each week leading on the topic of their expertise. The schedule turned out to be as follows (roughly):

Week
Presenters/Affiliation
Topic
1
Richard Moran (Harvard)
Self-knowledge and Irrationality

Ulrich Neisser (Cornell)
Models of the Self
2
Jennifer Whiting (Cornell)
Personal Identity and Multiplicity
3
Judith Armstrong (U of Southern California)
Multiple Personality
4
Katherine Loveland (U Texas Med. School)
Autism

Peter Hobson (Tavistock Clinic and University College London)
Autism
5
Josef Parnas (University of Copenhagen)
Schizophrenia

John Campbell (Oxford):
Schizophrenia
6
Louis Sass (Rutgers)
Wittgenstein and Schizophrenia

James Conant (Pittsburgh)
Wittgenstein and Freud

The Institute met in the mornings, five days a week, for six weeks. Afternoons and evenings were free with optional small group meetings scheduled for this time. These optional groups focused on particular issues, including multiple personality, autism, schizophrenia, philosophical approaches to self-constitution, psychoanalysis, and the body. A small writing group met as well with the purpose of reading drafts of papers and providing constructive criticisms. Reading for the morning sessions was assigned beforehand; when possible the visiting speakers for that week would attend the small group relevant to their expertise. These smaller groups often enabled more sustained, wide-ranging discussion. For instance, the multiple personality group was able to devote time to careful discussion of some themes in Ian Hacking’s recent book Rewriting the Soul, and the autism group read Simon Baron-Cohen’s Mindblindness.

We Institute participants were a diverse group. The authors’ own training was in Anglo-American philosophy of psychology, science and ethics. A few other participants had somewhat similar backgrounds to us. Others had different philosophical backgrounds, with several rooted in the continental phenomenological tradition. Nearly half the group was non-philosophers. This half consisted of psychologists with various forms of expertise, historians and literary theorists.

2. The Six Weeks of the Institute
The first two weeks of the Institute were dedicated to an examination of some general topics that the organizers believed to be relevant to framing future discussions of psychopathology. In the first week, Richard Moran discussed the philosophical problem in trying to understand irrationality. The problem might best be captured by seeing that our understanding is commonly taken to be constrained by the demands of rationality. There are limits to how irrational a person can be before she ceases to be interpretable at all. This idea, especially important in the work of Donald Davidson, has been important in philosophers’ attempts to understand self-deception. Moran set out the issues carefully and methodically; too slowly for some. He ended with the background to his own work on self-knowledge. Still, we had not yet come close to any sustained discussion of psychopathology.

During this first week we also heard from Ulrich Neisser. Neisser has a reputation as one of the more thoughtful psychological theorists of our time. The notion of the ecological self is interesting as well as important to many areas of psychological research - from child development to music theory. The plan, apparently, was to present his theory for use in later discussions of psychopathology. While Neisser did present us with detailed accounts of each of his five types of selves, his presentation seemed to lack in just the sorts of details that might make it relevant to our future discussions. For example, we never got a clear idea of how these different selves relate to or are integrated with each other. Moreover, the rationale for positing any one particular category of self was never given. Whatever empirical grounds there might be for positing these five categories of self was not offered up either. As a result, it was very unclear why this division was meant to be helpful to our thinking. Rather, Neisser's account came off as being merely a way for him to catalog a number of different psychological theories and experiments.

The second week continued much like the first. We briefly moved closer to the discussion of psychopathology (multiple personality disorder in particular), but then returned to the more general philosophical questions intended to provide some framework for future discussions. In fact, the foray into discussions of psychopathology, while tantalizing, was due to a couple of last minute cancellations on the part of individuals scheduled as discussants. The net result was that week two was disorganized and fit less well with the plan of the Institute as a whole.

In this week we had one day when Ulrich Neisser discussed false memory syndrome. He turned out to be strongly partisan in the dispute, basically favoring the skeptical views of Elizabeth Loftus, and having very little interest in the possibility that multiple personalities might exist. Jennifer Whiting brought the discussion back to philosophical concerns with her examination of theories of personal identity. There is a large literature addressing the question of what makes a person numerically the same individual over time, and whether the answer is dependent on factors such as cultural circumstances or personal preferences. Whiting raised numerous interesting questions concerning this subject, especially concerning whether we should be looking for a universal theory of personal identity, or whether it makes sense for different people to have different theories, depending on their values. Often our intuitions about whether a person remains numerically the same in unusual cases of personality change, personality disintegration or dissociation will change depending on whether we describe the change from a third-person, onlooker, point of view, or from the point of view of the subject of experience about to undergo, or having undergone the changes in question. In cases of multiple personality, we find difficulty in finding an adequate vocabulary to even describe the changes in a theory-neutral way. This was especially clear when it came to the question of whether two alters of a person with multiple personalities can literally be said to perceive each other’s experience. This raised general issues such as whether it is an a priori requirement that persons should be able to have first-person access to their own mental states.

While the motivation for raising such questions seems clear in retrospect, especially after the discussions in the ensuing weeks concerning multiple personality disorder (MPD) and schizophrenia, the connection was not made at the time. For this reason, some participants found it hard to see the motivation behind much of this discussion and it most likely lacked the overall impact on our discussion that it could have had.

It was only in the third week that the philosophy and the psychopathology started to come together. Judith Armstrong joined us at this time and shared with us not only her clinical experience but also her thoughts concerning the theoretical issues surrounding MPD. One of the main philosophical questions that arises in this context concerns how to understand the alleged multiplicity of personality while recognizing the existence of only one body. MPD challenges philosophical conceptions of how to individuate persons. Armstrong's insistence that MPD both exists and does not exist as a disorder, while seemingly contradictory, really helps to see the inherent problems with the philosophical questions that are being asked. While the experiences of the MPD patient are obviously organized in the form of one body suggesting that the multiplicity somehow lacks reality, Armstrong maintains that as a clinician charged with the job of reducing suffering and increasing the social functionality of the patient, the most promising approach is to start from the reality of the personalities. Her summary of the disorder - that there is nothing that it is like to be an MPD patient over and above what it is like to be one of the alters - nicely summarizes why, from a third-person point of view, the only point of entry to understanding the disorders is through an assignment of reality to such alters. However, on the question of whether the reality of the disorder is thereby determined, Armstrong remains agnostic.

Treatment cannot wait for the solution of difficult metaphysical problems. While the interaction of Armstrong and Whiting during this week worked well because it brought multiple perspectives together, it became clear that many of the standard assumptions about MPD in the philosophical literature surrounding personal identity turn out to rest on atypical cases or diagnostic criteria that have little descriptive value. Armstrong's presentations made it clear how to formulate the philosophical questions and, moreover, how practical concerns have a role to play in formulating the answers to such questions.

The fourth week on autism was valuable for similar reasons. There is a smaller philosophical literature on this topic, and it is less clear what the major philosophical questions are. It soon became apparent that maybe the primary question, both philosophical and clinical, is whether the extremely broad range of conditions that are now classified under the heading of autism really share something in common at their core. The diagnostic manuals may be able to reliably delineate a group of symptoms, but this does not guarantee that they correspond to a natural kind. The difficulty here seems to depend largely on finding which symptoms are the most telling ones about the condition, and this in turn depends on the etiology of the disorder, which is largely unknown. Kate Loveland and Peter Hobson each presented the results of experiments that they had performed, explaining the hypotheses they were testing and the speculations that the results prompted. Loveland’s presentation tended to be more evenhanded following closely the phenomenology of autism, while Hobson, who was more philosophically inclined, had more of a theoretical perspective to press. Both views differed from that of Simon Baron-Cohen, who has gained some philosophical attention with his view that autism is a form of “mindblindness,” and it became clear that this hypothesis, while potentially valuable in some cases, was unlikely to serve as a general explanation of autism.

Schizophrenia was the topic of the fifth week. The speakers, Josef Parnas and John Campbell, presented us with two very different approaches to understanding schizophrenia. Parnas began the week with a brief history of the concept of schizophrenia as well as some neurophysiological and developmental facts about the disorder. He then turned to his own views about the developmental pattern of schizophrenic symptoms, which he is currently writing about with Louis Sass. Concentrating on the phenomenology of the disorder, he argued that schizophrenia typically involves a diminishing sense of agency, or self and a discontinuity of conscious experience. At the same time, the schizophrenic becomes hyper-reflexive whereby the structure of intentional acts is distorted. Since all conscious life is centered around intentional acts, which under normal conditions bring about unity of the senses, the schizophrenic loses this unity. Parnas describes this, using a term of Merleau-Ponty's, as having the intentional arc disturbed.
In dramatic contrast, John Campbell suggested that the phenomenology of schizophrenia is largely irrelevant to its explanation. Instead, taking an idea of Frith (1992), he argued that some of the symptoms of schizophrenia could be better explained at a more sub-personal level, as a defect in the monitoring of the thinking process. This disagreement is not the same as the long standing one between psycho-dynamic vs. brain disease models of schizophrenia, although there are striking similarities between the debates concerning the place of phenomenology in the explanation of the disorder.

The interactions between Parnas and Campbell during this time proved to be quite stimulating. One aspect of their discussions concerned the recognition of three levels of understanding schizophrenia - the phenomenological, the computational and the neurological. Each was concerned to express the limitations he felt existed for a particular level in providing an adequate explanation of schizophrenia. Parnas took the position that reduction of the phenomenal level to the neurological level is just to re-describe things at the lower level. However, such a re-description does not teach us anything about the phenomenal first-person perspective. Campbell, however, maintained that the phenomenal level cannot provide causal explanations of the disorder and that some appeal to cognitive processes is needed for such explanations.

The final week was devoted to a wider discussion of the interrelation of schizophrenia and philosophy. Louis Sass discussed Ludwig Wittgenstein, exploring the idea of understanding schizophrenia in terms of Wittgenstein's account of solipsism. Many of the ideas he explored had been previously examined in his book The Paradoxes of Delusion: Wittgenstein, Schreber and the Schizophrenic Mind. Sass was particularly interested in exploring his idea that schizophrenia can be understood in a non-pathological sense. James Conant then devoted some time to replying to and criticizing Sass’s proposal. In particular, he was interested in criticizing Sass's idea that since one can read Wittgenstein's Tractatus as exhibiting schizophrenic phenomena, we can take this as a reflection of the author's mental state. Conant ended the week with some discussion of psychoanalysis and philosophy of mind.

3. Lessons to be Learned from the Institute
There are many comments we could make regarding particular features of the Institute. However, we wish to focus our attention on some conclusions concerning such multi-disciplinary work in general that might be drawn from our experiences. One of the main ways in which this multi-disciplinary endeavor differed from other such endeavors lies in the lack of clarity about what exactly the issues are that need to be addressed. For example, inter-disciplinary work in other sciences such as physics or biology addresses well-defined theoretical or conceptual issues. All parties involved in these discussions are quite familiar with the subject matter under consideration. However, as became clear early on in our discussion, it is not yet entirely clear just exactly what the issues are when it comes to the intersection of philosophy and psychopathology. It may be the case that there are conceptual and theoretical concerns that require philosophical reflection, however it also may be the case that the questions to be answered are simply empirical questions which will be answered with more empirical research. The exact nature of the problems remains an open question.

One of the reasons for this may be that the study of psychopathology, itself, resembles a pre-paradigmatic science -- to borrow from Thomas Kuhn's now famous account of the stages of science. Pre-paradigmatic science is characterized by the lack of and search for an overall theory to guide research, a methodology that delineates the acceptable ways in which research will be done and well-defined puzzles, or problems, that remain to be solved. During this stage of a science, almost anything goes. Multiple theoretical frameworks exist for understanding the phenomena, all of which are given fairly equal credence. Vastly different methods are used in the study of the subject matter and no one method seems to obviously provide a more useful way of proceeding. Perhaps, because of this, the Institute also lacked any guiding methodology or clearly defined problems to address. This, alone, is not necessarily a bad thing. However, it does suggest that progress may require focusing on such foundational questions within psychopathology (such as an overall theory to guide the research) before pursuing any particular question about specific disorders.

This multiplicity in approaches was all the more evident among the participants at the Institute. The problem may have been that our different approaches were incommensurable and that we had difficulty finding a common language. However, it seems to the authors that we as a group did for the most part understand each other: what we were unable to do was agree with each other’s starting assumptions and methodologies. This was a major stumbling block, and meant that exchanges of productive dialog were rare during the six weeks.

Attending the Institute was highly educational in providing us with a wealth of information about psychopathology that is not easily available from psychiatry textbooks. It gave us the highly welcome opportunity to interact with peers and experts with interests similar to our own. The connections we made will be important in helping to form a community in the growing world of philosophy of psychiatry. In these respects, the Institute was invaluable. To an extent, the stated aim of the Institute was achieved: there was some productive dialog between philosophy and psychiatry. But we, the authors, felt that the dialog was often far from ideal. We were left wondering how it could have been improved.

One possible suggestion for how to proceed from here is to have people from different background working together on some of the issues we addressed. The institute presented a wide array of approaches, but each was similar in that it came from one perspective. The clinicians and psychologists presented us with their clinical and scientific findings and their speculations about the best interpretations of their research, together with ideas on directions for future research. The philosophers stuck to their respective philosophical terrain. The Institute could have benefited greatly from some interaction among our presenters prior to the institute such that diverse ideas and approaches were integrated when presented.
More generally, we recognize that when thinkers from many different domains come together for dialog, there is bound to be some struggle in achieving mutual respect and helpful conversation. One approach to this is to simply hope that high standards across the disciplines and professional courtesy can be relied on to create the right conditions. However, our experience suggests that this is too optimistic. It may be that in interdisciplinary contexts such as that of the NEH Institute, it would be useful to address the differences in styles of thought more directly, and lay down some meta-level directives for methodology at the start, or narrow down the goals of the group. For if both the methods and the goals of the group are highly diverse, it will be hard to achieve any rapprochement between the participants. The frustrations experienced at the Institute are often shared by the wider group of people working on philosophical issues in psychiatry, for example at interdisciplinary conferences. One of the major challenges to be faced by philosophy of psychiatry is how to make these interactions more intellectually profitable. We hope that our experience at the Institute will enable us to recognize and negotiate this challenge more successfully in the future.

References
Baron-Cohen, S. 1995. Mindblindness: An Essay on Autism and Theory of Mind. Cambridge: MIT Press.
Frith, C. 1992. The Cognitive Neuropsychology of Schizophrenia. Cambridge: MIT Press.
Hacking, I. 1995. Rewriting the Soul: Multiple Personality and the Sciences of Memory. Princeton: Princeton University Press.
Sass, L. 1993. The Paradoxes of Delusion: Wittgenstein, Schreber and the Schizophrenic Mind. Ithaca: Cornell University Press.
Wittgenstein, L. 1922. Tractatus Logico-Philosophicus. London: Routledge and Kegan Paul Ltd.

Review of Self-Transformations: Foucault, Ethics, and Normalized Bodies by Cressida J. Heyes

2008-11-16T16:05:00.000-05:00

This review appeared in Philosophy in Review, Volume 28, Volume 4 (2008), pages 267-269.

Cressida J. Heyes Self-Transformations: Foucault, Ethics, and Normalized Bodies.
New York: Oxford University Press 2007. Pp. 175. CDN$110.95/US$99.00 (cloth ISBN-13: 978-0-19-531053-5); CDN$33.95/US$29.95 (paper ISBN-13: 978-0-19-531054-2).

This is a work in feminist ethics about our relations to our bodies. In five main chapters, Heyes sets out a theoretical framework, and then examines three central cases of bodies that are considered in need of changing: transgender people, overweight people, and people who want cosmetic surgery. She finishes with a proposal of a Foucauldian way for us to care for our bodies.
Heyes takes her theoretical resources primarily from feminist theory and the philosophy of Foucault. She places herself in her text, not just setting out her own views, but also giving some details of her own life and her own experiences in joining Weight Watchers, as well as discussing some of the problems she faces theorizing about other people of whose experience she has limited understanding. Thus it may be reasonable for me as reviewer to disclose more in this review than I would do in other cases, especially since my review will make some criticisms of the book. I am sympathetic to much of the feminist project but I don’t ally myself strongly with the theoretical standpoint of Foucault. Furthermore, I’m a male who has no direct experience of being transgender, being overweight or having or wanting cosmetic surgery.

The writing in this book does not rely excessively on jargon, and style is relatively straightforward. Chapters are divided into titled sections and Heyes summarizes her main points at the end of each chapter. She surveys a great deal of literature in the process of discussing each subject, and gives a sympathetic summary of each view relevant to the discussion, even when she disagrees with it. Furthermore, Heyes’ approach brings a set of theoretical approaches to issues such as weight loss and cosmetic surgery that are more sophisticated than in most other discussions in much feminist theory and certainly than in standard medical ethics. For that, she deserves a great deal of credit. On top of this, she advances existing debates in constructive ways. So there’s much to admire about this work.

One of the most important themes running through the book is the need to go beyond the dichotomy of either seeing people who engage in bodily changes such as sex change operations, dieting, or cosmetic surgery as either simply acting autonomously and therefore beyond criticism, or else acting out of false consciousness and therefore oppressed by gender stereotypes. Heyes acknowledges the importance of prior feminist critiques of idealized women’s bodies, and the problems with the pressures experienced by women to emulate those ideals. However, she also wants to acknowledge the importance of the care of the self, and the way that such focus on one’s own body can contribute to such self-care. In this, she draws especially on the last work of Foucault in the final two volumes of The History of Sexuality and some interviews.

In the chapter on Weight Watchers, probably the most accessible in the book, Heyes discusses in some detail the work of Susan Bordo and Sandra Bartky on the construction of femininity and the ways that focus on conforming to norms of beauty can oppress women. Heyes acknowledges their analyses of disciplinary practices relating to dieting, but she counterbalances these with a discussion of ‘the active, creative sense of self-development, mastery, expertise, and skill that dieting can offer’ (78). In her chapter on cosmetic surgery, she analyzes the issue through a discussion of the TV show Extreme Makeover. Again, she acknowledges the insight of influential feminist discussions of the representation of work on the body, in this case by Susan Bordo and Kathy Davis. Heyes finds no positive element of cosmetic surgery to counterbalance its problematic nature, but she does argue that current feminist critiques are not sufficient as forms of resistance or as solutions for women considering changing their bodies using medical technology.

The most provocative chapter in the book is the final main one where Heyes explores the possibility of caring for the self in a socially conscious, non-narcissistic way that would not contribute to oppressive practices. She defends Foucault from critics who accuse him of betraying his former political and ethical commitments in his final work, and she finds his discussion inspiring but elusive. She turns to the recent work of Richard Shusterman on somaesthetics for a more fully elaborated idea of what such caring for the self might look like, but still she does not find sufficiently concrete discussion. She finishes the chapter by considering three cases that might be considered as forms of caring for the self that might be ethically and politically admirable: bodily modification, British shipyard workers who practiced ballet, and yoga. She describes and evaluates each of these somewhat briefly, and she indicates that this topic is where her future work will be.

The theoretical position set out by Heyes is promising in its overall form, but her argument lacks enough detail to be convincing. In her short book, she covers philosophical methodology, sociology, cultural studies, feminist theory, medical ethics, and ethical theory. Her first main chapter uses Wittgenstein and Foucault to set out a way of thinking about the body in contemporary society, but really Heyes does no more than gesture at a theoretical position rather than develop a sustained argument.

While the earlier theoretical sections give some indication of how one might ground her approach, they don’t help much in explaining her later suggestions. Heyes is stronger in her discussion of mutual relevance of theory and personal experience or popular culture. Her positive suggestions about how we might understand an ethical approach to the care of the self are tentative and vague. I wish she had been bolder in her claims and had spent more time developing the ideas hinted at in her final chapter, especially those concerning yoga. Just when this book starts to get interesting, it finishes, and the reader is left wondering whether Heyes’ project for conceptualizing a progressive way to care for the self is indeed viable.

Christian Perring
Dowling College

Review of Bioethics and the Brain by Walter Glannon

2008-11-16T15:56:00.000-05:00

This review appeared in Philosophy in Review, Volume 28, Number 3 (2008), pages 197-199.

Walter Glannon. Bioethics and the Brain. New York: Oxford University Press 2007. PP viii+235 pages. ISBN13: 9780195307788
ISBN10: 019530778X. $45.00

Glannon addresses a number of issues relating to neuroscience and medical ethics. After his short introduction, his chapters examine the relation between self and brain, neuroimaging, pharmacological and psychological methods of changing people, direct interventions in the brain, and brain death. Glannon does not identify himself with well-known ethical theories, but rather examines issues on their own terms. His philosophy of mind tends more towards materialism than substance dualism, but he does not provide a label for his view. In his epilogue, he sums up his view of the relation between mind and body by saying "the mind emerges from the brain when it reaches a certain level of complexity, and ... the brain and mind are influenced by the ways in which a human organism interacts with the environment" (179). So Bioethics and the Brain does not set out a central philosophical thesis and systematically defend it. Rather, it examines the staked out views in its selected topics and comments on them. Aside from being about bioethics and the brain, there is not much to connect the different chapters.

The great strength of Glannon's examination lies in his knowledge of neuroscience and related technological developments. He manages to summarize large portions of technical knowledge in terms accessible to lay readers. He avoids jargon and minimizes scientific terminology, and explains it when he has to use it. So he is an excellent guide to neuroscience for readers who have not taken courses in the subject. However, the question arises, who is this book aimed at? Neuroscientists will already be familiar with the science that he summarizes. Yet Glannon also writes about philosophy in an introductory way. He introduces philosophers to the reader as if they may not have heard of them before: for example, he refers to "the seventeenth-century philosopher John Locke." Furthermore, it is enormously difficult to pin down Glannon's central philosophical claims. The book is full of discussions and explorations of ideas, but it is hard to know what he actually believes. For example, he says he adopts "the second, richer, concept of the self" (32). This is confusing because he has not contrasted two concepts of the self before this, but rather has said that self is a richer and more complex notion than mere conscious awareness of one's persistence through time. He seems to endorse V.S. Ramachandran's definition of the self as involving first-person conscious awareness of persistence through time, of internal coherence, of embodiment, and of agency. He also says that he would add to this account a fifth component: "the ability to perceive and respond appropriately to the external world" (33). Glannon explains that he will give an account how the capacities that constitute our selves correlate with brain processes.

Philosophers of mind will wonder what work Glannon's concept of self is doing here, and how we might assess its accuracy. He says neuropsychiatric disorders can "disturb, disrupt, or shatter the self" (32) but this sounds more like a metaphor than a literal truth. Glannon does not seem to be aiming to provide any necessary and sufficient conditions for having a self and he does not provide any clear criteria for what counts as disturbance or shattering of the self. Rather, his discussion rushes through Capgras syndrome, Asperger's syndrome, schizophrenia, near-death experiences, and a fictional character in a novel who has religious experiences. This all occurs in the space of a few pages. So philosophers of mind will not recognize this as scholarly work within their field, but conclude it is setting out some basic ideas for later discussion.

Glannon's discussion of neuroimaging first explains the basic science and techniques, and then proceeds to explore some of the philosophical issues it raises. He addresses some arguments that knowledge of the brain processes behind our actions may lead people to deny that we have free will, and he counters these views with some familiar arguments. He says that he defends a capacity-theoretic conception of free will and responsibility, and spends a paragraph explaining what he means, and then moves on. He proceeds to discuss some legal cases of the relevance of brain science to holding people responsible for their actions, and comes to the sensible conclusion that brain imaging should play a limited supplementary role in our current practices. In the process he has kicked up a great deal of dust, and it is far from clear what his central argument is, and what items in his discussion were peripheral.

In the chapter on pharmacological and psychological interventions, Glannon again does a good job of summarizing recent scientific developments. He surveys therapeutic psychopharmacology, placebos, forced behavior control, and cognitive and affective enhancement. He outlines some of the ethical concerns that arise concerning these issues and again makes sensible suggestions, urging caution and emphasizing the dangers of over enthusiasm for new medications and technology. Yet these issues have been discussed previously, at length, and Glannon's overview rushes by, passing from one issue to another without ever examining any of them in great detail. Similar remarks apply to the subsequent chapter on brain surgery and neurostimulation.

By far the most coherent chapter in the book is the last, in which Glannon argues that people are characterized essentially by their higher cognitive faculties, and so we should reject whole-brain death as our definition of death and adopt a higher-brain definition, or what he calls a "narrow neurological criterion" (149). Here his philosophical argument is more sophisticated and better integrated into the science and the particular recent and classic cases he discusses. His discussion of false neurological assumptions made by defenders of the whole-brain definition is particularly interesting. Philosophically, Glannon's argument is very familiar, but he does a good job at relating it to current neuroscience.

As a whole, Bioethics and the Brain will be informative to both neuroscientists and philosophers about areas outside their areas of expertise, but will not advance their knowledge within their areas of expertise. The book would work well as a text in an upper level interdisciplinary undergraduate course, and it should be helpful in interdisciplinary studies such as medical ethics and neuroethics.

Christian Perring, Dowling College

Review of In Praise of Blame by George Sher

2008-11-16T15:43:00.000-05:00

This review appeared in Philosophy in Review, Volume 27, Number 5, (2007) pages 375-377.

George Sher In Praise of Blame. New York: Oxford University Press 2006. Pp. 160. US$35.00 (cloth ISBN-13: 978-0-19-518742-7).

In this excellent monograph Sher sets out a defense of the practice of blaming people for wrongdoing. He argues that there is a need for such a defense because it has become increasingly common in contemporary society to claim that blaming is counterproductive and even neurotic. While punishment and even retribution continue to receive plenty of philosophical scrutiny, the attitude of blame itself has remained relatively unexamined in the literature.

Sher approaches his topic systematically. The argument is divided into six main chapters. In Chapter 2, Sher argues against the Humean claim that we blame people for bad actions that derive from their bad character, and the associated claim that we blame them because those bad actions derived from their character. Sher’s counterargument considers different cases of people who act in cruel or hurtful ways and whom our moral intuitions would cause us to blame, despite the fact that we would not deem them cruel or hurtful people.

In Chapter 3, Sher examines how the disapproval of a bad action can be extended to the blame of the agent without appeal to the notion of character. He points out that an action is the joint product of the desires, beliefs, and dispositions, and he claims that these items make her who she is. Thus there is a close connection between the person's action and her identity, and so it is conceptually coherent to blame her for her actions. He employs the fact that actions stem from a large network of desires and beliefs, and this makes his claim that they are strongly related to the person’s identity more plausible, although he says very little about when changes to a person’s beliefs, desires and dispositions could be said to lead to a change in the person’s identity.

In his fourth chapter Sher, taking the surprising route that it can be reasonable to blame people for aspects of themselves that they cannot change, argues that it can be morally reasonable to blame people for their character traits. He agrees that we should not blame people for accidents over which they had no control, but if their action proceeded from their bad traits, such as cruelty, then we can blame them. He first shows that claims that people should not be blamed for what they cannot control have not been well defended. He then proceeds to defend his view positively, by pointing out there is such a strong connection between a trait and a person’s identity that to believe a trait is reprehensible comes to the same thing as believing that the person herself is reprehensible, and thus blaming her for her bad trait.

Sher moves on to the nature of blame. In Chapter 5, he begins by addressing some views he believes to be mistaken. First, he shows the flaws in the utilitarian view that to blame someone is to express disapproval for an action or character as a way to change the person’s actions or improve her character. Here the argument proceeds swiftly, because it is possible to blame people without communicating one’s blame. So Sher is able to move to the position that blame is an attitude. But the question is: which attitude? Sher rejects any identification of blame with a simple belief, whether it be that the person acted badly, or that the person has stained her character. He next considers the idea, put forward by Peter Strawson, that blame is fundamentally an affective phenomenon. Sher agrees that emotions are an important common feature of blame, and need to be accounted for. However, he argues that this Strawsonian approach cannot adequately account for the blameworthiness of actions, and cannot adequately distinguish appropriate blame from inappropriate blame. Furthermore, he argues that there can be instances of blame which are not affective at all. It is possible to hold an attitude of blame to someone while experiencing no emotions of anger or hostility whatsoever.

The positive account of the nature of blame comes in Chapter 6. Sher’s theory is simple: blame of someone for an action or a character trait starts from the belief that the action or character trait is bad, and from the corresponding desire that the person had not performed the action or did not have that character trait. In order to make this account plausible, Sher needs to show how this belief-desire combination can give rise to the emotions and dispositions that are so closely linked to blame. A central problem for this account is that since it is impossible to change the past, then when blame includes a wish that an action had not happened, it means wishing for the impossible, which seems to make blame irrational or at least futile. In order to ameliorate this problem, Sher proceeds with a discussion of our reactions to frustrated desires and their links to future-oriented dispositions. He does not pretend to be giving a conceptual analysis of blame, so he does not present necessary and sufficient conditions for when a person has an attitude of blame. However, he does hold that a person with standard psychological dispositions and the appropriate belief-desire pair will go on to have the characteristic emotional reactions that we associate with blame.

The final chapter takes on the question of blameworthiness. Sher argues that to give an account of what it is to be blameworthy, it is not enough just to point out that person has acted badly or has a bad character. He claims that acceptance of a moral principle is conceptually linked to having the desire to blame someone when that person violates the moral principle. Thus, to explain a person’s blameworthiness we must refer to the moral principle as well as the relevant bad action or character.

Sher’s writing style is straightforward and methodical, although his arguments might have been clearer if he had stated his theory at the start and proceeded to justify it, rather than proceeding to his own view through a process of elimination of other positions. The topic of blame is important and Sher’s views are interesting and original. While there is still plenty of room for disagreement with many of his claims, he has made a valuable contribution to the literature.

Christian Perring
Dowling College

Review of The Limits of Medicine by Andrew Stark

2008-11-16T15:31:00.000-05:00

This review appeared in Philosophy in Review, Volume 27, Number 3 (2007), pages 227-230.

Andrew Stark. The Limits of Medicine. New York, Cambridge University Press, 2006. Pp. 256. $70.00 (Cloth: ISBN 978-0521856317); $25.99 (Paper ISBN 978-0521672269)

The Limits of Medicine addresses the enhancement debate in philosophy of medicine. Stark, a professor of strategic management at the University of Toronto at Scarborough, proceeds methodically through three main issues, using eight sorts of cases of purported enhancement to explain and develop his view. There are three chapters, bookended with an introduction and a conclusion. The first chapter examines the distinction between cure and enhancement; the second chapter asks when enhancements may reduce the authenticity of those who get them; and the third chapter scrutinizes when enhancements might be a form of cultural genocide. The eight conditions Stark considers for each chapter are "physical slowness for competitive runners, mild depression, black racial features, plain facial features, deafness, blindness, obesity, and anorexia" (17).

Stark rejects biological approaches to defining normality. He argues we need to use social norms in defining what counts as a medical condition, so that in one society, a condition can be normal, while in another the same condition can be abnormal. Specifically, his approach is that a condition can be seen as abnormal when the group of people who have that condition legitimately view their condition as socially abnormal. Clearly, a great deal of weight rests on the concept of legitimacy here.

According to Stark, when the frequency of a condition (mood, for example) is distributed over a bell curve, the curve itself gives us no help in determining the lines of normality. One reason for this is that a bell curve "has no landmarks," he says, quoting Edmond A. Murphy (36), and so it does not tell us where to draw the limits between normality and pathology. He says that standard deviations are not of "much help in precluding debate over the cutoff of norm on a bell curve" (37). By way of contrast, Stark argues that other distributions give more direction about where to make the demarcation between normality and disease. He argues that when "a group's condition falls not on the hump at all but on the recognizable tail of a skewed curve, it conclusively lies outside the norm" (39). He concedes in a footnote that "It's true that there can be disagreement as to where exactly the tail of a skewed curve begins" (208). Stark's point that some distributions of frequency of conditions are more easily separated into normal and pathological than others seems reasonable, but his suggestion that a bell curve gives no help in making the division is overstated. Having a bell curve distribution does not dictate where to draw the line between normal and abnormal, but it provides some help, and makes the decision at least slightly less arbitrary.

The approach taken by Stark allows for the medicalization of many conditions. He summarizes his view as follows: a condition is medical "if members of the group harboring the condition can legitimately view their phenotypic condition as falling outside the social norm ... or deem others to have reached the social ideal" (83). He argues that seven of his "eight conditions" are medical; only having black racial features would not count as a medical condition on his view. Maybe the least convincing case here concerns the slow runners. He defines a slow runner as someone "for whom there are always other runners capable of beating him, assuming that he and they all engage in the same rigors of training, exercise, and diet" (72). Stark argues that if they so wish, runners who are faster than the average for runners can still legitimately count themselves as in need of a cure (although not necessarily abnormal) because there are other people who are faster than them. He emphasizes that the fastest runner cannot claim a disordered status, because in order to count as disordered, one has to be slower than an actual runner, not just a possible runner, on his view.

It is implausible that Stark will capture all ordinary intuitions about what counts as a medical problem with his approach. While his general stance is clear enough, and he examines various cases in some detail, it is often difficult to discern the central ideas that motivate his approach. This elusiveness characterizes the second and third chapters as much as the first. Stark sets out what he calls a "Kantian" view of authenticity, which he explains has two main points. First, it is egalitarian in that people should not have advantages over others due to their inborn attributes or dispositions so it is legitimate to cure those with medical conditions to make them equal to others. Second, and with top priority, "cure should never diminish a person's genuine, struggle-born achievement, whatever it may be" (93). The basic idea seems to be that personal struggle and striving is good and provides authenticity, so cures should not be used to reduce struggle. Stark's insight here about the central role of struggle in the debate about the inauthenticity or artificiality of enhancements is important and worth emphasizing. Stark argues that when a person uses a technology to change herself and achieve more, this is compatible with an authentic life so long as she continues to struggle. This is clear enough, but when he argues that it would be inauthentic for slow runners to use steroids, on the grounds that this would erode genuine achievement, it is difficult to specify why this sort of case is different from the other seven cases.

The third chapter addresses the concern about enhancement enabling a cultural genocide of minority groups such as the deaf, the blind, the depressed, and so on. He introduces conceptions of "cultural spouses" and "cultural siblings" and with a complex argument arrives at the conclusion that the only group for which we might have a medical cure (remember that race is not a medical condition on his view and so is not a candidate for cure) that should not be used due to cultural considerations is that of the plain featured. Again, readers will likely finish the chapter unsure of how to assess the arguments.

The Limits of Medicine is intriguing yet ultimately disappointing. Stark would do well to restate his central arguments more succinctly in shorter papers making clearer the heart of his logic.

Christian Perring, Dowling College

Review of Creating Mental Illness by Allan Horwitz

2008-11-16T15:05:00.000-05:00

This review of Creating Mental Illness, by Allan Horwitz, appeared in American Journal of Bioethics 4.2 (2004):70-72

Allan V. Horwitz. Creating Mental Illness. Chicago and London. University of Chicago Press, 2002

In Creating Mental Illness, medical sociologist Allan Horwitz proposes a definition of mental illness, which he argues is close to the official definition used by the American Psychiatric Association in recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The definition of mental illness that Horwitz defends depends essentially on the concept of a harmful internal dysfunction, which he explicitly takes from Jerome Wakefield’s well-known approach; (see for example, Wakefield 1992). Horwitz argues the adequacy of such a disputed definition has to be judged by its usefulness, and a central task of this concept is to distinguish between mental disorders and normal reactions to social stressors. However, he claims that modern psychiatry has lost sight of this distinction, and has come to include many normal reactions to difficult circumstances among the conditions it classifies and treats as mental disorders. He lays the blame for this trend at the feet of psychoanalysis and symptom-based approaches to classification of mental disorders, which both tend to blur the distinction between internal dysfunction and normal reaction. Horwitz argues that while psychiatry has moved towards an explicitly neurophysiological understanding of mental illness, it has retained the overly-broad definition of mental disorder. He suggests that this serves the interests both of the profession and the interests of the powerful pharmaceutical industry. His conclusion is that psychiatry should narrow its classification of mental disorders to those conditions that are clearly harmful internal dysfunctions and as a society we should pay more attention to the social conditions that cause people distress.

Horwitz provides a wealth of detail to make his case. He surveys the history of psychiatry in the twentieth century, paying particular attention to the influences leading to the publication of DSM-III in 1980. His account tends towards the skeptical, prioritizing sociological and economic explanation over the logic of scientific discovery, and is heavily influenced by Kirk and Kutchins (1992). He documents many cases of surveys that report a large proportion of the population has mental disorders, and traces these apparent discoveries to overly-inclusive criteria that depend solely on lists of symptoms. He argues that surveys that fail to ascertain whether the symptoms indicate disorders. For example, he suggests that wrestlers who choose to lose weight quickly to qualify for particular weight classes, and who then eat large amounts of food afterwards would satisfy criteria for bulimia nervosa, when in fact they do not have a mental illness. Horwitz argues that surveys claiming, for instance, that 23 million people suffer from generalized anxiety disorder or that 14 percent of Americans have an alcohol disorder, tend to massively overestimate the numbers of people with mental illness. He insists that for a condition to count as a valid mental illness, it should arise “in the absence of any cause that would expectably give rise to them, be of severity and/or duration disproportionate to their precipitating cause, or persist after the causes that gave rise to them disappeared” (98). He argues at length that most of the conditions currently classified as mental disorders do not meet these any of these criteria. On his view, the clearest examples of valid mental disorders are schizophrenia and manic depression, and he is suspicious of the many other conditions that are often classified as mental illness.

To consolidate his argument, Horwitz addresses the purported biological understanding of mental illness, and points out methodological problems in many studies that apparently prove the genetic basis of many mental disorders. He claims that the rates of most mental disorders apart from schizophrenia vary widely across different cultures, and uses this to underline his skepticism about the validity of the classification of these less serious conditions as mental illness. Turning to talk therapy and medication, he presses the point that therapeutic effectiveness is no proof that the original distress was really a medical condition rather than a symptom of social problem.

Many of Horwitz’s criticism of psychiatry are thoughtful, well argued, and reasonable. He poses many important and pressing questions. However, his starting definition of mental disorder is highly problematic, and this flaw undermines the central argument of the book. He shows little awareness of the vigorous debate over the definition of mental illness and in particular over the adequacy of Wakefield’s approach (see Perring, 2002 for a survey of the literature). Even without entering into the literature on the topic, the problems for Horwitz’s definition are easily seen by considering how it would apply to other medical conditions. For example, a knife wound needs to be treated by a doctor, yet it need not involve any failure of the internal functions of the body. Indeed, the normal functioning of the body is what leads to the healing of the wound. Similarly, a person with a common cold is fighting off a virus in a normal way, but is not suffering from an internal dysfunction. Applying Horwitz’s approach to such cases would have the unacceptable implication that they are not medical conditions. What is more, while it may be possible to know with some confidence when an unusual physical condition counts as an internal dysfunction, our intuitions are far less clear when it comes to mental conditions. Wakefield has appealed to evolutionary psychology to provide an account of normal function, and has received much criticism for doing so. Horwitz does not make such a move, but provides no alternative account, and he provides no justification for his conception of dysfunction. If a person going through a stressful divorce becomes depressed, for example, he assumes that this is a normal reaction. However, others will argue that the stress of the divorce has caused an internal dysfunction. One needs an independent and compelling account of normal emotional function to settle such a disagreement about when a person has an internal dysfunction, but Horwitz provides no such account.

While Horwitz seems to regard it as a conceptual truth that mental disorders should not include normal reactions to social conditions, he also indicates at various points that the validity of a definition should also be assessed in terms of its social consequences. Yet he does not make clear what he takes to be the detrimental consequences are of medicalizing everyday unhappiness and how people's personal psychological troubles could be better through a more social approach. One can agree with Horwitz that we would do well to look at social causes and cures for the widespread incidence of personal distress and psychopathology without accepting his narrow approach to the definition of mental disorder. It is a legitimate concern that taking an increasingly psychiatric approach to people's unhappiness could lead us to overlook social solutions, but we need some evidence that this is indeed a significant trend in contemporary society. Horwitz does not provide any such evidence, and one may wonder what evidence there is. It could be plausibly argued that despite the language of neuroscience spreading to our ordinary self-descriptions and advertisements for antidepressants, both the general public and the mental health profession remain very much aware of the causal relation between social trends and mental disorders. One might speculate that the reason we often use the tools of psychiatry to treat social problems is not that we have overlooked the social causes, but rather that we have not found available social interventions that are as effective. While Horwitz's proposal to restrict the domain of psychiatry to the most serious mental illnesses is intriguing, the danger is that it would simply result in fewer people with emotional or behavioral problems receiving help of any kind.

In summary, Creating Mental Illness is a noteworthy contribution to the literature evaluating psychiatric nosology. It embraces a medical model of major mental illness such as schizophrenia and manic depression, yet takes a skeptical and antipsychiatric attitude towards other conditions currently classified as mental disorders. This duality is premised on a distinction between emotional and behavioral conditions caused by internal (mental) dysfunctions and those which are a normal response to difficult circumstances. Horowitz's argument suffers from the weakness that he does not provide a clear and plausible account of how to draw this distinction and he does not address the considerable body of philosophical literature that has already demonstrated the difficulty in providing this distinction with a value-neutral foundation.

References:
Kirk, S.A., and H. Kutchins. 1992. The Selling of DSM: The Rhetoric of Science in Psychiatry. New York: Aldine de Gruter.
Perring, C. D. 2002. Mental Illness. The Stanford Encyclopedia of Philosophy (Spring 2002 Edition), Edward N. Zalta (ed.), URL = http://plato.stanford.edu/archives/spr2002/entries/mental-illness/
Wakefield, J. C. 1992. The concept of mental disorder: On the boundary between biological and social values. American Psychologist. 47:373-88.

Review of The Illusion of Conscious Will by Daniel Wegner

2008-11-16T14:57:00.000-05:00

This review of The Illusion of Conscious Will, by Daniel Wegner appeared in Philosophy in Review 33.4 (2003):299-301

DANIEL M. WEGNER. The Illusion of Conscious Will. Cambridge, Massachusetts and London, England: Bradford Books, The MIT Press 2002. Pp. xi+405. (Cloth: ISBN 0-262-23222-7);

Daniel Wegner, Professor of Psychology at Harvard University, has devoted much of his career to understanding the nature of self-control and its limitations. He is perhaps best known to the general public as author of White Bears and Other Unwanted Thoughts (New York: Viking Press, 1989) that summarized research on the difficulty we have in controlling the contents of our thoughts. His new book, The Illusion of Conscious Will, branches out into the realm of philosophy, and surveys a wide range of phenomena and experimental work relevant to agency. It has chapters on neurophysiology, phenomenology, automatism (including automatic writing, Ouija boards, water divining, and dissociative personality), protecting the illusion of conscious agency (including posthypnotic suggestion, confabulation in split-brain patients, phenomena of 'alien control' in schizophrenia), projection of agency (including beliefs in intelligent horses and pigs, and facilitated communication), virtual agency (including possession, mediumship, multiple personalities), hypnosis, and a final chapter on the importance of our beliefs in free will and authorship. These chapters are for the most part sprawling and unfocused. Wegner examines many topics and gives his opinion of how best to interpret them, but the book is full of unsubstantiated interpretations. It is often unclear whether the facts he presents are meant to serve as evidence for his main thesis about the illusion of free will, whether they are meant to be consequences of his view, or whether they are merely interesting phenomena that are tangentially related to his main theme. There is repetition of ideas from chapter to chapter, but often the examination of particular topics is cursory. In short, the book reads like a rough draft rather than a finished version.

Wegner's writing style is often casual and he peppers his text with jokes and asides. There are many illustrations, from diagrams explaining his views about the will and setting out details of scientific experiments to drawings of mesmerism, a reproduction of an advertisement for the "hypno-coin," and a photograph of Peter Sellers in the role of Dr. Strangelove. One might hope this would make the book more readable, but instead, the book fails to be either good scholarship or popular psychology, and is likely to leave both academic philosophers and psychologists and the general reader unsatisfied.

Wegner's main claim is that "the experience of consciously willing an action is not a direct indication that the conscious thought has caused the action" (2). He defines will as a feeling (3) and says (apparently by way of explicating our concept of will) that an action is not willed if the person says it is not (4) – ignoring the possibility of error or deception on the part of the agent. Wegner then makes a great deal of cases of people who perform actions with no apparent experience of willing them, but he makes no effort to prove that his initial definition of will is satisfactory or that it is a conceptual truth that will is a feeling. It remains open to a defender of free will to argue that our knowledge of willing is defeasible, and so that Wegner's many cases of action without awareness of willing fail to prove that the will is an illusion.

A potentially useful distinction Wegner makes is between the phenomenal will – the person's reported experience of will – and empirical will – the causality of the person's conscious thoughts as established by a scientific analysis of their covariation with the person's behavior (14). At times, Wegner's main thesis seems to be the modest one that the phenomenal will and the empirical will are not the same, rather than a denial of the existence of will. He says we accept a simple explanation of our behavior, "We intended to do it, so we did it" and we do not see the physical and mental processes that go to make up the empirical will (27). However, Wegner never makes a strong case that the phenomenal will is indeed generally incompatible with the empirical will, and the claim is prima facie implausible. The common sense psychology of ordinary folk assumes that the empirical will and the phenomenal will are different, and that the former explains the latter.

The most interesting argument for the illusory nature of conscious will stems from the research of Libet and others on the timing of consciousness awareness of willing relative to the action performed. The awareness of willing of finger movement occurs after neurophysiological activity that leads to the finger movement, and this suggests the awareness is causally irrelevant to the action. Wegner concludes from such experiments that "consciousness is kind of a slug" (58). He seems oblivious to the need to be very careful about the interpretation of the experimental data and the risk in generalizing from such specialized experimental conditions to ordinary life. Suffice to say, he casts very little doubt on the ordinary supposition that through deliberating about our lives we can often decide what is best and then act on our decision.

The remaining discussion of the book provides a wealth of fascinating cases where a person's agency is contestable. Especially provocative is Wegner's claim that the experience of conscious will occurs only when conscious thoughts are (mistakenly) seen as causing perceived actions. Philosophers new to the psychological literature on the will should find the bibliography an excellent resource for further research, and Wegner's work makes a strong case that the psychological literature deserves attention from philosophers working on freedom of the will and personal autonomy. The central failing of Wegner's argument is that he attributes to defenders of the will implausible beliefs about the nature of will and its role in agency. When he proceeds to show how the experimental data are incompatible with those beliefs, the implications are not as significant as he claims. Psychology has shown how humans tend to be less rational than we like to suppose, and there are many cases where are self-understanding is limited. However, just as the claims of psychoanalysis and behaviorism to undermine our central beliefs in our self-control have in the past been shown to be overblown, so too Wegner's use of modern cognitive and social psychology to undermine our belief in conscious will is ultimately unpersuasive.

Christian Perring
Dowling College

Archive: WHiP: Philosophy of Psychiatry

2008-11-15T16:33:00.000-05:00

In 1999, I wrote 5 monthly columns for a "Philosophy of Psychiatry" section of "What's Happening in Philosophy," which was part of the online "Philosophy News Service." Unfortunately it all folded soon after it started, and the site went down. (It was revived recently with different people running it.)
Here are those columns.
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#1: August 1999

Conferences featuring Philosophy of Psychiatry

In the last year, philosophy of psychiatry has started to achieve noticeably more recognition from the academic philosophical establishment. In the US, during the summer of 1998. The National Endowment for the Humanities funded a six-week institute on Mind, Self, and Psychopathology, at Cornell University. Run by Jennifer Whiting of Cornell and Louis Sass of Rutgers, it featured about 10 well-known philosophers and psychiatric researchers engaging in discussion of philosophical problems in interpreting dissociation and multiple personality, autism, and schizophrenia. About 25 participants were drawn from many fields of academic life, including philosophy, psychology, history, and law. It was a brave if not totally successful attempt to foster serious interdisciplinary dialog.

This summer the European Society for Philosophy and Psychology devoted its opening symposium to Philosophy and Psychopathology. The meeting, held at the University of Warwick in Britain this July, as a whole featured such notable philosophers as Fred Dretske of Stanford and John Campbell of Oxford. The session on psychiatry consisted of talks by George Graham (University of Alabama, co-editor with Owen Flanagan of the MIT Press series Philosophical Psychopathology), Jose Bermudez of the University of Stirling in Scotland (author of The Paradox of Self-Consciousness), and Joelle Proust of CREA, France. Here I will briefly outline the talks to give a flavor of what kinds of issues preoccupy philosophers of psychiatry.

Graham talked about multiple personality and the self. He said that it is in this area that some of the most interesting work in philosophical psychopathology has been done. He explained that he is a realist about selves, although the conception of the self that he believes in is austere. Here he sets himself in opposition to theorists like Daniel Dennett, who advocate the view that the self is a fiction. Graham argued that once we realize that the self can be fuzzy, we can accept its existence. This is a relatively interesting idea, although it still raises many questions about what we mean by the “self” and what function the concept serves for us, and whether the term “the self” gets used in ordinary talk in the same way as it does when talking about the selves in multiple personalities. More interesting to me was a brief comment that Graham made about his experience of writing his book (co-authored with his colleague Lynn Stephens) When Self-Consciousness Breaks (forthcoming from MIT Press). He said that they had started out planning to write a grand synthesis of philosophy and psychopathology, but they found that this was too ambitious an aim. Finally, with the book two years overdue, they were ready to settle for a few relatively unadventurous philosophical claims. This reflects how difficult it is to do good philosophical work in psychiatry, since it requires so much empirical knowledge and so many interdisciplinary skills.

This touches on a theme explored by Joelle Proust, who raised the issue of the relation of philosophy and psychopathology. A naïve way of thinking about their relation, which Proust called the “Orthodox View,” is that we have philosophical theories of the mind and we can test them through the study of psychopathology. Associated with this view is that idea that philosophy can help psychological and psychiatric researchers to make conceptual distinctions. Furthermore, philosophers may, on this view, be occasionally able to suggest new empirical theories about causal connections between phenomena.

Proust raised two main problems for the Orthodox View. First, she claimed that the study of psychopathology is not a science. She gave several reasons to justify this claim, including the problematic inheritance of psychoanalysis and the uncertain taxonomy of the Diagnostic and Statistical Manual, with its focus on symptoms rather than syndromes. Her second objection to the Orthodox View is what she referred to as the interpretive plasticity or ambiguity of clinical data. The phenomena of psychopathology are not described, and may not be describable, in a theory-neutral way. The descriptions of what is sometimes called “phenomenological psychopathology” are already laden with theoretical and philosophical assumptions. Therefore, it is not possible to simply “read off” the philosophical implications of clinical data. The philosophical assumptions of the observer need to be examined and questioned before we can even begin to grasp the intricate relation between philosophical theories and psychopathological descriptions.

Finally, Proust warned against the danger that philosophers making implicit empirical assumptions in their investigation of psychiatry. She suggested that philosophers like to propose unwarranted causal hypotheses in the explanation of the phenomena of psychopathology. In particular, she thought that philosophers want to explain mental phenomena by reference to the beliefs and desires of the patient, what she called explanation at the personal level, as opposed to explanation at the subpersonal level, which would include brain modules and neurochemistry. Take, for example, the voices that a paranoid schizophrenic hears. The subpersonal explanation says that these are simply malfunctions of the brain. Proust is suggesting that some philosophers, like psychoanalysts, insist that there must be more to the phenomenon than that, and that the voices must be at least an expression of the patient’s beliefs and desires, and they might even be caused by the patient’s beliefs and desires. Her point about this is that philosophers are mistaken when they think that there must be an explanation of phenomena at the personal level. Sometimes problems, often classified as psychiatric, are simply malfunctions at a lower level of the brain.

Bermudez’s paper discussed some of the same themes as Proust, although from a very different angle. It was also the most technical of the three, and I suspect that most conference participants were as unfamiliar as I was with much of the psychiatric research literature he mentioned. His initial focus was on the distinction between neuropsychiatry and psychiatry. He said that it is often assumed that psychiatry is characterized by breakdowns in rationality, i.e. as problems at the personal level, while neuropsychiatry is concerned with breakdowns at the subpersonal level. With this as his background, he went on to discuss how to understand what happens in schizophrenia. Is schizophrenia best understood as a breakdown at the personal level or the subpersonal level? This is a very difficult question, and this is partly because it is so difficult to characterize accurately what makes a schizophrenic delusion a delusion. There have been many attempts, and Bermudez was partly showing the inadequacy of some recent attempts. These attempts distinguish between the positive and negative symptoms of schizophrenia, and link them to a distinction between epistemic and procedural rationality. In the short time available, it was not possible for me, nor I suspect, many other attendees, to fully grasp, let alone assess, the ideas he was setting out.

Other philosophy and psychology conferences this year also address issues from psychopathology. For instance, at the University of Copenhagen last May, there was Problems of the Self: Philosophical and psychopathological perspectives on self-experience. This August, there is the 1999 International Conference on Persons, featuring Louis Sass as keynote speaker, talking about his specialty, understanding schizophrenia as hyperreflectivity. The big conference to look forward to next year is Madness, Science and Society, to be held in Florence, in August of 2000. Sponsored by a number of different European organizations, it should be an important event for philosophy of psychiatry, with its focus on shaping the future of the field.

Related Links:
MIT Press Philosophical Psychopathology Series http://mitpress.mit.edu/books-in-series.tcl?series=Philosophical%20Psychopathology
Problems of the Self: Philosophical and psychopathological perspectives on self-experience, University of Copenhagen, May 28-30, 1999. http://lgxserver.uniba.it/lei/MINDE/co_9.htm

The 1999 International Conference on Persons http://www.canisius.edu/~gallaghr/forum/

European Society for Philosophy and Psychology
http://www.warwick.ac.uk/fac/soc/Philosophy/consciousness/ESPP.html

Renaissance 2000: Madness, Science & Society
http://www.swmed.edu/home_pages/aapp/Florence2000.html

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#2: September 1999

What’s Philosophical About Psychotropic Drugs?

This is only my second “monthly update” on philosophy of psychiatry, but I am already pondering that philosophy tends to move at a glacial pace, and a “yearly roundup” might be more appropriate. Despite my qualms, and in an effort the aid the integration of philosophy into the information age, this month I focus on a non-traditional arena of philosophical discussion, popular culture.

The media know what interests the public, and so they give plenty of attention to psychotropic drugs. Is Ritalin overprescribed? Are doctors and psychiatrists giving out too many antidepressants? Or are too many people with depression going untreated? I see reports on these topics often on the evening news, in the health section of my newspaper, and on the major health web sites. The publishing industry also knows that the public has an appetite for these issues: in addition to the usual flow of self-help books and memoirs of therapy and mental illness, there are also books highly critical of the psychopharmaceutical industry. Most notable is the psychiatrist Peter Breggin, who manages to write a book every year or so. In recent years he has produced Toxic Psychiatry, Talking Back to Prozac, Talking Back to Ritalin, and most recently, Your Drug May Be Your Problem (a title which strikes me as slightly comic—I can’t work out why though). Other authors have written antipsychiatry-flavored books with titles such as Running on Ritalin and Ritalin Nation.

The question of when to take psychotropic drugs might seem to be straightforwardly medical. Medicine, and the branch of medicine we designate as psychiatry, identifies pathological conditions and provides ways of ending the conditions or at least reducing their symptoms. Nevertheless, in fact the debate that continues to focus on these issues is not purely empirical: it involves profoundly philosophical issues.

Even standard medicine can be the proper subject of ethical scrutiny, for many sorts of reasons. Individual physicians sometimes act unethically, succumbing to temptations of personal gains at the expense of the patients. Furthermore, whole health care systems can be subject to ethical criticism, if they fail to live up to proper expectations. For example, much good work has been done showing how biased medicine has been with respect to gender.

These criticisms tend to operate from an internal perspective: they don’t challenge the fundamental aims of medicine, but rather they say that these aims are not being carried out in a fair way. Doctors are too ready to perform radical hysterectomies on women, ignoring how much effect his has on women and ignoring options that are more conservative. Maybe doctors in the US are too ready to recommend removal of the prostate in men with prostate cancer, when more conservative options are equally effective.

These internal criticisms can point to more global criticisms of medicine. It is a commonly made point that doctors can often focus too much on the disease rather than the patient, and in doing so they neglect the quality of life of the patient. By doing so, they start to forget what the whole point of medicine is. It is here that philosophical debates about the definition and ultimate purpose of medicine enter into the discussion. The whole discussion becomes more philosophical.

The sorts of worries concerning psychotropic drugs raised by the media tend to be internal. Is psychotherapy being denied to patients by their health maintenance organizations even when it would be the most effective treatment, because it is cheaper to prescribe drugs instead? Should talk therapists without medical degrees have the authority to prescribe psychotropic drugs to patients, or is a medical degree necessary for someone to be competent to prescribe drugs? Why is the rate of depression and suicide increasing in children?

However, we are now at a stage where we could move on to more global concerns about psychotropic drugs in psychiatry. It’s here that philosophy is in danger of missing its cue. This month’s update serves a prescriptive as well as descriptive function in discussing what’s happening in philosophy. Journals in medical ethics rarely discuss psychopharmacology. (I might mention here in shameless self-righteousness and self-promotion that I published a piece on prescribing Ritalin to children in Bioethics in 1997.) I have seen the issue discussed more at bioethics conferences, but still it gets far less attention than the more traditional debates over reproductive technology and physician-assisted suicide. It was a book by the psychiatrist Peter Kramer, Listening to Prozac, that has so far given one of the most thoughtful and philosophical discussions of these issues. Medical ethics does show some sign of addressing these issues under the general heading of human enhancement as concerns about genetic therapy and cosmetic surgery grow. Issues in psychopharmacology do certainly overlap with these other issues, but we need to remember that they also have some unique aspects.

Philosophical issues arising from psychopharmacology get even less attention in the more traditional journals such as The Journal of Philosophy, Ethics, Philosophy and Public Affairs, and Philosophical Review. This may reflect a general attitude of disinterest or even disdain concerning medical ethics from the philosophical establishment. Issues concerning medicine and psychiatry often get written off as “applied ethics,” which carries the implicit implication that real philosophers do pure ethics, who leave it to others to think through the implications of their abstract theories for the real world. It must be said that medical ethics often fuels this sort of disdain through a severe lack of quality control both at conferences and in journals. However, a look at the issue of psychopharmacology shows how wrongheaded this viewpoint is.

The philosophical issues that arise around psychopharmacology are certainly not purely moral in a narrow sense. Most obviously, we need to ask how we decide what should count as a pathological condition requiring treatment. How much unhappiness should count as clinical depression? How much restlessness and lack of concentration should count as attention deficit hyperactivity disorder? While some (mostly in the medical profession) still believe that these are purely medical questions, most recent discussion has agreed that criteria of mental disorder essentially involve value judgments. Social values and pragmatic considerations do and must enter into the deliberations both in drawing up the diagnostic criteria, and also in doctors deciding whether their patients meet those criteria.

Furthermore, larger questions soon enter into the discussion. Is the concern about psychotropic drugs based purely on their uncertain side and long-term effects? Clearly not: many people say that to live with one’s behavior and emotions regulated by a drug is to be less of oneself. The idea is that one’s personal identity is altered by these drugs. This is a metaphysical (in a non-pejorative sense!) claim, and belongs firmly in the camp of metaphysics and epistemology. Yet, philosophers have hardly scratched the surface of this issue.

Often philosophers like to see themselves at the vanguard of debate, asking difficult questions that the general population would prefer to ignore, yet need to face. It is therefore striking and a little ironic to see mainstream philosophy lagging behind popular debate in areas such as psychopharmacology. It is in editorials, magazine articles, and other discussions in popular culture that these important issues are being discussed. It is time for professional philosophers to add their expertise and careful methods to this debate.

Links:
The Enhancement Technologies Group: http://www.gene.ucl.ac.uk/bioethics/index.html
Peter Breggin's Center for the Study of Psychiatry and Psychology: http://www.breggin.com/
Conference on the Science and Ethics of Human Enhancement: http://www.cwpost.liunet.edu/cwis/cwp/but01/whatsnew/new208.html

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#3: October 1999 (?)

The US Surgeon General recently published a report on Mental Health. It's actually an impressive 458 page book, with chapters on children, adults, older adults, the structure and financing of mental health services, confidentiality, and the future of the mental health profession.
I expect to be covering several aspects of this important report in future WHiP columns, but what first struck me about it was its laying blame in its Introduction on Descartes for our western dualism of mind and body and the stigma of mental illness. It refers to "the misguided split between mind and body first proposed by Descartes," (p. 6) and says, "This partitioning ushered in a separation between so-called 'mental' and 'physical' health, ..." (p. 5).
Coming, as it does, under the imprimaturs of the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, and National Institute of Mental Health, this report is set to be influential and has the ability to perpetuate myths. This view about Descartes smacks of stereotyping of a sophisticated philosopher.
Of course, the Surgeon General is simply repeating what has become a standard view. For instance, the very title of neuroscientist Antonio R. Damasio's best-selling book *Descartes' Error: Emotion, Reason, and the Human Brain* refers to such a view. Nevertheless, even a little thought about the issue shows that Descartes should not be painted as a villain here.
For one thing, Descartes was certainly not the first to suggest that there is a split between mind and body. The idea dates back at least to Plato, who argued that not only is the mind a radically sort of entity than physical matter, but also that our knowledge of the mind and its contents is very different from our knowledge of the physical world. Subsequent philosophers were certainly influenced by Plato, and it is a standard observation that early Christian theology had strong Platonic elements. Indeed, any religious view that holds that persons can go on living after their bodies have ceased to exist needs to have some account of personhood as logically independent of the body.
Furthermore, I wonder what ground there is for saying that Descartes had such a profound influence on western medical thought. Is it not more plausible to blame Christianity as the more powerful social force? It's easy to imagine that history would be little different if Descartes had never written a word of philosophy, but it is hard to know what our society would like if Christianity had never caught on.
But from a philosophical point of view, maybe what is most important is that this view perpetuated by the Surgeon General misunderstands Descartes. I'm no scholar of early modern philosophy, so I asked Lisa Shapiro, Assistant Professor of Philosophy at Hampshire College, to give her expert opinion. Her Ph.D. dissertation at the University of Pittsburgh was on "The Union of Mind and Body: Descartes' Conception of a Human Being," and I have heard her reaction on previous occasions when Descartes was held responsible for our seeing mind and body as radically split. Here's what she wrote:
"While Descartes does claim that mind and body are separable, he also claims that these two substances are united in a human being and through this union they have the power to affect one another. Indeed, he thinks that we experience this union everyday, in the course of leading our lives, just in having the sensations we do, and feeling the passions we do. While Descartes is often assigned a Platonic view, wherein the mind is lodged in a body like a sailor in a ship, he explicitly distances himself from this view in both the _Discourse on the Method_ and the _Meditations_. He does not think that that model can explain the quality of our sensations, for it is clear that we do not have the kind of knowledge of our bodies that angels would have. Moreover, it is clear from his correspondence with Princess Elizabeth of Bohemia that he does think that mind and body are tightly connected. He diagnoses her chronic illness as an effect of depression due to family problems, such as the beheading of her uncle Charles I of England. And admits to her that certain diseases can impair our free will and with it our capacity to reason well. The view about the radical separation of mind and body usually assigned Descartes is perhaps due to the philosophical problems he faces in articulating the union. Descartes was influential in shaping modern medicine, insofar as he, like Harvey and others who followed (La Forge, Malebranche, La Mettrie), was committed to describing the human body as a machine. But describing the human body in this way raises real questions for the status of the human mind. Are we do think of it as a feature of the machine as well (like Hobbes was inclined to)? If not, how are we to explain the relation of mind (non-material, non-mechanical) and body? The rise of mechanist science, and the application of that mechanism to biology then gave rise to a dilemma: We could deny that mind and body were two different things, and so be materialists. This option presents problems for the Christian doctrine of the immortality of the soul, however. To preserve the doctrine of the immortality of the soul, and the view of ethics and responsibility associated with it, we could preserve the distinction between mind and body, and to avoid the difficulties of explaining how they relate to one another assert that the well-being of one did not affect the well-being of the other. I would see Descartes as trying to steer a middle course between these two. Critics have shown him not to have been successful in doing so. History has shown him unsuccessful in getting credit for trying."

Links
Mental Health:A Report of the Surgeon General http://www.surgeongeneral.gov/library/mentalhealth/home.html
RENÉ DESCARTES AND THE LEGACY OF MIND/BODY DUALISM http://serendip.brynmawr.edu/exhibitions/Mind/Descartes.html
Lisa Shapiro
Biographical Information at School of Humanities, Arts and Cultural StudiesFaculty Biographies 1999-2000 http://www.hampshire.edu/academics/hacu/faculty.shtml

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#4: November 1999 (?)

Rationality, Psychopathology, and Emotions.

This year's annual conference of the Association for the Advancement of Philosophy and Psychiatry was on "Rationality & Mental Health." As usual, it met just before the huge American Psychiatric Association meeting, which this year was in Chicago. Many different psychiatric groups meet at the larger conference, and the financial power of pharmaceutical companies is apparent, for instance in their provision of rather lavish tables of food for these different groups. Unfortunately, or perhaps fortunately, the funding of AAPP is modest by comparison, and we mostly made do with cups of coffee, although there was some very good cheese and fruit available at the Saturday reception.

This was one of the most successful annual meetings AAPP has had, due to a thematic unity among the papers and more time left for discussion of each paper, which also meant that there were fewer papers, and thus that the average quality of papers was higher.

Broadly speaking, the papers divided into two groups: those that addressed the relation of emotions and rationality, and those that did not.

A few papers did not address the issue of emotions at all: my own paper discussed whether principles of charity in the interpretation of others required by prominent philosophers of mind such as Daniel Dennett and Donald Davidson placed conceptual limits on how extreme psychopathology can me. Louis Berger gave an interesting discussion of to what extent the transaction between a psychotherapist and a client can be captured in any model, and argued that the main theories of psychotherapy indeed do not entail or fully describe what happens in psychotherapy. In the question period, it became clear that he was committed to an even more radical view, that no human behavior can be fully modeled with a theory. David Graves, despite jet lag, breathtakingly set out an ambitious theory of "modular rationality," which drew on a number of different ideas from cognitive science and elsewhere.

James Phillips gave a wonderful paper on the problems of defining the psychiatric concept of delusion. It is often mistakenly thought that a delusion can be simply defined as a belief system strongly divorced from reality, but Phillips showed some of the problems inherent in such an approach, and made his own suggestions about a more promising approach -- among his ideas was that the definition of delusion does need to bring in a concept of affect.

Neither of the keynote addresses were particularly concerned about emotion. Drew Western, a Harvard psychiatrist, outlined the relevance of cognitive neuroscience for our understanding of rationality. Of greater philosophical interest was John Deigh's paper on "Moral Agency and Criminal Insanity," which gave both a very useful history of the insanity defense, and a careful study of the moral psychology of irrational action. It was a paper that tended to split the audience: the analytic philosophers delighted in the careful distinctions, while others seemed to feel it was hair splitting. Deigh concluded with a discussion of to what extent we can be considered morally responsible for our actions that are due to mental disorder. This theme was taken up by Sarah Hamady in her Harry-Frankfurtian discussion of external desires and self-defeating behavior. She engaged the issue of how we can transform ourselves and accomplish a unity of goals and desires.

Many papers did focus on philosophical issues concerning emotion. Some of them were traditional philosophical issues such as the relation between rationality and affectivity: to what extent is it rational to have emotions, when are emotions irrational, and what emotions are. More innovative were the papers that drew stronger connections to psychopathology and psychotherapy, although still focusing on emotions. Some papers discussed whether various forms of mental disorders involved problems with rationality or problems with emotions; others discussed the goal of psychotherapy, and cognitive-behavioral therapy (allied with rational-emotive therapy).

I'll mention three of the papers on emotion. In one of the more continental papers of the conference, George Agich argued that models of mental illness put too much emphasis on the idea of failures of rationality and autonomy. He urged that we need to understand the importance of affect in mental disorder. Patricia Greenspan, one of the program co-chairs, took a slightly unusual step considering her position, and criticized the assumption she saw of the division of rationality and emotion in the Conference's Call For Papers. She argued, continuing the research project she has pursued for several years, that emotions can be rationally evaluated. York Gunther gave one of the more technical and challenging papers of the conference. He claimed, and here I quote from his abstract, that "Emotional contents ... are unique because they resist inferential structure and generally fail to take binary connectives." In order to show this, he considered in some detail what one is rationally committed to in having an emotion. He used this to conclude that emotions cannot be specified independently of their attitudes, which is to say that emotions cannot be identified purely propositionally. With a wry smile, Gunther admitted that his method harkened back to the heyday of ordinary language philosophy, and was eager to learn of other methods that could help him reach the same conclusions.

Reflecting on the conference, I am struck by how the divisions between analytic philosophers, continental philosophers and clinicians seemed much less significant and problematic than they have at previous such conferences. Of course these divisions still existed, but on the whole participants did not seem to divide up neatly into rather predictable groups, as so often happens at such interdisciplinary events. Rather, the discussion managed to find common ground, or at least to explore the strengths and weaknesses of individual ideas without resorting to standard "party lines." The most heated exchange, between a psychiatrist and an academic psychologist, was about the role of drug companies in the modern profession and the extent to which "scientific studies" of therapy and drugs are fair and unbiased. The conference as a whole was provocative and interesting, and could serve as a model for interdisciplinary work.

Link:
Twelfth Annual Meeting of the Association for the Advancement of Philosophy & Psychiatry: http://www.swmed.edu/home_pages/aapp/AnnualMeeting00.html

Books of relevance:
The Sources of Moral Agency : Essays in Moral Psychology and Freudian Theory by John Deigh
Emotions & Reasons : An Inquiry into Emotional Justification by Patricia S. Greenspan

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#5: December 1999 (?)

Philosophers on Drugs (Again)

One of the latest issues of The Hastings Center Report has a number of short articles on "Prozac, Alienation, and the Self." The authors are Carl Elliott, Peter D. Kramer, David Healy, James C. Edwards, and David DeGrazia. Of this group of writers, three are professional philosophers, and psychiatrist Kramer’s book Listening to Prozac was surprisingly sensitive to philosophical issues. Healy, another psychiatrist, is author of a number of social/historical books on psychopharmacology; of these, The Antidepressant Era, published by Harvard University Press, has gained the most attention.

The standard worry about Prozac is that it is used too much and for the wrong sorts of reasons; specifically some worry that people who are not seriously depressed, but merely want a crutch to help them deal with life use it. Such a life is thought inauthentic; the happiness of such a life would be a result not of flourishing, but rather a result of chemical manipulation. Furthermore, there may be some circumstances where happiness is inappropriate, and a sense of alienation is a better reaction. Elliott embraces this sort of worry about Prozac, and more generally about the individualistic approach of psychiatry: if modern culture is alienating, he suggests that the best response is not to feel better by taking Prozac; it would be better to examine our values and change the way we live.

Peter Kramer expresses doubt, in response to Elliott, that modern alienation is a reaction to social conditions. Furthermore, he suggests that we have a cultural preference for the melancholic over the sanguine, identifying the perfectionism, pessimism and sensitivity of melancholy with intellectual traits.. He does not necessarily endorse this preference, and does not think it provides a strong reason to be suspicious of Prozac. Prozac could help as much as hinder social change: “If Prozac induces conformity, it is to an ideal of assertiveness.” Kramer wants us to be at least open to the possibility that melancholy is not necessary for critical stance towards our surroundings, and that we should indeed question our attachment to melancholy. That is to say, he thinks a person can engage in a profound philosophical questioning and still be happy. With deliberate provocation, Kramer questions what he sees as a philosopher’s prejudice, the idea that “melancholy is appropriate to modernity.”

The most straightforward critique of psychopharmacology in the journal comes from Healy. He emphasizes the power of the pharmaceutical corporations. He casts doubt on the empirical date supporting the effectiveness of Prozac in treating depression. He states flatly that Prozac does not work for severe depression. Ultimately he calls into question the “pseudoscientific” mystique that has grown up around Prozac, and suggests that the abstract philosophical debate about Prozac and alienation is missing the most important questions.

Edwards gives the mildest suggestion of the group. Using the framework of Foucault and Heidegger, Edwards considers the source of our worries concerning the use of Prozac as mood enhancer. He suspects that we are suspicious of happiness that is not earned through suffering – there is a virtue in bearing pain. Edwards tries to separate out two attitudes towards technology, one that embraces it and another that eschews it. He suggests both are worth thinking about and we need to understand what assumptions are built into each, and most importantly, we should realize that we don’t have to be swept up in the frenzy for technological progress.

DeGrazia, in the last article of the collection, emphasizes that one’s self is partly created, rather than merely discovered, by oneself. He argues that Elliott does not sufficiently appreciate this point, and that Elliott’s criticism of an enhanced life on Prozac as inauthentic assumed that the self is static and given. Instead of Prozac creating a false self, mismatched with one’s real self, it might be possible to identify with one’s new self. A central question for DeGrazia then is just how malleable the self is. He quickly distances himself from the extreme view of Sartre that we are entirely self-creating and utterly malleable. It takes only a little reflection to see that people have limits and that they cannot always become whatever they want. He points out that one long-standing form of self-creation is psychotherapy, and this mode of self-change hasn’t been accused of creating inauthentic selves. Given that, why should the use of drugs like Prozac be any more troublesome than psychotherapy? DeGrazia can see no legitimate difference between these modes of self-change vis-à-vis authenticity. He ends by acknowledging that there may be reasons for qualms about the prospect of a society in which most people use self-enhancing drugs. Nevertheless, he argues, it should not be up to individual psychiatrists to refuse medication to their patients if their reason is such use of medication is not good for society as a whole. It is not for the psychiatric profession to impose its grand vision of the good life on society: patients themselves should make such decisions.

I’m hopeful that the debate about performance-enhancing and mood-enhancing drugs will gather momentum, especially as it becomes clearer how much it overlaps with debates about genetic technology and the increasing use of computers in the body, sometimes known as "cyborg technology." Kudos to the editor of The Hastings Center Report for taking one of the early steps to advance this debate in medical ethics and the rest of philosophy.

ENHANCEMENT TECHNOLOGIES GROUP
http://www.gene.ucl.ac.uk/bioethics/index.html

Books:
Listening to Prozac, by Peter Kramer
The Antidepressant Era, by David Healy
Erik Parens, Editor Enhancing Human Traits: Ethical and Social Implications

The Philosophy of Mental Health

2008-11-15T16:01:00.000-05:00

In 2004, I was asked to write a short summary of philosohical issues in mental health for the theatre playbill for a production of Joe Penhall's "blue/orange" by The Repertory Theatre of St. Louis, directed by Steven Woolf. The play was later produced by BBC Four in 2005.

The Philosophy of Mental Health

In the tradition of One Flew Over the Cukoo's Nest and Girl, Interrupted, Blue/Orange raises the questions of what counts as normal in our society and who should have the power to decide what is normal. Set in contemporary Britain, Joe Penhall's play refers to some "sections" of the Mental Health Act that give psychiatrists the power to hospitalize mentally ill people against their will for their own good or the protection of society, and some of the details of the law will be unfamiliar to American audiences. But the turning of a noun into a verb will be easy to understand: Bruce wants to section Christopher again, to keep him in hospital care. This language has become part of everyday usage in the UK, not just among mental health professionals, but for ordinary people. "Sectioning" now signifies psychiatric authority as much as "Bedlam," "straightjacket" and "lobotomy."
There has always been controversy and public debate about psychiatric theories and treatments. These days, society mostly agrees that people who are competent to make their own decisions should have the right to control their own lives and bodies, while those who lack mental competence can have guardians appointed to make decisions on their behalf. The central difficulty is in drawing the line between the sane and the insane. In the twentieth century, Sigmund Freud carved the intuitively plausible distinction between the neurotic and the psychotic, and notoriously argued that in modern civilization where we have to repress our animals drives in order to live in relative peace, we are all neurotic to some degree. Neurotics could benefit from psychoanalysis, he thought, but psychotics were so out of touch with reality that mere talk would be of no help to them.
These days, Freud's psychoanalytic theory is largely out of favor with the psychiatric establishment, and psychiatric training includes a mix of neuroscientific facts, psychological theories and sociological perspectives. Most of the research money is in the development of new medications, and public talk about mental health problems is dominated by the language such "chemical imbalances in the brain" and "low serotonin levels," and it is no surprise that some have jokingly referred to depression as a form of "Prozac deficiency." Psychiatry has been largely successful in shaking off its old tarnished image of being "pseudoscientific," and through embracing neuroscience and genetics, it holds its head high with other medical disciplines. Even some talk psychotherapy has been empirically proven to be effective, with health maintenance organizations and medical insurance companies showing more enthusiasm for "brief therapy" and limited sessions rather than the interminable analysis of the Freudian era.
In the 1960s and 1970s, there was great public interest in the "antipsychiatry movement," which was led by the theories of the psychiatrists R.D. Laing and Thomas Szasz and fueled by revelations about the mistreatment and institutionalization of patients in large psychiatric hospitals. With the added incentive of saving money, administrators and policy makers were keen to shut down those large hospitals and provide people with long-term mental health needs with care in the community. Laing suggested that the real problem was not located in the mentally troubled individuals but rather in families and even society at large, and attempted to create radical new approaches to the treatment of mental illness. His experiments did not have much success, and he himself abandoned them for different pursuits. Szasz, now in his eighties, has shown far more consistency in his approach, and is still publishing books on a regular basis denouncing psychiatry as a form of slavery and denying the very existence of mental illness. Szasz continues to believe that each individual must face the problems in living, and should always be morally and legally accountable for his or her actions. His extreme views continue to influence a minority of mental health professionals and are particularly attractive to many former patients who believe that they have been abused by the psychiatric system. On the Internet, one can find many websites created by "survivors" or former patients devoted to revealing the miscarriages of justice and even conspiracies by mental health professionals and multinational corporations.
However, the deinstitutionalization of people with chronic mental illnesses seems to have had little benefit, and it is not clear what practical alternatives the critics of psychiatry have to offer. Community care fails many psychiatric patients. Homeless people are conspicuous in the streets of any major American city are and a large proportion of them have been diagnosed with serious mental illness. Even those in some form of residential care are often neglected or suffer the consequences of minimal funding of essential resources. Groups such as the National Alliance for the Mentally Ill, run by families of people with severe mental disorders, embrace the model of brain diseases and call for more funding for psychiatric research and treatment, and insist on the importance for families to have the power to hospitalize their loved ones when necessary. If one visits the psychiatric wards of major hospitals, one is struck by how little time the patients have to stabilize before they are sent out again to cope on their own. It seems that much of psychiatric care for chronic illnesses focuses on crises, and there are insufficient resources to help people learn to cope with ordinary problems and lead fulfilling lives.
This is some of the background against which Blue/Orange is set. Despite the enhanced scientific status of psychiatry, there are still fierce debates about the objectivity of the classification of mental disorders and the ways that psychiatric authority can be used to oppress disempowered groups. The most developed and articulate criticisms have come from a feminist perspective, with a focus on mental disorders especially associated with women, such as the old category of "hysteria," and the more recent categories of eating disorders, depression, and borderline personality disorders. Equally familiar is the debate over the classification of homosexuality as a mental disorder. These cases have shown very clearly that psychiatric categories often do embody ethical assumptions about normality, and that the psychiatric establishment conceals its values in the guise of "scientific fact." Behind the supposed objectivity of treatment recommendations and research protocols, there are sharp disagreements amongst psychiatrists and other experts, and politics and power struggles can play as much a role in the treatment of patients as "the scientific method." Of course, professional associations have ethical guidelines for the treatment of patients, and most clinicians care deeply about the welfare of their patients. Nevertheless, much of the interaction between clinicians and patients occurs in private with no observation by others and people with severe mental illnesses have little ability to take action against the institutions and professionals who have provided questionable treatment. So it will not be surprising if abuses of power still occur at both the individual and institutional levels.
Compared to the issue of sexuality and gender in psychiatry, there has been less scrutiny of the role of race and ethnicity. In Blue/Orange, there are hints that Christopher is a pawn in a struggle between the psychiatrist-in-training Bruce and his well-established supervisor Robert, and that Christopher's ethnicity is a central factor. In an early scene, Christopher accuses Bruce of seeing him as an "uppity nigga," and of course Bruce denies this. Indeed, Bruce seems young and idealistic, naïve about the limitations of treatment, and Robert's more experienced advice is for him to just let Christopher go back to the community rather than to keep on treating him. But later in the play, Robert becomes keen to use Christopher in a study for his uncompleted Ph.D. He imagines what it would do for his career if he were the man who found the "cure for black psychosis." This immediately raises questions of identity and language, this time about race: who counts as black or African, and indeed whether it is racist to classify someone as black or to consider ethnicity as a factor in mental illness. In the exchanges between Bruce and Robert, these questions are not resolved, but Penhall manages demonstrates how troubling they are. The dialog shows powerfully a way in which minority patients can be reduced to their race in the search for psychiatric knowledge, and their status as a full person can be obliterated. When Robert tells Christopher that he is writing a book about "people like you," Christopher becomes just a label or category, black and crazy. Later, Robert says that Christopher's excitable behavior is normal "where he comes from," and in a moment of dark humor, Bruce points out that the patient is from Shepherd's Bush, a rather boring middle class suburb of London. Robert's categorization misses the simplest of Christopher's individual characteristics.
In a surprising twist, however, Robert is sympathetic to the humanistic existentialism of R.D. Laing, while Bruce, who shows more concern for Christopher's welfare, places his confidence in standard scientific psychiatry. It is Robert who has a more tolerant attitude to Christopher's odd beliefs, ready to interpret them as an expression of surrealism, and defends Christopher's right to live his life as he wants. Both psychiatrists have limited understanding of their patient, and his interests get lost in their battle for power.
Blue/Orange makes a powerful case that at the heart of disputes about how best to treat psychiatric patients are not only disputes about the rights of patients and different value schemes, but also the nature of a person and the concept of mental illness. These are complex philosophical issues, and should provoke audiences into deeper thought. Personally, I also hope that some mental health professionals will see the play, and that it might help those responsible for the training of future psychiatrists and psychologists to see the importance of works of literature and philosophy to understanding mental illness and its treatment.

Worries about Psychotropic Medication: A Philosophical Guide

2008-11-15T15:20:00.000-05:00

This paper dates from Fall 2001. I didn't work out where to submit it for publication, and it sat on my hard drive.

Worries about Psychotropic Medication: A Philosophical Guide

My aim in this paper is to explore reasons people may have to being worried about the widespread use of psychotropic drugs, and especially in cases when the drugs are not medically necessary. I will not take a strong position for or against this use, although I will express some skepticism towards some of the objections that have been made against the use of antidepressants. My motive for writing this paper is to try to encourage discussion of the issues, and in particular to get people who are against this use of medication to better articulate their reasons.
My approach here is solidly “bottom-up” as opposed to the alternative “top down” approach of starting with a certain sophisticated theoretical view and showing how it applies to particular cases, which I find to be of limited value. I will take some simple ideas and intuitions and try to develop them a little. Thus I will not start out with any discussion of great philosophers such as Aristotle, Hume, Kant, or Wittgenstein. Nor will I assume the truth of any fully worked out theories of the nature of nature, autonomy, or the good life. I will refer to some well known philosophical theories along the way, and I may argue that some have more plausibility than others, but my aim here is to be basically neutral in my stance among the various philosophical approaches that are relevant to this issue.

The Rise in Psychotropic Medication: Prozac and Ritalin
It is uncontroversial that there has been a massive increase in the use of psychotropic drugs. Eli Lilly boasts that 40 million people in 100 countries have taken Prozac. This maybe due to an increase in mental illness:
Millions of us are falling prey to what is now identified as a disease. Five million of us each year have some sort of depressive illness that would justify medical intervention. That's not much less than a tenth of the population. A third of those who go to the GP have underlying depression. The young, with the world ahead of them, should have the blithest hearts. Yet 12% of male students and 15% of female students at university are depressed. Yesterday, meanwhile, it emerged that university counsellors are reporting a dramatic increase in the number of students seeking help for severe mental problems. Just over a year ago, the World Health Organisation declared that depression had reached epidemic proportions. Within 20 years, the WHO said, it would be the world's second most debilitating illness after cardiovascular disease in terms of lost years of human productivity. [1]

The rise in psychiatric medication is especially noticeable among children. Between 1992 and 1998, in one study:
Prescription prevalence in school-aged children 6 to 14 years increased from 4.4% to 9.5% for stimulants during the study period, and from 0.2% to 1.5% for SSRIs. In 1998, stimulant prescription prevalence was highest for white school-aged males (18.3%) vs black females (3.4%) and SSRI prescription prevalence was highest for white school-aged males (2.8%) vs black females (0.6%).[2]

Furthermore, young people often use stimulants without a prescription.
Among the findings from a soon-to-be-published Massachusetts Department of Public Health survey: 13 percent of 6,000 high-school students and 4 percent of middle-school students admitted to an “illicit, unprescribed use” of Ritalin in anonymous, written surveys.[3]

They might do this for recreational use because they enjoy the experience, or possibly because it helps them study better, as often happens with students taking caffeine tablets. In this paper I am especially interested in the use of drugs to enhance one’s capabilities and to make up for one’s deficits, although if there are objections to the use of medication in these cases, they may also apply to cases in the gray area between illness and health, and even to treatment of cases of clear mental illness if there are alternative, non-medication treatments available.

Natural Remedies
There’s also an increase in the use of herbal remedies and vitamin supplements in the hope that they will improve one’s mental life.[4] One report that in the US, $400 million is spent on St. John’s wort each year. Furthermore, “Approximately 42 percent of U.S. health care consumers spent $27 billion on ``complementary and alternative medicine'' therapies in 1997, the most recent year for which data is available.”[5] “Americans spent $4.13 billion on all herbal supplement sales in 2000, with $248 million on top-seller gingko biloba, a product that presumably improves memory. They shelled out $210 million on echinacea, for its alleged immune boosting fighting ability; another $174 million on garlic, for its supposed infection-fighting properties; and $170 on St. John's wort, the so-called natural antidepressant.”[6] Sales are still growing, even though they are not growing at the same high rate as a few years ago.

Critiques of Psychopharmacology
Faced with this increased role of medication in our everyday lives, some social critics have suggested that it represents a deeply disturbing tendency. They have given various sorts of reasons, which can be divided into two kinds:

“Sociological Concerns” (based on assumptions about our society and other empirical claims)
Not addressing the real issues.
Many social critics have suggested that the rise in depression is a real phenomenon, but is a symptom of a deeper underlying problem. Generally, this problem is identified as the increasingly alienating nature of modern society, which involves less human contact, and more impersonal technology. However, there are other possible candidates for the “real problem”, including environmental toxins, the change in family structure due to the changes in women’s roles, or capitalism. This approach normally acknowledges that depression and anxiety are real, but point out that treating it on an individual basis rather than a social basis means that we never address the real problem, and indeed, mental health professionals may be perpetuating the problem or making it worse.
This is largely an empirical issue, although it may be hard to do studies that would decide which view is correct. Whether our society is really more alienating than it was one or two hundred years ago is hard to prove, since alienation is not an easy variable to measure, and there were no direct measures of alienation in previous centuries. Measures of the growth of the alienating nature of society have to be indirect, and are inevitably highly contestable. It is more feasible to do anthropological studies of alienation and depression, but even here, there’s a great deal of room for debate about what we can conclude from such studies. Cross-cultural comparisons introduce new concerns about what should count as depression, since symptoms of depression are often claimed to vary from culture to culture.[7] The alienation issue will arise again below, under “self” concerns.
The “increase in depression” is due to relabeling ordinary unhappiness
Some have suggested that the increase in the incidence of depression is not real: it is simply a result of lowering the criteria for what counts as depression, and also a result of introducing the category of dysthymia, chronic low level depression.[8] This is related to a claim that the reason for the change in criteria serves the interest of mental health professionals, because it brings them more work. As non-psychiatrists do more psychotherapy, psychiatrists find a need to preserve a role for themselves in modern society, and that role is to prescribe medication.
One might think that whether it is true that the official criteria for depression have become more liberal should be easy to determine: one could simply compare manuals from different decades. But in fact the criteria are relatively vague, and it’s debatable to what extent they determine the judgments of clinicians. It’s clear that what makes a difference is not what it says in diagnostic manuals and textbooks, but whether the actual criteria used by clinicians have changed, and this is especially hard to discover.
The Undue Influence of the Pharmaceutical Industry.
It’s clear that medication is big business, which in the US is now able to advertise direct to the public. Clinicians are given financial incentives to diagnose mental disorders and psychiatrists are given financial incentives to prescribe medication (rather than, or in addition to, suggesting psychotherapy). The facts about the power of the pharmaceutical industry are very impressive, but of course the industry itself would say it is providing needed and helpful resources for clinicians, and that it is performing a valuable service. There have been studies on the extent to which psychiatrists are influenced by perks, incentives, and free lunches offered by the pharmaceutical companies, and the results often show that the influence is strong.
However, there has been no proof that this sort of influence can explain the rise in the diagnosis of depression over the last fifty years. Even once we admit the potential power of the industry, we have not shown that this is in fact the correct explanation for the rise in the diagnosis of depression and the use of antidepressants. The most we will have shown is that it has played some role, but not how great a role.
The Side Effects of Medication
Some authors have argued that antidepressant medication has side effects that are underestimated.[9] The main idea is that these drugs are far more dangerous than people realize, and that the government drug trials used to test their safety are conducted over a short period and do not detect long-term effects or effects on children. These medications are used a great deal with children, but their long-term effects on children are unknown.
Although these criticisms are often put in alarmist form, they have been not received much attention, and have been largely ignored by the psychiatric establishment. There is often a pattern with popular drugs that after many years of use, it is found that they have unforeseen effects (e.g. Phen Fen, Valium) and they then become prescribed much less often, so it would not be very surprising if this criticism turned out to be true.[10] Nevertheless, it remains an empirical issue.

Distinct from the above concerns are three rather different ones, which I will call “Self Concerns.” They are more philosophical than empirical.
Dehumanizing Ourselves
First, it might be argued that in taking medication we are treating ourselves like machines, or like objects, rather than humans. I have heard people make this sort of argument, but it is clearly rather weak. Dehumanization cannot simply a matter of putting a foreign object into one’s body, because then eating would also be dehumanizing. It has to be a matter of ingesting technology, or possibly using technology to alter one’s emotional outlook. It would seem that this sort of view would mean that all manufactured medication is problematic, and this view seems highly problematic and far too extreme to be plausible. I turn quickly to a more sophisticated version of the objection.
Against the Natural Order
Some may argue that in medicating ourselves, we are going against the natural order. Christian Science religion takes such a view: they believe that God has his plans for us, and we should not resort to medicine in curing our illnesses because this goes against God’s plan. This view, I think, is implausible even for the theologically inclined, because it rests on unsupported Biblical interpretation. Nevertheless, to go back to the more general objection, the idea of a natural order is one that has a great deal of intuitive appeal. Many people have a sense that there is a natural way of being and that it is wrong or dangerous to interfere with this natural order, especially when one is considering mind-altering drugs. The problem comes when they try to articulate this sense, because the concepts of nature and the natural order are very hard to pin down or to justify.
Authenticity
Finally, there is the most plausible of the self-concerns, that taking mind-altering medication in some way reduced one’s autonomy or authenticity. At its crudest, this sort of objection relies on a problematic empirical claim that psychotropic drugs cloud one’s thinking or give one an emotional high[11]: while this may be true of alcohol, stimulants such as Ritalin or anti-anxiety drugs such as Xanax and Valium, (although it probably is not true when the medications are working as intended), there is very little reason to take this assumption seriously in the case of antidepressants. I speak partly from personal experience, having taken antidepressants myself, but more importantly, there is no scientific and little anecdotal evidence to support the ideas that one’s cognitive abilities are impaired by antidepressants or that one’s values are significantly altered (in ways unconnected with the depression) by the medication.[12] I have heard and read reports of people who say that antidepressants make them feel numb and incapable of feeling anything, and this is an important phenomenon.[13] This isn’t the intended effect of the medication, although it might be a clinically acceptable effect if it is the only alternative to agonizing depression. But for the philosophical objection to taking medication for enhancement to be interesting though, we need to consider the cases where the medication works well.
To make this “authenticity” objection plausible, one has two options. First, one can argue that the world is alienating, and thus that alienation and depression are rational responses to the world. To take antidepressants is then to interfere with a normal reaction, and can impair one’s ability to respond appropriately to the state of the world.
Secondly, one could argue that to bring in such radically foreign material into one’s central nervous system to affect the functioning of one’s brain is inherently to reduce one’s autonomy or authenticity. I will return to this at the end of the paper.

The Popular Media
Remarkably, the literature in medical ethics has largely ignored these concerns. The books that have most forcefully addressed these issues have been written by psychiatrists and psychologists. (A partial list would include David Healey’s Antidepressant Era, Peter Kramer’s Listening to Prozac, Lawrence Diller’s Running on Ritalin, Richard DeGrandpre’s Ritalin Nation, Lauren Slater’s Prozac Diary, and Peter Breggin’s series of books against psychotropic drugs. Shelves of less thoughtful self-help books have also been published on related topics.) Some might argue that these authors are indeed medical ethicists, and in a sense they are, but they are very much removed from the mainstream of medical ethics. They rarely publish their work in the prestigious medical ethics journals and they are not employed in bioethics institutes or centers.
The other main source of noticeable concern concerning psychotropic medication comes from mainstream media such as TV news shows and magazines such as Newsweek and Time. As we might expect, the analyses in these media are mostly shallow; what is interesting is that the bioethics establishment has done so little to follow up on the public concern expressed in popular culture.

Medical Ethics and Enhancement
Insofar as mainstream medical ethics has addressed the issue, although there has been some discussion of Prozac, the literature has mainly focused on how to make the distinction between curing a disease and enhancing a normal condition.[14] Certainly this is a very important distinction, and it seems that it is far less problematic to use medication to cure illness or to relieve the symptoms of illness than it is to enhance or alter a healthy person. It is worth discussing the relevance of this distinction to my main thesis here.
The general philosophical problem of the definition of disease is a long-standing and difficult one, which is still being discussed vigorously. Most people acknowledge that the categories of illness are value-laden, and there is much work to be done in finding in what ways the category of depression is value-laden. I’d prefer the claims of this paper to be independent of the debate about the definition of mental illness: whatever the correct definition, it’s clear there will be a large gray area between health and illness and that we will be able to get a good amount of intersubjective agreement about which cases constitute an enhancement of a normal person. My main point here is to do with cases of enhancement, although I am ready for the conclusion of the argument to be applicable to cases of taking medication to relieve depression. I am primarily interested in what could be philosophically problematic about taking medication, and I don’t believe this depends on the definition of mental illness.
It is worth also noting briefly that there have been empirical studies of “patient compliance” – i.e. the extent to which people are willing to follow their doctor’s instructions, as opposed to “disobeying” their doctor. It’s not unusual for people to accept a prescription, but then to not get it filled, or else to get their medication, but then to only take it for a week or two, rather than the recommended 4-6 weeks it takes to see if antidepressants are effective. Often there are pronounced side-effects of the drugs (e.g., dry mouth, nausea, fatigue or sleeplessness) that decline or disappear after a week or two of taking the medication regularly. One of the reasons that Prozac became a best-selling medication is that it has fewer side-effects than the older antidepressants, so patient compliance was improved, and this was demonstrated in studies. We should bear in mind though that these kinds of studies tend to be rather crude and operationalized, and certainly will give us little insight into people’s philosophical qualms about taking medication.

Genetic Ethics and the Suspicion of Technology
Some of the discussion concerning the morality of genetic engineering is applicable also to the use of psychotropic drugs. For this reason, I will make a small detour into the ethics of cloning. Philosophers such as Leon Kass have tried to articulate their reasons for a deep discomfort with our interfering with the natural order.
In his widely reprinted article “The Wisdom of Repugnance”[15] Kass argues that although to have a strong reaction to something is not an argument against it, but that repugnance can be an emotional expression of deep wisdom. He writes,
The repugnance at human cloning belongs in this category. We are repelled by the prospect of cloning human beings not because of the strangeness or novelty of the undertaking, but because we intuit and feel, immediately and without argument, the violation of things that we rightfully hold dear. Repugnance, here as elsewhere, revolts against the excesses of human willfulness, warning us not to transgress what is unspeakably profound. Indeed, in this age in which everything is held to be permissible so long as it is freely done, in which our given human nature no longer commands respect, in which our bodies are regarded as mere instruments of our autonomous rational wills, repugnance may be the only voice left that speaks up to defend the central core of our humanity. Shallow are the souls that have forgotten how to shudder. (page 19).

Kass goes on to set out some of the consequences that he holds to be repugnant, and I believe his argument is fairly weak because the supposedly awful consequences don’t seem so bad to me, certainly no worse than what we are already ready to accept in contemporary society. Nevertheless, his method and this passage in particular strike me as important, and it could be helpful for those who want to articulate their discomfort with the use of medication for enhancement. Note that his method is highly controversial. In a recent magazine article, Sheila Jasanoff of Harvard University’s Kennedy School of Government equates Kass’s method with expression of a “yuck” reaction, and prominent bioethicist Dan Brock is quoted as saying, “it doesn’t have any intellectual content.”[16] While I’m sympathetic to these criticisms, and certainly that there is a danger of this approach amounting to nothing more than the expression of mere opinion, I am also sympathetic to the possibility that we might be able to educate our moral sensibilities, and attune ourselves to moral reactions. Ultimately, I believe, moral sensibilities and intuitions play an important role in our moral epistemology, and so I am somewhat sympathetic to elements in the traditions of moral casuistry and moral particularism. Kass’s discussion of repugnance can be seen as an instance of particularist methodology. But even if we accept this approach, we still need some way to distinguish between irrational prejudices and reasonable moral perception. At a minimum, we should be able to articulate some similarity relation between fundamental intuitions, or some mutually supporting relation between intuitions and a plausible moral theory. Furthermore, it should not be possible to completely explain away the moral intuition as a prejudice or an effect of arbitrary moral conditioning. Furthermore, the stronger and more widespread a moral intuition is, the more reason there is to take it seriously.
Now it would be an exaggeration to say that people feel repugnance at the use to psychotropic drugs to enhance one’s abilities, (although some people do have strong negative reactions to the recreational use of drugs such as marijuana and cocaine, which may be related). I’d say that most people have qualms, worries, or reservations about the widespread of use of Prozac, Ritalin, and similar drugs. Even so, Kass’s approach could still be useful for this investigation.
Central to Kass’s thought here is his concern about using the body as an instrument of our will. Maybe this is a version of the idea of dehumanizing ourselves that I so swiftly dismissed earlier on, but at least this is a slightly more articulated approach. To take drugs to enhance one’s abilities could certainly be seen as treating one’s body as an object, although as I said previously, one needs to be able to distinguish this kind of case from that of consuming food and drink for sustenance. Presumably the distinction between the two kinds of cases rests on the idea that eating and drinking are natural activities necessary for living, while taking drugs is not.
It is worth briefly mentioning a related issue: some people have very strong intuitions against the use of genetically engineered food, body parts, or animals, often because they worry about the unforeseen results of such experimentation, but often simply because it is “messing with nature.” The worry about food can be strong when people consider that it means that they are ingesting something unusual and artificial. Many people say they only want to ingest natural foods.
One feature that distinguishes Prozac is that it is a designer drug, which makes it more parallel to the case of genetically engineered food and cloning. A great deal of research has gone into the creation of the drug: unlike most psychotropic drugs, it was not discovered by accident, but instead was created through years of research. This feature of Prozac makes it closer to the case of cybernetics, and I think people do have strong reactions, including repugnance, to this extremity of unnaturalness. We are facing the introduction of technology into our bodies and minds, and people do find this disturbing as well as exciting.

Conclusion
As I warned at the start of this paper, my aims have been modest: I simply aimed to explore the suspicion and worry people have about drugs that enhance our moods and cognitive capabilities. I have argued that there is a range of possible reasons for worry, some empirical, some philosophical; some plausible, some far more implausible. I want to end by suggesting that the three philosophical objections I have paid most attention to, that drugs are dehumanizing, unnatural, or inauthentic, are interconnected and may even amount to just one basic objection.
As I have suggested already, the idea that we treat ourselves as objects does not cause much concern if it applies equally to eating, drinking, showing concern for one’s body, and getting medical help. For the objection to carry much force, it needs to show that some kinds of treating oneself as an object are more problematic than others. It seems that the best way to do this is to distinguish between ordinary ways of manipulating oneself and extraordinary or unnatural ways of doing so: the more artificial the manipulation, the more worrisome it is.
But why should artificial manipulation of one’s mind be problematic? Of course, one might just say that the very fact it is unnatural is enough. Taking such a position would push one into the difficult position of having to say that one needs to live as natural a life as possible. Even if one could define what is natural, it would seem to leave one in an extreme position of rejecting much of modern life, and rejecting technology that could be very helpful to one. So I suggest that for this objection to be successful, it needs to bring in an extra element: it should limit itself to criticizing treating oneself as an object in an unnatural way when this reduces the person’s autonomy or authenticity. The immediate problem with this move is to give a non-circular account of the reduction of autonomy or authenticity: it is possible to just go in a tight circle, and say that one’s authenticity is diminished because one is treating oneself as an object rather than a subject.
I am not sure how to resolve this problem. Maybe the best option is to simply say that self-objectification, unnaturalness, and inauthenticity are a closely related group of concepts, and that they come as a package. They all become involved in a critique of the widespread use of psychotropic drugs.

[1] http://www.guardianunlimited.co.uk/g2/story/0,3604,419761,00.html
The low country, Tuesday January 9, 2001, The Guardian
[2] http://archpedi.ama-assn.org/issues/v155n5/abs/poa00346.html
Arch Pediatr Adolesc Med. 2001;155:560-565, Jerry L. Rushton, MD, MPH; J. Timothy Whitmire, PhD
Pediatric Stimulant and Selective Serotonin Reuptake: Inhibitor Prescription Trends 1992 to 1998
[3] Ritalin Alert: As Abuse Rates Climb, Schools Are Scrutinized, Katy Abel. FamilyEducation.com (Nov 17, 2000)
http://www.familyeducation.com/article/0,1120,2-20061-0-1,00.html
[4] http://www.guardianunlimited.co.uk/comment/story/0,3604,482144,00.html
Threatened by a herb, Jerome Burne, Thursday May 3, 2001, The Guardian
[5] http://www0.mercurycenter.com/partners/docs1/083952.htm
Tuesday, May 22, 2001, New studies may boost credibility of products, BY LISA M. KRIEGER, Mercury News.
[6] Friday May 11, 2001. Health - ABCNEWS.com. Study: Herbal Supplement Sales Down.
http://dailynews.yahoo.com/h/abc/20010511/hl/herbalsupplements010511_1.html
[7] For a summary of some cross cultural work on depression, see Richard J. Castillo, Culture & Mental Illness: A Client-Centered Approach. (Pacific Grove, CA: Brooks/Cole, 1997), Chapter 12.
[8] See the last chapter of Edward Shorter, A History of Psychiatry. John Wiley, 1998.
[9] Most notorious are the books of Peter Breggin, including Toxic Psychiatry and Talking Back to Prozac. More measured criticism is to be found in Joseph Glenmullen’s Prozac Backlash. Also directly relevant is David Healey’s The Antidepressant Era.
[10] See A Social History of the Minor Tranquilizers: The Quest for Small Comfort in the Age of Anxiety, Mickey Smith, PhD., Haworth Press, 1991.
[11] This is suggested by Louis Marinoff in Plato Not Prozac, [find reference] and Jeffrey Schaler [find reference]. It is also suggested in a slightly different way by Joseph Glenmullen.
[12] I should, in a fuller treatment of this issue, address the point that in some ways depressed people have more realistic expectations of the world than non-depressed people. Some studies have shown that depressed people rate probabilities of certain kinds of events or traits differently from normal people: normal people tend to have a rosy view of the world. For example, most people believe that they are better-than-average drivers and rather their children as above-average. For certain kinds of estimates, depressed people do not have this bias. However, note that in other ways depressed people have a distorted view of the world: they view their situations as hopeless, their lives as pointless, and they don’t think they have any friends.
[13] See the first person accounts in Living With Prozac: And Other Serotonin-Reuptake Inhibitors, by Debra Elfenbein, Harpercollins, 1995.
[14] The main example of this is Enhancing Human Traits: Ethical and Social Implications, edited by Erik Parens, Georgetown University Press, Washington DC, 1988. A recent issue of The Hastings Center Report was devoted to “Prozac, Alienation, and the Self,” Vol. 30, No. 2, 2000. Note that in this paper I have ignored the idea, propounded most forcefully by Carl Elliott in both these collections as well as in other work, that antidepressants are problematic because they lead us to treat alienation as a medical condition when it is really an insightful reaction to the world.
[15]The Ethics of Human Cloning, by Leon R. Cass and James Q. Wilson, AEI Press, 1998.
[16] The American Prospect. “Irrationalist in Chief,” by Chris Mooney. 12, #17, September 24 – October 8, 2001.

Defining and Defending ADHD

2008-11-14T22:52:00.000-05:00

This is a longer version of my paper "Medicating Children: The Case of Ritalin." Bioethics 11.3 (1997):228-240.

Defining and Defending ADHD:
On The Category of Attention Deficit Hyperactivity Disorder and Its Implications for the Controversy About the Overprescription of Ritalin[1]

Introduction
Public concern about psychopharmacology has existed since psychotropic medications started being prescribed to large numbers of patients about 40 years ago. The major tranquilizers, such as Thorazine, have unpleasant short term, and sometimes awful permanent, side effects. When the minor tranquilizer Valium became prescribed on a large scale in the 1950s and 1960s, feminists and other social critics suggested that the drug was used keep to women drugged up in their high-rise apartments or suburban homes, in order to prevent them from acting on their dissatisfaction. In the last few years, there has been worry that the antidepressant Prozac is being used to keep people from being critical about their surroundings, and that the chemical eradication of emotional depths will stifle human creativity. Many individuals suffering from bipolar mood disorder (more commonly known as manic depression) dislike mood stabilizing medication such as lithium that prevents their manic periods since they feel that it is during such times that they are at their most creative and productive.
Such worries also apply to some extent to the treatment of attention deficit hyperactivity disorder (ADHD) with stimulants. These worries are compounded by the fact that it is mostly children who are being prescribed these drugs. Recently, these concerns have centered around the issue of the prescription of Ritalin, which has been receiving much media attention. A search of Internet Web Sites and Usenet Newsgroups, for instance, will reveal many people wondering how they should deal with their own children, and many others proposing a wide variety of solutions. Numerous articles have appeared in magazines and journals about childhood ADHD, and when children should receive medication.[2] Maybe most striking is the number of books in the popular psychology and self-help sections of bookstores on attention-deficit disorder and hyperactivity, and the number of those which question conventional psychiatric wisdom over the causes and treatments for the condition. It might not be surprising that so many self-help manuals and guides to current treatments are available, since the ‘Health’ sections of the same book stores are also full of books giving advice about how to keep fit, eat well, and treat a wide variety of illnesses. But when it comes to mental health practice, what is offered is not just advice, but exposés, medical and political critiques at both academic and popular levels, and proposals for alternatives treatments or solutions.[3]
Where there is such open public questioning of psychiatric authority, philosophers of medicine and bioethicists have an opportunity, and indeed a responsibility, to address the legitimacy of these criticisms.[4] It is not a job one can simply leave to psychiatry and the wider mental health profession, for three reasons. First, the mental health profession is not, as a matter of fact, very good at defending itself in public debate. This may be due to the amount of internal disagreement within the profession, a sense of complacency, an unwillingness to take outside detractors seriously, a lack of public representatives of the profession, or just the fact the public is very skeptical about psychiatry. Second, even if the mental health profession did do more to speak on its own behalf, it might be seen as partisan.[5] Bioethicists could be seen by the public as more independent judges, and more trustworthy even despite their lack of full medical training. Third, and most importantly, the issues are not purely medical, but involve ethical and social issues, which brings them closer to the realm of expertise of biomedical ethicists. So I conclude that bioethicists have an appropriate role to play in this debate. It is not my aim to provide a definitive answer to the question 'Is Ritalin overprescribed?' or to list precise conditions for when its use is unjustified. Rather it is to set out and clarify the different issues that should be addressed in this debate, in a deliberately provocative way.
Despite the fact that the drug Ritalin has been prescribed since the late 1960s and that its use has been controversial almost from the start, my review of the bioethics literature turned up little discussion of the issue.[6] So the controversy over Ritalin's use is fairly new in biomedical ethics, and the debates it raises promise to be of increasing importance, if, as seems likely, the prescription of stimulants to children continues on a large scale, and new drugs are developed which will be more sophisticated in their ability to control and form the minds of children. It is important that we find appropriate questions to ask, and the right language to use in framing the discussion of these issues, since the form of the start of the debate may well influence its future course .[7],[8] For the most part, I will keep the discussion at an abstract level rather than rely on details of case histories and statistics of the use of Ritalin and other drug treatments for ADHD.
Thus the primary purpose of this paper is to survey ethical issues that arise when medicating children with Ritalin and to connect them with existing discussions within biomedical ethics. But I also aim to articulate a provocative view in favor of the widespread use of performance enhancing drugs, not just to treat illnesses, but for non-medical cases as well. I take this position because I think that many arguments against such use of drugs are not sound, and often rest on unarticulated and flawed assumptions. It will serve a useful purpose to clarify the issues by setting out a controversial position, and give others a set of arguments to which to react. While I tentatively endorse the position I arrive at by the end of this paper, I am not unequivocally advocating the use of drugs on children, and I would warn against an overly individualistic and biological approach to understanding the problems that children face. We should not lose sight of the political and social factors involved, on both national and international levels.[9]
This paper is in two main parts. First, I consider the issue of using the diagnosis of ADHD, and what can be said for and against it. This involves a fairly lengthy discussion of the normativity of the concept of illness, and its implication for ADHD. Second, I consider arguments against the widespread prescription of stimulants to children, and I rebut each one in turn.
Definitions and Data
To return to the focus of this paper, I will now set out some relevant data and history concerning the issue. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric Association in 1994, specifies the criteria by which all mental disorders are to be diagnosed in North America. ADHD is diagnosed by the presence of symptoms of hyperactivity and inattention that last for at least six months.[10] The prevalence of ADHD has several estimates. DSM-IV says it affects 3% - 5% of school age children and the male-to-female ratio estimate ranges from 4:1 to 9:1 (DSM-IV, 82). Also relevant are related conditions, which can overlap with ADHD. Conduct disorder, which is characterized by aggression towards people and animals, destruction of property, deceitfulness or theft, and serious violation of rules, is much more prevalent, with estimates ranging from 6% to 16% for boys, and from 2% to 9% for girls. (DSM-IV, 88). Oppositional Defiant Disorder (ODD), which is characterized by negativistic, hostile, and defiant behavior leading to significant impairment in social, academic or occupational functioning, is estimated to affect from 2% to 16% of the population, depending on the sample and methods of ascertainment, and rates are roughly equal among the genders after puberty (DSM-IV, 92).
History of Attention-Deficit/Hyperactivity/Impulsivity Diagnoses
ADHD has a history nearly a century old. In 1902 G.F. Still, publishing in the Lancet, identified children with hyperactive behavior patterns where there was no reason to think it was caused by brain damage.[11] In 1957 Laufer and his associates published a number of influential papers, introducing the terms "hyperkinetic behavior syndrome" and "hyperkinetic impulse disorder." They found that treatment by stimulants was effective. In fact, the stimulant D-Amphetamine was first used by Bradley in 1937 to treat hyperactive children.[12] "By the late 1960s, the concept of hyperactivity was firmly established in the literature." (Ross and Ross, 14) There has been controversy about the diagnosis and its treatment ever since.

Reliability of Diagnosis
A criticism often leveled at psychiatric diagnostic methods is that they merely identify collections of symptoms and do not identify a cause of the illness or disorder that can be tested for. No sophisticated brain scans or blood tests are available for the diagnosis of any common mental illnesses. Furthermore, identification of behavioral symptoms is often thought to be subjective and unreliable, because so much depends on the values and expectations of the person making the diagnosis. In order for us to be confident that we even have a condition to talk about, diagnosis has to be reliable, so that different health care professionals would for the most part agree on diagnoses. There is controversy about how much intersubjective agreement there is amongst doctors on ADHD. It seems that the U.S. has many more cases of ADHD than other countries, casting doubt on the objectivity of the diagnostic category. It would help consistent diagnosis if the symptoms of ADHD clustered together, but there is no good evidence that they do, (Ross, 17). There is also little evidence that all cases of hyperactivity have a common cause.[13]
Treatment Options
Even if there is an identifiable condition of ADHD, there is a separate empirical question about what treatments can alter the condition, and which are most effective. The most common drug treatment is Ritalin. Ritalin (methylphenidate) is a central nervous system stimulant, similar to amphetamines in the nature and duration of its effects. It is believed to work by activating the brain stem arousal system and cortex. Pharmacologically, it works on the neurotransmitter dopamine, and in that respect resembles the stimulant characteristics of cocaine. There are well documented dangers associated with taking Ritalin as well. The Physicians’ Desk Reference states that

Sufficient data on safety and efficacy of long-term use of Ritalin in children are not yet available. Although a causal relationship has not been established, suppression of growth (i.e., weight gain, and/or height) has been reported with the long-term use of stimulants in children.
Common reactions to the drug include nervousness and insomnia. It is possible that some children can become dependent on Ritalin (although some dispute this) or abuse the drug. There is reportedly now a flourishing black market in Ritalin in high schools, where students take it for the pleasurable sensations it provides, rather than to enhance their school performance.
With so many children taking Ritalin (one estimate is that 5% of boys between the ages of 8 and 14 are prescribed the drug in the US[14]), it is clear that there is a huge market willing to spend money on possible treatments, and given the discomfort some feel with the use of drug treatment, alternative options have proliferated; self-help books, alternative drug treatments, and different parenting and schooling methods are all available.
The conventional treatment options apart from stimulants are behavior management, environmental engineering, and personal or famliy therapy. It is generally helpful to provide a child who has ADHD with a hightly structured environment and clear, reliably enforced rules. It has been shown, however, that no single treatment plan will benefit all children with the disorder (Ross and Ross, 16). Different treatments can often be used in conjunction with each other and conventional medical wisdom is that this is often what works best for the child.

Worries About Labeling Hyperactivity an Illness
Now that we have some background facts, we can discuss the ways in which the diagnosis of ADHD and the prescription of Ritalin might be a problem. I will start with concerns about diagnosis. It is clear that some conditions are labeled psychiatric illnesses in part because they cause suffering to the person who has them or to those who must deal with that person. Labeling a child hyperactive is to decide that there is a problem with his or her condition, and to indicate that something should be done to stop it if possible. As with other controversial cases, such as very short children, unhappy and pessimistic people, homosexuals, women's menopause, and premenstrual irritability, we may well worry that this medicalization demonstrates intolerance of people's distinctive traits and differences from the norm. Furthermore, some would say this list of purported illnesses and disorders suggests that the disadvantaged and victimized people in society are further stigmatized by medical labeling.
As far as hyperactivity is concerned, some critics of conventional approaches argue that it is normal for children, especially boys, to be extremely energetic, even aggressive and to have short attention spans. On this view, the fault is not with the children, but with a hyperactive and inflexible society in which parents are too busy to play with their children and help them run off their energy. Making hyperactivity an illness also gives the medical and educational establishments more power over the lives of children, since they can use the status of the condition as illness to overpower the wishes of parents or children who do not desire treatment. Institutional power is increased by medicalization. Philip Graham suggests this is inappropriate, and writes concerning doubts about the wisdom of medicating children for these sorts of problem, it is not part of the psychiatrist's job to smooth out normal variations in learning ability, especially when a lower level of concentration is accompanied by greater vivacity, curiosity, and explorativeness, all of which have their own appeal, and maybe lost with exposure to medication.[15]

Furthermore, there is a general worry that labeling a child as having a mental illness, and letting the child know this diagnosis, will itself have a damaging effect upon the child. It may affect the self-image of the child, so he or she starts to think of him or herself as having a problem or being ill, and so he or she will continue to think and behave in such a way in the future. On top of this, once the child has been labeled, adults will treat the child differently, as if expecting him or her to behave in a certain way. The label will place the child on a different path, while if there were no label, the child might be able to move on and forget about the problem in a short period of time.

Reply to Worries about Using the ADHD Label
I do not find these worries I have listed to be very alarming. First, it is worth noting that the changes in treatment that the label of ADHD introduce are also beneficial to the child, since it leads to treatment which should normally give him or her a greater ability to concentrate on work, less disruption and conflict at home, and more attention from educators. Furthermore, a child is given many other labels in the course of his or her life, at home and at school, including diagnoses of illnesses. This labeling often does not have any damaging effects, and the child may just expect to get over his or her medical condition, or he or she can pay little attention to the diagnoses altogether. The worries about labeling may give us good reason to be careful how we label children, but it does not give a strong reason to avoid labeling them altogether.
Behind these issues is the question whether the label of ADHD is appropriate, and if so, what justifies it. To answer this, I will first go further into the objectivity of our the categories of illnesses. I do not propose the impossible task of reviewing all the literature on the concepts of health, illness, disease, and disorder. The discussion of the normativity of our concept of illness is one of the most debated issues within biomedical ethics, and has been joined by some of the major names in the field, such as Christopher Boorse, Robert Veatch, Arthur Caplan, Tristram Englehardt, as well as many more recent contributors with a range of different outlooks.[16] Here, I am not trying to add anything fundamentally new to add to what others have written on the topic. Instead, I will base my position on what I consider to be two of the most carefully considered approaches to the concept of disease, by William Fulford and Tristram Englehardt.
The main debate about the concept of disease concerns the possibility of specifying the nature of a disease, qua disease, purely within scientific, biological or other morally neutral terms. Despite the arguments of Boorse that one can define disease in purely biological terms, free from value judgments, there is now something approaching a consensus, at least among bioethicists and social scientists, if not among clinicians and medical researchers, that this is not possible, and that a negative evaluation of a condition is essential in classifying it as a disease. This idea has been formulated in various ways, such as "disease categories are essentially normative," or "diseases are socially constructed."
William Fulford, a British psychiatrist and philosopher, is one of the most prolific writers within the philosophy of psychiatry. Fulford’s argument for his view of illness and disease is set out in its most detailed form in his book Moral Theory and Medical Practice. I will not set out that argument here. Rather, I will use his more succinct statement of his views in a recent article.
Fulford allows that it is possible to stipulate a purely descriptive definition of disease, but says that “the concept is simply unable to do the work that is required of it in actual use without the reintroduction of an evaluative element into its meaning.”[17] He suggests that we should adopt a model in which we see that the terms ‘illness’ and ‘disease’ express a particular kind of medical value, as distinct from moral or aesthetic values. He says that insofar as there is a distinction between the concepts of illness and disease, “illness tends to refer to the patient’s experience, whereas disease refers to the doctor’s specialized scientific knowledge.”[18] On a science-based perspective, it is natural to try to define illness in terms of disease, but Fulford argues that it should be the other way around, i.e., “illness is the primary concept, our concepts of disease owing their logical properties, ultimately, to the patient’s experience of illness.” From such considerations, he draws the conclusion that not just doctors and scientists, but also philosophers should be involved in the process of deciding on what classification schemes should be used in psychiatry.[19] Understanding illnesses requires not just scientific knowledge, but the ability to understand the logic of value judgments, as well as philosophy of science, philosophy of action, and even the mind-body problem.[20] The work left to do in his project is to elaborate what medical, as opposed to moral or aesthetic values, are and should be presupposed in our nosology.
I think Fulford's terminology of ‘medical values’ is misleading here, in that it leads us to suppose he means a new realm of value distinct from the moral or the aesthetic. This is not what he means. He connects the evaluative element in the concept of illness to the idea of the incapacity of a person to act intentionally when afflicted by an illness.[21] Illness is the failure of action. Even though mental illnesses are characterized by forms of behavior and even action, it is the fact that the behavior is not fully voluntary that shows that it is a symptom of an illness. For instance, an person with a compulsion or who is suffering psychotic delusions is not acting freely, given that freedom requires both lack of internal and external coercion, and a knowledge of what one is doing. Truly compulsive action is forced by a kind of inner coercion, while in psychosis, a person fails to understand what he is really doing. On this analysis, we can see why there is legitimate controversy about the classification of alcoholism as an illness, since it is debatable whether the actions of alcoholics are really forced by an inner need or craving.[22] The involuntariness of a behavioral symptom is of course only a necessary condition for diagnosis of illness, not a sufficient condition. Fulford says that his project to spelling out what medical values is speculative, but essential to the enterprise of understanding the nature of illness. There are two major benefits that come from his approach.

In the first place, what now emerges is a more complete account of the properties of the medical concepts, in psychological medicine as well as in physical, and in primary health care (e.g., in general practice) as well as in hospital medicine. In the second place, it is with this more complete account that results, not merely explaining the logical properties of medical concepts, but with the implications for actual practice, are finally obtained.[23]
Thus Fulford's account of the nature of illness has useful practical implications, and I will bring it to bear on the case of ADHD.
But I also want to bring in one other writer, Tristram Englehardt. Englehardt has long defended the view that the concept of illness is value-laden and that it is this concept, rather than a zoological/evolutionary concept of disease, that is and should be used in medicine. He writes, in his The Foundations of Bioethics,

The experienced reality with which medicine deals is shaped by (1) evaluative assumptions regarding which functions, pains, and deformities are normal in the sense of proper and acceptable; (2) views of how descriptions are to be given; (3) causal explanatory models; and (4) social expectations regarding individual ills or particular forms of disease. (196)

Englehardt does not focus much attention on the difference between the internal and external factors that shape our experience of reality. I.e., our experiences depend partly on what we bring to them (internal factors), and partly on what there is in the world (external factors), although he is of course quite aware of the distinction. It is worth being clear when our understanding of reality changes because we discover something new about the world, and when it changes because of a shift in our values or expectations. This is especially important in deciding what form medicine should take, and what classifications we want to use. With this proviso, then, Englehardt's list of reality-shaping factors provides a useful way to structure my discussion of ADHD.[24]

The Normativity of the Concept of ADHD
As Fulford shows, for ADHD to be properly classed as a disorder it is crucial that the behavior associated with it is not chosen with full autonomy or voluntariness. This needs further investigation. And following Englehardt, I want to consider what model of proper and acceptable child development is behind the judgment of ADHD being undesirable and abnormal,
what are the causal explanatory models of the behavior associated with ADHD, and what are the social consequences of diagnosing children as having ADHD. I will skip the issue of how descriptions of ADHD affect our experienced reality, because I don't see that it is much relevance here. I will consider the above issues in a slightly different order from that in which I just listed them.
1. Causal Explanatory Models of ADHD
As we come to better understand the causes of illness, we start to classify it differently. Some researchers have suggested that having ADHD is closely linked to being predisposed to addiction.[25] We have seen that the causes of ADHD are not well understood, and what now is classified as one disorder may well eventually come to be seen as a collection of distinct conditions. But until we have one, our understanding of reality cannot be affected by a causal explanation of ADHD.
2. Voluntariness of ADHD Behavior
Typical childhood ADHD symptoms include a lack of close attention to details, careless and messy work or activity, lack of sustained attention, uncompleted tasks, failure to perform requested tasks, fidgetiness, persistent getting up and moving around even when requested to stay still, being noisy, being always "on the go," talking excessively, being impatient, blurting out answers before questions have been completed, interrupting others, clowning around, and engaging in potentially dangerous activities (DSM-IV, pp. 78-9). On what grounds could these symptoms be judged involuntary or non-autonomous? I have two quick notes to make here. First, the diagnostic criteria of DSM-IV do not mention that the behavior should be involuntary, but I take it that this is at least an implicit assumption. Second, although strictly speaking the concepts of voluntariness and autonomy are different, in this paper I will ignore the subtle differences between them.
Lack of patience and attention are not themselves actions, and it is implausible to suppose that the children are intentionally messy and careless, even if it was in their power to pay more attention to what they were doing. Some of the impulsive behavior could be seen as beyond the children's control, in the same way that an overexcited child will be unable to contain herself. However, the other forms of behavior do, on the face of it, look like intentionally performed actions. Are there reasons to question this surface appearance? I will tentatively argue that there are.
If we could show that this behavior was the result of an organic condition, it would at least be possible to blame that condition, rather than the child, for the behavior. There are plenty of chemical "imbalances" that have typical behavioral effects. High or low blood sugar can affect activity levels, and it is well known that children who have had too much candy are annoyingly active. A more unusual example is that the psychiatric symptoms of mercury poisoning include xenophobia, anxiety and severe irritability.[26]
However, since we have no way as yet to confidently attribute the symptoms of ADHD behavior to an organic condition or a chemical imbalance, we are in a more difficult position. If ADHD occurred as a distinct set of symptoms, and formed a clear natural kind, then we would have some reason to class it as a distinct condition, and this could license us in saying the symptoms are not voluntarily chosen. But again, as we have seen, ADHD symptoms does not generally come as a discrete package. Rather, it comes in a large variety of forms and degrees.
I would suggest that this leaves us with three options. First, we could remain agnostic on this issue until more is found out about the condition. However, given the pragmatic realities we are faced with, this is not feasible. We have to make some judgment, because we have to know what to do with children who are behaving badly now. We cannot tell the parents to wait for ten years. Second, we could simply rule that no behavior of children is fully autonomous, because children have not reached a required level of maturity to make autonomous decisions. Autonomy requires the ability to reflect fully on one's behavior, and children do not have the necessary experience or moral sensibilities to do this. This second option is extreme, since having such a high standard of autonomy would probably mean that a good deal of adult behavior is also not autonomously chosen. Furthermore, saying that children lack autonomy goes against many modern intuitions and practices, where we think of children as capable of original, creative and mature thought. The leaves the third option, which is say that it is reasonable to suppose the children's behavior is in some sense involuntary, because they would really obey their parents and teachers if they could. I.e., on this option, we make some judgment of what the children's "real" desires are, despite their behavior. Some evidence for this option would be if the children themselves expressed frustration about their behavior, and were unable to stop it despite sincere attempts to do so. Indeed, many ADHD children do show such frustration and regret.
I conclude from this that some slim justification can be given for saying that the behavior typical of childhood ADHD is involuntary. Further understanding of the causes of ADHD might increase our justification here in the future, but we should not expect any scientific evidence to be decisive when it comes to attributions of voluntariness, since this is a concept that is firmly in the realm of philosophy rather than science.

3. Models of Normal Child Development
While the voluntariness of children's behavior when they fit ADHD diagnostic criteria is an interesting and philosophically productive question, I suspect more controversy is centered around what should be our model of normal child development. Disagreement about conceptions of normality can lead to intense ideological argument, as is very apparent in the debate about homosexuality. If we accepted the "is/ought" distinction, we might expect that understanding human nature would be a purely descriptive enterprise, but of course it is highly prescriptive. There are many different conceptions of human nature and normal development. Some of these are meant to be universal, and so applicable to all cultures and races. However, even if a universal conception is applicable in the case of physical development, it is implausible to think that all cultures have or should have the same expectations for psychological development. Expectations vary over time and across cultures. There will be limits to the possible variation, but it will be hard to determine a priori what those limits are.
Given that it seems reasonable to take a fairly relativistic stance towards conceptions of psychological normality over time and across cultures, the question arises by what criteria we judge, justify or criticize, standards of normality in our own culture. Relativism can sometimes lead to a pluralist non-judgmental attitude, but it seems clear that we need at least a minimal conception of psychological normality, if only because many of our social institutions rely on such a conception. It is certainly hard to imagine how we could have a psychiatric profession that did not have a minimal conception of normal psychological development. What should determine this minimal conception?
The basic answer that psychiatry adopts, I venture, is that psychological health consists in the ability to work and love.[27] While this is overly broad, it is the answer I will also adopt. It is sufficient to give a justification for judging children with ADHD abnormal, since the condition strains their relationships with their family and friends, and makes their work in school suffer, which in turn affects their future prospects, even if the condition itself disappears by adulthood.
Critics will assert that it is a mistake to judge the child abnormal even if she fits the diagnostic criteria for ADHD, since either
(i) the expectations on all children to be able to be sensible, sit still and pay attention for long periods are inappropriate, or
(ii) while those expectations are not inappropriate, it is not a child's fault if she does not meet them, because the stresses of modern life and lack of adequate parenting make it very hard to do so. It is society itself that should be seen as abnormal and made to change.
This second version of the criticism depends on an empirical assumption about the influence of society and family on children. Presumably this assumption could be tested to some degree, although I am not aware not any studies that have done so. Even if there are data on this, I suspect that there will be similar problems that arise as in empirical claims about the effects of TV violence on children, or pornography on the rate of sexual assaults. There are relevant data, but there is controversy over its interpretation. Even if it is true that modern culture and society, with all its one parent families and two parent families where both have full time jobs, has a deleterious effect on children's attention span and obedience, it does not follow that children should not be diagnosed with ADHD. For they can be seen as having a mental disorder, caused by lack of care and nurturing, for instance.
Returning to the first criticism (i), that we should not place such high minimal expectations on children, I am unsure how to determine what these expectations should be. It is clear that it is not a purely medical or scientific issue. We might determine what minimal expectations we should have using utilitarian considerations, so that we chose whatever is best for society. Or we might use a variant of this, a Rawlsian 'maximin' principle, where we set the expectations on children's psychological abilities to maximize the benefit to the least well off. Or we could do what the American Psychiatric Association has chosen to do, and make the stated criteria vague, so that it is left largely to the discretion of individual psychiatrists whether a given child should be given an ADHD diagnosis.
I conclude then that these two criticisms of the conception of normal childhood development I am advocating do not pose significant problems for me.
4. Social Consequences of ADHD Diagnosis
I have already considered some of the social consequences of using the ADHD diagnosis in affecting people's perception of children so-labeled. With all too brief reasoning, I concluded that these consequences would not necessarily be serious enough to be of major ethical concern. However, there are other consequences to be considered, viz., the treatment that is given for ADHD, in particular, the use of stimulants. I consider this in the next section.
Several Worries About Using Psychoactive Drugs Like Ritalin
Western culture has a strong suspicion of mind-altering drugs, both regulated and non-regulated. We don't see anything wrong with making people less depressed, or increasing their attention span if this can be achieved through 'natural' means, such as exercise, vitamins, or homeopathic medicine. Using a drug to accomplish the same end, however, is sometimes deemed problematic. I will consider some possible reasons for this suspicion.
The most accepted use of drugs is to cure an illness or lessen the symptoms of an illness. We saw in the last section that it is debatable what conditions count as illnesses. Suppose that we can achieve a strict definition of ADHD, and even find some biological causes of the condition. If the use of stimulants or other drugs is shown to help more than any other treatment for children who clearly have ADHD, with the diagnostic criteria strictly applied, I imagine that there would be relatively little worry about this medicinal use of drugs. For our purposes, the more ethically perplexing and intriguing cases are those in the gray area between illness and health. The public concern about overmedication with Ritalin suggests that it is here that people feel most uncomfortable about the use of drugs on children. So I will from here on restrict my discussion to cases in this gray area. What reasons are there against the use of drugs on children to reduce their elevated levels of activity and energy, and to increase their attention span?

Side Effects.
Most obviously, there are the side effects of drugs. These can be very unpleasant and even dangerous. If they are just short term effects, then it might be worth making a short term sacrifice in order to get the positive effects that the drugs can deliver. However, a more serious worry comes from the possible long term effects of drugs. These may be especially important to consider since children's brains are still developing, and taking drugs which affect the chemical interactions within the brain strikes many people as potentially dangerous, whatever assurances drug manufactures might provide. Even if it has no long term effects on physical health, there might be long term effects on personality and cognitive skills. I take both short and long term side effects to be a serious worry. Some side effects are well documented, and even if others are not, there is still some risk involved in taking drugs. However, the fact is that most doctors consider Ritalin to be relatively safe and worth the risk, given the benefits it can provide in at least some cases.
Still, I think, there are misgivings about the widespread use of drugs on children over and above the possible side effects, and I want to investigate what the basis of such misgivings might be. I first list the possible concerns with short explanations, and then discuss some of them in more detail.
Unnaturalness.
The naturalness or unnaturalness of the drug seems to be a factor in people's views as to the wisdom of taking the drug. For instance, the use of lithium as a mood stabilizer seems to be more acceptable to some people as a treatment because lithium is naturally occurring. This might be due to an inclination to believe that naturally occurring drugs should be less dangerous.
Profit Motives.
Some are wary of psychotropic drugs because they are produced by large corporations, and these corporations are more concerned with their own profit margins than patients' health and best interests.
Thought Control.
Another worry about psychotropic drugs arises from a concern about the possibility of 'thought-control.' They are seen as a way for the medical establishment to enforce conformity on troublesome members of society. This sort of suspicion was widely voiced at the height of the Anti-psychiatry movement of the 1960s and early 1970s, (e.g. the use of ECT and lobotomy in 'One Flew Over the Cuckoo's Nest') and is certainly still around in a lot of libertarian ideas most clearly voiced by Thomas Szasz.[28] Anything which increases state and institutional power over the individual is seen as dangerous.
Competitiveness.
There is the worry that using drugs to enhance performance for some children will create a pressure on all parents (who can afford it) to get their children to take similar drugs.[29] We could imagine a time when most children take drugs to stimulate their curiosity, increase their attention span, make them more cheerful, and even make them less rebellious and more polite. Many would see this possible future as far from utopian, even if the children did seem to benefit from the drugs.
Doctors’ Power.
A final misgiving about the use of the drugs on children could arise from a discomfort with giving doctors or other professionals power over the lives of children and families that may not be necessary. This may be seen as taking control of their lives away from parents and even their children.

Why Most of Those Worries about the Use of Psychotropic Drugs are Ill-Founded
How do these worries stand up when given careful scrutiny? I hope that it will be uncontroversial to assume that the ethical discussion should center around the question of whether the use of stimulants is in the best interests of the child, and the larger effects on the whole of society should take second place. We can divide interests into short-term and long-term. The benefits in the short term would be that the child on Ritalin would be better able to pay attention at school, and not bother those around him so much, which in turn might well mean that he alienates fewer people. In some cases of ADHD, the affected child finds life very hard without the drug, and much better with the drug. The short term costs of taking the drug would be the discomfort and annoyance of the side effects, which could in turn impair the child’s performance in school and other activities. In the long term, the child should, ideally, reap many benefits from improved performance at school. The long term costs of taking Ritalin are uncertain, and there may be none.
These benefits may or may not outweigh the costs. This is a hard decision to make, at least as a generality. I will not attempt to provide a calculus by which we could weigh the benefits against the problem of side-effects. Rather, I want to concentrate on the other concerns I have just listed, and to do so, I propose that we consider a hypothetical situation, in which we have a drug which has no detrimental side-effects. Furthermore, this hypothetical drug not only provides the benefits of Ritalin, but also turns naughty children into well-behaved, diligent children. We can refer to this drug as the Wonder-Drug.
We might still have a sense of discomfort about using the Wonder-Drug in such a case. I will consider each of the possible sources of discomfort.
Unnaturalness.
This can be swiftly dispatched as an irrational worry. There is no a priori or empirical reason to suppose that natural drugs, per se, are any less dangerous than artificially manufactured ones. Natural drugs can be extremely harmful, while artificial ones can be extremely helpful.
Profit Motives.
There may be good reasons to be suspicious of the motives of large international corporations, but they seem no more powerful here than in other areas of life. The fact is that we do place trust in these corporations in many areas of our lives, and so if we insist on rejecting the technology offered in this case, we should be consistent and reject it in many other areas of life as well. Few people are willing to do this, and although some may yearn for a simpler age less dominated by technology, I doubt that most people would be willing to make the necessary sacrifices to return to such a simpler state, even if they were offered the choice.
Thought Control.
This worry, as it applies to the Wonder-Drug, would go as follows. “The doctor will be imposing his or her own values on the family and the child. What counts as naughty should not be within the jurisdiction of health care professionals to impose on children. It is the job of schools and parents to decide what is good and bad behavior, and getting children to do good deeds is not one of the aims of medicine. So the use of the Wonder-Drug is akin to mind-control. Doctors should simply aim to alleviate suffering and cure illness. Being badly behaved is not an illness, but rather a matter of morals and lack of respect for other people and their property.”
This worry has little rational backing. It can be split up into three issues:
1) would use of such a drug be a form of thought control?
2) if so, is there anything wrong with such a form of thought control?
3) even if not, should the medical profession be party to such thought control?
My answers to these questions will be, roughly speaking, (1) yes, in a way; (2) not in moderate forms; and (3) in limited ways. I need to explain these answers. I address the first two here, and the third in a few paragraphs, under the category of Doctor's power.
In what sense is the prescription of a good-behavior drug a form of thought control? It does alter the behavior of the child. However, doesn't all teaching alter the behavior of the child? Do we call all teaching a form of thought control? No. We like to think of it as the provision of knowledge and skills. It is seen as controlling when we force a view on a person when there is room for reasonable dispute about what the truth is. Giving children the Wonder-Drug would change behavior, but it is less clear that it forces a view of the world on children in an unjustified way.[30] Whether or not prescribing the Wonder Drug meets some definition of thought control is largely a stipulative matter. What is more clear is that we generally feel that parents have the right to control their children's minds. They create and enforce their moral lives, to the extent that they can, and enforce their aesthetic views as well. Children do sometimes rebel, but it is far more common to actually adopt the beliefs and values of their parents. We don't generally see anything morally problematic in parents' right to control their children's lives, even if we disagree with the particular views and choices involved. So if we find something wrong with the Wonder-Drug, it can't be in its effects. There is a lot of agreement about what counts as good behavior and politeness within even as diverse a society as that in North America. Cultural difference and relativism are not big problems here.
Competitiveness.
It may well be true that once some children start taking the Wonder-Drug for performance enhancement, there will social pressure on other children to also take it. But again, we have not used this phenomenon as a reason to stop children from using calculators or computers. Many countries allow parents to send their children to expensive high schools, colleges and universities where the advantage is not just, and sometimes not even, that they get a good education, but that the children gain useful connections with other people who could be beneficial to them in their future careers. We allow competitiveness and social pressure in all sorts of aspects of children’s lives, so it is arbitrary to draw the line at the Wonder-Drug, just because it helps the children in a different way. Some might object that there is a principled moral difference between technology and social institutions that improve our lives through external means, and pharmaceutical technology that changes us internally, through interfering with the chemical processes in our bodies. But I do not see that there is any principled moral difference between "external" and "internal" technologies.
I will have to leave the claim that there is no significant moral difference per se between the internal and external use of technology unargued for here. I suggest that it is up to those who say there is a difference to explain what it is. It may be that many people have intuitions that conflict with mine on this issue, and there is much to say about how our concept of autonomy is related to internal and external ways of changing people's thoughts and behavior. But however we map out that relation, we will still be left with a distinction between coerced change and noncoercive enhancement of abilities. As I say, I see no reason to suppose that the use of psychopharmacology to help adults or children is necessarily or worryingly coercive in most cases.[31]
Doctors’ Power.
Should doctors be the ones to prescribe behavior modifying drugs in cases of children who do not meet the strict criteria of illness? The obvious case against them doing do is that naughtiness is not an illness. Doctors are not in the business of prescribing good behavior, and should restrict themselves to only curing illnesses.
This view as it stands though is obviously faulty. Doctors do set themselves up in the business of cosmetic surgery. Some clinical psychologists offer to help people's careers and their living of their life, even when their clients don't have identifiable mental illnesses. There are plenty of performance enhancing methods that are tried on children by pediatric psychologists. So doctors and health care workers do sometimes do more than cure illnesses. There are limits to what they will attempt to do, but they are not as narrow as some suppose. Could the role of a doctor or psychiatrist extend to ensuring that children behave well? Some would argue that the medicalization of bad behavior such as conduct disorders shows that doctors have already taken on such roles. The view that the medical profession should not be involved in enhancing the performance of children is hard to justify because the roles of medical professionals are not narrowly constrained to curing illness or alleviating suffering in today’s society.

Conclusion
To recap the overall argument of this paper: I considered when and whether the label of ADHD should be applied to children. I argued that the extension of the concept ADHD, being a concept of medical disorder, is determined by non-scientific considerations as well as scientific ones. In order to be an illness or disorder, a condition must have symptoms not under the direct voluntary control of the subject, and it must be abnormal and disvalued. Furthermore, the social consequences of applying the diagnosis must be taken into account, because they can be such as to legitimately prevent the use of illness concept. I argued that ADHD did meet these requirements for being a disorder, since its symptoms can reasonably be counted as non-voluntary, and it is a condition which creates a problem for children in their prospects for living satisfying lives and fulfilling their potentials. The worries that arise from the effects, both individual and social, of children being labeled as ADHD and the effects of drug treatments are not serious enough to give reason to stop using the diagnosis.
What I am saying is then is that the fact that stimulants such as Ritalin are in such widespread use is not itself a bad thing. This still leaves open the possibility that many cases are being mishandled, in that the children's individual best interests are not being served by the treatment they are receiving. We can still see the rapid rise in the use of Ritalin as a warning sign meriting further investigation, even if it is not bad in itself.
William Fulford has commented that although there is a large literature on the concept of mental illness and the general concepts of illness and disease, “there has been remarkably little contact between this area and psychiatric classification.”[32] This paper has tried to bridge the gap between philosophy and theoretical psychiatry. While some of the arguments here have been too brief for my own satisfaction, I at least hope that it will serve the function of provoking replies, and so start more discussion within biomedical ethics of these important issues.[33]
[1]A shorter version of this paper is forthcoming in a special issue of Bioethics, July 1997, under the title "Medicating Children: The Case of Ritalin."
[2]As well as the predictable smattering of “women’s magazines” which have covered the issue, I came across a number of references to articles about ADHD in magazines for military families.
[3]Recent books proposing or considering alternatives to established ideas about attention deficit disorder include: Hartmann, Tom Beyond ADD: Hunting for Reasons in the Past & Present Underwood Books, Grass Valley, CA, 1996; Miller, David and Kenneth Blum Overload: Attention Deficit Disorder and the Addictive Brain Andrews and McMeel, Kansas City, 1996; Reichenberg-Ullman, Judyth and Robert Ullman Ritalin-free kids : safe and effective homeopathic medicine for ADD and other behavioral and learning problems Prima Pub., Rocklin, CA, 1996; Block, Mary Ann. No more Ritalin : treating ADHD without drugs Kensington Books, New York, 1996; Ingersoll, Barbara D. and Sam Goldstein Attention Deficit Disorder and Learning Disabilities: Realities, Myths and Controversial Treatments Doubleday, New York, 1993.
[4]This leads me to suggest, parenthetically, a peculiar difference between standard medical ethics and issues in the philosophy of psychiatry. While issues in mainstream biomedical ethics, such as abortion or physician assisted suicide, are often on the front page of major newspapers, or argued about in front of the Supreme Court, controversial issues concerning psychiatry tend to receive a different sort of popular attention. I.e., controversies in mental health provoke enough interest in the general public for magazine editors, book publishers, and TV producers to consider it worthwhile covering them, and maybe this helps to continue the controversies.
[5]To call someone speaking in her own defense biased might seem strange logic. However, I am struck how often students in introductory philosophy classes use such logic. In papers evaluating the contrasting views of two philosophers, it is not unusual for students to say "I think the arguments of philosopher X are better than those of philosopher Y, but I am biased because I agree with the views of philosopher X." Furthermore, students are willing to apply the same logic to others, and will very often counter an argument with a phase such as "But that's just your opinion." Rational justification is hardly seen as relevant. For a more systematic development of such an analysis of trends in popular reasoning, and their connection with the popular media, see Susan Bordo's paper on the jury decision and reasoning in the O. J. Simpson trial.
[6]This is one more example of how biomedical ethics has persistently neglected issues in psychiatry.
[7]However, we should not forget that there has been discussion of hyperactivity and the use of stimulants to stop it for over 20 years. The following is a partial list of relevant literature concerning the ethical dimensions of the issue: Schrag, P. and Divorky, D.: The myth of the hyperactive child. New York, Pantheon, 1975; Bosco, J. J. and Robin, S. S. (ed.) The hyperactive child and stimulant drugs. Chicago, University of Chicago Press, 1976; Jackson, Jane E, The coerced use of Ritalin for behavior control in public schools: legal challenges. Clearinghouse Review 10(3): 181-193, Jul. 1976. Box. S.: "Hyperactivity: the scandalous silence" New Society, 1 December 1977, pp. 548-60; Peter Conrad, "On the Medicalization of Deviance and Social Control" in Critical Psychiatry: the Politics of Mental Health edited by David Ingleby (Pantheon, 1980); O'Leary, James C. "An analysis of the legal issue surrounding the forced use of Ritalin: protecting a child's right to 'just say no'" [Note]. New England Law Review. 1993 Summer; 27(4): 1173-1209.; Breggin, Peter R. Breggin, Ginger Ross "The Hazards of Treating 'Attention-Deficit/Hyperactivity Disorder' with Methylphenidate (Ritalin)" Journal of college student psychotherapy. 1995 v 10 n 2 Page: 55; Kolata, Gina "Boom in Ritalin sales raises ethical issues" [News]. New York Times. 1996 May 15: C8.; LynNell Hancock, "Mother's Little Helper: With Ritalin, the Son Also Rises," Newsweek 18 March 1996 pp. 50-56; Jennifer Cunningham, "A deficit of education", Living Marxism issue 88, March 1996; Diller, Lawrence H., "The run on Ritalin: attention deficit disorder and stimulant treatment in the 1990s." Hastings Center Report. 1996 Mar-Apr.; 26(2): 12-18, and Kristin Leutwyler, "Paying Attention" Scientific American August 1996, pp. 12-14.
[8]Furthermore, the whole area of psychiatric ethics is underdeveloped, and the recent advances and developments that have occurred in the area in the last few years may have profound effects on the direction of subsequent discussion. So it is important for several reasons that we be careful how we frame these issues.
[9]See my article "Prozac, Psychiatry, and Political Activism," published in Clio's Psyche 3 (2) September 1996, pp. 55-56.
[10]The diagnostic criteria for ADHD are the following:
A. Either (1) or (2):
(1) six (or more) or the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulties sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) six (or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively

Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or three more settings (e.g., at school [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). (DSM IV, pp. 83-5)
[11]Dorothea M. Ross and Sheila A. Ross, Hyperactivity: Current Issues, Research, and Theory (2nd ed.), John Wiley & Sons, New York, 1982. Page 13.
[12]Brian E. Leonard, Fundamentals of Psychopharmacology, John Wiley & Sons, Chichester, 1992. Page 224.
[13]For a recent short review of this evidence, see the article in Scientific American from August 1996, "Paying Attention."
[14]See LynNell Hancock, "Mother's Little Helper: With Ritalin, the Son Also Rises."
[15]Philip Graham "Ethics and child psychiatry," in Sidney Block and Paul Chodoff (eds.) Psychiatric Ethics (2nd ed.) Oxford, Oxford University Press, 1991. Page 347.
[16]Here is a very selective bibliography on this topic: Arthur Caplan, H. Tristram Englehardt, Jr., and James J. McCartney Concepts of Health and Disease: Interdisciplinary Perspectives Addison-Wesley Publishing Company, Reading, MA, 1981; Robert M. Veatch, "The Medical Model: Its Nature and Problems," and Christopher Boorse, "What a Theory of Mental Health Should Be," both reprinted in Psychiatry and Ethics, edited by Rem B. Edwards, Prometheus Books, Buffalo, 1982; Charles M. Culver and Bernard Gert Philosophy in Medicine: Conceptual and Ethical Issues in Medicine and Philosophy Oxford University Press, New York, 1982; Lennart Nordenfelt and B. Ingemar B. Lindahl (editors) Health, Disease, and Causal Explanation in Medicine (Philosophy and Medicine Volume 16) D. Reidel Pub. Co., Dordrecht, 1984; Martin Roth and Jerome Kroll The Reality of Mental Illness Cambridge University Press, Cambridge, 1986; Reznek, L. (1988). The Nature of Disease. London, Routledge & Kegan Paul; Arthur Caplan “The Concepts of Health and Disease,” in Robert Veatch (editor) Medical Ethics Jones and Bartlett Publishers, Boston, 1989; K.W.M. Fulford Moral Theory and Medical Practice Cambridge University Press, Cambridge, 1989; Lawrie Reznek, The Philosophical Defence of Psychiatry, Chapter 10, Routledge, London, 1991; Philosophical Perspectives on Psychiatric Classification edited by John Sadler et al. (Johns Hopkins University Press, Baltimore, 1994), [henceforth PPPC]; H. Tristram Englehardt, Jr. The Foundations of Bioethics (Second Edition) Oxford University Press, New York, 1996, Chapter 5.
[17]K.W.M. Fulford, “Closet Logics: Hidden Conceptual Elements in the DSM and ICD Classifications of Mental Disorders,” in PPPC, p. 216.
[18]Ibid., pp. 219-220.
[19]Ibid., p. 229.
[20]Ibid., p. 230.
[21]Ibid., p. 222.
[22]Fulford discusses alcoholism at length in Moral Theory and Medical Practice, pp. 154-164.
[23]Moral Theory and Medical Practice, p. xiv.
[24]I want to pay particular attention to the subtleties of the ways in which normative judgments go into the classification of particular diseases, and we should be on our guard against taking over-general slogans too literally. There are ways in which disease classification is dependent on normative judgments, but also there are ways in which the classification is quite independent of other normative judgments, and it is a complex matter to sort out in what ways a disease classification is normative. Furthermore, some disease concepts are far more normatively loaded than others, are loaded in with much more controversial normative assumptions than others. This much is relatively obvious even from reading the definition of disorder in the Introduction to DSM-IV (which was also used in DSM-III and DSM-III-R).

... each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must be currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above. (DSM-IV, American Psychiatric Association, Washington , DC, 1994, pp. xxi-xxii.)

Obviously philosophers could pick holes in this definition for its circularity and vagueness. In fairness to the writers of DSM-IV, they do preface the definition with an admission that it is inadequate, and the minimal justification that they have not been able to find any better ones. I quote it to highlight the idea that values inevitably come into play in the interpretation of what are clinically significant or deviant forms of behavior, important areas of functioning, significantly increased risks, important losses of freedom, and so on. Furthermore, the way values come into play is complex. Disorders are not simply defined as undesirable conditions or conditions causing undesirable behavior. There are a whole host of other evaluative considerations that come into play when determining whether a particular condition, such as hyperactivity, is a disorder.
[25]Miller, David and Kenneth Blum, Overload: Attention Deficit Disorder and the Addictive Brain .
[26]See Mark S. Gold The Good News About Panic, Anxiety, and Phobias, Bantam Books, New York, 1989, p. 185.
[27]There is, I am sure, a quote of Freud to the same effect.
[28]This idea seems to have found a recent proponent in Louise Armstrong And They Call It Help: The Psychiatric Policing of America's Children Addison-Wesley, Reading, MA, 1993. See especially Chapter 8: The School Connection I. See also Schrag and Divorky, Op. cit.
[29]This has been discussed by Peter Kramer in connection with antidepressants in his Listening to Prozac Viking; New York, 1993.
[30]Consider the parallel case of depression. Antidepressants do not force more cheerful views of the world on patients, even if they do enable them to avoid despair and bleak views of their lives. Emotions have a cognitive component, and changing a person's emotions may be more than just changing their affect, so taking antidepressants may also affect their intellectual views as well. This is often seen as empowering.
[31]I aim to write more fully about this issue in a paper on psychopharmacology and autonomy.
[32]Closet Logics, p. 215.
[33]I read this paper to the Philosophy Department at Loyola University Chicago, and received some useful comments. My thanks to Georgeann Higgins for her comments on the substance and style of an earlier draft.