A Philosophy of Medicine Special Issue

This week on Imperfect Cognitions, we showcased a couple of posts by authors with papers published in a special issue from the European Journal of Analytic Philosophy (EuJAP). The special issue on the Philosophy of Medicine was guest-edited by Anke Bueter and Saana Jukola.

In this third and final post, the guest editors of the issue Anke and Saana give a summary of the special issue and the other papers included in it. Anke is an associate professor at Aarhus University. Her main research interests lie within feminist philosophy of science and philosophy of psychiatry. Saana is a post-doctoral researcher at the Ruhr-University Bochum. She is interested in the philosophy of medicine, social epistemology, and values in science.

Anke Bueter

Philosophy of medicine has become established as a distinct branch of philosophy relatively recently. Of course, philosophical questions concerning, for instance, the nature of disease or the ethical responsibilities of physicians are not new. However, less than 15 years ago it was possible to ask: “Does Philosophy of Medicine Exist?” (Marcum 2008, 3). Since then, the field of research has become increasingly independent from bioethics, philosophy of biology and other neighbouring subfields of philosophy. Philosophy of medicine now has professional associations, specialized journals, and textbooks. 

For the special issue on philosophy of medicine for the European Journal of Analytic Philosophy, we were particularly keen on receiving submissions investigating the interconnectedness of epistemic, metaphysical, ethical, and/or political aspects of medical research and practice. A major motivation for editing the special issue was the recognition that many of the critical philosophical questions that arise in the context of medicine and healthcare cannot be answered by drawing on just one philosophical tradition. 

For example, the current COVID-19 has clearly demonstrated how ethical and political considerations cannot be ignored when discussing what mitigation measures should be undertaken. In what follows, we briefly summarize the topics of the articles that appeared in this issue.

Saana Jukola

In their contribution “Diagnostic Justice: Testing for Covid-19” Ashley Graham Kennedy and Bryan Cwik discuss diagnostic testing. They argue that testing for COVID-19 has different goals depending on whether it is done for clinical care for individuals, as entry criterion to trials in clinical research, and in surveillance on population level. Each of these goals is connected to different epistemic challenges and moral obligations towards test subjects. 

Daria Jadreškić also looks at questions raised by the COVID-19 pandemic in her article “Adapt to Translate – Adaptive Clinical Trials and Biomedical Innovation”. Her focus is on clinical trials that have to be conducted under intense time pressure. Jadreškić argues that the validity of so-called adaptive trials has to be assessed on a case by case basis and with a focus on implemen­tation. 

In addition, she shows that adaptive trial design is not a novelty introduced by COVID-19 research, but can be placed within the larger context of the productivity crisis in pharmaceutical research and new developments in translational medicine.

In her article “Wrongful Medicalization and Epistemic Injustice in Psychiatry: The Case of Premenstrual Dysphoric Disorder”, Anne-Marie Gagne'-Julien shows how the framework of epistemic injustice can be applied to identifying problematic medicalization. 

She expands Kaczmarek's pragmatic account of medicalization by combining it with insights from theorizing on epistemic injustice and applies it to the case of "Premenstrual Dysphoric Disorder. According to her, this is a case of wrongful medicalization because the process of establishing the diagnosis was not adequately inclusive. You can read a blog post about her paper here. 

Jacob Stegenga’s contribution also deals with medicalization. The focus of his “Medicalization of Sexual Desire” is on low female sexual desire and the respective DSM diagnosis of “Female Sexual Interest/Arousal Disorder”. Stegenga analyses two conflicting perspectives on low female sexual desire: 

The so-called mainstream focuses on its biological underpinnings and considers it a genuine disease. The critical view, in turn, focuses on the social context and cultural factors that impact sexuality and respective ideas of normality. By examining arguments for both views, Stegenga suggests focusing on pragmatic considerations of the harms and benefits of medicalizing the condition.

Kathleen Murphy-Hollies’ paper “When a Hybrid Account of Disorder is not Enough: The Case of Gender Dysphoria” applies Jerome Wakefield’s concept of mental disorder as harmful dysfunction (HD). Murphy-Hollies argues that HD leaves the relation between its components (“harm” and “dysfunction”) undertheorized and, consequently, may lead to pathologization of normal states. 

Particularly in the case of gender dysphoria, assessing why purported dysfunctions are perceived as harmful and disvalued. This has two implications. Firstly, there is a distinction between sex dysphoria and gender dysphoria. Secondly, the legitimacy of the diagnosis of gender dysphoria depends on how we conceptualize gender in a sociological sense. You can read a blog post about her paper here.

In the final article of the special issue, “The Quantitative Problem for Theories of Dysfunction and Disease” Thomas Schramme addresses the issues of medicalization from a more general and conceptual angle. His focus is on the problem of how to draw a line between “functional” and “dysfunctional” traits. Schramme argues that this quantitative problem can be based on biological facts about goal-effectivity and does not require making value-laden judgments. 

Thus conceived, biological dysfunction is a necessary condition for a state or process to be a disease. Yet, it is not sufficient, as Schramme shows by introducing a distinction between biological and clinical dysfunction. While the identification of clinical dysfunction calls for evaluative and pragmatic considerations, the fact that it is based on empirical questions about biological functions helps to avoid over-medicalization, Schramme argues. 

Wakefield's Hybrid Account of Disorder and Gender Dysphoria

 This week on Imperfect Cognitions, we showcase a couple of posts by authors with papers published in a special issue from the European Journal of Analytic Philosophy (EuJAP). The special issue is on the Philosophy of Medicine with guest editors Saana Jukola and Anke Bueter. 

Today's post is the second post of the series. Kathleen Murphy-Hollies discusses her paper in the special issue, which you can read here. Kathleen is a philosophy PhD student and teaching fellow at the University of Birmingham, working primarily on confabulation and its effects for embodying virtuous traits. 

Kathleen Murphy-Hollies

In my paper, I discuss whether Wakefield’s hybrid account of disorder helps clarify the thorny issue of whether Gender Dysphoria (GD) should be included in the DSM as a disordered state or left out as merely a socially disvalued state. In the DSM-5, GD is described in individuals as “a marked incongruence between the gender they have been assigned to (usually at birth, referred to as natal gender) and their experienced/expressed gender”, which is accompanied with distress (APA 2013, 453). Symptoms include a desire to be the other gender, a preference for the typical roles, toys and clothes of the other gender, and a strong dislike of one’s physical sex characteristics.

Applying Wakefield’s hybrid account of disorder (1992), it appears that in cases of GD we have both a naturalist component of dysfunction and a normative component of harm (Wakefield and First, 2003). However, I argue it is hard to see the link between a dysfunction and all the symptoms we see in the diagnostic criteria for GD. In particular, I propose that we end up with an overlap of two distinct clinical groups: those who suffer dysphoria relating to their gender role and gendered expectations (which I term ‘gender-role dysphoria’) and those who suffer dysphoria relating to their physical sex characteristics (which I term ‘sex dysphoria’).

Whether we can talk of one dysfunction underlying both gender-role dysphoria and sex dysphoria brings us to the question of how to understand the word ‘gender’ in GD. I outline two very broad kinds of approaches we could take to understanding ‘gender’ here. The first, I call the ‘traditional account’ of gender. This approach understands gender to be an external, inherently harmful set of cultural roles, traits and expectations which are imposed onto people through socialisation, with an individual’s sex determining which roles and expectations are imposed. A second, I call the ‘identity-based account’ of gender. This account understands someone’s gender to be an internally generated part of their identity which in turn tells them which gender roles are appropriate for them.

Now, the DSM-5 appears to employ the latter identity-based account of gender, as this is the only account with which criteria such as “an insistence that one is the other gender” (my emphasis) can make sense. But it is not clear how one would go about justifying that the DSM should indeed be using this account of gender in forming its diagnostic criteria for GD. Without taking a stance on which account of gender we should adopt, I point out that this sociological issue of how we understand gender here has knock-on effects for whether or not cases of GD are indeed cases of pathologising a healthy state. For example, a traditional understanding of gender already understands them as inherently harmful, and so pathologising the rejection of gender roles appears to be appropriate. Whereas, an identity-based understanding of gender might focus on a harmful dysfunction in the formation of gender identity (accounts may vary). These two accounts of gender may also differ in how they approach understanding gender-role dysphoria and sex dysphoria.

In essence, the complex case of GD demonstrates the extent to which a successful account of what constitutes a mental disorder will have to engage with sociological discourses, such as those regarding the stratification of groups in society and how systematic oppression occurs, in order to end psychiatry’s troubled history of pathologising normal and healthy states. Wakefield’s hybrid account does not do this, and it leaves the specific connection between the dysfunction and harm components undertheorized. So, despite tying a normative harm to a naturalistic dysfunction in order to avoid pathologising socially disvalued states, the theory is still not comprehensive enough to do so successfully.

Medicalization and Epistemic Injustice: The Case of Premenstrual Dysphoric Disorder

This week on Imperfect Cognitions, we showcase a couple of posts by authors with papers published in a special issue from the European Journal of Analytic Philosophy (EuJAP). The special issue is on the Philosophy of Medicine with guest editors Saana Jukola and Anke Bueter. 

In today's post, Anne-Marie Gagné-Julien discusses her paper in the special issue, which you can read here. Anne-Marie is a postdoctoral fellow at the Biomedical Ethics Unit at McGill University and also affiliated with the École normale supérieure (ENS). She works on philosophy of psychiatry and medicine, social epistemology, and epistemic innocence. 

Anne-Marie Gagné-Julien

Medicalization is the process through which nonmedical problems are conceptualized and treated as medical problems (Conrad and Slodden 2013). It has become a controversial topic both within and outside psychiatry, especially since the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Several critics have argued that the DSM-5 medicalizes conditions that should only be considered “normal life problems”, “dangerous gifts”, or minoritized ways of being. Some specific revisions in the DSM-5 have been received with great suspicion, such as the diagnoses of major depressive disorder, bipolar disorder in children, personality disorders, and premenstrual dysphoric disorder. 

From a philosophical point of view, this raises the question of how to assess the medicalization of these diagnoses. Although medicalization in psychiatry is generally discussed from a critical perspective, the term itself is neither positive nor negative in itself: sometimes medicalization can bring good consequences, such as access to resources and decreasing blame associated with medicalized conditions. Sometimes it can lead to bad consequences, such as seeing all humans’ problems through a biomedical framework and spawning unnecessary clinical interventions. Therefore, what appears problematic are the bad forms of medicalization, or what I call “wrongful medicalization”. Regarding the many consequences and implications of medicalization, identifying cases of medicalization that are wrongful is a difficult undertaking. In other words, “what is a wrongful medicalization?” is a complex question.

In the paper, I propose to explore these issues with the philosophical framework of epistemic injustice (EI, e.g., Fricker 2007). EI are the harms suffered by individuals belonging to socially oppressed groups in their capacities to produce, access and/or share knowledge because of prejudicial identity stereotypes (e.g., racism, sexism, ableism, etc.) or because of their social marginalization. Where medicine is concerned, Kidd and Carel (2017) have depicted a particular form of EI that concerns prejudices associated with the experience of illness. It occurs when the knowledge of ill persons is dismissed, not even looked for, or confined to a purely biomedical discourse. As some have argued, the risk of encountering this type of EI is even greater in psychiatry because of widespread negative stereotypes associated with mental illness.

Using this framework is useful to think about what wrongful medicalization is. In the paper, I focus on Kaczmarek’s (2019) promising pragmatic approach to assessing medicalization. Using EI, I argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to assess medicalization (e.g., what model of discussion is the most fruitful to think about wrongful medicalization? Who should be included in these discussions and why? etc.). 

I demonstrate that the EI framework should complement Kaczmarek’s account in order to reduce the risk of epistemic injustices induced by medicalization, and therefore the risk of wrongful medicalization. To illustrate the relevance of my proposal, I apply this conclusion to a case study: the medicalization of Premenstrual Dysphoric Disorder (PMDD) in DSM-5. This leads me to defend more inclusive decision-making procedures regarding medicalization of PMDD in the DSM. I argue that Kaczmarek’s account complemented with the EI framework can help us achieve better forms of medicalization in psychiatry.

Lost for Words: Anxiety, Well-being, and the Costs of Conceptual Deprivation

Today's post is by Ditte Marie Munch-Jurisic (University of Copenhagen).

Ditte Marie Munch-Jurisic

A wave of influential voices in philosophy and psychology have argued that negative affective states like stress, discomfort, and anxiety are not necessarily detrimental for mental health, but that they can, under certain conditions, take productive forms that may broaden our epistemic horizons (Kurth 2018; Applebaum 2017; Harbin 2016; Bailey 2017; Medina 2013; Lukianoff and Haidt 2018; Jamieson, Mendes, and Nock 2013) and even contribute to social mobility (Munch-Jurisic 2020a). 

In my new article for the Synthese topical collection "Worry and Wellbeing: Understanding Anxiety", I identify one epistemic problem which has not been properly addressed by this new wave of research; to benefit from a surge of negative affect, agents need to be able to conceptualize and make sense of their internal, physiological states (Berntson, Gianaros, and Tsakiris 2018). Whether agents will understand their stress as potentially productive, or distressing (and potentially harmful) will depend on what hermeneutic equipment they have available to discern their emotional and physiological responses. 

By hermeneutic equipment, I am referring to the interpretive tools we rely on to understand the world and ourselves, i.e. the words, names, and concepts we apply to our emotional states both through (i) slow, deliberate processes of conscious thought and reflection and (ii) fast, automatic processes where we rely on mental short-cuts like cognitive biases, scripts, and other heuristics (Evans and Stanovich 2013).

In the paper I argue that the process of experiencing, interpreting, and applying our hermeneutic equipment to a specific set of affective states cannot be understood as an individual matter. Not only does the broader political, cultural and socio-economic context of agents shape the kinds of stressors they are exposed to (Ong, Deshpande, and Williams 2018), it also delineates the hermeneutic equipment that agents have available to interpret their experiences. To explain this specific problem of conceptual deprivation, philosophical and psychological theories on well-being and anxiety need to move beyond individualist perspectives.

Our hermeneutic equipment helps us orient ourselves in the world, and this form of orientation is inherently normative. It gives us guidance for how to properly understand and conduct ourselves. When there are no helpful concepts, words, or names to apply to an uncomfortable affective state, agents may lose their orientation; for some, this may have grave mental health consequences.

In a very basic sense, conceptual empowerment is key for our well-being. But some applications of our hermeneutic equipment may be personally beneficial (easing an agent’s stress and increasing their personal well-being) but morally corrupt and antithetical to social progress. 

Self-reflection and conceptual empowerment can benefit an individual while causing and perpetuating great harm to others—I detail this darker side of emotion regulation in my forthcoming book, Perpetrator Disgust: The Moral Limits of Gut Feelings. In this further sense, an individualist focus is insufficient. The substance of our self-reflections, deliberations, and conclusions draws on the environment around us while at the same time contributing to shape it.

Monothematic Delusions and the Limits of Rationality

Today's post is by Quinn Hiroshi Gibson and Adam Bradley, on how to understand monothematic delusions.

Quinn Hiroshi Gibson

Subjects with Capgras delusion form the delusion that a loved one has been replaced by an imposter:

The day after her arrival at home, [her] father could not open the front door because YY had locked it from the inside. He rang the bell and YY called the police because ‘there was an impostor outside the house who was picking the lock and pretending to be her father’. (Brighetti at al. 2007, p. 191)

 

Capgras is a monothematic delusion, a delusion whose content is restricted to a single topic, in this case the identity of YY's father.

In ‘Monothematic Delusions and the Limits of Rationality’ (published in the British Journal for the Philosophy of Science in 2021), we put forward a new account of such delusions. Our view is a version of the two-factor model according to which two factors are responsible for monothematic delusions (Davies et al. 2001). The first is a disruption in experience, e.g., a missing affective response to loved ones. The second is a cognitive impairment which inclines the subject towards delusional belief. This second factor distinguishes subjects with disordered experience but no delusion from subjects with disordered experience who form the delusion (Tranel et al. 1995).

Adam Bradley

We are motivated to develop a new view because we believe that existing theories do not satisfactorily explain why subjects initially entertain the delusional thought, e.g. "This person who looks like my father is an imposter" (Parrott 2016). The contents of most monothematic delusions are bizarre, and one wonders why subjects would even consider them, let alone believe them. A satisfactory account of monothematic delusions should help us understand this.

Existing two-factor views cannot explain the subject’s initial entertainment of the delusional thought because of their commitment to Maherian Rationality:

Maherian Rationality: The cognitive processes involved in delusion entertainment, adoption, and maintenance are of a generally rational kind whose operation is impaired in the domain of the delusion.

Traditional endorsement and explanationist views both seek to explain delusion formation on the model of rational belief-forming processes that have gone off the rails: either endorsement of the content of experience as a perceptual belief, or else an attempt to explain one’s disordered experience. But both endorsement and explanation are, in general, rational processes. So these views seek to explain delusion formation on the model of rational cognitive processes.

But the contents of monothematic delusions are typically so bizarre and that we must look beyond the rational faculties of the mind in order to explain them. When a subject with the Cotard delusion forms the belief that she is dead, she is not endorsing the content of experience or trying to explain anything. Instead, we argue, she is trying to express what her experience is like. Similarly, YY is not trying to explain bizarre experiential ‘data’, or taking on the content of her experience at face value. Instead, she is trying to articulate what her experience of her father is like.

The contents of monothematic delusions arise, then, not out of any rational process (not even a malfunctioning one), but from the sorts of processes involved in figurative thought and metaphorical language. There we have a rich repository of associations to draw on, associations which have already laid down ‘tracks’ in the mind along which thought naturally flows. 

 On our view, the delusional subject entertains thoughts like "I am dead" or "My wife has been replaced by an impostor" for the same reason that one might say "I am going to explode" as a way of describing their anger. We have a latent supply of figurative and metaphorical associations to draw on in thought and speech. These connections are already intelligible to us--we track them to understand poetry, for instance--but are not rational.

What is distinctive about the delusional subject is that she does not merely entertain such thoughts, she adopts them as beliefs. This calls for a second factor. Cotard delusion is typically thought to result from severe depression. But subjects who are not delusional express feelings of severe depression using terms such as ‘dead’ or ‘inanimate’ or ‘nonexistent’. A subject suffering from depersonalization may say: "I feel as if I am dead". The delusional subject, however, just thinks "I’m dead". They lose the ‘as if’ operator. 

We posit, therefore, that the second factor that causes the thought to become fixed as a delusion is a selective deficit in the subject’s capacity to understand figurative language as figurative in the domain of the delusion. As a result, delusional subjects come to confuse their figurative expressions of their experience for the literal truth.

Desire as Belief

Today's post is by Alex Gregory, University of Southampton. In this post, Gregory presents his new book, Desire-as-Belief: A Study of Desire, Motivation, and Rationality, published by OUP in July 2021. You can read some chapter summaries here. And here is a link to chapter 1, which the publisher has kindly agreed to make available for free as a sample. 

What is it to want something? Or, as philosophers might ask, what is a desire? I endorse desire-as-belief, the view that desires are just a special subset of our beliefs. More specifically, I say that to desire P is to believe you have normative reason to bring about P. This view is in one respect highly unorthodox, since many – e.g. Plato, Hume – hold that our desires are really quite different from our beliefs. The view is also unorthodox for suggesting that all our desires can be evaluated for whether they are correct or not. But despite being unorthodox in these ways, I argue that the view is nonetheless attractive. Some orthodoxies should change.

Why endorse the view? One attraction is that desire-as-belief allows us to accept the central and most attractive part of the Humean tradition – the necessity of desire for motivation – without accepting any attendant baggage about the motivational impotence of normative beliefs. According to desire-as-belief, desires are necessary for motivation, but this is wholly consistent with the fact that normative beliefs sometimes motivate us: they are desires, under a different description.

Another attractive feature of the view concerns its implications for rationality. Our desires seem highly relevant for rationality – if we are evaluating whether someone acted rationally, a standard view says to first examine their desires. But why should this be true? Why think of desires as a source of rational pressure rather than as sources of irrationality or else just plain irrelevant? Desire-as-belief supplies a tidy answer: because desires are normative beliefs, and because rationality consists in responding to the normative facts as best you can.

Alex Gregory

I hear you say: “Sure, the view would have some neat features if it were true, but doesn’t it face decisive objections?”. The book shows how the view can overcome a variety of worries that you might have. For illustration, here is a brief account of one small manoeuvre I make. Imagine that Sarah says “There are good reasons for me to give to charity, but I don’t want to”. Sarah’s assertion looks like a potential problem for desire-as-belief, according to which her believing she has reason to give more to charity just is her desiring to do so. But in fact Sarah’s assertion may be consistent with desire-as-belief. By “I don’t want to”, Sarah might mean that she wants not to do so, not that she fails to want to do so (W¬p, not ¬Wp). That is, by “I don’t want to”, Sarah might be reporting her belief that there are some reasons not to give to charity. Then her assertion as a whole reports a conflict between two reasons – two desires – rather than between a present belief and an absent desire. So understood, Sarah’s assertion provides no objection to desire-as-belief.

Of course, much more than this needs to be said to show that desire-as-belief is consistent with the full range of irrationality that we can display, and the full range of common-sense thoughts we have about desire. See the book!