Tuesday 22 December 2020

Doctors without 'Disorders'

In today's post I am going to present an argument I developed in an article for the Supplementary Volume of the Aristotelian Society, Doctors without 'Disorders'. The paper was recently listed among the best articles in Philosophy published by Oxford University Press in 2020 (and thus it is available open access at the moment). I also presented this idea at the Joint Session last summer in a symposium on the concept of disorder and a video of the presentation is available (click below to watch).

How do we decide whether the problems we experience deserve the attention of medical professionals? Many believe that the answer hangs on whether the problem we have is caused by a disorder: if it is caused by a disorder, then medical attention is appropriate. If it is not caused by a disorder, then it is still a problem, but not a medical problem. It is a problem in living, a problem we need to try and solve by some other means.

I argue that the dichotomy between medical problems and problems in living is unhelpful, because the presence of a disorder does not successfully demarcate those problems that deserve medical attention from those that need to be addressed differently. Indeed, both in the context of somatic and mental health, we may seek medical attention for problems whose causes are unknown or problems that we know are not caused by a disorder (such as pregnancy, obesity, back pain) given the most influential accounts of what a disorder is.

Counterexamples to the rule that we seek medical attention only for problems caused by disorders abound no matter which influential account of disorder we adopt, from value-free naturalist accounts where a disorder is a biological dysfunction to value-laden constructivist or normativist accounts where a disorder is an undesirable state that can be potentially addressed by medical intervention. 

In the paper, the example I develop in some detail is that of delusions. We tend to consider delusions as pathological beliefs. But what makes them pathological? There are several hypotheses about delusions being the outcome of a cognitive dysfunction but the failures of cognition observed in people with delusions could as well be the product of reasoning biases, so the naturalist account does not help. 

Delusions are regarded as harmful, but it is not clear that harm always accompanies a delusion or that the harm experienced by the person with delusions is due to the delusions themselves. Harm could be a consequence of whatever problem delusions are a response to, or to the stigma and resulting social exclusion that the person with delusions is likely to encounter. That means that normativist accounts are also inadequate to capture what is pathological about delusions.

Even if we could offer a plausible account of the pathological nature of delusions, would that explain why people with delusional beliefs often come to the attention of mental healthcare professionals? I suggest it wouldn't. The cognitive dysfunction often associated with delusions is also appealed to in the explanation of non-pathological phenomena such as self-deception; and delusions are not the only beliefs that are irrational and potentially harmful and yet they are considered as symptoms of mental disorders whereas equally irrational and potentially harmful beliefs (such as prejudiced beliefs) are not.

Another example that is not addressed in the paper but that people have recently discussed is that of anxiety at the time of a pandemic (see brief discussion below). Does it matter whether the troubling state of anxiety many people have experienced during COVID-19 is the manifestation of a disorder or a natural response to adverse circumstances? If a medical intervention can help, should we avoid seeking it because the problem we have is not caused by a disorder? My conclusion is that the notion of 'disorder' does not successfully demarcate the scope of medical practice. Something can be at the same time a problem in living and a medical problem.

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