Shallow subjectivism vs paternalist objectivism?
The Scylla and Charybdis of the philosophy of healthcare
These three sessions, designed for the UWL MSc on Person-centred Health and Social Care, explore the tension between subjectivism and objectivism in three distinct, though related, areas of the philosophy of healthcare:
1. The most well-known contemporary analysis of disorder based on biological functions and dysfunctions.
2. An explicitly value-laden approach to illness based on a failure of ordinary doing which is taken by its author to have implications for Values-Based Practice more generally
3. The Recovery Model in mental healthcare which stresses the positive goal of health over the absence of symptoms.
Although there is an emphasis on mental healthcare (see the video below), where conceptual complexities are particularly apparent, the issues apply more broadly across health and social care.
Content (3 short videos)
Overview of the three sessions
What is the difference between the subjective and objective?
1: Wakefield’s harmful dysfunction model: balancing subjectivity and biological objectivity?
Wakefield’s harmful dysfunction model is probably the most influential analysis of disorder, which promises to blend fact and value without giving up an objective foundation for disorder. In addition to the explicitly evaluative conjunct of harm, the analysis attempts to capture the prima facie normativity, or specifically medical value of something being (medically) ‘wrong’, through the idea of biological dysfunction. Since Darwin, biological functions have promised to reconcile apparently purposive or evaluative language (the eye is for seeing; a good eye sees) with blind causality (the mechanism of natural selection). Thus it promises an objective account of (the foundation of) health and illness. But can it?
The session will consider whether the very concept of function can sustain this ambition and whether it is possible to ground the notion of illness in an objective and universal account of human biological nature.
Content
Introductory video (play this first)
Slides with audio (running the slideshow starts the audio commentary and runs continuously but slides can be selected or skipped)
(Experimental MP4 version of slides - huge!)
Reading for session 1
The reading to start with is marked *. The other three are critical responses.
Cooper, R. (2015) ‘Must Disorders Cause Harm? The Changing Stance of the DSM’ Demazeux, S. Singy, P. (2015) The DSM-5 in Perspective Philosophical Reflections on the Psychiatric Babel, Dordrecht: Springer pp83-96
Kingma, E. (2013) ‘Naturalist accounts of mental disorder’ in Fulford, K.W.M., Davies, M., Gipps, R., Graham, G., Sadler, J., Stanghellini, G. and Thornton, T. (eds) Oxford Handbook of Philosophy and Psychiatry, Oxford: Oxford University Press pp363-84
Murphy, D. and Woolfolk, R. (2000) ‘The Harmful Dysfunction Analysis of Mental Disorder’ Philosophy, Psychiatry, and Psychology, 7:241-251.
*Wakefield, J.C. (1999) ‘Mental disorder as a black box essentialist concept’ Journal of Abnormal Psychology 108: 465-472
Suggested essay titles for session 1
To what extent does biological function support a universal view of health and illness?
Does biological function shed light on mental health and illness, or vice versa, or neither?
Can there be illnesses that are not grounded in biological first nature?
2: Fulford’s failure of ordinary doing and the origins of Values Based Practice
Bill Fulford is known both for a specific evaluative account of illness but also for a general framework for approaching Values Based Practice (VBP) motivated by it. His account of the former is twofold: first an argument that illness is a value term and second a substantive theory of the nature of that term: illness is a failure of ordinary doing. His account of the latter deploys a subjectivist view of values.
This session will address the questions: Does Fulford disarm worries raised by Szasz's claim that there is no such thing as mental illness? Does the link to values undermine the objectivity of diagnosis or the claim that someone really has an illness? Is the link to failure of ordinary doing a plausible account of medical values? A clue to Fulford’s own views here are his subjectivist and liberal view of values in VBP. But is that a satisfactory approach to VBP?
This session will conclude by addressing the question: does the argument that something is an illness because it has the features of an illness work? And if so can it settle which conditions so count?
Content
Introductory video (play this first)
Reading for session 2
The reading to start with is marked *. There is much overlap between the Fulford 1991 and 1999 readings so either would suffice. Fulford 2004 is his first major summary of VBP. The Pickering reading is a critical response to the form of argument in defence of the very idea of mental illness that Pickering thinks many writers including Fulford subscribe to but which is not successful.
*Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press chapter 7
Fulford, K.W.M. (1991) ‘The concept of disease’ in Bloch, S. and Chodoff, P. Psychiatric Ethics (second edition) Oxford: Oxford University Press: 77-99
Fulford, K.W.M. (1999a) ‘Analytic philosophy, brain science and the concept of disorder’ in Bloch, S. Chodoff, P. and Green, S.A. (eds) Psychiatric Ethics (third edition) Oxford: Oxford University Press: 161-192
Fulford, K.W.M. (2004) ‘Ten Principles of Values-Based Medicine’. In The Philosophy of Psychiatry: A Companion, ed. J. Radden. New York: Oxford University Press
Pickering, Neil (2003) ‘The Likeness Argument: Reminders, Roles, and Reasons for Use’ Philosophy, Psychiatry, and Psychology 10 (3): 273-275.
Suggested essay titles for session 2
· If ‘illness’ is a value term, what is the nature of the value or values involved and to whom do they belong?
· If ‘illness’ is a value term, what sense attaches to whether someone is (‘really’!) ill or healthy? Is this an objective or subjective matter?
· Can an analysis of illness such as Fulford’s provide a compelling reason to determine whether a condition really is an illness? Answer with reference to the idea of the ‘likeness argument’.
· To what extent does Fulford’s account of illness, and by implication health, determine the nature of Values Based Practice?
3: Recovery and the dilemma of avoiding both subjectivism and paternalism
Over the last 20 years, recovery has become the aim of mental health services but its nature is contested. Drawing on manifestos from the Recovery Movement, this session will suggest the essentials of a Recovery Model (though stopping well short of a formal analysis), will offer an argument for it (though concede that perhaps no such argument can be persuasive) but then address two substantial issues.
· Can mental health service users be mistaken about their own values?
· Can they value the wrong things?
Addressing these questions will highlight an analogy in the philosophy of personal autonomy (sketched in this session) and debate about VBP (from session 2). This in turn suggests an ineliminable tension concerning the avoidance of naïve subjectivism or paternalism, the very thing the Recovery Model is supposed to guard against. The session will end with some general discussion of how subjectivism vs objectivism plays out more generally in person-centred health and social care.
Content
Reading for session 3
The reading to start with is marked *. The other three diverging responses to the idea of Recovery.
*Davidson, L. and Roe, D. (2007) ‘Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery’ Journal of Mental Health 16: 459-470.
Hopper, K. (2007) ‘Rethinking social recovery in schizophrenia: what a capabilities approach might offer’ Social Science & Medicine 65: 868-879
Nussbaum, M. and Sen, A. (eds) (1993) The Quality of Life, Oxford: Clarendon, Introduction
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Suggested essay titles for session 3
· Is a Recovery orientation to (mental) illness incompatible with a bio-medical view?
· If the Recovery in (mental) healthcare is value-laden, what limits, if any, should be set on those values?
· Must paternalism be a bad thing? Explain via an account of what you take paternalism to be.
Final reflections on the sessions and links to person-centred health and social care
Interactivity
There will be an interactive session on January 15th 2022.
After the fact, there is now a new padlet for any comments, questions of notes, which I will monitor twice weekly for the next month.
My own work
I have not cited my own work in the readings but I have written extensively on the philosophy of illness, recovery, narrative and the person. Links to many of these are available elsewhere on this site.
Readings as a whole
Cooper, R. (2015) ‘Must Disorders Cause Harm? The Changing Stance of the DSM’ Demazeux, S. Singy, P. (2015) The DSM-5 in Perspective Philosophical Reflections on the Psychiatric Babel, Dordrecht: Springer pp83-96
Davidson, L. and Roe, D. (2007) ‘Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery’ Journal of Mental Health 16: 459-470.
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press chapter 7
Fulford, K.W.M. (1991) ‘The concept of disease’ in Bloch, S. and Chodoff, P. Psychiatric Ethics (second edition) Oxford: Oxford University Press: 77-99
Fulford, K.W.M. (1999a) ‘Analytic philosophy, brain science and the concept of disorder’ in Bloch, S. Chodoff, P. and Green, S.A. (eds) Psychiatric Ethics (third edition) Oxford: Oxford University Press: 161-192
Fulford, K.W.M. (2004) ‘Ten Principles of Values-Based Medicine’ in Radden, J. (ed) The Philosophy of Psychiatry: A Companion, New York: Oxford University Press: 205-34
Hopper, K. (2007) ‘Rethinking social recovery in schizophrenia: what a capabilities approach might offer’ Social Science & Medicine 65: 868-879
Kingma, E. (2013) ‘Naturalist accounts of mental disorder’ in Fulford, K.W.M., Davies, M., Gipps, R., Graham, G., Sadler, J., Stanghellini, G. and Thornton, T. (eds) Oxford Handbook of Philosophy and Psychiatry, Oxford: Oxford University Press pp363-84
Murphy, D. and Woolfolk, R. (2000) ‘The Harmful Dysfunction Analysis of Mental Disorder’ Philosophy, Psychiatry, and Psychology, 7:241-251.
Nussbaum, M. and Sen, A. (eds) (1993) The Quality of Life, Oxford: Clarendon, Introduction
Pickering, Neil (2003) ‘The Likeness Argument: Reminders, Roles, and Reasons for Use’ Philosophy, Psychiatry, and Psychology 10 (3): 273-275.
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Wakefield, J.C. (1999) ‘Mental disorder as a black box essentialist concept’ Journal of Abnormal Psychology 108: 465-472