Is illness value-laden?

Why is there an anti-psychiatry movement but no anti-cardiology movement? Why do people sometimes campaign to close acute psychiatric hospitals but never accident and emergency units? KWM (Bill) Fulford thinks that we can find the answers to those questions by learning lessons from the debate between Szasz, on the one hand, and Kendell and Boorse, on the other. His analysis is a form of philosophical diagnosis. The significant feature of the debate, he argues, is not so much on what they explicitly disagree but on what they implicitly agree and disagree. Once this is highlighted, a different conclusion can be drawn. Taking Szasz and Kendell to represent the poles of the debate, Fulford argues that:Both authors assume that mental illness is the target problem: Szasz wants to ‘raise the question, is there such a thing as mental illness’? Kendell, similarly, seeks to ‘decide whether mental illnesses are legitimately so-called’. Both then turn to the concept of physical illness, acknowledging certain difficulties of definition, but suggesting criteria which they take to be self-evidently essential to its meaning: Szasz’ criterion is ‘deviation from the clearly defined norms of the structural and functional integrity of the body’. Kendell’s is ‘biological disadvantage, which must embrace both increased mortality and reduced fertility’. Finally, both return to mental illness. Szasz points out that for mental illness, the relevant norms of bodily structure and functioning are not available: on the contrary, he argues, the norms of mental illness are ‘ethical, legal and social’. Kendell, on the other hand, draws on epidemiological and statistical data to show that many mental illnesses are biologically disadvantageous in his sense, being associated with reduced life and / or reproductive expectations. Hence by Szasz’ criteria of physical illness, mental illness is a myth, whereas by Kendell’s it is not. [Fulford 1999a: 169]

Both agree that mental illness is conceptually problematic. Both agree that physical illness is conceptually simple and also value free. They disagree on the details of the criteria they draw from physical illness. But their broader disagreement is then on how mental illness meets the criteria abstracted. Szasz argues that putative mental illnesses answer to evaluative norms and thus fail to meet the criteria for illness. Kendell argues that they fit his preferred criteria of increased mortality and decreased fertility.

Fulford goes on to argue that Szasz, like his fellow anti-psychiatrists, is right to claim that mental illness is value-laden. But he is wrong to contrast mental illness, conceptually, with physical illness. Mental illness and physical illness are both value terms even if this is not always noticed because mental illness appears to be more overtly value-laden than physical illness.

Kendell and Boorse argue in defence of psychiatry, that mental illness is value-free like physical illness. Fulford responds that whilst they are right to compare mental and physical illness in this respect, they are wrong to assume that the scientific foundations of medicine (including psychiatry) depend on eliminating values.

If this is right, how can Fulford explain the difference, above, between cardiology and psychiatry? Why does mental illness seem more value laden? Do we have any reason to believe his analysis? And if it is true, does it undermine the scientific status of medical care?

Reading:

• 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

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