This session stems from the question raised at the end of the previous one. Forgetting Szasz’ claim that mental illness does not exist, still, if mental illness answers to societal values, does that mean that what counts as an illness (at a time and a place) is determined by what a society, contingently, values? That seems in itself to be a radical idea because of our views about the nature of values. If, for example, values are subjective, in the eye of the beholder, and if illness depends on values, then what counts as an illness is merely in the eye of the beholder.
The view that illness depends on values is an instance of Zachar and Kendler call ‘evaluativism’ in their set of dimensions for theorising about psychiatric taxonomy.
Is deciding whether or not something is a psychiatric disorder a simple factual matter (“something is broken and needs to be fixed”) (objectivism), or does it inevitably involve a value-laden judgement (evaluativism)?
Whilst their example is not very good, the basic contrast seems clear. Now one response in discussion was to push for the opposite view, objectivism, and thus avoid the problem by saying that medical scientific findings about prognosis and epidemiology can show what is and isn’t illness. But that does not address the basic problem.
A full understanding of the biological underpinnings of a condition or its prognosis does not by itself address its pathological (or not) status. Only if the outcomes are clearly pathological, does an appeal to outcomes help. But that is just the issue. Evaluativists claims that pathology is evaluative.
(An example: if drugging plantation slaves made them sleep through the night and escape were impossible by day then that would, predictably and explicably, reduce the numbers running away. But that does not address the illness status or not of ‘drapetomania’ (the supposed illness causing slaves to flee). Knowledge of aetiology and prognosis does not of itself speak to pathology.)
To defend objectivism, one needs to do some work towards showing how the apparent values of illness (the idea that there is something ‘wrong’ with one or ‘bad’ for one about illness) are not irreducibly values. As mentioned in the previous session, one might attempt to use the idea of biological function to give an idea of failure of function without that being a mere value. If the biological purpose of the eye is to see then blindness is an illness because of that failure of function. But that seeing is the function of the eye is – on this view – simply a fact determined by evolutionary theory. That approach, however, faces challenges.
So, sticking with evaluativism, if what counts as an illness is a matter of values, what kind of 'judgement' is it that something is an illness. (Obvious answer: a value judgement, stupid! Yes, but is a value judgement really a ‘judgement’: something that aims at truth?)
One method is values based practice. We can take note of its first principle and see that it is not merely designed to address questions of how, ethically, to treat and manage illnesses. It is also implicated in diagnosis because VBP assumes evaluativism is right about illness.
(Why is that a more radical view? The obvious way of combining facts and values is in making choices about how, as clinicians, to act, to intervene, to change things. Such action, on a standard view going back 2,000 years, combines both a belief (as to the facts) and a desire (a value). If I want (values) bread and believe that a visit to the shop will provide bread (a belief as to the facts) then I visit the shop. But diagnosis looks to be a judgement not directly how yet to act but simply what is the case. And so, if not an evaluativist, one might have thought that it was a judgement about, only, the facts.)
But what kind of a 'judgement' does VBP involve. Principle 5 says that it is not about right outcome but good process. That suggests that VBP judgements do not aim to get anything right (the right outcome). They do not answer to anything. So it is not judgement proper.
But if so, then, in the words of my short paper this is a form of undisciplined evaluativism. And it is not clear that the right response to it is the drawing up of a taxonomy (since how can it even aim at validity)? But what is the alternative?
Disciplined evaluativism. That allows for progress in value-judgements because such judgements answer to something objective, even if the detection of such values requires having a particular kind of mind and responsiveness to the evaluative aspects of the world.