Psychiatry and Values

This issue of the Hastings Center Report includes a special report that comes out of a three-year Hastings Center research project on controversies surrounding the diagnosis and treatment of mental disorders in children. Over the last couple of decades, the number of children diagnosed with mental disorders has risen significantly, and so, too, has the number of children prescribed medications. Some critics have accused psychiatry of overdiagnosis—of sometimes diagnosing children with psychiatric disorders when their behavior is actually within the range of normal. This controversy led Erik Parens and Josie Johnston, authors of the report and the Hastings Center investigators in this project, to ask what a psychiatric diagnosis is: what kind of statement is it? Is it just a statement of fact? Or does it necessarily reflect individual and cultural values? Similarly, how does a treatment decision work?

These matters are exceedingly complex, Parens and Johnston argue. Both the diagnosis of a disorder and the decision about how to treat a disorder (when one is diagnosed) incorporate value judgments at several junctures. This dependence on value judgments helps explain disagreements in diagnosis and treatment. Of course, both diagnosis and treatment also incorporate facts that everyone can agree to, and ultimately, some factual claims about diagnosis are possible. One of the most significant of these noted in the report is that a careful examination of diagnostic patterns in pediatric psychiatry reveals not just overdiagnosis but also misdiagnosis and underdiagnosis.

The special report is part of a growing body of work at the Center that looks at how "normal" is defined and deployed. Parens, for example, has also conducted projects on surgical normalization of children's bodies, on prenatal testing for disability, and on the use of enhancement technologies. The approach toward which Parens has been moving over the course of these projects is characterized by what he sometimes calls "binocularity." That word does not pop up in this report, but the idea certainly does. The values at stake in diagnosis and treatment decisions sometimes compete with each other. Parens and Johnston argue, for example, that a treatment decision can be influenced both by the value of efficiency—it's nice when treatments are quick and convenient—and the value of engagement—for there is value, too, in taking time to work with a child and with his environment. Efficiency and engagement compete with each other on occasion, and when they do, it's important to remember both of them. That's binocularity: keeping competing values in tension with each other, recognizing that both values pull on our allegiance and that while some individuals may lean toward one value, others may in similar circumstances lean toward the other, and neither may be wrong.

Which is to say, neither is right. Both are defensible. As I understand it, then, binocularity assumes a distinction between public and private morality (between "cultural and individual values," in Parens and Johnston's language). That distinction is not widely accepted in bioethics, I believe—most discussions try to sort out which value should win out in which kinds of cases—but accepting it might well lead to a richer bioethics.