- Commentary on “Epistemic Value Commitments”
A disquieting feature of contemporary psychiatric nosology is the tendency to adopt positions that imply that current classifications are simply statements of fact. Clinicians and researchers alike seem to assume that the DSM diagnostic concepts are factual descriptions based only on scientific analysis that reflect the essential nature of psychiatric disorders. The architects of the DSM acknowledge in various ways that this is not the case. Frances et al. (1991), for example, noted the provisional and pragmatic nature of DSM-IV. Nevertheless, these cautions are largely ignored. The DSM is partly responsible. The assertion that the DSM is atheoretical with regard to etiology, although clearly incorrect, tends to generalize to other aspects of the system. Similarly, the emphasis on description that has proved so valuable in improving diagnosis is presented as if clinical description is unencumbered by values and assumptions. Moreover, the failure to state explicitly the assumptions underlying the classification encourages the conclusion that the system is free from theoretical and other influences.
In fact the DSM is theory laden. Implicit theoretical models and etiological concepts lie behind many diagnoses, including adjustment, dissociative, and posttraumatic stress disorders. Assumptions about the nature of mental disorders and the way psychopathology is organized underlie the entire system (Livesley and Jackson 1992). Pragmatic and political considerations influenced the final structure. Moreover, as Dr. Sadler and others working on the same issues (Fulford 1989, 1994; Agich 1994) point out, the DSM is also value laden. It is value laden not only in the obvious sense that some diagnostic concepts are highly evaluative or biased against certain groups (Kaplan 1983), but also in the fundamental sense that values are built into the very structure of the system (Agich 1994; Russell 1994; Wakefield 1992).
Value influences begin with the definition of mental disorder. As Wakefield (1992) and others have argued, the concept of disorder cannot be value free. Values are also involved in the descriptive terms adopted as diagnostic criteria (Agich 1994) and, as Dr. Sadler convincingly demonstrates, they are intrinsic to the way that the classification is constructed and evaluated—the very aspects of the classification that are generally assumed to be value free. By emphasizing this aspect, Dr. Sadler draws attention to the fact that despite being implicit and informal, these values exert a major influence. They influence kinds of information considered relevant to the classification, the way this information is weighted and evaluated, and the way it is organized into diagnostic concepts. Thus, values shape the classification and the research agenda. This point has not [End Page 223] been fully recognized, or at least not fully acknowledged, by those responsible for developing contemporary classifications. There is a tendency to assume that any values involved in the DSM are largely evaluative and incidental, as if they crept into the system inadvertently due to our limited knowledge. The implication is that their presence is merely a temporary embarrassment to be eliminated automatically as clinical description and phenomenology are refined. But this is not the case; any classification of mental disorders inevitably consists of fact plus value (Fulford 1994). Acknowledgment of the evaluative element does not detract from the achievements of the DSM. It is not a limitation but an essential component.
The general failure to attend to the non-factual or non-descriptive aspects of classification means that important aspects of classifications are neglected. The impact of pragmatic considerations, political and economic factors, and ethical and epistemic values on the organization and evaluation of scientific information has not received appropriate attention given the social, clinical, and scientific consequences of contemporary psychiatric classifications. In essence, only a limited aspect of classification has been studied, and even this has been studied in isolation from its context. Under these circumstances there is much to be gained from explicit acknowledgment and analysis of the value component. We are more likely to make progress in resolving nosological issues if we take a broad perspective.
For the nosologist, Dr. Sadler makes two useful contributions to understanding the broader view. First, the analysis of value is extended beyond discussion of evaluative or ethical values into a detailed analysis of the epistemic values that...