- Ethics Experts, Pedagogical Responsibilities, and Wishful ThinkingRevising the DSM
Ethics experts, pedagogical responsibilities, wishful thinking: Revising the DSM
Tamara Browne argues that many of the controversies that emerge in the process of revising DSMs could be solved by the creation of an Ethics Review Panel, similar to that of a research ethics committee. Members of such a panel would, in Browne's words, "help inform psychiatric classification" (Browne, 2017, p. 188). Browne's proposal is important on a number of levels, the most significant one being that it affirms the status of ethics as equal to that of science. An Ethics Review Panel would do more than merely make the processes of scientific and ethical judgments parallel: if Browne's suggestions were followed, it would raise ethical considerations to that of second-order status to scientific judgments in the revision process. I applaud the daring suggestions that Browne makes. Nevertheless, I am not yet sold on this idea. My remarks focus primarily on the idea of ethical experts.
Browne is correct in noting that science cannot authoritatively answer questions of value. Value judgments, as John Sadler has argued, are endemic to nosology, sometimes in a way that medicalizes social conditions with unjust and harmful results (Sadler, 2002, 2005). But I stumble when I read Browne's assertion that "the knowledge base and years of thought and research that [ethics] experts can bring to the panel probably places them in a better position to make recommendations on these issues" (Brown, 2017, p. 192). We who are trained in psychiatric ethics probably are just as vulnerable to our own value commitments, confirmation biases, and stubbornness about other people's ethical positions as are scientists. In referring to "those best placed" to weigh in on ethical considerations (Brown, 2017, p. 189), Browne makes a number of assumptions that should be questioned. First, even philosophers trained in ethics often are not adequately equipped to make good moral judgments on the ground; knowing theory is not the same as judging well in specific cases. Competing theories, and impassioned commitments to one's pet theory, make cooperative evaluations across theoretical differences difficult. For example, some philosophers argue that the distinction between killing and letting die is bogus and that the two actions are morally equivalent; others, like Francis Kamm (1996), disagree. No amount of ethics [End Page 203] training seems to be able to resolve the quarrels between this divide. Take the well-known trolley problem in ethics, which is meant to illustrate the messiness not only of the distinction between killing and letting die, but also the seeming arbitrariness of deciding this question. The trolley problem is this: "Edward is the driver of a trolley, whose brakes have just failed. On the track ahead of him are five people; the banks are so steep that they will not be able to get off the track in time. The track has a spur leading off to the right, and Edward can turn the trolley onto it. Unfortunately, there is one person on the right-hand track. Edward can turn the trolley, killing the one, or he can refrain from turning the trolley, killing the five (Thomson, 1976). This case is juxtaposed with another, where David, a transplant surgeon, has five patients, who all share the same rare blood type and who each needs a crucial body part to prevent their deaths, and David finds a healthy specimen with the same rare blood type. The question is why it would be impermissible for David to use his healthy specimen to save his patients' five lives yet permissible for Edward to turn to trolley to save the five lives. If David does nothing, his five patients will die; if Edward does nothing, five people will die. How are these cases then different? Kamm attempts to resolve the trolley problem by proposing that we adopt a principle of permissible harm, but this principle itself is contested (Otsuka, 1997). Kamm claims that there is a moral distinction between harm that is an effect or aspect of a causal means to the greater good and harm that is an effect or aspect...