A Modest Proposal

There are many points on which I agree with Kayali Browne (2017). I agree that value judgments necessarily play a role in constructing a classification such as the Diagnostic and Statistical Manual of Mental Disorders (DSM). I agree that people with different backgrounds and interests are likely to assess problems differently and that it would be a good idea for a more diverse body of people to have some involvement in revising the DSM. I agree that philosophers might usefully play a role when the DSM is being revised.

Overall, however, I am not convinced that Kayali Browne's committee would be a good idea. In her vision, such a committee would constitute a group of wise moral experts who would help to make the value judgments implicit in the DSM as well-informed as possible. Along with many others I am skeptical of the idea that philosophers should be construed as moral experts in the sense of being particularly good at making practical moral decisions (see, for example, Archard, 2011; Engelhardt, 2002). I worry that philosophers may not actually be able to make all that much progress in addressing the sorts of deep moral question that Kayali Browne envisages being addressed (e.g., how to weight the diffuse social harms caused by medicalization against the benefits that particular individuals might gain from treatment, how to distinguish between willful wrongdoing and disordered behavior). Although philosophers have an important role to play in reminding people that such issues remain unaddressed and lurking behind the decisions that inform the DSM, I do not think that a committee would be required to achieve this modest goal. I also worry that a committee of philosophers armed with veto rights over proposed revisions to the DSM would strain relations between philosophy and psychiatry. The risk is that the philosophers would come to be viewed as know-nothing busybodies. Some prominent psychiatrists already take such a view when humanities scholars write on mental health topics (e.g., Brown, 2010; Pies, 2010).

Rather than Kayali Browne's committee, I will suggest a more modest proposal. While Kayali Browne focusses on how hard and deep moral questions might be dealt with, I think the priority is to consider how tractable issues might be better addressed. I suggest how some value-based problems with the DSM might be avoided fairly easily, and then consider the particular roles that philosophers might play in revising the DSM.

Some of the value-based problems that afflict the DSM arise because the committees that write the DSM tend to be composed of a certain type of person (typically, middle-aged, affluent, clever, White, male, doctors). When such people write diagnostic criteria, they do so with their implicit view of 'normality' in mind. It is very easy for such people to assume, for example, that 'normal' children will work hard at school and not get into trouble with the police, and that 'normal' adults will drink a bit, but not too much, and be fairly independent, and gainfully employed. On occasion, such assumptions creep into diagnostic criteria and place the members of particular communities at increased risk of underdiagnosis or overdiagnosis. Often, all it takes for such criteria to be improved is for other people, with different life experiences and assumptions, to point out the biases that are at work.

To illustrate, consider the DSM-5 diagnostic criteria for phobia. In the DSM-IV, patients had to recognize their fears as unreasonable. In the DSM-5, the fear merely has to be judged by the clinician to be out of proportion. The change aimed to make possible the diagnosis of some older adults who develop intense fears, say of falling, but who perceive their fears to be reasonable (LeBeau et al., 2010). However, I suggest the revision was a mistake. Consider the case of someone who develops rational fears on the basis of information that the diagnosing clinician lacks. Take a scientist working on avian flu whose studies lead her to the conclusion that a worldwide pandemic is imminent. She comes to develop rational fears about sick birds...