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  • Even Ethics Professors Fail to Return Library Books
  • Havi Carel (bio)

Ethics, psychiatry, DSM, experience of illness

Tamara Kayali Browne's suggestion to create a formal role in revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) for philosophers, sociologists, and bioethicists is interesting and stems from a well-supported concern about how nosological psychiatric categories interact with both the epistemic norms of science and philosophy and with their consequences in the world. Browne is grappling with a problem that is clearly stated and pressing. However, I am not convinced that her solution, namely, using experts from these disciplines to form a veto-wielding ethics committee, is an ameliorative to this problem.

Browne identifies a problem: The process of DSM revision involves making value judgements that are not explicitly articulated nor fully disambiguated from scientific judgments about, say, the reality of some psychiatric condition. Browne suggests that a committee formed out of experts about value judgements (philosophers, sociologists, and ethicists) may inform the process and halt the production of categories that stem from confusion, ambiguity, or lack of recognition for the underlying causes of the condition. One of her examples, that of premenstrual dysphoric disorder, suggests that placing the disorder squarely within the symptomatic individual is not true to reality and does a disservice to the suffering person as well as to women in general.

Here are several points in response. First, I agree that psychiatric nosological categories require, indeed demand, the kind of scrutiny Browne advocates. However, such scrutiny cannot be limited to a committee made up of a small number of individuals. The categories need to be scrutinized more broadly by advocacy groups, patient fora, and discussion groups for health professionals, as well as by scholars and researchers who specialize in the kind of critical reflection required here. Browne seems to support the consultation process undertaken in preparing the DSM-V. However, it is not clear that a small group of experts (about which more below) would improve this already broad and open consultative process.

Second, to relegate the ethical, critical, and reflective role to philosophers and sociologists seems to miss an important point about health professionals in general, and psychiatrists in particular: Medicine is an art, as well as a science, and the virtuous or excellent psychiatrist (and medic more generally) is a skilled, thoughtful, [End Page 211] and well-informed clinician who is also equipped with additional skills. These include an attuned sensitivity and knowledge of the phenomenology of the conditions she treats, a deep understanding of how a psychiatric category plays itself out in the real world, a capacity for empathy and understanding of the background and past experiences of patients, a critical ability to question one's decisions and actions, a reflective stance towards one's own beliefs and practice, and an epistemic humility that drives a continuous desire to improve one's practice.

There is little reason to believe that a group of experts in philosophy, sociology, and ethics, who come into limited contact with the DSM creators and revisers, necessarily have these skills or have the capacity to develop these skills in psychiatrists. There is no evidence that philosophers and sociologists are more moral or more empathic than academics in other fields. It is also not clear that their expertise feeds into an improved understanding of the conditions and needs of mental health patients.

Moreover, the notion of expertise itself, as applied to ethics, may come under pressure when scrutinized. Take, for example, the work of Eric Schwitzgebel and Joshua Rust, who study the ethical behavior and beliefs of ethics professors. They have found that the kind of moral training ethics professors have does not make them more likely to behave more ethically or to have a better fit between their moral beliefs and behavior (Schwitzgebel & Rust, 2009, 2014). As they write, "Kantians lie, Confucians disrespect their elders, utilitarians buy expensive coffee" (2009, p. 1044). In fact, ethics professors behave much like anyone else; they vote as frequently as non-morally trained academics, eat meat, leave their seminar room untidy, and even misappropriate library books at roughly the same rate as other professors (Schwitzgebel & Rust...