- Valid Ethics Versus Probable Histories
DSM, premenstrual dysphoric disorder, nosology, counterfactual historiography
Tamara Kayali Browne's proposal for an Ethics Review Panel (hereafter, "the panel") for the Diagnostic and Statistical Manual of Mental Disorders (DSM) conceives of a state-sponsored panel of academic experts—philosophers, sociologists, and bioethicists—dealing in a reflective, systematic, and standardized manner with the "value judgements" that are an "integral and unavoidable part of psychiatric nosology" (Browne, 2017, p. 189). The panel would consider existing and new diagnostic categories, and issue authoritative vetoes and/or modifications as appropriate. Browne asserts that, "it should not be necessary to have protests and political activism, such as that involved in removing homosexuality from the DSM, in order for the status quo to be reassessed" (Browne, 2017, p. 192). The panel, in other words, is intended to do via expert deliberation what has been done previously via the apparently lesser methods of "protests and political activism."
My criticism of Browne's article concerns its historiographic argumentation. To exemplify the panel's work, she offers a counterfactual history of premenstrual dysphoric disorder (PMDD). The selection of PMDD—rather than, say, homosexuality—is unhelpful to her case, and her narrative of a counterfactual deliberation on PMDD does not sufficiently distinguish, nor defend, its historical probability.
Browne lists three areas that the panel of philosophers, sociologists, and bioethicists would respectively address: value judgements, societal consequences, and harm–benefit analysis (Browne, 2017, p. 193). She concretely illustrates these debates in her account of a hypothetical panel discussion of PMDD. The diagnosis is a DSM-5 category that Browne believes should be discontinued, and that she argues would have been vetoed by the panel, had it existed: "it is most likely that a panel of philosophers, sociologists and bioethicists would have rejected the proposal to list PMDD as a diagnosis in DSM-5" (Browne, 2017, p. 196). Note the counterfactual conditional: An important, concrete element in Browne's case for the panel is the inference that, had the panel existed, it would have rejected PMDD for valid reasons. Although I concur with analysis that regards counterfactual reasoning as essential, although often implicit, to historiography (e.g., Bunzl, 2004), I believe that there are at least two problems in Browne's argument by counterfactual history.
The first problem is the selection of PMDD. It is not explained why PMDD should be particularly useful for her historical argument. This is a significant omission because the history of homosexuality in DSM, and a corresponding counterfactual history, would seem a better-informed alternative. There is a growing body of material that refers specifically to homosexuality in DSM (e.g., [End Page 219] Bayer, 1981, Drescher & Merlino, 2007), beyond the brief intraprofessional historiography that Browne cites (Zachar & Kendler, 2012), and an indefinitely large hinterland of social and cultural histories of gay rights and activism. In particular, a discussion of homosexuality would have allowed Browne to identify what functions of "protests and political activism" could have been taken on by the panel. Because there is, for instance, no well-known equivalent of the Stonewall riots for PMDD, Browne's counterfactual history leaves unclear precisely what the panel would be taking over from the political and public spheres. The suspicion, therefore, arises that Browne's choice of PMDD stacks the deck in her favor: Because no substantive actual (i.e., non-counterfactual) history of PMDD is provided by Browne, one cannot readily discern, for instance, whether the panel's deliberations are an unlikely or improper substitute for "protests and political activism." Moreover, Browne's selection of a currently contentious diagnostic category poses a problem to readers who disagree with her conclusions on PMDD's validity. Those who have come (as they see it rationally) to a different (e.g., biomedical) conclusion about PMDD are confronted with a counterfactual history in which the panel comes to precisely the wrong conclusion. If they accept Browne's counterfactual historiography, but reject her nosology, then they will oppose her proposal. Choosing an uncontentious invalid category such as homosexuality would have circumvented this obstacle.
The second problem is that Browne's discussion of the panel's hypothetical deliberations simultaneously...