- Browne's External DSM Ethical Review PanelThat Dog Won't Hunt
Ethical imperialism, nosology, values, DSM, advisory committees
Before we respond to Tamara Browne's (2017) proposal for an external ethics advisory review panel to oversee content in the Diagnostic and Statistical Manual of Mental Disorders (DSM), we wish to introduce ourselves. One of us is a professor of bioethics, a lawyer, and a doctor of public policy (JM), and one of us is a philosopher of psychiatry who studies psychiatric nosology, and who has done bioethics work for two congressional advisory agencies (CP). Based on our backgrounds, we flatter ourselves that we might be considered as members of the DSM ethical review panel Browne proposes. However, we realize that one of us would likely be ineligible because of a lack of experience in psychiatry, and the other would likely be ineligible because she not only has experience in psychiatry but is a member of the American Psychiatric Association (APA).
Browne argues for the formation of an ethical review panel for DSM that exists external to the APA, and that has authority to reject proposed or existing DSM disorder or diagnostic criteria on moral grounds. Because some of the values DSM expresses are tacit, and because Browne sees psychiatry as incapable of identifying and exploring evaluative concerns about the DSM, she proposes a panel composed of philosophers of psychiatry, bioethicists, and sociologists (no psychiatrists) that would advise the APA about content, but would ultimately have the power to decide what is and is not included in the DSM.
Browne's review panel is meant to address two problems faced by the APA. The first is that unrecognized, tacit values in the DSM generate criticism of its content, revision process, and use. We deny that this is a problem for the APA so much as for Browne. The APA has never indicated that the debates or controversies over its nosology are in any sense unwelcome or unexpected. Rather, the APA has made efforts to include different points of view in its revisions, even if it has not been all inclusive or transparent in its deliberations (Spitzer, 2009). The DSM-5 revisions welcomed various perspectives in work groups, on its web site (DSM5.org), in the psychiatric literature, and at conferences. Because the DSM is by definition a work in progress, a summary of nosologic thinking at a particular temporal point that is intended to be further refined and developed over time, the APA treats it as a living document rather than the last word on mental disorders. It is not apparent that the APA considers itself in need of a panel [End Page 227] that would prophylax against any future criticism of the DSM.
The other ostensive problem Browne's proposal addresses is that the "current membership does not include experts who are well-placed to deal with [ethical] issues and their explicit assessment is currently not an essential part of the (DSM revision) process" (Browne, 2017, p. 198).1 Browne gives no indication that she knows anything of the academic training; personal, professional, or academic experience; or clinical concerns of those who use or write the DSM. As in any field of study—philosophy, sociology, and bioethics included—psychiatrists are not all one-trick ponies. As this journal attests, many psychiatrists are quite capable of discussing the subtleties of value theory and philosophy of psychiatry.
Again, there is no reason to think Browne is addressing an actual need of the APA, so much as expressing her own values. She does not demonstrate that psychiatry has inadequately identified tacit nosological values or ethical implications of nosological decisions, merely that it has been criticized for doing so. The existence of criticism, Browne's included, indicates nothing other than that such critics are unsatisfied with APA's deliberations and their product. Although Browne argues that vociferous public criticism of DSM-5 draft language "did not prevent those criticisms and recommendations from being ignored" (p. 191), this is an empirical claim for which she offers no support. The content of deliberations by which suggestions for DSM-5 were reviewed, and recommended or...