An Ethics Review Panel for the DSMA Worthwhile Challenge
Psychiatric classification, psychiatric nosology, values, mental disorders, ethics
I am grateful to the commentators for their thoughts on my paper. The commentaries present a variety of views on the proposal, ranging from the view that it has too much teeth, to the view that it does not have enough teeth, and come from a range of perspectives, reflecting the spirit of the panel I propose. I respond to the commentaries in themes, clarifying certain points along the way.
The Value of Training in the Humanities and Social Sciences
Some commentators have interpreted me as implying that philosophers have a 'royal road to the truth' or that they are confined to armchair philosophizing, yet I believe neither. In these disciplines, as in other disciplines, strong arguments are based on both sound logic and evidence, and there would need to be evidence underlying the predictions and judgments made by the panel. An argument does not cease to be philosophical once evidence is invoked to support it. Further, different conclusions can be drawn depending on which forms of evidence are privileged, and this, in turn, depends on the disciplinary backgrounds of those making the assessment. This point is exemplified by the case of premenstrual dysphoric disorder (PMDD), in which it is unclear if the sociological studies on PMDD were considered alongside the clinical studies, or how and why they ultimately did not inform its revision in the Diagnostic and Statistical Manual of Mental Disorders (DSM), because the reasons behind the decisions were not made public. Experts from different disciplines not only provide different perspectives, but also bring different evidence to the fore. Including a greater variety of perspectives and evidence would then provide a more holistic picture of the issues underlying proposed revisions.
Thus, it is not that I believe philosophers and sociologists have some sort of privileged access to values. Rather, it is that explicit discussions about values are their bread and butter. They are specifically trained in such fields in a way that scientists may not be, and the theories and evidence they can draw on from their fields could add to the scientific theories and evidence presented by the DSM committees. It is not that specialist training makes people in these fields better people, or more moral than others. If my assumption was that ethical judgments of the sort made in psychiatric nosology [End Page 235] would be best made by the most moral people, I may be better off suggesting people such as the Dalai Lama for the panel. Such a belief would also make me a virtue ethicist but, as Potter observes, I have consequentialist leanings. Rather, by including people from these disciplines on the panel, it becomes a forum in which the values implicit in DSM revisions can be addressed explicitly in a way that science alone cannot do. The sciences and social sciences would inform such discussions, just as they often do in applied philosophy.
I also do not claim that philosophers and sociologists are free from their own biases, as Carel (2017) has interpreted. However, part of their training is to recognize how science is colored by the social and cultural context of the humans undertaking it. If they are good philosophers and sociologists, they should at least be reflexive. Psychiatrists are not free from bias either, but currently occupy a privileged position in psychiatric nosology. Bias inevitably creeps in to everyone's judgments, but having as much diversity on the panel as possible should reduce the effects of such bias.
The assertion made by some of the commentators that being trained in ethics does not provide one with any advantage when it comes to applying that training to ethical judgments in real cases1 begs the question as to why anyone trains in ethics at all. Moreover, if such training cannot be applied to policies or real cases, it would render clinical ethicists and ethicists who work to inform public policy redundant, and 'applied ethics' an empty term. In contrast, Lieberman shows how conceptual, ethical, and sociological issues exist even in a clinician's routine practice, and seems to advocate for individuals trained in these areas to advise not only on nosology, but also on clinical cases (Lieberman, 2017). Failing this, Carel and Potter's suggestion to develop a knowledge of ethics and critical and reflective skills in psychiatrists via training in the medical humanities may be of benefit both in the clinic and for psychiatric classification, but it undermines Carel's claim that experts in the medical humanities would be of little benefit to DSM revisions (aside from proofreading). Why is it better to develop these skills in those already involved in DSM revisions than to include people who already have those skills? Moreover, if Carel and others believe that being an ethical person is what is required for the ethical decision making involved in DSM revisions, and that training in ethics does not make people more ethical (which I do not dispute), then ethical training would not make psychiatrists into more ethical people either, and they would be left just as unqualified for ethical decision making as their non-psychiatric counterparts. Nevertheless, I endorse Potter's suggestion of providing an education in ethics as part of psychiatric training. In fact, it will be necessarily to educate those on the DSM committees as to what standards and benchmarks the panel will be seeking for them to understand what is required to have a proposal accepted and to preempt how the panel would evaluate revisions.
Cooperative evaluations from people with different theoretical leanings would indeed be difficult but, as the history of ethics panels have shown, not impossible. The fact that there is no consensus among ethicists regarding how to solve ethical dilemmas does not make ethics a useless pursuit. It is worth remembering that achieving consensus among scientists on approaches to scientific problems can also be challenging. We may not be able to solve a problem definitively or to reach the 'right' answer any more than scientists can discover 'true' theories, but we can at least achieve some progress and improve upon the current process.
Facts and Values
Blease interprets my presentation of the issues by way of a table as an indication that I believe that facts are distinct from values. This was certainly not my intention. The table is simply a way of summarizing the issues rather than rehearsing all the literature on it thus far, but its presentation is also intended to make clear that each scientific determination had value assumptions inherent within them. Presenting them in a separate column is not to say that values exist separately, but to shed light on the fact that they are present, and what they are. The table was also not meant to imply that scientists only deal with facts and the humanities and social sciences only deal with [End Page 236] values (although at one point, it seems as though Blease implies this [Blease, 2017, p. 232]). The two are intertwined—facts inform values and vice versa—and saying so does not necessarily make me a Foucauldian or a social constructionist. As Hughes and Ramplin argue, clinical judgments in themselves reflect a certain set of beliefs and values because facts in the context of healthcare are inherently value laden:
The presence of a purpuric rash and the associated diagnosis of meningitis carries with it, inherently, the requirement to act in certain ways.... This is what the normativity amounts to and our suggestion is that this reflects the nature of clinical judgments as being, at one and the same time, ethical judgments.
It is because there is less agreement concerning the values inherent in the classification of mental illness than there is concerning the values inherent in the classification of other medical disorders that it is worth bringing the value judgments inherent in classifying mental illness to the fore, rather than explicitly dealing only with the facts as though those facts are not also infused with values. One need not rehearse the 30 or more years of literature on this issue to make this point.
Some of the commentators suggest that the panel would be even more effective if it also included experts from other disciplines such as anthropology, epidemiology, social policy, and psychology. I agree wholeheartedly. The panel need not consist only of philosophers, sociologists, and ethicists, nor does the panel have to be small. My focus in the original paper on value judgments in psychiatric nosology caused me to look to the fields in which this discussion has mostly taken place. However, the commentators are right in taking a broader perspective by looking to other fields that would inform such deliberations.
What is considered normal and pathological is dependent on our cultural context and the DSM applies an American perspective to these measures. Yet the DSM is relied upon not just in the United States, but in many other countries. Anthropologists would therefore provide valuable insight into the cultural issues and perspectives that should also inform DSM revisions.2 The panel would need to understand the effects as well as the determinants of psychiatric diagnosis at a population level, so epidemiologists would also provide useful expertise. As the commentators note, patients are also experts in their own right, with the sort of perspective that would be valuable in informing how DSM revisions are likely to affect people in practice. Indeed, their voice could be pivotal if there is a deadlock between, say, utilitarians and deontologists on a particular issue, which may well occur if there is a good plurality of perspectives represented on the panel.
There are also psychiatrists who are concerned with, and are able to discuss, the sorts of issues that would concern the panel, just as there are philosophers and others who are able to discuss the science. Such psychiatrists should also be included provided that they, alongside the others on the panel, are free of conflicts of interest. In fact, psychiatrists will certainly need to be included because they have the technical knowledge that is needed to inform the practical concerns of the panel, such as the likely repercussions of the panel's suggestions for clinical practice.
Pouncey and Merz's (2017) claim that I privilege my own disciplinary perspective and personal values (although they are unclear as to what my values are) and that I do not consider whose values matter is ironic. It is precisely because I recognize that those with power are those who decide what is and is not normal that inspired me to propose the multidisciplinary panel they dislike. Currently, those who revise the DSM come largely from one discipline. Rather than privileging this discipline, I suggest involving those from other disciplines in a way that would have real impact. Yet also, as Cooper (2017, p. 207) reminds us, "the committees that write the DSM tend to be comprised 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 would, therefore, be important to also include people from a variety of different cultures, ages, genders, and socioeconomic backgrounds, as well as different disciplinary backgrounds. [End Page 237]
Cooper and Carel suggest that philosophers could instead function as proofreaders, with Carel (2016, p. 212) suggesting that they could also "question the underlying framework of the psychiatric classification." Yet the latter would go beyond merely proofreading. Although proofreading is better than nothing, it is quite a modest role indeed and undersells the skills that philosophers can offer. If the fear of annoying psychiatrists stymies efforts to improve the DSM, this may hold back progress in the field. If a similar fear had prevented ethics review panels from being set up to assess scientific studies before they went ahead, both science and study participants could have suffered. As Enfield and Truwit (2008, p. 1335) state, "Though researchers may find the IRB [institutional review board] process overwhelming and overbearing, it is necessary to ensure that researchers are not left in the position of balancing the scientific benefits of new knowledge with the ethical dilemmas that seeking that knowledge might create." The practicalities of bringing such a proposal to fruition would not be easy, but may well be worth it. Cooper (2017) also suggests inviting individuals who have a different perspective from those already on DSM committees to comment on the draft criteria. Yet this has already been done, and does not seem to have prevented invitees such as Paula Caplan (2008) from feeling that their views were overlooked.
PMDD and Protests
Miller (2017) took issue with the PMDD example and I feel its function has been overstated. I used it merely as an example of how the panel might deal with a proposed DSM revision. I chose PMDD because the case of homosexuality in the DSM is now old and well-rehearsed, whereas PMDD is a very recent case. Obviously, I have no way of knowing what a panel would have actually decided regarding PMDD, or homosexuality for that matter. Regardless, as Miller notes, I need not know this to make the case for a panel—I merely have to show that it is better than the current process. Currently, anyone can make submissions to the American Psychiatric Association (APA) regarding DSM revisions, and anyone can protest if they wish (if they live in a country that allows public protest). Yet matters may need to be very problematic indeed to garner protests, and the absence of protests does not mean an absence of problems. Moreover, those most vulnerable to injustice are those who lack power, and may not even be able to protest—children, for instance. Thus, we should not rely on protests alone to tell us when a revision is questionable. This sort of pressure is not always successful either. A panel is not necessarily better than protests, but would be another mechanism through which concerns could be heard and addressed and can exist alongside activism. Having both should (one would hope) be better than protests alone.
The Biopsychosocial Approach
Having some biological symptoms does not necessarily mean it is "biology all the way down," and vice versa, as Porter notes. Indeed, I address this in my paper on PMDD (Browne, 2015). Yet the etiological neutrality that the APA has applied to the DSM has in practice translated into a onesize-fits-all biomedical model. The problem is that this model does not seem to fit all cases. Distress with different antecedents can have similar effects on the body and manifest in similar symptoms, but a focus on the symptoms and medical intervention can cloud the advantages of tailoring one's approach to suit the patient's circumstances and the antecedents of their distress. Socially rooted distress is no less real than that which is biologically rooted, and should be taken just as seriously. As Porter asserts, those from the humanities and social sciences can help to dissolve the ontological divide that effectively privileges the biological over the social in psychiatric nosology.
The Function of an Ethics Review Panel
Pouncey and Merz seems to be quite offended, while simultaneously unsure as to what they are offended about. To clarify, I suggest the panel vote on whether to accept, reject, or recommend modifications to proposed revisions, and the only value I promulgate here is that the values inherent [End Page 238] in psychiatric classification should be explicitly and expertly addressed (Browne, 2017). I believe that doing so could provide a better classification system, both for psychiatry and for society, because a similar process already in place for review of scientific studies, although imperfect, is better than not having one at all. (Although admittedly, the panel's concern with the potential impact on the population is much wider than that of IRBs, which are usually concerned with the potential impact on research participants.)
By arguing that the panel would be morally objectionable because it is inconsistent with the function of ethics review panels with which they are familiar, Pouncey and Merz first commit the is–ought fallacy. Even if it were true that such panels have no teeth, that would not prove that they should have no teeth. Second, ethics review panels do in fact have a similar function to that of the panel I propose, as exemplified by the U.S. Food and Drug Administration's explanation of the role of an IRB:
Under FDA regulations, an IRB is an appropriately constituted group that has been formally designated to review and monitor biomedical research involving human subjects. In accordance with FDA regulations, an IRB has the authority to approve, require modifications in (to secure approval), or disapprove research.
Moreover, privately funded clinical trials are also subjected to IRBs. So if a panel for the DSM is, indeed, "ethically imperialist," as Pouncey and Merz claim, then so are IRBs.
What is most egregious about Pouncey and Merz's argument is that their assumption that the power to make the value judgments inherent in psychiatric nosology should remain with those on the APA, most of whom are psychiatrists, is itself scientifically imperialist. Their argument implies that they favor the values of the DSM over others, and think that the values of the APA, which has a financial interest in widening the boundaries and increasing the number of diagnostic categories (Cosgrove & Wheeler, 2013), should trump the concerns of those from other disciplines who do not stand to gain from the DSM or its outcomes. Moreover, if scientists were to argue the same thing with regard to IRBs—that we should do away with them because it is ethically imperialist to suggest that scientific studies should be subject to any kinds of checks and balances—it would set bioethics back decades.
Despite being produced by a private organization, the DSM fulfils a public function. There are some who would suggest that because of this, it would be better to have the DSM out of the hands of private, for-profit industry altogether. However, I believe there remains scope for the APA to work with a panel such as the one I propose, particularly if the APA sees its benefit to the DSM. Even a panel that merely makes recommendations, if it is taken seriously and genuinely sought for guidance, may prove more effective than a panel that is only viewed as a mysterious hurdle to surmount. This is why it is important that there be goodwill among all parties in such an endeavor, and that once the details are worked out and the panel set up, its rationale is clearly communicated to the DSM committees.
In addition to being transparent (both to the APA and to the public), the panel should also be accountable. As such, its own decisions should be subject to audit. An audit would also provide an opportunity for the model to be reconfigured if need be. For instance, if the majority voting system begins to suffer problems, the process could be changed to an alternative, such as a qualified majority or a consensus. The panel, like many other panels, will be imperfect and certainly not capable of solving all the issues in psychiatry. Yet it would still be better to have one than none at all, and if it is adaptable it stands a better chance of responding to the issues it faces and improving with time.
The scholarly community has taken part in years of debate concerning the values inherent in psychiatric nosology and we know that this nosology has real consequences. Currently, these value judgements are being made by psychiatrists who may or may not be aware that they are doing so, and may or may not be trained to do so. My proposal presents a way of addressing these issues, explicitly and expertly. It may be challenging to set up but would, in the long term, likely prove beneficial. [End Page 239]
Tamara Kayali Browne is a Lecturer in Health Ethics and Professionalism at Deakin University, Australia. She completed her PhD at the University of Cambridge. Her book, Depression and the Self: Meaning, Control and Authenticity, will be published with Cambridge University Press in 2018. She is the author of several papers on the ethics of sex selection and the philosophy of psychiatry, which are collected at https://deakin.academia.edu/TamaraKayaliBrowne. She can be contacted at firstname.lastname@example.org
I am very grateful to Tim Krahn for his insightful feedback on this response.
1. Note that this is different to claiming that training in ethics makes one a better person, which I do not claim.
2. I am grateful to Beatriz Reyes-Foster for this point.