Volume 17, No. 2, 2021 Special issue in Philosophy of Medicine

I argue that the debate concerning the nature of first-person moral judgment, namely, whether such moral judgments are inherently motivating (internalism) or whether moral judgments can be made in the absence of motivation (externalism), may be founded on a faulty assumption: that moral judgments form a distinct kind that must have some shared, essential features in regards to motivation to act. I argue that there is little reason to suppose that first-person moral judgments form a homogenous class in this respect by considering an ordinary case: student readers of Peter Singer’s “Famine, Affluence, and Morality”. Neither internalists nor externalists can provide a satisfying account as to why our students fail to act in this particular case, but are motivated to act by their moral judgments in most cases. I argue that the inability to provide a satisfying account is rooted in this shared assumption about the nature of moral judgments. Once we consider rejecting the notion that first-person moral decision- making forms a distinct kind in the way it is typically assumed, the internalist/externalist debate may be rendered moot.

We advance an approach to logical contexts that grounds the claim that logic is a local matter: distinct contexts require distinct logics. The approach results from a concern about context individuation, and holds that a logic may be constitutive of a context or domain of application. We add a naturalistic component: distinct domains are more than mere technical curiosities; as intuitionistic mathematics testifies, some of the distinct forms of inference in different domains are actively pursued as legitimate fields of research in current mathematics, so, unless one is willing to revise the current scientific practice, generalism must go. The approach is advanced by discussing some tenets of a similar argument advanced by Shapiro, in the context of logic as models approach. In order to make our view more appealing, we reformulate a version of logic as models approach following naturalistic lines, and bring logic closer to the use of models in science.

Introduction to the book symposium “THE BIOPSYCHOSOCIAL MODEL OF HEALTH AND DISEASE: NEW PHILOSOPHICAL AND SCIENTIFIC DEVELOPMENTS BY DEREK BOLTON AND GRANT GILLETT”.

In this article we offer a two-part commentary on Bolton and Gillett’s reconceptualization of Engel’s biopsychosocial model. In the first section we present a conceptual and historical assessment of the biopsychosocial model that differs from the analysis by Bolton and Gillett. Specifically, we point out that Engel in his vision of the biopsychosocial model was less concerned with the ontological possibility and nature of psychosocial causes, and more concerned with psychosocial influences in the form of illness interpretation and presentation, sick role, seeking or rejection of care, the doctor-patient therapeutic relationship, and role of personality factors and family relationships in recovery from illness, etc. On the basis of this assessment, we then question Bolton and Gillett’s restricted focus on accounting for biopsychosocial causal interactions. The second section compares Bolton and Gillett’s account with a recent enactivist account of mental disorder that tackles similar conceptual problems of causal interactions. Bolton and Gillett’s utilize elements of the 4E cognition, but they combine these proto-ideas with an information-processing paradigm. Given their explicit endorsement of 4E approaches to mind and cognition, we illustrate some key ways in which a more fleshed out enactive account, particularly one that doesn’t rely on notions of information-processing, differs from the account proposed by Bolton and Gillett.

The biopsychosocial model, which was deeply influential on psychiatry following its introduction by George L. Engel in 1977, has recently made a comeback. Recently, Derek Bolton and Grant Gillett have argued that Engel’s original formulation offered a promising general framework for thinking about health and disease, but that this promise requires new empirical and philosophical tools in order to be realized. In particular, Bolton and Gillett offer an original analysis of the ontological relations between Engel’s biological, social, and psychological levels of analysis. I argue that Bolton and Gillett’s updated model, while offering an intriguing new metaphysical framework for medicine, cannot resolve some of the most vexing problems facing psychiatry, which have to do with how to prioritize different sorts of research. These problems are fundamentally ethical, rather than ontological. Without the right prudential motivation, in other words, the unification of psychiatry under a single conceptual framework seems doubtful, no matter how compelling the model. An updated biopsychosocial model should include explicit normative commitments about the aims of medicine that can give guidance about the sorts of causal connections to be prioritized as research and clinical targets.

After nearly fifty years of mea culpas and explanatory additions, the biopsychosocial model is no closer to a life of its own. Bolton and Gillett give it a strong philosophical boost in The Biopsychosocial Model of Health and Disease, but they overlook the model’s deeply inconsistent position on dualism. Moreover, because metaphysical confusion has clinical ramifications in medicine, their solution sidesteps the model’s most pressing clinical faults. But the news is not all bad. We can maintain the merits of holism as we let go of the inchoate bag of platitudes that is the biopsychosocial model. We can accept holism as the metaphysical open door that it is, just a willingness to recognize the reality of human experience, and the sense in which that reality forces medicine to address biological, psychological and social aspects of health. This allows us to finally characterize Engel’s driving idea in accurate philosophical terms, as acceptance of (phenomenal) consciousness in the context of medical science. This will not entirely pin down medicine’s stance on dualism, but it will position it clearly enough to readily improve patient care.

In The Biopsychosocial Model of Health and Disease, Derek Bolton and Grant Gillett argue that a defensible updated version of the biopsychosocial model requires a metaphysically adequate account of disease causation that can accommodate biological, psychological, and social factors. This present paper offers a philosophical critique of their account of biopsychosocial causation. I argue that their account relies on claims about the normativity and the semantic content of biological information that are metaphysically contentious. Moreover, I suggest that these claims are unnecessary for a defence of biopsychosocial causation, as the roles of multiple and diverse factors in disease causation can be readily accommodated by a more widely accepted and less metaphysically contentious account of causation. I then raise the more general concern that they are misdiagnosing the problem with the traditional version of the biopsychosocial model. The challenge when developing an explanatorily valuable version of the biopsychosocial model, I argue, is not so much providing an adequate account of biopsychosocial causation, but providing an adequate account of causal selection. Finally, I consider how this problem may be solved to arrive at a more explanatorily valuable and clinically useful version of the biopsychosocial model.

I respond to the 4 commentaries by Awais Aftab & Kristopher Nielsen (A&N), Hane Htut Maung (HHM), Diane O’Leary (DO’L) and Kathryn Tabb (KT) under 3 main headings: “What is the BPSM really?” & Why update it?; “Is our approach foundationally compromised?”, and finally, “Antagonists or fellow travellers?”.

This article is an introduction to the special issue on philosophy of medicine. Philosophy of medicine is a field that has flourished in the last couple of decades and has become increasingly institutionalized. The introduction begins with a brief overview of some of the most central recent developments in the field. It then describes the six articles that comprise this issue.”.

Diagnostic testing can be used for many purposes, including testing to facilitate the clinical care of individual patients, testing as an inclusion criterion for clinical trial participation, and both passive and active surveillance testing of the general population in order to facilitate public health outcomes, such as the containment or mitigation of an infectious disease. As such, diagnostic testing presents us with ethical questions that are, in part, already addressed in the literatures on clinical care as well as clinical research (such as the rights of patients to refuse testing or treatment in the clinical setting or the rights of participants in randomized controlled trials to withdraw from the trial at any time). However, diagnostic testing, for the purpose of disease surveillance also raises ethical issues that we do not encounter in these settings, and thus have not been much discussed. In this paper we will be concerned with the similarities and differences between the ethical considerations in these three domains: clinical care, clinical research, and public health, as they relate to diagnostic testing specifically. Via an examination of the COVID-19 case we will show how an appeal to the concept of diagnostic justice helps us to make sense of the (at times competing) ethical considerations in these three domains.

The article presents the advantages and limitations of adaptive clinical trials for assessing the effectiveness of medical interventions and specifies the conditions that contributed to their development and implementation in clinical practice. I advance two arguments by discussing different cases of adaptive trials. The normative argument is that responsible adaptation should be taken seriously as a new way of doing clinical research insofar as a valid justification, sufficient understanding, and adequate operational conditions are provided. The second argument is historical. The development of adaptive trials can be related to lessons learned from research in cases of urgency and to the decades-long efforts to end the productivity crisis of pharmaceutical research, which led to the emergence of translational, personalized, and, recently, precision medicine movements.

In this paper, my goal is to use an epistemic injustice framework to extend an existing normative analysis of over-medicalization to psychiatry and thus draw attention to overlooked injustices. Kaczmarek (2019) has developed a promising bioethical and pragmatic approach to over-medicalization, which consists of four guiding questions covering issues related to the harms and benefits of medicalization. In a nutshell, if we answer “yes” to all proposed questions, then it is a case of over-medicalization. Building on an epistemic injustice framework, I will argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to answer the four questions, and I will import the conceptual resources of epistemic injustice to guide our thinking on these issues. This will lead me to defend more inclusive decision-making procedures regarding medicalization in the DSM. Kaczmarek’s account complemented with an epistemic injustice framework can help us achieve better forms of medicalization. I will then use a contested case of medicalization, the creation of Premenstrual Dysphoric Disorder (PMDD) in the DSM-5 to illustrate how the epistemic injustice framework can help to shed light on these issues and to show its relevance to distinguish good and bad forms of medicalization.

Medicalisation is a social phenomenon in which conditions that were once under legal, religious, personal or other jurisdictions are brought into the domain of medical authority. Low sexual desire in females has been medicalised, pathologised as a disease, and intervened upon with a range of pharmaceuticals. There are two polarised positions on the medicalisation of low female sexual desire: I call these the mainstream view and the critical view. I assess the central arguments for both positions. Dividing the two positions are opposing models of the aetiology of low female sexual desire. I conclude by suggesting that the balance of arguments supports a modest defence of the critical view regarding the medicalisation of low female sexual desire.

In this paper I discuss Wakefield’s account of mental disorder as applied to the case of gender dysphoria (GD). I argue that despite being a hybrid account which brings together a naturalistic and normative element in order to avoid pathologising normal or expectable states, the theory alone is still not extensive enough to answer the question of whether GD should be classed as a disorder. I suggest that the hybrid account falls short in adequately investigating how the harm and dysfunction in cases of GD relate to each other, and secondly that the question of why some dysfunction is disvalued and experienced as harmful requires further consideration. This masks further analysis of patients’ distress and results in an unhelpful overlap of two types of clinical patients within a diagnosis of GD; those with gender-role dysphoria and those with sex dysphoria. These two conditions can be associated with different harms and dysfunctions but Wakefield’s hybrid account does not have the tools to recognise this. This misunderstanding of the sources of dysfunction and harm in those diagnosed with GD risks ineffective treatment for patients and reinforcing the very same prejudiced norms which were conducive to the state being experienced as harmful in the first place. The theory needs to engage, to a surprising and so far unacknowledged extent, with sociological concepts such as the categorisation and stratification of groups in society and the mechanism of systemic oppression, in order to answer the question of whether GD should be classed as a mental disorder. Only then can it successfully avoid pathologising normal or expectable states, as has been seen in past ‘illnesses’ such as homosexuality and ‘drapetomania’.