Value judgements in psychiatric diagnosis an explanation from ethical theory

Diverse explanations have been offered for the prominence of overt value judgements in psychiatric diagnosis. For some it endorses the radical antipsychiatry position that psychiatry is not a part of medical science. (18) Others have argued that it reflects the primitive state of the sciences underpinning psychiatry. (2 23) Ethical theory, by contrast, the area of moral philosophy concerned with the meanings and implications of value terms, offers an explanation which is fully consistent both with the status of psychiatry as a mature scientific discipline and, at the same time, with the pivotal role of value judgements in psychiatric diagnosis.

A clear account of the relevant ethical theory has been given by a former Professor of Moral Philosophy at the University of Oxford, R. M. Hare. (2,25) We shall look briefly at his work and then apply it to the medical context. Hare pointed out that value terms have two elements of meaning:

• an evaluative element proper—this is the value judgement expressed by the term in question (Hare called this the term's 'prescriptive' or action-guiding meaning);

• a factual element—this covers the factual criteria on which the value judgement expressed by the value term is based (Hare called this the term's 'descriptive' meaning).

Thus, the value term 'good eating apple' expresses the value judgement that an apple is good to eat (the term's evaluative meaning) based on facts about the apple in question such as that it is grub-free, clean-skinned, sweet, and so forth (the term's factual meaning).

Note, though, Hare continued, that where the use of a given value term depends on factual criteria which are widely settled or agreed upon, its factual meaning may come to eclipse its evaluative meaning. Thus, in a case like 'good eating apple' the factual criteria are widely agreed; for most people in most circumstances a good eating apple is one which is 'grub-free, clean skinned, sweet, and so forth'. By association, then, 'good eating apple' has come to mean an apple which, as a matter of fact, is grub-free, clean-skinned, sweet, and so forth. But in a case like 'good picture', by contrast, people's values differ widely; hence there are no widely agreed factual criteria available to become stuck by association to 'good picture' and the meaning of 'good picture' remains overtly evaluative.

We can now apply this to the medical case. The key point is that if 'illness' (including its cognates, such as 'disease') is a value term, then the persistence of overtly evaluative meaning in our use of ' mental illness' will reflect diversity of values. The details of this have been worked out by one of us elsewhere.(26) However, we can gain a general idea of the relevance of Hare's theory from the relative diversity of values in the areas with which physical medicine and psychiatry are respectively concerned.

• Physical medicine is concerned, by and large, with areas of human experience and behaviour over which our values are more or less uniform. Central chest pain and collapse, for example, are bad experiences for anyone.

• Psychiatry, in contrast, is concerned with areas of human experience and behaviour—emotion, desire, belief, volition, and so forth—over which our values are highly variable. What is judged a good or bad desire, a good or bad belief, and so on, varies widely, between individuals, between cultures, and at different times.

In this respect, then, physical illness is like Hare's 'good apple' case, whereas 'mental illness' is like Hare's 'good picture' case. Hence it is by virtue of diversity of human values, rather than because of any (supposed) deficiency in psychiatric science, that our diagnostic concepts in psychiatry are overtly value laden. In the language of science, we can say that whereas in much of physical medicine the values relevant to diagnosis are a constant (because people's values are the same), in psychiatry they are a variable (because people's values differ).

This explanation does not imply that psychiatry is any less scientific (because more overtly value laden) than other areas of medicine. On the contrary, Hare's distinction between the factual and evaluative elements in the meanings of value terms helps to clarify what is genuinely scientific in psychiatry. Careful examination of the mental state, the development of causal theories, and so on, remain as important here as in an exclusively scientific model of psychiatric diagnosis. This is why ethical theory is fully consistent with the status of psychiatry as a mature scientific discipline. It adds values to, rather than subtracting facts from, psychiatry. What the explanation from ethical theory does imply, however, is that whereas in much of physical medicine we can ignore individual values in making a diagnosis (because the relevant values are a constant), in psychiatry we cannot (because they are a variable). This conclusion has a number of important practical implications for the role of ethical reasoning as a key practice skill in medicine.

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