Doctors, psychiatrists and disease

Soc. Sci. Med. Vol. 20, No. 5, pp. 535-543, 1985 Printed in Great Britain

0277-9536/85 $3.00 + 0.00 Pergamon Press Ltd

DOCTORS, PSYCHIATRISTS A N D DISEASE MICHAEL LAVIN Department of Philosophy, The University of Tennessee, Knoxville, TN 37996, U.S.A. Abstraet~The paper's aim is to show how moral concerns may be kept segregated from strictly medical concerns. To do this, the doctor's speciality is characterized in terms of disease. Doctors may plausibly make special claims qua doctors when they are treating disease. Since mental diseases are sometimes thought to be no more than immoral behavior, the concept of disease receives detailed treatment. So-called 'antipsychiatric" arguments against the existence of purely mental disease are restated. It is accepted that these arguments illustrate the need to insist that genuine diseases have, at least in principle, an underlying physical pathology. It is then argued that prevalent philosophical analyses which seek to do away with the physical pathology requirement do not adequately meet antipsychiatric arguments, and threaten to allow the annexation of morals by medicine. Finally, some conclusions are drawn as to what conclusion might reasonably be drawn concerning psychiatry if it is allowed that diseases must involve physical pathology.

Medicine is commonly distinguished from morals. The distinction blurs when analysis fixes on a particular branch of medicine, psychiatry. As many, most notably Thomas Szasz, have noted, psychiatry tends to absorb what seem to be moral problems. Hence the charge that psychiatry routinely confuses problems of living with problems for medicine. The inclusion of such diagnoses as Telephone Scatalogia in the American Psychiatric Association's official diagnostic manual (DSM III) fuels the charge. The pervasive, underlying suspicion is that psychiatrists are imperialists who wish to make morals a colony of medicine. To clarify the suspicions about psychiatry, I shall soon consider what I want to call the doctor's speciality. The Oxjord English Dictionary states that 'speciality' means "a special or distinctive quality, property, characteristic, or feature" or a "peculiarity". Although I am unable to define the doctor's speciality--medical specialism is too broad and medical interests are too varied to make definition a realistic expectation--I shall argue that a particular characterization of the doctor's speciality illuminates many of the charges brought against psychiatry. I do not, however, believe that the peculiarity that I rely on to characterize the doctor's speciality is unique to doctors. My characterization should be judged by the insight it provides for assessing the charge that psychiatrists cannot distinguish, on any principled grounds, the medical from the moral. Since the paper is long, it is helpful to have a general outline of the argument. I shall proceed as follows: (1) I characterize the doctor's speciality in terms of disease. Doctors are indisputably engaged in medicine when treating disease. (2) I reconstruct 'antipsychiatric' arguments against the existence of purely mental disease, thereby undermining claims psychiatrists make for special moral entitlements based on their medical speciality. (These entitlements typically permit psychiatrists to overrule the presently expressed desires of their patients, since mentally sick patients are not fit judges of their own good.) ssM 20,5 ~

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(3) I argue that some prevalent philosophical analyses of disease do not adequately meet the antipsychiatric arguments. (4) I reflect on what conclusions may reasonably be drawn in light of (3). THE DOCTOR'S SPECIALITY Medical science has among its central tasks the prevention, palliation and when feasible, elimination of a portion of human suffering. But if doctors view these central tasks as specially their own, they might do so as a consequence of their speciality. For vast portions of human suffering neither do nor could respond to medicine. Economic hardships occasion misery as surely as plagues, but it is for plagues, not recessions, that doctors accept special responsibilities. The scope of the doctor's expertise and responsibility as a doctor is my theme. It is no trivial matter to settle on principled grounds what doctors have an obligation to do as doctors and on what matters doctors are specially expert. Often, to take one example, the extent to which individuals are held morally accountable for their behavior will depend on judgments about their health. And on health, doctors ordinarily have the last word. Consequently, courts may solicit expert psychiatric testimony when attempting to determine if a man's mental health is compatible with holding him responsible for something he has done. Moreover, principled decisions about the scope of a doctor's expertise and responsibility have broad social implications. These decisions help shape the way society marks off medical and nonmedical jurisdictions. For example, psychiatrists claim that they treat genuine diseases. Since psychiatrists believe that the mad are diseased, they have argued that diagnosis and treatment is not a matter of mere social convenience. Psychiatrists think that they as doctors should treat and diagnose the mad. In the Jenkins case, the American Psychiatric Association (APA) went so far as to file an amicus brief, urging the court not to accept testimony in insanity defences from clinical psychologists [1]. For if the mad are sick, it

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seemed to the A P A that it ought to be qualified doctors who make the diagnosis. And although psychiatrists now seldom claim exclusive competence in the diagnosis and treatment of mental patients, psychiatrists continue to exert powerful executive control over the mental health system. So at least one reason for reflection on the scope of the doctor's expertise and responsibility emerge. A determination of scope will clarify the basis for various moral claims made by, for, and against doctors. Now I propose that doctors ordinarily acquire professional responsibilities toward patients via two mutually compatible routes. Other more exotic routes probably exist, but for the moment I wish to understand the humdrum. The strategy I am about to pursue is intuitively obvious. It is to make the scope of the doctor's special responsibilities a function of the scope of his or her expertise as a doctor. First, then, some people may come under a doctor's care because they are diseased. To be diseased is, among other things, to have an increased need for medical care in general and the doctor's care in particular. Whether the diseased individuals are aware of their increased medical need is another matter. Sometimes they are; sometimes they are not. Second, some people, for reasons good or bad, desire medical attention. Typically, in such instances, the patient perceives the doctor as being especially, even uniquely, qualified to deliver the attention desired. Most cosmetic surgery illustrates this route. In any case patients need not be diseased for doctors to render morally unobjectionable care. The plastic surgeon's patients are well enough. They simply wish more closely to approximate prevailing standards of beauty. Although this second, nondiseased route to medical care is common, it does not promise to yield deep insights into the doctor's speciality. For recall, this speciality is to help in identifying suffering for which doctors recognize special responsibility. But medical treatment in the absence of disease is more discretionary. Plastic surgeons may turn away from a poor man with a big nose, but they may not as doctors turn away from a comatose diabetic. Hence it is the first route, the route of disease, which promises to highlight the doctor's special responsibilities. For diseases, which in medical and present jargon include injuries, are commonly thought to be the doctor's special province. Although others may ally themselves with doctors in fighting disease, doctors are presumed to have special and deep knowledge of disease. It is this knowledge, I am proposing, which marks the doctor's speciality. Of course this knowledge is not sufficient to make one a doctor. Other professionals may also have it, but the doctor is required to have it. Hence I want to make disease the investigative locus in my inquiry into what portion of human suffering doctors have special responsiblities for in order to see how this characterization of the doctor's speciality poses special problems for psychiatry. Despite the central place disease occupies in my account of the scope of purely medical responsibility, I am unable to offer necessary and sufficient conditions for being diseased [2]. But even in the absence of an analysis providing necessary and sufficient

conditions for disease, insisting on the presence, at least in principle, of physical pathology, broadly conceived, as a necessary condition for disease proffers considerable insight into the scope of the doctor's responsibility [3]. Waiving physical pathology as a necessary condition for disease would, ! argue, threaten to encumber doctors with responsiblity for suffering clearly outside the moral center of medicine. Doctors would, in short, have too many medical responsibilities. The result would be, and in practice often is, a confusion of medical and nonmedical responsibility, an overenlargement of the doctor's territory. The attendant danger of this enlargement would be that moral decisions requiring no medical expertise would be removed from the public and turned over to doctors. To sum up, I have been suggesting that (i) knowledge of disease marks the doctor's speciality and is indisputably successful in identifying uncontroversial portions of the doctor's expertise and that (ii) the correct conception of disease requires that diseased patients be reasonably supposed to have some physical pathology. Even though the requirement of physical pathology menaces psychiatric practice, I want nevertheless to insist on the appropriateness of the requirement. Analyses of diseases should not divorce it from physical pathology; for my characterization of the doctor's speciality, when conjoined to a more or less physicalist conception of disease, permits one to understand, in an intuitively satisfying way, the appropriate limits on the scope of a doctor's expertise and responsibility as a doctor. First, though, it is necessary to understand how psychiatry, when set free from physical medicine, threatens to absorb morality. Of all doctors psychiatrists are most often accused of objectionable excursions into morality. Where c o m m o n sense is likely to see moral rot, the psychiatrist is prone to see disease or personality disorder. But a conception of disease anchored in physical pathology makes many psychiatric diagnoses questionable. For the requirement that some, perhaps undetected, physical pathology underlie psychiatric diagnoses entails that there are no purely mental diseases. Consequently it is possibh, that a large portion of the problems psychiatrists treat are not essentially medical. These problems fall outside the doctor's speciality. Consider again, for example, such diagnostically coded disorders as 'telephone scatalogia' and ~passive aggressive personality disorder'. On the face of it, these diagnoses appear to extend the concerns of psychiatrists beyond their medical speciality. If what appears to be so is so, psychiatrists treating patients with diagnoses like these do not do so as a consequence of their being doctors per se. This should constrain psychiatric practice. Psychiatrists may treat an individual without physical pathology in the name of medicine when and only when that individual wants or accepts their help. If psychiatrists forcibly treat such individuals, moral, rather than medical, argument is needed in justification. For such treatments are medically elective if no disease is present. I do not, I hasten to add, mean that doctors may always forcibly treat diseased patients. I do, though, think that a finding of disease permits an argument for compulsory treatment to get

Doctors, psychiatrists and disease off the ground. Certainly doctors may speak expertly about the causes of a diseased patient's symptoms, and these symptoms may include aberrant behavior. Forcible treatment of a burn or hallucinating plague patient is, I think, justifiable. Forcible plastic surgery of the homely or forcible treatment of healthy (undiseased) psychiatric patients is not justifiable. Furthermore, no straightforward justification from medical expertise is available for limiting, as the A P A urged the court to do in Jenkins, the mental assessment of physically healthy, but peculiar, people to psychiatrists. Toward the end of this paper, I shall say more about the ethical limits my characterization of the doctor's speciality places on psychiatrists. But now, I want to restate and review arguments against the reality of mental illness and responses to them in order to show off the conceptual benefits of linking disease to physical pathology. AGAINST MENTAL ILLNESS The idea that there are no mental diseases is hardly a novelty. Writers such as Szasz, Laing, Goffman, Scheff and Sarbin have long urged the position [4]. Without restating the details of the numerous trains of argument that support skepticism about mental illness or disease, one can appreciate the intuitive force of the proposition that there are no mental illnesses by examining a series of definitions drawn from the Oxford English Dictionary (OED). Even though the O E D definitions no longer accurately re/tect current usage, these superannuated definitions point to the kind of considerations on which many standard antipsychiatric arguments covertly feed. If current usage has become more liberal in the application of health vocabulary to mind, then that is but one more liberalization of language antipsychiatrists can depolore. Four definitions of terms intimately bound to medicine suffice to elicit an appreciation of what might as well be called the Szaszian position that mental illness is a myth.

Disease, sb. . . . A condition of the body, or some part or organ of the body, in which its functions are disturbed or deranged; a morbid physical condition...fig. A deranged, depraved, or morbid condition (of mind or disposition, of affairs of a community, etc.)... Health, sb, Soundness of body; that condition in which its functions are duly and efficiently discharged. Illness... Bad or unhealthy condition of the body (or, formerly, some part of it); the condition of being ill; disease, ailment, sickness, malady. Psychiatry: The medical treatment of diseases of the mind Even though current usage no longer treats the application of terms from the health vocabulary to the mind as figurative, an intuitive appreciation of the Szaszian position on mental illness is readily available if one reads the old O E D definitions literally. Read literally the old O E D definitions support Szasz's contentions that real illness is to mental illness as real meaning is to metaphorical meaning, that calling for the doctor when confronting strange behavior is like calling for the TV repairman when confronting atrocious programming. For the old O E D definitions of'disease" stated that it is figurative uses of the word which apply to mind. But the O E D

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also defined 'psychiaty' as treatment of diseases of the mind. Straight away psychiatry becomes figurative medicine. An almost irresistible, although invalid, inference asserts that psychiatric treatment must be figurative treatment [5]. In short, the old O E D definitions lead to the Szaszian position: there are no mental diseases. Nothing is more natural than to respond to this argument by denying the accuracy of the O E D definitions. Even the best dictionaries provide no more than reliable indications of the way the educated presently talk. No general claims can be advanced that dictionaries are informative about how people ought to talk. Dictionary definitions may and should be revised to facilitate or reflect scientific advance. The Concise Oxford Dictionary's dropping the claim that uses of 'disease' to describe mental states are figurative may reflect scientific advance. Moreover, philosophical skepticism about dictionary definitions are often in order. Even when dictionaries give definitions that do accurately account for how people use a word, that is no reason to suppose that the definitions capture the underlying rationale of c o m m o n usage. In the case of 'disease' the criteria for employing the word may normally apply only when there is underlying physical pathology, but that may be an accident. Many psychiatric symptom constellations might also fulfill the underlying criteria for disease. Still more, prior to the last quarter of the nineteenth century, it was impossible to cite physical pathologies for most diseases. As a rule doctors based their diagnoses on distinctive sign-symptom clusters and, when these clusters failed to individuate a disease sufficiently, doctors considered prognoses associated with the natural history of contending diagnoses [6]. Often a doctor would have to observe a large portion of a disease's course before venturing a confident diagnosis. No sharp divide between psychiatric and nonpsychiatric diseases could have been discerned. Arguments which presume a sharp divide has always existed between mental and physical disease make a travesty of the history of basic health concepts. Or so a reply to antipsychiatrists might go. Despite the reasonability of this reply, it relies too heavily on the perpetuation of medical ignorance. Although it is true that doctors could not until recently distinguish diseases in terms of physical pathology, they can often do so now. The reply does not warrant clinging to conceptual antiques. The spectacular and dramatic successes in late nineteenth century pathology now frequently enable doctors to understand the causal underpinnings of their diagnoses. The visual irrefutability of necropsy becomes the ultimate justification of a diagnosis. A look supplants an inference. For modern medicine, it is this look which is the High Magistrate of diagnostic competence. In this sense, pathological findings have come to reshape medicine's conception of health and disease. The situation might be compared, to take an overworked example, to that in chemistry. Before the discovery of gold's atomic number and structure, many would have sought to identify gold on the basis of its appearance. But looks may be unreliable. All that glitters is not gold. After the discovery of gold's atomic number and structure, scientists ceased to call

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some things gold that they and others might previously have believed to be gold. The discovery of gold's ~essence' also led to the inclusion of some metals that would not have previously, at least by laymen, been classified as gold. The existence of white gold comes as a surprise to those who think that identifying gold must involve a reference to color. Similarly it is unreasonable to expect a requirement of physical pathology for disease to preserve all descriptive diagnoses. Some conditions now thought to be diseases might not be diseases. Nobody, of course, need deny that there are undeniably many candidate diseases which still escape the pathologists gaze. Presently nobody knows the physical pathology for such disorders as trigeminal neuralgia, migraine, schizophrenia, and bipolar m o o d disorder, to name a few. And ignorance in Pathology is longstanding. In the nineteenth century, at least after the 1840s, doctors would also have included homosexuality as a disease whose physical pathology is unknown. Not until 1973 did psychiatrists, more accurately a majority of psychiatrists, decide that homosexuality was not in itself a medical disorder [7]. But in any case, doctors classify conditions such as trigeminal neuralgia and schizophrenia as junctional disorders. What, though, might a medical understanding of a functional disorder be? Roughly, functional diseases involve a failure of a system to make its typical causal contribution to the body. When a system's functioning, or causal contribution, is 'subpar', the patient has a functional disease. Since organic systems may be diffuse, one need not expect that all functions are strictly localized. An unlocalized systemic dysfunction may be thought of as analogous to a machine going out of synchronization [8]. And so when necropsy fails to reveal a visible lesion for a putative disease, doctors may seek to retain their diagnosis by retreating to functional considerations. In short, an arrest in function need not involve a localized lesion. The attempt to identify a lesion, or structural damage, in a component of a functional system responsible for the system's 'subpar' causal contribution would, on the present account, be but the first step toward validating a diagnosis. Failure to discern a lesion may drive doctors who wish to preserve a medical diagnosis to speak of global dysfunction. Various psychiatric disorders or diseases fall into the same pattern. For example: suppose it were established that a man who thinks his body radioactive, who claims communion with aliens, and who believed that C I A agents were stealing his thoughts turned out to be in perfect physical health. Would psychiatrists withdraw a diagnosis of schizophrenia? I doubt it. The biological grounding of psychiatric diagnoses is but one psychiatric research program among many. Some psychiatrists, then, must believe that there is no logically necessary connection between their diagnoses and the presence of underlying physical pathology. For them my previous talk about dysfunction in bodily systems obscures an essential truth. Genuine psychiatric disease may be functional diseases of the psyche. There are, that is, purely mental illnesses. How, though, are such illnesses or diseases to be called 'diseases' in the ordinary sense

of that word? Why not simply call, as does Szasz, mental dysfunction a "problem of living' or something akin to that? ANALYZING DISEASE

Two natural lines of response suggest themselves: first, that mental diseases are diseases because they bear a close family resemblance to central cases of physical disease; second, mental diseases are diseases because they satisfy the same criteria as physical diseases. As a glib answer, there is much to recommend the family resemblance view. Many mental diseases exhibit characteristics associated with indisputable cases of physical disease. They incapacitate. They present themselves as undesirable to their victims, causing them to seek relief. I could continue to pile up similarities. Joseph Margolis makes the general point succinctly. One may "extend the concept of illness to hitherto unclassified patterns a n d . . , justify the extension by showing affinities between the new cases and the standard ones" [9]. Unfortunately, the view runs into difficulties. In the previous section, I pointed out that physical diseases do have a necessary condition, namely, the patient must either have or be supposed to have some underlying physical pathology. Once this necessary condition is noticed, talk of family resembalance is inappropriate. For the absence of physical pathology entails the patient is not physically diseased. So the family resemblance view has no application to physical diseases because it is a denial that there are necessary conditions. But if one wishes to claim that one means the same thing when one speaks of physical disease and mental disease (the 'physical' and "mental' merely giving the locus of the disease), then one needs to give an account of mental pathology which is pathological in the same way that physical pathology is pathological. That is, the grounds for saying that some biological happenings are pathological should be the same as the grounds for saying certain mental happenings are pathological. But that is to embrace the second alternative of showing that mental diseases satisfy the same underlying criteria as physical diseases. Two approaches to defending the claim all diseases are diseases in virtue of same underlying criteria seem plausible. One makes all diagnoses expressions of value. Peter Sedgwick has been its recent champion. The other views disease as being conditions which involve dysfunction in discoverable systems of the diseased organism and further maintains that the criteria for dysfunction are the same in psychiatry as in general medicine. Christopher Boorse has been this view's ablest champion. I shall begin with the first view. Peter Sedgwick has written: Outside the significances that man voluntarily attaches to certain conditions, there are no illnesses or diseases in nature

[lo1. For Sedgwick there are but events which happen. Germs enter a body, the body dies; a face hits a door, a nose breaks. "Yet these", writes Sedgwick, "as natural events do not prior to the human social

Doctors, psychiatrists and disease meanings we attach to them---constitute sickness" [ll]. For him, "the blight that strikes c o r n . . , is a human invention, for if man wished to cultivate parasites (rather than potatoes or corn) there would be no 'blight', but simply the necessary foddering of the parasite crop" [12]. He then goes on to claim that one may have a "unitary perspective on physical and mental illness, so long as a c o m m o n structure of valuation and explanation applies over the whole range of disorders of the person" [13]. Since Sedgwick does not so much argue for his claims as strive to reorder the c o m m o n sense intuition that diseases are in nature by presenting vivid examples, 1 shall only try to undo Sedgwick's reordering of the intuitions, not argue against Sedgwick in detail. First, why should one think about the corn blight case like Sedgwick? Suppose I wish to cultivate the blight. It seems I ought to farm by giving some corn a certain parasitic disease. Only if one thinks, as Sedgwick does, that diseases must be undesirable to o,pical human interest (parasitologists are interested in farming the parasites to study blight) will Sedgwick's construal of the case appear plausible. Yet anybody with flat feet during the Viet N a m war knows otherwise. A disease can be quite desirable to its bearer. Of course it may be true that undesirable diseases are the first to be studied, but values may direct inquiries without necessarily being the basis for an inquiries classificatory system. Think, for example, of the periodic table of elements. Second, even if it were true that diagnosis is only an expression of what is not valued, it is not clear that would lead to recognition of purely mental diseases. After all, diagnoses of mental diseases would be based on appraisals of what conduct is valued and disvalued. But there already is a well developed language for judging conduct, namely, the language of morals. So what is gained by speaking of mental diseases? Perhaps that the conduct can be explained medically. Surely, the moralist may grant that medicine might explain immoral behavior. The moralist may even grant that medicine may explain moral behavior. The possibility of explanation, medical or nonmedical, is compatible with the moralist's judgments about conduct. I claim that people do not believe that a person is diseased if his or her conduct is bad and medically explainable and undesirable. Third, Sedgwick is apparently committed to a rather crude nominalism. W h a t can it mean to talk about the significances that human beings voluntarily attach to certain conditions? If doctors talk of disease is about these conditions, if the talk refers to or denotes these conditions, then there are diseases in just the same sense that there are lions. To call something a 'lion' is also a voluntary attachment of significance. The difference between the two cases ought not to be that lions are easy to observe while diseases are not. Many objects are hard to observe. If Sedgwick means that diseases unlike lions do not exist independently of value judgments, then one returns to the first objection and the existence of the happily flat-footed. And if Sedgwick thinks that one just decides what is a disease, his analysis would include mental diseases, but only because it is a bogus analysis of physical disease.

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Fourthly, and perhaps most importantly, Sedgwick offers no evidence for his contention that there is a c o m m o n structure of valuation and explanation for mental and physical disease. For even if medicine did impose the same structure of valuation for physical and mental illness, it is far from obvious that the explanatory schemes for psychiatry and general medicine are relevantly similar. Although a patient's needs command the GP's respect, explanation of the patient's ailments may often be given in terms of physiological causes. Indeed, some elements of physical pathology must at least be suspected for the patient to be a fit object of the GP's concern. If the GP suspects no physical problems are present, the patient may well be referred to a psychiatrist; perhaps because the doctor suspects that the explanation for the patient's condition departs from that expected in physical medicine. Contrast, for example, an explanation of why a woman with a spinal cord injury cannot walk with an explanation of why a woman with Conversion Disorder (hysteria) cannot walk. It stretches the imagination to see the explanatory unity in the two cases. Let me now turn to Boorse, who makes a distinction useful for avoiding the kinds of confusions which analyses such as Sedwick's are given. Boorse insists on drawing, even at the cost of violence to ordinary usage, a clear distinction between disease and illness. Too many arguments about the reality of mental illness fixate on moral issues. Antipsychiatrists like Szasz love to trot out a parade of moral pleas costumed as psychiatric diagnoses. Boorse's distinction postpones confusion over the connection morality has to psychiatric diagnoses. Whether a condition is an instance of disease is an objective matter of fact; whether it is also an illness requires supporting moral arguments. In short, whether a disease excuses a patient for bad conduct depends on moral argument. That a condition is an instance of disease does not depend on likes, dislikes, or indifference. In Boorse's words, A disease is a type of internal state which is either an impairment of normal functional ability, i.e. a reduction of one or more functional abilities below typical efficiency, or a limitation on a functional ability caused by environmental agents [14]. Illnesses are a subset of diseases. A disease is an illness only if it is serious enough to be incapacitating, and therefore is (i) undesirable to its bearer; (ii) a title to special treatment; and (iii) a valid excuse for normally criticizable behavior [15]. With this distinction in hand, Boorse believes he can establish the reality of mental disease without having to defend the reality of mental illnesses. In Boorse's idiolect, the antipsychiatrists such as Szasz may show that there are no mental illnesses without having shown that there are no mental diseases. Boorse's argument for the reality of mental disease involves some metaphysical subtleties. For although Boorse claims the notion of function is the same in psychiatry as in physiological medicine proper, he simultaneously holds that psychiatry is a sui generis branch of medicine treating mental dysfunction. It is this move to sui generis psychiatry which would, if

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successful, rebut the claim that all diseases have a known or unknown physical pathology. To appreciate and discern the direction of Boorse's analysis, I shall offer a reconstruction of a favored antipsychiatric argument. The essentials of this argument are that (1) The reality of mental diseases without physical pathology is comprehensible only if dualism is true; (2) Dualism is a discredited theory; (3) Therefore, there are no purely mental diseases [16]. Boorse tries to show how psychiatrists who accept that mind and body are one still could cogently believe in the existence of mental diseases having no physical pathology. His strategy thus is to reject (1), offering a theory of mind which is not dualist, but which can apparently leave room for a sui generis psychiatry. But to make the virtues of Boorse's account plain, let me propound the above antipsychiatric argument in detail. Dualism in all its varieties is unlovely. Doctors treat human beings the only way they know how, as complex biological organisms. Now if mental illnesses or diseases are indeed, as is so often claimed, 'just like any other illness', then they too should have an analogous biological base. All other diseases do, or are thought to. So some physical pathology ought to be the basis of this or that mental disease. But then no purpose is served in calling the disease in question 'mental'. It is a disease, although the affects of a brain lesion may be more psychically dramatic than those of an intestinal lesion. Just as digestion may be grossly affected by an intestinal lesion, knowing what we do about intestines, so may thought and behavior be grossly affected by a brain lesion, knowning what little we do about brains. Hence if all that is meant in calling a brain disease a mental disease is that thought or behavior is impaired, rivers of philosophical blood could be spared by simply calling brain diseases 'brain diseases'. But if, as is evidently the case, believers in mental disease think that there can be disease without any physical pathology, they must, the argument continues, think that it is the mind itself which is diseased, perhaps having phantom lesions on its phantom substance. Moreover, we have not the slightest idea of how to begin to extend our health vocabulary to things mental. For there is, as dualists themselves recognize, an enormous gap separating the immaterial mind from the material body. Diseased minds would be a conceptual wonder. Is there a cancer of the mind where our identities multiply widly? Might a mind die? Are there contagious diseases of the mind? The possibilities are stupefying. The simplicity of this argument is appealing. Boorse sidesteps it. Somebody who holds that mind and body are one need not, Boorse points out, posit lawlike relations between kinds of mental and physical events. All those who believe in the oneness of mind and body need believe is that every mental event is identical with some physical event. That belief carries no commitment to the existence of psychological laws permitting one to judge that since a person is thinking about this kind of thing, she must be in this kind of neural state or vice versa. One has no reason, that is, for thinking that my hankering for a bottle of Budweiser is invariably identical with a

certain kind of neural pattern. The general idea behind Boorse's position is associated with the work of Donald Davidson [17]. To grasp the essentials of Boorse's denial that kinds of mental events stand in lawlike relations of kinds of physical events and vice versa, an example may help. Some objects are characterized by what they do, by what functions they perform. Suppose one tried to explain what a paperweight is. Since so many things might serve as a paperweight, one would have to explain paperweights by stating what the weights must do. Of course almost any suitably heavy object may be a paperweight, a bit of marble, a lamp, a book, etc. If one went on to try to formulate laws about paperweights, one would not expect these laws to be reducible to laws about a kind of physical object, even though every paperweight is identical with some physical object. There are no immaterial paperweights, though there is no one kind of physical thing that is a paperweight. Likewise, minds may be characterized in terms of what they do. So just as the same role, that of a paperweight, may be played by many different kinds of physical objects, so "the same motivational role might be played by different neural configurations in different people" [18]. After running through some further metaphysical complication, Boorse concludes: If the mentalistic vocabulary is not neurologically definable, there will be no way to reduce causal laws of the mind to causal laws of the body. If so, the distinction between conditions that receive one kind of causal explanation and those that receive another may be a permanent one, justifying an autonomous science of mental health [19]. It is this irreducibility of mental causal laws to neural causal laws which supports Boorse's claim that psychiatry is an autonomous branch of medicine. Mental diseases are then viewed as a reduction of one or more psychological functional abilities below typical efficiency. I propose to grant Boorse that there is no way of reducing causal laws describing mental functioning to causal laws describing neural functioning, and vice verse, but to argue against Boorse's claim that mental dysfunction should be thought of medically. As a first step, I want to describe the discovery of a bona fide physiological function. It is known now that the function of the heart is to circulate blood. How is this known? Harvey published his discovery in 1628, although he had been teaching that the heart's function is circulatory since 1616, in E x e r citation Anatomic de M o t u de M o t u Cordis et Sanguinis in Animalibus ( " A n Anatomical Exercise concerning the Motion of the Heart and the Blood") [20]. The theory supplanted by Harvey's was Galen's, which was far more comprehensive. According to the Galenic theory, the liver transformed digested food into dark blood. From the liver the blood returned to the whole body. Some of it flowed to the Vena Cava, then into the right atrium and ventricle. Once inside the heart, the blood supposedly divided, a portion of it leaking through the septum into the left ventricle. F r o m the heart a portion of the blood flowed up to the lungs. An exchange occurred. Some blood wastes passed into the lungs and were expelled as breath; the blood in turn was aerated. The blood in the left

Doctors, psychiatrists and disease ventricle flowed, via the left atrium, into the pulmonary artery where it mixed with the aerated blood returning from the lungs. From the pulmonary artery, the blood traveled and seeped throughout the body, a sort of tidal theory of blood flow. As a reminder, I should add that actual flow is as follows. First blood enters the right atrium, then the right ventricle. From the right ventricle the blood is pumped up to the lungs from which it returns via an artery to the left atrium. It then moves from the left atrium to the left ventricle, and on from there to the rest of the body. Without attempting to account for as much data as Galen, Harvey pondered a simpler question. Perhaps he was led to his skepticism about the Galenic theory when he realized that the division of blood posited by the theory could not take place. The septum, which separates the right and left chambers of the heart, is solid muscle. No fluids could pass through it. So Harvey directed his attention to the heart's contractions, pondering the volume of blood a beating heart expells. Suppose, for convenience, that a heart beats 72 times per minute. Experiments had taught Harvey that each beat expells, on average, about 2 ounces of blood. With 72 beats per minute, 60 minutes to the hour, and 2 ounces per beat, the heart pumps 8640 ounces per hour, or a bit over 552 pounds, about 3½ times average body weight. Galen's theory could not account for the discrepancy. Harvey concluded that blood circulates and that the heart is the engine of this circulation. Initially, however, Harvey could not specify the circulatory route in its entirety. Blood appeared in places where no veins were observable. To meet this difficulty, Harvey postulated the existence of capillaries. Malpighi discovered them with the aid of a microscope in 1661, writing: Hence it was clear to the senses that the blood flowed away along tortuous vessels and was not poured into spaces, but was always contained within tubules, and that its dispersion is due to the multiple winding of the vessels [21]. Harvey's method was and is a model of scientific progress. The discoveries of Harvey and Malpighi illustrate what the discovery of an objective function should be. One posits a function and then seeks to see how particular physical systems operate to realize it. Once a particular system is understood, doctors may go on to specify what statistically typical and superior functioning is, and how changes in the physical system realizing the function may enhance or inhibit functioning. This has been done in some detail for the heart and circulatory system. Now I believe that no psychological discovery of function analogous to Harvey's exists. In part this is trivial since Boorse wishes to make psychological functions independent of physiological functions in that the causal laws of mental function do not reduce to causal laws of neural function. What I, though, wish to suggest is that by divorcing the notion of psychological function from a realization in a particular physical system, Boorse leaves himself with no way of showing that psychological dysfunction and physiological dysfunction are relevantly similar. That is, in medicine functions are related to physical

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systems and dysfunction is conceived to involve some problem with physical systems such as structural damage or dyssynchronization. Boorse must show that the same kind of considerations apply in regard to psychological systems. To make my charge clearer, some additional remarks must be made about functions in medicine. Although the various parts of a car have functions, mechanical malfunction in a car does not mean that the car is diseased. Boorse wishes his account of dysfunction to be drawn from the notion as used in medicine. How, then, are biological functions distinguished from nonbiological functions. According to Boorse, biological functions are tied to species survival and reproduction [22]. Diseases, then, only involve those subpar species typical functions which are a detriment to survival and reproduction. Some evidence does exist that mental disease does adversely affect mortality tables. R. E. Kendell reports that the mortality for manic depressives is 1½ times increased. On the whole, the life expectancy for manic depressives is about 15~o below normal. In addition 15~o of manic depressives eventually commit suicide [23]. Suspicions exist that schizophrenics also die younger. These data support Boorse. There does appear to be evidence that mental diseases are dysfunctional in the same sense that physical diseases are dysfunctional. Nevertheless, these kinds of figures are not unambiguous. Having certain moral opinions (surely, an internal state) in certain parts of the world is likely to increase one's mortality. Yet few would allow that having principles, whatever their attendant risks, is to be diseased. Roughly, the nasty consequences of physical diseases do not seem to be susceptible to social conditions in the way that psychological diseases are. And even if one grants that the mental patient's plight is not a social artifact, it's still far from clear that psychiatric diagnoses depend on functional incapacities in a mental system. A decline in cognitive functioning may be observed in patients with a mental disease, but that decline is, one would think, distinguishable from the diseases as such. Standard diagnostic criteria in DSM III do not make direct references to mental functions. On the other hand, Boorse's analysis of disease made reference to internal states. Although DSM III diagnostic criteria do not straightforwardly refer to dysfunction, Boorse might argue that the observed symptoms and signs of mental diseases are caused by breakdowns in underlying mental systems, claiming that these mental systems are not making their typical functional, i.e. causal, contribution. So even if DSM III does not use functional criteria to diagnose a disease, DSM III may only have included conditions which were judged to involve an internal dysfunction. In his support, he could cite the technical glossary of DSM lII in which mental disorders (the psychiatric euphemism for mental disease) are characterized in terms of dysfunction. Unfortunately, Boorse is vague about how to determine mental functional norms for an underlying psychical system within a species. Boorse cites psychoanalysis as providing the right kind of theory for mental disease, evidently meaning the right kind of etiologic theory. Accordingly, I shall argue, briefly,

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with reference to psychoanalysis that species typical functioning of the psychical functional system cannot be given in the value neutral way that species typical functioning for a biological system can [24]. Psychoanalytic theory, if true, permits analysts to offer accurate causal accounts of human behavior in every instance and accurate etiological accounts of kinds of psychiatric diagnoses such as depression and paranoia. Characteristic analytic accounts are intrapsychic, explaining observable behaviors in terms of the subject's own mental life. Classically, mental life of a subject is conceived of in terms of psychical structures. These structures, the Id, Ego and Superego, are functionally defined [25]. Moreover, psychoanalytic theory includes a topological theory. The structures are distributed in the conscious or unconscious, the Ego being 'in' the conscious and the Id and Supergo being 'in' the unconscious. Since the Id, Superego and Ego are not literally things, but functions, some explanation, even at the risk of caricature, is in order. What constitutes these 'structures'? The mind has a multitude of representations. According to the economic theory, reservoirs of 'energy' in the Id may cathect, i.e. charge representations. Important representations have a big charge. The greater the charge, the greater a representation's causal force. During the first few years of a child's life, various representations cluster. Eventually the conscious Ego and then the Superego develop. The interactions between the charged representational systems is taken to be law-like. Representations in the Superego, for example, "censor' contrary representations arising from the Id. But it is assumed that when a representation, such as an unconscious desire for something, is contrary with a superego representation, some conscious manifestation will still appear. The conscious representation will be a covert satisfaction of the desire seeking to gain entry into consciousness, but which was unacceptable while undisguised. The ego 'selects' a compromise. Events in a subject's life are then explained in terms of these lawlike mental transactions. Although much fascinating detail has been left out of this caricature, the central point I should like to make is this: if true, analytic theory offers an account of whatever behavior one might desire to explain, but the explanation given need make no essential reference to psychopathology. The analyst may simply say that given a certain representational distribution, and the laws and principles governing relationships between representations, the subject's behavior is explicable, indeed inevitable. The Id, Ego and Superego never .fail to perform the functions assigned them. It is rather that what the functions produce depends on what the subject's history has been. This is unlike the heart in that hearts may fail to discharge their function. The notion of dysfunction has clear-cut application. In contrast to the heart case, when analysts speak of dysfunction, innumerable judgments about the rationality of the subject's beliefs must be made. The analysts must not only judge the subject's beliefs to be strange, but false. Here analysts move well beyond their medical specialty, for assessments of mental (dys)function involve such concerns as (i) what it is rational to believe given relevant available evidence, (ii) what relevant evidence is, (iii)

what conclusions individuals should be able to draw given the evidence they either do (or, should?) accept. This is not, as in the heart case, a matter of judging that a causal contribution is not being made to a system, but is rather a matter of appraising a subject's epistemology. Only after the subject fails an epistemic appraisal does the psychiatrist go on to offer an account, functional or otherwise, of the failure. It is this epistemic failure which is dysfunctional. That psychiatrists are specially qualified to make this appraisal is dubious. Finally, if Boorse were right, he would have to offer a value neutral account of species typical rationality if he ever hopes to offer an account of species typical mental functioning. Without such an account, there is no way of identifying dysfunctions in the mental system. Although to argue that there is no such account would require a separate paper, I take it that it is the duty of those who think that there is an objective account of species typical rationality to provide it. Until it is provided, one is reasonable to be skeptical of the claim that the notion of dysfunction is the same in psychiatry as in ordinary medicine. All the same, there is a basic intuition to Boorse's analysis which needs addressing. Suppose that experimenters induced a bizarre series of behaviors in an animal by giving it a disease. They then elicit the same behaviors by placing the animal in a perverse environment. Why, it might be asked, call the one sign-symptom cluster a disease and not the other? In the one case, the behavior is caused by a 'bug' and in the other by the environment. But why is that difference decisive? After all, in each case the animal is impaired. I think that the difference is decisive and a different example will make clear, I hope, why. It is a matter of fact that people have to learn to read. They do not, as it were, read by instinct. O f course, although it would be very strange, they might have. Now it is useful to mark the difference between things people do not do by nature and those that they do. 'Learning' and 'instinct' mark this distinction in English. Likewise, one might wish to distinguish between conditions people 'catch', 'come down with' and those they "learn'. Although learning has a biological base, most failures to learn are more readily explicable in terms of poor teaching than poor medicine or health. And whereas organic learning disabilities are most properly the concern of the doctor, the nonorganic are most likely the concern of the educator. Insisting on physical pathology for disease is a way of retaining this split of the medical and nonmedical, a way of distinguishing accounts emphasizing failures in causality from accounts emphasizing failures in rationality. Without this insistance in Boorse's case, no plausible way of preserving this useful distinction is evident. Medicine threatens to swallow too many disciplines. CONCLUDING OBSERVATIONS By now some may groan at my unorginality. Have not my comments been the stuff of which Szasz has built his career? I admit to being unperturbed. Discipleship, at least since Peter, has been no sin. But 1 do think some points of substance distinguish me from Szasz and other critics of psychiatry.

Doctors, psychiatrists and disease First, I have directed fire at critics who have claimed to have gotten r o u n d the Szaszian, Laingian, Sarbinian, Goffmanian, etc., insistance on physical pathology as a necessary condition for disease. If my arguments work, a large portion o f the general antipsychiatric critique still stands. There are no purely mental illnesses. Second, I am more liberal in my willingness to accept candidate diseases. To my mind the most plausible way of understanding schizophrenia is not pace Szasz in terms o f c o m m u n i c a t i o n theory, but in terms of disease. I think that most schizophrenics are physically sick. My personal skepticism tends to center on personality disorders and on the contention that all patients who meet diagnostic criteria for major mental illnesses are ill. I think many are, but not all. Third, particular instances o f patient assessment need to be analysed. Sometimes the s y m p t o m s are best u n d e r s t o o d as coded communications. Here 1 think we should do well to reject the disease model o f psychiatry. At other times the s y m p t o m s have no discernible meaning. Only the most rash would insist that since the s y m p t o m s could (on a thoroughly hypothetical, fanciful and u n c o r r o b o r a t e d interpretation) have meaning, they in f a c t have meaning. In such cases, the patient is most reasonably to be thought o f as sick. This suggestion requires more willingness than many psychiatrists have been able to muster to allow that not all o f their patients are sick. It also requires many 'antipsychiatrists' to reject d o g m a t i s m about the interpretability o f symptoms. I began this paper with some reflections on the d o c t o r s ' speciality. I t h o u g h t o f this speciality as being intimately connected with the treatment o f disease, l have now argued that psychiatrists do not, when they treat purely mental disease, in fact treat diseases. Purely mental diseases are myths. Hence in many instances, especially for psychiatrists trolling the murky waters of personality disorder, psychiatrists" roles do not depend on their being doctors per se. They, like their medical colleague the plastic surgeon, treat many conditions because it seems desirable that they do so. W h e n psychiatrists exercise their medical competence on disease free patients, they have no special rights o f claims. N o r is it a p p r o p r i a t e for courts to insist on treatment. Doing so would be like requiring plastic surgery for the homely. N o special authority comes to them to intervene on the basis o f their speciality. N o r does a rationale for limiting access as attempted in Jenkins have a medical justification. With all this in mind, one will have no trouble keeping morality distinct from medicine. The expertise o f doctors is distinguished from their h u m a n interests.

Aeknowledgements--I acknowledge support received from National Research Service Award 14641 while working on an early version of this paper. I personally thank friends and acquaintances in Wisconsin for early help, especially Norm Fost, Jim Greenly, Melinda Hogan, Joy Newmann and Dan Wikler. Finally, I thank two anonymous readers for Social Science & Medicine who forced me to write a better paper. REFERENCES

1. For some details on Jenkins see Glueck S. Law and SSM

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"Psychiatry, John Hopkins University Press, Baltimore, MD, 1962. 2. One could not even begin to discuss all the literature on the subject. In addition to some work I discuss later I should mention work by Clouser K. D., Culver C. M. and Gert B. Malady: a new treatment of disease. Hastings Center Rep. June, 1981; Kendell R. E. The concept of disease and its implications for psychiatry. University of Edinburgh, Inaugural Lecture, No. 57, 24 October 1974; Scadding J. G. Diagnosis: the clinician and the computer. Lancet 21 October 1967: and Kraupl Taylor F. Part 1. A logical analysis of the medicopsychological concept of disease. Psyehol. Med. 1, 1971 and Part 2. A logical analysis of the medicopsychological concept of disease. Psychol. Med. 2, 1972. This is of course no more than a smattering of the work done in the area. 3. l am taking for granted what seems to be the case in practice: the identification of physical states as pathological is not a problem. I am also assuming that physical pathology is not sufficient for disease, l do not think the scar on my leg spells disease, but a scar on my heart may. 4. With the exception of Sarbin, the work of these writers is notorious. On Sarbin, see Sarbin T. R. On the futility of the proposition that some people be labeled "mentally ill'. J. consult. Psyehol. 31, 444-453. 5. The inference is clearly invalid, as a moment's reflection on the practices of plastic surgeons would or should make clear. 6. For more on signs and symptoms see Feinstein A. R. Clinical Judgment, pp. 1312-132. Krieger, New York, 1967. 7. See Bayer R. Homosexuality and American Psychiatry. Basic Books, New York, 1981. 8. This image of being out of sync is a pale version of an example by F. Kraupl Taylor. Taylor F. L. The Concepts of Illness, Disease, and Morbus, p. 100. Cambridge University Press, Cambridge, 1979. 9. Margolis J. Psychotherapy and Mortality, p. 74. Random House, New York, 1966. 10. Sedgwick P. Illness mental and otherwise. Hastings Center Stud. 1, p. 30. 11. Ibid., p. 31. 12. Ibid., p. 30. 13. Boorse C. Ibid., p. 35. 14. C. Health as a theoretical concept. Philosophy Sci. 44, 567, 1977. 15. Boorse C. On the distinction between disease and illness. Philos. publ. Aft. 5, 61. 16. I am using the word 'antipsychiatrist' as a journalistic convenience. Many of the so-called antipsychiatrists reject the label, notably Szasz and Laing. This argument is, I trust, a familiar and notorious argument, made often enough, I guess, to no longer have an owner. 17. See especially Davidson D. Mental events. In Essavs on Actions and Events. Clarendon Press, Oxford, 1980. 18. Boorse C. What a theory of mental health should be. J. Theory soc. Behav. 6, 66, 1976. 19. Ibid., p. 67. 20. For details I am indebted to John Passmore's article on Harvey in The Encyclopedia of Philosophy and Sigerist H. E. Civilization and Disease. The University of Chicago Press, Chicago, 1943. 21. Quoted in Dampier W. C. A History of Science, p. 120. Cambridge University Press, Cambridge, 1971. 22. Boorse C. Philosophy Sci. 44, 562, 1977. 23. This and the preceding are from Kendell, p. 14. 24. Boorse insists the use in medicine is value neutral, Boorse C. J. Theory soc. Behav. 6, 78, 1976. 25. For an explication of the functional psychoanalytic metatheory, see Brenner C. and Arlow. J. Psychoanalytic Concepts and the Structural Theory. International Universities Press, New York, 1964.