We like to think of medical practice as scientific, but the fact is that diagnosis often fails, leaving patient and doctor without a scientific path forward. For decades care in these cases has been directed by an esoteric subdiscipline of psychiatry known as “psychosomatic medicine” – which encourages doctors to construe unexplained symptoms as psychiatric problems.
Quiet as this area of medicine may be, the Up to Date review system suggests that diagnosis of causes in the psyche occurs as often as all medical diagnoses combined in outpatient care, or at least that it should. This conclusion is echoed in the UK by the Joint Commissioning Panel on Mental Health.
This central area of medicine has managed to avoid public scrutiny almost entirely, because we continue to imagine that diagnostic science almost always succeeds. It has avoided ethical scrutiny because bioethics too has developed based on a diagnostic model. Most importantly, this area of medicine has avoided philosophical scrutiny. We have no philosophically coherent account of what it actually means to say that symptoms are caused by the psyche.
I begin with the view that medicine is deeply philosophical. This is the case not only because the mind-body diagnostic line has become so central in practice, but also because medicine has defined itself with the philosophical goal of “integrating mind and body”. Unfortunately, on both counts the profession has been guided by popular buzzwords rather than sound philosophical reasoning. I hope to change that. Medicine is an area where metaphysical clarity has a direct impact on human suffering and well-being, strange as that idea may be to philosophers. We cannot optimally improve health without a clear, well-supported position on mind in the context of medical science.
As an ethicist, I argue that women's health is routinely threatened by the principle in medical training that symptoms caused by the psyche predominantly afflict women. I challenge our understanding of patient autonomy, informed consent, and doctor-patient truthfulness in cases where diagnosis of this kind is made or considered. I suggest that medicine is sorely in need of “diagnostic ethics”, discourse that can articulate parameters for ethical management of diagnostic uncertainty.
As a speaker and advisor, I work for practical improvements in policy related to diagnostic uncertainty. In this capacity I have spoken to or advised organizations concerned with women's health, chronic Lyme disease, rare disorders, myalgic encephalomyelitis/chronic fatigue syndrome, Ehlers-Danlos syndrome, periodic paralysis and others. I do my best to contribute to health policy decisions in this area, including proposals responding to pending changes in the International Classification of Diseases, and developing changes to guidelines for managing ME/CFS in the UK.
Diane O'Leary, PhD
Rotman Institute of Philosophy
London, ON Canada
Adjunct Full Professor
Course Chair in Philosophy
University of Maryland University College
Kennedy Institute of Ethics
Fellow, Fondation Brocher
The brain is wider than the sky,
For, put them side by side,
The one the other will include
With ease, and you beside.
The brain is deeper than the sea,
For, hold them, blue to blue,
The one the other will absorb,
As sponges, buckets do.