Medicine's Metaphysical Morass: How Confusion About Dualism Threatens Public Health

revisions under consideration

What position on dualism does medicine require?  Our understanding of that question has been dictated by holism, as defined by the biopsychosocial model, since the late twentieth century.  Unfortunately, holism was characterized at the start with confused definitions of ‘dualism’ and ‘reductionism’, and that problem has led to a deep, unrecognized conceptual split in the medical professions.  Some insist that holism is a nonreductionist approach that aligns with some form of dualism, while others insist that holism is a reductionist view that primarily sets out to eradicate dualism.  It’s important to consider each version.  Nonreductive holism is philosophically consistent and clinically unproblematic.   Reductive holism, however, is conceptually incoherent - yet it is the basis for the common idea that the boundary between medical and mental health disorders must be vague.  When we trace that idea through to its literal implementation in medical practice, we find strong evidence that it compromises the safety of patient care in the great many cases where clinicians grapple with diagnosis at the mind-body line.  Having established that medicine must embrace some form of nonreductionism, I argue that Chalmers’ naturalistic dualism is a far stronger prima facie candidate than the nonreductive alternatives.  Regardless of which form of nonreductionism we prefer, some philosophical corrections are needed to give medicine a safe and coherent foundation.

The Value of Consciousness in Medicine

Forthcoming, Oxford Studies in Philosophy of Mind, Vol 1

We generally accept that medicine's conceptual and ethical foundations are grounded in recognition of personhood. With patients in vegetative state, however, we've understood that the ethical implications of phenomenal consciousness are distinct from those of personhood. This suggests a need to reconsider medicine's foundations. What is the role for recognition of consciousness (rather than personhood) in grounding the moral value of medicine and the specific demands of clinical ethics? I suggest that, according to holism, the moral value of medicine is secured when conscious states are recognized in everyday medical science. Moreover, consciousness fully motivates traditional principles of clinical ethics if we understand respect for autonomy as respect for the dominion of an experiencer in the private, inescapable realm of bodily experience. When medicine's foundations are grounded in recognition of consciousness, we understand how patients fully command respect even when they lack capacity to exercise their bodily dominion through decision-making.

Ethical Psychotherapeutic Management of Patients with Medically Unexplained Symptoms 

with Keith Geraghty

forthcoming in Oxford Handbook of Psychotherapy Ethics

Management of medically unexplained symptoms (MUS) is undergoing a period of change. We see this in the recent breakdown of consensus on mental health management of quintessential medically unexplained conditions (like myalgic encephalomyelitis/chronic fatigue syndrome), and in recent work in bioethics suggesting that the issue of biological versus mental health management of MUS is fundamentally an ethical matter. For these reasons, it’s important to think carefully about ethical aspects of MUS management in psychotherapeutic settings. In Part 1 of this chapter, we show how ambiguity in the term “MUS” leads to routine conflation of diagnostic uncertainty with psychological diagnosis for unexplained symptoms in medical settings. In Part 2, we explore evidence suggesting that substantial harm results from a failure to draw that distinction in medical settings, and we clarify the psychotherapist’s obligations to avoid those harms. In Part 3, we explore the risk for psychological harms when psychotherapists conflate diagnostic uncertainty with psychological diagnosis. Finally, in Part 4 we consider challenges to informed consent in psychotherapy for MUS. We conclude with principles for ethical psychotherapeutic management of MUS.

A concerning display of medical indifference: Reply to "Chronic fatigue syndrome and an illness-focused approach to care: Controversy, morality and paradox"

Forthcoming, Medical Humanities 

In “Chronic fatigue syndrome and an illness-focused approach to care: Controversy, morality and
paradox”, authors Michael Sharpe and Monica Greco begin by characterizing ME/CFS as illness-without-
disease. On that basis they ask why patients reject treatments for illness-without-disease,
and they answer with a philosophical idea. Whitehead’s “bifurcation of nature”, they suggest,
still dominates public and professional thinking, and that conceptual confusion leads patients to
reject the treatment they need. A great deal has occurred, however, since Whitehead
characterized his culture’s confusions one hundred years ago. In our time, I suggest, experience
is no longer construed as an invalid second cousin of bodily states in philosophy, in medicine, or
in the culture at large. More importantly, we must evaluate medical explanations before we reach
for philosophical alternatives. The NIH and IOM have concluded that ME/CFS is, in fact, a
biomedical disease, and all US governmental health organizations now agree. Though it would
be productive for Sharpe and Greco to state and support their disagreement with the other side of
the disease debate, it is no longer tenable, or safe, to ignore the possibility of disease in ME/CFS
patients, or to recommend that clinicians should do so. When we find ourselves in a framework
that suggests the possibility of medical need is somehow beside the point for medical providers, it
is time to reconsider our conceptual foundations.

"It's Time to Pay Attention to 'Chronic Fatigue Syndrome'"

Journal of Medical Ethics Blog, 5 March 2019.

Professional and public debate about myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) has reached a new pitch.  A London Times article in August described the “acrimonious scientific row” that’s erupted in the UK now that the US Institute of Medicine, National Institutes of Health, and Centers for Disease Control insist that ME/CFS is not a psychosomatic condition, but rather “a serious biological disease”.  Just a few weeks ago the issue was raised in Parliamentary debate, with a long stream of MPs taking a vocal stand on behalf of their constituents with ME/CFS, demanding a new practice guideline that protects access to biomedical care.  Two aspects of this situation are strange – very strange. First, where is the voice of ethics? For decades the public has pursued a vocal concern about access to biomedical care for ME/CFS, while bioethics has remained silent.  Second, psychiatrists who originally established the UK’s prominence in this area are, quite rightly, engaging in vigorous professional and public debate at this time.  The UK’s practice guideline is now under revision, and discussion of this kind is necessary to move forward. The trouble is that the focus of this debate is far off track – and no one seems to have noticed.

Few conditions have sparked as much controversy as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Professional consensus has long suggested that the condition should be classified as psychiatric, while patients and advocacy groups have insisted it’s a serious biological disease that requires medical care and research to develop it. This longstanding debate shifted in 2015 when US governmental health authorities fully embraced medical classification and management. Given that some globally respected health authorities now insist that ME/CFS is a serious biological disease, this paper asks whether it can be ethical for the UK practice guideline now in development to characterize the condition as a mental health disorder. Following a brief history of ME/CFS controversy, I offer three arguments to show that it would be unethical for the UK to now characterize ME/CFS as a mental health condition, considering the relevance of that conclusion for ME/CFS guidelines elsewhere and for other contested conditions.

Bodily distress syndrome: Concerns about scientific credibility in research and implementation

Journal of Biological Physics and Chemistry, Special Issue on Scientific Integrity, 18 (2018) 67–77.

The credibility of psychosomatic medicine has recently been called into question through challenges to the scientific integrity of the “PACE trial”, which claimed success for psychiatric treatment in managing myalgic encephalomyelitis/chronic fatigue syndrome.  A more recent product of research in psychosomatic medicine is “bodily distress syndrome” (BDS), a Danish diagnostic construct developed to replace “somatoform disorders”, “medically unexplained symptoms” and “functional somatic syndromes”.  I set out in this paper to examine the science that supports the construct of BDS, both in design and in implementation.  Following the Introduction, in Part 2 I clarify the details that define BDS, and the problems the construct is designed to resolve.  In Part 3, I explore three problems with the science behind BDS. In Part 4, I consider the World Health Organization’s effort to implement BDS in the International Classification of Diseases, noting that while BDS criteria fail in both WHO studies, the workgroup nonetheless insists that the ICD should recommend them for global use.  I conclude that BDS gives support to recent concern that scientific standards in psychosomatic medicine are inadequate, closing with a brief discussion of ethical problems that arise when global health policy decisions are not grounded in science.

Ethical management of diagnostic uncertainty: Response to open peer commentaries on 

“Why bioethics should be concerned with medically unexplained symptoms”

American Journal of Bioethics 18:5, 6-15 (August 2018).

Commentaries on my target article, “Why bioethics should be concerned about medically unexplained symptoms”, offer a range of valuable perspectives on the unconsidered ethical territory of medically unexplained symptoms (MUS).  In what follows I will briefly review the article’s central points, then hone in on three central challenges that arise in the commentary: the suggestion in Canavera that physicians should not focus on carefully distinguishing biological and psychosocial symptoms, the suggestion in Kanaan that psychogenic diagnosis rarely errs, and the suggestion in Preller, and in Sankary and Ford, that a risk/benefit analysis for patients with psychogenic symptoms supports the current status quo.  Finally, I will explore a suggestion that can unify most of the commentary, the idea that the best path to improving care in this area is truthful humility about diagnostic uncertainty.

Biomedical diagnostic science is a great deal less successful than we’ve been willing to acknowledge in bioethics, and this fact has far-reaching ethical implications. In this article I consider the surprising prevalence of medically unexplained symptoms, and the term’s ambiguous meaning. Then I frame central questions that remain unanswered in this context with respect to informed consent, autonomy, and truth-telling. Finally, I show that while considerable attention in this area is given to making sure not to provide biological care to patients without a need, comparatively little is given to the competing, ethically central task of making sure never to obstruct access to biological care for those with diagnostically confusing biological conditions. I suggest this problem arises from confusion about the philosophical value of vagueness when it comes to the line between biological and psychosocial needs.

Controversy over somatic symptom disorder (SSD) is indeed about where the line between medicine and psychiatry should be drawn, because SSD continues to play the same primarily medical role as its former cousins, regardless of the new inclusiveness. SSD is centrally an explanation for physical symptoms, one physicians will look to when faced with medical diagnostic challenges.  While it’s right to be concerned that this new line in the sand will generate needless psychiatric care, the real problem with SSD is really much more grave: it sanctions refusal to face the seriousness of the risk of error, the problem of medical harm that results when patients with medical problems are mistakenly denied medical care.

Theaetetan epistemology as Platonic epistemology

Australasian Journal of Philosophy 73(1), 49–70 (March 1995).

The Theaetetus is concerned largely with the thesis that perception and knowledge are one and the same thing.  Theaetetus suggests something like this to begin the main part of his conversation with Socrates, and Socrates proceeds to reveal what Seth Benardete described as the "parentage" of Theaetetus' view, that is, the strong similarity between Theaetetus' suggestion and the relativist views of Protagoras.  The conversation that ensues focuses on difficulties with Protagorean epistemology.  Once Protagoras is defeated, Socrates rejects the related view of Heraclitus, and finally, the possibility that knowledge is true opinion.  This is what occurs on the surface of the dialogue, but I shall argue that this surface is deliberately misleading.  What actually occurs in the dialogue is that Theaetetus offers the rich and promising Platonic suggestion that knowledge is nothing but perception, a suggestion that is subsequently misconstrued by Socrates as the claim that sense perception is identical to knowledge.  Though one is certainly tempted to blindly follow along, to accept without question Socrates' misconstrual, this is not in fact what Plato expects us to do.

Not-being and linguistic deception

Apeiron: A Journal for Ancient Philosophy and Science 29(4), 165–198 (December 1996).

Was Plato, at least in some moods, a philosopher of language? There can be no doubt that questions about the way language latches on to the world occur with some frequency in the dialogues, and with notable urgency in the Sophist. Indeed as our own era seems to be one in which philosophy of language is valued, the Sophist is often favoured as closer in spirit to contemporary thought than any of the other dialogues.  I suggest that Plato is concerned with linguistic matters in the Sophist not because he accepts the value of philosophy of language, but because he wants to explain what underlies the linguistic skepticism that runs through the dialogues. I argue that beneath the glistening surface of debate about reference and truth in the Sophist there lies a beautifully simple, rigorous, account of the disparity between language and the world it purports to represent. Embedded within the Stranger's most technical linguistic pursuits is something we should have been missing in the Platonic corpus, that is, an explanation of Plato's persistent suggestion that language is not a good place to turn for philosophical insight.

©2018 by Diane O'Leary, PhD.