WORK IN PROGRESS
FROM MIND TO MORALITY: THE VALUE OF CONSCIOUSNESS IN MEDICINE
We generally accept that recognition of personhood drove medicine’s shift away from the biomedical model, and that recognition of personhood remains foundational to medicine’s ethical concerns. In the context of patients in vegetative state, however, we’ve come to see that the moral and ethical implications of phenomenal consciousness are distinct from those of personhood. In this light, it seems important to reconsider the foundations of medicine. What is the role for recognition of consciousness (as distinct from personhood) in grounding the moral value of medicine and the specific demands of clinical ethics? I begin by pinning down the tenets of holism as they concern consciousness. Next, I discuss three ways in which holism’s concern with conscious states has changed medical science, and I clarify how these scientific changes force us to see medical practice as moral. Finally, I argue that the traditional principles of clinical ethics are fully motivated by consciousness in the absence of personhood. Most importantly, I suggest that respect for patient autonomy is respect for the dominion of an experiencer in the private, inescapable realm of bodily experience, so conscious patients command this respect even when they lack the capacity to exercise their dominion though decision-making. While philosophical discussion of this issue is valuable, it's also important that medical practice might be improved with clarity on the clinical and ethical roles for recognition of consciousness.
MEDICINE’S METAPHYSICAL MORASS: HOW CONFUSION ABOUT DUALISM THREATENS PUBLIC HEALTH
What position on dualism does medicine require? Our understanding of that question has been dictated by holism since that movement developed in the late twentieth century, but holism has been characterized from the start with confused philosophical terminology. This problem has led to misunderstanding about the philosophical foundation for medicine and psychiatry, and that misunderstanding has a direct impact on patient safety.
Following a brief overview of the history of holism in Part 1, I pin down confusions in use of the terms ‘reduction’ and ‘dualism’ in Part 2. Rectifying those errors clarifies holism’s philosophically muddled claims, but conceptual confusion remains because holism is understood to maintain contradictory positions on reductive physicalism. In Part 3, I explain why the idea of reductive holism is incoherent, then I show how the reductive strand of holism leads to quantifiable harm for patients in everyday medical practice. In Part 4, I explain how holism’s dualistic foundation is aligned with philosophical work on the mind-body problem that’s characteristic of our time. In the end of the day I argue that Chalmers’ naturalistic dualism serves better than the alternatives of supervenience physicalism or emergence as the nonreductive picture that underlies holism. I conclude with a list of the basic corrections that can finally give holism a coherent philosophical foundation.
A CONCERNING DISPLAY OF MEDICAL INDIFFERENCE
The battle between patients and professionals over ME/CFS has now become a battle between professionals, where many insist the condition is a serious biological disease, and many continue to maintain that it’s psychosomatic. In “Chronic fatigue syndrome and an illness-focused approach to care: Controversy, morality and paradox”, authors Michael Sharpe and Monica Greco ignore that core issue entirely. Asking why ME/CFS patients find illness-focused treatments to be unaccepable, they suggest the source of the trouble is a problematic conceptual bifurcation between illness-with-disease and illness-without-disease. I argue that several simpler and more compelling explanations are immediately evident, and that authors’ failure to consider them is problematic. Further, I suggest that because Sharpe and Greco fail to provide support for construing ME/CFS as illness-without-disease, or even to recognize the need for such support, their paper serves as a powerful example of the primary concern that leads patients to reject illness-focused treatments. Now that professional consensus on ME/CFS has dissolved, it’s important for professionals in psychosomatic medicine to heal the longstanding patient-professional
rift. To do so, they will need to state for the record that it’s no longer safe to assume ME/CFS patients suffer from illness-without-disease.
ETHICAL PSYCHOTHERAPEUTIC MANAGEMENT OF MEDICALLY UNEXPLAINED SYMPTOMS
With Keith Geraghty, academic chapter
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.
"WHAT ARE PSYCHOSOMATIC SYMPTOMS, NOW THAT WE'VE REJECTED CARTESIAN DUALISM?"
Psychosomatic symptoms are understood to be very common in medical practice, but it remains unclear what it means to say that symptoms are “psychosomatic” or “functional”. This paper explores that question from a philosophically informed perspective. Based on clarity about property dualism and the difference between brain states and mental states, we can clearly mark three senses in which symptoms are said to be psychosomatic in research and practice: (1) experience of bodily symptoms is primarily caused by psychological distress, (2) experience of bodily symptoms is caused by actual biological pathology that arises room (or is triggered by) psychological distress, (3) experience of bodily symptoms is caused by neurological pathology that may or may not be caused by long-term psychological distress or chronic pain. What we're working with in this area is really not a single idea, but three distinct ways for the mental states to impact bodily health – each demanding a distinct approach to treatment and research. The mind's relation to the body is complex. Success in this area of medicine depends on philosophical clarity.