Harm as a Necessary Component of the Concept of Medical Disorder: Reply to Muckler and Taylor

Wakefield's Harm-Based Critique of the Biostatistical Theory

Jerome Wakefield criticizes my biostatistical analysis of the pathological-as statistically subnormal biological part-functional ability relative to species, sex, and age-for its lack of a harm clause. He first charges me with ignoring two general distinctions: biological versus medical pathology, and disease of a part versus disease of a whole organism. He then offers 10 counterexamples that, he says, are harmless dysfunctions but not medical disorders. Wakefield ends by arguing that we need a harm clause to explain American psychiatry's 1973 decision to declassify homosexuality. I reply, first, that his two distinctions are philosophic fantasies alien to medical usage, invented only to save his own harmful-dysfunction analysis (HDA) from a host of obvious counterexamples. In any case, they do not coincide with the harmless/harmful distinction. In reality, medicine admits countless chronic diseases that are, contrary to Wakefield, subclinical for most of their course, as well as many kinds of typically harmless skin pathology. As for his 10 counterexamples, no medical source he cites describes them as he does. I argue that none of his examples contradicts the biostatistical analysis: all either are not part-dysfunctions (situs inversus, incompetent sperm, normal-flora infection) or are indeed classified as medical disorders (donated kidney, Typhoid Mary's carrier status, latent tuberculosis or HIV, cherry angiomas). And if Wakefield's HDA fits psychiatry, the fact that it does not fit medicine casts doubt on psychiatry's status as a medical specialty.

Beyond Conceptual Analysis: Social Objectivity and Conceptual Engineering to Define Disease

In this article, I side with those who argue that the debate about the definition of "disease" should be reoriented from the question "what is disease" to the question of what it should be. However, I ground my argument on the rejection of the naturalist approach to define disease and the adoption of a normativist approach, according to which the concept of disease is normative and value-laden. Based on this normativist approach, I defend two main theses: (1) that conceptual analysis is not the right method to define disease and that conceptual engineering should be the preferred method and (2) that the method of conceptual engineering should be implemented following the principles of Alexandrova's account of social objectivity in the context of the definition of disease.

Towards a dispositionalist (and unifying) account of addiction

Addiction theorists have often utilized the metaphor of the blind men and the elephant to illustrate the complex nature of addiction and the varied methodological approaches to studying it. A common purported upshot is skeptical in nature: due to these complexities, it is not possible to offer a unifying account of addiction. I think that this is a mistake. The elephant is real-there is a there there. Here, I defend a dispositionalist account of addiction as the systematic disposition to fail to control one's desires to engage in certain types of behaviors. I explain this position, defend the inclusion of desires and impaired control, and flesh out the notion of systematicity central to my account. I then illustrate how my dispositionalist framework can unify the disparate and seemingly incompatible accounts of addiction (and their respective methodological approaches). I close with a brief plan to extend and implement my account.

Personality disorders as a predictor of counterproductive knowledge behavior: the application of the Millon Clinical Multiaxial Inventory-IV

Purpose

This study investigates the role of personality disorders in the context of counterproductive knowledge behavior.

Design/methodology/approach

Data were collected through a survey administered to 120 full-time employees recruited from Amazon’s Mechanical Turk. Personality disorders were measured by means of the Millon Clinical Multiaxial Inventory-IV.

Findings

Personality disorders play an important role in the context of counterproductive knowledge behavior: employees suffering from various personality disorders are likely to hide knowledge from their fellow coworkers and engage in knowledge sabotage. Of particular importance are dependent, narcissistic and sadistic personality disorders as well as schizophrenic and delusional severe clinical syndromes. There is a need for a paradigm shift in terms of how the research community should portray those who engage in counterproductive knowledge behavior, reconsidering the underlying assumption that all of them act deliberately, consciously and rationally. Unexpectedly, most personality disorders do not facilitate knowledge hoarding.

Practical implications

Organizations should provide insurance coverage for the treatment of personality disorders, assist those seeking treatment, inform employees about the existence of personality disorders in the workplace and their impact on interemployee relationships, facilitate a stress-free work environment, remove social stigma that may be associated with personality disorders and, as a last resort, reassign workers suffering from extreme forms of personality disorders to tasks that require less interemployee interaction (instead of terminating them).

Originality/value

To the best of the authors’ knowledge, this work represents one of the first attempts to empirically investigate the notion of personality disorders in the context of knowledge management.

Unhealthy mind in a healthy body: A criticism to eliminativism in psychopathology

In this article we criticize the thesis "The diseases we treat are diseases of the brain". A first criticism is against the eliminativist perspective and in favor of a perspective that is still reductionist but emergentist and functionalist. In a second part, we try to answer the question "under which conditions can we consider this statement legitimate?". We argue that only those mental disorders whose neural substrate has clearly neuropathological characteristics, i.e., anomalies with respect to the laws of good neural functioning, can be considered "brain diseases." We propose that it is not sufficient to observe a simple difference between the brains of people with psychopathology, that is, with anomalies with respect to the laws of good psychological functioning, and that of people without psychopathology. Indeed, we believe it is a categorical error to postulate a neuropathology starting from a psychopathology. Finally, we summarize some research that shows how purely psychological interventions can reduce or eliminate the differences between the brains of people with or psychopathology and those of people without.

Directing Technology Addiction Research in Information Systems

In this second part of a series of articles to direct technology addiction research in the information systems discipline, we discuss the history, conceptualization, and measurement of technology addiction. We admit that it is possible to label the phenomenon as overuse or excessive use as long as it is defined and measured by the presence and the magnitude of the six core symptoms of behavioral addictions: salience, mood modification, tolerance, withdrawal, conflict, and relapse. The advantage of this terminology is that it does not attribute one's problems to helplessness and does not pathologize the behavior, implying that it may possibly be corrected. Nevertheless, we posit that the term technology addiction is currently the most reasonable choice that may need to be adjusted as we learn more about this phenomenon and its potential similarities to and differences from established behavioral addictions. Dependence, obsessive/compulsive use, and pathological/problem use terms should not be used as synonyms for technology addiction as a form of mental disorder. Researchers should not include the name of the IT artifact as the subject of addiction (e.g., "Facebook addiction"). Instead, they should focus on the activity that is mediated through the IT artifact (e.g., "addiction to Facebook use").

The harmful-dysfunction account of disorder, individual versus social values, and the interpersonal variability of harm challenge

This paper presents the interpersonal variability of harm challenge to Jerome Wakefield's harmful-dysfunction account (HDA) of disorder. This challenge stems from the seeming fact that what promotes well-being or is harmful to someone varies much more across individuals than what is intuitively healthy or disordered. This makes it at least prima facie difficult to see how judgments about health and disorder could, as harm-requiring accounts of disorder like the HDA maintain, be based on, or closely linked to, judgments about well-being and harm. This interpersonal variability of harm challenge is made salient by the difficulty faced by harm-requiring accounts of disorder in dealing satisfactorily with cases of intuitively disordered conditions that seem harmless because they do not deprive the individuals that they affect of anything that they value (e.g., desired infertility). I argue that this challenge is made more serious for the HDA by some clarifications Wakefield has recently made on harm. In recent publications, Wakefield dissociates himself from the sheer cultural-relativist view of harm attributed to him by some critics based on his linkage of harm to social values, and adopts a more qualified social-values-based view of harm that leaves room for criticism of the values endorsed by members of a cultural group at a given time. I show how Wakefield's qualified view makes it more difficult for the HDA to deal with the interpersonal variability of harm challenge, at least when applied to a Western cultural context where a high value is placed on autonomy and individual choice.

Healthcare in Extreme and Austere Environments: Responding to the Ethical Challenges

Clinicians may increasingly find themselves practicing, by choice or necessity, in resource-poor or extreme environments. This often requires altering typical patterns of practice with a different set of medical and ethical considerations than are usually faced by clinicians practicing in hospitals in the United States and Europe. Practitioners may be required to alter their usual scope of practice or their standard ways of medically treating patients. Limited resources will also often place clinicians in the position of having to make decisions about fairly allocating healthcare, which will alter the physician-patient relationship. This does not absolve physicians and other healthcare practitioners of providing the best quality of care that can be given under the circumstances. In addition, the lack of a well-developed healthcare infrastructure and limited resources will require working with established providers to determine the needs of the community, and what types of healthcare are feasible given these limitations. The essays in this issue of HEC Forum encourage readers to reflect on the unique ethical challenges faced in the extreme or austere environment.

Bioethics in the Ruins

In The Foundations of Bioethics (1986, 1996), former senior editor of The Journal of Medicine and Philosophy H. Tristram Engelhardt, Jr. (1941–2018) radically reassessed the nature and scope of bioethics, as well as the possibilities for this still-young field that he helped found, in light of the prevailing sociohistorical context, which he argued had been inadequately considered by bioethicists. This issue of The Journal of Medicine and Philosophy provides a snapshot of how bioethics is developing in the wake of Engelhardt’s critique. Topics covered include the relation between rule of law and US healthcare policy, the relation between autonomy and consent, the role of rights in bioethical discourse, the debate between naturalism and normativism in the theory of disease, and the question of when human individuals begin to exist. Although no single theme explicitly unites them, the papers in this issue were produced within and are fruitfully read in terms of what Engelhardt influentially characterized as a morally pluralistic postmodernity subsisting amidst the ruins of tradition. In the conclusion, I introduce a further wrinkle into this Engelhardtian picture—namely, the looming danger of a more general epistemological pluralism effected by new technologies like Deepfakes.