pistemic and Nonepistemic Values in Psychiatric xplanation and Classification A dissertation submitted to the Graduate School of the University of Cincinnati in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Philosophy of the College of Arts and Sciences by Aaron T. Kostko M.A. University of Cincinnati June 2008 Committee Chair: Valerie Hardcastle, Ph.D. Abstract My dissertation addresses two longstanding debates in the philosophy of psychiatry: the debate between objectivists and evaluativists regarding the relative significance of factual descriptions and evaluative judgments in attributions of psychiatric disorder and the debate between reductionists and pluralists over whether explanations of psychiatric disorders should proceed at a single level or multiple levels of explanation. The standard way to distinguish philosophical accounts of psychiatric disorder is in terms of the relative significance they grant to factual descriptions of abnormal functioning and evaluative judgments of this abnormal functioning. I argue that this way of categorizing philosophical accounts is overly simplistic and that a more fruitful approach is to focus on the role of epistemic and nonepistemic evaluative judgments in the contexts of psychiatric diagnosis, classification, and research. Using debates regarding the diagnostic criteria for diagnoses of Bipolar Disorder, I highlight the interaction between epistemic and nonepistemic value judgments and argue that the latter play a legitimate role in decisions regarding the relative risks of false positive and false negative diagnoses and whether to draw an inference quickly or wait for further evidence to reduce uncertainties. I show how this approach provides for a more straightforward comparison of the various accounts of psychiatric disorder by making explicit the role and type of evaluative judgments that are either ignored or often tacitly assumed by each account. The second half of my dissertation focuses on the debate between reductionists and pluralists. I outline and evaluate five specific reductionist theses within the philosophy of psychiatry literature: 1) ontological reductionism, 2) eliminative reductionism, 3) methodological reductionism, 4) epistemological reductionism, and 5) causal reductionism. I argue that eliminative, epistemological, and causal reductionism will likely not be borne out by the empirical evidence and that only ontological reductionism, characterized as a general commitment to physicalism, and methodological reductionism are consistent with the current evidence and explanatory aims of psychiatry. I then consider why reductionism has received so much attention and criticism despite the fact that there is no author who explicitly defends the view. I attribute this focus on reductionism to recent proposals to synthesize psychiatry with neuroscience. However, I argue that these proposals advocate nothing more than a general commitment to physicalism and a localized version of methodological reductionism and, therefore, that concerns about reductionist trends in psychiatry and the alleged harms associated with such trends are unwarranted. Pragmatism and pluralism are often defended as alternatives to reductionism in psychiatry. I examine three proposals for incorporating pragmatism into psychiatry and argue that they all fail to provide specific guidance as to how pragmatic considerations should influence decisions regarding psychiatric diagnosis and classification. I then examine proposals for incorporating empirically based pluralism and explanatory pluralism into psychiatry and argue that each view fails to fully address the problem of how to determine the relative explanatory significance of various levels of explanation. I argue that one can only address these shortcomings if one acknowledges a role of nonepistemic value judgments and that the inclusion of such judgments is the inevitable consequence of recognizing the complexity of psychiatric disorders and the provisional nature of psychiatric classification and explanation. ii Copyright © 2014 by Aaron T. Kostko iii Acknowledgements I would like to thank my dissertation director, Valerie Hardcastle, for supervising my project, and the members of my dissertation committee, John Bickle, Tom Polger, and Robert Richardson, for their support and patience. I am especially grateful to my advisor, John Bickle, for his continued encouragement and guidance. Much of my success is due to his mentorship and the congenial environment that he created both within and outside the department. I would also like to thank the faculty in the Department of Philosophy at the University of Cincinnati for their support and instruction as well as the graduate students for fostering a friendly and comfortable environment in which to exchange philosophical ideas. I have especially benefitted from conversations with Dan Hartner and Matt Van Cleave. I would also like to thank my parents for their unconditional love and support as I finished this project and for their encouragement to pursue a career that I truly enjoyed. Finally, I was able to pursue this project because of a Graduate Student Research Fellowship provided by the University Research Council at the University of Cincinnati and a Taft Dissertation Fellowship provided by the Charles Phelps Taft Research Center at the University of Cincinnati. I am very grateful for the generous support of these organizations. iv Table of Contents Abstract ii Acknowledgments iv Table of Contents v Chapter 1: Introduction: The Philosophical Landscape of Psychiatry 1-24 Causalism vs. Descriptivism 2 Reductionism vs. Pluralism 7 Objectivism vs. valuativism 11 Internalism vs. xternalism 14 Categorical vs. Dimensional 15 ssentialism vs. Nominalism 17 Personal vs. Impersonal 18 Conservatism vs. Revisionism 19 Chapter 2: The Role of Values in Philosophical Accounts of Psychiatric Disorder 25-93 The Constructivist and Anti-Psychiatry Challenge 27 Abolitionism 37 Objectivism 43 valuativism 52 Hybrid Accounts (Weak valuativism) 58 Reconceptualizing the Philosophical Landscape: pistemic and Nonepistemic valuative Judgments 73 Chapter 3: Reductionism in Psychiatry 94-155 What is Reductionism? 96 Ontological Reductionism 100 liminative Reductionism 103 Methodological Reductionism 105 pistemological Reductionism 106 Causal Reductionism 122 Are Proposals to Synthesize Psychiatry with Neuroscience Reductionist? 141 Chapter 4: Pragmatism and Pluralism in Psychiatry 156-181 Pragmatism in Psychiatry 157 Pluralism in Psychiatry 164 mpirically Based Pluralism (Integrative Pluralism) 169 xplanatory Pluralism 175 Bibliography 183 v Chapter 1: The Philosophical Landscape of Psychiatry Socrates: Now does not the science of medicine, which we have just mentioned, make men able to think and to speak about their patients? Gorgias: Assuredly. Socrates: Then medicine also, it seems, is concerned with words. Gorgias: Yes. Socrates: Words about diseases? Gorgias: Certainly. (Gorgias, 450a1-a9) The concepts of “health” and “disease” have long occupied the attention of philosophers of medicine. Philosophical debate in this area centers around which words one should use to describe health and disease. Of course, the words that one chooses to describe health and disease are typically intended to be more than just talk; they are intended to track real properties of an individual and an individual’s environment that are implicated in the etiology of disease. Moreover, the concepts of “health” and “disease” function to demarcate the proper domain of clinical medicine by distinguishing those bodily states that should be “medicalized” from those that should not. This is no less the case in psychiatry, where the scientific legitimacy of the discipline has critically depended upon choosing the right words to reliably distinguish the “mentally healthy” from the “mentally unhealthy” and the “mentally disordered” from the “mentally ordered.” One of the greatest challenges facing philosophers of psychiatry, however, is navigating and integrating the numerous ways of talking that permeate the discipline. Psychiatry, much more so than clinical medicine, is comprised of a relatively disconnected collection of theoretical perspectives, each equipped with distinct vocabularies, methodologies, explanatory targets, and philosophical commitments. This diversity of theoretical perspectives gives rise to a number of fundamental philosophical disagreements regarding the very nature of psychiatric disorders, the reliability of 1 diagnostic criteria for psychiatric disorders, the role of values in defining psychiatric disorders, and the very nature and structure of explanation and classification in psychiatry. This chapter introduces these fundamental philosophical disagreements by categorizing them along eight dimensions: causalism vs. descriptivism, reductionism vs. pluralism, essentialism vs. nominalism, objectivism vs. evaluativism, internalism vs. externalism, personal vs. impersonal, categorical vs. dimensional, and conservatism vs. revisionism. Kendler and Zachar (2007) first proposed six of these dimensions for categorizing philosophical disagreements, but I have added the dimensions of reductionism vs. pluralism and conservatism vs. revisionism, as these represent further fundamental philosophical disagreements within the literature. Addressing each of these debates in sufficient detail is beyond the scope of this dissertation. Some of the debates are already relatively settled while