A Myth in Creation

Takeaway: The societal dominance of biomedical narratives requires physicians to practice medicine with epistemic humility and in a deeply collaborative manner.   How medical explanations shape our self-understanding individually as well as collectively has increasingly been on my mind, and over time I have become acutely aware of medicine’s complicated relationship with epistemic justice. According to philosopher Miranda Fricker, epistemic injustice occurs when someone is wronged “specifically in their capacity as a knower.” (1) This comes in two forms, testimonial and hermeneutic injustice. Testimonial injustice happens when a person is assigned lower credibility due to prejudice and not based on any reasonable concerns about the testimony. The person belongs to a certain negatively stereotyped social group, and this creates a credibility deficit for members of that group. A common example would be not taking the testimony of someone as seriously as is warranted because th...

" Conversations in Critical Psychiatry " is my interview series for Psychiatric Times  that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo. Following interviews have been published so far. I will continue to update this page as new interviews are published. The list below is in the order of the original online publication. 1)  Conversations in Critical Psychiatry: Allen Frances, MD 2)  The Structure of Psychiatric Revolutions: Anne Harrington, DPhil (published in print with the title 'The Many Histories of Biological Psychiatry') 3)  Skepticism of the Gentle Variety: Derek Bolton, PhD 4)  Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD 5)  Chaos Theory With a Human Face: Niall McLaren, MBBS, FRANZCP 6)  The Rise and Fall of Pragmatism in Psychiatry: S. ...

A twitter thread by Dr. Gipps prompted me to look at the use of the term "understandable" more closely in the document " Understanding Depression " by the British Psychological Society. It appears to me that the term is used in an ambiguous and polysemous manner in the document, drawing on multiple themes and analogies, that are not only different but also generate different implications and subsequent questions. In this post I identify some of the different ways in which this term is used. A recurrent theme in the document, at least implicitly, is that depression being "understandable" poses some sort of a problem for a medical approach to depression; there is a crude sense in which it can be the case, but not necessarily. I briefly discuss this aspect of the problem as well.  1) "Another idea is that, rather than being an experience thrust upon us by biology, depression, like other emotions, is often an understandable human response to the world ar...

In this blogpost I am collecting some of my recent tweets on the topic of attribution of “disease” or “disorder” in medicine and psychiatry, and whether legitimacy of medicine depends on that. I have edited the tweets for clarity. (Also see the post Beyond Definitional Disagreements  for additional background.) Suffering, impairment, harm, neurobiological and psychological differences, these exist independent of anyone’s wishes, but whether we see them through the concept of “disease” is a different issue that can be validly debated without committing a philosophical or scientific error. ( link ) There are indeed truths out there, but “disease” is not among those truths. What does exist is suffering, impairment, harm, and various sorts of neurobiological and psychological differences, etc., but our conceptualizations of these phenomena do not constitute fundamental truths. ( link ) While characterization of distress/incapacity as “disease” is coherent and historically respect...

Some reflections in a piece for CLOSLER on looking at success in academic medicine through the lens of virtue ethics.

The following are comments from Mark L. Ruffalo, D.Psa., L.C.S.W and Ronald W. Pies, M.D. in response to my previous blogpost: " Can Symptoms Be Caused by Descriptive Syndromes? An Analysis ". As a reminder, my blogpost was written in the context of an article by Ruffalo and Pies (" What Is Meant by a Psychiatric Diagnosis? ") that had been written in response to an article by Jonathan Shedler, Ph.D (" A Psychiatric Diagnosis Is Not a Disease "). Both these article were in  Psychology Today . I will post the comments from Ruffalo and Pies, followed by brief comments from me. COMMENTS FROM MARK RUFFALO AND RONALD PIES Dear Awais, Thank you for the opportunity to respond to your thoughtful comments on our article in  Psychology Today,  and on the broader—and very complex—issues we are all raising. Our position, roughly speaking, could be summed up in three basic principles: 1) Avoid definitional essentialism 2) Embrace clinical...

In this post I want to examine the question of whether it makes sense to say that a patient’s anxiety is caused by ‘Generalized Anxiety Disorder’. Jonathan Shedler argues that it doesn’t. Mark Ruffalo and Ron Pies argue that it does . This is not a specific response to either, but simply a clarification of my own views. 1) The first thing I want to do is point to Hane Maung’s brilliant philosophical paper “ To what do psychiatric diagnoses refer? A two-dimensional semantic analysis of diagnostic terms ” (2016). Maung argues with great philosophical sophistication that reference of diagnostic terms in psychiatry can have two meanings or two intentions “ a diagnosis has a pre-theoretical mode of presentation that characterises the 1-intension, and an underlying structure that is discovered a posteriori and determines the 2-intension…. In the case of a diagnosis, the mode of presentation is the clinical manifestation and the underlying structure is the disease proce...

There are different philosophical ways of conceptualizing "medical disorders". You could take an essentialistic approach, that medical disorders have necessary and sufficient properties which make them medical disorders (for instance, a demonstrate biological dysfunction). An different approach is a pragmatic one, in which there are no necessary and sufficient criteria, and the characterization of something as a medical disorder depends on various scientific as well as practical considerations (whether the condition is distressing, whether people are seeking help for it, are treatments available, etc.). According to the essentialistic approach, calling something a medical disorder means we are saying something about the nature of the condition. According to the pragmatic approach, calling something a medical disorder does not commit us to any particular view of the nature of the condition (I prefer the pragmatic approach). There are two other aspects of this discussion...