Roundtable on Ethics Review for DSM Revision, in PP&P

The September 2017 issue of Philosophy, Psychiatry, & Psychology includes a discussion focused on a ‘philosophical case conference,’ with eight commentaries and a response to those by the featured author, Tamara Kayali Browne. Below we provide an overview of their respective points for your perusal. Author contacts are linked as well, if you’d like to continue the conversation directly.

Browne’s featured article is titled A Role for Philosophers, Sociologists and Bioethicists in Revising the DSM: A Philosophical Case Conference and is summarized in the abstract as follows:

The recent publication of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was accompanied by heated debate. I argue that part of the reason for these recent controversies is that the process of DSM revision involves making certain value judgments, yet requires a better means for explicitly and expertly addressing these issues. It is important to do so because a) there are certain value-laden questions that science cannot answer but nevertheless need to be addressed in psychiatric classification, and b) the effects of psychiatric classification stretch far and wide. I suggest a means by which the value judgments involved in psychiatric classification can be more systematically and comprehensively examined—by including an independent ethics review panel in the revision process. An ethics review panel could include bioethicists, sociologists, and philosophers of psychiatry who would be in a better position to address these issues.

In lieu of abstracts, here are excerpts from the commentaries, as well as from Browne’s response to their contributions:

Ethics Experts, Pedagogical Responsibilities, and Wishful Thinking: Revising the DSM

By: Nancy Nyquist Potter

“Tamara Browne argues that many of the controversies that emerge in the process of revising DSMs could be solved by the creation of an Ethics Review Panel, similar to that of a research ethics committee. Members of such a panel would, in Browne’s words, ‘help inform psychiatric classification’ (Browne, 2017, p. 188). Browne’s proposal is important on a number of levels, the most significant one being that it affirms the status of ethics as equal to that of science. An Ethics Review Panel would do more than merely make the processes of scientific and ethical judgments parallel: if Browne’s suggestions were followed, it would raise ethical considerations to that of second-order status to scientific judgments in the revision process. I applaud the daring suggestions that Browne makes. Nevertheless, I am not yet sold on this idea. My remarks focus primarily on the idea of ethical experts…. We who are trained in psychiatric ethics probably are just as vulnerable to our own value commitments, confirmation biases, and stubbornness about other people’s ethical positions as are scientists. In referring to “those best placed” to weigh in on ethical considerations (Brown, 2017, p. 189), Browne makes a number of assumptions that should be questioned. First, even philosophers trained in ethics often are not adequately equipped to make good moral judgments on the ground; knowing theory is not the same as judging well in specific cases. Competing theories, and impassioned commitments to one’s pet theory, make cooperative evaluations across theoretical differences difficult.”


A Modest Proposal

By: Rachel Cooper

“There are many points on which I agree with Kayali Browne (2017). I agree that value judgments necessarily play a role in constructing a classification such as the Diagnostic and Statistical Manual of Mental Disorders (DSM). I agree that people with different backgrounds and interests are likely to assess problems differently and that it would be a good idea for a more diverse body of people to have some involvement in revising the DSM. I agree that philosophers might usefully play a role when the DSM is being revised. Overall, however, I am not convinced that Kayali Browne’s committee would be a good idea. In her vision, such a committee would constitute a group of wise moral experts who would help to make the value judgments implicit in the DSM as well-informed as possible. Along with many others I am skeptical of the idea that philosophers should be construed as moral experts in the sense of being particularly good at making practical moral decisions…. Rather than Kayali Browne’s committee, I will suggest a more modest proposal. While Kayali Browne focusses on how hard and deep moral questions might be dealt with, I think the priority is to consider how tractable issues might be better addressed. I suggest how some value-based problems with the DSM might be avoided fairly easily, and then consider the particular roles that philosophers might play in revising the DSM.”


Even Ethics Professors Fail to Return Library Books

By: Havi Carel

“Tamara Kayali Browne’s suggestion to create a formal role in revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) for philosophers, sociologists, and bioethicists is interesting and stems from a well-supported concern about how nosological psychiatric categories interact with both the epistemic norms of science and philosophy and with their consequences in the world. Browne is grappling with a problem that is clearly stated and pressing. However, I am not convinced that her solution, namely, using experts from these disciplines to form a veto-wielding ethics committee, is an ameliorative to this problem…. Here are several points in response. First, I agree that psychiatric nosological categories require, indeed demand, the kind of scrutiny Browne advocates. However, such scrutiny cannot be limited to a committee made up of a small number of individuals. The categories need to be scrutinized more broadly by advocacy groups, patient fora, and discussion groups for health professionals, as well as by scholars and researchers who specialize in the kind of critical reflection required here…. Second, to relegate the ethical, critical, and reflective role to philosophers and sociologists seems to miss an important point about health professionals in general, and psychiatrists in particular: Medicine is an art, as well as a science, and the virtuous or excellent psychiatrist (and medic more generally) is a skilled, thoughtful, and well-informed clinician who is also equipped with additional skills…. There is little reason to believe that a group of experts in philosophy, sociology, and ethics, who come into limited contact with the DSM creators and revisers, necessarily have these skills or have the capacity to develop these skills in psychiatrists. There is no evidence that philosophers and sociologists are more moral or more empathic than academics in other fields. It is also not clear that their expertise feeds into an improved understanding of the conditions and needs of mental health patients. Moreover, the notion of expertise itself, as applied to ethics, may come under pressure when scrutinized.”


A Case of Major Depression: Some Philosophical Problems in Everyday Clinical Practice

By: Paul B. Lieberman

“After the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) in 1980, psychiatry no longer characterized psychological problems as ‘reactions,’ which seemed to assume unproven psychoanalytically derived explanations, and referred to them instead as ‘disorders,’ which, it was thought, could be identified phenomenologically and without theoretical ‘presuppositions.’ Since then, psychiatrists have typically made diagnoses without reflecting on the fact that any categorization, including psychiatric diagnosis, exists within a framework of beliefs and practices and will, therefore, have implications and consequences. The fact of making a diagnosis, the act of doing so, the nature of the diagnosis, and the various ways the diagnosis can be used all have implications and consequences whose importance cannot often be clearly discerned. Such effects are frequently a complex mixture of clinical, conceptual, ethical, and sociological features as Dr. Kayali Browne (Browne, 2017) has suggested. Yet the busy and usually philosophically untrained clinician is poorly situated to address these vexing matters during the routine course of his or her practice.”


Valid Ethics Versus Probable Histories

By: Gavin Miller

“Tamara Kayali Browne’s proposal for an Ethics Review Panel (hereafter, ‘the panel’) for the Diagnostic and Statistical Manual of Mental Disorders (DSM) conceives of a state-sponsored panel of academic experts—philosophers, sociologists, and bioethicists—dealing in a reflective, systematic, and standardized manner with the ‘value judgements’ that are an ‘integral and unavoidable part of psychiatric nosology’ (Browne, 2017, p. 189). The panel would consider existing and new diagnostic categories, and issue authoritative vetoes and/or modifications as appropriate. Browne asserts that, ‘it should not be necessary to have protests and political activism, such as that involved in removing homosexuality from the DSM, in order for the status quo to be reassessed’ (Browne, 2017, p. 192). The panel, in other words, is intended to do via expert deliberation what has been done previously via the apparently lesser methods of ‘protests and political activism.’ My criticism of Browne’s article concerns its historiographic argumentation. To exemplify the panel’s work, she offers a counterfactual history of premenstrual dysphoric disorder (PMDD). The selection of PMDD—rather than, say, homosexuality—is unhelpful to her case, and her narrative of a counterfactual deliberation on PMDD does not sufficiently distinguish, nor defend, its historical probability.”


Ontological Assumptions, a Biopsychosocial Approach, and Patient Participation: Moving Toward an Ethically Legitimate Science of Psychiatric Nosology

By: Douglas Porter

“Important philosophical work has gone into debunking thoroughly entrenched positivist notions that objective science proceeds in a value neutral manner. Dr. Tamara Kayali Browne’s (2017) article ‘A Role for Philosophers, Sociologists, and Bioethicists in Revising the DSM’ admirably takes the next step. Given the evaluative elements that permeate, in this case, the science of nosology—how do we deal responsibly with those evaluative elements? She correctly, in my opinion, concludes that dealing with evaluative issues responsibly is tantamount to dealing with them ethically. But, as her concrete example of the ethics of premenstrual dysphoric disorder (PMDD) demonstrates, dealing with the ethics of the science of nosology is a complex matter. The ethical dimensions of the science run deep, all the way down to the way we conceptualize the nature and meaning of mental disorder. I think that clarifying the implicit ontological assumptions that guide the science of nosology confirms Dr. Browne’s premise that philosophers and social scientists have an important role to play in the development of an ethical science of nosology. But, I would add that the ethical legitimacy of the science of nosology also hinges on patient or mental health service user participation…. Dr. Brown notes that regarding PMDD as a biological problem inside the patient could result in a failure to address underlying social determinants of the mental distress, and treatment could devolve into facilitating ‘successful’ adaptation to oppressive and unjust circumstances. I think this is exactly what will result if we hold the belief that, if mental distress is in some sense biological, then it is biological all the way through. In other words, if it is a biological problem it must have a biological cause and a biological cure. But, it is possible, and I would argue more helpful to those in distress, to take a more ‘biopsychosocial’ view of the nature, cause, and treatment of mental distress. The epistemological divide between the social and biological sciences does not necessarily translate into an ontological divide between the social and the biological in a person with mental distress.”


Browne’s External DSM Ethical Review Panel: That Dog Won’t Hunt

By: Claire Pouncey & John F. Merz

“…Browne’s review panel is meant to address two problems faced by the APA. The first is that unrecognized, tacit values in the DSM generate criticism of its content, revision process, and use. We deny that this is a problem for the APA so much as for Browne. The APA has never indicated that the debates or controversies over its nosology are in any sense unwelcome or unexpected. Rather, the APA has made efforts to include different points of view in its revisions, even if it has not been all inclusive or transparent in its deliberations (Spitzer, 2009). The DSM-5 revisions welcomed various perspectives in work groups, on its web site (, in the psychiatric literature, and at conferences. Because the DSM is by definition a work in progress, a summary of nosologic thinking at a particular temporal point that is intended to be further refined and developed over time, the APA treats it as a living document rather than the last word on mental disorders. It is not apparent that the APA considers itself in need of a panel that would prophylax against any future criticism of the DSM. The other ostensive problem Browne’s proposal addresses is that the “current membership does not include experts who are well-placed to deal with [ethical] issues and their explicit assessment is currently not an essential part of the (DSM revision) process” (Browne, 2017, p. 198). Browne gives no indication that she knows anything of the academic training; personal, professional, or academic experience; or clinical concerns of those who use or write the DSM. As in any field of study—philosophy, sociology, and bioethics included—psychiatrists are not all one-trick ponies. As this journal attests, many psychiatrists are quite capable of discussing the subtleties of value theory and philosophy of psychiatry.”


Philosophy’s Territorialism: Scientists Can Talk About Values Too

By: Charlotte Blease

“Tamara Browne proposes a provocative idea: She argues that philosophers, sociologists, and bioethicists should act as an independent editorial panel for future editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Her paper depends on some well-versed claims in philosophy of psychiatry: She argues that psychiatric classifications are inherently value laden and philosophers, sociologists, and ethicists are best placed to discern (i) the values are that embedded within scientific descriptions of mental disorders, and (ii) to speculate on the effects of any such classifications on individuals and the populace at large as a result of these classifications. I agree with Browne that the DSM (and indeed, medicine in general) requires outsiders—among them philosophers (including medical ethicists) and sociologists—to help influence diagnostic systems. My criticism is that Browne delimits the role of outsiders in medicine to the above academics, whom she sees as some category of elite experts in values. In what follows, I argue that the motivation for her proposal rests on a problematic interpretation of the fact–value distinction (one, I argue, that is prevalent in philosophy of psychiatry and does not see facts and values as fully entwined). Building on these comments, I conclude that although an ethics review panel composed of philosophers and sociologists might have (a few) teeth it would have a lot more bite if it also comprised a composite of academics drawn from the rest of the human sciences (including social psychology, evolutionary psychology, cognitive science, and anthropology).”


An Ethics Review Panel for the DSM: A Worthwhile Challenge

By: Tamara Kayali Browne

“Some commentators have interpreted me as implying that philosophers have a ‘royal road to the truth’ or that they are confined to armchair philosophizing, yet I believe neither. In these disciplines, as in other disciplines, strong arguments are based on both sound logic and evidence, and there would need to be evidence underlying the predictions and judgments made by the panel. An argument does not cease to be philosophical once evidence is invoked to support it. Further, different conclusions can be drawn depending on which forms of evidence are privileged, and this, in turn, depends on the disciplinary backgrounds of those making the assessment. This point is exemplified by the case of premenstrual dysphoric disorder (PMDD), in which it is unclear if the sociological studies on PMDD were considered alongside the clinical studies, or how and why they ultimately did not inform its revision in the Diagnostic and Statistical Manual of Mental Disorders (DSM), because the reasons behind the decisions were not made public. Experts from different disciplines not only provide different perspectives, but also bring different evidence to the fore. Including a greater variety of perspectives and evidence would then provide a more holistic picture of the issues underlying proposed revisions.

Thus, it is not that I believe philosophers and sociologists have some sort of privileged access to values. Rather, it is that explicit discussions about values are their bread and butter. They are specifically trained in such fields in a way that scientists may not be, and the theories and evidence they can draw on from their fields could add to the scientific theories and evidence presented by the DSM committees. It is not that specialist training makes people in these fields better people, or more moral than others. If my assumption was that ethical judgments of the sort made in psychiatric nosology would be best made by the most moral people, I may be better off suggesting people such as the Dalai Lama for the panel. Such a belief would also make me a virtue ethicist but, as Potter observes, I have consequentialist leanings. Rather, by including people from these disciplines on the panel, it becomes a forum in which the values implicit in DSM revisions can be addressed explicitly in a way that science alone cannot do. The sciences and social sciences would inform such discussions, just as they often do in applied philosophy.

I also do not claim that philosophers and sociologists are free from their own biases, as Carel (2017) has interpreted. However, part of their training is to recognize how science is colored by the social and cultural context of the humans undertaking it. If they are good philosophers and sociologists, they should at least be reflexive. Psychiatrists are not free from bias either, but currently occupy a privileged position in psychiatric nosology. Bias inevitably creeps in to everyone’s judgments, but having as much diversity on the panel as possible should reduce the effects of such bias.”