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

Abstract

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.

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Notes

  1. 1.

    I follow Wakefield here in using the term “disorder” to refer to the technical medical concept that he and other philosophers of medicine purport to analyze. The disorder concept is intended to include any condition that medicine regards as a departure from health, that is, not only conditions usually called “diseases,” but also other types of departures, such as injuries, poisonings, growth disorders, etc. (see Wakefield 2014, 653). Other authors (e.g., Christopher Boorse) refer to this concept with the term “pathology”.

  2. 2.

    A noteworthy aspect of the HDA is Wakefield’s characterization of the notions of function and dysfunction involved in the HDA’s dysfunction criterion along the lines of the selected-effects theory of function advocated by many philosophers of biology (e.g., Millikan 1989; Neander 1991; Godfrey-Smith 1994). I will not be concerned with this aspect of the HDA here.

  3. 3.

    In the present discussion, I will follow Wakefield and adopt a broadly understood method of conceptual analysis that focuses on the concepts of health and disorder that implicitly underlie medical professionals’ and lay people’s thinking about health and disease. Although this method is controversial (see e.g., Lemoine 2013; Schwartz 2014), I will adopt it here to locate my discussion in the same methodological space as that in which Wakefield locates his defense of the HDA.

  4. 4.

    A similar example sometimes brought out in the philosophy of medicine literature is that of bound feet in pre-20th-century China, which was socially valued, but was presumably nevertheless a disordered condition (see Schramme 2002, 62; Kingma 2017, 11).

  5. 5.

    Here, I assume the validity of the position recently adopted by the Academy of Nutrition and Dietetics: “Appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes” (see Melina et al. 2016).

  6. 6.

    Along similar lines, harm-requiring accounts of disorder would seem to imply that a committed vegan who is allergic to honey, or to seafoods like shrimp, lobster and crab, would not be disordered.

  7. 7.

    I should note that Hausman’s point in highlighting the above differences between assessments of well-being and assessments of health is slightly different from mine. Hausman’s point is to show that health cannot be considered as a kind of well-being, while my point is to argue that health (and disorder) cannot be defined (fully or partly) in terms of well-being (and harm). I think the differences he highlights nevertheless support my point. I should also note that Hausman (2016, 33) highlights a fourth difference between well-being and health: assessments of well-being, he claims, concern a person’s whole life, whereas assessments of health concern a person’s condition during some period. I leave this fourth difference aside here.

  8. 8.

    The view that assessments of disorder should be consistent or standardized across individuals is controversial. Some maintain that disorder judgments should align with individuals’ personal assessments of their condition (e.g., Cooper 2002; 2021; De Block and Sholl 2021). Rachel Cooper (2002, 274) brings up the case, very similar to my above infertility and meat allergy cases, of an artist who becomes colorblind after a head injury, and who comes to consider his condition as preferable to color vision because it makes him more sensitive to textures and patterns. For Cooper, cases like this one illustrate that, contrary to what I presuppose (following Hausman), “one and the same condition can be pathological for one person but not for another.” As I will soon show, unlike Cooper, Wakefield is committed to providing an account that does not allow assessments of disorder to vary across individuals, and so his HDA faces the interpersonal variability of harm challenge.

  9. 9.

    Wakefield develops his more considered view of harm partly in response to criticism by Powell and Scarffe (2019), and Rachel Cooper (2021), pressing him to adopt a more objectivist view of harm in replacement for his social-values-based view. Wakefield remains skeptical about the objectivist view and motivates his preference for the social-values-based view (Wakefield and Conrad 2019, 2–3; Wakefield 2021b, 555–559). I will not discuss the implications of integrating an objectivist view of harm for the HDA, but I think it would raise essentially the same issues that I will raise below for Wakefield’s qualified social-values-based view.

  10. 10.

    Indeed, its dysfunction criterion might provide another ground on which the HDA could potentially explain the depathologization of homosexuality. Wakefield could set aside the question of whether their sexual orientation is harmful to homosexual people, and maintain that the homosexual orientation is likely not caused by a dysfunction in the selected-effects sense (for support for such a claim, see Lewens 2015, 187). Wakefield, however, commits himself to defending the view that homosexuality would not be a disorder even if it were caused by a (selected-effects) dysfunction. Hence, for the sake of the present discussion, I will follow Wakefield in assuming that what is a stake with regard to the HDA’s implications for homosexuality is whether homosexuality is harmful.

  11. 11.

    Wakefield considers that the dysfunction that causes dyslexia is not a disorder in preliterate, or eventually in future postliterate societies (Wakefield 2005, 89; Wakefield and Conrad 2019, 2; Wakefield 2021a, 517; Wakefield 2021b, 558).

  12. 12.

    This reading of the socially-mediated harms associated with dyslexia could perhaps be challenged, since, arguably, the limited access to social goods experienced by dyslexic people is, to a not insignificant degree, an effect of social value judgments about what legitimizes reduced (or enhanced) access to resources and occupational or recreational activities. I will nevertheless grant, for the sake of the discussion, that there is a meaningful difference between the harms that result from ostracizing attitudes towards homosexuality and some of the harms associated with conditions like dyslexia.

  13. 13.

    Of course, this is the case only if we assume that homosexuality involves a (selected-effects) dysfunction, and whether it really does so is debatable (see footnote 10 above). As I said, for the sake of the present discussion, I follow Wakefield in assuming that what is a stake with regard to the HDA’s implications for homosexuality is not whether homosexuality involves a dysfunction, but whether it is harmful.

  14. 14.

    I thank Anne-Marie Gagné-Julien for insights that reinforced the points made in this paragraph.

  15. 15.

    I am thankful to an anonymous referee for noticing the typicality and dispositionality qualifications. Wakefield and Conrad (2020) treat these qualifications as equivalent, but I will deal with them separately because I think they are distinct. Typicality may be understood in strictly statistical terms, whereas dispositionality cannot, because a disposition can have actualization conditions that rarely obtain and therefore be actualized infrequently.

  16. 16.

    Here, I consider Wakefield and Conrad’s remarks in abstraction from some details they give in order to locate their analyses within the context of the particular theories of well-being and harm discussed by Muckler and Taylor (e.g., the objective-list theory, hedonism, etc.).

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Acknowledgements

The author is thankful to Christopher Boorse, Anne-Marie Gagné-Julien, Christian Saborido, and two anonymous referees for very helpful comments that led to significant improvements of the paper. He also thanks Alice Everly for editing the manuscript.

Funding

The work for this paper was supported by a research grant from the Fonds de recherche du Québec-Société et culture (FRQSC, 2018-CH-211053).

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Correspondence to Antoine C. Dussault.

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Dussault, A.C. The harmful-dysfunction account of disorder, individual versus social values, and the interpersonal variability of harm challenge. Med Health Care and Philos 24, 453–467 (2021). https://doi.org/10.1007/s11019-021-10021-8

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Keywords

  • Health
  • Disorder
  • Harmful-dysfunction account
  • Jerome Wakefield
  • Harm
  • Social values