Wrongful Medicalization and Epistemic Injustice in Psychiatry

Abstract

In this paper, my goal is to use an epistemic injustice framework to extend an existing normative analysis of over-medicalization to psychiatry and thus draw attention to overlooked injustices. Kaczmarek (2019) has developed a promising bioethical and pragmatic approach to over-medicalization, which consists of four guiding questions covering issues related to the harms and benefits of medicalization. In a nutshell, if we answer “yes” to all proposed questions, then it is a case of over-medicalization. Building on an epistemic injustice framework, I will argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to answer the four questions, and I will import the conceptual resources of epistemic injustice to guide our thinking on these issues. This will lead me to defend more inclusive decision-making procedures regarding medicalization in the DSM. Kaczmarek’s account complemented with an epistemic injustice framework can help us achieve better forms of medicalization. I will then use a contested case of medicalization, the creation of Premenstrual Dysphoric Disorder (PMDD) in the DSM-5 to illustrate how the epistemic injustice framework can help to shed light on these issues and to show its relevance to distinguish good and bad forms of medicalization.

Philosophy of psychiatry: theoretical advances and clinical implications

“…As the philosopher R. Cooper has illustrated using a weeds and daisy metaphor, we can all agree on what a daisy is as a species, but disagree on its status as a weed 38 . Similarly, researchers can agree on the biological mechanisms of premenstrual dysphoric disorder, but disagree on its status as a mental disorder 39,40 .…”

“…Further, several authors have advocated for consultative decision-making processes that would include patients' voices on the question "What is a mental disorder? ", in order to ensure that patients' interests are represented in psychiatric concepts and classifications 39,[74][75][76][77][78][79][80][81] .…”

“…The awareness of the impact of psychiatric diagnoses on the self-conception and self-understanding of those diagnosed has supported the view that people with lived experience might usefully contribute to the development of psychiatric classifications. They may be better situated to assess the impact of changing diagnostic criteria on access to care or the potential risk of stigma associated with certain nomenclature issues, or be better able to identify mismatch between diagnostic criteria and subjective experiences 39,[74][75][76][77][78][79][80][81] .…”

Reconsidering harm in psychiatric manuals within an explicationist framework

“…On the other hand, having explicit reference to harm enables us to uncover and explicitly reflect on the connections between the scientific studies of the causal basis of mental disorders with ethical and social practices that involve thinking about how harms should be reduced, avoided, and fairly compensated (see, also Powell and Scarffe 2019). For instance, when thinking about how to direct resources for research and devise psychiatric treatment polices our judgments are typically guided by categories of mental disorders as adopted by diagnostic manuals (Cooper 2005;Jurjako and Malatesti 2020;Gagné-Julien 2021). Thus, to make ethically justified decisions when creating the relevant psychiatric categories and when thinking how to invest resources and which conditions to treat, we should be sensitive to the relevant normative considerations that go beyond thinking about whether some condition is dysfunctional or not (Stegenga 2021).…”

Epistemic injustice and the psychiatrist

“…Practicing psychiatrists balance many considerations when evaluating information provided by their patients: a general need to believe what patients say, a recognition that any person's account of events can be mistaken, and the importance of maintaining a solid therapeutic relationship. Recently, commentators from within and outside of psychiatry have tried to complicate this balance by arguing that psychiatrists should strive to avoid epistemic injustice in their interactions with their patients, but that they are frequently guilty of perpetrating it (Bueter, 2019; Crichton, Carel, & Kidd, 2017; Drożdżowicz, 2021; Gagné-Julien, 2021; Harcourt, 2021; Kurs & Grinshpoon, 2018; Sanati & Kyratsous, 2015).…”