Bengt Brülde

The goals of medicine. Towards a unified theory.

The purpose of this article is to present a normative theory of the goals of medicine (a theory that tells us in what respects medicine should benefit the patient) that is both comprehensive and unified. A review of the relevant literature suggests that there are at least seven plausible goals that are irreducible to each other, namely to promote functioning, to maintain or restore normal structure and function, to promote quality of life, to save and prolong life, to help the patient to cope well with her condition, to improve the external conditions under which people live, and to promote the growth and development of children. However, it seems that all these goals need to be qualified in different ways, e.g. it does not seem reasonable to improve physiological function or functional ability unless this is expected to have positive effects on quality of life and/or length of life, or to improve the quality of life in any respect, or by any means. These qualifications all suggest that the proposed goals are, as goals, conceptually, and not just causally, related to one another, and that they should therefore not be regarded in isolation. Instead, we should think of the medical enterprise as having a multidimensional goal structure rather than a single goal. In order to depict clearly how the different goals are related to one another, a multidimensional model is constructed.

What Is Mental About Mental Disorder

The recent discussion of the concept of mental disorder has focused on what makes a mental disorder a disorder. A question that has received less attention is what makes a mental disorder mental rather than somatic. We examine three views on this issue—namely, the internal cause view, the symptom view, and the pluralist view—and assess to what extent these accounts are plausible. In connection with this, three strategies that have been used to pinpoint the mental in psychiatry are identified, namely negative characterizations (the mental as the nonsomatic), exemplification of paradigmatic mental features, and an appeal to intentional content. We also examine different versions of nihilism, the view that the distinction between mental and somatic disorder is ill founded. Finally, it is observed that the discussion of what makes a mental disorder mental has largely been unaffected by conceptions of the mental in the philosophy of mind.

On defining “mental disorder”: Purposes and conditions of adequacy

All definitions of mental disorder are backed up by arguments that rely on general criteria (e.g., that a definition should be consistent with ordinary language). These desiderata are rarely explicitly stated, and there has been no systematic discussion of how different definitions should be assessed. To arrive at a well-founded list of desiderata, we need to know the purpose of a definition. I argue that this purpose must be practical; it should, for example, help us determine who is entitled to publicly funded health care. I then propose eight conditions of adequacy that can be used to assess competing definitions (e.g., the ordinary language condition, the coherence condition, and the condition of normative adequacy). These conditions pull in different directions, however, and we must decide which are most important. I also suggest that there is no single definition that can help us deal with all the relevant practical issues.

Normative Responsibilities: Structure and Sources

Normative responsibilities have a central role in everyday moral thinking, largely because they are taken to ground requirements to act and react in certain ways. If parents are responsible for the ...

Inequity, inequality, and the distributive goals of public health.

What is the ultimate goal of public health activities, e.g. health promotion or health education? Or rather, what should these activities try to realize or maximize? One central goal of public health is to improve the average health status (healthy life expectancy, or the like) in the relevant population. This is not the only goal, however; e.g. it can also be argued that public health should try to reduce health inequalities or inequities between groups or individuals. In short, the ultimate goal of public health is both aggregative and distributive. It is unclear whether the goal to create equal opportunities for health (“equal health chances”) is ultimate, and it will not be investigated in this editorial.

Dysfunctions, Disabilities, and Disordered Minds

Richard Gipps’ and Jerome Wakefield’s commentaries on our article are so different from each other that we have decided to deal with them separately. Gipps suggests that we adopt a different framework altogether. In his view, our main question—“What makes a mental disorder mental?”—is somehow defective, and it ought to be replaced by an alternative question, namely, “What makes a mind disordered?” He thinks he can answer this question by providing an alternative account of the mental in terms of intentionality and sui generis psychological understanding. He also suggests that mental disorders are “alterations within the intentional order.” Wakefield, on the other hand, shares most of our “framework assumptions”; for example, he accepts the way we formulate our central question and how we present the different possible answers. The only part of our general project to which he objects is the attempt to find a principled account of what makes a mental function (dysfunction, mechanism, ability, or the like) mental. His main purpose is to defend and develop his own version of the internal cause view, namely, the idea that mental disorders are (harmful) mental dysfunctions. Because Gipps’ comments are of a far more general nature than Wakefield’s, we respond to Gipps first. This gives us an opportunity to make our “framework assumptions” more explicit. Gipps’ Criticism of the Notion of Mental Disorder

Well-Being, Happiness and Sustainability

We know that climate change will most likely have detrimental effects on the well-being of future generations, but here the focus is on how the well-being of present people might be affected if we decide to reduce our greenhouse gas emissions to a more sustainable level. The central question is how a more sustainable lifestyle would (most likely) affect our well-being, but I am also concerned with whether it is possible for us to live lives that are both good and sustainable. It is assumed that well-being can be understood in terms of happiness, and that these questions can be specified in these terms. There are several considerations that might give cause for “optimism” in this area, many of which are inspired by findings in empirical happiness studies. I critically examine seven such considerations, e.g. the idea that reduced consumption would not make us less happy, that the most happiness-inducing activities require little use of energy, and that shorter working hours is beneficial both from a sustainability perspective and from a happiness perspective. The conclusion is that most of these considerations are invalid, and that most people would probably be less happy if they lived more sustainable lives, at least in the short run. (We might adapt hedonically to such lifestyles over time, however.) This suggests that we should not appeal to people’s self-interest if we want to get them to live more sustainably. Instead, we should appeal to the interest of future generations and the world’s poor.