by Chuck Ruby, PhD

The thrust of the argument in The Social Construction of “Disease,” about whether disease/illness is a normative or naturalist matter is off the mark. The article argues that a definition based on social norms can be legitimate, and that physiological defect doesn’t need to be present in order for something to be considered a disease or illness. But the crucial question isn’t how to define disease/illness, it is whether those who claim to treat disease/illness, however defined, are qualified to do so and what are the social implications. From the article:

“Normativists argue that the classification of a condition as a disorder depends in an essential way on some sort of evaluative judgement. Naturalists argue that this classification depends primarily on natural facts, such as facts about statistical deviation from species typical functioning or failure of mechanisms to perform functions for which they are naturally selected.”

This essentially says disease/illness can be based in societal judgments about appropriate experiences and behaviors. But it sets up a distracting dichotomy between those who argue in favor of disease being defined with social norms (normativist) or disease being defined with evidence of physiological dysfunction (naturalist). It obscures the far more important issue that both normativist and naturalist approaches are evaluative judgments in themselves about the proper role of medical professionals. It comes down to what a society wants the medical profession to handle, even if the problem being handled has nothing to do with defects of bodily functioning. 

I addressed this in my book, Smoke and Mirrors, with the intent of pointing out its crucial effects on critical psychology and psychiatry efforts:

“It must be remembered that definitions are not absolute or “God-given.” They all reflect the values of those doing the defining. So if we, as a society, value the idea that any feelings of unease brought on by life struggles are illnesses to be subjected to medical forms of oversight and care, even without evidence or theory of disease processes underlying those feelings of unease, then “mental illness” would rightly fit the definition of illness and I would stop writing this book.” (p.4.)

So the important point is, regardless of how we define disease and illness, do we want medical professionals to apply supposed medical expertise to those problems. If we are to value medical professionals treating people not only for physiological dysfunction but also for being emotionally distraught or acting in unwanted ways, then so be it. But let the buyer beware. We would be opening the door for medical professionals to morph into moral guides - no, not just guides, but rulers.

Furthermore, so-called mental illness has a different status than other illness with the former allegedly involving mental compromise. If this weren’t the case, there would be no reason to distinguish it as a separate kind of illness. In other words, the story goes that those so afflicted do not have the full benefit of a healthy mind, thus, decision-making is suspect. And this is without any evidence of a dysfunctional brain or other physiological structure, as there is with Alzheimer’s disease, lead poisoning, and hypothyroidism. Psychiatrists (and other clinical professionals) would then have society’s permission to act as paternalistic monitors, judging people for their experiences and actions, and prescribing (demanding) “corrective” experiences and actions.

Therefore, those who would invite a medical professional to treat them for a mental illness are essentially risking their right to self-determination. The cherished principles of informed consent and “first do no harm” go out the window with mental illness. This is not to say that all people diagnosed mentally ill are denied that right to self-determination. But, it would be very naive to think it is a guarantee. Our experiences have shown us that the right is frequently and capriciously denied, especially when the prescribed treatment is ineffective. The moral guide takes charge of that person’s decision-making.

Chuck Ruby, PhD, is a psychologist who has been in private practice for the past 25 years, after a 20-year career with the U.S. Air Force. You can read more about him at his personal website. He is the author of Smoke and Mirrors: How You Are Being Fooled About Mental Illness - An Insider's Warning to Consumers. Dr. Ruby is the past Chairperson of the Board for ISEPP and has been the Executive Director since 2015.