Alice Elizabeth Kelley

This dissertation is comprised of three chapters: Chapter 1 intervenes in debates about the medicalization of grief, focusing on the recent addition of a grief-specific disorder – Prolonged Grief Disorder (PGD) – to the DSM. Opponents of medicalization have been primarily concerned with potential negative looping effects – ways that classificatory processes like medicalization (treating something as a disorder) contribute to harmful social practices or distortions of a person’s self-conception. Contrastingly, I call attention to unappreciated beneficial looping effects that might be achieved by medicalizing (some) experiences of grief. Alongside this, I highlight that the concerns about negative looping effects rest on the philosophically significant and conceptually optional assumption that “normal” parts of human experience should not be medicalized. Consequently, I argue that rather than removing PGD from the DSM, the better path forward is to help grievers reconceive the role of diagnostic categories by moving away from a background understanding of health conditions as pathologies. Chapter 2 develops an account of healthy grief as a constructive dialectical process – rather than either a state or a healing process aimed at “recovery”. On the account I develop, it is not a condition of healthy grief that it dissipates over time. Endless grief can be both appropriate and compatible with flourishing. In this respect, my account departs from various well-known accounts of grief (of which perhaps the most illustrious is Freud's in Mourning and Melancholia). In addition, my account sets itself apart from others in that it includes respect-for-the-lost-one as a central component of the dialectics of grieving. This move is pivotal, as it sets the stage for a picture of grieving on which grief is a positive component of living a flourishing life. In addition, the account I develop here has implications for our understanding of health, medicalization, and disorder; most notably it reinforces the case against conceptions of health that reduce health and human flourishing to merely the absence of pathology, dysfunction, or disease. Chapter 3 extends the account of grief developed in the previous chapter to other forms of loss, with a particular focus on anticipatory grief. Considering multiple forms of loss elucidates two notable features of grief (i) object plenitude: in grief, there is never just one object of loss; the objects stand in intimate and overlapping relations with each other such that there are not always boundaries between them and (ii) object generation: the process of grieving partially determines which things are seen as losses. Having elucidated these features, I show how my account sheds light on some of the different ways that we can become “stuck” in our experiences of grief. Finally, I consider the practical (clinical, social, and interpersonal) upshots of my account.

The most recent versions of official psychiatric diagnostic guidelines include a new addition: Prolonged Grief Disorder (PGD). PGD is controversial due to concerns about harmful looping effects. Some opponents of PGD’s inclusion in the DSM worry that the diagnosis may pathologize normal human experiences and alienate grievers from their grief. This paper argues that these concerns are less troubling than they initially appear (in part because they assume an unhelpful, and conceptually optional, background understanding of health conditions as pathologies) and calls attention to overlooked beneficial looping effects that might be achieved by medicalizing (some) experiences of grief.

Nicholas Makins makes a valuable contribution to the literature on medical decision-making, highlighting the role that risk attitudes play in deliberation and subsequently arguing that, in medical choices under uncertainty, if considerations of autonomy and beneficence support deference to patient values and outcome preferences then they also support deference to patients’ attitudes to risk.1 Crucially, however, Makins suggests that it is not simply first-order risk attitudes that are the appropriate target of deference but, rather, patients’ higher-order risk attitudes. In other words, Makins argues that if considerations of autonomy and beneficence support deference in medical decision-making, this deference should include the risk attitudes that individuals desire to have or reflectively endorse. This commentary draws out a morally relevant and overlooked distinction between: (1) deferring to patients’ higher-order attitudes that endorse the first-order risk attitudes they currently hold. and (2) deferring to patients’ higher-order attitudes that endorse risk attitudes that are at odds with the first-order risk attitudes they currently hold (which equates to a higher-order desire to change one’s first-order risk-attitudes). I agree with Makins that if respect for autonomy and beneficence support deference to patient preferences, then these considerations may also support deference to at least some higher-order risk attitudes, namely, those of type (1). But I think that whether they support deference to those of type (2) is less clear. In particular, it does not …