Reinier Schuur

The title of my dissertation is ‘The Disease Versus Moral-Problem-in-Living Distinction: Four Papers in the Philosophy of Medicine’. This dissertation consists of an introductory chapter and four papers. This dissertation addresses the following question: should medicine be primarily concerned with problems of an involuntary and non-moral nature? This question concerns what I call the ‘disease versus moral-problem-in-living’ distinction. I do not defend any definition of disease. Rather, I clarify the disease versus moral-problem-in-living distinction, point out the problems that this distinction causes, and argue that we should reject this distinction as a means to constrain the scope of medicine because it denies or undermines the value of moral guidance. Paper one provides an overview of the concept of disease and mental illness debate. Much of the concept of disease debate has been isolated from developments in philosophy concerning the fact versus value distinction and philosophically methodology. I argue for drawing on such developments to inform the debate on what should be the nature and scope of medicine. Paper two provides an alternative reading of Thomas Szasz’s argument that mental illnesses are not real illnesses. I argue that Szasz’s primary concern was not that mental illnesses are not real illnesses. Rather, I argue that his primary concern was the medicalisation of moral- problems-in-living as such, which he saw the concept of mental illness as representing. His solution to this concern was to argue for a clear disease versus moral-problem-in-living distinction to constrain the scope fo medicine. The rest of the dissertation is a criticism of this approach and an attempt to provide an alternative solution to the medicalisation of moral-problems-in-living. Paper three challenges Gene Heyman’s choice model of addiction as a solution to the puzzle of addiction. I argue that Heyman’s distinction between two ways of thinking about our best interest, a local versus a global temporal choice framework, is promising in solving the puzzle of addiction. But I argue that Heyman’s appeal to a ‘natural bias’ to the local choice framework has serious problems. I argue that Heyman’s assumption that the global choice framework is sufficient for both knowing what is in our best interest and for acting in our best interest gives rise to his appeal to a natural bias as part of his solution. I draw on the work of Hanna Pickard on the role of denial in addiction to argue that Heyman is wrong to assume that the global choice framework is sufficient for knowing what is in our best interest and for acting on such knowledge. I then draw on the work of Gena Gorlin on Cognitive integrity as a framework to explain how we can act contrary to our best interest even when we have knowledge of what is in our best interest. Paper four clarifies the different ways that the disease versus moral-problem-in-living distinction has been used and then argues against one of those uses. The first is an explanatory distinction within medicine, the second is as a means to constrain the scope of medicine. I make a further distinction between a hard and soft version of the disease versus moral-problem-in-living distinction as a means to constrain the scope of medicine. The hard version of the distinction rests on a narrow conception of disease that has already been rejected in the concept of disease debate. I argue that the soft version of the distinction is incompatible with a broad conception of disease and therefore a broader scope of medicine. I argue that we should therefore reject the disease versus moral-problem-in-living distinction as a means to constrain the scope of medicine.