Feb 4Liked by Awais Aftab

Well said!

This also relates to a paper of mine from last year, "a wide-enough range of test environments for psychiatric disabilities". I discuss an earlier paper by Rachel Cooper where she introduces the idea of "test environment", which I think often plays an implicit role in arguments even when people don't explicitly talk about it. The idea is that we can tell, at least in principle, if someone is neurodivergent or inherently ill/impaired by placing them (for real or as a thought experiment) in different test environments. If there's an environment in which they do fine, they're just neurodivergent, even if they struggle in their actual situation. If they'll struggle in any realistic test environment, they're ill/impaired.

Cooper says herself that it's an ethical and political question how wide a range of test environments we should consider here. She thinks it's clear that someone who only does fine in an unrealistic and bizarre society which is completely tailored to this individual and their needs still counts as impaired. But this still leaves room for lots of disagreement and debate over the relevant range.

I argue that there's a regrettable tendency to focus solely on adjustments that can be done locally, in school, the workplace, at home, and forget that some people might do much better if various large-scale political changes happened.

In any case, you absolutely cannot draw the line between inherently neutral neurodivergences and inherently harmful impairments without value judgments, like how wide a range of test environments we OUGHT TO consider. You can't draw the line by mere empirical investigations, that's impossible.

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I love this idea! Will read the paper in detail for sure.

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It's behind a paywall, but just tell me if you want a preprint sent. I looked at the paper again and realized I cite you. :-)

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This is an important paper, and you have provided a very good discussion, Awais. Much more could be said, but I would like to focus on your well-founded statement that,

"Medicine is a human and social institution; it emerged to address experiences of “illness” and promote “health,” among other things. The boundaries of medicine coexist with other human domains such as law, psychology, social work, nutrition, education, etc. in complicated ways that reflect the contingencies of human history. It is odd to think that this messy human practice has to depend on some intrinsic fact of nature that defines what disease is. It gets the order of things wrong! And in the case of psychiatry, it sets up a contentious Szaszian battle where the appropriateness of a medical response to psychological suffering depends on speculative ideas about cellular pathology, evolutionary design, or some such thing."

Indeed, it is precisely the "Szaszian battle" that has muddied the debate over disease for the past 60 or more years, as I have argued since 1979! [1] And since you raise the issue of "cellular pathology", it is important to note that Szasz misread and misunderstood his hero, Rudolf Virchow, who (remarkably!) stated the following:

"‘What we call disease is solely an abstract concept with the help of which we separate particular phenomena of daily life from all others, without there being such a separation in nature itself.’ [2]

Philosophers will continue to debate the concepts of disease, disorder, illness, malady, morbus, etc. until the stars fall from the sky. Physicians know that these matters are "settled" (pragmatically) not in learned journals, but in the clinic, hospital and waiting room. More on all this in an upcoming article for Psychiatric Times, titled, "Misreading Virchow."



Ronald W. Pies, MD

1. Pies R. On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry. 1979 Feb;36(2):139-44. doi: 10.1001/archpsyc.1979.01780020029002. PMID: 369469.

2. Virchow R. Handbuch der speciellen pathologie und therapie. Bd. 1: allgemeine

stoerungen. Erlangen: Enke, 1854. [for translation from the original German, see:

Gerber A, Hentzelt F, Lauterbach KW. Can evidence-based medicine implicitly rely on current concepts of disease or does it have to develop its own definition? J Med Ethics. 2007 Jul;33(7):394-9. doi: 10.1136/jme.2006.017913. PMID: 17601866; PMCID: PMC2598145. This is an excellent paper, with a very useful diagram [Figure 3], showing that "...there is a grey zone—that is, a zone where healthy and sick may not clearly be separated..."

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