The Case for Dualism in Medicine—Philosophical Misunderstandings and Clinical Implications: Diane O’Leary, PhD

CONVERSATIONS IN REVISIONIST PSYCHIATRY

Diane O’Leary, PhD, is a philosopher, disabled independent scholar, and 2023 Equality Now/Oped Project Fellow on Advancing the Rights of Women and Girls. She has been a visiting faculty member at the Center for Philosophy of Science at the University of Pittsburgh and at the Rotman Institute of Philosophy in Ontario. O’Leary has published key articles and chapters on dualism, consciousness, and medically unexplained symptoms, along with public writing and interviews in Stat News, IAI News, Vice News, and elsewhere. She is a frequent speaker and is a member of the Primary Care Research in Diagnostic Error Learning Network at The Center for Patient Safety Research and Practice, Brigham and Women’s Hospital. Currently she is toggling between 2 books in progress: one for general readers, Gaslight: How Bad Philosophy Corrupts Good Medicine, and the other for clinicians and academics, Medicine’s Mind-Body Problem: A Safe, Sound Solution.

Awais Aftab, MD: Your impressive work on dualism in medicine and psychiatry has forced me and many others in medicine and psychology to reexamine long-standing assumptions. I would refer readers to your papers on medicine’s metaphysical confusion, the biopsychosocial model, and your recorded talk as part of the Philosophy of Psychiatry webinar series to learn about your views in detail.^1-3 Can you briefly explain your argument that medicine has misunderstood dualism?

Diane O’Leary, PhD: Many thanks for the kind words, Awais. The misunderstanding has its roots in George Engel’s work. Along with a whole lot of rich and valuable insights, Engel offered 2 confused philosophical claims. First, dualism and reductionism combine in the biomedical model, and that is the source of its problems. Engel attributed the combination to Descartes, and he offered the biopsychosocial model as a remedy for both. Second, dualism is the separation of mind and body in our thinking, language, or medical practice. To fix the biomedical model, then, all we need to do is to change the way we think, talk, and practice in relation to mind and body. If we stop separating them, if we just orient ourselves around the person holistically, dualism and reductionism will go away, and all will be well.

It is actually impossible for the biomedical model to embrace reductive dualism, or dualistic reductionism, because that is like saying it is both day and night, the lights are both on and off, or your new dress is both beautiful and hideous. Dualism and reductionism about mind and body are diametrically opposed views that cannot both be true. More importantly, dualism is not the separation of mind and body in our thinking or practice. In fact, dualism is not something we do at all. Descartes is not a dualist because he thinks of mind and body as separate. He is a dualist because he thinks both minds and bodies exist, and they will keep on existing as 2 things no matter what anybody says or does.

Why does this matter? It matters because Engel was right that medicine’s view on mind and body has a big impact on its success at helping individuals be well. First, the campaign to stop thinking of mind and body as separate is self-refuting if we accept Engel’s goals. When we see mind and body as one, we are reductionists—but reductionism is the problem that Engel sets out to fix. Second, well-meaning individuals believe they must try to eliminate separation of mind and body in their thinking and language because philosophy says that is a good idea. But philosophy says no such thing. As far as philosophers are concerned, if some form of dualism is true, it will keep on being true even if no one ever thinks or speaks of it again, ever.

Finally, efforts to avoid “dualism” interfere with patient care. (I put “dualism” in quotes when I am referring to separation of mind and body.) In cases of unexplained symptoms, for example, clinicians are advised to end diagnostic effort because it is “dualistic.” Similarly, in countries where medical aid in dying is permitted for mental illness, avoidance of “dualism” has been the primary supporting argument. What is permitted for medical illness, the argument goes, cannot be denied for mental illness, because to do so would be to separate mind and body. Whatever we happen to think about that practice, it seems clear that lives should not be ended on the basis of a misguided definition of dualism. Even the DSM has apologized for implying that mind and body are separate, confessing that, despite effort, “dualism” has yet to be overcome.

I recognize that it is very difficult for individuals in medicine to imagine that dualism is not what they think it is, and that philosophy does not care about controlling how we think and talk about it—but bad philosophy is not benign in medicine. This is something we need to address.

Aftab: One thing I want to note is that philosophers themselves are deeply divided on issues related to dualism and philosophy of mind. For instance, in the 2020 PhilPapers survey of philosophers, 52% accepted (or leaned toward) physicalism, while 32% accepted nonphysicalism (N = 1733). On the issue of consciousness, 22% accepted dualism, 4.5% accepted eliminativism, 33% functionalism, 13% identity theory, and 7.5% panpsychism (N = 1020).⁴ I hesitate to ask psychiatrists to take a strong position on a matter that commands no consensus among philosophers.

O’Leary: First, let’s think through the idea that there is no consensus among philosophers on the issue of dualism, because that is not an accurate conclusion about this survey. On the choice between physicalism and nonphysicalism, folks in medicine will assume that this question is really a choice between physicalism and dualism. Philosophers will not see it that way, though, because philosophers are not thinking of Descartes when they see ‘dualism.’ They are thinking of a new form called ‘property dualism.’

Susan Schneider explained this beautifully: “Contemporary philosophy of mind sees the question of the nature of substance as being settled in favor of the physicalist. Dualism about properties, in contrast, is regarded as being a live option.”⁵ So we have settled the question of Descartes’ dualism against Descartes. We agree now that all things are physical things, even human beings. But that does not settle the question of dualism because we still need to ask: How many of us physicalists are dualists about properties? That is a live question in our time, so the fact that most philosophers are physicalists tells us nothing at all about the popularity of dualism.

The same kind of problem arises with consciousness. Folks in medicine assume that all the “isms” on this daunting list—dualism, eliminativism, functionalism, identity theory, panpsychism—are mutually exclusive, so if you accept one, you reject the others. That is a misunderstanding. Many forms of functionalism are forms of property dualism (eg, Shoemaker), because, as the Stanford Encyclopedia of Philosophy puts it, functionalism is “officially neutral” on dualism.⁶ It is hard to say what proportion of functionalists are property dualists, but this poll certainly does not tell us that only 22% of philosophers are open to dualism. In fact, many panpsychists are property dualists, too.

The clearest line we can draw within the list of “isms” is not between dualism and the rest, but between views compatible with dualism and those diametrically opposed to it. On the yes-or-maybe side, you have got dualism, panpsychism, and functionalism, and together that is 63% of philosophers—3 times more than you get on the absolutely-no side with eliminitivism and identity theory. If you had taken this poll in, say, 1970, the imbalance would have leaned just as far in the other direction, so things have dramatically shifted. Fifty years ago, philosophy fiercely opposed dualism, but that is no longer the consensus.

Aftab: A related aspect of the hesitation I mentioned earlier is that it is evident that psychiatry accepts the ordinary existence of subjective experience and mental states, but it is not clear to me that psychiatry has to take any particularly strong position on whether these mental states are, in some fundamental ontological sense, radically different kinds of things than physical states of the brain. (I am borrowing the language here from Stanford Encyclopedia of Philosophy: “In the philosophy of mind, dualism is the theory that the mental and the physical—or mind and body or mind and brain—are, in some sense, radically different kinds of things.”⁷)

O’Leary: For the first part of your hesitation, then, dualism actually does command consensus among philosophers—at least insofar as true reductionists, eliminitivists, or identity theorists have now become rare. Given that, the main point I would like to make is that I agree. I am also hesitant to ask psychiatrists to take a position. On the issue of which “ism” is the right one for medicine or psychiatry, I have never made any claims. What I have said is that medicine and psychiatry are confused about what the word ‘dualism’ means in philosophy, and when we correct that, we find that medicine is already based on property dualism.

You have said, “It is evident that psychiatry accepts the ordinary existence of subjective experience,” and I think you are right. In fact, I cannot imagine anybody disputing it. This is an assertion of property dualism, plain and simple. You are saying that psychiatry accepts that subjective experiences exist, and that is an ontological claim no matter how you slice it. You are not saying that experiences are things, of course, in the sense of substances. You are saying that experiences are states, or properties, that human beings have.

The reality of experience is so obvious to individuals in mental health fields that it seems like it cannot possibly be a substantive claim. But in the context of philosophy, it is. In fact, the existence of experience is precisely what we are debating with the question of dualism. When you accept that there are properties of experience, you actively distinguish those from physical properties of the brain. You recognize that the way you feel when you are tired and you get hold of your morning coffee is distinct from the biochemical facts that characterize the state of your brain at that moment. No matter how committed we are to catchphrases like “integration of mind and body,” your first taste of morning coffee is a private fact, a subjective fact, while the physical state of your brain at that moment is a public fact, an objective fact. I know we agree that these are correlated in some inextricable way, but they are distinct just the same. In fact, they could not be correlated if they were not distinct.

Aftab: How much can we infer about the nature of mental disorders from a metaphysical position on the mind-body relationship? I am doubtful that a metaphysical view such as property dualism, by itself, supports or challenges any particular view on the etiology of psychiatric disorders or says much about the appropriateness of diagnosis, pharmacological treatment, or the medical framework in psychiatry. Whether the medical model applies well or applies poorly to psychiatry seems to be an issue that is orthogonal to property dualism. What do you think?

O’Leary: First, if we want to make sense of the nature of mental disorders, we will need a coherent picture of what “mental” means. So far, I have not offered that. I mean, there is nothing prescriptive about my suggestions, except for psychiatry to get its philosophical house in order. Psychiatry is in a real stew now, with every kind of foundational question up for grabs. I think this kind of breaking point was inevitable because the mind-body picture that underlies psychiatry has been incoherent for a long time. How can the field respond to a complex challenge like the antidepressant debate if we do not even know what we mean by “mental,” and we have no coherent options for making sense of the relation between mental and physical?

This much about dualism is certain to be useful: Go ahead and separate mind and body! It will not be possible to make sense of mental disorders—as distinct or not distinct from purely biological diseases—unless we can freely consider the difference between the subjective experiences of the human being in front of us and the biochemical states of their brain. Mental disorders begin with the mental.

Second, once we see that we have assumed property dualism, we open the door to an account of mental disorders that is grounded in subjective experience. I am not saying that is the only right view. I am just saying that psychiatry needs to consider what a disorder of experience would amount to, and how it would be different from, and related to, purely biological disease. That will require new philosophical clarity. We are starting to see a lot of new effort in this direction from phenomenology and from consciousness studies reaching over into psychiatry. There is a marvelous paper called “Putting the ‘Mental’ Back in ‘Mental Disorders,’” by Traschereau-Dumouchel and colleagues last year; “Taking Subjectivity Seriously” by Kyzar and Denfield, which ties new insights from phenomenology and psychiatry to neuroscience^8,9; and Cecily Whiteley’s marvelous paper, “Depression as a Disorder of Consciousness.”¹⁰ This new kind of inquiry is deeply opposed to the campaign against dualism, so a new conceptual foundation is needed.

Aftab: You have talked about how confusion around dualism has led to an attitude of deliberate diagnostic vagueness that has negatively impacted care of “medically unexplained symptoms.” Can you say more about that?

O’Leary: I suggested in 2018 that “deliberate diagnostic vagueness” is a real problem.¹¹ Standards of care for unexplained symptoms come from research in psychiatry, and all of this research is driven by the idea that it is bad for clinicians to separate symptoms caused by disease from those caused by psychosocial distress. To avoid “dualism,” they should accept unexplained symptoms as diagnostically vague, as mind-body problems rather than one or the other, ending the quest to determine whether disease is present.

Clearly this is unsafe, because a great many individuals suffer from diseases that are hard to diagnose. And although it is commonly believed that error is rare in this area, research supporting that idea is poorly designed and generally not reviewed in medicine. This is not rocket science. No diagnosis will be reliable if it is based on philosophy rather than science, and things will go particularly badly when the philosophy is misguided.

It is unclear to me why this issue plays such a small role in critical psychiatry discourse. Public anger toward psychiatry about this problem is substantial, and growing rapidly as long COVID grows more common. More broadly, because medical training on psychosomatic conditions comes from psychiatry, and psychiatry continues to center on gender in diagnostic recommendations, it is psychiatry more than medicine that needs to address gaslighting as a threat to women’s health. Somatic symptom disorder is generally understood to occur in females 10 times more often than in males. And while that extraordinarily dangerous figure appears regularly in reviews and practice recommendations, no one seems to think that it requires evidence.¹² Incredibly, Medscape and American Family Physician have recommended the 10:1 ratio for years citing only each other.^13,14

Figures on women’s difficulty accessing health care for serious everyday disease are nothing short of alarming. Still, we have yet to see even the tiniest bit of movement from psychiatry toward protecting women from mistaken attribution of disease to the mind. Confusion about dualism seeps into every area of psychiatry. For me, as a matter of social justice, this one is the most urgent.

Aftab: There is a problematic attitude of diagnostic vagueness, for sure, but its relationship to “dualism” is complicated. We can talk about bodily (physiological) dysfunctions and mental (psychological) dysfunctions, but both sorts of dysfunctions exist across the mind-body divide. Bodily dysfunctions often present with psychological symptoms, and psychological factors often play important roles as risk factors or as moderators for recovery. Psychological dysfunctions are embodied: They involve brain processes; they often present with bodily complaints; and physiological factors often play important roles as risk factors. Furthermore, we can have problems that arise from a complex set of interacting physiological factors, a complex set of interacting psychological factors, or a complex set of both physiological and psychological factors. Sure, we may separate mental properties and physical properties, but there is no way to extend this sort of separation to clinical problems in a clean or straightforward manner.

It is the case that in psychiatry, we have generally not found the project of separating “symptoms caused by disease from those caused by psychosocial distress” to be very productive. Paradigmatic psychiatric disorders such as depression and schizophrenia are not explainable with reference to psychosocial distress or psychosocial causation; they have causal risk factors that are distributed across multiple levels of explanation and involve psychological as well as neurophysiological mechanisms. It is also the case that meaningful but overlapping distinctions are to be made between psychiatric disorders and other medical disorders such as autoimmune disorders. It would be a serious error to misdiagnose an autoimmune disorder as a primary psychiatric disorder (eg, schizophrenia), just as it would be a serious error to misdiagnose an autoimmune disorder as a primary disorder of joints (eg, osteoarthritis) or as a primary disorder of the cardiovascular system (eg, essential hypertension).

The problem in the case of “medically unexplained symptoms” is that clinicians end up offering bad explanations of psychosocial causes (“it is stress”) or they misdiagnose the problem as a psychiatric disorder (as depressive disorder or as anxiety disorder, which may very well be comorbid but is not the correct diagnosis for the complaint). This basically conveys the implicit message that the problem is “all in one’s head” and becomes a powerful form of dismissal, invalidation, and neglect.

This is all compounded by the inability of current health care professionals and systems to patiently work with unexplained symptoms and provide adequate care. Brian Teare has written about the experience of remaining undiagnosed after a series of medical tests: “I was betrayed by my own GP. She did not say the phrase It is all in your head, but she might as well have… I keep imagining what it would have meant to have encountered a doctor who said, I am at the end of the care I can give you, and although I could not diagnose your illness, I believe you are ill and you need more comprehensive testing than public health can provide.”¹⁵

Resultantly, I cannot help but be dissatisfied with the idea that the solution to our current poor care of medically unexplained symptom lies in doubling down on some sort of dualism between “mind problems” and “body problems” when many complex, multifactorial problems cannot be neatly categorized in this manner. The essential thing, in my opinion, is a transparent acknowledgment of our ignorance and our state of knowledge; avoiding premature closure of the search for causes; resisting bad causal explanations; challenging misdiagnosis; and confronting clinical invalidation and medical neglect.

O’Leary: We have all doubled down on dualism, I am afraid, because psychiatry does not work unless we accept the reality of subjective experience. Philosophy provides no reason to resist dualism in diagnosis, and no reason to avoid separating mind problems from body problems. In fact, medicine gives us no reason to avoid it, because concern about separation has been (wrongly) attributed to philosophy for so long that no one has bothered to support it clinically.

You suggest that separation is unproductive in psychiatry, but I think, first, that you really do not believe that. You recognize the difference between bodily pain and psychosocial distress, and you understand what is happening when a patient with bodily symptoms is referred to psychiatry. If you did not separate in these basic ways, you could not function as a psychiatrist. I think what you mean is that psychiatry is more effective when we accept complex interactions between mind problems and body problems—and I fully agree with that. I am just pointing out that there are no interactions at all between a thing and itself. When we provide care that recognizes mind-body interactions, we begin by separating.

Second, it is important to think about what psychiatry communicates to a doctor-in-training when it tells them that medically unexplained symptoms are “complex, multifactorial problems that cannot be neatly categorized.” It tells them that deliberate diagnostic vagueness is the best approach, that their usual determination to diagnose disease should be set aside. Most impactfully, whatever we tell doctors-to-be about unexplained symptoms, we tell them about health care for women—because psychiatry has trained every MD to believe that these are the most common symptoms in medicine, and they affect women almost exclusively.

If you [as a man] and I [as a woman] see our primary care doctors today for new symptoms, I will be 10 times more likely to leave the office with talk about “complex, multifactorial problems that cannot be neatly categorized.” You will be 10 times more likely to leave with a diagnosis, or an uncertainty that is understood to require resolution. If we both have pain, you will be more likely to get pain medication and I will be more likely to get sedatives.¹⁶ If we were both older than 55 years with heart disease, I would be twice as likely to be misdiagnosed with a mental health condition, and 7 times more likely to be mistakenly sent home from the emergency department in the midst of a heart attack.¹⁷

When we allow pseudophilosophy to override diagnostic caution, patients die. When we combine that approach with entrenched professional gender bias, women die. Purely as a matter of numbers, few problems in psychiatry cause harm to more patients than this quiet combination.

Aftab: I want to press you here on what exactly it is that we are trying to distinguish. We begin with property dualism, according to which there is such a thing as subjective experience. Fine. But then you go further and seem to say that accepting this property dualism also means accepting that a (sharp? mutually exclusive?) delineation is to be made between “mind problems” and “body problems.” That, to me, is a very different sort of distinction than property dualism.

Let’s take a patient with chronic pain who has lumbar radiculopathy. There is the subjective experience of pain, the activity in the nervous system (the neurobiological mechanisms) that makes the experience of pain possible, and the narrowing of the space around the nerve root (the cause of the pain). Let’s consider 2 patients with depression. The first is someone who has recently had a stroke and has a textbook presentation of poststroke depression. Here we can distinguish among the subjective experience of mood alterations, the neurobiology of mood regulation, and how that neurobiology is disrupted by the stroke. The second patient is experiencing a severe depressive episode after a divorce, and here we can distinguish among the subjective experience of mood alterations (and other symptoms), the neurobiological and psychological mechanisms that are associated with those experiences, the relationship between those experiences and divorce as a life event, and other risk factors that predispose the individual to experiencing depression. It is clear to me that the mere fact of altered subjective experience does not tell us much about the relevant mechanisms, causes, and risk factors. Are you suggesting that the mechanisms and causes that are associated with any experience of illness can be neatly packaged into “mind problems” (mental mechanisms and mental causes) and “body problems” (neurophysiological mechanisms and neurophysiological causes)? If that is the case, I do not see what justifies such a binary packaging and why we should accept it.

More fundamentally, it is not clear to me here what a “mind problem” exactly is. Psychiatric disorders or mental disorders are disorders that have “distinctive features [that] can be adequately characterized only by using the vocabulary of the mental” but acknowledging so does not take away the fact that psychiatric disorders involve psychological as well as neurophysiological mechanisms, causes, and risk factors.¹⁸ Is there a “mind problem” that does not involve neurophysiological mechanisms, causes, and risk factors? What are we talking about here?

O’Leary: First, we can recognize the difference between mind problems and body problems and still see that their interaction can be complex. Second, the distinction in no way implies that the 2 kinds of problems can be “neatly packaged,” as you put it, in practice. It may be that in many cases clinicians are unable to disentangle them. This is no basis for imagining that it is a bad idea to try to be clear about the nature of the problem. At this time, many clinicians believe that they should walk away from the diagnostic process as soon as they get near the mind-body line. That idea is dangerous and patients gain nothing from it. They gain from clinical awareness of complex interactions between mind problems and body problems. That awareness is impossible without a distinction between them.

You have basically articulated a kind of mind-body stew, a list of the many ways that mind and body are related in psychiatry, as if this suggests that effort to better understand is a bad idea. I do not see what supports that leap. Once we see that we are property dualists, we have got a tool that can draw us out of the stew into clearer territory. We start by accepting that there are states of subjective experience, and these are correlated with, but different from, brain states. Keeping that in mind, we can rely on this basic distinction: Mind problems are caused by brain states correlated with experience, while brain problems are caused by brain states not correlated with experience. (For diagrams, see my webinar for the Philosophy of Psychiatry series.³) In a nutshell, as long as we are clear that all experiences are correlated with brain states, we might say that mind problems are caused by experience, while body problems are caused by purely biological states.

This gives us at least 1 consistent, science-friendly way to understand the difference between mind problems and body problems. More than that, it allows us to locate problems in the realm of the mental (with Bortolotti and Broome) without ever losing sight of the fact that [the] brain is always involved. So, delusion is subjective experience correlated with a brain state, and pain is subjective experience correlated with a brain state. We might be inclined to toss up our hands, concluding that there is just no difference between them, but that conclusion is not supported. There is a difference.

In many cases, delusion is caused by a brain state—a kind of body state—that is correlated with experience, perhaps a trauma, while pain is caused by a body state all on its own, like lumbar radiculopathy. Of course, there are exceptions to these rules, and we can easily make sense of them. Some cases of delusion are body problems because they are caused by brain pathologies or other bodily pathologies all on their own, and some cases of pain are mind problems because they are caused by brain states correlated with experience. Moreover, there are many cases of delusion, and many cases of pain, where the interplay between mind problems and body problems is so complex that we cannot possibly sort it out. All of this is easy to manage. We will need at least 1 more stipulation to handle hard cases, but this much seems clear: Property dualism provides an objective, science-based way to understand the difference between mind problems and body problems while staying true to the aims of biopsychosocial medicine. It is a tool that makes sense of psychiatry’s ability to plant one foot in the realm of experience and the other in the realm of physical science.

Aftab: Thank you!

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He leads the interview series “Conversations in Critical Psychiatry” for Psychiatric Times and he writes for his Substack newsletter “Psychiatry at the Margins.” He is also a member of the Psychiatric Times Editorial Board.

Dr Aftab and Dr O’Leary have no relevant financial disclosures or conflicts of interest.

References

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