Values and Psychiatric Diagnosis By John Z. Sadler. Oxford: Oxford University Press. 2004. 540 pp. £34.95 (pb). ISBN 0198526377

For more than ten years Sadler has been thinking about the ways in which psychiatric classification is imbued with judgements of value, even when it purports to be objective. Operational definitions of psychiatric disorders are intended to be universal, in some sense scientific, and as such should do away with value judgements. Sadler, whose massive scholarship is demonstrated in this book, shows the extent to which such judgements persist and why this is inevitable.

‘Massive’ is not hyperbole. The message that psychiatric diagnosis involves values is not too difficult to convey. What Sadler shows, however, is how values are involved, not just in the wording of particular diagnostic categories, but at every step of the way. They are involved in the very idea of pinning down psychiatric illnesses and placing them in categories: the determination that this can be done in a scientific manner involves ‘value-commitments’. How the enterprise of creating a classificatory system is undertaken (e.g. with openness to non-psychiatric participation) is itself a political matter involving ethical and pragmatic values. Sadler lays bare the ways in which our world views - involving culture, religion, sex and gender - can shape our definitions of mental disorder. This was most starkly shown in 1973 when, in America, homosexuality was voted not to be a mental disorder. How this is squared with the underpinning essentialism of nosology - according to which diseases have an invariant nature - shows the complexity of things; because an essence should be found, not voted in or out (which sounds more like the social construction of disorder). What emerges is the importance of our ontological assumptions: where we stand on how things are in the world.

It has to be said that this is a long book. Nevertheless, its individual chapters could be highly recommended to specific groups for various purposes - none more so than the chapter on technology, in which the need for a balance between technological practice (which is efficient, productive and economical) and poietic practice (to do with creativity, tradition, nature, connectedness) is suggested. Sadler, who is one of the main movers in the field of the philosophy of psychiatry, emphasises the need for balance between scientific and philosophical understandings, which is crucial if clinical practice is to aspire to excellence.