Wednesday, 16 April 2014

Cultural formulation, diagnosis and validity #2

(The draft second section of a draft chapter.)

The two factor model of cultural variation

One way to understand how culture affects mental illness would be to think of the expression of mental illness as the result of two factors: an invariant endogenous factor and a cultural shaping. On this view, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate such as an essential human nature. This is the first factor.

Perhaps the most obvious candidate for such a substrate is human biological nature. This would fit a common emphasis within mental healthcare on the centrality of biological psychiatry especially for accounts of the aetiology of mental illness. It would also be consistent with Jerry Wakefield’s analysis of the concept of disorder as a harmful biological dysfunction. Setting aside the role of the value term ‘harm’ for the moment, the first factor in a two factor account of culture-bound syndromes might be a biological dysfunction picked out or explained in evolutionary terms.

Whilst biological nature is the most obvious candidate for the first factor, others are also possible. Consider Louis Sass’ account of Schreber’s delusions in Paradoxes of Delusion [Sass 1994]. The main claim of the book is summarised in an early passage thus:

[Schreber’s] mode of experience is strikingly reminiscent of the philosophical doctrine of solipsism, according to which the whole of reality, including the external world and other persons, is but a representation appearing to a single, individual self, namely, the self of the philosopher who holds the doctrine… Many of the details, complexities, and contradictions of Schreber’s delusional world… can be understood in the light of solipsism. [ibid: 8]

But the elucidation or understanding that Sass seeks isn’t merely aimed at one delusional experience or even at Schreber as a whole. It is meant to shed light more generally on schizophrenia. The reason it can (according to Sass) is that it derives from a general feature of rationality:

[Madness] is, to be sure, a self-deceiving condition, but one that is generated from within rationality itself rather than by the loss of rationality. [ibid: 12]

So one might take the first factor of a two factor theory of cultural psychiatry to be an invariant feature of human mindedness whether biologically unified as a biological dysfunction or not. It might attach to the nature of rational subject-hood however that is biological realised or underpinned. This would form the basis or underpinning of mental illness across cultures and not specific to any one of them.

Cultural variation enters this picture only with the second factor. Culturally invariant pathologies of human nature such as biological nature or essential features of our rationality or mindedness are overlaid by local cultural variation in how they are expressed where ‘expressed’ could carry either or both of two meanings. First, it might mean that standing possibilities for biological dysfunction or failings of rational subjectivity might be differently prompted by different social or geographical contexts. This would be akin to akin to variation in heart disease rates and causes in different cultures and hardly merits the label ‘cultural concept’. (I will return to this possibility a little later and will suggest it is better thought of as a one-factor model.)

The more interesting idea is that variation in ‘expression’ picks out the way in which underlying pathologies might be plastic to the different self-interpretations that different people come to possess and thus the way they feel and are avowed. This would be an example of a cultural idiom of distress in the vocabulary of the DSM-5. But whereas for physical illness, how one understands one’s illness might be thought to be an accidental superficiality compared with the real underlying condition (as understood, perhaps, by the medical profession), one might argue that for mental illness its esse is percipi: how it is perceived at least partly constitutes it. Thus in the case of Sass’ account of schizophrenia, a two factor model would be premissed on the idea that cultural variation might make it difficult to realise that the symptoms reported in different cultures resulted from something like the same failure within rationality. Identifying the common element would require significant interpretative work reflected in a cultural formulation.

I suggested earlier that on a two factor model, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate. That difference between these options is the difference between thinking that the alloy of invariant underlying pathology and variant cultural overlay itself comprises what we mean by mental illnesses themselves. One might think, for example, that khyal cap and panic disorder have the same underlying biological mechanism but that the characteristic way in which the former carries its own ontology (ie that subjects think of their distress through the conceptual lens of a wind-like substance) is sufficient to mark it off as a different kind of mental illness. Biological dysfunction is then thought of as the common cause of two distinct illnesses depending on cultural context. On the other hand, one might think that the real illness is whatever is common to khyal cap and panic disorder. It is merely that the form that that illness takes can vary.

Whichever view is taken of whether the first factor is the illness or merely the common underpinning of different illnesses, a two factor view of cultural concepts of mental illness suggests a particular view of the aim of a cultural formulation in psychiatric diagnosis. It is a way of reverse engineering, from locally divergent symptoms, the common underlying causes. The aim of sensitivity to cultural difference would be to find a way to penetrate beneath it to a common substrate appropriate for scientific psychiatric research.

This seems to be the view of Mezzich et al. in their discussion of ‘Cultural formulation guidelines’ when they say:

The cultural formulation of illness aims to summarize how the patient’s illness is enacted and expressed through these representations of his or her social world. [Mezzich et al 2009: 390]

and

Performing a cultural formulation of illness requires of the clinician to translate the patient’s information about self, social situation, health, and illness into a general biopsychosocial framework that the clinician uses to organize diagnostic assessment and therapeutics. In effect, the clinician seeks to map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry. [ibid: 391]

On their account, the only positive role cultural factors can then play is as a source of contingent health promoting resources:

The aim is to summarize how culturally salient themes can be used to enhance care and health promotion strategies (e.g., involvement of the patient’s family, utilization of helpful cultural values). [ibid: 399]

Mezzich’s view is a half way house between two more radical views of the possibilities for cultural psychiatry both of which of versions of a single factor which I will now outline.

Two versions of a one factor model of cultural variation

The two factor model requires a distinction between surface appearance and underlying pathology. But it might be that this distinction cannot be drawn. That is, the various ways one might want to flesh out the contrast between underlying pathology – for example as biological or some other underpinning notion of universal human nature – and surface appearance might fail. Consider the two versions of the first factor outlined above: biological dysfunction cashed out in accord with evolutionary theory and a pathology of rationality as such. In the first case, drawing a distinction between surface form and underlying invariant function or dysfunction might seem unproblematic in the case of physical illnesses. But in the case of mental dysfunctions there may be no principled way of drawing a distinction between ways of thinking that are problematic within a particular culture and some underlying cognitive function underpinning several different forms. The surface form may simply be the dysfunction. Why? It is unlikely that there is no such thing as biological human nature and hence some shared biological underpinnings for human mentality and cognition. Some such notion, corresponding to what John McDowell calls ‘first nature’, might come free with our identity as an animal species [McDowell 1994: 183]. But it might not, unaided, determine mental pathology because it might not – without education and enculturation, for example – determine the kind of mindedness that mental illness threatens. Mental illness might be a feature of what McDowell calls our ‘second nature’, or, in German, bildung. Perhaps learning a language is necessary for some, at least, forms of mental illness such as thought disorder. Perhaps there is no principled way to factor conditions like depression into those aspects that require conceptual thought or language and mere biological underpinnings.

A one factor model need not imply that there is any cultural variation of mental illness. It might be that our second nature, or rather that aspect of it relevant for the formation of mental illnesses, is universal. If so, mental illness would be akin to heart disease, varying only in external features such as rates and superficial and unimportant local understandings of it. Apparent deeper variation would be a mark of our ignorance, our misdiagnosis. So a conservative version of the one factor model likens mental illness to heart disease with no significant space for cultural variation and no need for a cultural formulation to extract or excavate the underlying commonalities because they are open to view.

On this conservative view, culture-bound syndromes such as khyal cap can have either of two statuses. They are either really other names for universal conditions also picked out by the vocabulary of Western psychiatry such as ‘panic disorder’. Or they do not exist. For example, if it is an essential part of the theoretical apparatus of khyal cap that it is caused by the rising up of a wind-like substance then there is no such condition. Those who self-report it, or its characteristic symptoms, are in some sense in error about their own conditions.

But it is also possible that, because second nature depends on enculturation and because cultures vary, second nature also varies. If so, the richer notion of human nature now in play, beyond mere biology and sufficient for a conception of mental illness, might not be universal. Cultural variation might go ‘all the way down’.

To flesh this example out it will be helpful to consider again but in more detail Sass’ account of schizophrenia according to which it is a failure of rationality from within, or driven by, rationality itself rather than an absence of rationality. The symptoms of schizophrenia are a kind of lived experience f the philosophical stance solipsism according to which only the subject of experience – I – exist. Everything else is merely an idea (for me: one of my ideas). Solipsism is thus idealism whose implicit consequences have been explicitly adopted since if everything that exists is merely an idea only the first person subject of thought (for me: me) can have those ideas. But as Wittgenstein influentially argued, solipsism is strictly nonsensical because it presupposes a contrast between self and other (in the claim that everything is merely an idea) which it cannot consistently draw (since everything is an idea) [Wittgenstein 1929]. Sass, controversially, embraces this further feature of solipsism – that it is nonsense – to shed light on the pathological status of schizophrenia (for criticism of just this point see Read **; Thornton **).

Such an account can be used to illustrate both the conservative and the radical version of the one factor model of cultural concepts. If one thinks that the history of Western philosophy merely illustrates and unpacks conceptual connections implicit in the rationality of any thinker then solipsism is also a standing possibility for any thinker and hence, on Sass’ account, so is schizophrenia as its lived version. That would be a conservative one factor model. Any apparent culturally determined variation in the experience of schizophrenia, such as the specific contents of delusions by contrast with invariant forms, would be merely superficial requiring no great cultural sensitivity to detect. (It is the thought that it is merely superficial which distinguishes this from a two-factor model with its demand for a cultural formulation.)

If on the other hand one thinks that Western philosophy has been driven not merely by the abstract demands of rationality but by historically contingent assumptions about the nature of subjectivity and the connection of mind and world then the temptation towards solipsism will seem to be a merely local cultural matter. At the risk of being glib, had Descartes not existed, there would have been no such thing as schizophrenia.


This version of the one factor model is more radical than the two factor model even though both agree on the need for some sort of cultural formulation. A one factor model of a cultural formulation is more radical because it does not enable one to dig beneath surface difference to find underlying common pathologies but would instead be an articulation of the genuinely different ways people can be ill in different cultures. According to it, there are genuinely different forms of mental illness which need have nothing substantial in common across different cultures. In their account of the role of cultural formulation, Mezzich et al. ignore this possibility.

Monday, 14 April 2014

Cultural formulation, diagnosis and validity

The draft start of a draft chapter.

Cultural factors in DSM-5
DSM-5 attempts to shed light on the role that culture, and cultural differences, can play in psychiatric diagnosis. This section will outline some of those ways before drawing out their implications.
In Section III of DSM-5 there is a discussion of the role of what is called a ‘Cultural Formulation’ including a semi-structured interview to help investigate cultural factors. In the Appendix there is a ‘Glossary of Cultural Concepts of Distress’ which describes nine common conditions (though see below) including: **.

In the introduction, a number of suggestions are made as to how cultural factors might affect diagnosis and prognosis and thus should be investigated in a cultural formulation [APA: **]. Culture may affect:
·         The boundaries between normality and pathology for different types of behaviour.
·         Vulnerability and suffering (by amplifying fears that maintain panic disorder).
·         The stigma of, or the support for, mental illness.
·         The availability of coping strategies.
·         The acceptance or rejection of a diagnosis and treatments, affecting the course of illness and recovery.
·         The conduct of the clinical encounter itself thus affecting the accuracy of diagnosis, acceptance of treatment, hence prognosis and clinical outcomes.

The introduction also summarises (in fact at greater length than the later discussion of the cultural formulation’) three distinct ways that culture can impact on diagnoses. The single idea of culture-bound syndromes is replaced by three notions: cultural syndromes, cultural idioms of distress and cultural explanations (or perceived causes) of illnesses (or symptoms). It is worth quoting the summary in full:

1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context (e.g., ataque de nervios). The syndrome may or may not be recognized as an illness within the culture (e.g., it might be labeled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer.
2. Cultural idiom of distress is a linguistic term, phrase, or way of talking about suffering among individuals of a cultural group (e.g., similar ethnicity and religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming essential features of distress (e.g., kufiingisisa). An idiom of distress need not be associated with specific symptoms, syndromes, or perceived causes. It may be used to convey a wide range of discomfort, including everyday experiences, subclinical conditions, or suffering due to social circumstances rather than mental disorders. For example, most cultures have common bodily idioms of distress used to express a wide range of suffering and concerns.
3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress (e.g., maladi moun). Causal explanations may be salient features of folk classifications of disease used by laypersons or healers.
[ibid: **]

Although the authors distinguish between these different ideas, they concede that the same elements may play a role in all three categories. For example, in the West, depression is used as an idiom of distress whether of an illness or pathology or mere normal but significant sadness. But it is also recognised as a mental illness syndrome gathering together a number of symptoms. Finally, it is taken to be the cause of those symptoms. Just as depression can play the role of syndrome, idiom of distress and explanation, so can other concepts local to other cultures.

Given this complication, although the ‘Glossary of Cultural Concepts of Distress’ describes nine common culture-bound syndromes, the concepts described may also play a role as idioms of distess and purported explanations or causes of experiences.

One example of a cultural concept of distress described is khal cap. Again, it will be helpful to quote this one example in full to suggest the kind of description offered in the other cases too:

Khyal cap
‘Khyal attacks’ (khyal cap), or ‘wind attacks,’ is a syndrome found among Cambodians in the United States and Cambodia. Common symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities, as well as other symptoms of anxiety and autonomic arousal (e.g., tinnitus and neck soreness). Khyal attacks include catastrophic cognitions centered on the concern that khyal (a windlike substance) may rise in the body—along with blood—and cause a range of serious effects (e.g., compressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope). Khyal attacks may occur without warning, but are frequently brought about by triggers such as worrisome thoughts, standing up (i.e., orthostasis), specific odors with negative associations, and agoraphobic type cues like going to crowded spaces or riding in a car. Khyal attacks usually meet panic attack criteria and may shape the experience of other anxiety and trauma- and stress or related disorders. Khyal attacks may be associated with considerable disability.
Related conditions in other cultural contexts: Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka (vata), and Korea (hwa byung).
Related conditions in DSM-5: Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder.

The other main cultural concepts of distress described are ataque de nervios (‘attack of nerves’), dhat (‘semen loss’), kufungisisa (‘thinking too much’ in Shona), maladi moun (‘humanly caused illness’) nervios (‘nerves’), shenjing shuairuo (‘weakness of the nervous system’ in Mandarin Chinese), susto (‘fright’), taijin kyofusho (‘interpersonal fear disorder’ in Japanese). Each is related to similar but different concepts found in other cultures.

But the description of khal cap will serve to raise a preliminary interpretative question: what stance does DSM-5 have to the content of the cultural concept, so set out? Does the cultural sensitivity aimed at in a formulation and the semi-structured interview protocol require the adoption of a kind of anthropological relativism? Or is it consistent with the privileging of a particular cultural standpoint: that of twenty-first century western psychiatry?

On the face of it, no such relativism is necessary. Khal cap can serve as an ‘idiom of distress’: the conception of an experience had by a subject. If someone describes their experience as the rising up of a wind-like substance then that is simply an anthropological fact about the culture. It can serve as a ‘cultural explanation’ because, again, that is a fact about how a culture explains particular experiences without implicit endorsement of that theory of aetiology by the ascriber. But, by the standards of twenty-first century western psychiatry, it can even be described as a ‘cultural syndrome’ since that is defined as ‘a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context’. If, for whatever reason, the symptoms described co-occur then it is reasonable to call them ‘khal cap’. In other words, the sincere use of ‘khal cap’ by a transcultural psychiatrist need not cause any intellectual difficulty.

But such a reading of the description carries with it some cost when it comes to understanding the possibilities for culturally sensitive psychiatry. If the concept of a khyal attack is only ever used within the (intensional) context of what someone from that culture believes – his or her conception of the nature and explanation of the experiences – rather than as an objective description of what is really causing the attack, then that suggests a distinction of kind between cultural concepts (or culture-bound syndromes) and the main elements of DSM-5’s taxonomy.

Consider the question asked from a Western psychiatric standpoint: ‘But from what are they really suffering?’. The description above suggests a ready answer selected from the list of related conditions in DSM-5: ‘Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder’. Such a response suggests that a culturally sensitive psychiatry is merely a sensitivity to other cultures’ errors: the truthful ascription of a false belief about the causes of abnormal experiences. To avoid that, however, seems to require a willingness to use – in anger, as it were – explanations of experiences as  resulting from an increase in the wind-like khal in the body. What are the options for transcultural psychiatry?

Tuesday, 8 April 2014

Is there any such thing as nursing knowledge?

Introduction

‘What is nursing knowledge?’ is a complex question, the answer to which helps define nurses as a profession? [Hall 2005: 34]

Is there such a thing as ‘nursing knowledge’? What do and should we mean by that phrase? And does it help define nursing itself? It may seem that denying that there is such a thing, or unified kind, as nursing knowledge risks undermining the profession of nursing and runs counter to its new graduate status in the UK. But I will argue that on one understanding of the question, at least, it is correct to answer ‘no’ but that this is no threat to a picture of nursing as richly knowledge-based.

To do this, I will consider three important distinctions of kind and argue that, in each case, nursing knowledge is distributed across both sides. This suggests that implausible to think that it is unified. At the same time, however, I will suggest that in each case there is reason to think that what is involved is, indeed, a form of knowledge. Finally, I will suggest that there is a key intellectual skill at the heart of nursing but that this takes the form of an art rather than a science.

Knowledge and justification

But to begin, what is knowledge or what does ‘knowledge’ mean? Note that there might not be a very helpful answer to this question. Imagine someone asks what stickiness is or what the word ‘sticky’ means. One might offer a word that means more or less the same: such as ‘tacky’. But this does not help explain the concept of stickiness so much as swap one word for it for another. Or one might offer a more substantial explanation of the concept such as ‘a propensity of a body to adhere to another on contact’. This may more or less equate to the concept but it isn’t obvious that a speaker who understands the word ‘sticky’ should be able to offer such a formal paraphrase. Further, it raises further questions such as what does the word ‘adhere’ mean? So we should approach the question of what knowledge in general is with some caution. There may not be a very helpful definition available.

But some features of knowledge can be abstracted. Suppose that Sandy knows that, because it is 5pm, Mr Smith is due for medication. If so, she must hold it to be, or take it to be, true that it is time for his medication. That is, she must believe it. Second, if Sandy does know that Mr Smith is due for medication, then he must really be due for medication. If she has knowledge, what she believes must be true. Third, her belief cannot merely be accidentally true. Suppose her belief that the time is nearly 5pm is based on the ward clock but that this stopped the day before. By chance, however, it is now nearly 5pm. If so, although Sandy has a true belief about Mr Smith’s medication she does not know it.

These constraints on knowledge have motivated an account of knowledge which dates back to Plato: knowledge is justified, true belief. The justification condition is supposed to rule out cases of merely lucky true beliefs.

Justification also plays a second role. It provides a means of aiming at true beliefs. It is one thing to worry that one’s beliefs about the efficacy of rival surgical techniques may not be correct, but quite another to work out how to avoid error. It would not be helpful to be told to replace any false beliefs with true beliefs. To hold a belief is to hold it to be true. (To hold that something is not the case is not to believe it.) Thus beliefs which are, in fact, false are not be transparently so to someone who holds them. But the advice that one should ensure that one holds only beliefs that are justified is helpful. And by aiming at justified beliefs one should in general succeed in reaching true beliefs since justification is, in general, conducive of truth.

Sadly the analysis of knowledge as justified true belief faces a challenge. In the 1960s Edmund Gettier showed how to construct counter examples to the analysis in which a subject has a true belief and a justification for it but the justification only works through the intervention of luck and so, intuitively, is not a case of knowledge [Gettier 1963]. Hence the analysis must be false. One example runs as follows. Smith and Jones have applied for a job. Smith has good reason to hold that Jones will get the job (he has been told by the CEO) and that Jones has ten coins in his pocket (Smith has counted them) from which he concludes that the successful applicant has ten coins in his pocket. By chance, he himself gets the job rather than Jones and, again by chance, he himself has ten coins in his pocket. Did he know after all that the successful applicant has ten coins in his pocket? Intuitively, no because even though he believed it, had a justification and it was true, it took a stroke of luck for his belief to be true.

One possible response to Gettier’s example (and cases like it) would be to raise the standard of what we mean by ‘justification’. One might argue that Smith was not in fact justified in believing that Jones would get the job (despite being told this by the CEO) because Jones did not, after all, get the job. If so, the example is not a counter-example to the traditional analysis. But if justification has to guarantee the truth of what it justifies then justifications may be in short supply.

Or one might concede that Gettier has indeed refuted the traditional analysis and turn instead to a different third condition such as that knowledge is true belief arrived at by a reliable process. This modern view of knowledge called ‘reliabilism’. Again, the extra condition in addition to true belief is supposed to eliminate knowledge-undermining luck. Sadly if the necessary reliability of the process is anything less than 100%, Gettier style counter-examples can also be offered for reliabilism [Goldman 1976].

There is no general agreement as to how best to respond to Gettier’s challenge to accounts of knowledge. One possible approach, however, is to accept the idea of raising the bar on justification, so that to be justified is to be in a position to have knowledge, but to deny that justifications fall into general kinds that can be identified independently of the knowledge they underpin [McDowell 1982]. Thus for example, the general kind or type of justification that is being informed by a CEO who will get a job is not (always) sufficient for knowledge. But being told on a particular occasion by a particular person may be. Similar, whilst simply looking at a clock (which may have stopped) is not sufficient to know the time, looking at a particular clock on a particular day may be enough to grant Sandy, in the example mentioned above, knowledge of the time.

Such an approach has the key virtue of maintaining the knowledge’s pedigree (which is what the standard model was supposed to do). Knowledge is reliable (with a small ‘r’) and rationally commands trust. That is why it is also the rational aim as the underpinning of nursing practice. nevertheless, there is reason to think that whilst all nursing knowledge has what the status of knowledge requires that it is not more generally unified by subject matter of methodological approach. I will now examine three key distinctions across which nursing knowledge divides.

Explanation and understanding

The first distinction I wish to consider dates back to debates about psychology in the late nineteenth century, the so-called Methodenstreit. This concerned whether the human sciences (the Geisteswissenschaften) should try to emulate their far more successful cousins the natural sciences (Naturwissenschaften), or whether they should go their own methodological way. ‘Positivists’, including John Stuart Mill, in England and both Auguste Comte and Emile Durkheim in France, argued that the human sciences were no different from the natural sciences. Others argued that the human or cultural sciences were different from the natural sciences either in terms of the nature of their subject matter or their methodology or both. The latter, in Germany, included Heinrich Rickert, Wilhelm Dilthey and Wilhelm Windelband.

Of particular relevance to mental health nursing, however, was the philosopher and psychiatrist Karl Jaspers. At the start of the twentieth century, German psychiatry was dominated by academic neuroscientists working under the assumption, epitomised by the German psychiatrist Wilhelm Griesinger’s famous aphorism, that ‘Mental illnesses are brain illnesses’. But Jaspers felt that the natural science approach to psychiatry had been taken too far and needed balancing. Thus, drawing on his understanding of the Methodenstreit, he stressed the importance of understanding in addition to explanation. Whilst explanation tracked objective measurable symptoms, understanding was necessary to grasp subjective symptoms. Taking empathy to be a key aspect of understanding he said:

Objective symptoms can all be directly and convincingly demonstrated to anyone capable of sense-perception and logical thought; but subjective symptoms, if they are to be understood, must be referred to some process which, in contrast to sense perception and logical thought, is usually described by the same term ‘subjective’. Subjective symptoms cannot be perceived by the sense-organs, but have to be grasped by transferring oneself, so to say, into the other individual’s psyche; that is, by empathy. They can only become an inner reality for the observer by his participating in the other person’s experiences, not by any intellectual effort. [Jaspers 1968: 1313]

A different but similarly motivated distinction was promoted by the post-Kantian philosopher of science Wilhelm Windelband. He distinguished between scientific approaches which explained phenomena in general terms, as instances of general laws of nature, which he called ‘nomothetic’ (‘nomos’ means law in Greek) from equally scientific but nevertheless individually focussed sciences such as history which he called ‘idiographic’.

In their quest for knowledge of reality, the empirical sciences either seek the general in the form of the law of nature or the particular in the form of the historically defined structure. On the one hand, they are concerned with the form which invariably remains constant. On the other hand, they are concerned with the unique, immanently defined content of the real event. The former disciplines are nomological sciences. The latter disciplines are sciences of process or sciences of the event. The nomological sciences are concerned with what is invariably the case. The sciences of process are concerned with what was once the case. If I may be permitted to introduce some new technical terms, scientific thought is nomothetic in the former case and idiographic in the latter case. [Windelband 1980: 175-6]

These distinctions between explanation in terms of natural laws and understanding via something like empathy or an idiographic focus on the individual have an echo in the balance in contemporary mental healthcare between evidence based medicine or practice, on the one hand, and person centred care, on the other. Whilst EBM emphasises the importance of generalities by privileging evidence derived from large scale randomised control trials, person centred care stresses the importance of a focus on individual patients. This balance of demands on healthcare, resembles the balance called for by Jaspers, and is reflected, for example, in the recent call by the World Psychiatric Association for the development of a ‘comprehensive’ model of diagnosis or assessment as part of its ongoing Institutional Program for Psychiatry for the Person. A WPA workgroup charged with formulating ‘International Guidelines for Diagnostic Assessment’ (IGDA) has published a guideline called ‘Idiographic (Personalised) Diagnostic Formulation’ which recommends an idiographic component alongside criteriological diagnosis.

This comprehensive concept of diagnosis is implemented through the articulation of two diagnostic levels. The first is a standardised multi-axial diagnostic formulation, which describes the patient’s illness and clinical condition through standardised typologies and scales... The second is an idiographic diagnostic formulation, which complements the standardised formulation with a personalised and flexible statement. [IDGA Workgroup, WPA 2003: 55]

Intuitive though the distinction between nomothetic and idiographic seems, however, there are some challenges in analysing what it means. After all, it cannot just be the difference between a focus on repeated and unique events since nomothetic sciences such as cosmology may study and attempt to explain unique events such as the Big Bang. It would have to be somehow essentially individualistic. But in Windelband’s own account, the way that idiographic approaches address their subject matter is not satisfactorily explained [Thornton 2008]. Further there is a challenge which arise from the idea that a truly idiographic form of understanding could never amount to knowledge. As summarised in the first section, knowledge has a pedigree, is reliable, is not a matter of luck. But a form of judgement essentially aimed at a unique event and which carried no general connections to other possible – even if not actual – cases could not be thought of as the product of a reliable sensitivity to how things are in that particular case. Knowledge requires some sort of generality.

The more promising distinction seems to be that between explanation and understanding in which the latter refers to the ways in which sense of human subjects is made by exploring their experiences, beliefs and utterances hang together in rational patterns. Borrowing phrases from the philosophers Wilfrid Sellars and John McDowell, the distinction between explanation and understanding can be thought of as the difference between subsuming events under natural laws (thought of as descriptions of what typically happens), the ‘realm of law’, and fitting them into normative patterns of good reasons, the ‘space of reasons’.

With this distinction in place, the knowledge that nurses need in order to care for patients and service users clearly spans both sides. They need to grasp the laws that govern the workings of human physiology and which describe the course of illnesses including mental illnesses. But they also need to be able to understand mental health service users or patients: their hopes, fears, beliefs, desires and experiences. With understanding itself understood to be a matter of placing subjects into a space of reasons, however, this is still a form of knowledge even if of a different kind to that of explanation of other natural events.

Knowledge of facts and values

In the previous section, I outlined the importance of a distinction between explanation couched in lawlike generalities (‘nomological’ or ‘nomothetic’) and understanding individuals in a distinctive way by trying to fit their utterances, experiences and actions in the ‘space of reasons’. A paradigmatic instance of the former approach is the deployment of generalities inferred from randomised control trials (RCTs) or, better, the meta-analysis of RCTs which is the gold standard for evidence in Evidence Based Medicine or Evidence Based Practice.

In their influential book, Evidence-based Medicine: How to practice and teach EBM, David Sackett, Sharon Straus, Scott Richardson, William Rosenberg, and Brian Haynes define it as follows. ‘Evidence based medicine is the integration of best research evidence with clinical expertise and patient values.’ [Sackett et al 2000]. This is a surprising definition. Normally the focus of EBM is on the first element of that tripartite division: research evidence. But Sackett et al widen their definition to include two further aspects: expertise and values. They give a further brief preliminary sketch of each as follows.

By best research evidence we mean clinically relevant research… New evidence from clinical research and treatments both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious and safer.
By clinical expertise we mean the ability to use our clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations
By patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.
[ibid: 3]

This looks to a broad definition not just of EBM as such but something that should be based on it: good clinical practice, perhaps, or good medical care. But it serves a convenient reminder of another relevant distinction for nursing knowledge: that between facts and values.

Nurses need not only to know about research evidence concerning the workings of the brain and mind, or the prognoses for particular psychiatric diagnoses – the biomedical facts – but they need to know about values: those of their patients and service users but also their own and those of broader society. They need to know, in other words, not just about evidence based practice but also about values based practice.

Outlining the nature of values based practice, or the competing views of what it should involve, is beyond the scope of this chapter. But a preliminary survey suggests that knowledge of facts and values can be very different. There’s no equivalent of RCTs for the empirical determination of how we ought to act. The closest equivalent to knowledge of the empirical laws governing natural phenomena might be, in the case of medical ethical values, knowledge of ethical principles such as the Four Principles approach of respect for beneficence, non-maleficence, autonomy and justice [Beauchamp and Childress 2001]. But whereas the physical forces, for example, can be added together using the mathematics of vector addition, there is no general calculus for saying when, for example, the principle of autonomy should trump beneficence and when the other way round. Further, ethical values are merely one subset of the values, preferences, traditions that need to be taken into consideration in vales based practice and thus the prospect for codifying all the value judgements relevant for clinical decisions are dim.

Some proponents of values based practice argue for an even more dramatic difference in the nature of knowledge of facts and values. Bill Fulford, for example, argues that successful values based practice does not so much aim for a correct judgement as a good process [Fulford 2005]. It is a matter of following the appropriate deliberative process rather than aiming to get the values in a particular situation objectively right. If so, the knowledge involved is knowledge of how to follow a procedure. This contrasts with a natural view of the aims of EBM in aiming to discover the psychiatric facts. Others argue that even though there is no algorithm for forming a view of what to do in a particular situation, that does not rule out the idea that value judgements aim at correctness [Thornton 2011]. On this view, whilst knowledge of values is not reducible to or codified in general principles it is still a form of general recognitional ability to chart evaluative demands made on subjects with eyes to seen them by worldly situations.

But whatever the best view of values based practice – and it is an interesting question whether this means the most correct or the most desirable – there is no doubt that values based practice and evidence based practice call on different kinds of expertise based on a sensitivity to different features of the world: the bio-medical facts and patients’ and others’ values.

Tacit and explicit knowledge

The characterisation of evidence based medicine from Sackett et al also highlights a further distinction of kind within what nurses need to know. They define expertise as the ‘ability to use our clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations’ [Sackett et al 2000: 3].

This characterisation contains two elements already mentioned in the previous distinctions. Clinical expertise is directed towards individuals and their unique states and circumstances, picking up the understanding side of the first distinction (explanation versus understanding). It is also directed at their values and expectations, picking up the values side of the second distinction (knowledge of facts versus values). But it also suggests a practical recognitional skill is in play and that suggests a third, important, distinction: between explicit and tacit knowledge.

The idea of tacit knowledge (or ‘tacit knowing’, as he preferred) was first promoted by Michael Polanyi. In his book The Tacit Dimension he says:

I shall reconsider human knowledge by starting from the fact that we can know more than we can tell. This fact seems obvious enough; but it is not easy to say exactly what it means. Take an example. We know a person’s face, and can recognize it among a thousand, indeed among a million. Yet we usually cannot tell how we recognize a face we know. So most of this knowledge cannot be put into words. [Polanyi 1967: 4]

The suggestion is that tacit knowledge is tacit because it is ‘more than we can tell’. We cannot tell how we know things that we know tacitly. But why not? There is, however, a constraint on any plausible answer to this question which turns on an apparent tension in the very idea of tacit knowledge. To be a form of knowledge, there must be something – some content – known. As was set out in the first section, on the standard model of knowledge, this content is a belief (eg. that , Mr Smith is due for medication). But if so, why can this not be put into words? What kind of content could be known but not be put into words? Being knowledge and being tacit seem to be conflicting ideas.

A clue as to how to resolve this comes from a frequently cited example of tacit knowledge from a totally different area: the chicken industry. There is a great economic advantage to be able to determine the gender of chicks as soon as possible after they hatch. In the 1920s, Japanese scientists discovered a method by which this could be done based on subtle perceptual cues with a suitably held and gently squeezed chick. It was, nevertheless, a method that required a great deal of skill developed through practice. After four to six weeks practice, a newly qualified chick-sexer might be able to determine the sex of 200 chicks in 25 minutes with an accuracy of 95% rising with years of practice to 1,000 - 1,400 chicks per hour with an accuracy of 98% [Gellatly 1986: 4].

One reason that this is cited as an instance of tacit knowledge is that early Australian investigators were unable to determine the nature of the skill involved. Further, the story has developed that the chick-sexers themselves were unable to express the nature of their knowledge (aside from saying which were male and which female). Hence it seems that this is a form of knowledge which cannot be put into words alone.

The example suggests a resolution to the tension mentioned above. Chick sexing counts as knowledge because the content known is practical, underpinned by a general and reliable ability. The relevant content is how to tell the difference between male and female chicks through manipulation and observation. But it counts as tacit because it cannot be put into words without also a practical demonstration involving chicks. So it cannot be put into words alone. Further, as the Australian investigators reveal, such demonstrations only work for others with ‘eyes to see’ or rather the relevant practical knowledge. On this model, tacit knowledge is practical knowledge the articulation of which requires a practical demonstration in the right context. It is situation specific practical knowledge.

As a practical discipline, mental health nursing contains aspects of tacit knowledge so understood. This includes all the situation specific knowledge of how to do things: basic clinical skills but also recognitional skills summarised by Sackett et al. These are the kind of recognitional skills which Benner describes using Dreyfus’ five stage hierarchy connecting novice to expert practitioner. [Benner 2004; Dreyfus and Dreyfus 1986]. There is, however, a further argument from Polanyi which suggests that mental health nursing might involve a further key area for tacit knowledge based in an area of mental healthcare that might be thought to be paradigmatically explicit. This concerns mental illness diagnosis.

Two historic factors have encouraged an approach to diagnosis which stresses explicit knowledge. Firstly, on its foundation in 1945, the World Health Organisation set about establishing an International Classification of Diseases (ICD). Whilst the chapters of the classification dealing with physical illnesses were well received, the psychiatric section was not widely adopted and so the philosopher Carl Hempel was invited to address the American Psychological Association conference of 1959. He recommended the use of operational definitions (following Bridgman’s book The Logic of Modern Physics), although construed loosely to fit a notion of measurement appropriate for mental illness [Bridgman 1927]. This view has been influential up to the present WHO psychiatric taxonomy in ICD-10.

The second reason for the emphasis on reliability and hence operationalism was a parallel influence from within American psychiatry that shaped the writing of DSM-III. Whilst DSM-I and DSM-II had drawn heavily on psychoanalytic theoretical terms, the committee charged with drawing up DSM-III drew on the work of a group of psychiatrists from Washington University of St Louis. Responding in part to research that had revealed significant differences in diagnostic practices between different psychiatrists, the ‘St Louis group’, led by John Feighner, published operationalised criteria for psychiatric diagnosis. The DSM-III task force replaced reference to Freudian aetiological theory with more observational criteria.

This stress on operationalism has had an effect on the way that criteriological diagnosis is made explicit or codified in DSM and ICD manuals. Syndromes are described and characterised in terms of disjunctions and conjunctions of symptoms. The symptoms are described in ways influenced by operationalism and with as little aetiological theory as possible. (That they are neither strictly operationally defined nor strictly aetiologically theory free is not relevant here.) Thus one can think of such a manual as providing guidance for, or a justification of, a diagnosis offered by saying that a subject is suffering from a specific syndrome. Presented with an individual, the diagnosis of a specific syndrome is said to be justified because he or she has enough of the relevant symptoms which can be, as closely as possible, ‘read off’ from their presentation. Such an approach to psychiatric diagnosis plays down the role of individual judgement or tacit knowledge amongst clinicians.

Nevertheless, according to Polanyi, even apparently explicit knowledge such as this rests on a substrate of tacit. The reason for this is that

[I]n all applications of a formalism to experience there is an indeterminacy involved, which must be resolved by the observer on the ground of unspecified criteria. Now we may say further that the process of applying language to things is also necessarily unformalized: that it is inarticulate. Denotation, then, is an art, and whatever we say about things assumes our endorsement of our own skill in practising this art. [ibid: 81]

Consider someone who can recognise the letters of the alphabet including, for example, the letter ‘e’. Although learnt through exposure to a finite number of examples, such an ability is general and open ended. It enables the expert to recognise a potentially infinite number of letter ‘e’s. But such examples will vary across different fonts, for example, or be printed at different sizes or in different colours, or be hand written with varying degrees of irregularity or surrounded by different other letters (in different words). Polanyi’s passage suggests the following possibility. The ability to recognise all these different particular letters as instances of the same general kind (the letter ‘e’) may outrun the expert’s ability to explain or articulate just how the shape has to be for it to count as an ‘e’. It may be ‘unformalized’ or ‘inarticulate’. The expert may ‘know more than they can tell’.

If this holds for recognising a letter it holds even more obviously for the recognition of mental illness symptoms. The signs and symptoms of depression or bipolar disorder can be recognisably of the same type whilst varying in numerous ways between the people who have them.

Criticising the ability of the DSM criteria to capture the nature of schizophrenia, the President of the World Psychiatric Association Mario Maj, for example, argues that:

[W]e have come to a critical point in which it is difficult to discern whether the operational approach is disclosing the intrinsic weakness of the concept of schizophrenia (showing that the schizophrenic syndrome does not have a character and can be defined only by exclusion) or whether the case of schizophrenia is bringing to light the intrinsic limitations of the operational approach (showing that this approach is unable to convey the clinical flavour of such a complex syndrome). In other terms, there may be, beyond the individual phenomena, a ‘psychological whole’ (Jaspers, 1963) in schizophrenia, that the operational approach fails to grasp, or such a psychological whole may simply be an illusion, that the operational approach unveils. [Maj 1998: 459-60]

In fact, Maj favours the former hypothesis. He argues that the DSM criteria fail to account for aspects of a proper grasp of schizophrenia, for example, the intuitive ranking of symptoms (which have equal footing in the DSM account). He suggests that there is, nevertheless, no particular danger in the use of DSM criteria by skilled, expert clinicians for whom it serves merely as a reminder of a more complex underlying understanding. But there is problem in its use to encode the diagnosis for those without such an additional prior understanding:

If the few words composing the DSM-IV definition will probably evoke, in the mind of expert clinicians, the complex picture that they have learnt to recognise along the years, the same cannot be expected for students and residents. [ibid: 460]

Maj’s criticism that the DSM criteria do not capture a proper, expert understanding of the diagnosis of schizophrenia suggests that even aspects of mental health nursing where the greatest effort has been made to codify and make knowledge explicit still rests on a bedrock of tacit knowledge. Not everything can be put into words.

Is there such a thing as nursing knowledge?

I can now return to the question of whether there is such a thing as ‘nursing knowledge’ and whether it helps to define nursing itself? In a recent article called ‘Defining nursing knowledge’, Angela Hall says suggests that the answer to both is ‘yes’. She says ‘”What is nursing knowledge?” is a complex question, the answer to which helps define nurses as a profession’ [Hall 2005: 34].

Consider a possible contrast between those roles or disciplines whose related expertise or knowledge defines the role or discipline and those where the relationship is the other way round. One might think that theoretical physics or neurology, or mathematics, belonged to the former category. The idea is that what unifies the role or discipline of practitioners is the nature of the knowledge in question. Thus mathematicians could be identified as those possessors of mathematical knowledge which could in turn be understood directly. For this to be the case, the body of knowledge has to be in some way intrinsically unified, a natural kind.

This side of the contrast faces a challenge even in the case of the relation between mathematicians and mathematics because the extension of the concept of mathematics has, from time to time, been disputed. There was disagreement about whether Newtonian fluxions (calculus), Cantor’s ‘paradise’ of the mathematics of infinities and the computer based solution to the four colour problem counted as properly mathematical. This suggests that mathematics – and hence knowledge of mathematics – is sometimes, at least, fixed by the view taken by mathematicians rather than the other way round. But it is the other side of the contrast that matters here: disciplines whose knowledge is identified by whatever the discipline, itself picked out in some other way, requires and where there is no presupposition that what needs to be known is intrinsically unified.

On this other side of the distinction, there might be roles such as restaurant proprietorship for which what is known, or needs to be known, is not intrinsically unified. The role gathers together diverse areas of subsidiary knowledge as the knowledge proper to restaurant proprietorship. This might include some of what is involved in cookery, customer relations, tax law etc. To identify restaurant-proprietorship-knowledge, one needs to identity first the role and only then whatever is the knowledge that turns out to be necessary to carry it out successfully. Further, the knowledge so needed is not particular to this role. It involves the right mix of what is known in other roles by chefs, social psychologists and moral agents, and tax lawyers.

Given this contrast in principle in the order of determination of professional role and underpinning knowledge on which side does nursing lie? I have argued in this chapter that the knowledge nurses need to have lies on both sides of a range of significant distinctions: knowledge necessary for explanation but also for understanding; of facts but also values; and both explicit and tacit. This suggests that ‘nursing knowledge’ is not intrinsically unified but instead comprises different elements necessary for the practice of nursing.

Does this mean that there is no such thing as ‘nursing knowledge’? In a related context, the epistemologist Michael Williams suggests an analogy with Francis Bacon’s (1561–1626) discussion of the nature of heat.

Think of Bacon’s notorious natural history of heat, which brings together various things we call ‘hot’, including bodies warmed by the sun’s rays, substances undergoing exothermic reactions, and ‘hot’ oils and spices that ‘burn’ the tongue. Is there a single thing here, heat? There is no reason, in advance of theory, for supposing that there is. [Wiliams 1988: 424]

Bacon’s method is to survey all the things we call ‘hot’. Now in one sense, this is, indeed, an account of heat, all the things which have heat. But as the list implies, the sense of ‘hot’ or ‘heat’ involved varies across the cases. There is no underlying unity to them. (To achieve a unity, to advance a science of heat, would involved rejecting some of Bacon’s examples, such as ‘hot’ spices, as not instances of the revised unified concept.)

To reject the idea that there is a unified underlying concept of nursing knowledge is not to reject the idea that the different aspects highlighted in this chapter are instances of knowledge. They are but they are gathered together in virtue of a prior understanding of the nature and role of the profession of nursing: perhaps centrally what is needed for caring for patients and health service users. Nursing knowledge is whatever knowledge is needed properly to realise that aim or role.

If this is the case it suggests a related task for the nurses as experts in diverse forms of knowledge. In the presence of a particular patient of mental health service user, they have to select the knowledge appropriate to ‘each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations’ in Sackett et al’s phrase. This task fits a distinction between determinate and reflective judgement suggested by Kant in his Critique of Judgement [Kant 1987].

If the universal (the rule, principle, law) is given, then judgment, which subsumes the particular under it, is determinate... But if only the particular is given and judgment has to find the universal for it, then this power is merely reflective. [Kant 1987: 18]

The model at work here is of judgement as having two elements: a general concept and a particular subject. Judgement subsumes a particular under a general concept. The contrast between determinate and reflective judgement is then between an essentially general judgement, when the concept is already given, and a particular or singular judgement, which starts only with a particular. The former, determinate judgement, appears to be relatively mechanical and thus unproblematic. The idea that if a general principle is already given then judgements which deploy it are relatively unproblematic can be illustrated through the related case of logical deduction where a general principle is already given. If, for example, one believes that

1: All men are mortal; and
2: Socrates is a man.
Then it is rational to infer that:
3: Socrates is mortal.

One reason this can seem unproblematic is the following thought. If one has accepted premises 1 and 2 then one has, ipso facto, already accepted premiss 3. To accept that all men are mortal is to accept that Tom, Dick, Harry and Socrates are mortal. So given 1 and 2, then 3 is no step at all [though see Carroll 1895]. By contrast, for reflective judgement, there is a principled problem in how to get from the level of individuals to the level of generalities, or how to get from people and things to the general concepts that apply to them. That is not a matter of deduction because the choice of a general concept is precisely what is in question. To move from the particular to the general that applies to it is somehow to gain information not to deploy it. Reflective judgement thus cannot be a matter of mechanical derivation.

Kant suggests that the reflective judgement is an essentially imaginative ability and he connects it to aesthetic judgements or judgements of art. The key element of aesthetic judgment, he suggests, is the ‘ability to judge an object in reference to the free lawfulness of the imagination’ in which there is ‘a subjective harmony of the imagination with the understanding without an objective harmony’ [ibid: 91-92]. It is the harmony of the faculties of imagination and understanding in judgment which is both the source of pleasure that grounds aesthetic judgment. This connection between reflective judgement and art suggests a final characterisation of nursing.

Whilst there is no such thing as nursing knowledge, understood as a unified kind, that very fact puts a key selective skill at the heart of nursing, a key piece of know-how or tacit knowledge. Good patient-focused nursing requires the exercise of judgement which seeks, rather than presupposes, appropriate general knowledge. It is thus what Kant would call a reflective rather than determinate judgement. And thus, still following Kant, it is an art not a science. So the knowledge at the heart of nursing, the knowledge to select the right subsidiary knowledge called for by particular patients in particular situations, is an art not a science.

References
Beauchamp, T.L. and Childress, J.F. (2001) Principles of Biomedical Ethics Oxford: Oxford University Press
Benner, P. (2004) ‘Using the Dreyfus Model of Skill Acquisition to Describe and Interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education’ Bulletin of Science, Technology & Society 24: 188–19
Bridgman, P.W. (1927) The Logic of Modern Physics, New York: Macmillan
Carroll, L. (1895) ‘What The Tortoise Said To Achilles’ Mind 4: 278-280
Dreyfus, H. and Dreyfus, S. (1986) Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer, New York: The Free Press
Fulford, K.W.M. (2004) ‘Ten Principles of Values-Based Medicine’ in Radden, J. (ed) The Philosophy of Psychiatry: A Companion New York: Oxford University Press, 205-34
Gellatly, A. (1986) The Skilful Mind: An Introduction to Cognitive Psychology, Milton Keynes: Open University
Gettier, E. (1963) ‘Is Justified True Belief Knowledge?’ Analysis 23: 121-123
Goldman, A. I. (1976) ‘Discrimination and Perceptual Knowledge’ Journal of Philosophy, 73: 771–791
Hall, A. (2005) ‘Defining nursing knowledge’ Nursing Times 101: 34–37
IDGA Workgroup, WPA (2003) ‘IGDA 8: Idiographic (personalised) diagnostic formulation’ British Journal of Psychiatry, 18 (suppl 45): 55-7
Jaspers, K. ([1912] 1968) ‘The phenomenological approach in psychopathology’ British Journal of Psychiatry 114: 1313-1323
Jaspers, K. ([1913] 1974) ‘Causal and “Meaningful” Connections between Life History and Psychosis’, trans. by J.Hoenig, in S.R.Hirsch and M.Shepherd. in Hirsch, S.R., and M. Shepherd, Themes and Variations in European Psychiatry, Bristol: Wright: 80-93
Kant, I. (1987) Critique of judgment Indianapolis: Hackett
McDowell, J. (1982) ‘Criteria, defeasibility and knowledge’ Proceedings of the British Academy 68
Maj, M. (1998) ‘Critique of the DSM-IV operational diagnostic criteria for schizophrenia’ The British Journal of Psychiatry 172: 458-460
Polanyi, M. (1967) The Tacit Dimension, Chicago: University of Chicago Press
Sackett, D.L. Straus, S.E. Richardson, W.S. Rosenberg, W. and Haynes, R.B. (2000) Evidence-based Medicine: How to practice and teach EBM, Edinburgh: Churchill Livingstone
Thornton, T. (2008) ‘Should comprehensive diagnosis include idiographic understanding?’ Medicine, Healthcare and Philosophy 11: 293-302
Thornton, T. (2011) ‘Radical liberal values based practice’ Journal of Evaluation in Clinical Practice 17: 988-91
Williams, M. (1988) ‘Epistemological realism and the basis of scepticism’ Mind 97
Windelband, W. ([1894] 1998) ‘History and natural science’ Theory and Psychology, 8: 5-22

Wednesday, 2 April 2014

Social science citations and literature reviews

In my role as Research Degree Tutor in the School of Health, I read quite a bit of social science based PhD research and have long been struck by how the use of citations differs from philosophy. I suspect that it is related to something else I have a problem with: the expectation that philosophy-based research should have something like a social science literature review. Perhaps even a systematic review. It is quite difficult to explain why not doing this in philosophy is not merely another example of the laziness of non-empirical research or another example of how such research is merely an ‘opinion piece’.

First here’s how social science citations look to me (forgive the mangled version of Harvard, for speed).

1: Meaning is use [Wittgenstein, L. (1953) Philosophical Investigations].

If one is a philosopher, this will seem a very odd sentence but I assume it won’t to social scientists. In philosophy, one simply doesn’t say that sort of thing even though Wittgenstein is an authority (the greatest philosopher of the C20?) and is widely credited with defending such a thesis. This example, although odd, is modelled on something which in another context is much more straight forward and which uses the citation to attempt to head off potential objections by an appropriate appeal to authority. For example in natural science one might say:

2: Smoking causes cancer. [U.S. Department of Health and Human Services (2010) How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health]

This seems fine but immediately suggests a problem for treating citation in this way in philosophy: conflicting authority is the norm rather than the exception. Returning to the subject area of sentence 1, we may also appeal to Davidson, for example, to say:

3: Meaning is not use. [Davidson, D. (2005) Truth, Language, and History. Oxford: Oxford University Press, p13]

So philosophy cannot rely on authority without running the risk of baldly saying odd things like:

4: Meaning is use [Wittgenstein etc] and is not use [Davidson etc].

The social science citations that bother me are those that move from a context where appeal to authority seems to me appropriate (like 2) to one where it is not (like 1). I read comments in methodology sections of social science PhDs along these lines:

5: There is no such thing as absolute truth. [Smithers 1998]

For every such authority-backed claim there will be a conflicting one somewhere out there in the world of published papers. So how can arbitrarily selecting one and citing it justify anything? But there is a further issue which this (and the foolish 1) prompts. Do we really understand what the sentence is saying? Sentence 1 fails as an assertion in a philosophy paper because it doesn’t tell us enough about the nature of meaning and of use and the way the connection sheds light on either. If Wittgenstein really does connect meaning and use, the connection is nuanced and stands in need of careful explanation. The work of articulating the connection, however, begins to display not only the nature of the thesis advanced but also its plausibility (cf this previous post). Once this is done, whilst a citation is necessary to avoid plagiarism, to show that it is Wittgenstein’s work that is being explicated, it is no longer asserting extra-textual authority. The text itself takes on that burden.  (This is a bit like moving from saying in the playground: 'My brother is bigger than yours' to saying 'My brother has taught me this technique with which I will now analyse your argument'.)

This difference between the way philosophy and social science relies on citation also connects to the absence of systematic literature reviews in the humanities. Reviewing the literature has a quite different status in the (social) sciences and the humanities.

I suspect that the background reason is that there is a presumption in the sciences that knowledge accumulates, that progress is made, and that this is reflected in the process of peer reviewed publication. Because of peer review, if something is published there is reason to hold that it is true unless there is specific reason (such as a conflicting publication) to doubt it. Hence also the habit of bald social science citation. If Smith has published the claim that p, then it is likely that p.

No such presumption operates in the humanities for at least two reasons. First, even though the humanities aim to tell the truth about their particular subject areas (one cannot just make things up), there is less idea of an actual accumulation of truth, perhaps even the very possibility of accumulating truth in areas like literary theory or the history specific events such as World War 1, eg. Second, the peer review process for journals establishes that papers meet a standard of rigour but that does not imply that they establish truth (even though that is their aim). The same journal might, without embarrassment, simultaneously publish conflicting papers, for example.

Hence there is no obvious point in undertaking a systematic review in the humanities because mere publication is no guide to anything. As a result the reviewer needs to take on some of the work of establishing what is probably true him- or herself. So there is no distinction between a literature review and the work of the research. But if so, reviews may as well be very selective.

Monday, 24 March 2014

At the limits of shared intelligibility: delusions and non-doxasticism

At the limits of shared intelligibility: delusions and non-doxasticism. 

An abstract for a proposed talk (offered to the Philosophers Rally, Nijmegan, Netherlands, April 2014)

Delusions present a challenge to the attractive assumption that shared intelligibility is the mark of the mental since, according to Karl Jaspers, primary delusions are un-understandable. This has motivated a philosophical project to ‘solve simultaneously for understanding and utter strangeness’ in Naomi Eilan’s useful metaphor. That is, to provide a degree of understanding rather than mere explanation of the content of delusions whilst preserving their prima facie strangeness. In this presentation I will consider the merits of a recent approach: non-doxasticism. It takes seriously the disanalogies between delusions and normal belief-like states to argue that delusions are better understood to be some different kind of intentional state. I will argue, however, that on either of two broad versions of non-doxasticism, this approach cannot help with Eilan’s challenge and will draw some general conclusions about that challenge.

Some further comments

A familiar problem for delusion takes the form of an argument:
  1. Intentional mental states are essentially governed by the Constitutive Ideal of Rationality (cf the Generality Constraint).
  2. Delusions violate the Constitutive Ideal of Rationality.
  3. So delusions are not intentional mental states.
  4. But delusions seem like mental states.
This is much too fast but has echoes which go back to Jaspers and the apparent tension in his stress on empathic access as the heart of psychological understanding – suggesting that understandability is the mark of the mental – with his definition of primary delusions through un-understandability. In the face of it one might deny the first premiss but the danger here is that one thus gives up the project of shedding light on what marks out a state as a mental state. To avoid that, one would need to replace appeal to the Constitutive Ideal of Rationality with something.

A more modest response is to question the second premiss. Construed as world-answerable states, delusions appear to violate the Constitutive Ideal of Rationality. But not all mental states are bound by that Ideal in the same way. And hence if one construes delusions as some other kind of state, one can deny premiss 2 and hence avoid the conclusion. This is the more familiar recent version of non-doxasticism. 
Perhaps delusions are, or have elements of, acts of imagination? I do not think, however, of three interesting and potentially promising versions of this approach that they can work.

But there is a different way of thinking about non-doxasticism. This is not so much to think of delusions as within the conceptual map of intentional states, though not the beliefs, but rather to think of them as pushing the idea intentional states to the limit. One further preliminary point: delusions may not press the limits of shared intelligibility in the same way.

Thursday, 6 March 2014

Nursing knowledge: art or science?

In a conversation this week over a coffee at Tiggis restaurant with one of my many line managers, Karen Wright, and her other minions (colleagues!) from my School’s mental health teaching division, I found myself mulling over the nature of ‘nursing knowledge’: the knowledge that underpins (good) nursing. Issues we discussed included whether such knowledge forms a natural kind, whether it is distinct from other forms ie. it is sui generis, and whether it is better thought of as a science or art (depicted*, sort of). I don’t think that my own train of thought was particularly compelling but here it is.

First, consider the contrast between those roles or disciplines whose related expertise or knowledge defines the role or discipline and those where the relationship is the other way round. One might think that neurology or physics or mathematics belongs to the former category. What unifies the role or discipline of practitioners is the nature of the knowledge in question. (I must admit to some scepticism about this side of the contrast: that the subject of mathematics, for example, individuates itself, comprises a natural kind, independently of the toil of self-identified mathematicians. I can imagine a need for a sociology of mathematics to explain why branches of reasoning, such as Newtonian fluxions, were counted as properly mathematical. But despite this, it might help demonstrate a scale if not a distinction.)

The distinction is, at least, supported by what seems to be related. Where the knowledge is prior to the role it is more likely to be sui generis. In this case, our understanding of the subject matter of mathematics is not settled elsewhere than by the work carried out by mathematicians. It seems plausible to think that where that is the case, the subject matter of the relevant knowledge can be used to define the role or discipline, rather than the other way round.

On the other side of the distinction, there might be roles such as restaurant proprietorship for which what is known, or needs to be known, is not intrinsically unified. The role gathers together diverse areas of subsidiary knowledge as the knowledge proper to restaurant proprietorship. This might include some of what is involved in cookery, customer relations, tax law etc. To identify restaurant-proprietorship-knowledge, one needs to identity first the role and only then whatever is the knowledge that turns out to be necessary to carry it out successfully. Further, the knowledge so needed isn’t sui generis to this role. It involves the right mix of what is known in other roles by chefs, social psychologists and moral agents, and tax lawyers.

Given that rough contrast of the order of determination of professional role and underpinning knowledge, I think that nursing lies in the second  camp. First, one identifies the role – in this case centrally via the caring for patients and health service users, though that would need to be articulated – and only then the knowledge necessary for that. Further, addressing the issue of whether it is sui generis, what is known is the right mix of knowledge taken from other disciplines. The argument for this is empirical: a casual glance at the diversity of the nursing curriculum.

Art or science? A first informal answer to that, again looking at the mix of modules in a nursing undergraduate degree, is both. The sciences of physiology and patho-physiology rub shoulders with communication skills, law and values based practice. But there’s a more interesting answer which starts from the challenge raised by the order of determination and rejection of the idea that nursing knowledge might be a sui generis natural kind: how does one select, from the range of other disciplines, which to draw on when?

Suppose that what one means by scientific knowledge (in the specific context of the contrast of science and art: this would not get one through a philosophy of science module!) is what can be deductively codified in a general major premiss and a situation specific minor premiss of a syllogism. (One might mean something like this especially if one has been reading Kant’s Critique of Judgement.) The regress implicit in the frame problem in AI suggests that the selection problem nursing faces cannot be solved by the exercise of science so understood. It requires the exercise of judgement which seeks, rather than presupposes, an appropriate major premiss. It is thus what Kant would call a reflective rather than determinate judgement. And thus, still following Kant, it is an art not a science. So the knowledge at the heart of nursing, the knowledge to select the right subsidiary knowledge called for by particular patients in particular situations, is an art not a science.

(*Picture from the very excellent: http://www.waxoil.com/)

Wednesday, 5 March 2014

Being towards death

I have never understood why Dasein, that being for whom being (I want to write: Being) is an issue, should be essentially orientated towards death. I can see how, for being/Being in general, or the fact of one’s own being, to be an issue, one might need to have a conception of not being. And so it might seem that the way that comes about is via an orientation towards, or awareness of the possibility of, one’s own death. But I don’t see why that should be necessary. Why couldn’t the possibility that one might not have existed be enough, for example? Perhaps an orientation towards one’s contingent birth?

I mention this in the context of a health scare this year which – rationally I think – made me at least take seriously the more than merely abstract possibility of ceasing to be: the sense of not having a future. Hence a quick thought on that.

Bill Fulford has taught me the use of a thought experiment or class exercise to illustrate the diversity of values in values based practice beyond moral values. It turns on this scenario:

You have an illness which will prove fatal in n weeks/months/years.
There is a potential treatment which has a 50% complete success rate and a 50% instant fatality rate but you must take it today.
Question: for what value of n would you prefer to risk the treatment?

Typically this question prompts a wide range of student answers from months to nearly a normal expected full life term. At one extreme, a young trainee medical student at Warwick University preferred the fixed fatality over the 50:50 life or death providing that n was, merely, at least a week or two. That is, for a value of n as small as two weeks, he preferred that small fixed life to the 50% chance of dying that day. When questioned, he replied that he would want to put his affairs in order and that would be possible in a couple of weeks and so even a fortnight was to be preferred to the potential treatment which might rule out any time for sorting things out.

But this student’s sang-froid was way beyond my own resources of character this year. With the normal (perhaps presumptuous, given the standing possibilities of being knocked off one’s bike) confidence in some sort of future undermined, I found that I wanted to take to my bed or pour a stiff drink, not as positive project of enjoying the sleep or the drink but merely as an escape. With the prospect that the future might not exist simply made more than normally concrete, the practices that constitute a life seemed unavailable to me.

So whilst I don’t get the idea of being towards death as a fundamental existential dimension, an orientation towards an open future does seem an essential feature of my kind of non-morally-serious existence.