Friday, 30 October 2009

Recovery, values and subjectivity

I’ve been invited by Joana Ferreira, a psychiatry resident in Coimbra, Portugal and lecturer in psychopathology to psychology students at at the Catholic University of Braga and who attended the INPP conference in Lisbon, to submit a paper based on my grouchy presentation on recovery to their college magazine on psychiatry, psychology, philosophy and religious themes.

(PS see also this later published paper.)

So here is a very rough first rough stab (coming in at 3,500 words).
Recovery, values and subjectivity
In the UK, the recovery model has been promoted to guide mental healthcare in reaction against what is perceived to be an overly narrow traditional bio-medical model. It has also begun to have an influence in thinking more broadly about mental health both for individuals and for communities and in the latter case has been linked to policies to promote social inclusion. In this widening application, however, there is a risk that the model (assuming that it is a model) becomes too broad and includes too many factors, severing its connection to health.

In this short paper, I attempt to sketch (although not rigorously defend) an argument for a recovery model that distinguishes it from a bio-medical model through the essential presence of a normative dimension in the values that characterise its goal. Nevertheless, I argue that, by distinguishing hedonic from eudaemonic values, it is still possible to maintain a degree of normative assessment in what should properly be called a matter for recovery.

A recent policy paper published by the Sainsbury Centre for Mental Health called ‘Making recovery a reality’ begins by summarising some key points of emphasis which characterise the approach. These points include:

· Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
· Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
· Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
· Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’.
· The helping relationship between clinicians and patients moves away from being expert / patient to being ‘coaches’ or ‘partners’ on a journey of discovery. Clinicians are there to be “on tap, not on top”.
· People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services.
· Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability.
[Shepherd, Boardman & Slade 2008: 0]
As this list suggests, recovery is not so much an explicit theoretical model of the nature of health and illness as a practical orientation to the kind of care that should be involved and the roles of patients or service users and clinicians or carers. Nevertheless, the points listed do suggest an implicit theoretical model which I will attempt to draw out. A key clue to that is the idea that recovery is to be characterised through a positive goal of health and wellness rather than the avoidance of the negative aspects of pathology and illness. That positive goal is connected to the agency of the individual, to their own situation-specific self management of the process, and to their identity.

The list also connects recovery to social inclusion through the empirical claim that social inclusion promotes recovery. But given the links between policies promoting recovery at the individual level and policies promoting social inclusion at the level of communities this raises a further question that helps shed light on the connections between recovery and values: need recovery promote social inclusion? By stressing individual autonomy as the final arbiter of the values that form the goal of recovery, the model suggests a view of society as a group of individuals satisfying their private preferences. That seems to threaten, rather than support, the notion of social inclusion and the idea of collective values or goods.

But further, if the satisfaction of just any preference can be part of the conception of recovery then the model degenerates into subjective whimsy, unconnected to the notion of health, and the use of the label ‘recovery’ is misleading. It is not so much a corrective of the bio-medical model as a totally different venture.

I will attempt to sketch a justification for a conception of recovery which is distinct from a bio-medical approach but which is still sufficiently normatively charged that it can avoid both of these risks. I will not, however, attempt to defend it against rival approaches to recovery. My aim is to rationalise rather than justify a model of recovery.

The normativity of illness / disease / disorderTo begin, it will be helpful to look back to the recent history of discussion of mental health and illness. In his attack on the very idea of mental illness, Thomas Szasz stressed that the concept of illness, whether physical or mental, carries with it the connotation of deviation from a normative standard, a standard that carries a distinction between correctness and incorrectness. (In what follows ‘normative’ will be used to refer to any such standard; the key contrast is with the merely statistically normal.)

The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm, deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm may be, we can be certain of only one thing: namely, that it must be stated in terms of psychological, ethical, and legal concepts… [Szasz 1971: 15]

Szasz used this point as the basis for an argument against mental illness. Nothing can both satisfy this condition and the condition of being medically treatable. Thus one possible route to defend that concept would be to disagree that illness need carry a normative connotation. (A distinct defence is to accept the condition but argue that it does not support the conclusions Szasz draws [Thornton 2007: 11-19].) Perhaps illness could be defined in merely statistical terms. But as even as biologically minded a psychiatrist as Robert Kendell realised, such an approach cannot work. Reviewing the history of the debate he commented:

By 1960 the ‘lesion’ concept of disease, and its associated assumptions of a single cause and a qualitative difference between sickness and health had been discredited beyond redemption, but nothing had yet been put in its place. It was clear, though, that its successor would have to be based on a statistical model. [Kendell 1975: 309]

But, as Kendell went on to say, whilst a statistical model may address some of the weaknesses of a single lesion model, statistical abnormality by itself cannot distinguish between ‘deviations from the norm which are harmful, like hypertension, those which are neutral, like great height, and those which are positively beneficial, like superior intelligence’ [ibid: 309]. Some further criterion is needed to address the fact that illness is a specific kind of deviation from the norm and Kendell followed the work of the British chest physician, JG Scadding in suggesting that biological advantage is the key idea.

More recently there has been an attempt to explain this normative dimension using the idea of biological or proper function of sub-personal traits (not just advantage or disadvantage to whole individuals). The hope is that whilst illness or disease may carry the irreducible notion of harm, a core notion of disorder can be fitted within a purely descriptive scientific account, drawing on evolutionary theory. The prima facie normative dimension of disorder can be explained through the apparently normative notion of biological function. But functions can be analysed through the plainly descriptive or factual notion of what best explains their continued presence within evolved organisms.

A natural function of a biological mechanism is an effect of the mechanism that explains the existence, maintenance or nature of the mechanism via the same essential process (whatever it is) by which prototypical nonaccidental beneficial effects... explain the mechanism which cause them... It turns out that the process that explains the prototypical non-accidental benefits is natural selection acting to increase inclusive fitness of the organism. [Wakefield 1999: 471-2]

The aim is thus to milk a normative function from a plain description of evolutionary history. There are, however, two challenges to this approach. First there is the longstanding objection raised elsewhere in philosophy that norms are smuggled back into the particular choice of evolutionary explanation [Godfrey-Smith 1989, Thornton 1998: chapter 2, Thornton 2000]. In other words, functional explanation is not plainly descriptive. More specifically for psychiatric disorder, it is unclear that the necessary distinction between natural and merely social functions can be maintained [Bolton 2008: 124-5].

In what follows, I will assume that there is no prospect of a plainly descriptive account of disorder and hence of illness or disease. If so then to identify some of the behaviour of either a whole person or a sub-personal biological system as expressive of illness is to conceptualise it in normative terms. To put this another way, different behavioural dispositions have to be filtered through some sort of normative sieve to yield a conception of illness or disease.

There have been attempts to analyse the nature of the normativity of illness or disease. KWM (Bill) Fulford, for example, has proposed and defended a model of illness as a ‘failure of ordinary doing’ [Fulford 1989]. Drawing on Austin’s characterisation of ordinary doing as the kind of action that one ‘gets on and does’ without explicit intentions or trying, Fulford argues that a failure to be able to do this kind of thing, in the absence of external constraint, captures the paradoxical character of experiences of illness [Austin 1957]. He suggests that it helps to explain its normativity or, more specifically, values-ladenness because the ineliminable concept of failure (of ordinary doing) itself suggests an ineliminable (negative) value judgement.

It is still a matter of debate whether Fulford’s account successfully accounts for illness. However, even if the norms that characterise illness cannot be reduced to some other normative notions in the way that Fulford, for one, proposes, the failure of a reduction to the plainly descriptive leaves the concept of illness as an essentially normative notion. That, however, may not imply that recovery is, as I will now discuss.

The normativity, or not, of recoveryEven if one assumes that the concept of illness is essentially normative (statistically unusual behaviour is not sufficient for illness, for example), recovery may not be so. On the picture sketched above, one identifies tracts of behaviour (of people, or of their biological systems) as expressive of illness by filtering all forms of behaviour through an appropriate normative sieve. The filter may use other normative terms such as Fulford’s failure of ordinary doing or be a primitive amd irreducible notion such as sufficiently resembling paradigmatic illnesses. Once it has been applied, what remain are normatively selected states or behaviours.

Recovery itself might plausibly be thought of as the return from such states to a state of health. Health itself, however, might be conceptualised in merely statistically normal (rather than normative) terms. If so, whilst the states that individuals have an interest in recovering from are those with particular normative properties (whatever precisely those are), recovery itself might be characterised in non-normative terms.

For physical health, this is at least a reasonable picture although some initial qualifications are necessary. Age, for example, makes a difference. What is a healthy physical state for an 80 year old will not be for an 18 year old. Further, it may even be statistically normal for most members of particular groups of people (small children, the elderly) to have some illness or other in some or other biological system. If so and if health were defined in normal terms, normality would have to be defined for each such sub-system rather than for the wholse person. But given suitable qualification, there is something plausible about such an approach. It avoids any idealisation of health. One can be healthy – that is: not ill – without being at the peak of physical condition. The fact that one would prefer to be fitter, stronger or more muscled does not imply that one is not healthy as one is.

An analysis of physical health in statistically normal (rather than normative) terms helps rationalise a bio-medical approach to recovery. Once the starting point has been identified, a state picked out as an illness, no further mention need be made of normative notions, for example values. Recovery, so construed, would be merely an engineering problem for the human body.

If a non-normative model of physical health helps to justify a bio-medical approach, can a contrasting recovery model be articulated? I suggest one can based on the following line of thought. Although it is plausible to define physical health in statistical terms, in the case of mental health, however, the end point might have to be essentially normatively, or more precisely, evaluatively characterised. According to this line of thought, mental health cannot be construed as a statistically average kind of life but rather, in line with the opening quotation, a particular kind of life autonomously chosen, valued and hoped for by the individual concerned, the kind of life connected to their identity.

If this were the case, there would be no hope of defining the endpoint of recovery for mental health in non-normative or non-evaluative terms. A specific endpoint would be correct for, or suited to, each individual. And thus recovery should be aimed at a specific and normatively characterised or valued endpoint.

Is this the only way of approaching matters? I do not think so. To defend, rather than merely rationalise, a recovery model for mental health so construed would require dismissing a variant of the statistically normal approach. Whilst characterising a statistically normal kind of life seems misguided, the capacities that enable one to live a life so chosen may be more appropriate for that treatment. So, in the service of an autonomously chosen and hoped for life, mental health might be defined in terms of statistically normal mental abilities. I will, however, ignore this possibility in what follows.

To summarise this section, contrasting approaches to physical and mental health help to justify two contrasting approaches to recovery:
Recovery1: a return to normality (albeit from a position picked out by a normative sieve).
Recovery2: a move (from a position picked out by a normative sieve) to a normatively characterised endpoint, for example, a conception of a valued form of life.

Recovery2 suggests that whether someone has recovered or not depends not on the plainly descriptive matter of whether they have returned to a statistically normal state but rather on reaching a normatively or evaluatively characterised state that constitutes wellbeing.

But if there are no constraints on how that endpoint is selected, if it is simply a matter of personal preference, of the expression of individual autonomy, then that suggests that recovery is a matter of subjective whimsy. The idea of recovery is severed from any notion of health. Further, it threatens the aim of social inclusion with which recovery has historically been associated.

The right values for recovery?The key assumption in my rationalisation of a recovery model for mental health is that the endpoint of recovery has to be characterised in normative terms. There is something appropriate or correct rather than merely usual about the endpoint. But, perhaps because of the rise of autonomy as the key medical ethical value, there is a standing temptation to construe this normative dimension in a particular way. That is, in accord with the preferences of the individual concerned. And put like that, it is tempting to wonder whose preferences should be preferred. Nevertheless, if the norms are subjective preferences then the idea of recovery collapses into the idea of individual preference satisfaction and that also puts the idea of social inclusion at the level of communities under pressure.

But that is not the only way to think about the normativity implicit in the recovery model. Consider two contrasting views of wellbeing: hedonic and eudaemonic. On the hedonic view: wellbeing is a matter of satisfying one’s preferences. The normativity of recovery based on this approach is exhausted by the combination of the satisfaction of the preferences (only some ways the world comes to be satisfy an antecedent wish; the wish imposes a normative constraint on ways for the world to be) and by issues of rationing of scarce resources or balancing conflicting wishes.

On a eudaemonic view, wellbeing is ‘activity in accordance with virtue’. It thus builds in the idea that some values are more valuable than others and not merely more (that is, statistically) preferred. By keeping the key connection between eudaemonia and flourishing or wellbeing in focus, an approach to recovery based on it can restrict the kind of values that characterise its aim: values relevant to flourishing and not just subjective preferences.

Thus, in addition to the normative standards implicit in the hedonic view, a eudaemonic view introduces two further degrees for normative assessment. First, the values that characterise the endpoint of recovery are not just any preferences but values connected to human wellbeing. This helps maintain the pre-theoretic notion that recovery is connected to health and wellbeing. Second, values can be better or worse and can be subject to rational criticism and scrutiny. Thus, for example, if human flourishing really does depend on social inclusion then that fact places principled limits on the value of individual autonomy and thus principled limits on the nature of recovery. Not just any preferred endpoint constitutes the proper aim of recovery, so construed.

Having sketched the conceptual space for a normatively charged conception of recovery based on a eudaemonic view I will finish with three clarificatory comments.

First, Aristotle himself held substantial views about the nature of human flourishing. According to his doctrine of the mean, for example, flourishing requires achieving a middle ground across character traits where both deficiency and excess amount to vices. But a broadly eudaemonic view of recovery need not be tied to any particular view of flourishing, such as Aristotle’s. What flourishing is needs to be investigated and subject to ongoing critical scrutiny.

Second, especially in the light of the flight from medical paternalism to patient or service user autonomy, the idea that some values are more valuable than others may smack of authoritarianism. But it need not. Just as the empirical world serves a normative standard for what empirical beliefs we should hold without that implying that science has to be authoritarian, so a conception of real and objective values need not lead to authoritarianism either. Rather, it imposes a standing obligation for critical reflection on the values we hold.

Third, the eudaemonic view of recovery does not preclude a role for hedonic values in mental health care. Sincerely held, harmless hedonic values may indeed play a role in a broader values based practice. The subjective preferences of service users, who indirectly pay for the services, should indeed be taken into account. And thus models for managing competition for limited resources and other values-based conflicts will be needed. But it is surely a point in the favour of the a eudaemonic view that such values need have nothing to do with what we ordinarily understand by ‘recovery’ and its direct connection to health.

I have sketched an argument for (although not fully defended) a model for the goal of mental healthcare distinct from a bio-medical model in which recovery1 is a characterised in non-normative and value-free terms. On the alternative view sketched above, the goal of recovery2 has to be determined through the conception of a life autonomously chosen and valued by the subject concerned. Such a conception is normative or value-laden in so far as it fits, or is appropriate to or correct for, the individual’s self-identity. There is a danger, however, that such a view collapses into a subjective whimsy which severs the connection between recovery and health or wellbeing and may undermine the related goal of social inclusion. For those reasons I have argued for a eudaemonic rather than hedonic view of the values in play. On the eudaemonic view ‘recovery’ can retain a firm connection to health and healthcare, without collapsing back into a narrow bio-medical model.

BibliographyAustin, J.L. (1957) ‘A plea for excuses’ Proceedings of the Aristotelian Society 57: 1-30
Bolton, D. (2008) What is mental disorder, Oxford: Oxford University Press
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Godfrey-Smith, P. (1989) ‘Misinformation’ Canadian Journal of Philosophy 19.
Kendell, R.E. (1975) ‘The concept of disease and its implications for psychiatry’ British Journal of Psychiatry 127: 305-315
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Thornton, T. (1998) Wittgenstein on Language and Thought, Edinburgh: Edinburgh University Press (translated into Portuguese as Wittgenstein - Sobre linguagem e pensamento, Brazil: Edições Loyola)
Thornton, T. (2000) ‘Mental Illness and Reductionism: Can Functions be Naturalized?’ Philosophy, Psychiatry and Psychology 7: 67-76
Thornton, T. (2007) Essential Philosophy of Psychiatry Oxford: Oxford University Press
Wakefield, J.C. (1999) Mental disorder as a black box essentialist concept. Journal of Abnormal Psychology 108: 465-472

Wednesday, 28 October 2009

The philosophy of the social aetiology of mental illness

I've been asked to contribute to an initiative to develop training in the area of the social aetiology of mental illness for a Canadian initiative called SAMI. Here is an outline.

The philosophy of the social aetiology of mental illness

A proper understanding of the social aetiology of mental illness requires an understanding of causation; its connection to laws of nature; the contrast between a causal explanation and an understanding based on reasons; and the issues raised by attempting to reconcile meaningful factors within causal models. Additionally, it prompts an assessment of the role of understanding individuals and how this relates to general law-like understanding.

1: Aetiology and problem of understanding individual causes

The practical problems of establishing the aetiology of illness and disease are compared to the principled problem identified by Hume of seeing causal connections in even the best possible circumstances. Hume’s general response is sketched. An initial link is forged to issues of validity in psychiatric taxonomy and the rise of EBM.

Main readings:
Rizzi, D.A. (1994) ‘Causal reasoning and the diagnostic process’ in Theoretical Medicine 15: 315-333
Hume, D. (1975) Enquiries Concerning Human Understanding, (Oxford: Oxford University Press sections II and III pp17-24.

2: The link between causation and laws of nature

Building on the first topic, the relation of causes and laws of nature is set out. This raises the question of distinguishing lawlike generalities from merely accidentally true generalisations. The role of laws in underpinning scientific explanations is also set out.

Main readings:
Mackie, J.L. (1993) ‘Causes and conditions’ in Sosa, E. and Tooley, M. (eds.) Causation, Oxford: Oxford University Press: 33-50
Papineau, D. (1987) ‘Laws and accidents’ in MacDonald, G. and Wright, C. (eds.) Fact Science and Morality, Oxford: Oxford University Press:189-218

Davidson, D. (1995) ‘Laws and cause’ in Dialectica 49: 263-279

3: Reasons vs causes

Whilst within natural science causes are best understood in the context of a system of natural laws which also connect to causal explanation, understanding using reasons fits into a different kind of conceptual structure. The distinction between the ‘space of reasons’ and ‘realm of law’ is explored via the notion of rule governed activity. This suggests that understanding is fundamentally distinct from causal explanation.

Main readings:
Winch, P. (1988) The Idea of a Social Science and its Relation to Philosophy, London: Routledge chapter 3 pp66-94
Bolton, D. and Hill, J. (1996; second edition 2003) Mind Meaning and Mental Disorder, Oxford: Oxford University Press

4: Meaning and social constructionism

The claim that mental illness has a social aetiology has both more and less radical forms. One route to a more radical account is via the claim that mental states and thus mental illnesses are socially constructed. Arguments for and against this claim are discussed. The less radical claim that mental illnesses are socially caused but not socially constituted is examined.

Main readings:
Sabat, S.R. and Harre, R. (1994) ‘The Alzheimer’s disease sufferer as a semiotic subject’ Philosophy Psychiatry and Psychology 1: 145-160
Thornton, T. (2005) ‘Discursive psychology, social constructionism and dementia’ in J. Hughes, S. Louw and S. Sabat (eds) Dementia: Mind, Meaning and the Person Oxford: Oxford University Press: 123-141

5: Fitting meanings into aetiological structures

The distinction between reasons and causes suggests that one can seek either to understand mental illness or to explain it causally via aetiology. But it is plausible to think that psychiatry can and should aim to do both: to fit meaningful factors into aetiological models. This session explores three general approaches to this: via the reduction of meanings to causes, via the idea of intentional causation and via a more subtle local accommodation as exemplified in Brown and Harris’ Camberwell study of the aetiology of depression.

Main readings:
Bolton, D. and Hill, J. (1996; second edition 2003) Mind Meaning and Mental Disorder, Oxford: Oxford University Press
Brown, G. W. and Harris, T. (1978) Social Origins of Depression, London: Tavistock
Thornton, T. (2009) ‘On the interface problem in philosophy and psychiatry’ in Bortolotti, L. and Broome, M. Psychiatry as Cognitive Neuroscience, Oxford: Oxford University Press: 121-136

6: Idiographic versus nomothetic understanding

In addition to the idea that mental illnesses can have social aetiology there is a further idea that person centred care requires a particular kind of understanding of the experiences and particular social context of individuals. The WPA, eg., calls for a psychiatry for the person to include idiographic understanding. But if so, what is idiographic understanding, does it threaten diagnostic validity and how does it relate to narrative understanding?

Main readings:
Windelband, W. (1980) ‘History and natural science’ History and Theory & Psychology 19: 169-85.
Phillips, J. (2005)
‘Idiographic Formulations, Symbols, Narratives, Context and Meaning’ Psychopathology 38: 180-184
Thornton, T. (2008) ‘Should comprehensive diagnosis include idiographic understanding?’ Medicine, Healthcare and Philosophy 11: 293-302

Key written resources

Fulford, K.W.M, Thornton, T. and Graham, G. (2006) The Oxford Textbook of Philosophy and Psychiatry Oxford: Oxford University Press chapters especially Part III
Fulford, K.W.M. (Bill) and Thornton, T. (forthcoming) ‘The role of meanings and values in the history and philosophy of the science of psychiatry’ in Basant Puri, B. and Treasaden, I. 9eds) Psychiatry: an evidence-based text for the MRCPsych, London: Hodder Arnold, Health Sciences
Thornton, T. (2005) ‘Discursive psychology, social constructionism and dementia’ in J. Hughes, S. Louw and S. Sabat (eds) Dementia: Mind, Meaning and the Person Oxford: Oxford University Press: 123-141
Thornton, T. (2007) Essential Philosophy of Psychiatry Oxford: Oxford University Press
Thornton, T. (2008) ‘Should comprehensive diagnosis include idiographic understanding?’ Medicine, Healthcare and Philosophy 11: 293-302
Thornton, T. (2009) ‘On the interface problem in philosophy and psychiatry’ in Bortolotti, L. and Broome, M. Psychiatry as Cognitive Neuroscience, Oxford: Oxford University Press: 121-136

Friday, 23 October 2009

From the 2009 INPP conference in Lisbon

I am at the INPP conference in Lisbon enjoying, if not the sun I had expected, at least a packed schedule of plenary and parallel sessions from 9am until 8pm each day. The conference is well attended. Martin Baum is selling books from the OUP IPPP book series as though they were hot cakes. This is, I guess, the conference of the book series and a number of OUP authors are speaking.

As sometimes happens, I’ve enjoyed the short (perhaps too short in some cases) presentations rather more than the formal plenaries. (They happen in a huge formal hall which doesn’t make for interaction.)

Three, randomly picked such sessions, have been:

Jeffrey Bedrick argued that it was a mistake to worry about the nature of the concept of disorder in mental disorder. Instead one such concentrate on the mental and let that take care of disorder. In a Kantian tradition he argued that the mental is the realm of freedom. He then suggested that mental disorders are thus disorders of freedom.

Now if the premises were true, this last step would be analytic. But he wanted a little more. The scale of full freedom to its lack not only maps the mental to its opposite but also health to its opposite. Now that seems an interesting idea but I wondered why he assumed that freedom would deal with both issues. On the face of it, only particular kinds of failure of freedom would correspond to illness.

Dominic Murphy argued against something Rachel Cooper says in her most recent book. She says, I understood, that, in psychiatry, causal explanation is complemented by two distinct other forms: natural history explanations (Miffy is afraid of dogs because she is a rabbit) and case histories. But in a brisk presentation, Dom suggested that both additional forms are, however, not really distinct from causal explanation. Natural historical explanation works because it gestures at where one should look for causal explanation (and serves as a standard for purported natural kinds).

But I couldn’t help noticing that his argument presupposed the virtues of causal explanation and then used it causally to underpin natural historical explanation. It didn’t, in other words, address an opposition to such an underlying assumption about the importance of causal explanation such as a teleological view of natural historical explanation. But the real question I went away with was whether he aimed to undermine the idea of a distinct logic of explanation or whether it was more modestly that a different logic was, as a matter of fact, underpinned by causal connections.

Neil Pickering (pictured) used his 15 minutes to criticise a view he ascribed to Richard Gipps that mental illnesses are illnesses merely in secondary sense. His argument certainly helped to make that idea seem a desperate move. I’ll have to remind myself of what the argument for it might be. But one comment he made seems interesting. With the background thought that secondary sense is distinct from metaphor or simile because there are no shared features that justify it, he commented that a secondary extension of the use of a word is under no rational obligation.

That seems right, in the context of the contrast with simile, but less so without a codification of rationality. Isn’t it rational for those with minds like most of us to rebel against the substitution of synonyms in poetry, to treasure the picture of one’s beloved and so forth? I’m not sure. (I’m also not sure because a firm criterion here - ruling those out as instances of rationality - might come back to bite in the context of what following a rule isn’t: ie being gripped by a self-interpreting interpretation of a general rule.)

More generally, a few years ago when the INPP conference was organised by Gerrit Glas in Leiden I noticed the rise of ‘three e’ approach to the philosophy of mind within analytic philosophy: embodied, embedded, enactive. This year there has been a similar emphasis from within the phenomenological tradition on the role of the person and claims about the both upwards and downwards causation and the role of intersubjectivity in characterising individuals.

Over a coffee, Dariusz Galasinski expressed the worry that this might simply be a kind of cloak. Although presenting a comparatively rich picture of the person, the fact that it is still biologically based might be enough to justify, eg, drug interventions although now described as intervening in an embodied person rather just a body.

I didn’t have that suspicious reaction. But I have felt the lack of a right to this sort of approach. There’s been no reductionist opposition, no scrapping a satisfactory result of which would have given the picture some justification.

I have left until last one solitary but important session: the first at an INPP conference (I am told) organised by a mental health service user group. Jan Verhaegh, Service User Activist and member of the European Network of (ex) Users and Survivors of Psychiatry (ENUSP), held a workshop to address a number of questions but mainly how mental health service users, clinicians and philosophers could be brought into useful dialogue. It was pointed out by one member of the group that this discussion was held in a tiny windowless room in the basement whilst all the more luxurious rooms were occupied by other, obviously non mental health service user led, discussions. So, at the very least, one might aim for a higher priority in the future.

I can say that this is one of the aims for the next INPP conference in Manchester next year, organised by UCLan in conjunction with ENUSP. At the same, I also worry a little that we had better make the dialogue positive for all concerned otherwise the clinicians we would most want to engage may simply not come out of a kind of professional anxiety.

My own presentations are here: on the uncanny; on recovery; and on diverse logics.

Sunday, 18 October 2009

Research @ ISCRI

I’ve been trying write the organisational cv for part of my school at UCLan: ISCRI (the International School for Communities, Rights and Inclusion). The challenge is to try to put as succinctly as I can the two dimensions of overlap that characterises it.

At the level of research methods, ISCRI has three overlapping approaches:

1) a practically innovative but theoretically minimal (ie adopting no particular social science research method) approach to community engagement. The approach is ideological rather than theoretical: the communities researched are treated as partners in the research, subjects for rather than objects of, perhaps.
2) a psycho-social research method. Not only is the interaction of the psychological and social of interest but it is (often) approached according to models drawn from the psycho-therapeutic literature.
3) philosophical, phenomenological and conceptual research: the kinds of issues researched are philosophical as much as they are empirically complex and thus conceptual clarification is a necessary aspect of inquiry.

At the level of research subject, the broad concerns are with the nature and norms governing community interaction and cohesion. This might vary from a bespoke inquiry into the needs of a particular and perhaps excluded social community (an ethnic grouping in a particular northern town) to the fundamental norms that should guide our interaction with the natural environment as a whole. (My own research in philosophy of mental healthcare connects to this agenda through understanding the interactions between clinicians and service users. Of course, not everything I do, nor others within ISCRI, fits this. But it a shared central area of research.)

Discussing this yesterday with David Morris (pictured), of NSIP, he asked what role philosophy could have in his own work for social inclusion. I should add that, as an elder of the Institute for Philosophy, Diversity and Mental Health at UCLan, he asked this with a twinkle of the eye (the same ocular twinkle which, together with his silver locks, strongly suggests that he will be giving us his Father Christmas in many an ISCRI panto to come).

David’s work concerns not just issues of social inclusion but also ‘recovery’, construed along the lines of the recovery model in mental health. David expressed an interest in the question of whether intervention (via social policy) aimed at individual recovery was likely to increase inclusion at community level. (Not an a priori truth, it seems to me.) But this, immediately, prompts philosophical as much as empirical questions. What conceptions of inclusion and recovery are in play? And even if one is thought of as a matter for individual subjects and the other for communities, can social inclusion be thought of as individual community recovery?

But more interestingly, if the uber value at the heart of recovery/inclusion is autonomy, and if policy aimed at inclusion aims to track the particular values of individual subjects or communities, is this just a matter of preference satisfaction? And, if so, this prompts the question of the status of those particular values. Surely any decent model of inclusion should include a role for a normative investigation of the values espoused?

(An example: very few people from the Asian sub-continent visit the Lake District National Park despite significant populations within striking distance. Now, there may be active barriers preventing this. But it might also be the result of a lack of education as to just how beautiful and accessible the Park is. And if so, policies for inclusion should challenge those values that help block the thought that the Park is a natural place to go.)

Thus one ought to augment any evaluation of the success of policies of social inclusion with a critique both of individual values and of the models of inclusion and evaluation in play.

David expressed some worry that this might result in direct criticism of the policies. Whilst I am not sure why that would be a problem, if policy agencies are such delicate creatures, one might simply provide a kind of conceptual articulation of the explicit and implicit models being used, the assumptions and values on which they are based, and how other possible assumptions might lead to other possible models. Either way, I can’t see how one could attempt seriously to assess social inclusion without hiring a philosopher for, say, half a day a week at professorial rates.

PS: One result of this lunch time chat was this presentation at Lisbon, and thus this draft paper.

Thursday, 15 October 2009

INPP 2010 @ ISCRI Manchester

As I may have mentioned, ISCRI, my School within UCLan, is hosting the INPP (International Network for Philosophy and Psychiatry) conference in Manchester next June (so less than a year away).

Here is the first call for abstracts.

This is the website:


Jean Tinguely at the Liverpool Tate

On the way to the excellent production of the Caretaker at Liverpool’s Everyman theatre on Saturday I called in to see the Jean Tinguely exhibition at the Liverpool Tate.

Co-curated by Michael Landy, the chap who, rather irritatingly, destroyed all his possessions in a disused C&A shop on Oxford St, the first part of the exhibition shows Tinguely’s sometimes rather delicate and spindly machines and others which playfully rearrange the elements of Russian formalist art destroying by slow rotations the original’s essential right angles. These give way, however, to méta-matic machines which produce, via random motion, paintings or drawings, like giant spirographs.

The focus of the exhibition is, however, a particular one off art event in New York in 1960: his Homage to New York. Tinguely constructed a kind of sculpture from pots and pans, a bathtub, percussion instruments, a weather balloon and a piano apparently chaotically, or perhaps merely intuitively, engineered into a larger structure connected by cables and pulleys. The machine included substructures such as a méta-matic and at least two smaller vehicles which were supposed to emerge from it reminding me of the way the head of the corpse grows spider’s legs and scuttles away in a key scene in John Carpenter’s The Thing. One such, the suicide chariot, was supposed to take itself off and ‘drown’ itself in a nearby pond.

Anyway, the idea was that the machine would be put into motion and a number of processes and events would occur in some sort of sequence. But, and this is the connection to Landy, it would end when the machine destroyed itself with gunpowder and petrol after 27 minutes. (In fact most things seem not to have worked and so the final destruction had to be an anti-climactic assisted suicide after a couple of hours.) Still, little of the machine survives except fragments and the event was merely partially successfully captured on two films, both of which are shown.

What struck me was the difference between art event witnessed in New York in 1960 and the exhibition in Tate Liverpool now.

The former was supposed to be a one off, akin to the claim in Windelband:
[E]very interest and judgment, every ascription of human value is based upon the singular and the unique… Every dynamic and authentic human value judgment is dependent upon the uniqueness of its object. [Windelband 1980: 181-2]
Nothing from the machine itself was supposed to escape the city dump (its origin and telos).

The latter has no temporal aspect: it’s a potentially permanent display and, aside from a couple of fragmentary remains, is multiply reproducible. And yet it is billed, not as education about an art experience (from 1960), but an art experience itself. Odd.

Windelband, W. (1980) 'History and natural science' History and Theory & Psychology 19: 169–185

Sunday, 11 October 2009

Mind and World as transcendental anthropology?


Mind and World is a work of therapeutic philosophy. It rejects systematic and theoretical answers to the questions it raises about mind and world, norms and nature. Instead it aims to address the hidden assumptions that lead to those puzzles rather than respond to them on their own terms.

It is, however, an unusual work of therapeutic philosophy in that it is not merely destructive. It does not only aim, in Wittgenstein’s phrase, to destroy the ‘houses of cards’ that past philosophers have erected. In addition to such destructive criticism, it also draws on the philosophical canon in a positive way to set out descriptions of human nature and practice through a kind of anthropological perspective. But how, in that case, can an anthropological perspective be reconciled with a therapeutic aim? What kind of philosophical insight does Mind and World offer?

In this chapter I examine this question in the light of McDowell’s relation to the work of Jonathan Lear’s description of Wittgenstein’s Philosophical Investigations as a form of transcendental anthropology. For simplicity, I focus on the particular insight that McDowell aims to offer into the nature of norms or normativity since that lies at the heart of Mind and World and is central to Lear’s account of Wittgenstein.

Lear’s account of the harmony between anthropological and transcendental philosophy is sustained by two threads, one homely and one radical. Following McDowell’s explicit criticism, I will argue that Lear mars his plausible first strand with an implausible second. But Mind and World also contains implicit criticism of Lear that threatens this homely line. In the final section of this chapter, I will argue that it is better to distinguish rejection of an endogenous factor from rejection of the endogenous Given. Rejecting the latter leaves a plausible role for an anthropological aspect to therapeutic philosophy.


For the purposes of this paper, there are two key discussions in Mind and World. The main theme of the first three lectures is, roughly, the role of experience in enabling intentionality or, more accurately, to block obstacles to viewing this role correctly, obstacles which threaten to make intentionality mysterious. This account of the role of experience is present within a broadly Kantian picture of nature.

The key theme, for my purposes, of lectures 4-5 is the nature of norms and normativity and their place in nature. In so locating norms, Mind and World might be described as ‘naturalising’ normativity providing that that term is not understood reductively.

These two key discussions fit together in the following way. McDowell suggests that the claim that experience has a central role in a satisfactory account of intentionality is a minimal and uncontentious philosophical starting point. He says (elsewhere):

I do indeed take transcendentally motivated empiricism to be innocent…[It] belongs among my commitments. [McDowell 1998: 405]

Although the thought that experience has a transcendental role for intentionality is supposed to be innocent, it is obscured by an unhelpful view of nature which excludes normativity. To play its transcendental role, according to the argument of the first lecture, experience, or experiential openness to the world, must be normatively connected to judgements and, for that to be unmysterious, must itself be conceptually structured. The content of experience must thus be both conceptually structured but also a form of direct openness to the world and the presence of conceptual norms seems to make this impossible. Using the idea of ‘spontaneity’ to refer to the faculty responsible for conceptual judgement, McDowell says:

But it can seem impossible to reconcile the fact that sentience belongs to nature with the thought that spontaneity might permeate our perceptual experience itself, the workings of our sensibility. How could the operations of a bit of mere nature be structured by spontaneity…?What is at work here is a conception of nature that can seem sheer common sense… [McDowell 1994: 70]

Thus, to disarm a threat to an account of how experience can play a transcendental role, McDowell has to provide an account of normativity which shows how it can be a part of nature. Or rather, he has to show why no substantial account is necessary once some distorting assumptions are rejected. Hence the two themes – the role of experience and place of normativity - are interdependent. It is only because of a prejudice about the nature of normativity that excludes it from a place in nature that the transcendental role of experience is threatened. Or so, at least, McDowell argues. Thus the insight into normativity provided by lectures 4-5 is necessary to complement the transcendental role of experience described in lectures 1-3.

What kind of insight into normativity does McDowell then aim to provide? He explicitly rejects attempts to reduce norms to more basic notions as ‘bald naturalism’ [McDowell 1994: 73]. Instead he aims at a ‘dualism-debunking and problem-dissolving’ piece of therapeutic philosophy [McDowell 1994: 154]. But, within a broadly therapeutic conception of philosophy, there appear to be two strands at work in Mind and World. One strand is exemplified elsewhere by Wittgenstein’s remarks:

Where does our investigation get its importance from, since it seems only destroy everything interesting, that is, all that is great and important?... What we are destroying is nothing but houses of cards… [Wittgenstein 1953 §118]

and also by his famous marginal remark where after transcribing a music theme he comments:

That must be the end of a theme which I cannot place. It occurred to me today as I was thinking about my work in philosophy & said to myself: “I destroy, I destroy, I destroy—” [Wittgenstein 1984: 21e]

On this approach, therapeutic philosophy plays a purely critical role. Its purpose is to undermine fallacious substantial philosophical theories by, for example, pointing out internal inconsistencies. In so doing, it can discharge its premises. An example of this in Mind and World is McDowell’s criticism of the Myth of the Given which cannot perform its intended role of grounding thought in experience.

Mind and World is not simply destructively therapeutic, however, but often involves an anthropological and descriptive aspect. It advances substantial positive descriptions drawn from the philosophical canon. Thus, for example, the idea of second nature is introduced by the following substantial account drawn from Aristotle:

The best way I know to work into this different conception of what is natural is by reflecting on Aristotle’s ethics… For Aristotle… virtue of character...includes a specifically shaped state of the practical intellect: “practical wisdom”… This is responsiveness to some of the demands of reason… The picture is that ethics involves requirements of reason that are there whether we know it or not, and our eyes are open to them… so practical wisdom is the right sort of thing to serve as a model for the understanding, the faculty that enables us to recognise and create the kind of intelligibility that is a matter of placement in the space of reasons. [McDowell 1994: 79]

In this passage, McDowell uses Aristotle’s discussion to recommend a particular view of what is natural. It is natural to be able to respond to demands that reason makes of us, demands that are there whether we know it or not.

It might be that this is set out simply to remind the reader of a neglected option which, perhaps with the elimination of all other options, is all that remains to think. But it would be implausible to think that such exhaustive elimination is the general approach of the work. Instead, it seems that the reminder itself is put forward as descriptively plausible in its own right.

This, then, prompts the question of the status of such descriptions. How can an anthropological element be part of a therapeutic conception of philosophy? There seem to be three interpretative options. One can construe Mind and World as:

· wholly negatively therapeutic, debunking dualisms etc. and putting forward nothing in an anthropological mood.
· Quinean, asserting general empirical truths continuous with empirical science, there being no separation between necessary and analytic truths to maintain a distinct philosophical mood.
· in some way yet to be determined, both therapeutic and anthropological, charting substantial a priori claims.

As I have already suggested, whilst much of Mind and World is critical, the first option does not fit the whole of the text. The second is undermined by a passage in the ‘Afterword’ in which McDowell suggests that the rejection of scheme-content dualism of lecture 1 need not commit one to Quine’s attack on analyticity.

The suspect notion of the analytic is the notion of schemes in the suspect sense, the sense in which schemes are conceived as dualistically set over against the world…. [W]hen we reject the dualism of scheme and world, we cannot take meaning to be the stuff of schemes, on the dualistic conception of schemes. But this does not deprive us of the very idea of meaning. So if I am right that Quine’s insight is really a glimpse of the unacceptability of the dualism, perhaps we can rehabilitate the idea of statements that are true by virtue of their meaning, without flouting the real insight.

If, as I suggested, the notion of a conceptual scheme need not belong to dualism, meaning can constitute the stuff of schemes in an innocent sense. We can reject the two factors without threatening the idea that there are limits to what makes sense: that our mindedness, as Jonathan Lear puts it, has a necessary structure. The idea of a structure that must be found in any intelligible conceptual scheme need not involve picturing the scheme as one side of a scheme-world dualism. And analytic truths (in an interesting sense, not just definitionally guaranteed truisms such as “A vixen is a female fox”) might be just those that delineate such a necessary structure.
[McDowell 1994: 157-8]

In this passage, McDowell rejects Quine’s attack on analyticity and thus rejects the second option above. But in so doing, and in thus preserving the idea of truth in virtue of meaning alone, he also suggests a clue for filling out the third option. There could be analytic truths of the sort that Jonathan Lear describes.

In the next section, I will consider the potential of a connection to Lear’s work. Lear suggests that a combination of anthropological and transcendental elements is present in Wittgenstein, especially his discussion of rules or norms. If his account of transcendental anthropology is successful, especially given McDowell’s debt to Wittgenstein, it might shed light on Mind and World.

Lear’s transcendental anthropology

Jonathan Lear argues that Wittgenstein’s discussion of norms has two aspects: transcendental and anthropological.

The transcendental aspect aims at non-empirical insight. Starting with the Kantian idea that a ‘transcendental argument for X is concerned with establishing the legitimacy of X [Lear 1984: 223]’, Lear suggests that that definition should be broadened and weakened: ‘so that a non-empirical inquiry into rule-following counts as a transcendental investigation’ [Lear 1986: 270].

The anthropological aspect consists of empirical descriptions of human nature and practices:

The anthropological stance would seem to encourage a naturalistic outlook: ‘What we are supplying’, says Wittgenstein at one point, ‘are really remarks on the natural history of human beings; we are not contributing curiosities, however, but observations which no one has doubted, but which have escaped remark only because they are always before our eyes.’ [Lear 1986: 268]

Although Lear thinks that Wittgenstein’s discussion contains both aspects, he also thinks that they are in tension, both with each other and with other explicit aspects of Wittgenstein’s claims about philosophy. Crucially, the anthropological approach threatens to turn a philosophical discussion of norms into an explanation of them and that violates Wittgenstein’s separation of philosophical and explanation. Further:

[I]t would threaten Wittgenstein’s repeated demand that philosophical reflection should leave our practices and customs intact… Why should we not come to view the law of non-contradiction as merely one of the deeply held tribal beliefs of our tribe? [Lear 1986: 270-1]

Lear suggests that the Philosophical Investigations remained an incomplete work because Wittgenstein was never able to work through the full consequences of interaction of these two approaches. Nevertheless, he thinks that a model of philosophy as transcendental anthropology is possible given two claims he draws from Wittgenstein’s discussion of rules or norms: the first homely, the second radical.

First, non-empirical, and thus transcendental, investigation of what might come to mind shows that grasping a rule or norm cannot consist of entertaining any kind of a mental image or inner sign or speech or other kind of talisman. The ‘individual’s inner experience cannot endow his practical ability with normative content’ [Lear 1984: 235]. And thus the result of a piece of critical reflection suggests instead a need to look outwards to practices to grasp the nature of rules or norms. The anthropological description of norms is justified by the transcendental investigation of what can and cannot come to mind.

Second, and more radically, Lear proposes a strong, although complex, connection between the content of rules or norms and our ‘mindedness’. Mindedness is defined in terms of ‘shared perceptions of salience, routes of interest and feelings of naturalness’ and thus rightly studied through an anthropological perspective. But it is also what conditions our concepts, rules or norms. The conditions of possibility of our thought have an ‘essential relation to our mindedness’ [Lear 1984: 238]. Thus the anthropological perspective is in service of a transcendental inquiry into norms.

This latter connection is, however, a difficult one. The appeal to the idea of mindedness must avoid both tautological vacuity but also making a substantial but false empirical claim. Lear suggests that he can avoid the first because in appending “We are so minded” to our thoughts - so as to demonstrate what conditions them - we make a substantial and synthetic claim [1984: 229]. He attempts to avoid the second by arguing that our mindedness is not merely one sort among many possible.

Considering the question of what 7 + 5 equals, Lear suggests that there are two possible answers. Either 12 or ‘anything at all, just as long as everyone is so minded’. The first is the correct answer but:

After studying the later Wittgenstein, one is tempted to say that [the latter] also expresses some sort of truth. But it is important to realise that [it] does not express an empirical truth. [Lear 1982: 385-386]

It is not an empirical truth because that would licence counterfactuals of the form: 7 + 5 would equal something other than 12 had we been other minded:

But these counterfactuals cannot for us express real possibilities; for the notion of people being other minded is not something on which we can get any grasp. The possibility of there being persons who are minded in any way at all is the possibility of their being minded as we are. [ibid: 386]

He suggests that this transformation is a modal gestalt shift:

In one gestalt, one becomes aware that there is nothing to guarantee one’s continued correct language use beyond the fact that one happens to share with one’s fellow man routes of interest, perceptions of salience, feelings of naturalness etc. From this perspective, one’s continued hold on the world appears the merest contingency... As the gestalt shifts, one comes to see that there is no genuine possibility of having fundamentally different routes of interest and perceptions of salience, for that is the spurious possibility of becoming other minded. The illusion of possibility is engendered by considering our form of life as one among others. [ibid: 386]

Thus, on reflection, the ‘we are so minded:’ cancels out. Mindedness is not a part of the empirical world but is a limit concept.

Philosophy is substantial and non-empirical because it investigates the conditions that our mindedness imposes on our language and our world. It is not continuous with empirical investigation because our mindedness is not one among others. The very idea of an alternative to being minded as we are makes no sense. Explicating how mindedness can underpin substantial philosophical insight, however, requires some qualification of Lear’s attitude to the modal gestalt switch. Mindedness must be made sufficiently vivid that it can condition our world but must not lapse into an anthropological, empirical, ‘one among many’ notion.

Is Mind and World transcendental anthropology?

Although, in the passage I quoted earlier, McDowell expresses approval for the idea, which he attributes to Lear, that our mindedness has a necessary structure, he advances both explicit and implicit criticism of the picture Lear himself proposes to sustain that idea. The explicit criticism focuses on the idea that the discussion of a necessary structure helps to vindicate our norms.

[T]he disappearance of the “we” should not take on the aspect of a reassurance, but should rather figure as part of the reason why a reassurance should never have been needed. “How we go on” is just our mindedness, which is ex hypothesi in constituted harmony with our world; it is not something that constitutes the harmony, as it were from outside. [McDowell 1994: 159]

On Lear’s picture there is a residual element of transcendental idealism. Although he appears to reject the link, summarised in the first gestalt above, between our logic and mathematics and our mindedness, he really rejects a reading of this position which makes logic depend on a contingent ‘one among many’ kind of mindedness. It remains philosophically important that one can have the insight this describes when construed as a gesture towards transcendental idealism. But this construal can only be made manifest or shown. It cannot be said.

Why must philosophy be done by pointing? Because we cannot step outside our form of life and discuss it like some objet trouve. [Lear 1982: 385]

The difference between Wittgenstein and the conventionalist can be summed up as follows: the conventionalists state a falsehood; Wittgenstein tries to point beyond to a transcendental insight. [Lear 1982: 387]

McDowell attempts to undercut this picture by suggesting that the notion of mindedness is not sufficiently independent of what it is supposed to underwrite. Because it is introduced through the idea of shared perceptions of salience, routes of interest and feelings of naturalness, it cannot at the same time explain or constrain those notions.

McDowell’s actual remarks here suggest that Lear’s main focus is on empirical concepts and a harmony between those concepts and the empirical world. This does not fit so happily the latter’s concentration on logical and mathematical concepts. But McDowell’s point can be extended to criticise the legitimacy that Lear seeks for our logical or mathematical rules by ruling out other ways of going on. McDowell’s criticism complements the worry that Lear merely illicitly attempts to keep both aspects the modal gestalt in play. Without at least a glimpse of other ways of going on, then our ways cannot be legitimated over other possibilities. But anything more than a glimpse threatens to undermine that legitimation by undermining the necessity of our ways of going on.

This explicit line of criticism, however, undermines the second and more radical strand of Lear’s account of the relation between anthropological and transcendental. It undermines the role of mindedness in constraining thought and thus underpinning the ‘interesting analytic truths’ that philosophy can investigate. But in addition to this criticism, McDowell offers a second implicit line of criticism. In addition to undermining Lear’s second, radical, strand this also threatens the first more homely strand and thus threatens the possibility of analytic truths rather than just a substantial explanation of them.

McDowell’s explicit criticism is complemented by a general hostility throughout his philosophy to a ‘sideways on’ perspective on concepts and practices In Mind and World, rejecting the sideways on perspective is connected to a central idea: the rejection of scheme-content dualism, a dualism of endogenous and exogenous factors.

If we embrace the picture I recommend…, in which the conceptual realm is unbounded on the outside, we make it unintelligible that meaning’s impact on determining what we are to believe is endogenous as opposed to exogenous. (Not that it is exogenous instead; the need to make this kind of determination simply lapses.) [McDowell 1994: 157]

On McDowell’s picture, the conceptual realm cannot be separated into a dualism of scheme and worldly content, or endogenous and exogenous factors. McDowell claims that one can still have analytic truths even without a factoring their explanations into endogenous and exogenous: ‘We can reject the two factors without threatening the idea that there are limits to what makes sense: that our mindedness, as Lear puts it, has a necessary structure.’ [McDowell 1994: 158] This does not address the following worry, however. With the dualism of scheme and content in place, there is a putative explanation of substantial necessary truths: features of the conceptual scheme or the endogenous component of thought. Without the separation of two factors, it is not clear how interesting analytic truths can be stabilised into slippage into a merely Quinean picture of the web of belief. Without some notion of an endogenous by contrast with an exogenous factor, how can McDowell’s invocation of meaning and a necessary structure be distinguished from the Quinean picture of language?

One suggestion to address this worry is made in a footnote. Of analytic truths that delineate a necessary structure McDowell suggests ‘Perhaps this is the category in which we should place at least some of the ‘hinge propositions’ to which Wittgenstein attributes a special significance in On Certainty’ [McDowell 1994: 158 fn 35].

This suggestion has two virtues. First, according to Wittgenstein’s account, ‘hinge propositions’ such as ‘this is a hand’ are not, as Moore supposed, examples of certain knowledge. Rather, they help to determine the rules that govern the limits of the game of asking for and giving justifications.

Thus, my certainty regarding, say, the judgement ‘This is a hand’ is to be seen as a pre-epistemic attitude that is in part constitutive of my practical ability to speak the language. the judgement that this is a hand is not a piece of knowledge – a true, justified belief, based on evidence – but an authoritative expression of my established mastery of English. [McGinn 1989: 144]

Whilst the middle period Wittgenstein stressed the prescriptive and sense-determining role of grammatical rules (such as that there is no such thing as reddish green; pink is lighter than red; 2 + 2 = 4), the later Wittgenstein extended this role to apparently empirical propositions which, despite their appearance, are not strictly propositions at all because not capable of truth and falsity. [Moyal-Sharrock 2007].

Second, despite this sense determining role, charting hinge propositions looks to be a suitable role for an anthropological stance. Describing what an individual or community hold certain is a substantial, non-vacuous description.

Despite these virtues, the suggestion is not as helpful as it first appears. First, McDowell suggests merely that at least some hinge propositions might serve as a model of necessary structure reflecting analytic truths without specifying which. Second, whilst hinge propositions have a sense determining role they seem far from capable of describing the ‘necessary structure’ of ‘any intelligible conceptual scheme’. This is because they include very many contextual and even personal factors (such as grasp of one’s own name). It is the grammatical prescriptions of middle period Wittgenstein rather than the motley that make up On Certainty’s hinge propositions that best serve that purpose.

Thus whilst McDowell’s explicit criticism of Lear merely threatens his more radical account of mindedness, the implicit criticism also threatens the very idea of conceptual truths which, according to a non-Quinean view, philosophy can chart.

Rejecting the endogenous Given

The threat of the slippage into a merely Quinean picture is the result of the rejection of a two factor model with endogenous and exogenous elements. Denying that distinction undermines the notion of truths true in virtue of meaning alone. But there is another option available by making only a small change to the official account in Mind and World.

In escaping the oscillation between, on the one hand, coherence theories in which there is no friction on thought imposed by contact with the world and, on the other, the Myth of the Given which attempts to ensure such friction but, impossibly, from outside the space of reasons, McDowell does not reject the idea of an exogenous constraint on thought (as coherence theories do). He merely rejects the idea that such constraint takes the form of something Given in accordance with the Myth. What does that amount to? Recently, McDowell has put forward the following short summary of Givenness.

Givenness in the sense of the Myth of the Given would be being given something for knowledge without needing to have capacities that would be necessary for one to be able to know it. [McDowell 2008: 1]

Thus the idea of the exogenous Given can be rejected without threatening the idea that contents can be given in an anodyne sense in empirical experience providing that what is so given does not outstrip the subject’s conceptual capacities. That is to restate my brisk earlier summary of a key claim in lectures 1-3. I suggest, however, that a similar moral applies to the endogenous factor which contributes to a conceptual scheme. Rejecting the idea of the endogenous Given need not threaten the idea of an endogenous factor.

Suggesting that the right response to Lear is to reject the endogenous Given requires a delicate balance: characterising what such a notion involves without violating its nonsensicality. But the idea that thought might be constrained by an endogenous Given is not unfamiliar. In Lewis Carroll’s dialogue between the Tortoise and Achilles, Achilles attempts to persuade the Tortoise to accept the truth to the conclusion of an argument at first by accepting, as additional premises, the principles governing a series of lengthening arguments. When this fails he invokes a version of the endogenous Given: logic itself, independently of the Tortoise’s understanding of logical consequence must surely compel him.

Achilles joyfully exclaimed, as he ran the pencil into its sheath. “And at last we’ve got to the end of this ideal race-course! Now that you accept A and B and C and D, of course you accept Z.” “Do I?” said the Tortoise innocently. “Let’s make that quite clear. I accept A and B and C and D. Suppose I still refused to accept Z?” “Then Logic would take you by the throat, and force you to do it!” Achilles triumphantly replied. “Logic would tell you ‘You can’t help yourself. Now that you’ve accepted A and B and C and D, you must accept Z!’ So you’ve no choice, you see.” [Carroll 1985: 279-80]

Achilles attempts to block the Tortoise’s scepticism not by examining the Tortoise’s reasoning capacities but by appeal to a constraint simultaneously neither exogenous (and thus, instead, endogenous) nor, however, within the limits of reasoning capacities. Logic is supposed to impose a constraint independently of the Tortoise’s own conceptual understanding. But there can be no such endogenous Given.

Lear’s invocation of mindedness is similarly illicit. It is supposed to constrain our ways of going on, again both independently of the empirical world but also outside our conceptual capacities, thus vindicating them. McDowell’s explicit criticism of Lear can be cast as a rejection of the endogenous Given and distinguished from his implicit criticism based on the two factor view.

This leaves room for a non-Quinean view of philosophy. In accordance with Lear’s first homely strand of thought, the anthropological stance is needed to chart the content of rules which structure human language and practices. It thus charts the interesting analytic truths which form an endogenous constraint on what we can think and which can be philosophy’s special domain but without running the risk of Givenness.


Carroll, L. (1895) ‘What the Tortoise Said to Achilles’ Mind 4: 278-280
Lear, J. (1982) ‘Leaving the world alone’ Journal of philosophy 79: 382-403
Lear, J. (1984) ‘The disappearing ‘we’’ Aristotelian society supplement 58: 219-258
Lear, J. (1986) ‘Transcendental anthropology’ in Pettit, P. and McDowell, J. (eds) Subject thought and context, Oxford: Clarendon
McDowell, J. (1994) Mind and world Cambridge Mass.: Harvard University Press
McDowell, J. (1998) ‘Precis of Mind and world’ and ‘Reply to commentators’ Philosophy and phenomenological research 58
McDowell, J. (2008). ‘Avoiding the Myth of the Given’ in Lindgaard, J. (ed.). John McDowell: Experience, Norm, and Nature, Oxford: Blackwell pp 1–14
McGinn, M. (1989) Sense and Certainty, Oxford: Blackwell
Moyal-Sharrock, D (2007) Understanding Wittgenstein’s On Certainty, Basingstoke: Palgrave Macmillan
Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell
Wittgenstein, L. (1984) Culture and Value, Oxford: Blackwell

Thursday, 8 October 2009

Determining best interests

A group of us (within ISCRI at Uclan) are putting together an interdisciplinary bid on the determination of best interests for people who are deemed to lack the capacity to make a relevant decision under the mental capacity act. The act itself is accompanied by a code of practice which gives advice on the factors that should be taken into account (by clinicians, eg.) to work out what is in someone’s best interests and also what is ruled out. But, perhaps obviously, such judgements can only be codified to a certain extent.

Whilst the main thrust of the research proposal is empirical, the very idea of the ‘determination of best interests’ is laced with philosophical issues. Just what is meant by best interests? What constraints (a priori vs. a posteriori; individual versus universal; subjective versus objective; normally governed by first person privilege or not; constituted by or reflected in judgements) govern it and how do these affect judgements or determinations of it?

The main thrust of the proposed study is empirical, however, because there is an important practical question of how such judgements are actually being made, whether in accord or not with the code of practice, and using what kind of interpretation of the guideline factors in actual contexts. But this is one of those areas where some a priori idea of the range of possible ideas and values in play looks important to shape, and then later be shaped by, the empirical inquiry. The philosophical inquiry also looks to offer some sort of normative judgement not just of how such determinations are being made but whether those could be effective ways of tracking a person’s best interests.

Anyway, my being a philosopher was my justification for contributing to the philosophical thread running through the bid. But I was also impressed by the way ideas for methods of conducting the more empirical aspects were considered. Should we follow clinicians and other professionals or patents and clients? And given that, how many cases would be needed to have good data? Such questions have ideological aspects. For patient centred care we should naturally favour following patients.

But such ideological aspects might easily be trumped by practical consequences for timescale (smaller numbers of cases but each with several judgements of best interests vs. many synchronic judgements), miles to be travelled and time spent in distinct requests for ethical clearance. There was also a question of validity: how many cases would be needed to get reliable data? What struck me was how tricky that question seems for richly detailed qualitative social science (not just a matter of confidence intervals and chi square tests as for quantitative data). ‘Oh about 15’ was the accepted answer to one such question ‘That seems about right’. That, I understood was the number that past experience of this kind of inquiry, with these kind of questions, suggested was needed to get the same answers repeating. How delightfully a matter of skilled judgement even the empirical aspect of the research promises to be.

Monday, 5 October 2009

Oxford Handbook of Philosophy of Psychiatry

I’m rattling back on the train from Oxford from a planning meeting organised by Bill Fulford for the Oxford Handbook of Philosophy of Psychiatry. (One can just about day trip using the 6:20am train out and getting back around 9:30pm.) Twenty or so academics (including Givoanni Stanghellini, Werdie van Staden, the Matthews: Broome and Ratcliffe, Rachel Cooper, Lisa Bortolotti, Richard Gipps, Gerrit Glas, (pictured)), mainly philosophers, from Europe, South Africa and the USA came to Oxford and a few joined in by phone.

Martin Davies described being recruited onto the project by Bill Fulford. Thinking along the lines of the philosophy of psychology with which he is very familiar, he had assumed that such a book would be planned by writing down the agreed problems or areas which made up the subject and then commisioning the agreed experts. He was thus surprised when Bill said that there wasn’t that degree of consensus in our subject. Thus the aim of today’s perhaps otherwise eccentric meeting - just think of the opportunity cost! - was to attempt to address that issue. (At the very least we need ways to manage the dissensus.)

One initial finding concerned the opposition between a book structured around a series of problems and one ‘chunked’ by broader subject areas (as my own slim book is). As a matter of fact, there was some agreement at least on possible subject headings but almost none about an orientation around some key problems. We will discover in the next few weeks whether there’s agreement at the lower level of individual chapter topics or problems. There may be. It may be that the problem comes one level up at the length of chunking 50 chapters into a handful of areas.

Martin Davies also suggested that if, as had been suggested, psychiatry is unified at the level of practice rather than through a single science (perhaps by contrast with, say, cognitive psychology) the book should adopt something like the clinical process as its unifying structure. At Warwick the locally taught philosophy of mental health course did just that for one term, weaving together aspects of the philosophy of science and values. What I now realise more than I did then was that such an approach would have to be balanced by some realisation that such a medical process is already to assume something about the nature of the right response to mental distress. (That isn’t to say it couldn’t form the heart of the book but it would need augmentation.)

That point suggests another. The issue that seemed to me to be least present today (in a group of philosophers with perhaps a bias towards philosophy of mind) was a sense of the significance of the mental health service user movement. As I’ve pondered before: in a philosophy of psychiatry book not just any such representation would be appropriate. (It is not the handbook of the politics or sociology of psychiatry, for example.) But there’s a danger that this other key difference from the philosophy of cognitive psychology might go missing.