Thursday, 8 January 2015

Particularism and personalised medicine workshop, MMU

I have been at a two day workshop at MMU on Particularism and Personalised Medicine organised by Anna Bergqvist. Anna herself gave a paper outlining a friendly criticism of Values Based Practice. She suggested that VBP shares with moral particularism a distrust of the importance of deduction from principle (what Bill calls ‘quasi-legal medical ethics’). But, as I am, she was suspicious of its proceduralism which risks a kind of subjectivism. But her specific focus concerned the important role of narrative in setting out points of view but only under the right understanding of it. Summarising the main worry, she argued that current thinking seems to assume that the significance or meaning of symptoms in decisions about treatment and management of illness is fixed by either scientistically in light just of the evidence from ‘above’, as it were, or by a kind of viewer narrative construction. The meaning is determined by persons autobiographic narrative. Borrowing on work by Peter Goldie, Anna suggested that stressing the role of narrative need not be confused with thinking of lives, or people, as themselves narratives. There is a difference between a narrative and what the narrative presents. The narrative can reveal or obscure the meaning of a symptom but does not determine it. Instead it is an aid to the discernment of the normative significance of features of the situation.

In the end I wasn't entirely sure whether the appeal to narrative introduced a fresh criticism of VBP above the general worry about subjectivism or whether it was a way of filling out the form of that worry in a different way. Assuming we agree that narratives are ways of charting moral reasons, the difference between radical VBP and particularism will also play out in their differing construal of narratives.

Ben Smith raised some questions about what sort of position particularism is. For example, an ontological or epistemological thesis? A positive or a negative thesis about the nature of moral reasons? A reaction against a dominant form of generalism or principlism or, if it is to be found in Aristotle, an articulation of an orthodoxy? He suggested that one clear lack was a coherent account of the epistemology of particularism including the nature of the judging subject: the person. But persons are also key as the ‘object’ of moral judgement. As a contribution to sketching an account of persons he described the role of trust in human relations. The key claim was that there was a kind of preconceptual, pre-reflexive notion of trust which served as a precondition for any explicit, contractually established trust relations. Loss of such trust was a feature of depression.The moral seemed to be that if such basic trust is a key feature of human relations, playing a transcendental condition, and if it is below the level of and presupposed by reason-relations, then any form of particularism based on moral reasons is wrong. 

I am not entirely sure of the force of this argument and offered him, over coffee, the following analogy. In epistemology, one might think that knowledge is matter of having the right reasons (much will need to be specified about them, of course). But the possibility of giving reasons plausibly presupposes that reasons come to an end in something which is not supported by reasons: perhaps, Wittgensteinian animal certainties. Still such a precondition would not refute the idea that knowledge is a matter of reasons. It would just show that there were some preconditions of being able to play that game. Perhaps the same applies to particularism about reasons. Ben seemed happy enough with this: such reason-based particularism isn't necessarily wrong but merely only tells part of the story. 

Phil Hutchinson spoke after me and so I wasn’t as able to take it in as when fresh. But he sketched an interesting parallel between two areas of work. His previous research into the nature of emotion suggested a way of dealing with the difference between cognitivist and neo-Jamesian accounts as being pitched at the level of the whole person but as a kind of pre-judgemental seeing-as the world in particular way. The same sort of approach now struck him as a way of thinking about the way the placebo effect works: a kind of stance to the medical intervention. But if so, placebo itself is a kind of psychotherapy. This connection was further contextualised in the thought that the rise of EBM makes it hard for any approaches that do not fit RCTs. But given its nature as the ‘other’ in RCTs, the placebo effect cannot easily be given positive support in this way. 

Anna Zielinska questioned the nature of bioethical expertise. In an introduction she criticised a widespread assumption that bioethics needs principles which she suggested might be the influence on the early bioethical thinkers of their own theological backgrounds. Even casuistry, which seems to stand in contrast to principlism, was not so take by its main proponent David Jonsen who suggested instead that it might be used to construct a principle based bioethical theory. Anna's main content, however, was an empirical investigation of the working of research ethics committees. Looking in detail first at French committees but with preliminary glances at the UK and Germany she suggested that the actual reasons deployed by ethics committees for rejecting applications did not fit any ethical framework. Even those members who explicitly espoused utilitarianism deployed quite other reasons. (Of course, for anyone who favoured principled or bioethical-theory-driven decision making, this would merely show that something was wrong with the practice of ethics committees so Anna’s prior commitment to particularism shaped the way she took this evidence: its normative force.) Her practical suggestion was that committees would thus benefit not by an attempt to develop a bioethical theory but by including the views of particularism moral philosophers.

In the final presentation, Per Nortvedt raised a worry which went something like this. Despite the force of arguments for impartiality in moral judgements, there is a prima facie case that professional roles introduce a need for a reasonable element of partiality. If I followed the line of thinking it seemed to be that capturing what was right about impartiality required principlism and what was right about partiality required particularism and hence a global objection to principlism by particularism was shown to be wrong by this case. Even after the question period I realised I had failed to grasp the nature of the worry (because I could not see why particularism versus principlism and partiality versus impartiality were not debates pitched at different levels: that either of the former approaches could embrace a version of either answer in the second debate though, of course, a particularist could not offer a general principled argument for why, e.g., an impartiality reason was always a good thing). But my blindness here was probably because it was the final paper.