Friday, 21 April 2017

Latest Association for the Advancement of Philosophy and Psychiatry bulletin

The latest edition of the Association for Advancement of Philosophy and Psychiatry newsletter from its secretary/editor and president James Phillips and Peter Zachar is now out.

It is a 56 page summary by the author, and set of commentaries from leading philosophers of psychiatry, on Peter's recent A Metaphysics of Psychopathology from MIT Press.

My own contribution (previously posted here) is included and Peter's response to it is one of his many responses. I will be keen to find out how he responded to my worry that in his attempt to police a boundary between what lay within and without experience, he said too much (by his own standards) about what lay outside it (again, on his own account). Curious also to find myself in the same camp as my colleague and friend Rachel Cooper.

Thursday, 6 April 2017

At the Hermeneutic Phenomenology Symposium at UCLan today

I was generously invited by my colleague Gill Thomson to sit at the back of a one day workshop on hermeneutic phenomenological social science at UCLan today. I have just listened to the first two talks, one (by Bridget Taylor) on sexuality and intimacy in couples with a dying partner and the other (Lesley Kay) on the views of childbirth in advance of experiencing it of expectant mothers. In both cases, the aim was to capture the thoughts and experiences of those concerned and hence both were clearly phenomenological, in the sense in which it applies to social science. Both were fascinating the the former was also rather moving.

Both were also phenomenological in a second sense. They actively drew on Heideggerian vocabulary and ideas explicitly in the analysis they offered. To take just one example, Bridget Taylor invoked Heidegger's discussion of technology as a particular attitude to the world, seeing it as offering resources in the form of 'standing reserve', in order to discuss the taking of Viagra. She suggested that light could be shed on the generally (in fact, entirely, in her study) negative views of it by participants by seeing it as involving a merely technological view of the body and the penis (seeing the body thus as merely a standing resource) in a way that undermined intimacy. Similar familiar notions such as being towards death, idle talk, the they etc were deployed in both sets of analysis.

It strikes me as interesting and quirky that Heidegger and a few other philosophers play this role of providing a vocabulary for social science analysis and the case for it this morning was that it seemed to work, in some cases, such as the viagra example, in quite striking ways. So it may be that the vocabulary receives a kind of justificatory support bottom up from such empirical work. But the vocabulary is obviously deployed top down. It is because Heiddegger wrote his essay 'On the question concerning technology' that that vocabulary became available and hence is now applied in social science.

And hence this suggests a question. Might there not be a tension between these two senses of 'phenomenology' in social science? That is, imposing a top down vocabulary from a dead German on the utterances of the living (most of whom will not have heard of him) might distort a neutral account of their take on the world, their experiences and thoughts. Wouldn't it be more phenomenological in the first sense to give up this vocabulary - unless that is that one's participants are Heideggerian philosophers - and simply to try to re-present the participants only in their own words? Replace Heidegger with the approach sketched by the Wittgenstenian philosopher Peter Winch?

Monday, 27 March 2017

Values and the singular aims of idiographic inquiry

I have been revising a presentation I prepared for a conference on ‘idiographic science’ in Naples last year. I still like the basic idea that idiographic inquiry is not so much a different form of judgement - in the way that I am unfashionable enough to think that understanding is a distinct form of judgement from explanation, that there is something in that distinction - but something seems amiss in the middle where I try to use Christoph Hoerl’s discussion of Jaspers on understanding. And can I really get away with saying so little as to what an idiographic interest is: an analogy with the Daily Express’s fascination with Lady Di?

Values and the singular aims of idiographic inquiry

Abstract

In response to the concern that criteriological psychiatric diagnosis, based on the DSM and ICD classifications, pigeon-holes patients, there have been calls for it to be augmented by an idiographic formulation [IDGA Workgroup, WPA 2003]. I have argued elsewhere that this is a mistake [Thornton 2008a, 2008b, 2010]. Looking back to its original proponent Wilhelm Windelband yields no clear account of the contrast between idiographic and nomothetic judgement. Abstracting from Jaspers’ account of understanding an idea of idiographic judgement based on the contrast between singular and general causal relations also fails. I argue, however, that Windelband does provide a helpful clue in his remark that ‘every interest and judgement, every ascription of human value is based upon the singular and the unique... Our sense of values and all of our axiological sentiments are grounded in the uniqueness and incomparability of their object’ [Windelband 1980: 182]. This suggests a role for the idiographic not as the content of a particular kind of judgement but rather as characterising its aim. I argue that this connects to the issue of the generalisability of small scale qualitative social science research and to the critique of ‘looking away’ in moral philosophy.

Key words

Causation, explanation, idiographic, interventionism, Jaspers, nomothetic, understanding, Windelband.

Introduction

The idea that psychiatric diagnosis or, more broadly, psychiatric formulation should include an idiographic element is explicit in publications by psychiatrists working on the WPA initiative Psychiatry for the Person. It forms part of the explicitly broad conception of diagnosis called a comprehensive model or concept of diagnosis. The Idiographic (Personalised) Diagnostic Formulation closely connects a comprehensive model with an idiographic component:

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]

The role of the idiographic aspect is to complement and contrast a general approach through ‘typologies and scales’ with something personal and individual. The psychiatrist James Phillips makes this individual focus explicit: ‘In the most simple terms, a[n] idiographic formulation is an individual account’ [Phillips: 2005: 182 italics added].

But this raises the following question. If an idiographic element is to be a genuine complement to general typologies and scales, what kind of understanding of an individual does it comprise? How is it different from criteriological diagnosis, for example? Although the term ‘idiographic’ has a settled use in psychological research to refer to small scale qualitative studies, that use does not explain how an idiographic element would be a genuine complement to criteriological diagnosis in psychiatry which already aims at individuals rather than general populations.

Windelband and individuals

The distinction between idiographic and nomothetic forms of understanding was first introduced by Wilhelm Windelband in his rectoral address of 1894. Windelband, as a post-Kantian philosopher, was familiar with the debate about the relation of the human and natural sciences called the ‘Methodenstreit’, a debate which shaped, for example, psychiatrist and philosopher Karl Jaspers’ views of the importance of empathy for understanding psychopathology [Thornton 2007: 90-2]. That distinction is usually thought of as a distinction between explanation and understanding. Jaspers contrasts explanation in terms of causal connections with understanding of meaningful connections (and further subdivides understanding into phenomenology and empathy, for example) [Jaspers 1974]. This has in turn led modern philosophers, especially those in the Wittgensteinian tradition, to characterise understanding as a form of intelligibility suited for the meaning-laden actions and utterances of rational animals hence stressing its rational and normative character that ‘finds no echo in physical theory’ [Davidson 1980: 231].

In his address, however, Windelband stresses instead that the difference between nomomethetic and idiographic, whilst still a distinction in method or form of knowledge rather than subject matter, concerns the difference between general and particular.

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. Should we retain the customary expressions, then it can be said that the dichotomy at stake here concerns the distinction between the natural and the historical disciplines. [Windelband 1980: 175-6]

Windelband remarks that the distinction he is attempting to frame is not based on a distinction of substances: sciences of nature or natural science [Naturwissenschaften], versus the sciences of the mind [Geisteswissenschaften]. Such a distinction is hostage to the fortunes of that dualism. If the reductionist project of explaining mental properties in physical terms were successful then that contrast would be undermined.

Even with these characterisations in play, however, the distinction as so far introduced is not clear. Consider the contrast between ‘what is invariably the case’ and ‘what was once the case’. There are three problems with using this contrast to characterise a notion of ‘idiographic’. First, it threatens to slip back from a methodological distinction of how a subject matter is approached to the underlying nature of the events in question (whether, as a matter of fact, they are invariant or unique). Second, a substantive distinction does not explain in what way an idiographic understanding differs from any other sort. Third, the uniqueness of its subject matter cannot separate the idiographic and nomothetic. The gravitational forces on a mass, for example, depend in principle on a vector sum of its relation with every other object in the universe and thus some of the events described by physics are likely to be unique.

One of the clues Windelband himself offers is to suggest that history is a paradigm of idiographic sciences which ‘provide a complete and exhaustive description of a single, more or less extensive process which is located within a unique, temporally defined domain of reality’ [Windelband 1980: 174] However, this does not explain how historical explanation differs from physics, say. Windelband’s further comments about historical judgement are unhelpful. He says:

[H]istory seeks structural forms… [Windelband 1980: 178]

[I]n the historical sciences,… [thought] is devoted to the faithful delineation of the particulars… [ibid: 178]

The historian’s task… is to breathe new life into some structure of the past in such a way that all of its concrete and distinctive features acquire an ideal actuality or contemporaneity. His task, in relation to what really happened, is similar to the task of the artist, in relation to what exists in his imagination. [ibid: 178]

But the task of ‘describing structure’ is shared by some nomothetic sciences like chemistry. ‘Delineation of particulars’ is also the common aim of both idiographic and nomothetic sciences. The physics of a particular mass concerns that individual. Talk of ‘ideal actuality’ may be uniquely appropriate for the idiographic sciences but hardly sheds light on what this amounts to.

It might be assumed that using history as a paradigm suggests a connection to the other broad way of construing the Methodenstreit mentioned above as marking a distinction between explaining natural events and understanding meaning-laden events or rational subjects. But Windelband offers an example of historical understanding that is of a merely biological process, which show that this is not what he has in mind.

Consider… the subject matter of the biological sciences as evolutionary history in which the entire sequence of terrestrial organisms is represented as a gradually formative process of descent or transformation which develops in the course of time. There is neither evidence nor even a likelihood that this same organic process has been repeated on some other planet. In this case, the science of organic nature is an idiographic or historical discipline. [Windelband 1980: 176]

In summary, although Windelband coins a distinction between idiographic and nomothetic, stresses that it is a distinction of a form of intellibility rather than of types of subject matter and offers history as an example of the idiographic, it remains unclear what the distinction amounts to.

Elsewhere I have suggested that the appeal of idiographic judgement stems from a recoil from subsuming human individuals under conceptual categories – from pigeon-holing people – and hence instead attempting to understand them in other ways or other terms, a kind of ‘individualising intuition’ [Thornton 2008a, 2008b, 2010]. The problem is then to explain what novel form of judgement would address this task. If judgement in general takes a subject predicate form – s is P – then there are two elements to consider: the referential element and the predicational element.

The referential element does not seem to be a hopeful place to look to draw a distinction between nomothetic and idiographic. Consider the traditional deductive-nomological model of explanation as an example. This contains general laws (hence the name). But it also refers to particular circumstances in the explanans. Whether an adequate formal model of explanation or not, since the DN model of explanation is designed to fit paradigmatically nomothetic sciences mere singular reference to particular circumstances is not sufficient to distinguish a different form of intelligibility.

But ‘individualising’ the predicational element seems equally unpromising albeit in a different way. Such a predicate would have to be designed for a particular single element carrying with it no possible application to, and hence comparison with, other individuals. What could such a predicate be? What property would be picked out such that it could not possible apply to other cases? The closest idea seems to be a kind of name designed for specific individual (person or event). But that collapses this proposal back into the referential element of the judgement. In neither way can the ‘individualising intuition’ be satisfied through a novel form of judgement.

Singular causation

I suggested earlier that Windelband’s distinction between idiographic and nomothetic is a distinct variant of a broader discussion of the difference between human and natural sciences that in more familiar forms concerns understanding and explanation. In this section I will attempt to construct a conception of idiographic judgement by taking a version of understanding (by contrast with explanation) that stresses individual cases and then subtracting characteristically mental elements from it. Nevertheless, I will argue, the result fails to shed light on Windelband’s distinction between idiographic and nomothetic.

The distinction between understanding and explanation plays a key role in Karl Jaspers’ discussion of psychopathology although it is not carefully articulated and distinguished. Christophe Hoerl suggests that Jaspers’ contrast has both an epistemic and ontological dimension [Hoerl 2013]. Epistemically, the distinction runs as follows:

Explaining, Jaspers thinks, requires repeated experience – it is achieved by “observation of events, by experiment and the collection of numerous examples” (GP, 3 p. 302), which allow us to formulate general rules and theories. Understanding, by contrast, is achieved (if it is achieved) directly upon confrontation with a particular case. As Jaspers also puts it, “[p]sychological understanding cannot be used mechanically as a sort of generalized knowledge but a fresh, personal intuition is needed on every occasion” (GP, p. 313). We might thus say that Jaspers subscribes to a form of epistemic particularism regarding understanding. Understanding is not achieved by bringing certain facts under general laws established through repeated observation. Rather, the grasp it delivers of how one psychic event emerges from another in a particular case strikes us “as something self-evident which cannot be broken down any further” (GP, p. 303). [Hoerl 2013: 108]

Ontologically, understanding and explanation chart different aspects of reality: meaningful psychic connections and rules of causality, respectively. Hoerl points out that Jaspers suggests that the former are not causal. In this, he resembles the 1970s Wittgensteinian philosophers criticised by Donald Davidson in his ‘Actions, reasons and causes’ [Davidson 1980: 3-19]. But Hoerl objects both that this makes it ‘quite obscure what genuine epistemic gain understanding could deliver’ [Hoerl 2013: 109] and also that Jasper’s talk of events ‘emerging’ from others seems to be a causal notion [ibid: 110]. The difficulty here is a dilemma. If understanding is construed as non-causal then it risks epistemic obscurity. But if it is causal, it risks collapsing into explanation.

Hoerl suggests a reconciliation via the distinction between singular and general causation. General causation links properties. Singular causation is token causation between two actual events. He cites Elizabeth Anscombe who stresses the importance of singular causation and rejects neo-Humean nomological accounts of causation. She argues that:

[C]ausality consists in the derivativeness of an effect from its causes. This is...the common feature of causality in its various kinds. Effects derive from, arise out of, come of, their causes. For example, everyone will grant that physical parenthood is a causal relation. Here the derivation is material, by fission. Now analysis in terms of necessity or universality does not tell us of this derivedness of the effect; rather, it forgets about that. For the necessity will be that of the laws of nature; through it we shall be able to derive knowledge of the effect from knowledge of the cause, or vice versa, but that does not show us the cause as source of the effect. Causation, then, is not to be identified with necessitation. [Anscombe 1981: 136]

There is some debate about whether the distinction between singular and general causation implies that there are two distinct concepts of causation or whether some shared notion can accommodate both [Hitchcock 1995]. But the distinction between particular instances of causation and general causal conncetions between properties is clear enough to suggest a solution to the dilemma Jaspers faces. Hoerl suggests that:

When he talks about (mere) causal explanation, what he has in mind are general causal claims linking types of events. Understanding, by contrast, is concerned with singular causation in the psychological domain – i.e. with the particular way in which one psychic event emerges from or arises out of another on a particular occasion. [Hoerl 2013: 111]

This fits Jaspers claim that ‘Psychic events ‘emerge’ out of each other in a way we understand’ [Jaspers 1997: 302]

This contrast between particular and general is suggestive of Windelband’s distinction between idiographic and nomothetic. But it will not do as an account of the latter because Jaspers’ notion of understanding is restricted to the mental realm whereas Windelband suggests that it would be possible to take an idiographic approach to episodes of evolutionary history. So could this restriction be stripped away to leave something with a focus on particular cases but not restricted to the mental?

To consider this, I will sketch John Campbell’s discussion of interventionism in the context of psychiatry. Hoerl also moves from outlining his suggestion for interpretation of Jaspers to an account of Campbell. But his aim is to contrast the Anscombian idea of an effect arising out of a cause – a notion which fits Jaspers account of empathic understanding – with Campbell’s interventionism. My aim is to use Campbell to abstract from Hoerl’s suggested interpretation of Jaspers a more general notion of intelligibility which contrasts the particular and the general. Again, I will argue that it does not help shed light on Windelband.

Campbell’s discussion of interventionism within psychology and psychiatry starts by rejecting two connections which philosophers find natural: between non-mental causal connections and mechanisms and between mental causal connections and rational relations.

Campbell suggests that there is an analogy between:

1 the idea that propositional attitude ascriptions depend on the ascription of rationality to the subject, and 
2 the idea that all causal interactions between pieces of matter must be comprehensible in mechanistic terms. Both ideas express an insight – that we find it extremely puzzling when we encounter causal relations among propositional attitudes that are not broadly rational, just as we find it extremely puzzling when we encounter causal interactions between physical objects that are not mechanistic, and that involve spooky ‘action-at-a-distance’. Both ideas express a natural impulse of philosophers – to elevate this kind of point into a kind of synthetic a priori demand that reason makes on the world. This impulse has to be resisted. [Campbell 2009: 142]

Campbell concedes that, in both cases, there is a genuine insight. As a matter of custom and habit, we find an absence of material mechanisms and an absence of rational connections between mental states puzzling. But in both cases it is a characteristic philosophical error to promote this natural expectation into a justified a priori claim that the world must respect. Mere custom and habit cannot rationally sustain any such demand on how the world must be.

Campbell rejects the necessity of both physical mechanisms and rational connections in favour of an interventionist approach to causation. With respect to the latter, he argues:

Suppose you believe: 1 that this man is stroking his chin, and 2 that this man believes you need to shave. What is it for the first belief to be a cause of the second? On the interventionist analysis, it is for the intervention on the first belief to be a way of changing whether you have the second belief. So if some external force changed your belief that this man is stroking his chin, you would no longer believe that he believes you need to shave. There is no appeal to rationality here, no appeals to mechanism. [Campbell 2009: 143]

The causal connection between one state and another is underpinned in interventionist terms based on the idea that if intervening on the first belief is a stable way of bringing about a change in the second then this is sufficient for there to be a causal connection between them.

For propositional attitudes to count as causes of other propositional attitudes such as delusions, Campbell suggests two conditions have to be met. There should be ‘systematic relations between cause variables and the subsequent delusion’ and there should be a correlation between a change of the cause and a change of the effect [Campbell 2009: 146]. More generally for the causal explanation of mental states, the causal variables, which he calls ‘control variables’, should have large, specific and systematic correlations with their effects akin to the way the controls of a car systematically control its behaviour. These conditions do not require a rational connection, however.

The classical philosophical approach has been to regard propositional attitudes as part of a ‘conceptual scheme’ that we bring to bear in describing the ordinary world. This conceptual scheme is taken to have strong a priori constraints on its applicability. In particular, as we have seen, rationality is taken to be a norm with which the scheme has to comply... The appeal I have just been making to the notion of a control variable is intended to replace this invocation of rationality... [I]t is the fact that we have control variables, not the fact that we have rationality, which means that we are ‘at the right level’ to talk of beliefs and desires. [Campbell 2009: 147]

Taken together, Hoerl’s and Campbell’s accounts suggest a recipe for constructing a concept of idiographic judgement. Hoerl suggests that Jaspers’ version of understanding charts singular psychological causal relations and that singular causal relations can be construed on either Anscombian or interventionist terms. Campbell argues, on interventionist grounds, that the assumption that causal connections between psychological states must presuppose rational relations between them is mistaken as is the parallel assumption about physical mechanisms. There need be neither a physical mechanism nor a kind of psychological rational equivalent of mechanism for causation to hold in either the physical or the psychological ream, respectively.

This rejection of mechanism (either a literal physical mechanism or a rational analogue) may seem to count against Anscombe’s idea of effects arising out of, or coming of, their causes and Jaspers idea of meaningful connections. That, at least, is Hoerl’s view. But it might equally be thought that the counterfactuals underpinning interventionism illuminate rather than contrast Anscombe’s central idea of causality. Whichever is the case, the combination of singular causation and interventionism without rational or physical mechanism suggests an austere view abstracted from and hence no longer tied to the psychological realm. Hence the possibility that this might offer substance to Windelband’s emphasis on the particular rather than the meaningful. Perhaps idiographic judgement trades in singular causal relations shorn of rational relations?

Although emphasis on the singular looks to be a promising match to Windelband’s sketch of the idiographic, it will not do for three reasons. First, it would be a distinction of subject matter rather than the form of intelligibility: an ontological distinction between actual token causal relations rather than general properties. Second, that distinction does not seem a helpful way of distinguishing disciplines. For example, astronomy would count as ‘nomothetic’ when dealing general causal claims such as the behaviour of solar systems in general but ‘idiographic’ when applied to the historical behaviour of particular planets. Third, whilst interventionism does not require the existence of laws of nature to underpin causal claims, it does require relations of some generality and invariance across some range of interventions [Woodward 2003: 239-314]. The possibilities of intervention or manipulation require relations of some generality. Hence if singular causal claims are accounted for using interventionism, their understanding presupposes some general claims, thus undermining a distinction of kind.

In summary, the idea in this section was the following. It might be possible to spell out a notion of idiographic judgement by looking at one version of the related distinction within the Methodenstreit between understanding and explanation. According to Hoerl’s interpretation of Jaspers, understanding concerns singular causation in the psychological domain. Such causation is, on one model at least, underpinned by the idea of intervention rather than nomological generality. Further, according to Campbell, even in the psychological domain, such singular causation need not trade in rational relations. At this point in the combination of ideas, the analysis offered may no longer be an account of Jasperian understanding but seems, partly for that very reason, to be a promising match for Windelband’s emphasis on particularity within and without the mental realm. Sadly, the distinction between singular and general causal relations is a poor match for Windelband’s requirement for a distinction in form of intelligibility rather than subject matter.

Values and the singular aims of idiographic inquiry

So far I have suggested that two broad approaches to filling out Windelband’s account of idiographic understanding have failed. Attempting to articulate a form of judgement that eschews implicit comparison between individuals undermines the content of the putative judgements. Stressing singular rather than general causation produces a distinction of subject matter rather than a distinction in between forms of intelligibility.

In this final section I will sketch a different approach. The clue comes from another passage in Windelband’s rectoral address in which he again stresses the importance of the contrast between the general and specific to his distinction of nomothetic and idiographic.

[T]his distinction connects with the most important and crucial relationship in the human understanding, the relationship which Socrates recognized as the fundamental nexus of all scientific thought: the relationship of the general to the particular. [Windelband 1980: 175]

The commitment to the generic is a bias of Greek thought, perpetuated from the Eleatics to Plato, who found not only real being but also real knowledge only in the general. From Plato this view passed to our day. Schopenhauer makes himself a spokesman for this prejudice when he denies history the value of a genuine science because its exclusive concern is always with grasping the specific, never with comprehending the general... But the more we strive for knowledge of the concept and the law, the more we are obliged to pass over, forget, and abandon the singular fact as such… [ibid: 181]

So far these passages repeat the importance of the singular over the general that has already been discussed. But in explaining why this is important, Windelband introduces a further element:

In opposition to this standpoint, it is necessary to insist upon the following: every interest and judgment, every ascription of human value is based upon the singular and the unique... Our sense of values and all of our axiological sentiments are grounded in the uniqueness and incomparability of their object. [Windelband 1980: 182]

Now in one respect this does not help since it merely stresses the the uniqueness and incomparability of the objects of idiographic judgement and, as the discussion above has suggested, this does not help single out a form of judgement or intelligibility to stand in opposition to the nomothetic. But there is a further idea: that what we as subjects value in judgement and sentiment is tied to uniqueness and incomparability.

This is a contentious claim and it is far from obvious that it is true. The Categorical Imperative implies, to the contrary, that love of the good has an essential generality. More mundanely, one might value a piece of industrial design – a car, bicycle or cutlery – despite or even because of its mass production. But there are some cases where value seems to be tied to uniqueness: feelings of love and friendship directed to particular individuals – by contrast with a generalized love of humanity – being paradigmatic.

This suggests a different way of thinking about the idiographic: not as a novel form of judgement or intelligibility but rather as pertaining to the nature of interest taken in its subject matter. In some cases, one is interested in individuals because they are instances of generalities. In others, the interest is in them as individuals.

Here is a mundane example of the contrast. In 2009, UK members of parliament (MPs) were found to have taken part in widespread abuse of their expenses system to augment their incomes. UK newspapers investigated many such cases and every day printed new instances of the absurd financial claims made. But the focus seemed to be to use each new instance to justify the general claim that MPs as a whole were a corrupt group rather than having an interest in any previously obscure MP. The reputation of politicians as a class of people was the target. By contrast, in 1997 Diana, Princess of Wales, died in a car crash provoking much newspaper coverage. One particular newspaper – the Daily Express – continued, for a decade afterwards (!), to favour for its front cover any story about the late princess. But the claims advanced were not intended to shed light on royalty, or even princesses, in general. Rather the focus was relentlessly on Diana herself. The interest was, in the sense I have suggested, idiographic.

One consequence of moving the conception of idiographic from a form of intelligibility to the nature of the interest taken in individuals is that it places no constraints on the kind of intelligibility in play. Materials from either side of the traditional explanation versus understanding distinction, for example, could be deployed for idiographic purposes. No attempt need be made to frame descriptions that could only fit one individual.

Given this, however, it may seem that the contrast between idiographic and nomothetic as proposed does not amount to very much. What does it matter with what interest or value the subject matter of idiographic inquiry is approached if the actual judgements offered are as they would be in nomothetic inquiry?

In response to this question I will suggest two general consequences. The first is that idiographic inquiry – so understood – can simply escape one of the conceptual challenges of small scale qualitative social science research. This is the question of whether and how the results can be generalised. By contrast with large scale often quantitative research, a narrow but deep qualitative focus may not be based on a statistically significant sample and hence may not reliably generalise to other individuals or populations. But if not, what is the point of the inquiry? Idiographic inquiry, however, can bite on this bullet because it has no interest in other individuals or populations. Like the Daily Express’s interest in Diana, its focus is on the particular for the sake of the particular.

The second is that idiographic inquiry is naturally resistant to a source of error that Jonathan Dancy calls ‘looking away’ [Dancy 1993]. This is a virtue he claims for particularism over generalism in moral philosophy. Generalism claims that moral judgements can be codified in context-independent principles. Particularism opposes this and insists that small differences in a particular situation can reverse their moral valence. Hence Dancy argues from his particularist commitments for the importance of scrutinising particular situations with great care rather than being distracted by a premature comparison of that situation with others.

Particularism claims that generalism is the cause of many bad moral decisions, made in the ill-judged and unnecessary attempt to fit what we are to say here to what we have said on another occasion. We all know the sort of person who refuses to make the decision here that the facts are obviously calling for, because he cannot see how to make that decision consistent with one he made on a quite different occasion. We also know the person (often the same person) who insists on a patently unjust decision here because of having made a similar decision in a different case. It is this sort of looking away that the particularists see as the danger in generalism. Reasons function in new ways on new occasions, and if we don’t recognize this fact and adapt our practice to it, we will make bad decisions. Generalism encourages a tendency not to look hard enough at the details of the case before one. [Dancy 1993: 64]

Although the motivation differs, idiographic inquiry ‘sees’ its subject matter not primarily as interesting because it instances generalities but interesting for being the particular individual it is. And hence, whilst any subject matter will instance generalities – and such is the content of the any judgement made about it – the focus is bottom up: from individual to general characteristics rather than top-down from generalities to instances.

Conclusion

Recent calls for psychiatry to augment criteriological diagnosis with a more individualistic element have glossed this as an idiographic element. But this prompts the question of what the idiographic could amount to. Windelband’s various characterisations do not yield a distinct account of a form of judgement to contrast with nomothetic judgement. Nor is the use of singular causation an appropriate fit for this purpose.

Instead, Windelband’s suggestion that there is a connection between a focus on individuals rather than generalities and what is of value suggests a distinct response. On this suggestion, idiographic inquiry does not have a different form of intelligibility of its subject matter but rather has a particular kind of interest in it. It is an interest in the individual as such. This helps sidestep a worry about how to generalise small scale qualitative research and to avoid an epistemic bias of ‘looking away’: prematurely looking away from the individual to generalities. It is in such differences, rather than the form of judgement taken, that the difference between idiographic and nomothetic lies.

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Thornton, T. (2007) Essential Philosophy of Psychiatry Oxford: Oxford University Press

Thornton, T. (2008a) ‘Does understanding individuals require idiographic judgement?’ European Archives of Psychiatry and Clinical Neuroscience 258 Suppl 5:104–109

Thornton, T. (2008b) ‘Should comprehensive diagnosis include idiographic understanding?’ Medicine, Healthcare and Philosophy 11: 293-302

Thornton, T. (2010) ‘Narrative rather than idiographic approaches as counterpart to the nomothetic approach to assessment’ Psychopathology 16: 284-291

Woodward, J. (2003) Making Things Happen: A Theory of Causal Explanation. Oxford: Oxford University Press

Wednesday, 22 March 2017

Delusion post in Imperfect Cognitions

Lisa Bortolotti's Imperfect Cognitions blog has recently published a short summary that Bill Fulford and I wrote, advertising the view of delusions we took in our chapter in Schramme, T. & Edwards, S. (eds) Handbook of the Philosophy of Medicine.

I try to resist being drawn into substantial theorising but in this case I think a kind of non-theory theory might be called for. It also serves as a reason to connect delusion to tacit knowledge.

We think that there is a clinically recognizable local breakdown in that those relations which is not sufficient to take someone outside the space of reasons (a mere machine) but which resists specific understanding because, as Jaspers emphasised, the reasons cannot be shared. Further, just as rationality as a whole resists codification so breakdowns in the space of reasons do too. Recognising delusion is thus a matter for tacit rather than explicit knowledge.

Wednesday, 15 March 2017

Big or small p philosophy and/of psychiatry?

I gave a talk (briefly described here) at the Northern Ireland division of the Royal College of Psychiatrists the other day and so decided to pitch it at the idea that philosophy is a more or less obligatory part of self-conscious mental healthcare. The contrasting foils I considered were that it was either a debunking account of psychiatry in other terms such as an exercise of social control or, as Jennifer Hansen suggested to the AAPP a few years ago, a desperately needed defense of psychiatry against criticism essentially from outside it. I suggested instead that philosophical reflection grows organically out of internal debates in thoughtful psychiatry.

Afterwards, and after some interesting questions and debate, one person expressed surprise that the talk had been more about the philosophy of psychiatry than he had expected. I think he said that he had expected more philosophy with a small ‘p’. But I think he meant what I would express by saying philosophy with a large ‘P’: general, unapplied philosophy. So I have volunteered to go back and do that, if they wish, in the future. Mainstream philosophy for psychiatrists, as it were.

The irony is that when I was first invited to give philosophy of psychiatry sessions at large international psychiatry conferences by Bill Fulford, he always stressed that psychiatrists would be most interested in the standard philosophical debate about the mind-body problem. At the time, this was fortunate because there wasn’t a wealth of bespoke philosophy of psychiatry (not that I could bring myself to do quite or only that). Now with somewhere between 50-100 books published in the last 20 years by philosophers and by psychiatrists on what we thus call philosophy and psychiatry (and 30 years of PPP) it seems curious if actually Bill’s suggestion for what is really wanted remains true.

Tuesday, 21 February 2017

The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health

I see that the Palgrave Handbook of Sociocultural Perspectives on Global Mental Health edited by Ross White, Sumeet Jain, David Orr and Ursula Read has now been published (see here).

The publishers' blurb runs:

This handbook incisively explores challenges and opportunities that exist in efforts aimed at addressing inequities in mental health provision across the globe. Drawing on various disciplines across the humanities, psychology, and social sciences it charts the emergence of Global Mental Health as a field of study. It critically reflects on efforts and interventions being made to globalize mental health policies, and discusses key themes relevant for understanding and supporting the mental health needs of people living in diverse socio-economical and cultural environments. Over three rich sections, the handbook critically engages with Global Mental Health discourses. To help guide future efforts to support mental health and wellbeing in different parts of the world, the third section of the handbook consists of case studies of innovative mental health policy and practice, which are presented from a variety of different perspectives.

My self-centred interest is that I have chapter in it on 'Cross-cultural psychiatry and validity in DSM-5'

Abstract
The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, DSM-5, puts greater emphasis than previous editions on cross-cultural factors affecting mental illness [APA 2013]. Diagnostic criteria have been revised to take account of cross-cultural variation, there is a more specific cultural formulation and a glossary lists nine ‘Cultural Concepts of Distress’. But the DSM does not present a clear view of the universal or local constitution of mental illness. Nor does it give an account of the relation of the cultural concepts to the rest of the taxonomy of disorders nor the extent to which they are put forward as valid diagnoses. The first section of this chapter outlines three possible views of the nature of cultural concepts of distress. On one view, which dates back to the German psychiatrist Karl Birnbaum, an underlying universal ‘pathogenic’ component is overlain by a variable ‘pathoplastic’ cultural shape [Birnbaum 1923]. This combination suggests the possibility of two single factor models: pathogenic-only and pathoplastic-only. But, as the second section argues, establishing the correctness of any one of these is difficult. Two influential approaches to the nature of the concept of disorder – Wakefield’s harmful dysfunction analysis and Fulford’s failure of ordinary doing – can be pressed with only minor adjustment to support any of the a priori models of cultural concepts. The final section examines one of the nine cultural concepts: khyal cap or wind attacks, a syndrome found among Cambodians. On inspection none of the three models helps accommodate its own incompatible aetiological theory with the biomedical view of the rest of the DSM. This suggests that the very idea of cultural concepts of distress fits uneasily with the aspirations to validity of the rest of DSM-5.

Monday, 20 February 2017

Philosophy as a research method in health research

Here is another video of me. Sorry. But it was made a year ago to promote health research methods at UCLan. Such videos persuade me of the real skills of those who make presentation both seamless and natural. I manage neither here.


Tuesday, 14 February 2017

Kant's schematism, Wittgenstein and David Bell on the art of judgement

Some years ago I suffered prolonged writer's block and lost the ability to write or think about philosophy. I was teaching a module on Wittgenstein at Anglia Poly whilst employed by Warwick University and I drove across the A14 every week, drinking a couple of pints and eating corn beef hash at the Tram Depot with my friend Neil Gascoigne and moaning about my inability to think.

Anglia was organising a conference on the analytic -continental divide in philosophy and he suggested, more or less arbitrarily, that I could write something about the problem raised in Kant’s schematism. Starting from David Bell’s paper on the art of judgement which connects that issue to Wittgenstein served as a prompt. Bell suggests, among other things, that the kind of understanding one has of a Jackson Pollock could serve as the right kind of middle ground between full blown conceptual understanding and something which isn't understanding at all. (So my worries about this are akin to my objections to Hannah Ginsborg's 'primitive normativity'.)

The paper wasn’t great but released the block and got me to a few conferences including in Canada. But I was never able to place it. (Mind, for example, said it was too aesthetic; the British Journal of Aesthetics said it wasn’t aesthetic enough.) So some years later I published it in a Polish theology journal. I doubt it has ever been read.

Anyway: here’s a video I have found last week on my university server of an attempt I made a couple of years ago to explain it – not very successfully - to an audience of social scientists.

Friday, 10 February 2017

Emergence, meaning and rationality

Although the word 'emergence' has never featured in any paper I have written - it is not 'in my index' as Rorty delightfully says somewhere - I was an 'emergence fellow' at Durham's Institute of Advanced Study the year my parents died. Hence as a form of singing for my supper I wrote a paper on emergence for their in-house journal before I left. It is now here.

Possibly not my best work, on rereading it, but I was distracted.

Wednesday, 8 February 2017

Dialogues in Philosophy, Mental and Neuro Sciences

"Dear Colleague,
I'm pleased to inform you that the new issue of the international online journal Dialogues in Philosophy, Mental and Neuro Sciences has been published, it is freely readable at:

The issue contains:
Volume 9, Issue 2, December 2016

ORIGINAL ARTICLES
M. Aragona
The roots of psychopathological understanding: Karl Jaspers' Verstehen and the influence of Moritz Geiger's empathy

R. Gatta & M. C. Segneri
Biographies of Asylum in Italy: Body, Illness and Rights

A. M. Petta, M. Aragona, P. Zingaretti, C. Ottaviani, G. Antonucci, A. Sarnicola, G. F. Spitoni
Psychopathology, body uneasiness and self-identity in patients with non-BED obesity compared to healthy controls

HISTORY OF MENTAL CONCEPTS
E. C. Laségue & J. Falret
La folie à deux (ou folie communiquée)

DIALOGUES
J. Korf
A short comment on the "Defence of Chalmers" by Hane Htut Maung

H. H. Maung
Two Concepts of the Mental: A Comment on Korf's Reply


Dialogues in Philosophy, Mental and Neuro Sciences proposes and includes Original Papers, Negative Experimental Results, History of Mental Concepts, New Ideas and Dialogues, as described in the guidelines for the authors.

Would you like to write a Dialogue? It is a short article (up to 600 words) freely published and without any deadline commenting another article already published on the previous issues of our Journal.
If you have any question about this Journal then please feel free to contact me at your convenience. I hope you find at least some of our publications of interest and value.
If you think someone of your friends or colleagues could be interested in our Journal please forward them this email. Anybody can register himself at our service of email-alert which will inform about new issues or other news about the Journal through an email. The service is completely free atwww.crossingdialogues.com/alert.htm

Kind regards
Daniela Cardillo
Editorial Office

Friday, 3 February 2017

Some videos from the 2011 INPP conference in Sweden

are here following an email from Helge Malmgren.

"Dear friends, 

I hope that you are all well and do not work too much (the first half of this is true of me). 

The videos from our 2011 conference Ethics, Experience and Evidence have not been possible to watch for some time. Since I think they have a lasting value I have now put them on a new page, in a large (720p) format and using the Vimeo service. If you watch them and find anything that ought to be corrected (matters of fact or aestetic aspects), please notify me. 

With my very best wishes Helge Malmgren 

Helge Malmgren, PhD, MD, emeritus professor 
Dept. of Philosophy, Linguistics and Theory of Science Researcher, 
Dept. of Medicine, 
Sahlgrenska Academy University of Gothenburg, Sweden 
E-mail: helge.malmgren@filosofi.gu.se"

Wednesday, 25 January 2017

Vagueness in Psychiatry

I have just received my copies of the OUP / IPPP book Vagueness in Psychiatry in which I have a chapter. The book itself is as pleasing in design as the rest of the series but is not too dauntingly enormous.

Vagueness in Psychiatry 

Edited by Geert Keil, Lara Keuck, and Rico Hauswald 

International Perspectives in Philosophy and Psychiatry 

  • Addresses the problem of indeterminacy in psychiatry and its social, moral and legal implications 
  • Represents the first systematic effort to draw various lines of inquiry together, including the debates about the principles of psychiatric classification, categorical versus dimensional approaches, prodromal phases and sub-threshold disorders, and the problem of over-diagnosis in psychiatry, and relates these debates to philosophical research on vagueness and demarcation problems, helping readers to navigate through the various debates surrounding the problem of blurred boundaries in the classification and diagnosis of mental illness 
  • Brings together eminent scholars from psychiatry, philosophy, and law, thus addressing a broad readership from various disciplines, and encourages interdisciplinary discussions
In psychiatry there is no sharp boundary between the normal and the pathological. Although clear cases abound, it is often indeterminate whether a particular condition does or does not qualify as a mental disorder. For example, definitions of subthreshold disorders and of the prodromal stages of diseases are notoriously contentious. 

Philosophers and linguists call concepts that lack sharp boundaries, and thus admit of borderline cases, vague. Although blurred boundaries between the normal and the pathological are a recurrent theme in many publications concerned with the classification of mental disorders, systematic approaches that take into account philosophical reflections on vagueness are rare. This book provides interdisciplinary discussions about vagueness in psychiatry by bringing together scholars from psychiatry, psychology, philosophy, history, and law. It draws together various lines of inquiry into the nature of gradations between mental health and disease and discusses the individual and societal consequences of dealing with blurred boundaries in medical practice, forensic psychiatry, and beyond. 

Part I starts with an overview chapter that helps readers to navigate through the philosophy of vagueness and through the various debates surrounding demarcation problems in the classification and diagnosis of mental illness. Part II encompasses historical and recent philosophical positions on gradualist approaches to health and disease. Part III approaches the vagueness of present psychiatric classification systems and the debates concerning their revision by scrutinizing controversial categories such as post-traumatic stress disorder and by looking into the difficulties of day-to-day diagnostic and therapeutic practice. Part IV finally focuses on social, moral, and legal implications that arise when being mentally ill is a matter of degree.

Friday, 20 January 2017

The Handbook of the Philosophy of Medicine

Bill Fulford and I have a chapter on delusion in the following book. I love the tone of excitement of the press release.

Hot off the digital press! 

The Handbook of the Philosophy of Medicine, edited by Thomas Schramme and Steven Edwards, is available now online and in print! 

SpringerLink: http://bit.ly/2iML4GQ 

This handbook... 
- Is the first comprehensive, multi-authored handbook in the field of philosophy of medicine 
- Contains articles written by distinguished specialists from multiple disciplines, including philosophy, health sciences, nursing, sociology, political theory, and medicine 
- Covers the underlying philosophical foundations of many important social, political and ethical issues in health care 

For more info, go to Springer.com: http://bit.ly/2iV0dTQ

Four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017)

The University of Central Lancashire and Robert Gordon University are delighted to invite you to attend the following:

A four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017) aimed at postgraduate research students, researchers and academics working within health and social care areas who are new/novices in this theoretical and methodological approach. During the course, participants will receive an introduction to, and beginning experience in, designing hermeneutic phenomenology studies, collecting and analysing data, and reporting themes, qualities and patterns. (Please note this event includes a three-day methodology course and attendance at the one-day symposium detailed below)

A one-day Hermeneutic Phenomenology Symposium (6th April, 2017) aimed at postgraduate research students, researchers and academics working within health and social care. This is an exciting opportunity to listen to experienced researchers who have used a hermeneutic phenomenological approach to a) highlight some of the challenges in undertaking this type of study and b) to demonstrate how philosophical concepts can be applied to illuminate meaning within health and social care related research projects. A panel discussion will also be held to provide opportunities for further questioning and elaboration.

For full details about these events, please contact Liz Roberts, UCLan Conference and Events; HealthConferences@uclan.ac.uk 01772 892650 or visit the website: www.uclan.ac.uk/conferences. Alternatively you can contact the event convenors - Dr Gill Thomson (GThomson@uclan.ac.uk) or Professor Susan Crowther (s.a.crowther@rgu.ac.uk).

Think Globally, Act Locally: Health and Wellbeing across the Life Course

3rd International Health and Wellbeing with Real Impact Conference
“Think Globally, Act Locally: Health and Wellbeing across the Life Course”
Monday 5th June 2017
University of Central Lancashire

Conference Announcement and Call for Papers
Our third international, interdisciplinary conference is being organised by the Faculty of Health and Wellbeing at the University of Central Lancashire.
The conference convenor is Lois Thomas, Reader in Health Services Research, UCLan.
The conference will address the theme “Think Globally, Act Locally:  Health and Wellbeing across the Life Course”.  International experts will share innovative approaches to addressing inequalities in health and wellbeing across the globe.  We will then showcase examples of how global innovations are becoming a reality in our own Region.
Keynote SpeakersEthics, Professor of
  • Rafael Perez-Escamilla, Professor of Epidemiology & Public Health, School of Public Health, Yale University, USA.
  • Dominic Harrison, Director of Public Health, Blackburn with Darwen Borough Council, UK; Honorary Professor, University of Central Lancashire, UK.
  • Trevor Hancock, Professor and Senior Scholar, School of Public Health and Social Policy, University of Victoria, Canada.
  • Doris Schroeder, Director, Centre for Professional Ethics, Professor of Moral Philosophy, University of Central Lancashire, UK.
  • Professor Heike Köckler, Professor of Social Space and Health, Hochschule fur Gesundheit Bochum, Germany.

Participants
Participation and attendance is encouraged from practitioners, academics and students across a spectrum of disciplines to include:
• Nurses, Midwives and Allied Health Professionals
• Public Health teams and the wider public health workforce
• Local government officers and members
• Voluntary, Community and Faith sector
• General Practitioners
• Sports therapists and scientists

Abstract Requirements (Deadline Monday 6th February 2017)
Papers or posters are invited on:
a.       Starting well: the health of mothers before and during pregnancy and good parenting to ensure the best start in life.
b.       Developing well: encouraging healthy habits as children develop and avoiding the adoption of harmful patterns of behaviour.
c.       Growing up well: identifying, treating and preventing mental health problems in childhood.
d.       Living and working well: promoting lifestyle choices in adulthood to facilitate longer term health and wellbeing.
e.       Ageing well: supporting older people to remain resilient to ill health by maintaining their social networks and by being physically active.
Papers will be presented at concurrent sessions and posters will be displayed and discussed during designated poster sessions.

Abstracts should be submitted by email to Bethany Cooke, bcooke1@uclan.ac.uk.
All abstracts will be reviewed by the Conference Scientific Review Committee chaired by Dr Lois Thomas.
The abstract must include the following:
• Title of abstract
• Author/presenter name(s), institution represented, postal address, email address
• Primary contact person for the conference information
• An introduction, methods, results and conclusions
• The abstract should include subheadings
• The abstract should be referenced, citing between 2–4 references
• The references should be presented in Harvard APA

Length should be no more than 500 words (including title, author information and references)
Please state your preference for a paper or poster presentation
Please also supply a short biography of each author.

Conference venue
The conference venue is Darwin Building, University of Central Lancashire.

Conference Booking and Enquiries
All presenters will be required to register for the conference and pay the fee (£90). Students and members of UCLan staff will be admitted free of charge.
For conference enquiries please contact Bethany Cooke, Conference Administrator, University of Central Lancashire, Preston PR1 2HE
Tel: +44(0)1772 893419


For academic queries please contact Dr Lois Thomas on lhthomas@uclan.ac.uk

Against Michael Crotty's daft view of constructionism

Faculty of Health and Wellbeing

Health and wellbeing Research Methodology and Implementation (HeRMI)

25th January 2017 12:00 - 13:30 HeRMI

Group: Philosophy

Against Michael Crotty's daft view of constructionism

Synopsis: In his widely used textbook, The Foundations of Social Research, Michael Crotty seems sympathetic to constructionism (by contrast with objectivism and subjectivism) at the highest level of his hierarchy of approaches to research. But he also ascribes to it some daft views of reality if meant seriously and literally. I will highlight the daftness of the views and suggest a diagnosis (that he thinks objectivism has to hold a premodern view of the book of nature and, to counter that, that reality inherits the contingency of human concepts). But, more sympathetically, I will try to rationalise the temptation to hold such absurd views and suggest why they are difficult, though not impossible, to avoid. Presenter: Professor Tim Thornton, Professor of Philosophy and Mental Health, UCLan.

All Seminars are free to attend and open to all. Exact venues will be confirmed on registration - All will be held on the UCLan Preston Campus

Please note that Seminars may be visually and audibly recorded - You will be notified on registration if this is the case

For registration and any queries please contact the Faculty of Health and Wellbeing’s Research Support Team Email: rsenquiries@uclan.ac.uk Tel: +44 (0)1772 895111

Wednesday, 18 January 2017

A fragment on ethics

A fragment on ethics for a chapter called 'Ethics in catheter-based cardiovascular interventional therapy' co-authored with P. Lanzer, MD.

Abstract

This chapter examines the ethics involved in catheter-based cardiovascular interventions as nested within iterated larger structures of ethics. The ethics of catheter-based cardiovascular interventions are a particular instance of medical ethics. Those in turn are a particular application of professional ethics. And those in turn are the application of general ethical concerns to the specific case of those subjects bound into a profession or institution. Hence the chapter starts with a thumbnail sketch of the most general context and philosophical approaches taken to it and subsequently refines this to consider the increasingly specific matters.

Glossary of Terms

Consequentialism: the view that the moral value of an ethical judgement or action depends only on whether it has good consequences

Deontology: the study of duty and obligations underpinning judgments of the compliance of an actor with deontological ethics and hence the moral status of their actions

Ethics: field of philosophical study concerned with morality, both its general nature and particular prescriptions

Morality: the standards of goodness, virtue or of right conduct. Common morality concerns shared moral standards, if they exist; applied morality concerns particular moral standards of specific human practices such as membership of a profession.

Knowledge-that: propositional knowledge of facts or of what is the case. Such knowledge is often analysed as true belief with a suitable pedigree such as justification or warrant.

Knowledge-how: knowledge required to perform actions sometimes called ‘know-how’.

Ontology: the philosophical study of what exists including most abstractly Being itself but also puzzling ‘objects’ such as numbers and values and their place in nature

Particularism: the view that moral judgements cannot be encoded in moral principles and instead answer to the objective moral values inherent in particular situations.

Principlism: the view that moral judgements can be encoded in moral principles.

Phronesis: a type of expertise directed at recognizing the practical demands and moral obligations implicit in particular situations.

Profession: a profession an activity requiring institutionalized training, specialized knowledge and standards on practice. Professionals are adequately trained, qualified and certified individuals required to adhere to professional standards. Expertise of professionals is based on exercise of specific knowledge and morality

Virtue ethics: the view that the moral value of ethical judgment depends on the character of a moral subject

Abbreviations

CBCVI - Catheter-based cardiovascular interventions

QALY - Quality Adjusted Life Year

General ethics

‘Ethics’ is the name for the philosophical study of moral standards, the standards of goodness, virtue or of right conduct. Such philosophical study divides roughly into normative ethics, on the one hand, which concern prescriptions for how to act, for example by the articulation of general rules for good conduct and, on the other hand, meta-ethics which addresses more abstract questions of what kind moral or ethical claims are. It is a metaethical question whether moral claims can be true or false and if so what makes them so. A contrasting meta-ethical view is that they merely express the feelings or emotions of a subject and do not answer to anything else. Such a view, emotivism, compares moral claims with a cry of ‘boo!’ or ‘hurrah!’ which are not even candidates for truth or falsity.

Similarly, given the former view that moral claims can be true or false; whether theyare codifiable in principles (principlism) or are essentially situation-specific judgements (particularism) and hence calling for situation-specific expertise (phronesis), is a metaethical debate (see e.g. 1).

It would be helpful if there were consistent terminology such that, for example, ‘ethics’ always referred to normative ethics and moral philosophy to meta-ethics. But sadly this is not so. Further, whilst some debates within ethics seem clearly meta-ethical or normative, there is often an overlap. For example, the debate about whether there is a common morality – a universal understanding of moral demands applicable across all times and cultures – has implications for the kind of status that moral claims have but also impacts on the nature of prescriptions that might be advanced (e.g. whether they can be advanced as anything more than local views).

Evolutionary ethics is a more recent development which has consequences for all three areas. At its most general, it aims to shed light on general ethics, the practices of making ethical claims and having moral feelings. In his book Sociobiology: The New Synthesis, Edward Wilson claims that “scientists and humanists should consider together the possibility that the time has come for ethics to be removed temporarily from the hands of the philosophers andbiologicized (2)

One reason for the relevance of evolutionary theory is that it purports to explain some of the building blocks for philosophical accounts of general ethics. “[T]he hypothalamus and limbic system ... flood our consciousness with all the emotions - hate, love, guilt, fear, and others – that are consulted by ethical philosophers who wish to intuit the standards of good and evil. What, we are then compelled to ask, made the hypothalamus and the limbic system? They evolved by natural selection. That simple biological statement must be pursued to explain ethics.” (2).

One test case for evolutionary approaches is whether they can explain how altruistic behaviour, or the ability to think that altruism is the right response in a situation, could have evolved given our ‘selfish genes’. But it is easy to see how such an explanatory project might come to have normative ethical implications if the standard of good and bad has to fit with evolutionary fitness. Further it can seem to have metaethical consequences if it is thought that ethical claims do not answer to anything external to human evolutionary history. That is, if ethical practices can be fully explained via the evolutionary advantages of, say, cooperation then that might seem to undermine the idea that moral claims answer to additional objective standards of goodness and badness. On the other hand, an evolutionary account may be of the capacity to form moral judgements in response to genuine ethical standards akin to the capacity to reason correctly about mathematics which does not reduce the apparent truths of mathematics to the contingencies of human evolution. Thus the significance of evolutionary approaches to ethics is open to debate.

There are three main competing normative ethical traditions. They are:

Consequentialism: As its name suggests, this is the view that the moral value of an ethical judgement or action depends only on whether it has good consequences. That simple characterisation hides an immediate further complexity. How should the good consequences be characterised? If the aim is to explain moral judgments, in other terms – to reduce moral to non-moral concepts, then the consequences might be, for example, defined in terms of human happiness. Thus, moral judgment would be explained as that which leads to happy consequences, morally good thus being explained using a non-moral concept of happiness. Of course, like any reductionist definition, it is open to question whether the concept of moral good can be explained using non-moral concepts. Such an approach seems to be vulnerable to G.E. Moore’s ‘open question’ objection (3). That is, because it seems to make sense to concede that an action maximizes happiness but still to question whether it is right, then goodness cannot mean maximizing happiness.

A more modest non-reductive form of consequentialism, by contrast, might instead help itself only to a morally rich notion of ‘good consequences’, or morally good consequences. This would not attempt to shed light on what is meant by ‘morality’ using independent concepts. It would not be an analysis of moral goodness in other termsbut might still help to emphasize that what matters are the effects of, rather than the motives for, moral actions.

The most famous instance of a consequentialist approach is JS Mill’s Utilitarianism which Mill summarizes as follows:

The creed which accepts as the foundation of morals, Utility, or the Greatest Happiness Principle, holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure. To give a clear view of the moral standard set up by the theory, much more requires to be said; in particular, what things it includes in the ideas of pain and pleasure; and to what extent this is left an open question. But these supplementary explanations do not affect the theory of life on which this theory of morality is grounded- namely, that pleasure, and freedom from pain, are the only things desirable as ends; and that all desirable things (which are as numerous in the utilitarian as in any other scheme) are desirable either for the pleasure inherent in themselves, or as means to the promotion of pleasure and the prevention of pain. (4)

In medicine, utilitarianism lies at the heart of the assessment of healthcare in terms of number of years of survival; Quality Adjusted Life Year (QALY) which assesses both the quantity and quality of years lived and often forms the basis of quasi-economic assessment of competing claims for resources. The basic idea is that a year of life enjoyed with full health is given a numerical value of one. A less than fully healthy year of life scores less on a scale which reflects the experienced quality. The value of medical care can then be assessed by predicting the outcome expressed in QALY relative to the economic cost.

A central challenge for consequentialists is to reconcile the idea that the moral value of an action depends upon a kind of calculus of outcomes with our everyday ignorance of the longer term consequences of our actions. Another problem is that a utilitarian calculation may threaten individual rights if collective happiness or good sufficiently outweighs – according to consequentialist or utilitarian calculation – individual suffering. But the idea that individual rights can be so outweighed may not accord with antecedent intuitions about morality.

Deontology: On this approach, the moral value of an action is independent of the action’s actual consequences but depends instead on one or more general duties to act. Particular kinds of action are simply precluded or, contrastingly, demanded by general principles. The challenge for its supporters is thus to articulate a consistent set of principles or general duties that capture morally correct action and to explain their origin. Some duties, such as the Hippocratic injunction to do no harm, are widely and deeply held but can conflict with other equally deeply held principles to do patients well.

The most famous form of deontological theory is Kantian ethics which centres on a single high level ‘categorical imperative’ or principle:

Act only according to that maxim by which you can at the same time will that it should become a universal law. (5)

This principle flows from Kant’s argument that the key feature of morality is that moral guidance must be capable of application in any possible set of circumstances. Generality is of the essence of morality, in this view.

But even this formal constraint has content because some maxims would be self-stultifying if generalised. Kant gives the example of someone who borrows money promising to repay it but who has no intention ever to do so. If the particular case were made universal, that is if everyone behaved this way, then the institution of lending money would cease. Hence it is impossible to ‘will’ that such a principle becomes a universal law because it would undermine the possibility of satisfying the desire to borrow money. Thus, according to Kant, borrowing money with no intention to repay it cannot be a moral act. A similar example for healthcare would be selfishly deciding to benefit from blood banks, and at the same time sabotaging its very principle of blood donation. Subverting the universal maxim (blood banks are useful and needful)would conflict with the continued existence of blood banks from which one hopes to benefit, it would be self-defeating to ‘will’ it.

In addition to ruling out some actions because a maxim derived from it could not be generalised without contradiction, the first formulation of the categorical imperative also gives rise to more specific advice. Kant’s view of morality is based on a highly rationalist view. A moral agent should want to do what is good not for any subjective reasons but for an absolutely or categorically compelling end. Thus free will is a basic precondition of moral action, albeit a will to be governed by absolute principles. And if it is to be universalized, it would contradict the categorical imperative as set out above to claim that another person can be morally treated as merely a means to some end, rather than being valued intrinsically for their own sake. Hence Kant gives a further derivation of the first imperative

Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end.

The main challenge to a Kantian version of deontology is to show how all the intuitively morally compelling principles can be derived from the formal requirement for universality. The challenge for any version of deontology that accepts a basic plurality of principles (such as the Four Principles Approach discussed below) is to explain away the problem that they may conflict in particular circumstances.

Virtue ethics: On this approach, the moral value of ethical judgment depends on the character of a moral subject. The fullest original statement was Aristotle’s Nicomachean Ethics (6). The central practical aim of virtue ethics is the development of a moral character. Thus, one of the Aristotle’s key tasks is to offer an account of the sort of characteristics a virtuous person has (and from which the value of ethical judgments derives). The ultimate aim of virtue ethics is eudaimonia, meaning flourishing. Thus success in ethical judgments is underpinned by a conception of a good, happy and fulfilling life. It is a matter of debate whether the concept of a good life is always morally charged or whether, by contrast, some kind of reduction of moral properties to some non-moral form of the good life is intended.

Virtue ethics seems to be an answer to a different kind of question to that to which deontology and consequentialism respond. It does not directly answer the question of what is the right thing to do in a particular circumstance except to say that it is what a virtuous agent would rightly choose to do. This is because it, unlike them, denies that moral demands can be codified in general principles. It is, in other words, particularist rather than principlist.

Even a brief summary of these three distinct general approaches reveals the conceptual and practical difficulties of normative ethics. First, the rival ethical models or theories need to be fully articulated. Second, because they can give different results, a justified choice has to be made about which to follow. A consequentialist or utilitarian approach might suggest that the consequences of Robin Hood’s actions are sufficiently good to justify stealing from the rich. A deontological approach might insist that stealing is always, as a matter of principle, wrong. Third, the ‘data’ – the full details of (e.g. clinical) situations – have to be interpreted and related to favored ethical theories. Fourth, a judgment has to be derived from the favored theory as applied to the case at hand. At each of these stages, there can be reasonable disagreement between different parties. Such judgments lack reliability in the medical sense.

Professional ethics

Independently of existence or absence of a universal and timeless common morality at the most general level, there seem to exist subsidiary moral codes at lower and more applied levels. One such subsidiary level is represented by the existence of different forms of professional ethics. One way to think of these is that whilst the most general ethical demands appeal to rational subjects universally, the adoption of a specific professional role adds further ethical obligations contingent on that role.

Key attributes of a profession include specialized knowledge, institutionalized training and preparation, normative standards governing professional practice and core moral values not always explicitly articulated. Members of the profession are required to adhere to the professional standards defined by the responsible bodies. Typically the candidates must complete a defined training curriculum, pass the required examinations and comply with the expected norms, standards and formal regulations.

While knowledge transfer can be both, explicit and tacit, the transfer of moral values is frequently tacit and largely empirical. Thus, besides fulfilling the professional knowledge-based requirements and qualifications, the proper conduct of a professional requires embodiment of the expected moral attitudes.

It is open to question whether adopting a professional role merely makes explicit general moral demands as they apply to specific professional contexts or whether professional ethics can conflict – and even trump – more general ethical demands. To take a non-medical example, defense barristers have duties to their clients that trump the requirements on impartial investigation of, say, police officers. They must present their clients in their clients’ best light not necessarily in the most plausible light. Thus, it may be that the professional ethics of defense barristers can conflict with the requirements on honesty and rational appraisal of others in general ethics. On the other hand, it may be that this moral attitude is simply an instance of moral complexity that general ethics have to acknowledge.

Medical ethics

Medical ethics is a further sub-species of normative professional ethics. One of its key roles is to frame tools to aid clinicians, and other participants in clinical judgements, to assess the ethical aspects of a situation. Raanan Gillon, a general practitioner and professor of medical ethics, for example, aims to demonstrate the efficacy of his favoured approach – Beauchamp and Childress’ Four Principles approach (see below) – by showing how it can simplify a range of factors that might otherwise have to be assessed individually (7). In a paper called ‘Ethics needs principles – four can encompass the rest – and respect for autonomy should be “first among equals”’ Gillon considers as an example of another ethicist’s analysis of the merits of a free market in human organs, and draws from it the following daunting list of the relevant considerations (7):

people’s rights and claims;
different sorts of interests and their relative strength;
human wellbeing;
loss of life;
what would be good or bad for people;
democratic acceptance;
consultation;
sensitive moments;
benefits and harms;
grief and distress;
an obligation to make sacrifices for the community;
an entitlement of the community to deny autonomy and even to violate bodily integrity in the public interest;
the system of justice;
public safety;
public policy considerations;
danger;
civil liberties;
individual autonomy;
and saving and protecting the lives and liberties of citizens. [Gillon 2003: 308]

He goes on to say: ‘my hypothesis entails that all of them can be explained and justified by one or some combination of the four principles’(7). Thus one role for a philosophical theory of medical ethics – a theory of normative ethics, of how one ought to act – is to codify and rank competing factors to guide judgement.

The four principles to which Gillon appeals are based on perhaps the most famous framework for normative medical ethical thinking; the ‘Four Principles approach’ – as it is generally called - is a deontological approach set out at length by Tom Beauchamp and James Childress in their Principles of Biomedical Ethics (8). In it, the authors set out four general principles to guide medical ethical reasoning as follows:

Autonomy: The patient or user’s perspective is fundamental and informed consent to treatment is thus a key derivative ethical aim.

Beneficence: The good of the patient is a key aim.

Non maleficence: Harm should be avoided where possible.

Justice: Benefits, risks and costs should be distributed fairly. Subjects in similar positions should be treated in a similar manner.

These four principles are supposed to capture medical ethical reasoning. The approach is indebted to the principlist approach to general ethics of the early 20th century represented by the British philosopher W.D. Ross. According to Ross (9), moral duties are encoded in general principles. Each principle imposes a ‘prima facie’ duty: a duty that would be obligatory all other things being equal, that is if no other principles were to apply. Whilst the principles encode prima facie duties, the obligation to act in a particular situation requires an actual or concrete duty: the all things considered duty imposed by the situation as a whole. This demand reflects the interplay of the principles – possibly a subset of them – that are relevant to the case. But because the different principles can pull in different directions the actual duty depends on which duty, in the situation, is the strongest.

Ross himself proposed seven such duties: fidelity, reparation, gratitude, non-injury, harm-prevention, beneficence, self-improvement and justice. Beauchamp and Childress’ Four Principles – beneficence, non-maleficence, autonomy and justice – are a smaller number of universal duties more relevant to medicine. Nevertheless, even with this smaller number, the principles can conflict. They do not derive from any single higher principle. Thus they need both ‘balancing’ and further ‘specification’ when applied to particular situations because the principles can conflict. Standardly, for example, beneficence and non-maleficence are in tension in virtually all fields of medicine including surgery, drug therapy and catheter-based interventions. In psychiatry, autonomy and beneficence are in tension in the case of involuntary treatment. The judgment of which principle should dominate in any particular context looks to be an exercise of situation specific judgment or phronesis suggesting that, ultimately, the Four Principles approach collapses into particularism. The ‘principles’ are not really principles governing a judgment but rather helpful reminders for what might be relevant for phronesis. (Ross himself does not offer an account of what determines which principle dominates in a given situation. This is the basis of a criticism of him by the contemporary moral philosopher Jonathan Dancy (10).)

Such ‘quasi-legal medical ethics’ (as Fulford calls it (11)) has come under fire from another direction. The values that should govern medical interventions are more than just explicitly ethical values (even medical professional values) but also include a wider set of preferences of those involved in treatment decisions. Hence a properly values based practice should not start with a limited set of values but rather in needs to be sensitive to a potentially open ended set of concerns and values (11).

Ethics in catheter-based cardiovascular interventions



Summary

Ethics, a traditional field of study and expertise in philosophy, has become an integral component of medicine in its myriadformats. In CBCVI, to date, issues of ethical professional conduct have as yet to be formalized. To further develop and to maintain standards of excellence in the CBCVI profession, the establishment of ethics curricula is an urgent and an important target.

References

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