Psychiatric taxonomy #2

A while back I mentioned writing a commentary on Peter Zachar and Kenneth Kendler’s (latter pictured) suggested conceptual framework to assess psychiatric taxonomy for the AAPP bulletin. That is now out with a reply by Zachar and Kendler to a number of commentaries though I’ve not yet had time to digest it but will report back.

More surprisingly, Thomas Szasz has agreed to write a reply to Brendan Kelly’s ‘portmanteau’ paper with this author list: BD Kelly, P Bracken, H Cavendish, NCrumlish, S MacSuibhne, T Szasz, T Thornton. We still have to find somewhere to publish it, of course.

PS. Cancel that. With the thought that ‘I doubt that the American Journal of Psychiatry would publish it if I were one of the authors (or even if I was not)’ TZ has pulled out. Oh well.

Peter Lucas on dignity and self-knowledge

At today’s philosophy research seminar, Peter Lucas (pictured) summarised one theme of a substantial piece of work he’s been doing on dignity and self-knowledge. Taking as his starting point a notion of the respect of dignity, he first outlined a Kantian idea. On this familiar line, respect for dignity is respect for self-regulating agents. Thus it’s respect for another’s autonomy. Further, that we ought to have a respect for dignity (which surely doesn’t follow from any of the plain facts about a person’s autonomy) can follow providing we additionally bind ourselves by the categorical imperative. This leads naturally to the thought that respect for another’s autonomy, not treating them as a mere means to an end, suffices for respect for dignity.

Peter, however, wanted to outline a defence of a more substantial notion of the dignity of others as also involving their capacity for self-knowledge. Now this is a broader project based on a additional philosophical investigation. Today, to give an illustration of this idea in limited time, he appealed to Andrea Dworkin’s work in the 1980s. A key idea was that respect for dignity involved avoiding objectification. Now Dworkin suggested three ways of objectifying people (a conjunction), to be avoided of course. The first was a merely Kantian notion: treating others as means not ends. But the others were fetishisation and stereotyping.

Concentrating on the sexual objectification by men of women, Dworkin – according to Peter - placed pornographic representation as the primary vehicle of sexual stereotyping leading women to struggle to live up to a merely debased conception of themselves. But, further, because the object of men’s sexual interest was a mere pornographic conception – and thus a mere object - rather than a real woman, this interest was fetishistic.

Given that on Dworkin’s account (as reported) women were also complicit in the maintenance of the debased stereotype, this involved not a simple denial of their subjectivity but an occupation of it. Hence simply respecting dignity as autonomy was not enough. We should also avoid behaviours and forms of communication that lead to a debased self-conception.

Peter suggested that Dworkin’s account of objectification had philosophical roots both in Sartre’s discussion of sado-masochism (where sadism requires an element of dishonesty in not merely indifferently treating subjects as objects but humiliating subjects but knowingly so treating them, keeping their subjectivity in half-view) and Marx’s account of alienated labour. But he ended on two practical thoughts. First, that there were dangers concerning genuine capacity to consent whenever someone was ‘an object of knowledge and an object of manipulation’ in scientific trails, for example. Second, that it was possible for even scientific truths to be a basis for a debased self conception.

He attempted to motivate that final thought with the imaginary case of a young woman who has the aptitude for a well paid career but one that requires significant training and investment from a company as well as herself. She knows, however, that the chances of women of her age taking a career break a few years later are significant and that that is costly for the company whose aims she values. Should this knowledge be taken into account?

Well not by an employment selection panel! They have to ‘put it out of play’ for fear of discrimination (glossed at this point in the presentation as ‘judging individuals inappropriately’). But neither should she as it ‘offers the victim an inappropriately restrictive (possibly debased) self conception’. It would be ‘dishonest’.

Now I suspect that the final thought is not interestingly true. The idea that truths might be perniciously stereotyping seems very odd to me. (It might be true in a not very interesting way simply because if the thesis is ‘scientific truth can sometimes be a basis for a debased self conception’ then that does not specify how the debased conception depends on the truths and how much might is taken elsewhere by other beliefs. If I have been persuaded that professional philosophers are the scum of the earth and I truly believe myself to be – for the moment! – a professional philosopher, then that will lead to a debased self conception: one which requires that innocent truth to hold pernicious sway.) But after trying a few moves and counter-moves on each other over the last few weeks, I doubt that either of Peter or I will persuade the other of their view in the near future. Today, however, I wonder whether it was made more plausible by some key moves (Wittgensteinian trickery perhaps!) earlier on in the presentation which I will attempt to summarise.

With a G&T in hand now, my worry is this. If one has reason to think that being the object of a conception is pernicious then both the final thoughts will be well motivated. Merely to be subject to conceptualisation would be a bad thing. So if – pre-philosophically – stereotyping means something like forming an overly simplified conception, that merely pragmatic defect can inherit the moral overtones of being the object of a conception and the case of the potential employee works out the way Peter intends. (Before we put it through a philosophical mill, stereotyping is bad because it is bad to over-simplify in one’s conceptions. That’s not to say that simplifying through conceptual subsumption is generally a bad thing, though I often hear that in discussions of diagnosis in the philosophy of psychiatry.)

How do we get to the idea that being the object of a conception is a bad thing? Through the idea that to be interested in, or through, or via, a conception is to be interested in an object. And in the case of sexual interest, then that’s a fetish. But it seems very odd to think that a conception of someone is itself an object in the way a shoe is. (I fear for neo-Fregeanism if this were so.)

(In discussion Peter suggested that in festishistic interest, the object of interest represents something. That’s why one is interested in it. But:
a) that seems to open up a regress. Not all interest could be indirect in this way. It must terminate in interest in something / someone for their own sake. But if one is ever interested in Y because Y represents X and one is interested in X simpliciter, then why could there not be a fetishistic interest in X if it were, say, shoes, and one’s interest was in it simpliciter? Now one might attempt to sidestep this by weakening the notion of representation. So it is not that the fetish ‘object’ has to represent something but, rather, one is interested in it because it exemplifies a general concept, a concept, that can be of something else (eg. interest in someone because of the shoes they wear). But if so,
b) that requires that in non-festishistic interest one is never interested for a general conceptual reason and that seems wrong (maybe one is attracted to the merry sound of her voice; his serious mood etc). Brutely to be interested in someone idiographically or non-conceptually smacks of the myth of the given. (That a concept can be of something else is just the Generality Constraint.))

It seems more likely that a post-porn interest – if the general story were right – gets women wrong, is a bad conception. Now it may be that it’s a bad conception because it’s some variant on a ‘conception-as-object’. But if so it will not generalise to make mischief with the idea that being the object of a (general conceptual) conception is to be conceived as an object in anything other than the innocent sense that if the conception aims at objectivity, it aims to get you right.

I should add that I’ve not touched here on the key idea: that respect for dignity involves respect for self-knowledge. That I find an increasingly attractive thesis however quickly a connection to objectification can or cannot be made.

PS: Peter kindly responded to this summary of his talk. Given that it runs to a few paragraphs I've posted it, whole, here.

More on know-how

I’ve spent some of my commuting time to Preston and back catching up on some of the growing literature on the analysis of know-how stemming from Stanley and Williamson’s paper, which I mentioned a month back. In it, they argue both against Ryle’s regress argument for the priority of know-how over knowledge-that, and proffer an analysis of know-how as a particular sub-species of knowledge-that. Hannah knows how to ride a bicycle iff, relative to a context, there is some contextually relevant way ώ such that Hannah stands in the knowledge-that relation to the Russellian proposition that ώ is a way for Hannah to ride a bicycle, and Hannah entertains this proposition under a practical mode of presentation.

Of the papers I’ve just been looking at (mainly drafts on the web hence the lack of page references etc.), Alva Noë (pictured) attacks Stanley and Williamson’s criticism of Ryle’s argument and defends a close connection between know-how and ability. Ted Poston and Elia Zardini independently point out problems for know-how that it would inherit from a too close connection to knowledge-that. Phil Joyce argues for the existence of practical modes of presentation through a different route. And John Bengson and Mark Moffett attempt to explain why know-how sometimes implies ability and sometimes does not through a substantial theory (to which it will turn out I do not get on this train journey).

I’ll come back to Ryle’s regress argument another time. (No time for research, really, in my current role.) But, having attempted to defend something like it, Noë argues for a much closer association of know-how and ability than Stanley and Williamson allow. They use the failure of this connection to motivate a different ‘intellectualist’ account of what it comprises. But Noë argues that the counter examples they deploy can be explained away as perfectly ordinary cases where possession of a general ability is not sufficient for action because of contextual impediments. Absence of a piano or loss of one’s arms (!) need not undermine one’s ability to play and thus its connection to know-how.

Noë also says something that seems to me just right about Stanley and Williamson (and I said roughly like this in my previous post).

I don’t mean to suggest that that the fact that Stanley and Williamson analyse knowledge-how as a special kind of knowledge-that derogates from their claim that it is, for all that, a bona fide species of knowledge-that. They are right to defend themselves against that charge (433ff). What I would suggest is: (1) Stanley and Williamson’s analysis is merely technical – it presents a new notational or conceptual framework within which it is possible to make the same old distinction. (2) Whereas the distinction between knowing how and knowing that is pretty straightforward and is easily illustrated with examples, the account of the distinction that Stanley and Williamson offer is somewhat obscure. [Noë 287]

Although, in order to argue that know-how is a species of knowledge-that, Stanley and Williamson place most weight on some linguistic analysis, they also address a potential source of disanalogy (which might undermine the assimilation) which involves Gettier cases.

We can imagine cases of justified true belief that fail to be knowledge-that, because they fail to satisfy some extra condition. It may appear difficult, however, to formulate examples that fall short of being knowledge-how for a similar reason. That is, one might think it is difficult to conceive of Gettier-cases for knowledge-how. But if knowledge-how is really a kind of knowledge-that, there should be such cases. [Stanley and Williamson 435]

Ted Poston addresses this point. He argues that there is a conflict between the necessary requirement for something to count as a Gettier case of know-how and for it to count – contra to its Gettier status – as knowledge.

The first premise of the argument states that Gettier cases for know-how, if they exist, require that the subject intelligently and successfully φ, where φ ranges over actions. In general, Gettier cases for know-how, if they exist, would require that the intelligence condition and the success condition are satisfied. These conditions are analogous to the justified belief condition and the truth condition in Gettier cases of knowledge-that. In a Gettier case for know-that justified belief comes apart from the truth in a way that is incompatible with knowledge-that. So also, in a purported Gettier case for knowledge-how the intelligence base the subject uses doesn’t connect to success in the right way to yield knowledge-how…The second premise of the argument is that one knows how to φ, if one can intelligently and successfully φ. If, for instance, Sally intelligently moves this way and that way with the goal of riding a bike and she succeeds then Sally knows how to ride a bike. So given the first premise, the sufficient condition for knowing how laid down in the second premise is satisfied. Therefore any alleged Gettier case for knowing how will turn out not to be a Gettier case, for it will be a genuine case of knowing how. [Poston]

The important step of this argument is the second. It would not help intellectualists to challenge Poston’s specific suggestion for how Gettier cases of know-how are to be constructed. The key claim is that successful action (of the right intelligent sort) implies possession of know-how.

Poston goes on to suggest, interestingly, that the underlying disanalogy between knowledge-that and know-how is that the latter is not affected in the same way by intuitions of luck. Acquiring the right sort of skill though luck does not undermine the status of the know-how ascribed on the basis of that (right sort of) skill. ‘Knowledge-how isn’t constrained by the same anti-luck intuitions as propositional knowledge’ [ibid].

Elia Zardini connects his criticism to Stanley and Williamson’s need to appeal to a practical mode of presentation. Without it, knowing that some way is the way to play a piece of music is not sufficient to have practical know-how: to know how to play it. Adding this idea into the mix stops the account ‘overgenerating’ cases of know-how (in cases of mere spectatorship). But, Zardini argues, the resulting account ‘undergenerates’ the range of cases of know-how.

Although there is conceptual complexity in the connection between dispositions to act and know-how, still action can be evidence for know-how.

Now, as Carl Ginet (1975, pp. 8–9) first pointed out, much care is needed when considering any putative connection between knowing how to F and being disposed to F (or even being able to F): Segovia himself may know how to play the guitar without being disposed to play it, maybe because he has decided never to play it again, or maybe because, every time he touches one, he falls asleep (in the latter case it would even seem right to say that he cannot play the guitar, even though he knows how to play it). Yet, it seems that, however complex and mediated it may be in view of Ginet-like cases, some such connection between knowledge-how and disposition to intelligent and successful action must exist, on pains of jeopardizing what seem to be our best grounds for attributing and withholding knowledge-how. [Zardini]

Zardini offers the following biconditional: One knows how to F iff, under suitable conditions, one is disposed intelligently and successfully to F. So we have a couple of equivalences in play. There is one between intelligent and successful action and know-how; and one between know-how and knowledge that a certain way of acting is right under a practical mode of presentation (the equivalence that Stanley and Williamson set out).

But just as Poston suggested the link from practice to know-how undermined the connection between know-how and knowledge-that in Gettier cases, so Zardini argues that it blocks a distinction between knowledge-that and merely true beliefs that. This results from the intuition that if knowledge under a practical mode of presentation would be sufficient for practical ability then so would merely true belief under a practical mode of presentation. So, going the other way across the biconditional, practical ability may imply something less than knowledge and so, if Stanley and Williamson’s analysis of know-how as knowledge-that were correct, there would be much less knowledge about.

The very same materials employed by them to address the overgeneration problem (PMPs [practical modes of presentation]) can thus be turned against them to raise what seems to be a serious undergeneration problem. [ibid].

So Noë, Poston and Zardini all use the connection between practical ability and know-how to make trouble for the connection between know-how and knowledge-that. Of course the first connection is, at the very least, a complex one. But there is surely something right about it and thus forceful about their arguments.

In support of intellectualism, Phil Joyce has an independent argument for practical modes of presentation based on the ‘different mode of presentation’ response to Frank Jackson’s knowledge argument. Just as in the normal case, this reply argues that Mary acquires a familiar physical proposition under a new mode of presentation, so in a case of knowledge of the physics of riding a bicycle, Mary does not yet have those propositions under practical modes of presentation. But I do not think that this suggestion gets to the heart of my interest. I can’t seem the harm in talking about practical modes of presentation. But it seems to me that this is just a label for know-how, not a step towards understanding it in other terms and is thus a small part of the intellectualist case.

That leaves (for now) John Bengson and Mark Moffett’s intellectualist paper but the lights of Kendal are now visible through the train window and I must get off the train.

Minimal subject-hood

I saw Slumdog Millionaire on Saturday night in Lancaster, (which suddenly seemed quite far away as the rail network was reduced to 50mph for fear of forecast storms). It’s been widely described as a ‘feel good’ film and in some sense it is. But although there’s a happy romantic ending, that doesn’t take away the poverty and suffering or the blinding and amputation we’ve seen such evidence of. It’s not as though the narrow narrative is more broadly transforming. (This aspect – that no broader good would come of the central story – is reflected within the narrative of the film itself, though, when members of the urban proletariat crowding his taxi wish the central character well in becoming even richer.)

But the feature of the film which made me perhaps a little less immediately enthusiastic than I might have been is how minimal the central character is. Aside from his specific romantic drive (which exists as a brute and unexplained force), he remains a cipher even though the business of the film is to tell us about him and to tell us it from his perspective. How could that not result in an account of the sense events have had for him and thus who he is? But I have to say it didn’t seem like that to me.

This is also a feature to be grappled with in Dance to the Music of Time (I'm two novels and 500 pages in so far). Does it matter that things seem merely to happen around the narrator whilst he remains so transparent that nothing of his nature gets expressed to the reader?

By chance, the Guardian offered a typically critical summary by Jim Crace of the first novel a couple of weeks ago. The key sentence is: “As usual, I had no thoughts of my own on the subject and continued my impression of a parasitic tabula rasa.” My colleague Peter H-K, however, suggested to me that this isn’t really a problem. It’s just something to work around.

“I’ve been trying to decide whether Crace’s implicit criticism about Jenkins having no inner life really matters (though I’d rather say that he gives hints only of a rather minimal inner life). On the whole, I’m not sure it does: this is not really Jenkins’s story, but the story of all the odd characters with whom he comes into contact. He is at best a bemused, sane observer, a point of view which works very well when it comes to some of the more outrageous characters (you’ve got Dr Trelawney still to come). (However, sometimes it’s just darned silly: when Jenkins gets married, you have no real sense of why, and he subsequently refers to ‘our child’ without giving any clue of what the child is called, or what he/she is like. Indeed, he seems to have absolutely nothing to do with him/her.)”

There’s a sex scene which I had to read twice to check that that is what had happened, so little did the central character seem to be involved.

I was conscious of Gypsy changing her individuality, though at the same time retaining her familiar form; this illusion almost conveying the extraordinary impression that there were really three of us - perhaps even four, because I was aware that alteration had taken place within myself, too - of whom the pair of active participants had been, as it were, projected from out of our normally unrelated selves.
In spite of the apparently irresistible nature of the circumstances, when regarded through the larger perspectives that seemed, on reflection, to prevail - that is to say of a general subordination to an intricate design of cause and effect - I could not help admitting, in due course, the awareness of a sense of inadequacy. There was no specific suggestion that anything had, as it might be said, “gone wrong”; it was merely that any wish to remain any longer present in those surroundings had suddenly and violently decreased, if not disappeared entirely. [Powell, A. (2000) A Dance to the Music of Time: Spring, Arrow: 490-1]

This stands in a striking contrast with, eg, the central character in last year’s There Will Be Blood. In a pub in Aberdeen at the end of a cycle holiday when, the work over, we fell to banter, Dr Ian Lyne suggested that that film is like a Tractarian ‘resolute reading’. So, just as the Tractatus is supposed, on this reading, to attract the reader with seductive metaphysical noises but then force the reader to realise that no proper meaning can attach to those noises or signs, so we think that we understand Daniel Day Lewis’ character. We think we can see in his reactions a and utterances those of a rational subject in extreme circumstances. But no, on Lyne’s account, actually we come to realise, perhaps especially in that climactic final scene, that our understanding has been a sham. Noone can be like that. It’s a parody of rational subject-hood.

Mere minimal subject-hood isn’t like that. But once it itself comes into focus (once one is aware that the subject is mininal rather than merely of what goes on around him or her), and unless there is some reason for it, it threatens to introduce a dischord into the narrative flow.

In contrast, I saw Che: Part One last night (in Kendal). Its robustly third person and documentary style has the consequence that the issue of the inner life of the central character is never an issue. It is true that we are given no sneak previews of how things seem for him. But that is just what we expect from this narrative style. (Fine film, by the way.)

Life and Action

Whilst there’s no extended area of high ground in England (unlike Scotland), crossing the country in the north requires crossing the Pennines and this can be quite desolate. Late on Sunday, in the dark and in a storm, my partner and I were surprised by a tree that had fallen, blocking the road and, about a second later, hit it at some speed. The car was a write-off. We were both completely unscathed, however.

I was surprised to find that I still suffered debilitating symptoms of shock (fortunately only for a couple of days). These seemed to fit rather well, interestingly, with what can seem like a dualism at the heart of a Davidsonian picture of the mind between a nomologically causal and a rational pattern of events. So whilst one set of rational considerations turned on my good fortune and the robust nature of modern cars, causally my emotional responses went off on their own disturbing course.

But the unexpected day at home gave me an opportunity to begin to look at Michael Thompson’s new book Thompson, M. (2008) Life and Action: Elementary structures of practice and practical thought, Cambridge, Mass.: Harvard University Press. Here I must admit to some embarrassment. I know nothing about Michael Thompson other than the fact that an essay of his (which appears in this book) is footnoted by McDowell in ‘Avoiding the Myth of the Given’. Thus beginning the book was like arriving at a cinema to see a film the reviews of which one has, astonishingly these days, completely missed.

For the moment the content of the book is a bit of a surprise. The book examines three, in part interrelated, notions: life, action and practice. Jim Conant says on the back (I cheated and looked at that bit) that the account is compelling and stands a chance of transforming the subject. But, if I understand the treatment of life in the first section, it seems a very minimal and rather subtle approach.

Very, very briefly (and with more than my usual caveat), there’s a critical discussion of typical biology textbook accounts of the signs of life (eg: life-forms are organised, are homeostatic, grow and develop, take energy from the environment and transform it etc). But, as Thompson plausibly argues, these signs have to be interpreted in the right sort of way (since, eg., the warming of tarmac is a merely lifeless way of taking energy). In the right way, they are illustrative of a particular kind of process, a vital operation. But whilst stages of the process can be described in, eg., chemical or physical terms (since physics, at least, seems to be able to describe pretty much whatever happens) capturing the process as it expresses life requires seeing a particular form of unity in the right set of events (the events that do not include the intervention of a nuclear bomb, for example).

Bringing that unity into view requires looking to a broader context which frames the subsidiary events. This is the life-form in question. And this thought links to a discussion of the peculiar timeless grammar expressed in utterances such as: “The bobcat breeds in spring” or “As the heat of the summer approaches, the cubs will learn to hunt”. These ‘Aristotelain categoricals’ fit a kind of idealised and functional description appropriate for life-forms.

Well that’s my very rough first understanding of the first third of the book. All very interesting but not in itself what I was expecting, I'd have to say. But I’m waiting with baited breath to see how it will fit first with an outline of a naïve form of action explanation and then finally morally charged practices.

(I return to the second essay here and the third here.)

Demian Whiting on pathological values

Interestingly, reading Demian Whiting’s paper I see that I got the emphasis wrong rather more than the structure. Sometimes in philosophy, however, emphasis is crucial.

More than I’d wanted to present it as, the paper is a direct reply to another paper by Jacinta Tan and others which does argue that, in cases of anorexia, pathological values undermine the capacity to make treatment decisions, even though the standard tests of capacity are passed [Tan J., Stewart A., Fitzpatrick R. and Hope T. (2006) ‘Competence to make treatment decisions in anorexia nervosa: thinking processes and values’ Philosophy, Psychiatry and Psychology 13:267-282]. That implicit dialogue affects where the weight of the argument lies in Whiting’s paper and this is explicit in his abstract:

Decision making capacity (DMC) is normally taken to include: (1) understanding (and appreciation); (2) the ability to deliberate or weigh up; and (3) the ability to express a choice. In an article published recently in PPP, Jacinta Tan and her colleagues suggest that DMC requires also (4) the absence of ‘pathological values’ (i.e. values that arise from mental disorder). In this paper I argue that although (1)–(3) might be necessary for DMC, (4) is not necessary (barring cases where pathological values interfere with (1)-(3)). My argument will simply be that (4) fails to be supported by the empirical data provided by Tan et al, which I claim supports the view that people with pathological values do often have DMC. I also consider but reject the claim that pathological values entail incapacity because they are not ‘authentic’ to the person. I conclude that the absence of pathological values does not comprise an additional element of DMC and that we cannot justify compulsory treatment of people who have (1)–(3), but not (4), on the grounds they lack DMC. [Whiting, manuscript]

Thus the main argument for the claim that pathological values do not undermine capacity unless they undermine the component tests (points 1-3, above) takes the form of pointing to empirical descriptions of subjects with anorexia (rather than dealing with the dilemma as I’d thought).

The main worry, as I see it, with the view that patients with pathological values have compromised DMC even in cases where they possess (1)-(3) is simply that it fails to be supported by the empirical data, which, in my view, supports the position that such patients do possess DMC. Indeed the patients interviewed by Tan et al serve only to illustrate that point, as patients when described as possessing (1)-(3) appear to be very able to engage in the decision making process (see, e.g. Tan 2006:271). After all they are able to understand the nature of the treatment proposed, to deliberate regarding the risks and benefits of not eating or losing weight, and, on the basis of their deliberation, to arrive at and communicate a decision. [ibid]

Whiting goes on to say that they make different decisions to ones they would have made without the values (which is uncontentious) but in so doing they are still exercising a decision making capacity. This means that what I took to be merely stage setting is actually the main argument. Tan et al have provided, Whiting thinks, enough material to undermine their own case.

Thus what I took to be the main argument is now a piece of mopping up and the dilemma discussed is motivated by something that Tan et al actually say:

If a value or value system can be clearly determined to arise from a mental disorder rather than the person, then this value cannot be seen to be authentic to the person himself or herself, and, if it affects treatment decision making, should be considered suspect in terms of compromising competence. [Tan et al 2006:278]

I got the treatment of dilemma two thirds right (I think) but the discussion of the second horn has, in addition to the, as it were, ‘anti-existential’ (not his phrase) point this further and more significant argument:

[E]ven if we put this [ie the ‘anti-existential’] worry aside, it is clear that (B) [the 2nd horn of the dilemma] constitutes no reason for thinking that patients with pathological values have compromised DMC. This is because (B) only begs the question at issue. For the question at issue is: why should we hold that values that have been caused by mental illness compromise DMC? And that question clearly cannot be answered by replying that those values are the responsibility of the mental illness, not the patient, which, according to (B), is precisely what we would be saying if we answered that question by replying that those values are not authentic to the patient. [Whiting, manuscript]

We would need to be told more about why a value stemming from an illness was not a value held by the subject. My hunch is that, additionally, the fact that someone has passed points 1-3 of a capacity test itself puts pressure on answers to this. If the values have not undermined the test, why think that they are, in some more direct sense, intrinsically pathological and capacity undermining. Since Whiting is replying to Tan et al, if they have not substantiated this point, then he has done enough.

This makes thing much clearer to me and I like the paper even more than I thought.

I guess my lingering question (aside from doubts about how much capacity tests can be distinct from tests of wisdom) is whether nothing more could be said about how values might be directly pathological (independent of their undermining general decision making capacities). Couldn’t one imagine a case where, through a discrete process, a subject suddenly acquired a small set of values inconsistent with their general commitments but which remained stubbornly outside their rational control? Such surd values would be ones that resisted integration into the rest of a worldview despite their incompatibility. Perhaps they could be induced through hypnosis, illness, cult-membership or whatever. If so, wouldn’t that count as pathological and not merely as an unusual way of acquiring values (even given that values are never fully autonomously chosen)?

Now one might think that this would undermine capacity because it would undermine an ability to weight up evidence in which case it wouldn’t be a problem for Whiting. And in his helpful email yesterday he commented:

I agree that pathological (or even ‘radically surd’) values might often entail that patients weigh information DIFFERENTLY than if they did not have such values, but disagree that this means they fail point 3 on your competence test, as they are able to weigh up information (albeit differently than if did not have such values).

But I am not sure I’m happy to think that, if there were mechanisms by which surd values could be introduced into my thinking, that I would subsequently merely be reasoning autonomously but differently. Surely the process would undermine my capacity to make genuine decisions in those areas related to their specific domain of application even if – unlike the case of rash alcohol induced values, eg. – no general decision making capacity were affected?

Of course my worry now is that my reactions to this example and to John McMillan’s fear example seem directly opposed. Thus I worry that this is itself evidence of the induction of surd and hence pathological values through the influence of philosophy.

Compulsory treatment, illness and capacity

There were a number of interesting papers at Rachel Cooper’s one day workshop on philosophy of psychiatry yesterday but a couple were interestingly interrelated. John McMillan (pictured) considered the justification for the compulsory treatment of mentally ill subjects.

First, he suggested that the debate about the reality or not of mental illness is independent of the debate about whether compulsory treatment is ever justified. One might think that such illness exists but still deny it is a justification for compulsion. Equally, one might deny the existence of mental illness (qua illness) but still think that compulsory treatment is justified (I’m guessing either by thinking that medical treatment of a related physical illness is justified or by thinking that dealing with non-medical conditions might be merit the label ‘compulsory treatment’). Thus there is no a priori direct connection between mental illness and compulsory treatment.

Second, he considered what independent justification of compulsory treatment could be offered given that. Starting with Bill Fulford’s observation that mental illness is unique in that it is an area of medicine where fully conscious adult patients of normal intelligence can be treated against their will, McMillan asked what of the other cases implied by that. Fulford’s comment suggests a disjunction of conditions might justify compulsory treatment including: being an unconscious adult, being a child as well as suffering a (kind of) mental illness. So, what, McMillan asked, do these have in common? Is there an underlying condition that explains the disjunction?

His idea was that compulsory treatment is justified by a balance of non-intentionality and harm. If one’s actions fail, sufficiently, to be intentional (whether unintentional or non-intentional) and risk sufficient harm, then that justifies paternalistic intervention. One example given was a sufficient irrational fear causing sufficient harm. If the fear – he suggested – weren’t cognitively penetrable (that is, being persuaded of its lack of justification did nothing to ease it), that might justify intervention.

One virtue of this approach is that there is a plausible overlap with the mental illness defence: the latter causes a lack of intentionality. Further, this promises some possibility of borrowing some of what Bill Fulford plausibly says about how specific cases of mental illness justify treatment (in his Moral Theory and Medical Practice). Still, I’m not sure what to make of the one example McMillan offered.

I should say, I’ve never been entirely convinced by Bill Fulford’s explanation of the mental illness justification either. It has always left me with an Open Question style response. I agree that mental illness (often) causes a breakdown at the heart of deliberate action but why does that justify compulsory treatment? What exactly is the link?

Still in McMillan’s case, I am not sure whether I agree that if someone has an irrational and resistant fear that is life threatening, realises that fact but, because of the fear, resists treatment he or she should be overpowered. The presence of something like insight in the case seems to make such intervention an act of unjustified violence.

In an earlier paper, Demian Whiting asked whether having decision making capacity required an absence of ‘pathological values’. Taking this phrase, preliminarily, to refer to values held because of having a mental illness, he pointed out that such values could undermine capacity because they undermined some component ability in the capacity test (see below). But could that test be passed and then independently trumped by the presence of pathological values? The stalking horse was anorexia. If someone’s values concerning food and risk to life were held because of their illness, does this undermine their capacity?

The key part of the paper was a dilemma and, I’m sad to say, I lost concentration at just that point. So my summary is based on extrapolation from the handout (a more accurate summary of the paper is now here). Whiting suggested that there were only two ways of unpacking ‘pathological values’.

Either, they are not actually held by subjects. Here I can imagine arguing that they look to be held: they shape behaviour, guide judgements and may be quite long term.
Or, subjects are not responsible for holding them. But, as Whiting did argue, it is far from clear that we are the self-determining source of many of our values. So this cannot be what makes some values pathological.

Given that neither horn of the dilemma looks to provide a satisfactory definition of pathological value, there is no account to trump the starting assumption that if one passes the capacity test, the values that shape one’s decisions just are one’s values and thus do not – by virtue merely of being ‘pathological’ – undermine that.

The tenor of Whiting’s conclusions thus ran counter to McMillan’s (of course, being a good philosopher, he didn’t take himself to have ruled out other ways in which values might impact on capacity; just not via pathological values). Whatever an anorexia sufferer’s unfortunate values, providing they pass the capacity test, then their decisions about treatment – or its lack – should stand (unless there are additional reasons in play). McMillan would probably argue that providing there were some way in which their actions were not intentional, the risk of harm could justify compulsory treatment.

But, at the risk of relying on merely my inattentive failure to hear the full force of the paper, it looks to me that Whiting's dilemma was rather briskly outlined and dealt with. So one might think of values as held by a subject but nevertheless being pathological because of their inconsistency with other values also held. The pathology would be a surface feature of the holism of the subject’s beliefs and values. Held versus not held does not seem a very helpful way of unpacking what might seem pathological in the case of anorexia, to return to the example.

The alternative again seems too crude a distinction. Whilst no one is as self-creative as the French existentialists wanted, still one might think of values as being determined not by a culture or tradition, for example, but by an illness. If a symptom of having a particular illness is holding otherwise uncharacteristic values, then it might be useful to describe those as ‘pathological’. Perhaps a subject, on recovering from the illness, does not merely announce that she has changed her values: she expresses horror and surprise at what she had been saying whilst ill. The idea of pathology would stem from the underlying illness, whether or not the resulting values were synchronically reconcilable with the subject’s other (synchronic) values.

Of course, for either of these sorts of cases to be a counter-instance to Whiting, they would have also not to block capacity by blocking one of the component tests ie

1 understand the information relevant to that decision
2 retain that information
3 use or weigh that information as part of the process of making the decision
4 communicate their decision (whether by talking, using sign language or any other means).

And it is difficult to know whether the third test can be passed by someone who has radically surd values which resist revision in the light of holistic considerations. That I think is a problem with thinking that capacity could ever be assessed independently of the content of decisions and thus independent of their wisdom. So I am not sure whether I disagree with Whiting's overall views or not.

PS: Demian emailed to explain that I'd not got his position right. A correction is thus here. But I have left this version up because the differences are - a little - interesting.

PPS: capacity has come up again: here and here.

Housekeeping

Well that’s that. Keeping up with family tradition we held an Epiphany party (a couple of days early) to mark the end of the holiday period and pretty much everyone who came goes back to work tomorrow. (In my case, my first day is a one day workshop on philosophy of psychiatry in Lancaster organised by Rachel Cooper.) With no particular determinate answer to the question of how best to think about the season, I’m struck by how clear the end of the period seems, nonetheless. The first day back to work at this time is notoriously one of the most depressing days of the year.

Since my last round up in September, my article ‘Does understanding individuals require idiographic judgement?’ has come out with the European Archives of Psychiatry and Clinical Neuroscience. This was a fairly short paper which considered what kind of ‘individualising’ judgement might be thought implicated by idiographic understanding (in what way might the judgement be thought to be independent of others?). But as a result of its publication, the editor of Psychopathology is uneasy about publishing the other longer draft paper previously requested which started where this one left off and then considered the narrative understanding alternative but did repeat the key objection to Windelband (the climax, as it were, of one paper and the starting assumption of the other). I will have to think how, and whether, to deal with this (and how to deal with a tricky referee’s report (one of three; two are fine) which seems quite off kilter to me).

Two PPP papers will come out in a few months in an edition on EBM and VBM. Again I have a bit of an overlap problem because I’ve used some material in one of these that I also put in an AAPP commentary on Peter Zachar (pictured) and Kenneth Kendler’s suggested conceptual framework to assess psychiatric taxonomy and I’d assumed that the AAPP commentary would have come out a good six months before its reworking and extension in PPP but it is delayed until at least later in January. Since Zachar and Kendler have replied, I wouldn't want, perhaps more honourably, to pull the AAPP version.

The chapter I wrote with Bill Fulford for a WPA edited book on psychiatric diagnosis (Salloum, I.M and Mezzich, J.E. (eds) (forthcoming) Psychiatric Diagnosis: Patterns and Prospects, Hoboken: Wiley) had, at the last minute, a section on Greek philosophy injected by George Christoudolou. My original drafting cannot have been a very seamless creation because his late insertion didn’t seem to me to upset the flow of the chapter very much if at all.

Bill and I have also just put together a chapter called ‘Meanings and Values as a Complement to Neuroscience: A Case Study in the History and Philosophy of Science’ for Puri, B. and Treasaden, I. (eds) Psychiatry – an evidence-based text for the MRCPsych, London: Hodder Arnold, Health Sciences. For this I combined material on Jaspers and on Windelband to suggest that there were two useful but independent additions to scientistic science (Jaspers doesn't seem to do values). Since the psychiatry students who will read this chapter will not have read any of the journal papers (or my book), it seemed rational to base it on previously written material, reworked for this chapter. But it was rather dull to write, as a result.

The moral of all this is that I’ll retire all previously worked on philosophy of psychiatry material as of now. Three years of developing a number of connected themes for as many publications as I could manage (to justify my post) in applied philosophy journals, non-philosophy journals, a book and book chapters was bound to produce overlap in written articles but I think I’ve done too much of that now. A new year is a good time to think about some new things and start again from scratch.