Clinical Judgement and the Medical Humanities

It may just be too embarrassing to have this obviously unscripted talk on my blog for long. But, briefly and in case anyone is interested, this is the audio for a talk I gave, a month ago and to some medics, on Clinical Judgement and the Medical Humanities. (I have no idea whether it is complete as I could not stand to listen to my own voice for more than a few seconds. Too, too mortifying. From the inside I sound - to myself - like a cross between Christopher Eccleston and Pierce Brosnan, honestly. (But in effetely writing 'too, too mortifying' I realise that I am hardly helping my own case.))

A short email dialogue with Harry Collins

I have here summarised a brief but, for me, helpful email exchange I have had today with Harry Collins starting with a query he had about the final line of my previous blog entry on his group’s new thinking about interactional and contributory expertise. I had said that it seemed to have undermined what seemed interesting to me in the original account: that there was a fundamental kind of non-practical but still tacit knowledge. But Harry pointed out that:

“There are still people who have tacit knowledge in virtue of their language alone and nothing from [practice]; some of those are special interactional experts. The point is that there are lot more non-special interactional experts than we thought: these have something from the practice but most of it from the language.”

Now the point I was trying to make was that one difference between the new and the old picture was that on the old picture, interactional expertise (IE) seemed to be a further development from contributory expertise (CE) (with the latter serving as a paradigm of tacit knowledge for a reader like me). So IE seemed like an interesting extension to (a kind of optional extra to) CE. But on the new picture, with language at the base of everything, IE isn’t an extra but is instead presupposed by CE. (And that isn’t really affected by the existence of logical limit case of Special Interactional Experts (SIEs) who have the language without any of the practices.) So whilst I like the new picture because it places (if I follow) language (or conceptually structured ability) at the heart of tacit knowledge, interactional expertise as a phenomenon looks less interesting.

Harry replied by pointing out that the ubiquity of interactional expertise shouldn’t make it any the less interesting:

“I don’t see IE as less interesting because it turns up everywhere. We just hadn’t noticed that most of what was going on was IE rather than CE and that seems very interesting to me. It seems interesting that though language is practice-based it, as it were, contains the practice on which it is based so to that an understanding of that practice can be acquired by individuals via acquisition of the language alone. And we now realise it has to be that way if we are going to have society as we know it.
Sociology, and policy-wise, the ‘special IE’ people are still specially interesting over and above this, of course, because they are normally excluded from decision-making as they have no obvious practical credentials.
All that has changed outside of the SIEs is that we now discover that even those with practical credentials are using their practical experience hardly at all, or not at all, when they make judgments. The whole programme of research has been going this way from the beginning when IE was first thought of as an exception, then when it was realised that managers have it, then when it was realised that it was central to the division of labour and this is just the ‘gestalt switch’ was inevitable as things went along in this way.”

This reply helped me focus my worry. The most obvious way in which “though language is practice-based it, as it were, contains the practice on which it is based” is an intellectualist account of the priority of language over practice. It would be true, eg, of the platonist account that Wittgenstein undermines (and which Collins summarised in the introduction to Changing Order). Language would contain practice by fully describing it. (Of course to speak is to take part in a practice so there would still be an element of truth to language also being practice-based.)

Thus my worry was that the trajectory of Collin’s research group seems to be from those who put practice over autonomous platonist codification (Wittgenstein, Ryle, the early Heidegger on some interpretations) towards those who play up knowledge-that as the basis of knowledge-how (very influentially these days: Timothy Williamson in Oxford, but in a kind of a way also Jerry Fodor in his AI-inspired approach to the mind). Amongst those latter people, the idea that there may be SEIs without any CE wouldn’t come as any surprise: they (the SEIs) are just those people who master a language. Others - mere artisans, as it were - may also acquire some additional CE but it now seems to be an inessential add-on since language itself already contained the practices in question.

What would thus look to have gone missing would be the idea that there is a fundamental contextual element to practical expertise, an element not contained in what those who merely master general language learn. As a long standing fan of Changing Order, that’s a qualm.

Fortunately Collins has, apparently, not given way to an intellectualist dismissal of the fundamental role of tacit knowledge, replying:

“Well Tim, I am not a philosopher but the key idea might be the following. You say:‘Language would contain practice by fully describing it.’I say, absolutely not! The practice is not contained in what people can say, it is contained in their saying it. Language, as one might say, is a practice and it is that practice that contains the other kind of practice (the understanding of physical practice). It is quite hard to know how to say that well. But I am still completely with Changing Order in that the visible formal descriptive content of language cannot capture practice and that still means there are no recipes for experiments and so forth.As far as Changing Order is concerned I would now like to redo my TEA-laser study, say, and work out how much of the learning that went on when laser-builders actually visited other laser builders took place in the talk and how much my practical manipulation in the lab. Probably impossible to pull apart in practice but pull-able apart in principle.”

The first distinction in this reply suggests a distinction with which analytic philosophers have not, in the main, been very interested but might be that between ‘langue’ and ‘parole’.

I can also see how, especially perhaps with that distinction in mind, the further exploration of the distinction between manipulation and talk would be intriguing. But I wonder what Collins could find there. He said that the ‘visible formal descriptive content of language cannot capture practice’. What difference does moving to consider the particular moves that might be made in say the Cavendish coffee room (as opposed to the moves that were grammatically licensed) make? Here’s my worry: leave a tape recorder running to capture these utterances and write them down. What difference is there now between these and an instruction manual written for a Wiley science textbook in formal descriptive language?

Where one might have a difference is (to echo Changing Order) in the laboratory itself with an expert saying to a student: the connections should look like that! This isn’t transferable in merely conventional linguistic terms because we need to see the connection to know what the concept of ‘like that’ means. I’m a disciple of a particular view of a bit of philosophy (McDowellian) which says that this is itself a concept (so not all concepts are fully linguistically codified). This also fits with what Wittgenstein says about samples being part of language. So I’d say that this was consistent with your general ‘language is at the heart of expertise’ view (with language construed as conceptual activity governing both words and samples). But it doesn’t sit happily on either side of your distinction between talk and practical manipulation. So I’m not sure that that’s a helpful distinction.

In reply to these thoughts, Harry said:

“OK Tim,
You are getting there but still haven’t quite got it.
I would not find any interest in what was in the Cavendish conversation – what was recorded on the tape that I could listen to – I would be interested in how long the novice spent in conversation with the others about technical matters.
Think of this as an analogy. When a child learns a natural language like English the child learns, for example: Verb in the middle not at the end. But nothing you the philosopher/sociologist would hear on the tape would correspond to ‘verb in the middle not at the end’ (unless you already knew grammar and could do some meta-analysis of the conversation). What you, as a child, would be learning would be how to do it (put the verb in the middle) and you would have learned how to do it without being aware that you had learned or even that you now knew it. You would just have learned to speak.
I visualise the practical knowledge you learn in becoming fluent in a practised-based language as being like this grammar: it isn’t spoken, yet it is contained. The reason it can be contained is that the language is formed by the physical practices in the first place. It is in the silences, as one might say (or in the form of the words, the nuances, the balance of the vocabulary for this and that, and I don’t know what else). You get none of this from books -- you must have fluency.
Is that better?
Harry”

I will have to think a little more about how this analogy works between learning verb placement from utterances and practical knowledge from utterances. Of course, things are made much more difficult because of the well known problem of both codifying the patterns of correct usage children learn (in, for example, transitions between questions and statements) and the apparent paucity of evidence for merely inductive generalisation (which is why Chomsky thinks grammar is innate). But if that could be put aside for the moment (and I am going to assume that there will be no equivalent of Chomskian innativist explanation in the other part of the original analogy: getting science practice from science utterances), what is the sense in which correct verb order is or isn’t in the utterances?

Well it is not contained in a meta-linguistic grammatical instruction (the one which is also so hard to formulate). So it’s not there in that sense. And it might seem now that that metalinguistic rule has merely a shadowy presence in the actual utterances. But there is something that is simply there in the utterances a child hears: correct verb placement. Contra Harry’s reply it seems to me that it is spoken. The child hears the correct pattern in the utterances they hear, a pattern which we might now explain (in the absence of the metalinguistic rule) through the use of the same examples the child hears. So that doesn’t seem too mysterious after all (pace the major Chomskian issues).

The other complication in the analogy is that the child is learning grammar, not moves then to be made within grammar. So they are learning the possibilities of what was earlier called the ‘visible formal descriptive content of language’ which was, it was suggested, not up to the job of capturing practice. It’s not clear to me whether we can apply this in the case of the apprentice scientists learning from the utterances, their gaps, foci and pregnant silences, to say that they too are learning a ‘grammar’ of scientific practice, a grammar which, for the analogy to help, could not be captured in a textbook account of the basics of science which might also have characteristic gaps, concentrations and odd silences.

I’ll have to think more on this. I’m not unaware, of course, of the irony that I’m sitting in my philosophical study talking theoretically about tacit knowledge to a sociologist who actually investigates it practically!

PS: on the following day.

Tim,
Yep, I'm happy with that as a reproduction of our email conversation.
It's your blog so you should have the last word but let me just say one more thing -- whether you put it up or not is up to you.
Note that neither the child nor the philosopher/sociologist (who is not already dealing with the abstract notion of grammar) in the analogy, ever `knows' that the verb is in the middle. The philosopher/sociologist who merely listens to the conversation will not possess the knowledge that the verb goes in the middle. The child only comes by that knowledge by actually learning to speak. That is why there is such a stress on participatory methods in sociology: you come to know not by observing but by participating. And you generally do not know what you know. But having learned to participate you can use this `unknown' tacit knowledge to make good judgements even if you don't know how you make them.
The idea of learning a language to the degree of fluency required by the interactional expert is, then, congruent with idea of learning a physical practice like bicycle-balancing. You come to know (that is not know) how to do it by practicing not by observing and when you have acquired the practice you cannot describe the contents of what it is you have acquired. Language is the same -- language is in this sense `a practice.' The idea of interactional expertise is that in learning (not observing) a physical-practice-based language you also learn to understand the practices on which the language was based. You don't learn them explicitly, you learn them after the fashion of acquiring tacit knowledge.
This exchange is useful to me because, perhaps because of the tradition I have always worked in, it has always felt good enough to me to say things like `language is a practice, and contains practice -- geddit?' I always assume that those around me will be satisfied with that. I am now being forced to spell it out a bit more. I am now `thinking on my feet' but one way fluency can contain knowledge is through the un-self-conscious acquisition of the frequency with which something is said in the community. For example, if I want to know the importance of, say, some source of noise in an apparatus -- is it just a nuisance or is it fatal? -- I might pick it up from how often it is mentioned in conversation. I might also pick it up from whether it causes people to joke about it in a certain way (which they do in the case of serious things), or joke about it in another way (which they do about silly things), the reverence with which it is mentioned and how all these things balance out. Of course, in lived language the balance of these kinds of things is changing all the time which is why the interactional expert's abilities to make good practical judgments diminish rapidly as soon as they are no longer in touch with the language community.
I am not here trying to develop a calculus of conversation or a recipe for the tacit knowledge in language, just indicating one way in which it is possible for there to be knowledge in fluency that is not in the descriptive content of what is said. But I would no more think about trying to work this out fully than I would want to try and work out what it is in the muscles, brain and nerve pathways that enable a person to balance on a bike. All I want to do is show how it can be that fluency in a language can contain much more than is said.
Cheers
Harry



PS: For my first thoughts on his recent book on tacit and explicit knowledge see this.

Transitive and intransitive meaning

Richard Gipps has been trying to persuade me, over the last couple of years, to have a less monolithic attitude to meaning. The moral I’ve taken him to be trying to impress on me is twofold.

First, we need to avoid both the pitfalls of platonism and constructionism about meaning. Wittgenstein should be taken to be opposing a notion of meaning that severs all connection to our meaning-laden reactions (on the opposed platonist picture, rails that lead to infinity take care of meaning without our reactions, eg.). And thus, by extension, Wittgenstein opposes a picture in which one can begin to gesture towards other meaning-driven ways of going on, ways which, however, we can make nothing of – cannot understand or follow – but can still think of, from a detached philosophical perspective at least, as norm- or meaning-driven (cf Lear).

At the same time – and still part of the first aspect – we should not react to this rejection by adopting a view of meaning in which we simply make things up as we go along. We should not think of meaning as a matter of piecemeal construction.

All that is the first part of the moral, I think, that I’m being urged to accept. And I do accept all this. Steering a middle ground between platonism and constructivism seems to me to be a helpful way of characterising whatever is positive in Wittgenstein’s description of meaning [Thornton 1998]. Of course, this isn’t a positive substantial or explanatory theory of meaning.

What I have found harder to accept, until recently, is a second thought: notwithstanding the rejection of platonism – and thus the rejection of the idea, at least, of other ways of going on – this doesn’t imply that we have now fully left the domain of meaning and our meaning-related reactions. It’s possible to maintain the rejection of platonism but still have a more pluralistic response to its absence. Richard and I are finishing a research bid that charts just this space for the case of nonsensical delusional thought and expressions.

Against this background I have been re-reading Wittgenstein’s Remarks on Frazer’s Golden Bough, Peter Winch’s The Idea of Social Science and its Relation to Philosophy and reading Phil Hutchinson, Rupert Read and Wes Sharrock’s There is No Such Thing as a Social Science.

This has forced me to rethink what one might call an intransitive notion of meaning. We can think of this on the basis of what Wittgenstein says in passages of the Brown Book in which he criticises a constitutive theory of meaning (passages which I think that Louis Sass misuses) and distinguishes transitive and intransitive uses of ‘particular’ (in order to criticise the idea that meaning something consists in a ‘particular’ experience). (I should add that using this distinction positively doesn’t undermine my worry that there is something wrong in sass using Wittgenstein’s account of what meaning isn’t and cannot be to shed light on delusional thinking.)

Now the use of the word "particular" is apt to produce a kind of delusion and roughly speaking this delusion is produced by the double usage of this word. On the one hand, we may say, it is used preliminary to a specification, description, comparison; on the other hand, as what one might describe as an emphasis. The first usage I shall call the transitive one, the second the intransitive one. Thus, on the one hand I say "This face gives me a particular impression which I can't describe". The latter sentence may mean something like: "This face gives me a strong impression". These examples would perhaps be more striking if we substituted the word "peculiar" for "particular", for the same comments apply to "peculiar". If I say "This soap has a peculiar smell: it is the kind we used as children", the word "peculiar" may be used merely as an introduction to the comparison which follows it, as though I said "I'll tell you what this soap smells like:...". If, on the other hand, I say "This soap has a peculiar smell!" or "It has a most peculiar smell", "peculiar" here stands for some such expression as "out of the ordinary", "uncommon", "striking". [Wittgenstein 1958: 158]

Now the intransitive notion of meaning might be what’s in play in a passage in which Wittgenstein compares musical and semantic understanding such as:

527. Understanding a sentence is much more akin to understanding a theme in music than one may think. What I mean is that understanding a sentence lies nearer than one thinks to what is ordinarily called understanding a musical theme. Why is just this the pattern of variation in loudness and tempo? One would like to say "Because I know what it's all about." But what is it all about? I should not be able to say. In order to 'explain' I could only compare it with something else which has the same rhythm (I mean the same pattern). (One says "Don't you see, this is as if a conclusion were being drawn" or "This is as it were a parenthesis", etc. How does one justify such comparisons?--There are very different kinds of justification here.)
531. We speak of understanding a sentence in the sense in which it can be replaced by another which says the same; but also in the sense in which it cannot be replaced by any other. (Any more than one musical theme can be replaced by another.)
In the one case the thought in the sentence is something common to different sentences; in the other, something that is expressed only by these words in these positions. (Understanding a poem.)
532. Then has "understanding" two different meanings here?--I would rather say that these kinds of use of "understanding" make up its meaning, make up my concept of understanding. [Wittgenstein 1953]

I have always been suspicious of this because of the use of it which David Bell intends when he suggests that intransitive meaning can serve as the basis for transitive meaning, addressing Kant’s schematism worry (what other than a rule can guide the application of a concept to a particular?). But there is no need to saddle Wittgenstein with Bell’s project. And if not we have a notion of meaning in play but not meaning anything. (‘[I]f, recognizing this, I resign myself to saying "It just expresses a musical thought", this would mean no more than saying "It expresses itself"’ [Wittgenstein 1958: 166])

So what notion of meaning is this?

A recurring theme in the Remarks of Frazer’s Golden Bough is Wittgenstein’s criticism of Frazer’s method of shedding light on the alien cultural practices by looking for underlying causes (such as quasi-scientific attempts to intervene in nature through rain dances). To a first approximation, Wittgenstein suggests instead that the meaning of cultural practices lies open to view (for those, at least, with eyes to see). One comparison he uses is to remind us of our habit of kissing a picture of one’s beloved. This is not the means to any distinct end. (A really helpful comment in the Hutchinson, Read & Sharrock book is to suggest that we are NOT supposed to find our own habit here unsurprising. Although this is what we do, still on reflection, it’s a bit strange. So, I infer, we can find our way to a degree with the aliens even if what they do remains a bit strange.)

(There’s a section which I cannot fit quite into this approach. The Beltane Fire festival, pictured, is a disturbing ritual involving cake eating, buttons and simulated death. Of this, Wittgenstein wants to suggest that part of what makes it disturbing is its ancientness. But that it is ancient is not a Frazer style hypothesis about . Rather its very appearance bespeaks ancientness. That seems rather hard to swallow.)

So we have a notion of understanding which might be put like this. On Frazer’s approach, the rituals described in one way mean something else. A dance that, we know, cannot have any effects on the weather, is nevertheless attempted for that reason. That is the kind of act it, intentionally, is. On Wittgenstein’s approach we can come to an understanding of the rituals (albeit by a potentially painful process of self-transformation) in their own terms. They mean what they mean.

My slight qualm is that I’m not yet fully beyond my monolithic impulses. I’m not sure that this, failing to be transitive, is any sort of meaning. Or better: it is meaning merely in secondary sense. This is part of what I wish to research.

Bell, D. (1987) 'The art of judgment’ Mind 96: 221–44
Hutchinson, P, Read, R., and Sharrock, W (2008) There is No Such Thing as a Social Science, Aldershot: Ashgate.
Thornton, T. (1998) Wittgenstein on Language and Thought, Edinburgh: EUP
Winch, P. ([1958] 1990). The Idea of a Social Science and its Relation to Philosophy, London: Routledge.
Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell.
Wittgenstein, L. (1958) The Blue and Brown books, Oxford: Blackwell.
Wittgenstein, L. (1978) Remarks on Frazer’s Golden Bough, Doncaster: Brynmill Press

Richard Sennett’s The Craftsman

Some time on a train gave me a chance finally to finish Richard Sennett’s The Craftsman. I had hoped for a sociologically informed but still theoretically structured study of craftsmanship: of what is involved in craft skills. That expectation was probably the result of reading, many years ago, Harry Collins fine empirical study of the nature and transmission of tacit knowledge: Changing Order.

Indeed Sennett’s The Craftsman has some interesting moments. There are discussions both brief and lengthy of the craftmenship manifested by the community of Linux programmers, the workshops of C17 violin making families, medieval goldsmithing and the rise of, and response to, machines at the start of the industrial revolution. But these examples, and indeed all of the promise of the book, are contained only within the first of three sections.

Therefter in the book, nothing really gels. There’s a chapter on hand skills: a potentially fascinatingly locally embodied focus. But it seems merely a description of the linear growth of forms of manual dexterity.

A chapter on verbal instructions and three literary tropes for avoiding merely ‘dead denotation’ in cookery books doesn’t seem to address the fundamental issue: just what is so dead about denotation? That might be the locus of an issue about the relation between skills of craftsmanship and what can be linguistically codified. Perhaps, for example, denotation would indeed be dead without a background of craft skills. Without that, it is interesting that different chefs use different styles of prose but really, so what?

Too much of the book baldy asserts general claims – which might be necessary or essential claims about the nature of craftsmanship – on the basis neither of an argument nor detailed sociological or historical study. (There is a comparison of Wittgenstein’s attitude to the house he built for his sister and to his changing philosophy of language. But it is sub third year undergraduate essay material.)

Perhaps Sennett is simply too famous and too prolific. The book needs a good edit. Or perhaps this reflects something which might be grist to the mill for a book in this area. Perhaps broadly sociological work simply doesn’t need, as a literary genre, as a means of avoiding dead denotation, the kind of tight argumentative structure of a philosophy book (although Collins managed it perfectly well). Perhaps a suitably inducted craftsman sociologist is able, as I’m not, to fill in the gaps, to see an implicit structuring argument. But for whatever reason, at least I now know I don’t have to address this book in my own. That is a kind of positive result in a loosely falsificationist spirit.

Collins, H. (1985) Changing Order: Replication and Induction in Scientific Practice, London: Sage
Sennett, R. (2008) The Craftsman, London: Penguin

Everyday illness phenomenology #2

I’ve mentioned before that it would be interesting to have a descriptive phenomenology of banal illnesses (to augment the more serious phenomenology of more serious illness). In the middle of a typical (except for the absurd amount of sleep I’ve needed) but still unpleasant and lengthy autumn cold, I want to mention a couple of points that might get into such an account.

Firstly, the balance of indulgence and boredom. A sufficiently obvious minor illness is enough to justify not working, including justifying to oneself not working in one’s own time (even though that book won’t write itself). So it buys one guilt-free independence of a whole often unpleasant tract of reality. And if one needs to sleep, there’s some pleasure in such guilt-free indulgence.

I don’t, however, think that any of that removes the boredom of drifting in and out of sleep for many hours a day, the boredom one would feel under normal circumstances in just resting and doing nothing interesting. (I've now not logged onto work email for 3 days. How could I not therefore have made progress with Richard Sennett's The Craftsman, even if not the rather drier Kendler and Parnas collection on psychiatric explanation? What have I been doing?!) But, like the case of pain and some analgesics, whilst the boredom (like the pain) is still there, under the control of sickness it doesn’t particularly bother one.

Secondly, and this may be peculiar to me, the right space or environment becomes important. Obviously, the bedroom for sleeping. But for me, the bedroom, also, for wakeful languid groaning. But there comes a point when I simply must get up and have a stab at being ‘up’ for some sort of truncated evening and thus down to the drawing room. (My study, otherwise my favourite room, doesn’t get a look in when I’m ill.)

The same sense of what is right attaches to entertainment. If I’m not up to reading (it is sometimes said that colds call for Miss Read though I can’t say I’ve tried: Iris Murdoch for me), it’s the radio during the day, but television is the right thing for the evening (again even a whole evening of television would be an allowed indulgence).

My hunch is that this latter pattern is important for me because so is a sense of normality, of the ordinary, and it is that as much as anything that is threatened by minor illnesses. So, now, sitting on the bed listening to Radio7, seeing in the now dark window that I have lost yet another day (the sun sets so early in Kendal), it is the return to simply feeling (and in that sense being) normal as much as the return of ordinary ability or thus to ordinary doing [Fulford 1989] that I’m impatient for.

Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Kendler, K.S. and Parnas, J. (eds) (2008) Philosophical Issues in Psychiatry: explanation, phenomenology, and nosology, Baltimore: Johns Hopkins University Press
Sennett, R. (2008) The Craftsmen, London: Penguin