At the INPP 2010 conference in Manchester

I’ve spent the last three days at the 13th INPP conference co-hosted by my university and ENUSP. The aim of that partnership was to stimulate a wider dialogue about issues in the philosophy of psychiatry than is usually the case at such conferences. I’m not sure I can judge accurately how much progress was made but I think we can say that we made an honest attempt at a first step.

There are a number of fundamental intellectual tensions in the area (to pick another: the idea that understandability might be the mark of the mental together with the problem of articulating the content of good quality delusions) which cannot simply be side-stepped. In the relationship between psychiatry and service user groups, the issue of coercion looks to be another unavoidable tension which cannot simply be wished away.

One other obvious feature of the conference was a rare chance to hear Thomas Szasz. It was interesting to hear how resolutely he rejected being co-opted into strategic alliance with members of the audience who thought they agreed with him. He was also admirably self-consistent following inferences no matter how unappealing the final destination.

My random selection of papers included Paul Hoff singing the praises of Jaspers’ less well know rival Arthur Kronfeld and his notion of autological psychiatry. Sadly insofar as Kronfeld emphasised the role of an irreducible mental starting point (to complement external heterological causal and physiological factors), he was stuck on what Bermudez calls the 'interface problem' rather than having a bright idea to get round it (at least that is what Paul Hoff thought over coffee).

Victor Dura-Vila presented preliminary findings from a joint anthropological study of nuns’ and others’ views on personal identity. My hunch is that testing variation on initial intuitions might destabilise one view of philosophy if it turns out that there is wide variation. (That view is that philosophy starts from and aims to preserve as many as possible of, our intiutions, though necessarily sacrificing some. If there were wide variation in starting intuitions, there might not be much point to that venture.) But, on the train this morning, Gloria Ayob disagreed: any such inquiry necessarily initiated a philosophical investigation not a theory neutral sampling of stable intuitions. This made me wonder whether, punning on the word ‘intuition’, philosophy might be Hegelian rather than Kantian, with no intuitional constraints on it from outside it.

Clarissa Dantas, a colleague of Claudio Banzato, presented a very clear account of the presence of values in the negative symptoms of schizophrenia. Given that profs Sadler and Fulford were in the room (both committed to the irreducible presence of values in diagnosis), I tried to get her to comment on the idea that these might be explained away through biological dysfunction but she modestly declined.

Louis Charland (picturerd) raised a very simple but powerful issue: is it ever possible to get informed consent from addicts for studies of addiction. It struck me as bang on.

My own presentations are here and here. In addition I tried to co-host a session with Anne Laure Donskoy aimed at non-philosophers to explore from first principles just how philosophical insight was so much as possible: (for me at least) much the hardest thing I’ve recently tried.

Naturalism and dysfunction

At the Sorbonne conference yesterday, I gave a presentation (here) to an audience which included Jerome Wakefield. My presentation, in a nutshell, was that the Wittgensteinian argument I’d deployed against Millikan in my 1998 book only worked against one of two reductionist aims. But that that is OK since that is the relevant aim for the philosophy of disorder.

Taking there to be a distinction between Fodor’s aims and his actual arguments in Psychosemantics as an example, I contrasted the logic of his practice with the logic of the practice of Millikan. Fodor’s aims are made clear in this passage.

I suppose that sooner or later the physicists will complete the catalogue they’ve been compiling of the ultimate and irreducible properties of things. When they do, the likes of spin, charm and charge will perhaps appear upon their list. But aboutness surely won’t; intentionality simply doesn’t go that deep. It’s hard to see... how one can be a Realist about intentionality without also being, to some extent or other, a Reductionist. If the semantic and intentional are real properties of things, it must be in virtue of their identity with... properties that are neither intentional nor semantic. If aboutness is real, it must be really something else. [Fodor 1987: 97]

The promise of the programme is that intentionality itself will be naturalised through reduction. If not, then it would be convicted of being unreal (since the third position: appearing on the physicists’ basic list of properties isn’t a runner).In fact, however, what actually happens in Psychosemantics is more basic. A causal theory of reference is turbocharged by the asymmetric dependence theory to try to make space for the possibility of false thought (which is as far as he goes towards providing an account that is sufficient for the normativity of mental content) and then tied to a language of thought: syntactically characterised inner representations. But none of this goes any way towards reducing the nature of content as such, of the normative liasons between concepts and contents.

Thus what he actually attempts is to show that it is not mysterious (that it is natural) that creatures like us can think thoughts or can, if you will forgive me, respond to the space of reasons. Thus the question is: Given the space of reasons, how is it possible for creatures like us to respond to them?

Millikan, by contrast, aims to do something more ambitious with her evolutionary theory. Assuming a tool which is already more developed to account for the normativity of content (because, in turn, she has in one sense a less ambitious aim: to reduce intentionality to biology not physics) she has a check list which is then more ambitious.

First, it is not simply that a general evolutionary theoretical explanation can be given for the possession of intentional mental states (of why it is advantageous to be able to represent the world). It is rather that each particular type of content can be explained in this way. Thus the explanations cannot be question-begging: the selective advantages conferred must be characterisable in non-intentional terms. The meaning must drop out of the evolutionary theory.

But second, more relevant to my concerns, and perhaps motivated by the thought that once she is in for the penny of all of the first point she might as well be in for the pound of this also: she aims to naturalise the space of reasons itself (not just our ability to respond to it). She will naturalise conceptual liaisons themselves. Given a teleological account, logic itself will become ‘the first of the natural sciences’ [Millikan 1984: 11]. So her key question is: Given our biological natures, how is it possible for creatures like us to respond to what we take to be the space of reasons, whatever it is.

We can think of the differences in accord with the Euthyphro ‘paradox’. We all agree that: For any act x: x is pious if and only if x is loved by the gods. But: Is the pious loved by the gods because it is pious, or is it pious because it is loved by the gods? Fodor’s and Millikan’s projects take opposing views. In effect, Fodor derives engineering constraints on the gods given that we know that they are able to track piety, antecedently understood. Millikan, by contrast, aims to explain piety by describing the engineering of the gods.

There is, however, a familiar objection to Millikan. A teleological account of function is a form of interpretational theory. Past behaviour is a set of signs to be interpreted. Like the interpretation of signs, such behaviour is consistent with an unlimited number of possible functions or rules including both continuations that seem natural and logical and an unlimited number of other ‘bent’ rules that deviate in unnatural ways.

What ensures the determinacy of biological function – what selects just one of the rules – is an explanation of the presence of a trait couched in intentional terms which interprets what the trait is for. But finite past behaviour can be explained as exemplifying many different or ‘bent’ functions or rules, all of which would have been equally successful in the past but which diverge in the future.

Millikan’s reply to this is:
[The ‘bent’ rule] is not a rule the hoverfly has a biological purpose to follow. For it is not because their behaviour coincided with that rule that the hoverfly’s ancestors managed to catch females, and hence to proliferate. In saying that, I don’t have any particular theory of the nature of explanation up my sleeve. But surely, on any reasonable account, a complexity that can simply be dropped from the explanans without affecting the tightness of the relation of explanans to explanandum is not a functioning part of the explanation. [Millikan 1993: 221]

But this reply only works if the simplicity of an explanation can be assessed in a non-question-begging way. The problem is that the explanation of the survival value of the trait corresponding to a particular mental content has to be given without presupposing its content. And, of course, the content of the proper function is not just a matter of looking to behavioural dispositions but selecting a function which best explains them.

I am now less convinced than I used to be about the universal applicability of this argument against a reductionism based on biological functions. It depends, also, on the aim of the reduction. So if the question is: Given the space of reasons, how can we respond to them?(construed as an invitation to armchair engineering) then the Wittgensteinian objection has no force because the explanation presupposes merely conceptual normativity which was always simply presupposed in the reductionist question. But if the aim is to naturalise the conceptual space of meaning itself then the objection looks to hold because a key question is begged about that space.

What then the reductionist aim of the invocation of biological function in the philosophy of illness, disease or disorder? Two options can be articulated by translating from Fodor’s and Millikan’s questions in the philosophy of content. There, I suggested that Fodor’s question is: Given the space of reasons, how is it possible for creatures like us to respond to them? Translated into medicine we get something like: Given the conceptual space of illness, how is it possible for creatures like us to suffer it? And that doesn’t seem a question worth giving an a priori answer to.

Millikan’s question was: Given our biological natures, how is it possible for creatures like us to respond to what we take to be the space of reasons, whatever it is? Translated into medicine, we get something like: Given our biological natures, how is it possible for creatures like us to suffer what we take to be illness, whatever it is.

Millikan’s looks the better model question for the philosophy of medicine. It makes questioning the nature of the concept of illness itself central, jnot just something presupposed. But of so, because it shares the task of naturalising the normativity of pathology, Wittgenstein’s objection is a serious objection. (That is, a biological teleological account cannot rule out wildly divergent accounts of the functions in play, functions which explain the presence of traits.) And if so, we need a better version of naturalism for the philosophy of medicine.

I didn’t understand Jerry’s reply (to which I wasn’t allowed by the circumstances of the session to reply). It seemed to have two elements (but I may simply not have got the first part at least of what he was saying). He first suggested that my argument turned on a Quinean notion of the indeterminacy of translation. Quine (by implication: like Wittgenstein) had established that meaning is indeterministic. I took the implication of this to be that nothing much follows from that about meaning.

But second – and this argument I thought I did follow – Millikan’s project does require determinacy of meaning which a Quinean argument undermines. But the functions involved in disorder do not require such determinacy. So a Quinean argument for the former does not apply to the latter.

There would still be something a bit odd about this, though. If one believed that Quine was right about meaning one could not also his views as an argument against a reduction of meaning via function by arguing that the latter wasn’t deterministic. Quine’s account of the nature of meaning would make the target of the reductionist analysis indeterministic. So if the analysis was also indeterminsitic, so much to the good for the reduction via function.

So I think what he must have been saying was that Quine was wrong about meaning but Quinean arguments about indeterminacy had something right about them. (And in fact he said a few times last week that he’s a bit of a Searlean: meaning has to do with consciousness and is irreducible.) Had Quine argued with Millikan he would have argued for the indeterminacy of her analysis of functions. Given that meaning is deterministic, that would have been a problem for her. But the kind of function involved in functional accounts of disorder can tolerate such indeterminacy so that would not be a problem for his own analysis.

I’m not a persuaded by this reply because the translation from Wittgenstein to Quine is misleading. Quine accepted a degree of indeterminacy in his positive account of meaning. He thinks that the evidence that fixes meaning only goes so far. This of course is because Quine builds in an assumption that the evidence has to be physicalistically described. Against that background, meaning would be indeterministic. But what justifies that restriction? (Answer: Quine’s scientism.)

Wittgenstein does not think that meaning is indeterministic. The contexts which play a role in constraining it are described in intentional terms. What Jerry takes to be a parallel between Quine and Wittgenstein is not part of the latter’s positive account but rather a reductio ad absurdum of reductionism. More significant, however, is that the negative argument does not deliver merely a domesticated indeterminacy but rather no shaping of content in the future at all.

On the value of company

As I leave my socially solitary time in Paris (days spent at seminars and in conferences have their own logic and purpose and so don’t count here) I have been struck by the way that an individual existence can seem undermined or lacking in a kind of validity because it isn’t shared with others. Describing this – by email! – to a couple of friends, I've had reports of similar experiences. Thus one friend described an occasion of returning home alone from the pub recently:

“It was a beautiful evening - warm, still, beautiful inky blue colour in the sky, stars, the sound of oystercatchers in the distance. I sat in my garden thinking that it ought to be a lovely moment, that I should immerse in it but I was so conscious of thinking about the moment in that way that I spoilt it.”

She wondered whether, because she was alone in the garden that evening, it seemed somehow “not to count”. That describes exactly a doubt I have: that when one is alone for a period, what one does lacks a kind of validation and that, in turn, undermines the point of things.

But it isn’t clear to me that it would have to be like that (even for those of us who accept the worry in principle). Here’s the alternative to thinking that one needs to share things for them to have that kind of validity.

I think it helps to start by conceding something. There’s obviously a difference between some kinds of appetite and lots of other sorts of wishes, aims or ventures. With the appetites, eating another slice of pizza (eg to finish a pizza before one) or another glass of wine (from the bottle to hand) is just a simple intrinsic pleasure. But to cross Paris to drink another kind of beer; to take a trip out to buy a pizza from a wood-fired pizzeria (when some convenience food is available close by); to visit Notre Dame at dusk: these are all to be involved in something more like the example of looking at the stars (when the alternative is to give up and go to bed). For these projects then it is so much easier – I find this month! - to have a 2nd person ready to hand. Unlike simple appetites, the pleasure in such ventures is not so simply there, to outweigh the costs. There has to be more involved in the motivation of the venture. The addition of another, or others, to share the experience seems enough to tip the scale, but it can seem that when alone the project, in each case, isn’t worth it, doesn’t somehow count enough.

What I’ve been wondering (whilst in Paris but also before) is whether the extra normativity of a practice or custom might also tip the scale. To be able to say: I do this now - search out new pizza / beer / art - because it’s part of a custom to which I’m committed, might be more than just a calculation of immediate pleasure and say something more about longer term meaning. I think that there are two arguments for this. First, it just seems somehow right that that appeal to custom has weight in the case in which the individual activity gains meaning from association with a more general existential orientation.

But second, what one does in company is often not what would be the most pleasurable thing - as regards appetite - even for those (plural) involved. Dragging Lois across town for an obscure beer (were she so to need dragging, I hasten to add: it’s a hypothetical case) doesn’t make that event necessarily more immediately pleasurable overall. The costs, as well as the benefits, have gone up (doubled, perhaps) after all. So it’s not clear that it is people that does it. Rather, I suspect, we have in mind a kind of communal custom or practice. If this is what we do in general, it makes sense for us to do this now. But if that’s the case, it is not the communality that matters, it is the custom, and maybe that can be enacted by the individual. (Obviously I’m recklessly applying Simon Blackburn’s ‘The individual strikes back’.)

I think that there’s some plausibility to this. We’ve not had a decent summer in Kendal since 2006 but that year I got into the habit of filling my chimenea with garden wood and sitting outside listing to the sound of nose flutes on Radio 3’s Late Junction with a mochito in hand, whether or not Lois could make the time to join me. But on each occasion, the work of foraging, fire making, and mochito mixing (goodness, I sound like a scaled down Ernest Hemingway!) was a significant cost compared to the benefits (the sound of nose flutes under the stars). But once the individual acts were bound together as a custom, of how I spent the summer of 2006, as part of a sense giving practice, then the weighing of costs and benefits changed. Eventually, one does not even question whether it is the right thing to do that evening: it is just what one does.

That said, although that’s what I thought in principle, I’m not sure that my Paris habits quite reached the stage of a happy individual custom.

An overview of TK101

Sometimes when trying to write a paper or chapter, the glad start with which I begin (to use Wittgenstein's familiar phrase) proves mistaken. Although I thought I knew what I was doing it just doesn't seem to work. That, sadly, is how my introduction to tacit knowledge is at the moment. So I need to stand back and get clear on the structure. Here is a stab at the first 80% of that.

********
A number of philosophers have argued for the importance of something in the area, at least, of tacit knowledge. These include Heidegger, Polanyi, Ryle and Wittgenstein. But their arguments are of different kinds (empirical versus philosophical and narrowly focussed on an argument versus a more general metaphysical picture). What they suggest is the importance of something practical. But does it amount to tacit knowledge?

This prompts the question of what kind of thing tacit knowledge is? My method of answering this is to address the dual status of tacit knowledge.

Start with two arguments for the tacitness of tacit knowledge.

• Dreyfus’s account of skilled coping provides an explicitness argument for the tacitness of the ability involved
• Collins discusses the transfer of tacit knowledge (explicitly so called). Central is the idea that the transmission of tacit knowledge is invisible and capricious. It is tacit because it is silent in transmission and cannot be explicitly demonstrated.

But whilst both of these lines of thought suggest a reason to take tacit knowledge to be tacit, they do so only at the cost of undermining its knowledge status.

In Dreyfus’ case, there may be an ability, something practical, in play but since it is non-conceptual, animal and mindless, it cannot be a candidate for knowledge.

In Collins’ case then

• Either the fluid conception of the transfer of tacit knowledge is simply mysterious (and thus this violates intuitions that knowledge is immune to luck)
• Or the content so conveyed simply lies outside the ken of all concerned.

How then can we accommodate both the tacitness and the knowledge status. One clue is that there has to be a way to substantiate the idea that there is some content known. (But to say, eg, that Florence knows that snow is white would be to purchase content and hence, possibly, knowledge but only at the cost of tacitness.) So one route is to return to Dreyfus’ account of skilled coping – which at least seems to involve a kind of practical demonstration of the content – and address the non-conceptual status of coping.

Hence, a paradigmatic approach is to correct Dreyfus with McDowell.

Paris #2

Things have not quite worked out as I hoped when I arrived in Paris (thus). As I left England, my father fell gravely ill (full knowledge of the nature of which would have been reason not to come out) and thus anxiety about him has coloured my experience of my stay in this city.

So it’s hard to know what is a generalisable feature of being away – the sort of thing I would like to write about on my blog – and what is particular to this experience. But one general thing is that to be installed in a flat anywhere in the first world is still, these days, to be connected to the web ands thus via email and chat programmes immediately to one’s home. This year also, an improvement on my trip to Dallas last, I’ve not had to forego BBC radio. Of course, the downside of all this is that my poor French language ability has hardly improved.

But there is something contestable about this. Meeting Simon Wessely, from the Institute of Psychiatry, at last week’s conference, knowing that he works with the armed forces, and with thoughts about the play Kursk I saw the other day in mind, I asked him about the mental health of submariners. Apparently they do much better than army soldiers posted abroad because – in part at least – they have no communication back home. They accept their three months of isolation. By contrast, soldiers have easy access to systems akin to Google Talk but this causes no end of difficulty with the merely partial connection back home it helps to emphasise. The army would like, now, to go back to their men having little home contact but obviously can’t.

From a work point of view, that seems very attractive. (Whilst my UCLan colleagues may reasonably judge that I’ve not been pulling my weight back in Preston, neither have I been able to avoid working through emails etc so it has not been quite a short sabbatical either.) But socially or emotionally all this electronic communication seems to me to make things much easier.

A second issue is a practical tension, for me at least, to do with authenticity in a foreign city. If I were on a brief holiday in Paris, I’d consult the Rough Guide and tick off some sights: museums, bars, restaurants and so forth. I would have no sense that I was being anything other than a tourist.

But there is a temptation in spending a little longer somewhere, and further, approaching, at least, the idea of living there (‘dwelling’!) that one might do things in a subtly different way. I imagine, for example’ saying “Of course when I lived in Paris in the summer of ’68, I …”.

But here’s a problem. If I were actually living here, I would just do the things that please me and, crucially, the overlap with my actual historical life in Kendal would be akin to the overlap between there and Cubbington and, before that, Cubbington and London. I would cook and eat thus and so. But if I do that, if I replicate life in Kendal – modulo the odd baguette – that seems not to be taking enough advantage of being in Paris. There is an incentive to be authentically Parisian in a way which is not really to be authentic at all.

I am not at all sure how to balance this with the authentic desire, also, to get some writing done.

Values Based Practice

I've been thinking today about just what values based practice is. The best articulation of it seems to me to be Bill Fulford's 2004 statement in the Radden collection [Fulford 2004]. But I am not sure that that really brings out its radical status.

Here is a draft commentary on VBP with the usual warning of ongoing later editing. This is very rough: I have worked on this for only three hours this afternoon after a visit to the Pompidou this morning and a solitary pint in the Frog and Rosbif. (A paper based on this is now out.)

Radical liberal values based practice

Abstract
Values based practice is a radical view of the place of values in medicine which develops from a philosophical analysis of values, illness and the role of ethical principles. It denies two attractive and traditional views of medicine: that diagnosis is a merely factual matter and that the values that should guide treatment and management can be codified in principles. But it goes further in the adoption of a radical liberal view: that right or good outcome should be replaced by right process. I describe each of these three claims but caution against the third.

Introduction
Values Based Practice, VBP, is a radical view of the place of values in medical practice. In this commentary, I aim to set out the steps one needs to take to reach it and thus to highlight its radical status. My aim is more to rationalise the position than fully to defend it, however. I will reveal my own failure of nerve when it comes to endorsing the radical liberal version of the position. Modest VBP seems to me to be a more stable view.
To begin with, it will be helpful to have a contrasting view in mind whether or not it has ever been explicitly defended. (It is, in my experience, widespread among medical students at least.) On this traditional view, medical diagnosis is a matter of getting the facts right independent of any values. Values come into play in guiding – along side good evidence based medicine – treatment and management. And when they do, they are codified in a set of principles, a proper understanding of which form a kind of moral calculus. The first two steps towards appreciating the radical status of VPB are recognising that it rejects both aspects of this traditional view. Values are implicated in diagnosis as well as treatment. And any moral principles to which we might appeal are insufficient. There is also a third step, however, against which I will caution.
The main principles of Fulford’s Values Based Practice are set out below [1]. I will explicitly mention some of these – principles 1, 2, 5 and 8 - in what follows.

Ten Principles of Values Based Practice
1: All decisions stand on two feet, on values as well as on facts, including decisions about diagnosis (the “two feet” principle)
2: We tend to notice values only when they are diverse or conflicting and hence are likely to be problematic (the “squeaky wheel” principle)
3: Scientific progress, in opening up choices, is increasingly bringing the full diversity of human values into play in all areas of healthcare (the “science driven” principle)
4: VBP’s “first call” for information is the perspective of the patient or patient group concerned in a given decision (the “patient-perspective” principle)
5: In VBP, conflicts of values are resolved primarily, not by reference to a rule prescribing a “right” outcome, but by processes designed to support a balance of legitimately different perspectives (the “multi-perspective” principle)
6: Careful attention to language use in a given context is one of a range of powerful methods for raising awareness of values (the “values-blindness” principle)
7: A rich resource of both empirical and philosophical methods is available for improving our knowledge of other people’s values (the “values-myopia” principle)
8: Ethical Reasoning is employed in VBP primarily to explore differences of values, not, as in quasi-legal bioethics, to determine “what is right” (the “space of values” principle)
9: In VBP, communication skills have a substantive rather than (as in quasi-legal ethics) a merely executive role in clinical decision-making (the “how it’s done” principle)
10: VBP, although involving a partnership with ethicists and lawyers (equivalent to the partnership with scientists and statisticians in EBM), puts decision-making back where it belongs, with users and providers at the clinical coal-face (the “who decides” principle)

Values are involved in diagnosis as well as treatment and management
The first step to VBP is to recognise that values are involved in diagnosis as well as treatment and management. The argument for this claim is threefold. First, it helps make sense of the recent history of debate about the status of mental illness in which mental illness is compared either favourably or unfavourably with physical illness. Second, to an unprejudiced eye, pathology – mental or physical – is an evaluative notion. Third, attempts to reduce the concept of illness or disease (or even disorder) to non-evaluative notions have failed for principled reasons.
Fulford’s own influential argument for the first of these considerations runs as follows [2]. The key assumption that mistakenly drives both anti-psychiatry and biological defences of psychiatry is that physical illness is conceptually simple and value-free. This motivates anti-psychiatrists such as Thomas Szasz to compare mental illness unfavourably with physical illness [3]. But it also motivates defenders of psychiatry such as Kendell and Boorse to attempt to argue that mental illness is, like physical illness, value-free [4, 5]. Without the first assumption, however, neither mistaken argumentative move is necessary nor justified. In setting out the consequences of this first claim – that physical illness is evaluative – Fulford draws particularly on Hare’s early work, especially his Language of Morals, on the logical properties of value terms [6].
Hare pointed out that the value judgments expressed by (or implicit in) value terms are made on the basis of criteria that, in themselves, are descriptive (or factual) in nature. The value judgment expressed by ‘this is a good strawberry’, in one of Hare’s examples, is made on the basis that the strawberry in question is, as a matter of fact, ‘sweet, grub-free’. Hare then points out that where the descriptive criteria for a given value judgment are widely agreed or settled upon, it is these descriptive criteria that may come to dominate the use of the value term in question. This is a simple consequence of repeated association. In the case of strawberries, most people in most contexts value (prefer, like, enjoy) strawberries that are sweet and grub-free. Hence the use of ‘good strawberry’ comes to be associated with descriptions such as ‘sweet, grub-free, etc’ to the extent that it is this descriptive meaning that becomes dominant in the use of the term. This contrasts with, say, pictures where there are no settled descriptive criteria for a good picture because there is no general agreement about pictorial aesthetics. Hare’s general conclusion, therefore, is this: value terms by which shared values are expressed may come, by a process of simple association, to look like descriptive (or factual) terms, whereas value terms expressing values over which there is disagreement, remain overtly value-laden in use.
This general claim applies equally to medical language. If illness (generically) is a value term, and if mental illness is more overtly value-laden than physical illness this is neither because (as Szasz argued) mental illness is a moral rather than a scientific concept, nor (as Kendell and Boorse argued) because psychiatric science is less advanced than the sciences in areas of physical medicine such as cardiology. Rather, Fulford argues, it is because psychiatry is concerned with areas of human experience and behaviour, such as emotion, desire, volition, and belief, where people’s values are particularly highly diverse. This line of thinking is reflected in VBP in the principle that: We tend to notice values only when they are diverse or conflicting and hence are likely to be problematic (the “squeaky wheel” principle).
Fulford then goes on to conduct an exercise in what Gilbert Ryle called the ‘logical geography’ of medicine, of the given features of the uses of the medical concepts to justify this value-laden view of the subject. If medical terms are value terms, in Hare’s sense, then many of the features of their use, including a detailed analysis of the many different kinds of disease concept, follow from the general logical properties they share with all value terms, combined, of course, with contingent features of human values (in particular the diversity of values in psychiatry).
There is a second consideration to support an evaluative view of diagnosis. To an unprejudiced if at least inquiring eye, both the general concept of illness and specific instances of illnesses at least simply look to be evaluative. On the second point, John Sadler has devoted considerable care to detailing and taxonomising the values involved in the DSM IV codification of mental illnesses [7]. He claims that psychiatry is thoroughly charged with values but, at the same time, it disguises or denies the role that values play. Thus one key aim of his book is to explore the multiple roles of values in a variety of different areas. These include broad themes such as the patient and professional roles, technology, culture and politics. But it also concerns more specific areas of psychiatric interest such as sex and gender and genetics. So if Sadler’s piecemeal analysis is convincing then there is reason to believe that in mental illness, at least, values are widespread in diagnosis.
But on the more general point, Fulford’s picture is sustained by the idea that there is more to pathology in general (including outside psychiatry) than what is unusual, for example. Illness is bad for us. So unless there is a way to explain away that apparently evaluative or normative aspect of illness, there is good reason to believe appearances. And, arguably at least, that is the case. Merely statistical analyses of what is usual and unusual do not seem to capture the fact that high intelligence is in itself a good thing and low intelligence is a bad thing.
More sophisticated attempts to use the notion of biological function have had the more modest aim of explaining away evaluative or notions from the concept of disorder, rather than illness or disease, conceding that the latter notions also contain the ineliminable notion of harm [8, 9]. But even with regard to that modest aim, it is far from clear that the notion of failure of function presupposed explains, rather than smuggles in, normative notions.
If this is right, then even if it were the case that the set of illnesses, diseases or disorders could be captured using merely factual criteria, this would only be because, contingently, we agreed about the underlying medical values. (In much the same way if the criteria for apples which can be sold as fit for purpose are purely factual, this is because we happen to agree on which kinds of apples we like.) Such agreement may be merely culturally and temporally a local matter rather than answering to purely factual constraints about the nature of illness.
To summarise this first step, VBP is radical because it contests the idea that medical care is based on a value free diagnosis. Values are in play in diagnosis as well as treatment or management. Hence:
1: All decisions stand on two feet, on values as well as on facts, including decisions about diagnosis (the “two feet” principle).
2: We tend to notice values only when they are diverse or conflicting and hence are likely to be problematic (the “squeaky wheel” principle).

Principles are insufficient for value judgements
The second step to articulate Values Based Practice is the rejection of both the sufficiency and the fundamental importance of moral principles in guiding medical practice. One reason for the first element of this is not as far from medical orthodoxy as it might appear but tends to remain hidden in medical ethical teaching [10]. It is implicit in the most influential recent approach to medical ethics: the Four Principles approach, a deontologcal or principles-based approach set out at length by Tom Beauchamp and James Childress in their Principles of Biomedical Ethics [11]. In it, the authors set out four general principles to guide medical ethical reasoning: autonomy, beneficence, non maleficence and justice.
These four, which do not derive from any single higher principle, are supposed to capture medical ethical reasoning. They can, however conflict. Standardly, for example, beneficence and non-maleficence are in tension in both surgery and drug treatment. In psychiatry, in particular, autonomy and beneficence are in tension in the case of involuntary treatment. And thus an implicit part of the Four Principles approach is to frame ethical judgements which go beyond the resources of the principles alone.
Beauchamp and Childress describe two methods for dealing with such conflicts: specification and balancing. Specification is a way of deriving more concrete guidance from the fairly abstract higher level principles. It is described in outline thus:
Specification is a process of reducing the indeterminateness of abstract norms and providing them with action guiding content. For example, without further specification, do no harm is an all-too-bare starting point for thinking through problems, such as assisted suicide and euthanasia. It will not adequately guide action when norms conflict. [11]
This looks at first to be a kind of deduction. Much as, once particular assumptions are made, Kepler’s Laws of planetary motion can be (more or less) derived from Newtonian physics, so a specified rule can be derived from a higher level principle. And just as Kepler’s Laws are useful in the specific context of planetary systems so a specified principle – such as that doctors should put their patients’ interests first – can be tailored to give concrete guidance to cases of, for example, euthanasia. But although specification is some form of derivation, it cannot strictly be deduction because ‘specified’ lower level rules have more content, more information, than the principles from which they are drawn.
The second tool for generating an actual duty from apparently conflicting principles is more obviously not a matter of simply unpacking the principles. It is called ‘balancing’ and complements specification thus:
Principles, rules and rights require balancing no less than specification. We need both methods because each addresses a dimension of moral principles and rules: range and scope, in the case of specification, and weight or strength, in the case of balancing. Specification entails a substantive refinement of the range and scope of norms, whereas balancing consists of deliberation and judgement about the relative weights or strengths of norms. Balancing is especially important for reaching judgements in individual cases. [11]
Thus despite the emphasis on the importance of the four principles, Beauchamp and Childress do still suggest the need for a degree of non-principles-driven judgement explicitly in the case of ‘balancing’ and implicitly in the case of ‘specification’. And thus even on this influential approach to medical ethics, the principles themselves are insufficient to guide practice. (That is why I stressed that there is no higher order principle. The view of which principle should dominate is not determined by the principles themselves but, somehow, from outside them.)
Values Based Practice goes further than this, however. Although it concedes that there can be sufficient agreement about some values that they can codified to provide the basis for ethical codes and guidelines, these remain just a small part of the values that have to be taken account of in guiding medical practice which include individual preferences, desires, wishes, firmly held faith and convictions and so forth. By stressing this multiplicity, it stresses the standing possibility of disagreements and clashes in thinking about particular circumstances.
This contrasts with the Four Principles approach, which tempts us to think that there are standard solutions, even where there are well known clashes. Thus, for example, the case of the Jehovah’s Witness who competently refuses essential, life-saving treatment is taken to exemplify the conflict of beneficence and autonomy and on the standard solution, autonomy is taken rightly to dominate [12, 13]. (Things differ in the standard case of his or her young child.) The case is sketched in abstract and ideal terms and becomes, itself, a kind of rule to be applied to further actual cases. Competence in solving standard cases, in applying the principles and giving them standardly approved weight, becomes second nature to medical students keen to pass their ethics course and the element of individual judgement is downplayed.
So Values Based Practice makes explicit an idea implicit and often downplayed in conventional thinking about medical ethical practice, that there are diverse values in play and that attempts to codify them in principles is just a small part of the picture. Local context and individual preferences are the norm for VBP. Hence the downplaying of principles driven reasoning in the VBP claim:
8: Ethical Reasoning is employed in VBP primarily to explore differences of values, not, as in quasi-legal bioethics, to determine “what is right” (the “space of values” principle).
Taken together with the claim that such values are in play in diagnosis as well as treatment, this is already quite a radical view of the place of values in medical care. But there is a third, and yet more radical step.

Radical liberal VBP
The yet more radical third step is what leads to principles 5 and 8:
5: In VBP, conflicts of values are resolved primarily, not by reference to a rule prescribing a “right” outcome, but by processes designed to support a balance of legitimately different perspectives (the “multi-perspective” principle).
9: In VBP, communication skills have a substantive rather than (as in quasi-legal ethics) a merely executive role in clinical decision-making (the “how it’s done” principle).
It picks up something that ought to have been a worry about the comments above about the Four Principles approach to ethical judgement. I described it as a deontological or principles-based approach. But I then went on to suggest that, according to its own methods, the principles themselves are often insufficient for ethical judgement. Both specification and balancing require elements of judgement uncodified by the principles. Values Based Practice embraces this feature and suggests that principles only have a limited role, in cases where there is agreement in values. But this should prompt two questions: what governs ethical judgements when they are not constrained by principles? And, why is there ever agreement in values?
Before I address these questions on behalf of radical Values Based Practice, I will first outline a more modest answer. The more modest approach takes ethical judgements to be more like judgements of facts than they are like arithmetic judgements. Arithmetic can, at least arguably, be formalised in accordance with axioms and thus the correct answer to an arithmetic question can be determined or derived algorithmically from those first principles. This is the picture of moral judgement to which a full blooded principlist account subscribes. Moral judgements are determined by accord with principles. Those are what make such judgements true or false. But the Four Principles account does not seem able to live up to that because extra-principled forms of judgement enter through specification and balancing.
An alternative to principlism is particularism. Moral judgements answer to real moral features of the world: the moral particulars realised in specific cases. And thus one way to interpret the Four Principles approach is on these lines. The principles do not determine the correctness or otherwise of judgements, despite first appearances. Rather, they serve as useful reminders of the sort of things to take into account when thinking through particular cases. Further, when we agree about moral values, this can be because we are correctly responding to real features of the world in the way that agreement about factual matters can be partially explained by those facts themselves impacting upon us.
One might take this to be the way to think about Values Based Practice [cf 14 pp49-88]. If so, it can accommodate Fulford’s emphasis on the complexity of particular cases and the necessity to develop skills in responding to conflicting values. But this does not seem, at least, to be Fulford’s own view which appears to be rather more radical.
The clue to this is the claim that ‘conflicts of values are resolved primarily, not by reference to a rule prescribing a “right” outcome, but by processes designed to support a balance of legitimately different perspectives’. Now particularism would also reject the idea of a rule prescribing a right outcome (because particularism stands opposed to principlism). But this VBP claim seems to go further and to replace the idea of there being a right or good outcome with a right process [cf 15]. This thought is further reinforced by the claim that ‘communication skills have a substantive rather than (as in quasi-legal ethics) a merely executive role in clinical decision-making’. Their role is substantive because the most there is of a right outcome is right process. It is not that the process is a reliable way to determine the antecedently real moral particulars. Rather, the process is the end itself. So in response to the question: what makes a value judgement true or false, the answer seems to be neither accord with a principle or principles; nor accord with the real moral particulars; but rather, nothing further than competing views having been heard.
So construed Values Based Practice is a radical liberal position. Fundamentally, all and any values deserve a hearing. All and any can be valued if they survive the right process. If there is sufficient agreement about values then codifications – whether ethical or legal or other – can contingently be formulated. But the explanation for such agreement is not that there are real values out there that command the agreement of right thinking people. That approach – particularism – which I favour perhaps smacks of authoritarianism and, in the context of medicine, may recall the dangers of totalitarian psychiatry.

Conclusions
I have attempted to set out some of the key themes of Values Based Practice. It rejects both aspects of a traditional picture of the role of values in medicine. There is no value-free medical core. Even diagnosis is an evaluative business although, if we happen to agree on the values, we can fail to notice that fact. Further, evaluative principles are insufficient to guide value judgements. What principles there are do not go far enough to guide actual context-specific judgements with multiple legitimate perspectives. But further, the very idea that there is a right or good outcome is misleading. There is instead a concentration on balancing competing views in a market place of values: radical liberal VBP.
Such a view is not without its problems, however, and I will end by mentioning just one [cf 16]. What is the status of the claim that: in VBP conflicts of values are resolved primarily, not by reference to a rule prescribing a “right” outcome, but by processes designed to support a balance of legitimately different perspectives?
Note first that although it says that conflicts of values are resolved… this is in the context of Values Based Practice. So it should be read as saying: conflicts of values should be resolved … by processes designed to support a balance of legitimately different perspectives. But now we can ask, why should they? (It may be an analytic truth that they are within Values Based Practice, but we are invited to adopt this approach.) And now the worry is that this seems to be a value of a different order from the values that should be put through the right process of balancing views. This seems to be a higher order value, inconsistent with Values Based Practice’s own approach. This then suggests a dilemma for radical VBP. It can either address the question of why we should value values in the way it suggests, but at the cost of violating its own principles, or it can attempt no such question, in which case it lacks the prescriptive force that gives it teeth.

References

1 Fulford, K.W.M. (2004) Ten Principles of Values-Based Medicine. in Radden, J. (ed) The Philosophy of Psychiatry: A Companion. New York: Oxford University Press, 205-34
2 Fulford, K.W.M. (1989) Moral Theory and Medical Practice. Cambridge: Cambridge University Press
3 Szasz, T. (1972) The Myth of Mental Illness. London: Paladin
4 Kendell, R.E. (1975) The concept of disease and its implications for psychiatry. British Journal of Psychiatry, 127: 305-315
5 Boorse, C. (1975) On the distinction between disease and illness. Philosophy and Public Affairs, 5, 49-68
6 Hare, R.M. (1952) The language of morals. Oxford: Oxford University Press
7 Sadler, J.Z. (2004) Values and Psychiatric Diagnosis. Oxford: Oxford University Press.
8 Wakefield, J.C. (1992) The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values. American Psychologist, 47, 373-88
9 Wakefield, J.C. (1999) Mental disorder as a black box essentialist concept. Journal of Abnormal Psychology, 108, 465-472
10 Thornton, T. (2006) Judgement and the role of the metaphysics of values in medical ethics. Journal of Medical Ethics, 32, 365-370
11 Beauchamp, T.L. and Childress, J.F. (2001) Principles of Biomedical Ethics. Oxford: Oxford University Press
12 Beauchamp, T.L. (2003) Methods and principles in biomedical ethics. Journal of Medical Ethics, 29, 269-274
13 Macklin, R. (2003) Applying the four principles. Journal of Medical Ethics, 29, 275-280
14 Thornton, T. (2007) Essential Philosophy of Psychiatry. Oxford: Oxford University Press
15 Rubin, J. (2008) Political Liberalism and Values-Based Practice: Processes Above Outcomes or Rediscovering the Priority of the Right Over the Good. Philosophy Psychiatry and Psychology, 15, 117-123
16 Gascoigne, N (2008) The value of ‘value’. Philosophy Psychiatry and Psychology, 15, 87-96

The initial history of psychiatric epidemiology

I’ve spent the last couple of days, here at Paris-Descartes, at a conference on the history of psychiatric epidemiology, an area twice removed from my own interests. By contrast with the last such intellectually distant conference I braved, I do feel a familiarity with the methodology or methodologies involved. That is not so much because the history or social history of epidemiology is philosophical in the way a Winchian might hope. Nor because there is much by way of a familiar philosophy of psychiatry issue: that the possibilities of psychiatric epidemiology turn on issues of classificatory validity. Only Allan Horwitz’ paper was explicitly concerned with the way that operationalising depression had made it over inclusive. (Allan Young's (pictured) fascinating paper on PTSD didn't really address the connection to epidemiology to my ear.)  But rather, having spent time in the Cambridge HPS department I still have some sense of the disciplinary standards of social history of science.

That said, there is still something that I just didn’t ‘get’. Even though the subtext of the conference was that the history of psychiatric epidemiology has only just got off the ground – such that there isn’t yet an agreed history – and even though there is obviously something interesting about the choices that were made by earlier actors (psychiatrists and more general epidemiologists) in looking at health or illness and the quirky contingencies of just what data was to hand in different countries, still I’m not sure why this is an area one would select for an academic life. No one pulled off what seemed so striking about Schafferite history of science: the sense that the negotiations of historically distant agents were both vitally interesting in their own terms but also had something interesting to tell us about ourselves in an almost novelistic sense.

(I wonder, however, what one of the historians here would make of a philosophical conference on the unboundedness, or otherwise, of the conceptual. Involvement in that, also, might seem a worse choice than becoming an engine driver or firefighter.)

More specifically, I also wonder whether the history of epidemiology will already be over, by the time it’s written (which is not at all to suggest that epidemiology will be either over or uncontested). It has been hard to avoid a sense that, other than the problems of psychiatric validity (ie not specific to epidemiology), stirling progress has been made by great men and women in striving towards enlightenment. It has seemed quite teleological. (Even Allan Young's paper left me in doubt as to whether it really was critical or just suggesting a complexity about how to capture the real distress in the area (an instance of the slippage between debunking and validating).)

This seems an odd impression because one thing that has clearly happened is that choices made previously in epidemiological study constrain present views about what us real and thus researchable and it is at least plausible to say that some choices that have been made were questionable. But that hasn't been made explicit this week. That said, there are other confereneces to come in the same series which may make that more of an issue.

Housekeeping

I’ve just heard that the paper I wrote for Psychopathology with the snappy title ‘Narrative rather than Idiographic Approaches as Counterpart to the Nomothetic Approach to Assessment’ is out now electronically. It is based on a talk I gave way back in November 2007 in Berlin and finishes my business with idiographic understanding.

I submitted the paper from last week to the Journal of Mental Health Training Education and Practice. They warn me that it will not be out before December even if accepted. That was based on the Lancaster conference from April.

I am still waiting – not impatiently! – for the European Journal of Analytic Philosophy paper on psychiatric explanation and understanding, due out any time now.

My paper – co-authored with Peter Lucas – on recovery is still under review with the JME.

Still to come, sometime ( / ahead this year!), are:

(forthcoming) ‘Capacity, mental mechansisms and unwise decisions’ Philosophy Psychiatry and Psychology

(forthcoming) Thornton, T. and Schaffner, K. ‘Philosophy of science for psychiatry for the person’ (Special issue on Conceptual Bases of Psychiatry for the Person) Psychopathology

Harry Collins in the New Scientist

I see that Harry Collins has an article about tacit knowledge in the New Scientist.

What strikes me as particularly interesting is the way he aims to demystify tacit knowledge, contrasting his own account with that of Polanyi. He says:

To find a space for his idea, Polanyi made tacit knowledge seem more mysterious than it is. Now we know science is not perfectible we do not have to fight so hard to retain a conceptual space for that which cannot be done by logic and mathematics. This means we can take a calmer look at tacit knowledge and remove some of the mystery. [Collins 2010]

But I have always taken it that Collins thinks tacit knowledge is mysterious. Back in Changing Order he describes its transfer as ‘capricious’ because similar relationships between teacher and learner can or cannot transfer it.

In his more recent work, in trying to capture the expertise of science managers who lack the skills of coal face practitioners but nevertheless gain an understanding of the science through linguistic immersion, he describes a form of interactional expertise which is still supposed to be tacit.

Now I am not as sure as I would like to be about this latter idea. It seems to me that on Collins’ picture the transmission of knowledge for such middle managers is a bit weird: spoken language, distinguished from strings of symbols, ‘contains’ in some tacit form, aspects of practices such that hearers who acquire fluency in the language also still rather mysteriously acquire understanding of the practices.

It seems to me that Collins’ talk, in the New Scientist article, of both relational and collective tacit knowledge is compromised because of the twin issue of balancing the status of tacitness and also of knowledge having moved away from bodily skills. Some of this is in play when he says:

[Y]ou may not know what you need to know and I may not know what I know. Thus, in the early days of TEA lasers scientists did not necessarily know that the inductance of the top lead was important but by copying existing designs they built in successful short top leads without knowing why. The bottom line is any piece of relational tacit knowledge could be made explicit but logistics prevent it all being made explicit at once. [ibid]

The TEA example surely stands in contrast to the second element of the first part of this thought (I may not know what I know) since it seems that the requirements on the top lead were not, in fact, known. It may be a tacit element in what was passed on but it wasn’t known. In general I suspect Collins plays up the tacit at the risk of the knowledge element and that’s why it ends up musterious and capricious.

My hunch is that it is misleading to concentrate on the transmission of TK – to get at the tacit – rather than on an articulation of the content of the knowledge. In fact I am not convinced by Collins’ basic picture. Earlier in the article, he sets up a contrast thus, which I’ll quote as a whole and then look at piecemeal:

In The Logic of Tacit Inference, Polanyi argues persuasively that humans do not know how they ride, but he also provides a formula: ‘In order to compensate for a given angle of imbalance α we must take a curve on the side of the imbalance, of which the radius (r) should be proportionate to the square of the velocity (v) over the imbalance r~v2/α.’

While no human can actually ride a bike using that formula, a robot, with much faster reactions, might. So that aspect of bike-riding is not quite so tacit after all.

That we humans do much of what we do without following explicit rules is no more mysterious than my cat hunting without knowing rules about hunting or a tree growing without knowing rules about forming leaves. We only think it's mysterious if we think explicitness is the norm, but explicitness is a rare thing, restricted to humans, and used only now and again because it is often more efficient to allow causal, neural connections in the brain and body to execute an action with little (or, indeed, no) conscious calculation - after all, cats do pretty well this way. [ibid]

So Polanyi’s formula would be sufficient, against the right robot background, for robot bike riding. Collins says ‘So that aspect of bike-riding is not quite so tacit after all’. Now what does he mean? Does he mean that the formula shows that human bike riding is no longer tacit? Surely that is too rash a claim (that whenever a formula would be sufficient, against an engineering background, to replicate or mimic a skill, tacit knowledge of that skill is universally ruled out).

Or does he mean that, because robots can ride bikes when so engineered, then bike riding in general need not be tacit (although human bike riding may be). But that does not seem right since there is no reason to think that a robot system, engineered in accordance with that formula, follows any explicit rule.

He continues:
‘That we humans do much of what we do without following explicit rules is no more mysterious than my cat hunting without knowing rules about hunting or a tree growing without knowing rules about forming leaves.’
Now I’m a bit concerned that human doing is compared to trees growing. Surely the latter has nothing to do with tacit knowledge? This is another instance of playing up the tacit at the expense of the knowledge part of TK.

Then:
‘We only think it's mysterious if we think explicitness is the norm, but explicitness is a rare thing, restricted to humans, and used only now and again because it is often more efficient to allow causal, neural connections in the brain and body to execute an action with little (or, indeed, no) conscious calculation.’
This seems roughly the right kind of thing to say, but for two things.

First, it sets up at the end the expectation that the distinction between the tacit and the explicit depends on the absence or presence of ‘conscious calculation’. The problem of setting out an account of tacitness like this is that such consciousness admits of degrees.

Second, that thought doesn’t hook up with the contrast with ‘causal, neural connections in the brain and body to execute an action’. Even where knowledge is not tacit, I would not wish to deny that the execution of an action is a matter of  ‘causal, neural connections in the brain and body’.

So I am not sure that this is the right basic picture after all.

Collins, H. (2010) 'Tacit knowledge: you don't know how much you know' New Scientist 31st May

PS: Other posts on Collins are here and here. But there are many others.
My, later, first reactions to his new book, Tacit & Explicit Knowledge are here.