Tuesday 23 December 2014

Debates in Values-Based Practice: Arguments For and Against

This came out whilst I’ve been away and so now I can have a quick skim read. Obviously I won’t find my own chapter terribly interesting. But the rest looks to be. Well done to Michael Loughlin for getting it together. The official blurb from the CUP website runs thus:

Demands on healthcare systems are increasingly complex and diverse. Consumerism, multiculturalism and regulation challenge practitioners and policymakers. This has led to urgent debate about the value and purpose of healthcare as people seek to make serious, well-thought through decisions. This book helps readers to make rational decisions about healthcare provision in the context of complex and diverse values. It offers no easy solutions, instead presenting a range of perspectives and arguments on values-based practice, an increasingly influential approach to managing value-conflicts/differences in medicine, psychiatry, health and social care. Readers must make their own minds up about the controversies, but this book will give them a sense of the scene and the ability to defend their own position with clarity and confidence. This is a valuable resource for health practitioners and managers, academics in health services research and policy and students of management, bioethics, applied philosophy and political and social theory.

“What a privilege to listen in to a civilised discussion between the originator of value based medicine, Bill Fulford, and those who seek to understand, to take it further, practically and philosophically, and to dissent. This book gives us all of that and the gracious response of Fulford to both friend and foe alike. It shows how such discussion can improve the practice of medicine and, by extension, inform approaches to global health. There is much here for philosopher and practitioner alike.” Sir Michael Marmot, Director, University College London Institute of Health Equity.

List of contributors
Editorial introduction Michael Loughlin
Part I. VBP: Values, Practice and Philosophy:
1. Values-based practice: the facts K. W. M. (Bill) Fulford
2. Values-based clinical reasoning Ed Peile
3. Liberating practice from philosophy – a critical examination of Values-Based Practice and its underpinnings Elselijn Kingma and Natalie Banner
4. Values-based practice and authoritarianism Tim Thornton
5. VBP: but which values? And whose? Bob Brecher
6. Reframing health care: philosophy for medicine and human flourishing Phil Hutchinson and Rupert Read
7. Values-based practice: a new tool or a new package? Mona Gupta
8. Values or virtues? Richard Hamilton
9. Values-Based Practice, competence and expertise Gideon Calder
10. Wishing to remain ill: an unacceptable value? Harry Lesser
11. VBP and global health Sridhar Venkatapuram
12. Is VBP useful in psychiatry? – A practitioner's view Alistair Stewart
13. Living with uncertainty: a first person plural response to eleven commentaries K. W. M. (Bill) Fulford
Part II. VBM and the Basis for Medical Decisions: Survival, Security and Flourishing:
14. Values, foundations and being human Miles Little
15. Eliciting axioms to enrich debates about the pharmaceutical industry Wendy Lipworth and Kathleen Montgomery
16. Using the survival-security-flourishing model to explain the emergence and shape of the medical profession Kathleen Montgomery and Wendy Lipworth
17. Does medicine need a base? A critique of modest foundationalism Ross E. G. Upshur
18. VBM and the challenge of person-centred medicine Andrew Miles
19. Values-based medicine, foundationalism and casuistry Mark R. Tonelli
20. Values-based medicine and patient autonomy Robyn Bluhm
21. Responses to contributions, suggestions and critiques Miles Little
Part III. Conclusions:
22. Walking the VB-talk: concluding reflections on models, methods and practical pay-offs K. W. M. (Bill) Fulford and Miles Little

Monday 22 December 2014

Dialogues in Philosophy, Mental and Neuro Sciences

“Dear Colleague,
I'm pleased to inform you that the new issue of the international online journal Dialogues in Philosophy, Mental and Neuro Sciences has been published, it is freely readable at :
The issue contains:
Volume 7, Issue 2, December 2014

T. Ofengenden
Memory Formation and Belief

O. P. O'Sullivan
Losing control: the hidden role of motor areas in decision-making

G. Farina
Some reflections on the phenomenological method

B. G. Miraglia
A new classification of mental illness based on brain functions

A. Rastogi
Brain Network Commonality and the General Empirical Method

R. Henman
Neuroscience and generalized empirical method: a response to A. Rastogi

J. E. Porcher
The falsity criterion in the definition of delusion

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

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

Daniela Cardillo
Editorial Office info@crossingdialogues.com

Workshop: Particularism and Personalised Medicine, MMU 7-8 January 2015

Call For Registration
Workshop: Particularism and Personalised Medicine
Manchester Metropolitan University, 7-8 January 2015
Venue: New Business School, G.33 Lecture Theatre 4, MMU All Saints Campus
Organiser: Dr Anna Bergqvist, a.bergqvist@mmu.ac.uk

Dr Anna Bergqvist, Manchester Metropolitan University.

Professor Per Nortvedt, University of Oslo.

Dr Anne Raustøl, Diakonhjemmet University College Oslo.

Dr Benedict Smith, Durham University

Professor Tim Thornton, University of Central Lancashire.

Dr Anna Zielinska, CERSES Sorbonne.

Project Outline
This two-day workshop builds on our previous networking workshop on the topic Particularism in Bioethics, Professional Ethics and Medicine at MMU in Manchester (June 2014).  Our focus this time is Particularism and Personalised Medicine, focussing on conceptual issues and different research strategies for incorporating “personalised care” in public health care provision in Europe with a view to effect a comparative study of the prospects for applied particularism in the different national locations.

Traditionally conceived, the core of professional ethics and medical epistemology consists of impartial and universal ethical principles, e.g., non-maleficence and respect for autonomy. These principles are supposed to apply to all moral agents.  But patients, health care professionals and clinical settings differ in many and in crucial respects. One problem of the principled approach is to how to account for the ways in which impartial and universal principles are supposed to be sensitive contextual parameters such individual attitudes, cultural aspects and situational differences. Moral particularism is a philosophical tradition that is well equipped to make sense of how health care can be personalised in a context sensitive way. According to particularists, moral thought and judgement neither need nor should be principle-based but rather requires the exercise of discernment in a case-by-case basis. It is high time to move this theoretical debate into a wider, more practical context.

After long having been neglected, the possibility of applied moral particularism is once again being given serious consideration. For instance, there has been a strong emphasis on partiality and the development of personal relationships in the field of bioethics and professional ethics. Elsewhere in clinical medicine, there has been a renewed interest in the methodology of narrative medicine, personalised (or precision) models of medicine and value based practice. Nationally in the UK, in view of the Francis Report and the Secretary of State for Health’s initial response to the crisis in the Mid-Staffordshire Trust, the language of discernment, compassion, engagement and context which drives and motivates the distinctive particularist approach is becoming increasingly important as a focus for debates over the moral and vocational nature of health care and nursing ethics.

The workshop will bring together emerging and established scholars who have made notable contributions to the reception of moral particularism in applied philosophy and the health care profession.  
The workshop also serves as the inaugural workshop of the international research consortium Particularism in Bioethics, Professional Ethics and Medicine, directed by Anna Bergqvist, ccomprising Manchester Metropolitan University (UK), Durham University (UK), Uppsala University (Sweden), University of Oslo and Diakonhjemmet University College (Norway), Tilburg University (The Netherlands), CERSES Paris 1 Sorbonne (France). More information about the project can be found here:

Workshop Schedule
Wednesday 7th January 2015

9.30 – 10.00 Welcome and Registration

10.00 – 11.30 Anna Bergqvist (MMU): ‘Narrative Understanding, Value and Perspective: A Particularist Response to Fulford’

11.30 – 11.45 Tea and Coffee

11.45 – 13.15 Benedict Smith (Durham): ‘Particularism and Persons’

13.15 – 14.45 Lunch

14.45 – 16.15 Tim Thornton (UCLan): TBA

16.15 – 16.30 Tea and Coffee

16.30 – 18.00 Anne Raustøl (Oslo, Diakonhjemmet): ‘Compassion and Clinical Reasoning’

19.00 Dinner at Kro Bar (at self cost), 325 Oxford Road, Manchester M13 9PG

Thursday 8th January 2015

10.00 – 11.30 Anna Zielinska (Sorbonne) ‘Holism Without Principles: Decision Making in Ethics Committees in France, Germany and the UK’

11.30 – 11.45 Tea and Coffee

11.45 – 13.15 Per Nortvedt (Oslo, UiO): ‘Particularism – a Relevant Perspective in Bioethics?

13.15 – 14.30 Lunch and Roundtable Discussion

14.30 – 17.00 General meeting and networking activities of the consortium Particularism in Bioethics, Professional Ethics and Medicine.

17.00 Workshop Close

Financial Support
The organisers gratefully acknowledge the generous support of the Wellcome Trust and Manchester Metropolitan University Research and Knowledge Exchange.

Workshop Registration

Attendance is free and open to all. Registration by email to Dr Anna Bergqvist.

Tuesday 16 December 2014

Informal end of term report on my IAS fellowship / research leave

Coming to the end of my time as an Emergence Fellow at the Institute for Advanced Study, University of Durham, I have to write an end of fellowship report. But that prompts me to think more broadly about what it has been about. (A friend of mine once told his daughter that he had had a good day. The daughter apparently replied: ‘What was it about?’ I think I share her instinct.)

Naturally in academia, a first thought is output. In 12 weeks, I have written four draft articles totalling perhaps 25,000 words. One is owed to the IAS, Durham for their in-house electronic journal but will form the nucleus for a CUP chapter I owe on Wittgenstein and Davidson. The others are owed to an OUP edited book on gradualism in psychiatric taxonomy, an MIT edited book on harmful dysfunction as analysis of disorder and a Palgrave collection on transcultural psychiatry. My hunch is that all will probably be published after revisions. It also halves my list of outstanding commissions.

I have given an internal seminar to the IAS, one to the Philosophy Department, a closing paper to the Psychology Department’s graduate research day (a really good day attended by lots of staff) and an evening public lecture in the historic Senate Suite of University College (recording available here).

I have made significant inroads into the UK based backlog of work for the journal PPP, which resulted from my mother falling ill and dying earlier in the year, including helping it move to electronic submission at long last. (I should say that authors have been very understanding of the reasons for delay this year and that John Sadler (US Founding Editor) and Linda Muncy (who manages the journal) have been hugely supportive.)

More broadly, I have had many more academic conversations than I would have had at UCLan by attending more seminars, conferences, visiting international speakers, college dinners etc. But also, having a 30 minute coffee break with fellow IAS fellows and other visitors has been stimulating. Not always, I should add. Sometimes we have just talked about the eccentricities of UK trains. But that is also part of the accepted risk. An outgoing pro-VC at UCLan conducted a series of seminars asking what our university would look like if it looked like a world class university. I suggested it would look as though we were doing less because it would look as though we had time for coffee and other random social interaction across the institution. I don’t think that this was adopted as a central recommendation but it seems a pity as Durham clearly embraces just such a view of the importance of interaction. They do quite well at research, including interdisciplinary. (My own School within my University is, however, looking at just this issue as part of a Google inspired undirected time. Well done it!)

I hope that my PhD students haven’t suffered too much thanks to Skype, emails and one furtive visit to Preston. Thanks also to my colleague Gloria for looking after the Philosophy and Mental Health masters programme which I had not intended to step back from but was forced to.

I taught, or perhaps it would be better to say convened, what seemed to me this year to be a particularly successful six week post-doctoral module on the philosophy of the social aetiology of mental illness for the University of Toronto. So much depends on the students that I take no credit for it going well. This year they were happy to explore the idea that their interests raised as many conceptual as empirical issues.

I ran 235km. I drank in too many of the pubs of Durham. On the penultimate night, the IAS fellows took part in a pub quiz at Ye Old Elm Tree, Durham. It must have cost about £200,000 to assemble the team there. We came fourth.

All of that, however, seems quite lucky. I might have done nothing. My father’s death on the third day I was here has been harder to accept than I would have expected, not least after the death of my mother four months earlier. I might have just retired to bed. I certainly wanted to. So I think I have been lucky to be out of the direct firing line and coaxed by the very excellent IAS staff (both the academic leadership and administrative support) and fellows. So thanks to them. But also, and as much, to my Dean of School for letting me spend time ‘having coffee with a bunch of academics’ in his delightfully ironic phrase, a year ago.

Friday 12 December 2014

Emergence, meaning and rationality

A fourth draft paper written whilst a fellow of the Institute for Advanced Study, University of Durham

On ‘emergence’ in philosophy
In philosophy, ‘emergence’ is a semi-technical term whose meaning calls for stipulation as much as description since, unlike every day words with lives outside philosophy though subject to philosophical investigation, for example ‘knowledge’, it lacks a settled use. I take it, however, to be related, but to stand in contrast, to reduction.
Consider the length of a standard 4 x 2 stud Lego brick (that is 4 studs in length and 2 wide). These are 31.8 mm and they are constructed so that when slotted onto a studded base they leave a 0.2mm gap between bricks (to stop them sticking). Thus the effective length of a brick is 32mm. And thus a Lego building built using a line of 10 such bricks will have a length of 32mm x 10 – 2 x 0.1mm = 319.8mm or approximately 320mm. That overall length results from the combination of the basic length of the bricks, the ‘logic’ of the combination (in this case the small engineered gap between each) and some basic mathematics. The overall length can thus be reduced to a combination of the basic properties of the components. But the overall length would not, within philosophy, generally be said to emerge from those basic properties.
The mind, by contrast, is often said to be an emergent property. Tom Nagel proposes a distinction between reductive and emergent in the following way:
A reductive account will explain the mental character of complex organisms entirely in terms of the properties of their elementary constituents… An emergent account, by contrast, will explain the mental character of complex organisms by principles specifically linking mental states and processes to the complex physical functioning of those organisms—to their central nervous systems in particular, in the case of humans and creatures somewhat like them. The difference from a reductive account is that, while the principles do not reduce the mental to the physical, the connections they specify between the mental and the physical are all higher-order. [Nagel 2012: 54-5]
(Nagel uses the term ‘reductive’ for analyses or explanations of complex wholes using whatever properties of their most basic elements and ‘reductionist’ for a subset of those using exclusively physical properties.)
This use of ‘emerge’ attempts to reconcile two opposing intuitions. On the one hand, the mind is something to do with the brain or brain and body or brain, body and world. Perhaps it is a causal effect or perhaps a redescription highlighting different properties. Certainly possession of a brain seems to play a central role in also having a mind. And yet, on the other hand, it seems mysterious how the combination of the merely physical properties of physical material can result in the mind, or mental properties.
Two particular features of the mind seem to drive this latter intuition. First, the qualitative aspects, the phenomenology (small ‘p’) or qualia, of experiential states seem quite unrelated to physical properties. But second, the ‘aboutness’ or intentionality (another semi-technical term for the world-directedness of content-laden mental states or propositional attitudes) of mental states, the ability to have thoughts about things whether real or unreal, appears unlike any basic physical property. And hence some philosophers (and others outside philosophy) say that the mind is an ‘emergent’ property of the brain, or brain and body, or brain, body and world
Not all philosophers share this view of the intractability of the second intuition. In a book on intentionality, Jerry Fodor offers the following rationale for reductionism about the mind:
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, in face of this consideration, 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 (or maybe of their supervenience on?) properties that are neither intentional nor semantic. If aboutness is real, it must be really something else. [Fodor 1987: 97]
The argument turns on the idea that a future completed physics serves as the benchmark of what is real. For any property there then seem to be only three possibilities.
·         They appear on the basic list.
·         They are reducible to something on the basic list.
·         Or they are not a real property after all.
Since the aboutness or intentionality of mental states is both real and ‘doesn’t go [as] deep’ as fundamental physics, it seems that it must be reducible to something on that list.
In fact the passage hedges its bets by introducing, in parenthesis, the possibility of something weaker. Perhaps intentional properties are real in virtue of merely their supervenience on fundamental physics. Supervenience is a brute dependency: fixing the physical fixes the mental but not vice versa. Thus this remark looks to acknowledge the possibility of the intractability of the second intuition above: that mental properties cannot be reduced. In fact, however, Fodor does aim to reduce intentional properties by combining an explanation of the systematicity and compositionality of thought via structured mental representations or symbols in a language of thought with a variant of a causal theory of how the symbols come to have worldly content or reference [Fodor 1987, 2008].
Nevertheless, Fodor’s argument highlights a key question, and hence distinction, in thinking about the motivation for emergence understood in this broad way. What is the nature of the mystery of the dependence of, in this case, mind on brain, body and external world? It could be that it marks a contingent de facto epistemic lack. Perhaps, for example, we cannot explain the connection at present. If so, some further work would be needed to articulate the standard of explanation in play. If, for example, it is the provision of some causal information a la David Lewis then some explanation of the connection of mind and body does seem to be available (minimally: the occurrence of the Big Bang) [Lewis 1986]. If, on the other hand, it requires a logically sufficient condition, then almost nothing in the universe can be explained [Hempel 1965].
A more promising approach is to look for a reason for the lack of explanation. We may lack an explanation of the general relation between mind and body because no such general explanation is possible because the kind of relation on which it would rely does not, and perhaps could not, exist. That would provide a principled distinction between reduction and emergence. In what follows in this brief note I will take this as a clue to emergence.

Davidson and radical interpretation
Fodor aims to shed on the nature of intentionality by reducing it. On his account mental content is supposed to reduce to, rather emerge from, neural states. But my focus here is with a contrasting approach to intentionality: the anti-reductionist approach of the recent American philosopher Donald Davidson. Davidson examines the nature of both linguistic meaning and mental content through the thought experiment of radical interpretation. His aim is to clarify the nature of both linguistic meaning and mental content more generally by examining how it is determined in radical interpretation. ‘What a fully informed interpreter could learn about what a speaker means is all there is to learn; the same goes for what the speaker believes’ [Davidson 1983: 315].
Radical interpretation is interpretation from scratch [Davidson 1993: 77]. It is a philosophical abstraction from the kind of interpretation undertaken by a field linguist having first contact with an alien tribe. Such interpretation cannot appeal to bilingual speakers or dictionaries because it precedes those resources. Furthermore, it cannot presuppose access to the content of the mental states of speakers. Whatever the connection between mental content and linguistic meaning, radical interpretation must earn access to, and cannot simply assume, facts about both. The intentional contents to which Grice appeals in the analysis of linguistic interchange, for example, cannot be identified prior to the interpretation of the agent’s language [Grice 1957]. Thus they cannot be appealed to in radical interpretation. Interpretation must, instead, rely only on the evidence of correlations between utterances and the circumstances which prompt them:
[The radical interpreter] interprets sentences held true (which is not to be distinguished from attributing beliefs) according to the events and objects in the outside world that cause the sentence to be held true. [Davidson 1983: 317]
Davidson thinks that the facts about mental content have to be determined in the same way. Meanings and contents are interdependent. This presents a principled difficulty for radical interpretation:
A speaker who holds a sentence to be true on an occasion does so in part because of what he means, or would mean, by an utterance of that sentence, and in part because of what he believes. If all we have to go on is the fact of honest utterance, we cannot infer the belief without knowing the meaning, and have no chance of inferring the meaning without the belief. [Davidson 1984: 142]
Thus the interpreter faces the task of unravelling two sets of unknowns - facts about meaning and facts about beliefs - with only one sort of evidence: linguistic actions which depend on both meaning and belief. Normally, we can find out what someone believes by asking them. But that presupposes we know what they mean. Equally, if we know what they believe then we can use this to establish what they mean in expressions of their beliefs. But if both factors are simultaneously unknown, how can one break into the circle?
Davidson’s solution has two ingredients. Firstly, he takes the evidential basis of radical interpretation to be the prompted assent of a speaker, which he characterises as ‘the causal relation between assenting to a sentence and the cause of such assent.’ [Davidson 1983: 315] It is possible to know that a speaker assents to a sentence without knowing what the sentence means and thus what belief is expressed by it (or vice versa). Characterising a speaker as holding a particular sentence true is an intentional interpretation of what is going on - the speaker is described by relation to a propositional content - but it does not presuppose a semantic analysis of the sentence. That will be derived later.
The second step is to restrain the degrees of freedom of possible beliefs in order to interpret linguistic meaning. The interpreter must impose his or her own standards of truth and coherence on ascriptions of beliefs and meanings. There must be a presumption that any utterance or belief held true is true and that beliefs are structured in accordance with basic logic, probability theory and decision theory. This underpins the interpretation of familiar logical connectives such as ‘and’, ‘or’, ‘not’ etc. [Davidson 1990: 326-328].
This complex of related assumptions governing the rationality imputed - generally briskly labelled the ‘Principle of Charity’ - enables interpretation to get off the ground. If utterances and underlying beliefs are assumed by the interpreter to be generally true, rationally structured and to concern the worldly states of affairs which prompt them, then they can be correlated with those observed states of affairs and their meaning determined.
But Davidson goes further. He argues that the facts available to radical interpretation are the only facts about meaning there are. After all, the only justification that can be offered for knowledge of a first language – the only potentially contrasting case – depends on facts available from the radical interpretation of the contextually located utterances of kith and kin. Since access to the only facts there are about meaning has to be mediated by the Principle of Charity, this is not merely an epistemological shortcut. It reflects an ontological feature of belief content and linguistic meaning itself. Both are governed by a constitutive principle: the ‘Constitutive Ideal of Rationality’ [Davidson 1980: 223]. Belief and meaning (both facets of human intentionality) are essentially governed by rationality.

Reduction to, or emergence from, the physical?
Davidson’s account of radical interpretation is a development from his teacher W.V.O. Quine’s account of a similar thought experiment: radical translation [Quine 1960: 26-79]. But one key difference is its characterisation of the evidence available to the interpreter or translator:
The crucial point on which I am with Quine might be put: all the evidence for or against a theory of truth (interpretation, translation) comes in the form of facts about what events or situations in the world cause, or would cause, speakers to assent to, or dissent from, each sentence in the speaker’s repertoire. We probably differ on some details. Quine describes the events or situations in terms of patterns of stimulation, while I prefer a description in terms more like those of the sentence being studied; Quine would give more weight to a grading of sentences in terms of observationality than I would; and where he likes assent and dissent because they suggest a behaviouristic test, I despair of behaviourism and accept frankly intensional attitudes toward sentences, such as holding true. [Davidson 1984: 230]
Davidson realises that his project cannot escape all meaning-related notions and especially in later accounts drops the requirements about its non-semantic nature:
My way of trying to give an account of language and meaning makes essential use of such concepts as those of beliefs and intention, and I do not believe it is possible to reduce these notions to anything more scientific or behaviouristic. What I have tried to do is give an account of meaning (interpretation) that makes no essential use of unexplained linguistic concepts. (Even this is a little stronger than what I think is possible.) It will ruin no plan of mine if in saying what an interpreter knows it is necessary to use a so-called intensional notion - one that consorts with belief and intention and the like. [Davidson 1984: 175-6]
This is significant because it marks a distinction between Quine’s scientistic project of reducing meaning-related notions to behaviouristic notions and hence, in principle at least, initiating a first reductionist step. Davidson has no such aims.
Further, a key aspect of Davidson’s broader philosophy of mind is to argue that the Constitutive Ideal of Rationality has ‘no echo in physical theory’ [Davidson 1980: 231]. Hence there cannot be lawlike relations between the rational domain of mental states and the nomological domain of underpinning neurological or physical states. Such lawlike connections would violate the constitutive principles of the mental. So mental content cannot be reduced to neural properties. The most there can be is something like emergence of the mental from the physical domain.

Reduction to, or emergence from, the rational?
Although Davidson denies the possibility of a reductionist project, using that word in Nagel’s sense to mean reducing mental properties to physical properties, the argument from radical interpretation nevertheless suggests a reductive project. Facts about meaning and mental content are reduced to a prior understanding of the demands of rationality in accord with the Principle of Charity. But the connection between meaning and mental content, on the one hand, and rationality, on the other, might place explanatory priority differently akin to the Euthyphro dilemma. Given a suitable theology, the following biconditional would be true:
·         For any act x: x is pious if and only if x is loved by the gods.
The dilemma stems from considering the ‘order of determination’, in Crispin Wright’s phrase, of this biconditional [Wright 1992]. Is the pious loved by the gods because it is pious, or is it pious because it is loved by the gods? In the epistemic approach to it outlined above, it looks as though Radical Interpretation explains meaning and mental content in terms of rationality. But it may be the case that the connection highlights an ontological dependence the other way. Or, it may be that there is equal priority.
One reason for denying that it is the first priority is the idea that grasping the meaning of words introduces new rational norms or ‘oughts’. Davidson himself argues that the output of Radical Interpretation can be codified using the logical machinery of Tarski’s semantic conception of truth [Tarski 1944]. Tarski uses this to shed light on the nature of truth (or, more accurately, the set of truths expressible in a language) presupposing facts about meaning. Davidson inverts that use to shed light on meaning by presupposing truth, in accord with the Principle of Charity. A central feature of both Tarskian and Davidsonian approaches is the derivation of instances of what is called the ‘T-schema’:
·         ‘Snow is white’ is true if and only if snow is white.
It has been argued that meaning relations as exemplified in instances of the T-schema are merely descriptive rather than normative [Hattiangadi 2006]. One argument for that is that it is hard to see how the norm in question could be, for example, a moral ought since there is no general moral obligation to use ‘snow’ to speak of snow. So what kind of ‘ought’ could it be?
But in accord with the general though experiment of radical interpretation – that is, if the ground rules for that thought experiment are accepted – such an equivalence is surely not normatively inert:
[W]hat makes it correct among speakers of English to make a claim with, say, the words ‘Snow is white’... is that snow is indeed white. I stress ‘correct’: truth in the sense of disquotability... is unproblematically normative for the practice of using the sentence mentioned on the left-hand side of T-sentences. [McDowell 2009: 214]
The equivalence expresses the kind of normative standard on which Radical Interpretation is built. In order to break into the circle of interdependence of belief and meaning, the Principle of Charity imposes rational constraints that speakers believe and say what they ought to in this sense. In this case, in order to say that snow is white in English, one ought to say ‘Snow is white’. Such a principle is part of the armoury of the radical interpreter in his or her broader holistic project of interpretation. The normativity, however, is not moral or prudential or any other species but specifically semantic.
On the Tarskian-Davidsonian conception the ‘oughts’ in question – the ‘oughts’ that are built into the idea of, say, denotation – are not separable from the idea of correctness in assertion... I think once we see that the intuition that meaning and aboutness are ‘ought’-laden does not require the relevant ‘oughts’ to be pre-semantical... we can see that there is no ground for the idea that linguistic behaviour must be governed by... proprieties that can be formulated in non-semantical terms... [McDowell 2009: 215-6]
The distinction between semantic and other kinds of normativity does not undermine the normativity of the former. It is sui generis. But its location within the broader framework of radical Interpretation suggests that it is nevertheless bound by the Constitutive Ideal of Rationality.
Davidson’s own presentation of Radical Interpretation seems to suggest that meaning is accessible to any rational subject since the standards of rationality mentioned are as general as logic, probability theory, and decision theory. Indeed, this thought underpins his argument against the very idea of many untranslatable and also of a single substantial conceptual schemes or scheme [Davidson 1984: 183-98].
Changing the priority suggests another possibility. If rationality and meaning go hand in hand, the rationality relevant for a particular tract of meaning may require a particular kind of mind. It may take a particular special design of mind to respond to and grasp certain kinds of meaning. Rationality may not be a universal ‘cognitive prosthetic’ in Charles Travis’ phrase. He says:
Our special design opens our eyes, as [John McDowell] puts it, to particular tracts of reality. That our eyes may be thus opened shows where, and how, there may be facts that it takes special capacities, not enjoyed by just any thinker, to see... Special knowledge-yielding capacities may be insusceptible to cognitive prosthetics. That is, what, with them, one is equipped to see need not be what would be derivable from some statable set of principles by a thinker lacking those capacities. [Travis 2002: 305, 325].
McDowell’s invocation of special design is usually associated with sensitivity to moral demands. The idea is this. On the assumption that, notwithstanding the influential contrary tradition in the moral philosophy, moral judgement cannot be codified in a set of principles, it must instead answer to the values inhering in worldly situations: moral particulars (or the evaluative equivalent of the facts to which empirical judgements answer). But in order to address a potential disanalogy with at least some empirical facts concerning primary qualities such as length and mass, McDowell suggests that moral values may be akin to secondary qualities such as colour, taste and smell. Grasp of secondary qualities and moral properties requires having a particular kind of perceptual system, or mind, or underpinning way of life: our special design. This in turn suggests that to understand those concepts, the meaning of the relevant words, and the norms that govern them also requires having a special design.
The possibility of an equal priority in the relation between the ideal of rationality and the facts about meaning and mental content it structures and the additional plausibility of the idea that some concepts are not accessible to just any rational subject suggests a more complex picture of the emergence of mind or, rather, minds. Whilst Davidson’s presentation of radical interpretation suggests a method to break into the holism of belief and meaning from a prior grasp of the ideal of rationality, the equal priority view suggests no such route and instead a more encompassing holism. Hence whilst Davidson denies the possibility of a reductionist account, he does suggest the possibility of a reductive one reducing meaning not to the physical but to rational relations. The alternative I have sketched is doubly emergent.

Davidson’s account of belief and meaning through the thought experiment of radical interpretation presents a principled account of intentionality in this sense. It offers an answer to the question: what justifies the description of a state as meaning-laden. The answer is that it plays a role within radical interpretation: the project of making sense of speech and action against the Constitutive Ideal of Rationality. Davidson uses this to argue against the reduction of the mental to the physical and hence against reductionism, in Nagel’s phrase. But the simplest way to think of the thought experiment, encouraged by Davidson’s own presentation, is, nevertheless, reductive: reducing the mental to the rational.
The equal priority view of meaning and rational norms sketched above suggests a more complex picture. Interpretation is still structured by respect of rational norms or ‘oughts’ but these are augmented by grasp of meanings. Further, some aspects of rationality are not universal. They require a special design of mind for their conception and detection. And hence an articulation of what it is like to have our kind of mind is an articulation from within \a particular grasp of the world. And hence it is couched in terms which are both higher order but also local.
This view, however, raises a question about the nature of philosophical inquiry. Reductive, and sometimes reductionist, approaches to complex concepts provide a model for philosophical clarification. Fodor’s argument for reductionism, quoted above, can serve as a manifesto for philosophical naturalism. Complex concepts can be fitted into a broader conception of nature and thus rendered unmysterious by reducing them to more basic constituents. But the equal priority view just sketched suggests no such method. Reduction to the physical world at best plays no role in the account of meaning or, at worst, is ruled out by a Davidsonian a priori argument. Even the connection to rationality provides no theory-neutral entry for thinking about meaning. Instead, the account is pitched within the phenomena it aims to clarify, highlighting internal constraints. In accord with Nagel’s suggestion for emergence, the connections are all higher order. But unlike Nagel’s account, no attempt is made to connect this to the world outside meaning except for its role in radical interpretation. This prompts the question of the kind of philosophical insight such an account can give. It can only address an audience of those with appropriate eyes to see and ears to hear. I suggest that this a puzzle for an emergentist account and suggests a paradox. The account can only be grasped by those who seem to have no need of it.

This paper was written whilst a fellow of the Institute for Advanced Study, University of Durham. My thanks both to the IAS, Durham and the University of Central Lancashire for granting me research leave.

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Davidson, D. (1983) ‘A coherence theory of truth and knowledge’ in Heinrich, D. (ed) (1983) Kant oder Hegel, Stuttgart: Klett-Cotta pp 423-438
Davidson, D. (1984) Inquiries into Truth and Interpretation, Oxford: Oxford University Press.
Davidson, D. (1990) ‘The Structure and Content of Truth’ Journal of Philosophy 87: 279-328
Davidson, D. (1993) ‘Reply to Jerry Fodor and Earnest Lepore’ in Stoecker, R. (ed) (1993) Reflecting Davidson, Berlin: de Gruyter pp77-84.
Fodor, J. A. (1987) Psychosemantics: the problem of meaning in the philosophy of mind, Cambridge, Mass.: MIT Press.
Fodor, J. A. (2008) LOT2: The language of thought revisited, Oxford: Oxford University Press
Grice, H. P. (1957) ‘Meaning’ Philosophical Review 66: 377–88
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Hempel, C.G. (1965) Aspects of Scientific Explanation London: Free Press
Lewis, D. (1986) ‘Causal Explanation’ in Lewis, D. Philosophical Papers. Vol. 2, Oxford: Oxford University Press. pp. 214-40
McDowell, J. (2009) Having the World in View, Cambridge, Mass.: Harvard University Press
Quine, W.V.O. (1960) Word and Object, Cambridge, Mass.: MIT Press
Tarski, A. (1944) ‘The Semantic Conception of Truth’, Philosophy & Phenomenological Research 4:341-375
Travis, C. (2002) ‘Frege’s target’ Royal Institute of Philosophy Supplement 51: 305-343
Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell.
Wright, C. (1992) Truth and objectivity, Cambridge, Mass.: Harvard University Press

Monday 8 December 2014

Some notes on David Papineau’s Durham Emergence talk: Emergent Causation and the Philosophy of Mind

I went off to hear my old Masters degree supervisor David Papineau talking on an aspect of the emergence theme. The abstract ran:

Intuitively, causal relations might seem to depend on impacts between microscopic physical objects. However I shall show that this is a superficial illusion, and that causation is an essentially macroscopic phenomenon. On this basis, I shall draw various conclusions about the causal autonomy of the mental realm.

My notes run as follows:

“How does the mind affect the physical world. Interactionist dualism is an intuitive default view. The mind is separate but has the power to come done and produce physical effects. But it is no longer popular in or outside philosophy. Why not?

Because  it seems plausible that all the laws governing brain and bodily processes involve only physical properties. This threatens to make any separate mental realm merely epiphenomenal. There is no space left for the mind to make any difference. A causal dangler. It is merely an illusion that the mental makes a difference, like a child with a toy steering wheel in a car. Worse than unattractive: it is incoherent. Conscious pain, eg., is never the reason for expressing it by a movement of the lips.

To avoid it, with the rise of materialism, one can instead argue that mental events just are complexes of neural events. The problem of causation is now akin to how political parties ever make a difference given that it is groups of people who produce social effects.

But since it seems to be the only contemporary option, why is it such a modern theory? 100 years ago it would have been a minority view. Answer: the assumption that all the laws governing brain and bodily processes only physical properties is itself a modern view. 150 years ago 'nervous energy' was not merely a metaphor. The conservation of energy would have included sui generis chemical, life, and mental energies. A kind of Newtonian interactionist dualism. But evidence has accumulated that there are no special forces operating within the body that do not also operate outside. Eg familiar electrical processes governing cellular processes.

Libet's work might suggest epiphenomenalism. But in other cases mental choices do have bodily effects. Libet's set up is not a paradigm of choice.

But are mental events just arrangements of neurons? One reason: the multiple realisation of mental states construed as functional, rather than type type physical states. But if so, the problem of epiphenomenalism returns since it is surely the neurons / hardware that moves the body around: epiphobia: the fear of functionalists who fear they are turning into epiphenomenalism. Much materialist literature aimed at resolving this problem. Striking that few people have attempted to explore gaps in the fabric of physical law. (Lowe is an exception.)

[It may be worth adding here that the fear of epiphenomenalism in the modern era is not that particular mental states or events are the epiphenomenal effects of neuronal causation. Since mental states are supposed just to be neuronal states, that cannot be the case. There can be no synchronic causation between what seem to be two states but which are really just the very same state. The worry is that the mental types or properties that particular token mental states possess play no causal role.]

A different route is to reexamine the nature of causation. Most philosophers think of causation as a series of pushes and pulls. But basic physics is symmetric in time whereas causation is not. This suggests that causation is a high level phenomenon akin to entropy. Increase in entropy cannot be explained in terms of basic physics because basic physics is symmetric in time. To explain the increase in entropy requires an addition to physics: two additions.

An analogy with the mixing up that a mix of hotter and colder gases will typically undergo. To explain the general pattern that such systems get mixed up requires throwing away information about each particular system.

On an analogous account, causes are macroscopic states that can be realised in different ways at the level of basic physics and their causal powers hinge on probabilistic facts about the  distribution of their realisers. At the level of basic physics, one loses the probabilistic structures on which causation (and entropy increase ) depend. Although this may not be how we intuitively think of causation that doesn't mean it isn't true.

Causation requires variable realisers.

So sometimes physical effects have mental causes and not specific neuronal causes. I waived for the taxi because I wanted to stop it , not because of specific neuronal arrangements.

Cf Stephen Yablo. The bull is angered by the cape's redness not its more specific crimson ness. Yablo turns out to be talking about real causation and not just explanatory salience. (The causal oomph need not be at the most basic level.)

Some effects result from specific neuronal arrangements such as the specific wys in which I waggle my arm. But in many cases mental states will be causes in their own right.

Once we realise that causation as emergent phenomenon relative to basic physics then we can understand how there can be autonomous mental causation.”

A couple of thoughts after the fact.

First, David Papineau was my first philosophy lecturer and so it is perhaps no surprise that much of the presentation and stage setting seems very familiar: the spatial metaphors for synchronic versus diachronic etc. I found that rather comforting.

Second, there is something admirable about the strategy of the talk. Causation at the microphysical level causes worry for functionalist physicalists about the merely epiphenomenal status of the mental (or mental properties). So the purpose of the talk was to destroy the very idea of causation at the microphysical level. Without it, there is no worrying comparison.

Still I have three immediate qualms.

First, it seems a high price to pay. So there is no causation at any level which does not admit multiple realization. I’m guessing at the physics here but that suggests that no Higgs Boson collision can cause anything. But we might think that it raises the probability of particular events, or is connected in some lawlike relations, or if the collision had not happened then neither would the subsequent event, or, by intervening on the Higgs Boson, one might be able to bring about some other desired event. Each of these is the core of a philosophical account or theory of causation. Papineau’s comment to defuse this seemed merely to be: although this may not be how we intuitively think of causation, that doesn't mean it isn't true. But it would be helpful to have some further argument for thinking it better to preserve causation only at the higher level.

Second, it seems to me that for a mental level causal link there might be a neuronal underpinning and that neurones are surely functional features thus themselves susceptible to multiple realisation. But if so causation continues at that level. And isn’t that how the worry about epiphenomenalism is usually put?

Third, I am not sure that the worry about epiphenomenalism need be couched in causal terms if causal terms are so understood. Suppose that the microphysical level cannot sustain causal relations. Still it might sustain sufficient conditions cashed out in nomological terms. (Some people might think this a matter of causation.) Suppose that that is the case. Would the nomological sufficiency of a microphysical redescription of a mental cause not itself be enough to raise the threat of epiphenomenalism?

Thursday 20 November 2014

Pro-social behaviour

One of the presentations I heard at a graduate psychology conference at Durham this week (to which I had been generously invited to give the closing lecture) concerned an investigation of the factors that encourage pro-social (the antonym of anti-social) behaviour in some example universities. The potential impact of the research was that it might indicate how to make universities better but in particular more harmonious places especially important in the light of the rise of tuition fees in the UK and the need for high student satisfaction scores.

One stage of the research concerned self assessments of instances of pro-social behaviour undertaken by individuals themselves identified via questionnaires. A further stage included objective external measures including both experimental and descriptive data gathering. So for example, for the latter, total quantities of recycling might be weighed for particular student groups. For the former, students might be asked to throw some paper away being offered, without comment, both recycling and non recycling rubbish bins. Both self assessment and more objective measures required, however, some identification of what counted as pro-social behaviour. And this was picked out, not by a priori experimenter imposition, but by preliminary research of what students themselves thought of as pro-social with then some editing out of idiosyncratic outliers.

I was struck by the fact that recycling was used as an example of what is pro-social. This, it seems to me, is obviously a good thing. But it isn't clear why it counts in this case, as pro- social as opposed to pro- some other good (eg future generations, the good of the planet, ecology etc) especially given the link made in the presentation to social harmony. Of course, if everyone in the community agrees on this value then subscribing to it will count as pro-social and non recyclers will look disruptive of harmony but it seems interestingly contingent that this value, the value of recycling, promotes harmony. In communities elsewhere, or in the past, the ardent recycler will be / was a thorn in the side of the harmonious wasteful consumers.

This struck me as an interesting feature of the research because of an event a couple of weeks ago. Working one evening in my room in college, in a castle in Durham, I was disturbed by odd noises from the stairwell outside. There, I found a group of young men undertaking a drinking rite, one sitting in the dungeon like basement on a chair being cheered, or perhaps jeered, on by an audience as he drank quantities of beer. When I asked - like you do - whether they were OK or were killing one another, everyone insisted they were fine including the victim (I was reminded of the cheery wave of the man being beaten up in the children's cartoon pastiche of the TV series Life on Mars) and a quick informal assessment of capacity suggested I should leave them alone. Later, when I left the building, I warned them I was off out and thus no longer able to get help should it be needed, but they still seemed to have capacity though by now there was a 20 foot tube down the stairs feeding the beer into the mouth of the (now different) victim from above. I left in a strangely bad mood but they were doing nothing worse than many other adult students across the UK and across time. Further, unpleasant though the scene seemed to me, such behaviour no doubt survives from generation to generation precisely because of its function in sustaining and underpinning a kind of social harmony in the groups concerned.

But when I asked my psychologist researcher, she assured me that such behaviour had not featured in her research into what is pro-social. I suspect an implicit normative control was in place. That doesn't look good when it comes to thinking about harmonious university life in the era of high tuition fees.

Call for papers: moral and legal responsibility in the age of neuroscience

23-25 SEPTEMBER 2015


 The focus of this conference will be moral and legal responsibility in people who have been diagnosed with mental disorders. This is an exciting area in which recent developments in policy and research are casting a new light on old problems.

The conference is not confined to psychiatrists and is open to anyone with an academic, professional or personal interest in this area. We hope to bring speakers from different backgrounds together with the aim of promoting an eclectic, multi-professional approach to this area. We would welcome submissions from patient, offender and victim advocacy groups.

Suitable topics would include the following but submissions in any other related area of scholarship will be considered:
Neuroscience and criminal responsibility
Autonomy and suicide
Recent developments in legal mitigation e.g. ‘loss of control’ defence and diminished responsibility
Agency and responsibility in personality disorder
Assessment of legal capacity
Deprivation of liberty in patients who lack capacity
Responsibilities of clinicians and service users
Responsible research and policy
Psychiatry and political violence

Submissions for oral and poster presentations are invited. Speakers will have 30 minutes for their presentations.

A summary no longer than one side of A4 should submitted to the conference organiser, Dr John Callender by 31 January 2015. Please submit by e-mail to john.callender@nhs.net or jscall@doctors.org.uk.

Tuesday 18 November 2014

Psychiatric diagnosis, tacit knowledge and criteria

A third draft paper written whilst a fellow of the Institute for Advanced Study, University of Durham.

For the last 50 years, both of the major psychiatric diagnostic systems – DSM and ICD – have aimed at reliability at the potential cost of validity. They have done this by codifying diagnosis in the form of criteria, influenced by operationalism from the philosophy of physics and down playing aetiological theory. It is an empirical question whether DSM-III, -IV and now -5 and the parallel ICD classifications have achieved this aim overall.
There have been criticisms, however, that the explicit criteria under-determine the diagnoses made by skilled clinicians. That is, the criteria themselves have a vagueness for which experienced psychiatrists have to compensate in diagnostic judgements in response to particular patients expressing particular signs and symptoms. The overall top-down or gestalt judgement is more precise than the component criteria on which it is supposed to be based.
The aim of this chapter is not to address whether this is so but rather how it could be so. In doing so, I will make two suggestions. First, diagnosis may involve an important tacit element. As a recognitional judgement, it may share characteristics of an uncodifiable form of know-how. Second, the postulation of criteriological intermediaries between the skilled clinician and their patients’ or clients’ actual conditions may distort the recognitional process. Judgement of the underlying mental states of patients and clients may be more secure than the operationalised criteria.
Background: the rise of criteriological diagnosis
Over the last half century, there has been a concerted effort to improve the reliability of psychiatric diagnosis by pruning the two main diagnostic systems of possibly over hasty aetiological theory and stressing instead more directly observational features of presenting subjects. Two main factors explain this. (For a fuller account, see [Fulford et al 2005].)
First, on its foundation in 1945, the World Health Organisation set about establishing an International Classification of Diseases (ICD). The chapters of the classification dealing with physical illnesses were well received but the psychiatric section was not widely adopted. The British psychiatrist Erwin Stengel was asked to propose a basis for a more acceptable classification. Stengel chaired a session at an American Psychological Association conference of 1959 at which the philosopher Carl Hempel spoke. As a result of Hempel’s paper (and an intervention by the psychiatrist Sir Aubrey Lewis) Stengel proposed that attempts at a classification based on theories of the causes of mental disorder should be given up (because such theories were premature), and suggested that it should instead rely on what could be directly observed, that is, symptoms.
In fact, Hempel’s paper provided only partial support for the moral that was actually drawn for psychiatry. He argued that:
Broadly speaking, the vocabulary of science has two basic functions: first, to permit an adequate description of the things and events that are the objects of scientific investigation; second, to permit the establishment of general laws or theories by means of which particular events may be explained and predicted and thus scientifically understood; for to understand a phenomenon scientifically is to show that it occurs in accordance with general laws or theoretical principles. [Hempel 1994: 317]
These two requirements – that terms employed in classifications should have clear, public criteria of application and should lend themselves to the formulation of general laws – correspond to the aims of reliability and validity respectively. But it was the former that was adopted by psychiatry as the key aim at the time. With respect to it, Hempel claims that
Science aims at knowledge that is objective in the sense of being intersubjectively certifiable, independently of individual opinion or preference, on the basis of data obtainable by suitable experiments or observations. This requires that the terms used in formulating scientific statements have clearly specified meanings and be understood in the same sense by all those who use them. [ibid: 318]
He commends the use of operational definitions (following Bridgman’s book The Logic of Modern Physics [Bridgman 1927]), although he emphasises that in psychiatry the kind of measurement operations in terms of which concepts would be defined would have to be construed loosely. This view has been influential up to the present WHO psychiatric taxonomy in ICD-10.
The second reason for the emphasis on reliability and hence operationalism was a parallel influence within American psychiatry on drafting DSM-III. Whilst DSM-I and DSM-II had drawn heavily on psychoanalytic theoretical terms, the committee charged with drawing up DSM-III drew on the work of a group of psychiatrists from Washington University of St Louis. Responding in part to research that had revealed significant differences in diagnostic practices between different psychiatrists, the ‘St Louis group’, led by John Feighner, published operationalised criteria for psychiatric diagnosis. The DSM-III task force replaced reference to Freudian aetiological theory with more observational criteria.
This stress on operationalism has had an effect on the way that criteriological diagnosis is codified in DSM and ICD manuals. Syndromes are described and characterised in terms of disjunctions and conjunctions of symptoms. The symptoms are described in ways influenced by operationalism and with as little aetiological theory as possible. (That they are neither strictly operationally defined nor strictly aetiologically theory free is not relevant here.) Thus one can think of such a manual as providing guidance for, or a justification of, a diagnosis of a specific syndrome. Presented with an individual, the diagnosis of a specific syndrome is justified because he or she has enough of the relevant symptoms which can be, as closely as possible, ‘read off’ from their presentation. The underlying syndrome is connected to more accessible, epistemologically basic signs and symptoms.
An objection to criteriological approaches
Although the rationale for a criteriological, or bottom up, approach to diagnosis seems clear, it has not escaped criticism. The charge is that combining individual symptoms understood initially in isolation from context and only assembled in the conjunctions that add to diagnosis is vague.
In a paper called ‘Phenomenological and criteriological diagnosis: different or complementary?’ Alfred Kraus, professor of psychiatry at Heidelberg, argues that diagnostic systems such DSM and ICD miss out an important element of psychiatric diagnosis [Kraus 1994]. Because they assume that diagnoses are built up from a number of individual and conceptually independent symptoms they cannot capture top-down and holistic elements of diagnosis.
One key criticism that Kraus makes of what he calls this criteriological approach to diagnosis, is that rather than providing a reliable foundation, the connection between individual symptoms and conditions lacks specificity. There remains widespread disagreement about the correlation between individual symptoms and underlying syndromes. By contrast, according to Kraus, a top-down holistic model is more specific because it allows a correlation between schizophrenia and particular kinds of catatonia or delusional structure. Correlations are not between schizophrenia and delusions in general. Such a connection is vague. Specificity attaches to the link between schizophrenia and delusions with a specific schizophrenic colouring. But this connection can only be established with a top-down rather than criteriological model of diagnosis. The bottom up approach is vague whilst the top down approach is more specific.
Kraus also argues that in the bottom-up model, symptoms can only be added together through conjunction. But no mere conjunction of individual symptoms—a ‘Chinese restaurant menu’ approach—can capture the psychological integrity up to which the individual parts add. For that, one again needs a holistic approach. This is not to say, however, that particular elements cannot be identified in a holistic diagnosis. It is just that the individual elements have a different logic.
One way of marking this distinction (although not Kraus’ own) is to contrast parts that are independent pieces and parts that are essential aspects. The pieces of a jigsaw add up to a whole, but each piece can exist independently of the others. By contrast a musical note has both a tone and a pitch, but neither aspect can exist independently of the other. Thus, according to a holistic approach, psychological symptoms are interdependent aspects of a psychological unity.
Kraus combines with these two comments on the limits of a criteriological model of diagnosis with a further philosophical explanation of the difference in approach. This is why he contrasts the criteriological with a phenomenological rather than merely a holistic model. This concentrates not on psychiatric diseases but on the mode of being of whole persons, the ‘whole of the being in the world of schizophrenics or manics’. Thus the phenomenologically based diagnosis of schizophrenia turns on an overall assessment of the patient—a ‘praecox feeling’—as having a very different form of ‘being-in-the-world’. But whether or not that more general view is correct, the criticism suggests that the operational structure of psychiatric manuals contributes to the vagueness of diagnosis strictly based on them.
Mario Maj makes a similar criticism. Again taking the example of schizophrenia, he argues that:
One could argue that we have come to a critical point in which it is difficult to discern whether the operational approach is disclosing the intrinsic weakness of the concept of schizophrenia (showing that the schizophrenic syndrome does not have a character and can be defined only by exclusion) or whether the case of schizophrenia is bringing to light the intrinsic limitations of the operational approach (showing that this approach is unable to convey the clinical flavour of such a complex syndrome). In other terms, there may be, beyond the individual phenomena, a ‘psychological whole’ (Jaspers, 1963) in schizophrenia, that the operational approach fails to grasp, or such a psychological whole may simply be an illusion, that the operational approach unveils. [Maj 1998: 459-60]
In fact, Maj argues that this shows the weakness of the operational approach. He argues that the DSM criteria fail to account for aspects of a proper grasp of schizophrenia: for example, the intuitive ranking of symptoms (which have equal footing in the DSM account). He suggests that there is, nevertheless, no particular danger in the use of DSM criteria by skilled, expert clinicians for whom it serves merely as a reminder of a more complex prior understanding. But there is a problem in its use to encode the diagnosis for those without such an additional underlying understanding:
If the few words composing the DSM-IV definition will probably evoke, in the mind of expert clinicians, the complex picture that they have learnt to recognise along the years, the same cannot be expected for students and residents. [ibid: 460]
Maj’s criticism that the DSM criteria do not capture a proper, expert understanding of the diagnosis of schizophrenia raises the question of how or why that could be the case. If the criticism is right, is it that the wrong criteria have been used: either the wrong symptoms and / or the wrong rules of combination? Or is there something more fundamentally wrong with the criteriological approach as applied to psychiatry?
Josef Parnas suggests the latter. In a paper describing pre-operational approaches to taxonomy and diagnosis as a ‘disappearing heritage’ he comments on an underlying difference in attitude towards signs and symptoms of schizophrenia.
When the pre-DSM-III psychopathologists emphasized this or that feature as being very characteristic of schizophrenia, they did not use the concept of a symptom/sign as it is being used today in the operational approach. This latter approach envisages the symptoms and signs as being (ideally) third person data, namely as reified (thing-like), mutually independent (atomic) entities, devoid of meaning and therefore appropriate for context-independent definitions and unproblematic assessments. It is as if the symptom/sign and its causal substrate were assumed to exhibit the same descriptive nature: both are spatio-temporally delimited objects, ie, things. In this paradigm, the symptoms and signs have no intrinsic sense or meaning. They are almost entirely referring, ie, pointing to the underlying abnormalities of anatomo-physiological substrate. This scheme of ‘symptoms = causal referents’ is automatically activated in the mind of a physician confronting a medical somatic illness. Yet the psychiatrist, who confronts his ‘psychiatric object’, finds himself in a situation without analogue in the somatic medicine. The psychiatrist does not confront a leg, an abdomen, not a thing, but a person, ie, broadly speaking, another embodied consciousness. What the patient manifests is not isolated symptoms/ signs with referring functions but rather certain wholes of mutually implicative, interpenetrating experiences, feelings, beliefs, expressions, and actions, all permeated by biographical detail. [Parnas 2011: 1126]
The claim here is that the criteriological approach has the wrong model of psychiatric symptoms and signs in two respects. Just as smoke can mean fire or tree rings the age of a tree, the criteriological approach takes signs to be free standing items which causally indicate underlying states. Furthermore, these relations are independent of one another: they are atomic. By contrast, Parnas suggests, psychiatric signs and symptoms are both essentially meaning-laden rather than brutely causal and also mutually interdependent wholes. It is the latter claim which plays the more important role in his criticism.
One argument for their interdependence is that it is only in particular contexts that symptoms are reliable. Thus, for example, mumbling speech is comparatively widespread (Parnas estimates 5% of the population) but in – and only in – the context of other features such as ‘mannerist allure, inappropriate affect, and vagueness of thought, it acquires a psychopathological significance’ [ibid: 1126]. So the effectiveness of the sign is context-dependent. In some contexts it is indicative and in others not. Excluded from context – as it is in the criteriological context – it is vague. But it is precise in context. Parnas goes further by suggesting a more than merely additive view. Grasp of psychiatric symptoms is likened to seeing the figure of the duck-rabbit first as a rabbit and then suddenly as a duck: seeing the signs and symptoms under an overall aspect or gestalt.
A Gestalt is a salient unity or organization of phenomenal aspects. This unity emerges from the relations between component features (part-whole relations) but cannot be reduced to their simple aggregate (whole is more than the sum of its parts)... A Gestalt instantiates a certain generality of type (eg, this patient is typical of a category X), but this typicality is always modified, because it is necessarily embodied in a particular, concrete individual, thus deforming the ideal clarity of type (universal and particular). [ibid: 1126]
So the model of diagnosis is one in which the skilled clinician grasps the right diagnosis as an integrated whole in which different aspects can be seen as abstractions from that whole rather than as its basic building blocks. Such a view would accommodate Kraus’ rejection of a ‘Chinese restaurant menu’ approach and Maj’s suggestion that criteriological elements serve as reminders for already skilled clinicians. They do – on this view – in the sense that, after the fact, such articulations of the overall picture are possible, as a musical note may be divided into its pitch, tone and duration whilst it cannot be built up from those as independent building blocks. But that does not imply that the expert judgement of the whole could be built up from the individual criteria understood in isolation.
Diagnosis and tacit knowledge
This criticism of the criteriological approach prompts two further questions. The bottom up codification of diagnosis through simpler, more basic signs and symptoms suggests an explanation of how complex diagnostic judgement is possible. It is possible because it is based on simpler more epistemically accessible building blocks. The first question concerns the nature of an overall ‘gestalt’ judgement if that explanation is rejected. On what is top-down judgement based and what is its relationship to the criteriological approach? In this section, I will suggest an analogy with context-dependent tacit knowledge to try to make this seem a less puzzling possibility [for a more detailed discussion see Thornton 2013]. But it will also help highlight how the move from context-dependent recognition to explicit criteria introduces vagueness into psychiatric diagnosis.
Second, if diagnostic judgement is not based on more observational features of a clinical encounter, how can it yield knowledge of underlying mental states. In the final section, I will suggest an analogy with the more general ‘problem of other minds’ and outline what may initially seem a counter-intuitive view outlined by the philosopher John McDowell which inverts the epistemic priority of judgements about behavioural signs and symptoms and judgements of underlying mental states. Again it will suggest that reliance on basic criteria comes at the cost of introducing vagueness into diagnosis.
I suggested at the start that the development of the theoretically minimal criteriological approach to diagnosis in psychiatry was partly influenced by operationalism in the philosophy of science in the first part of the twentieth century. The aim was to minimise uncodified elements in psychiatric diagnosis so as to maximise reliability. But there was, in the second half of the century, a contrasting view about the nature of scientific knowledge: the chemist turned philosopher Michael Polanyi’s arguments for the importance of tacit knowledge. (Polanyi himself talks of tacit knowing rather than knowledge. I will, nevertheless, use ‘knowledge’ whilst talking about his views but will return to emphasise the practical dimension to what is tacit.) Top-down or gestalt judgement in psychiatry can be thought of as an instance of tacit knowledge.
Polanyi gives the following example:
We know a person’s face, and can recognize it among a thousand, indeed among a million. Yet we usually cannot tell how we recognize a face we know. So most of this knowledge cannot be put into words. [Polanyi 1967b: 4]
This is an instance of what he takes to be a general phenomenon. Indeed, he begins his book The Tacit Dimension with the following bold claim:
I shall reconsider human knowledge by starting from the fact that we can know more than we can tell. [Polanyi 1967b: 4]
The broad suggestion is that knowledge can be tacit when it is, on some understanding, ‘untellable’. ‘Tellable’ knowledge is a subset of all knowledge and excludes tacit knowledge. But the slogan is gnomic. Does it carry, for example, a sotto voce qualification ‘at any one particular time’? Or does it mean: ever?
The very idea of tacit knowledge presents a challenge: it has to be tacit and it has to be knowledge. But it is not easy to meet both conditions. Emphasising the tacit status, threatens the idea that there is something known. Articulating a knowable content, that which is known by the possessor of tacit knowledge, risks making it explicit. There is a second strand through Polanyi’s work which helps address this problem. At the start of his book Personal Knowledge in which he says:
I regard knowing as an active comprehension of things known, an action that requires skill. [Polanyi 1958: vii]
These two features suggest a way to understand tacit knowledge: it is not, or perhaps cannot be made, explicit and it is connected to action, the practical knowledge of a skilled agent. The latter connection suggests a way in which tacit knowledge can have a content: as practical knowledge of how to do something. Taking tacit knowledge to be practical suggests one way in which it is untellable. It cannot be made explicit except in context-dependent practical demonstrations. It is not that it is mysteriously ineffable but that it cannot be put into words alone.
Psychiatric diagnostic judgement can be thought of as an example of such a skill: the ability to recognise in context the manifestation of psychiatric illness. Polanyi also compares recognition to a practical skill, likening it to bicycle riding:.
I may ride a bicycle and say nothing, or pick out my macintosh among twenty others and say nothing. Though I cannot say clearly how I ride a bicycle nor how I recognise my macintosh (for I don’t know it clearly), yet this will not prevent me from saying that I know how to ride a bicycle and how to recognise my macintosh. For I know that I know how to do such things, though I know the particulars of what I know only in an instrumental manner and am focally quite ignorant of them. [ibid: 88]
In both cases, the ‘knowledge-how’ depends on something which is not explicit: the details of the act of bike riding or raincoat recognition. Whilst one can recognise one’s own macintosh one is, according to Polanyi, ignorant, in some sense, of how. Thus how one recognises it is tacit. Polanyi makes the same claim for linguistic labelling generally.
[I]n all applications of a formalism to experience there is an indeterminacy involved, which must be resolved by the observer on the ground of unspecified criteria. Now we may say further that the process of applying language to things is also necessarily unformalized: that it is inarticulate. Denotation, then, is an art, and whatever we say about things assumes our endorsement of our own skill in practising this art. [ibid: 81]
Polanyi seems here to say that explicit recognition of something as an instance of a type is based on the implicit recognition of subsidiary properties of which one is focally ignorant. To recognise a feature one must a) always recognise it in virtue of something else (subsidiary features) of which b) one is focally ignorant. But it is not clear that either part of this claim is true.
To consider the claim, it will help to make clearer what Polanyi means by focal attention and subsidiary awareness. Elsewhere he uses the sample of pointing to something using a finger.
There is a fundamental difference between the way we attend to the pointing finger and its object. We attend to the finger by following its direction in order to look at the object. The object is then at the focus of our attention, whereas the finger is not seen focally, but as a pointer to the object. This directive, or vectorial way of attending to the pointing finger, I shall call our subsidiary awareness of the finger. [Polanyi 1967a: 301]
In looking from the finger to the object, the object is the focus of attention whilst the finger, though seen, is not attended to. It is not invisible, however, and could itself become the object of focal attention. This suggests that the first part of the general claim that Polanyi needs itself faces an objection based on a regress. The recognition of an instance of a type or kind depends on subsidiary awareness of something else which could have been the object of focal awareness and thus would have depended on subsidiary awareness of something else.
This is a potential rather than a vicious regress. (It is not that in order to have subsidiary awareness of something one must already or actually have had focal awareness of it or anything else. Combined with Polanyi’s general claim, that thought would have generated a vicious regress.) Nevertheless, even the potential regress suggests something implausible about Polanyi’s general claim. It does not seem reasonable to think that it is always the case that recognition depends on subsidiary awareness of something else. Take the case of the direct perceptually based recognition that a part of a wall is red. Surely that turns on the focal awareness of the colour independent of subsidiary awareness of anything else?
Polanyi seems to assume that the question of how one recognises something as something always has an informative answer and then to cover cases where it is not obvious what this is he suggests it can be tacit. But whilst it sometimes may have an informative answer, there is no reason to think that it always has. What of the second aspect: that one must be focally ignorant of the subsidiary features?
Even in cases where one recognises a particular as an instance of a general kind in virtue of its subsidiary properties and cannot give an independent account of those properties, it is not clear that one need be focally ignorant of them. It may be, instead, that the awareness one has of the subsidiary properties is simply manifested in the act of recognition. I might say, I recognise that this is a, or perhaps my, macintosh because of how it looks here with the interplay of sleeve, shoulder and colour even if I could not recognise a separated sleeve, shoulder or paint colour sample as of the same type. Whilst it seems plausible that one might not be able to say in context-independent terms just what it is about the sleeve that distinguishes a or my macintosh from any other kind of raincoat (one may, for example, lack the vocabulary of fashion or tailoring) that need not imply that one is focally ignorant of, or not attending to, just those features that make a difference. Recognition may depend on context-dependent or demonstrative elements, such as recognising shapes or colours for which one has no prior name. But if anything, that suggests one has to be focally aware, not focally ignorant, of them.
Thus Polanyi’s own account of the tacit nature of recognition faces some key questions. But, in setting out the issues, a more minimal account of tacit knowledge has already been suggested. Recognition is tacit because it is a skill – for example, developed through repetition and critical practice and demonstrated in applications – and because it can thus be articulated only in context-dependent terms such as ‘like this!’. It cannot be explicated in words alone independently of additional practical demonstrations in context.
If the skilled diagnostic judgement described in the previous section by Kraus, Maj and Parnas is thought of as tacit knowledge as just explicated then it can be contrasted with criteriological diagnosis in the following way. The criteria set out in ICD and DSM are an attempt to make psychiatric diagnosis explicit. They attempt to set out context-independent descriptions of psychiatric syndromes.
Such an attempt is akin to attempting to model an ability to recognise colours and shades on general knowledge of the names for colours that ordinary people have. For most people, the ability to recognise, think about and recall (at least for some period) particular shades of colour goes beyond what they can make explicit linguistically. The ability can instead be manifested by pointing to particular instances of colour themselves. By contrast with the fine discriminations that can be made in context, colour vocabulary is generally vague.
Similarly, by contrast with the context depending discriminations of skilled clinicians, the criteria set out in diagnostic manuals are vague and imprecise. Because they are context-independent, the criteria in DSM and ICD are portable. There is an advantage in communication of a linguistic codification of diagnosis that floats free of particular contexts. But it is bought at the cost of precision. By contrast, the features that play a role in the top-down diagnoses of skilled clinicians are identified in the context of a particular patient’s or client’s psychological whole. Such recognition cannot be captured in words alone.
Criteria and other minds
In the previous section, I suggested that tacit knowledge can be used to shed light on the idea that an overall top down or gestalt diagnostic judgement could be more specific than a diagnosis based on general but vague criteria. A skilled clinician has a recognitional skill which can only be exemplified in context-dependent judgements about particular patients or clients. That is to approach the problem from an epistemological perspective: what it is to have knowledge in this way. In this section, I will complement that by taking an ontological view. What could the relation be between the underlying mental states and conditions amounting to mental illness or disease syndromes and the more epistemically accessible criteria set out in DSM and ICD?
To outline an answer to this question I will outline a debate from the philosophy of mind that our knowledge of other minds in general is based on behavioural criteria. Although the argument against that view that I will outline does not directly carry over to the case of psychiatric diagnosis, it does suggest why criteriological diagnosis is vague compared to top-down or gestalt judgement.
The concept of a criterion was introduced into the philosophy of mind as a solution to the problem of other minds by followers of the philosopher Ludwig Wittgenstein. The influential Wittgenstein exegete PMS Hacker, writing in the Oxford companion to philosophy, defines a criterion thus:
A standard by which to judge something; a feature of a thing by which it can be judged to be thus and so. In the writings of the later Wittgenstein it is used as a quasi-technical term. Typically, something counts as a criterion for another thing if it is necessarily good evidence for it. Unlike inductive evidence, criterial support is determined by convention and is partly constitutive of the meaning of the expression for whose application it is a criterion. Unlike entailment, criterial support is characteristically defeasible. Wittgenstein argued that behavioural expressions of the ‘inner’, e.g. groaning or crying out in pain, are neither inductive evidence for the mental (Cartesianism), nor do they entail the instantiation of the relevant mental term (behaviourism), but are defeasible criteria for its application. [Honderich 1995]
Key features of this definition are that the criteria of, for example, an ‘inner’ state like pain are fixed by convention and are partly constitutive of what we mean by the word ‘pain’. Thus groaning and crying out are not mere symptoms but rather part of what we understand by pain, connected by definition not induction. At the same time, however, the criteria of pain are defeasible.
The reason for this qualification is the following intuition. Whilst, in general, pain behaviour is the expression of underlying pain, on occasion behaviour which resembles pain behaviour in every detail is not the expression of pain. It may be the result of acting or pretence. (And equally, genuine underlying pain may sometimes be stoically kept from expression.) As a result, the criterial support that apparent pain behaviour gives for a judgement that someone is in pain is taken to be defeasible. It can, on occasion, be overturned.
The idea that criteria give only defeasible support for a claim is combined with a further assumption which the philosopher John McDowell, in his criticism of this very notion, describes thus: ‘if a condition is ever a criterion for a claim, then any condition of that type constitutes a criterion for that claim, or one suitably related to it’ [McDowell 1982: 462-3]. In other words, criteria are types. Whilst on most occasions, when instances of some general type of criterion are satisfied the underlying fact for which those instances are criteria also obtains, on some occasions the type of criterion is satisfied (by some particular circumstances) but the fact does not obtain. In such cases, the criterion is satisfied but is nevertheless also defeated.
This suggests that there is an essential vagueness in the support that criteria, so understood, provide for judgements about mental states. In any particular case, some expression, some sign or symptom of pain for example, may or may not actually mean that the person expressing it is actually in pain.
This worry provides the basis for McDowell’s criticism of the use of criteria, understood in this way, to explain how knowledge of other minds is possible. On the assumption that it is sometimes, at least, possible to know someone else’s mental state, McDowell asks how such knowledge is supposed to be based ‘on an experiential intake that falls short of the fact known... in the sense [of]... being compatible with there being no such fact’ [McDowell 1982: 459].
The worry is this. If one knows something, then it cannot be the case that - ‘for all one knows’ - things may be otherwise. That possibility is ruled out precisely because one knows what is the case. But if criteria fall short of implying the fact that they are supposed to enable one to know, then they cannot themselves rule out the possibility that the fact does not obtain. So if our everyday concept of knowledge does rule this out then such knowledge cannot be based on perception that the criteria for some mental state are satisfied. A possible alternative view in which the perceived the criteria is supposed merely to be enough to satisfy linguistic conventions for the ascription of knowledge would also not address this objection, either.
If experiencing the satisfaction of ‘criteria’ does legitimise (‘criterially’) a claim to know that things are thus and so, it cannot also be legitimate to admit that the position is one in which, for all one knows, things may be otherwise. But the difficulty is to see how the fact that “criteria” are defeasible can be prevented from compelling that admission; in which case we can conclude, by contraposition, that experiencing the satisfaction of ‘criteria’ cannot legitimize a claim of knowledge. How can appeal to “convention” somehow drive a wedge between accepting that everything that one has is compatible with things not being so, on the one hand, and admitting that one does not know that things are so, on the other? [McDowell 1982: 458]
Imagine that there are two observers who both see that the behavioural criteria, so construed, for two other people being in pain are satisfied but that only one of them really is in pain: the other is pretending. If the observers’ experiences are the only grounds for them knowing the mental state of their respective subject and if their perceptions are the same in both cases (seeing that the criteria for pain are met) then how can one observer know their subject’s mental state and the other observer not? Surely, neither has knowledge even if one has, by chance, a true belief. It seems merely a matter of luck that one observers’ experience is of undefeated criteria whilst the other’s is of defeated criteria, that in one case the observed subject really is in pain and in the other merely pretending. The luckier observer has done nothing extra to earn the right to knowledge.
There is, however, an alternative view of criteria and of knowledge of other minds based on them. Rather than assuming that, in the case of pretence, the criteria for mental states are satisfied but are also defeated - by the fact that it is a case of pretence - one can instead construe it as a case of the criteria only appearing to be satisfied. This is a rejection of the idea that criteria are defeasible types of situation. Instead, McDowell presses the idea that, when criteria are satisfied, one’s experience does not fall short of the facts. So there cannot be cases where the criteria are satisfied without the fact for which they give criterial support also holding.
McDowell supports this interpretative possibility by considering a passage in which Wittgenstein discusses criteria in a non-mental context.
The fluctuation in grammar between criteria and symptoms makes it look as if there were nothing at all but symptoms. We say, for example: “Experience teaches that there is rain when the barometer falls, but it also teaches that there is rain when we have certain sensations of wet and cold, or such-and-such visual impressions.” In defence of this one says that these sense-impressions can deceive us. But here one fails to reflect that the fact that the false appearance is precisely one of rain is founded on a definition. [Wittgenstein 1953 §354]
Wittgenstein rejects the temptation to say that both the fall of a barometer and also sensations of wet and cold (or visual impressions) are mere symptoms of rain. Instead, and by contrast with the barometer fall, the connection between the sensations (or the visual impressions) and rain is definitional or criterial. They are used in an explanation of what ‘rain’ means. This thought can, however, be interpreted in two ways.
Commentators often take this to imply that when our senses deceive us, criteria for rain are satisfied, although no rain is falling. But what the passage says is surely just this: for things, say, to look a certain way to us is, as a matter of ‘definition’ (or ‘convention’... ), for it to look to us as though it is raining; it would be a mistake to suppose that the ‘sense-impressions’ yield the judgement that it is raining merely symptomatically - that arriving at the judgement is mediated by an empirical theory. That is quite compatible with this thought... when our “sense-impressions” deceive us, the fact is not that criteria for rain are satisfied but that they appear to be satisfied. [McDowell 1982:466]
Someone who steps outside their house when the lawn sprinklers are switched on may think that by having experiences of wet and cold they have experienced the criteria for rain, albeit on this occasion defeated. After all, when being taught about rain they may have been taught it through practical definitions involving experiences that felt similar. But the experiences used in the practical definition were not just any experiences of wet and cold but wet and cold experiences of rain falling. Similarly in the case of criteria for mental states, pretence can make it seem that the criteria for pain, for example, are satisfied when, in fact, they are not
Taking the criteria to be merely any experience of wet and cold (for rain) or any experience of high pitched cries (for pain) makes them too vague to sustain knowledge. Correcting this requires rethinking the generality and the descriptive nature of criteria. If the criteria for pain are given in both general and also behavioural terms, they are too vague to underpin knowledge. So one might think of them as particular though still behavioural. If so, only particular instances of behavioural criteria (particular instances of crying out and rubbing knees etc) are valid guides to underlying pain. Such a suggestion maintains the behavioural character of criteria for mental states but denies their generality. The alternative is to maintain (something of) their generality but deny the restriction to merely behavioural signs and symptoms. On such an account, the criteria for pain do not have in common anything that could be given in mind-free behavioural terms. Rather they share the essentially mind-involving generality of being expressions of pain.
McDowell offers a philosophical diagnosis of why such a view of criteria seems to go unnoticed which goes back to the influence of Cartesian dualism. If one starts from that basic picture then it invites a contrast between the behavioural states of other people to which one can have direct perceptual access, and mental states, which are, in some sense, hidden behind them. According to Descartes, they even exist in different kinds of space (res cogitans and res extensa). Cartesian dualism suggests an alienated picture of human behaviour in which all that anyone else can ever see is bodily movement which is only contingently associated with minds. Because perception of, and judgements about, such ‘behaviour’ is taken to be unproblematic whilst access to other people’s mental states is taken to be problematic, a route is needed from one to the other. Thus it seems plausible to think that judgements about mental states have to be grounded in independent judgements about behaviour. The alienated picture of human behaviour survives in approaches to the philosophy of mind which have long since rejected Descartes’ conception of the mind as res cogitans (or thinking stuff) existing in a different dimension to matter (res extensa).
This picture of the relation of mind and body is neither obligatory nor natural, however. One can instead think of mind and body as more closely linked. What one says and does expresses what one thinks and feels. Whilst one person’s mental states do not themselves fall within the direct experience of another their expression of their mental state does. Such expression is not one that is consistent with the absence of the inner state. So McDowell replaces an account in which all that is visible to an observer is another person’s intrinsically brute or meaningless behaviour, standing in need of further interpretation and hypothesis, with one in which that behaviour is charged with expression.
By denying that our ‘access’ to the minds of others must proceed through a neutrally described behavioural intermediary (their behaviour), McDowell can offer a much less technically charged account of criteria which he summarises thus:
I think we should understand criteria to be, in the first instance, ways of telling how things are, of the sort specified by “On the basis of what he says and does” or “By how things look”; and we should take it that knowledge that a criterion for a claim is actually satisfied - if we allow ourselves to speak in those terms as well - would be an exercise of the very capacity we speak of when we say that one can tell, on the basis of such-and-such criteria, whether things are as the claim would represent them as being. [McDowell 1982: 470-1]
Knowledge of other minds depends on what people say and do. It does not require a kind of direct mind reading. The judgement is based on, emerges from, what they say and do. But the conceptualisation of what they say and do need not be couched in mind-independent neutral terms. As Dowell comments:
This flouts an idea we are prone to find natural, that a basis for a judgement must be something on which we have firmer cognitive purchase than we do on the judgement itself; but although the idea can seem natural, it is an illusion to suppose it is compulsory. [McDowell 1982: 471]
It may be easier to see patterns and generalities in behaviour construed as essentially expressive of minds than in neutrally described bodily movement. So even though judgements about others’ minds may be based on their behaviour, the description of the behaviour may be less secure than the description of what it expresses.
I have set out two contrasting accounts of criteria from the philosophical discussion of the problem of other minds to shed light on the more specific issue of mental illness diagnosis. There are, however, two related important differences between the two cases which need mention.
First, the application of the idea of criteria in the more general problem of other minds and in the case of psychiatric diagnosis differ in one clear respect. It is merely a theoretical idea in the former case but set out in practical detail in recent editions of the DSM and ICD in the latter case. Second, and related to this, is an important difference in the dialectical context of criticism of behavioural criteria in the two cases. The argument above assumes that it is possible to have knowledge of other minds. Since the standard model of criteria (as defeasible behavioural types) makes knowledge impossible, it cannot be the basis of our knowledge of other minds.
But one might object that psychiatry does not aspire to knowledge when it comes to diagnosis but some weaker state such as a belief with a particular degree of probability. And hence an argument which shows that knowledge cannot be based on criteria, so understood, need not undermine that project. Such an objection carries risk, however. Since psychiatry is a practical discipline, diagnoses form the basis for action (concerning treatment and management). Thus clinicians need more than merely having beliefs with a particular (suitably high) probability of being true, they need to know that they do.
Nevertheless, even if psychiatric diagnosis need not aspire to knowledge itself but merely to some known probability of being correct, it could be based on criteria understood as behavioural types (ie the target of the criticism of this section). Providing that there are other methods of arriving at diagnoses, such as the considered judgement of skilled clinicians or longitudinal studies, it would be possible to make an assessment of the sensitivity and specificity – in probabilistic terms – of types of behavioural criteria. The dialectical context differs for defenders of defeasible criteria for knowledge of other minds because they assume that there is no more fundamental way of having such knowledge and hence no independent test of the construct validity of the criteria.
Despite these differences, McDowell’s discussion of the two accounts of criteria and the role, in the account he defends, of the idea that behaviour can be more than mere behaviour but rather expressive mental states sheds light on the possibility, at least, of the relative vagueness of criteriological diagnosis compared to the specificity of gestalt judgement. Both the DSM and ICD stress operationalised descriptions as opposed to more essentially psychiatric descriptions couched in aetiological terms. They do this in an attempt to provide secure foundations for diagnosis. But that very strategy makes the criteria mere approximations of the underlying psychopathological states they aim to capture. As Kraus, Maj and Parnas suggest, precision requires thinking of psychiatric symptoms as abstractions from a diagnostic whole rather than built up from neutral – or more neutral – criteria whose obtaining does not strictly imply the presence of the psychiatric syndrome for which they are supposed to be signs.
An alternative view of diagnostic criteria, drawing on McDowell’s account and influenced by the empirical claims of Kraus, Maj and Parnas would stress the specific schizophrenic colouring of particular delusions, for example. It may seem that this carries the risk that identifying that a patient or client is experiencing such a delusion is riskier than the vaguer claim that they are experiencing some sort of delusion or other. But this may not be so in context. In particular cases, the justification for thinking that the delusion carries a specific schizophrenic colouring may be what warrants the more general claim that they are thus experiencing some more general category of delusion.
I have considered the charge made against criteriological models of diagnosis that, compared with the gestalt judgement of a skilled clinician, they are essentially imprecise and vague. I have argued that two independently plausible considerations help explain how this could be so. Epistemologically, such diagnosis could be akin to the kind of context-dependent practical skill that underpins one model of tacit knowledge. Such skill resists codification in general context-independent terms akin to the DSM and ICD’s diagnostic criteria but is nevertheless a form of conceptually structured knowledge. Ontologically, the diagnostic criteria of the DSM and ICD may be merely more or less behavioural abstractions from underlying psychological reality. Skilled clinicians need not rely on neutral criteria but on the direct expression of complex psychological wholes.
This chapter was written whilst a fellow of the Institute for Advanced Study, University of Durham. My thanks both to the IAS, Durham and the University of Central Lancashire for granting me research leave.
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