Rough first thoughts for a booklet on On Certainty

Wittgenstein’s On Certainty contains a commitment to the existence of hinges: items - of some sort - which are ‘held’ fast and about which inquiry in some sense turns. My aim is to see whether this basic idea can be combined with a plausible account of knowledge and then to see what happens to scepticism. Along the way I will discuss my differences from Norman Malcolm, Avrum Stroll, Danièle Moyal-Sharrock, Annalis Coliva, Marie McGinn, Duncan Pritchard, Crispin Wright and Michael Williams.

Now hinges might be extra-conceptual and purely animal behaviours: the Malcolm and Stroll view (Stroll thinks that Wittgenstein slowly moves to this from a more propositional view). Perhaps the animal certainty with which my cat uses her limbs is some form of hinge for her. But Stroll and Malcolm link this view to the rational standing of linguistic agents too: people with inherited ‘realistic pictures’ of the world. I follow neo-Fregean thinking here. If hinges contribute to the epistemic standing of rational agents then they must be conceptual. They must be something for the agent and that implies they are entertained as something like a Fregean sense. That is, they lie in the realm of the conceptual, the space of reasons. Thus one key claim of this book is that Wittgensteinian hinges are conceptual items standing in the space of reasons.

Against this, one might object that we not stand in any specifically epistemic relation to hinges. That denial may be claimed to be part of the point of Wittgenstein’s discussion of hinges. But if so, what is it that they do for the agent? Why are they not blankly external to him/her? Two general strategies exist in the literature to respond to this question.

First, one might claim that hinges are non-epistemic but contribute in some other way to a rational agent’s mental economy via some other sort of propositional attitude. Both Wright and Pritchard suggest this. I do not think that either Wright’s or Pritchard’s proposals seem plausible even by their own terms. Wright makes the attitude a piece of prudential reasoning, severing the connection from knowledge. Pritchard conjures up a bespoke propositional attitude (akin to Andy Egan’s conjuring up of ‘bimaginings’ in the philosophy of delusion) but a) does not specify its functional properties and b) disguises this lack behind his further construction of an ‘uber-hinge’.

Second, one might deny the conceptual or propositional form of hinges while locating them outside the merely animal. Danièle Moyal-Sharrock, Annalis Coliva (and in a sense Stroll too) do this. For Moyal-Sharrock, this depends on a semi-technical notion of propositional form. Since hinges lack ‘bipolarity’ they do not count as propositions. But their status with respect to sense is not akin to nonsense as resolute readers of Wittgenstein (e.g. Conant) would hold. Technically, they lack propositional status and hence cannot be objects of propositional attitudes or knowledge. Conveniently, however, it is possible to take a hinge and convert it into a meaning-related doppelganger so as to explain how it can seem to have an empirical sense. I do not think that there is conceptual space for this, however. Such hinges are not mere syntactic patterns. They must be patterns with some sort of use. But what use? Not an empirical use. Nor are they akin to tautologies: emptied of all specific empirical content. So what could they be?

I take it that hinges lie within the space of reasons, are conceptual and contribute to an agent’s epistemic standing even if they do not form premises for arguments to knowledge that the agent makes. Their holding might contribute to the doxastic responsibility of the agent. Contentiously, I take it that they are known even if they are not known as the result of an inference nor a direct perception. (Michael Williams is a sometimes ally of this point.) They are part of a conceptually structured world picture held in place by holistic considerations.

Wittgenstein suggests, however, that they differ in some respects from other knowledge claims. Now it may be tempting to suggest that a difference lies in the fact that knowledge claims are advanced for good enough reasons but are not certain. Coliva implies this with her description of mere criteriological ascription of knowledge on a roughly Baker and Hacker line on criteria (contrast: McDowell's rather more plausible view). This, however, seems to me to be wrong for reasons that McDowell - speaking perhaps as a late representative of Oxford Realism - has outlined especially in response to Brandom. Knowledge, too, is certain.

But the difference is suggested by something right in Marie McGinn’s and in Coliva’s rather different accounts. Certainties comprise the framework of representational techniques. Normatively, ‘This is a hand’ can serve as an instruction for the correct use of ‘hand’. The utterance is conceptual and prescriptive/normative. So far this accords with McGinn and Coliva. But, going beyond their descriptions, accord with such a prescription involves something. What? I propose that it is knowing that this is a hand. In other words, I take the idea that hinges are normative – a view suggested by both McGinn and Coliva – implies that they are known, a view contrary to McGinn and Coliva.

Now knowing that this is a hand might seem to involve two distinct achievements: grasp of the meaning of ‘hand’ and a practical recognitional grasp of hands. As Wittgenstein stresses, agreement in meaning involves agreement in judgements. This is shown in the application of ‘hand’ to the world. So knowledge of hinges is a form of tacit knowledge - knowing how to deploy a set of representational techniques - but which also carries with it ‘knowledge-that’. It enables a speaker to recognise a hand in paradigm conditions.

This rapprochement is made more plausible by my previously articulated account of tacit knowledge as conceptually structured, context specific practical knowledge. Linking the tacit to the conceptual via McDowell’s relaxed account of the conceptual helps to locate certainties within the space of reasons. It helps to show how hinges can seem akin to the animal while still being both conceptually structured and also knowledge.

Both Wittgenstein and commentators seems to make heavy weather of Moore’s ‘I know’ (see especially Coliva). One worry seems to be that Moore misrecognises knowledge as a mental state that could serve as a source of certainty. But that doesn’t seem to me to be the problem. A sincere ‘I know’ claim expresses objective certainty though it cannot guarantee it. ‘I know’ is fallible. So it can be a mental state - as Oxford Realism takes to be uncontentious - even if not a source of certainty. Nor is it a problem that Moore attempts to enumerate what he knows (even the usually reliable Williams gets caught up on this because of his own signature dish: epistemological realism). That too seems perfectly possible on a fallibilistic mental state picture. But the fallibility of knowledge avowal does not apply to knowledge itself, contra what Coliva assumes when she suggests merely a defensible criteriological relation between reasons and knowledge. Knowledge is factive and we can be both fallible about the contents of a knowledge claim and the fact that we think we know it. Too much ink is spilled worrying about the ‘I know’ while a retreat to ‘he knows’ would have been clearer. Moore's failure to say something in his strangely contextualised assertion does not carry over as to whether he actually knows there is a hand. (On this point: imagine if his defence in court had been that he did not know that he had a hand. Imagine if Wittgenstein’s pair of tree labelling philosophers claimed in court that they had not known there was a tree in front of them, in daylight, with non-defective vision. As Avner Baz stresses, sometimes knowledge is a burden that is not easily denied. That we do not know the point of a hypothetical knowledge claim does not imply that no knowledge is had.)

If hinges are known then neither Pritchard’s non-belief nor Moyal Sharrock’s non-propositional view will help defeat scepticism. Neither of their arguments could be used, for example, to block closure. So the full weight of an anti-sceptical argument will fall on whether supposedly known hinges can evade sceptical hypotheses in something like the way that rejecting a merely highest common factor picture of experience in response to the argument from illusion can undercut scepticism about perceptual knowledge. What’s needed is the idea that our epistemic standing can take in how the world is even if there is no additional assurance from outside our epistemic practices that it does. There is, however, a partial analogy between hinges as construed here and disjunctivism about perceptual knowledge. Of course, the picture offered by disjunctivism of a direct embrace of the world in object-dependent experiences or singular thoughts will not apply to all hinges. But there is an analogy in the use of samples and the role of showing in the later Wittgenstein. The representational system cannot float free of the world because its elements are made up of the world.

The contemporary importance of the idiographic in mental healthcare

In response to concerns about the subsuming of individuals under essential general psychiatric diagnostic categories, there have been calls for an idiographic component in person specific diagnostic formulations. The distinction between the idiographic and nomothetic was introduced by Windelband as his contribution to the Methodenstreit. However, as I have argued elsewhere, it is unclear what the distinction is supposed to comprise. In this chapter, I attempt to shed light on the motivation for the distinction by looking at a number of recent approaches to healthcare that share a concern with a focus on individuals. Despite this shared element in their motivation, I argue that none help to articulate the nature of the idiographic itself.

This chapter broadens the central claim of my chapter in the 2018 Yearbook of Idiographic Science, here drawing on a clue from Windelband’s student Rickert to argue that there is a role for the idiographic in healthcare though not as a form of judgement, understanding or intelligibility but rather a specific singular interest in an individual. It is this that also underpins developments in healthcare related to the individual or person..

Introduction

One of the standing concerns expressed by mental health service users and clinicians alike about contemporary diagnosis in psychiatry is that it risks pigeon-holing subjects rather than respecting their individuality. As an anonymous reviewer of one of my papers once put it: ‘Time and time again the categorical, pigeon-holing, approach to diagnosis has to be bent in order to accommodate the individual account’ (Thornton 2008b). The suggestion seems to be that the criteriological model of diagnosis that lies at the heart of the Diagnostic and Statistical Manual and the International Classification of Diseases, is, by itself, inadequate to capture, and perhaps respect, patients and service users as people in all their individuality (American Psychiatric Association 2013; World Health Organization 1992).

This concern forms the motivation for proposals in psychiatry such as the World Psychiatric Association’s Idiographic (Personalised) Diagnostic Formulation which called for an ‘idiographic component alongside criteriological diagnosis’ (IGDA Workgroup, WPA, 2003: 55). It aimed ‘at understanding and formulating what is important in the mind, the body and the context of the person who presents for care’ (ibid: 55). Taking my lead from the word used by the World Psychiatric Association, I will call this concern for capturing the individual nature of the patient or service user a concern for ‘idiographic’ understanding. This, however, raises the question of the nature of the idiographic. As I will argue, it proves harder to analyse than it might first appear. Having looked at its origins in Wilhelm Windelband’s rectoral address, I will look at a number of contemporary approaches to healthcare that, I believe, are motivated by the same concern with the individual. I will argue, however, that none is able to shed light on the idea of idiographic understanding. At the end, I will suggest that the felt need for a special form of understanding can be met, instead, in a different way. It lies in an interest in individuals which is also hinted at by Windelband but also his student Rickert.

This chapter sketches a broad overall picture of a number of healthcare ‘philosophies’ seen through the conceptual lens of the idiographic. It thus writes a cheque that would need to be redeemed by careful and sober argument. That, however, will not be offered here.

Windelband and the idiographic

The first articulation of the idiographic was given by the post-Kantian philosopher Wilhelm Windelband in his 1894 rectoral address (Windelband 1980). Windelband worked in the broad tradition of the Methodenstreit, which concerned methodological distinctions between the natural and social sciences. It is usually associated with a distinction between understanding and explanation exemplified, for example, in Karl Jaspers’ General Psychopathology (Jaspers 1997). Understanding and explanation are supposed to be distinct ways of conceptualising their subject matters, with the former tied to human thoughts, feelings and actions and the latter to the totality of merely natural events.

Rather than understanding versus explanation, Windelband contrasts idiographic and nomothetic sciences. He links that distinction, primarily, to a very general distinction between the particular and the general. Such a distinction – between distinct forms of judgement in different disciplines – looks to be tailor-made to capture the contrast between a pigeon-holing approach implicit in general criteriological approaches in psychiatry and a form of judgement that captures patient and client individuality.

In their quest for knowledge of reality, the empirical sciences either seek the general in the form of the law of nature or the particular in the form of the historically defined structure. On the one hand, they are concerned with the form which invariably remains constant. On the other hand, they are concerned with the unique, immanently defined content of the real event. The former disciplines are nomological sciences. The latter disciplines are sciences of process or sciences of the event. The nomological sciences are concerned with what is invariably the case. The sciences of process are concerned with what was once the case. If I may be permitted to introduce some new technical terms, scientific thought is nomothetic in the former case and idiographic in the latter case. Should we retain the customary expressions, then it can be said that the dichotomy at stake here concerns the distinction between the natural and the historical disciplines. (Windelband 1980: 175-6)

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

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

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

The referential element does not seem to be a hopeful place to look to draw a distinction between nomothetic and idiographic. Consider the traditional deductive-nomological model of explanation as an example (Hempel 1965). This contains general laws (hence the name). But it also refers to particular circumstances in the explanans. Whether an adequate formal model of explanation or not, since the DN model of explanation is designed to fit paradigmatically nomothetic sciences mere singular reference to particular circumstances is not sufficient to distinguish a different form of intelligibility.

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

I think that the ‘individualising intuition’ is a widespread in recent responses to/against conventional psychiatric medicine. And so it may help to identify how it can be achieved by looking at other initiatives concerning healthcare. In what follows, I aim for breadth rather than depth. I will merely paint an abstract picture of the lie of the land. Justifying the connections I sketch breathlessly would require careful argument for which there is not space here.

Person Centred Medicine

The ‘individualising intuition’ is one of the motivations for the recent growing popularity of a long-standing approach to healthcare, in parallel with the growth over the last thirty years of evidence-based medicine (EBM), namely person-centred medicine (PCM). Though the roots of PCM lie in, among other places, Paul Tournier’s advocacy of ‘medicine for the person’, conceptions of the clinician-client relationship in psychotherapy, and models of patient-centred care, it has recently risen to prominence just as EBM has seized the clinical imagination. While EBM stresses the importance of evidence based on large scale population side studies, PCM presses the idea that the proper focus of healthcare should be on individual people construed as persons rather than, say, merely biological systems. The former emphasises the role of generalities in medicine, the latter individuals. This is not to say that there must be an incompatibility between looking to population-wide studies as the basis for reliable evidence and to individuals as the focus of such evidence-based care but the apparent need to re-emphasise the latter suggests an inchoate concern that the patient or client as an individual risks being lost from sight.

The nature of PCM is, however, particularly contested. For some authors, the contrast between persons and patients is key, for others not. For some, the main contrast with persons is sub-personal systems. For others, it is illnesses. For yet others, the contrast is a focus on the needs of patients rather than on the needs of clinicians. Despite having a particular focus on individual patients, understood as persons, conflicting claims are made about the values necessary either to maintain that focus or as a proper response to it.

Given these competing views, is there anything essential that all forms of PCM must hold? I have argued elsewhere that any plausible version of PCM must commit to two claims (Thornton forthcoming). Ontologically, the level of the person is an irreducible and significant feature of ontology and a proper focus for healthcare. Epistemologically, not only is knowledge of the human person (human beings, people) possible and significant in healthcare, there are also irreducible forms of person-level knowledge which are important to healthcare. A commitment to PCM is thus a substantive commitment to ontological and epistemological claims. Do either of these claims shed light on the nature of the idiographic?

I think not. First, although the two commitments are distinct – because they concern ontology and epistemology respectively – with respect to the question addressed here, they can be reduced to one. What makes the knowledge specifically personal is the ontology known. This, I suggest, following the philosophers Wilfrid Sellars and John McDowell, is characterised by a distinction between two conceptual orders: the ‘space of reasons’ and the ‘realm of law’ (McDowell 1994; Sellars 1997). The irreducibility of the level of the person follows from the irreducibility of the space of reasons to the realm of law. The former is a normative realm of reasons, motives, rules that applies to rational subjects. The latter is a realm of mere generalities concerning mindless happenings in broader nature. So, does a characterisation of the space of reasons shed light on the idiographic? To consider this I will turn to narrative understanding.

Narrative medicine

The World Psychiatric Association suggests, as an alternative to the characterisation of ‘idiographic’, that what needs to be added to criteriological diagnosis in a more comprehensive model is a narrative formulation. Any such move faces a strategic choice. Is the very idea of narrative interpreted broadly to have wide application, even at the risk of evacuating it of specific content, or is it tied to particular literary notions of narrative, thus risking narrowing its application and making it inapplicable to non-literary contexts?

At its broadest, we might use ‘narrative’ to label the kind of intelligibility required for any exploration of the space of reasons: charting the reasons, motives, rules and actions that characterise the human realm. That would also be a way to fill out the ‘understanding’ side of the ‘understanding versus explanation’ contrast in the Methodenstreit. Understanding could be characterised as narrative understanding of the space of reasons and explanation could chart the nomological realm of law. If so, the normative structure of narrative offers a genuine complement to generality based criteriological diagnosis. It offers a view of the rational coherence of a subject’s thoughts and feelings, of why they think and feel what they do according to them, over and above what is merely generally or statistically the case, in accord with the realm of law.

Despite this difference, narrative accounts are nevertheless couched in general terms and consequently narrative understanding does not address the felt need for an essentially singular judgement purpose built for an individual. This is because they are conceptually structured and, according to a very plausible principle, concept mastery is an essentially general ability. The most famous statement of this is the philosopher Gareth Evans’ Generality Constraint.

It seems to me that there must be a sense in which thoughts are structured.... I should prefer to explain the sense in which thoughts are structured, not in terms of their being composed of several distinct elements, but in terms of their being a complex of the exercise of several distinct conceptual abilities.... Thus if a subject can be credited with the thought that a is F, then he must have the conceptual resources for entertaining the thought that a is G, for every property of being G of which he has a conception. (Evans 1980: 100-104)

Because narrative understanding of others rides piggy back on conceptual thought in general, it inherits the latter’s essential generality. This suggests, too, that narrowing down, or making more specific, the model of narrative would not change this fundamental point. Even if a person-specific diagnostic formulation were more closely modelled on what we might call a ‘story’, with the necessary dramatic components of that genre, still the basic elements would be general concepts, applicable to more than one person and hence not addressing the individualising intuition. The danger of pigeon-holing would continue to exist. An individual might be subsumed under an appealing narrative or story to which they do not fully fit.

Values-based practice

Like person-centred medicine, values-based practice (VBP) is another explicit attempt to complement to EBM (generalised from medicine to practice), which aims to promote the role of patients’ and clients’ values alongside (evidence of) facts in healthcare decisions. In the original and influential statement of VBP, in addition to arguing for the general importance of values, Bill Fulford asserts the central importance of the individual patient or client: ‘VBP’s ‘first call’ for information is the perspective of the patient or patient group concerned in a given decision (the ‘patient-perspective’ principle)’ (Fulford 2001). Unlike conventional bio-ethics, VBP is concerned with a full range of values and preferences that inform patient choices rather than concentrating on ethical values. And, again unlike most – though not all – approaches to medical ethics, Fulford places no great importance on principles, contra eg Beauchamp and Childress’ Four Principles approach (Beauchamp and Childress 2001).

On Fulford’s account, further, values are subjective. Value judgements are the preferences of individuals rather than answering to anything objective. The result is an essentially subjectivist account of values in healthcare decisions. The idea of a correct medical decision is replaced by proper deliberative procedure.

In VBP, conflicts of values are resolved primarily, not by reference to a rule prescribing a “right” outcome, but by processes designed to support a balance of legitimately different perspectives (the “multi-perspective” principle). (Fulford 2001: 206)

In the context of a contrast between the particular and the general, Fulfordian VBP suggests a complementary contrast between subjective and objective. Could this be used to explain a difference between idiographic and nomothetic?

There is a prima facie problem with this idea, however. A subjectivist version of VBP is susceptible to an objection from circularity. This can be illustrated by asking: what is the status of the claim that: in VBP conflicts of values are resolved primarily, not by reference to a rule prescribing a ‘right’ outcome, but by processes designed to support a balance of legitimately different perspectives? Note, first, that although Fulford says in the quotation above that conflicts of values ‘are resolved…’ this is in the context of Values Based Practice. So it should be read as saying: conflicts of values should be resolved by processes designed to support a balance of legitimately different perspectives. But now we can ask, why should they? (It may be an analytic truth that they are within Values Based Practice, but we are invited to adopt this approach.)

The worry, now, is that this seems to be a value of a different order from the values that should be put through the right process of balancing views. It seems to be a higher order value, inconsistent with Values Based Practice’s own approach. This then suggests a dilemma for radical VBP. It can either address the question of why we should value values in the way it suggests, but at the cost of violating its own principles, or it can attempt no such question, in which case it lacks the prescriptive force that gives it teeth (Thornton 2011, 2014).

The alternative favours an objective understanding of the subject matter of value judgements and hence a particularist, rather than a subjectivist, opposition to principlism (Dancy 1993). That leaves a different account of VBP’s account of the role of values. Although not governed by general principles, values are objective, albeit situation specific features of the world. Thus, VBP adds an emphasis on getting the values of a patient or service user right along with the biomedical facts. This is a genuine and important addition to the generalist underpinnings of EBM. But again, while a patient’s situation may be unique, the concepts used to describe it in both factual and evaluative terms are general. And hence the individualising intuition is again not met. Even acknowledging the general idea that psychiatric categories are value-laden as well as factual does not make them essentially tailored to the individual. The risk of pigeon-holing remains.

The biopsychosocial model

George Engel’s biopsychosocial model of healthcare shares with the more recent World Psychiatric Association’s comprehensive model of diagnosis the aim of a fuller picture of diagnosis and healthcare (Engel 1977). Drawing on some of the same historical forebears as PCM – some proponents of which explicitly draw on the biopsychosocial model in return – the biopsychosocial model is explicitly aimed at augmenting, though still including, the biomedical model. Its key metaphysical idea is that nature comprises a hierarchy of levels: from the subatomic to the societal. The biopsychosocial model augments the biomedical model by adding in factors from higher up the hierarchy.

To provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which he lives, and the complimentary system devised by society to deal with the disruptive effect of illness, that is, the physician role and the health care system. This requires a biopsychosocial model. (Engel 1977).

The biopsychosocial model explicitly aims to accommodate a person-level account alongside the bio-medical underpinnings of disease diagnosis. Might it, by that very aim, also accommodate idiographic understanding?

The problem is that merely adding higher levels of organisation to basic levels of physics, chemistry and biology does little to address the underlying concerns that motivated the quest for idiographic understanding in the first place. Merely adding higher levels does nothing to address a concern about the use of general descriptions and the concern of a connection to pigeon-holing.

Idiographic as an interest

In this final section, I will set out a different response to the ‘individualising intuition’ drawing on incidental clues found in Windelband and his student Heinrich Rickert. In his rectoral address, Windelband comments:

[T]he more we strive for knowledge of the concept and the law, the more we are obliged to pass over, forget, and abandon the singular fact as such. We can see this disposition in the characteristically modern attempt ‘to make history into a natural science’ the project of the so-called positivist philosophy of history… In opposition to this standpoint, it is necessary to insist upon the following: every interest and judgment, every ascription of human value is based upon the singular and the unique... Our sense of values and all of our axiological sentiments are grounded in the uniqueness and incomparability of their object. (Windelband 1980: 181-2)

This passage suggests a contentious connection between values and uniqueness. It is contentious in both directions. With respect to the implication from values to uniqueness, Kant’s Categorical Imperative, for example, implies that love of the good has an essential generality. But the implication from uniqueness to values is also unclear. This, however, is the focus of Rickert’s general account of the relation between and contrast of natural and historical science in his The Limits of Concept Formation in Natural Science (Rickert 1986). I will briefly outline his broad methodological picture.

Rickert argues that, because concepts are general, they abstract away from the concrete details of the particular, individual and perceptual aspects of reality. This is the limit of generalised scientific conceptualisation, in the sense of what it cannot represent. Given that, at least according to our experience of it, reality is infinite in extent and infinitely complex or subdividable, the only way for concept formation following this generalising strategy to be possible is to look for abstract generalities and away from the perceptual and the real. There is thus a gap between a generalised conceptual account of the world and the world itself. This is called the ‘hiatus irrationalis’ in post-Kantian philosophy. It is an hiatus because the conceptual cannot capture every aspect of reality and it is irrational because it is only by being subsumed under concepts that we can have a rational understanding of reality.

The move to a generalised scientific account moves away from the real, individual and particular towards the general and conceptual. And hence generalised scientific concepts are emptied of their perceptual character and all its detail. Rickert points out that scientific laws have the form of conditional statements: if one thing occurs then so will another. And thus he asserts ‘It lies in the concept of law of nature that it has nothing to say about what really occurs here or there, now or then, with a uniqueness and an individuality that cannot be repeated.’ (ibid: 41)

Against the potential objection that the practical application of natural science to make specific predictions shows it deals with individuals, Rickert argues.

[T]he fact that we calculate the real in advance does not imply that the concepts of natural science comprehend its total contents… It is not a question of grasping individual and perceptual realities in their individuality and concrete actuality. We are able to say only that in the future, an object will appear that can be subsumed as a case under this or that general concept. But this does not give us knowledge of the individuality and concrete actuality of future objects. Should we be interested in this sort of knowledge, we are always obliged to wait until the objects are really at hand. (ibid: 42)

Given the hiatus irrationalis between abstract concepts and reality, generalised science cannot reproduce reality. It aims instead at valid judgement. The truth of a judgement, its validity, is distinct from a resemblance or reproduction.

The concepts of the natural sciences are true, not because they reproduce reality as it actually exists but because they represent what holds validly for reality. (ibid: 44)

But because science does not copy reality, it opens up the possibility of more than one relation between concepts and reality. The limit case of generalised natural science suggests one such alternative (in fact, the only other one). One can try to capture the individuality of the concrete, real, perceptual rather than the general.

There is a representation of reality that proceeds not by generalising but by individualising, a representation that is therefore able to satisfy the interest in the unique, individual event itself. (ibid: 51)

[T]he science of the unique and the individual is necessarily the science of the event that has occurred in the past… Every account of reality itself, every account that on the basis of the foregoing reasons, concerns the unique, individual event that takes place at a specific point in space and time, we call history. (ibid: 47-8)

But as Rickert emphasises, the arguments concerning the gap between concepts and reality apply just as much to history as to natural science.

History too, insofar as it is a science, can produce only a conception of reality based on a specific logical perspective. As a result, the immediacy of reality is necessarily destroyed, but that consideration does not alter the legitimacy of this point of departure for a logical investigation. (ibid: 53)

Hence he owes an account of the principles of concept formation that govern history analogously with the abstraction and framing of laws that governs the natural sciences. It turns out, however, that the question he answers is more specific. It is how historical subjects are selected rather than the nature of historical concepts. Subjects are selected because, in addition to being specific individuals (of which there are too many!), they are specific individuals of value. This resembles the quotation from Windelband above which highlights a connection between what we value and uniqueness. Rickert argues that history is concerned with ‘in-dividuals’ not just individuals. He offers a lengthy analysis of the nature of the values in play but given that it does not, after all, address a distinction in kind between an approach to generalities and individuals it is not relevant here. Of the concepts actually deployed in historical accounts, Ricket concedes that they are general and he merely qualifies the scope of the generality compared to the natural sciences.

Even though many, perhaps even most, historical concepts have a general content in the sense that they comprehend what is common to a plurality of individual realities, in the historical nexus of a unique developmental sequence this generality is always considered as something relatively specific and individual. (ibid: 63)

In other words, despite the philosophical framework he offers, Rickert does not provide a conceptual distinction between generalising and individualising accounts. Both lie on the conceptual side of the hiatus irrationalis and both deploy general concepts. In that respect, he is no more successful than Windelband in suggesting how the individualising intuition is to be met.

Despite that, one summarising passage in The Limits of Concept Formation in Natural Science suggests a clue.

There is a profusion of things and events that interest us not only because of their relationship to a general law or a system of general concepts but also because their distinctiveness, uniqueness, and individuality are significant to us. Wherever this interest in reality is present, we can do nothing with natural scientific concept formation. (ibid: 46 bold added)

Combining this with the suggestion from Windelband – that ‘every ascription of human value is based upon the singular and the unique’ – this suggests that the way to think about the individualising intuition is not that it requires a specific form of idiographic understanding or judgement, a specific conceptualisation. Rather it reflects an interest in individuals that might be met in any number of ways. It is not a novel form of judgement or intelligibility but rather is the nature of interest an inquiry takes in its subject matter. In some cases, one is interested in individuals because they are instances of generalities. In others, the interest is in them as individuals (Thornton 2019).

What is the nature of this interest? One element is suggested in an earlier quotation from Rickert: ‘Should we be interested in this sort of knowledge [knowledge of the individuality and concrete actuality of future objects], we are always obliged to wait until the objects are really at hand.’ This suggests that one mark of an interest in an individual is that the referential element of thoughts about them is fixed by singular or object-dependent component of the thought. The actual existence of an object is necessary to be able to think singular, as opposed to descriptive thoughts, about them. But singular thought is not sufficient for an individualising interest because one may also have singular thoughts about objects in which one has an interest merely because they are instances of a generality. Further, one may think of an object via a descriptive thought even if one has an individualising interest. Thus the nature of the interest is not determined by the logic of the thought even though the possibility of singularity is a necessary component.

Construing the idiographic as a specific form of interest, rather than a sui generis form of understanding, is liberating. It removes the need to try to formulate a novel form of concept especially tailored for the individual. Any kind of concept may, in the right context, serve the interest of shedding light on an individual. But it also helps contextualise the different approaches to healthcare discussed earlier in this chapter. The call for diagnostic formulations in addition to criteriological diagnoses, person centred medicine, the stress on personal narratives, values based practice and the bio-psycho-social model are all motivated by an interest in individuals. Each stresses different conceptual structures that might help in this but all are expressions of the same guiding concern. In response to the worry that generalities may, contingently, obscure the proper subject matter of healthcare, each of these concerns attempts to place the individual back at the centre of healthcare. That is the contemporary relevance of the idiographic, construed not as a form of judgement but as a value.

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), Washington, D.C.: American Psychiatric Association

Beauchamp, T.L. and Childress, J.F. (2001) Principles of Biomedical Ethics, Oxford: Oxford University Press

Dancy, J. (1993) Moral Reasons, Oxford: Blackwell

Engel, G.L. (1977) ‘The need for a new medical model: a challenge for biomedicine’ Science. 196: pp. 129-36

Evans, G. (1980) Varieties of Reference, Oxford: Oxford University Press

Fulford, K.W.M., (2001) ‘Ten Principles of Values-Based Medicine’ In The Philosophy of Psychiatry: A Companion, ed. J. Radden. New York: Oxford University Press

Hempel, C.G. (1965) Aspects of Scientific explanation. London: Free Press.

IDGA Workgroup, WPA (2003) ‘IGDA 8: Idiographic (personalised) diagnostic formulation’ British Journal of Psychiatry, 18 (suppl 45): 55-7

Jaspers, K. (1974) ‘Causal and “Meaningful” Connections between Life History and Psychosis’, trans. by J.Hoenig, in S.R.Hirsch and M.Shepherd. in Hirsch, S.R., and M. Shepherd, Themes and Variations in European Psychiatry, Bristol: Wright: 80-93

Jaspers, K. (1997) General psychopathology, Baltimore: Johns Hopkins University Press

McDowell, J. (1994) Mind and World, Cambridge, Mass.: Harvard University Press

Rickert, H. (1986) The Limits of Concept Formation in Natural Science: A Logical Introduction to the Historical Sciences Cambridge: Cambridge University Press.

Sellars, W. (1997) Empiricism and the Philosophy of Mind, Cambridge, Mass.: Harvard University Press

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

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

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

Thornton, T. (2011) ‘Radical liberal values based practice’ Journal of Evaluation in Clinical Practice 17: 988-91

Thornton, T. (2014) ‘Values Based Practice and authoritarianism’ for Loughlin, M. (ed) Debates in Values-based Practice: arguments for and against, Cambridge: Cambridge University Press pp50-61

Thornton, T. (2019) ‘Values and the Singular Aims of Idiographic Inquiry’ in De Luca Picione, R., Nedergaard, J., Freda, M.F. and Salvatore, S. (eds.) Idiographic Approach to Health, Charlotte, NC Information Age Publishing.

Travis, C. (2006) Thought’s Footing Oxford: Oxford University Press

Windelband, W. (1980) ‘History and natural science’ History and Theory & Psychology 19: 169-85.

World Health Organization (1992). The ICD- 10 Classification of Mental and Behavioural Disorders

Postscript on Annalis Coliva’s book on Moore and Wittgenstein: Scepticism, Certainty and Common Sense

I finished Annalis Coliva’s book on Moore and Wittgenstein: Scepticism, Certainty and Common Sense (2010) but I was a little disappointed. After the care with which she set out Moore’s and Wittgenstein’s philosophical discussions, it was as though she just did not care so much about her own. In the introduction there was some discussion about being an historian of philosophy as well as a philosopher. Perhaps in this book that was where the interest lay. (I’ve also been reading but not commented on her book on extended rationality. That is delightfully philosophical but just not what I need at the moment.) I think, however, that her own view is expressed by endorsing summaries of Wittgenstein often earlier in the book.

The one thing I wanted was a careful account of hinges on her view. Unlike the Norman Malcolm paper I’ve just re-read, Coliva plays down the merely animal certainty of hinges and plays up the idea that hinges are propositions, albeit set against a background of merely animal certainty. So she contrasts with Daniele Moyal Sharrock’s non-propositional and ineffabilist view, too. She connects both these rejected views at the start of the book thus:

Moreover, as to our attitude with respect to them, if we held the ineffabilist conception of hinges, whereby, failing to be propositions, they could neither be said, nor made the object of any propositional attitude, our certainty with respect to them would have to be thought of as non- propositional, non-conceptual and therefore of a merely ‘animal’ kind. (ibid: 9)

The fullest account of her own position starts from this rejection. Coliva takes hinges to be propositions, to be or to contain conceptual contents. A key claim is that this does not require that we stand in an epistemic relation to them.

Finally, it remains to characterize our relationship to these propositions, whose role is that of norms. As Moyal-Sharrock and other interpreters have emphasized, it is thoroughly non epistemic and thus unlike belief, knowledge or even psychological certainty, for Wittgenstein. What they have failed to notice, in my view, however, is that this doesn’t entail, nor supports the view that it is animal or instinctual, and hence utterly non-propositional. After all, it has propositions – albeit of a normative kind – as its objects. So, what kind of propositional attitude may it be? I think an analogy would be useful here. Think of our rules of conduct, for example, we ought to stop at traffic lights when red. In fact we can and do say that we accept such a norm. That is to say, we behave in accord with it and would either reproach those who don’t, or accept to be reproached ourselves if we didn’t. Furthermore, we teach our children to obey it. This pragmatic sense of accepting a proposition whose nature is normative, to be contrasted with an epistemic sense of accepting empirical propositions for which we don’t have (enough) evidence, and with respect to which it would make utterly no sense to talk of epistemic evidence as it has norms as its objects, is, I submit, what Wittgenstein is alluding to when he talks of certainty with respect to hinges qua hinge-propositions. Now, the interesting aspect of our acceptance of hinges is that while being a pro-attitude, it is itself constitutive of epistemic rationality, and not merely a pragmatist acceptance due to an evaluation of its expected practical utility. (ibid: 174)
Yet, this pragmatic acceptance of rules tallies with many of Wittgenstein’s remarks which allude to our certainty as displayed in our way of acting. In particular, to acknowledge this sense of ‘accepting’ allows us not to go all the way down the path of mere ‘animal certainty’ and is compatible with saying that we accept, often implicitly and as a result of our upbringing, norms both of language and of evidential significance, and ‘instinctively’ behave in conformity with them, in ways which show no doubt. It must be stressed, moreover, that such an instinctive behaviour is not the one of the animal, but that of the human animal. That is to say, of the creature who has been drilled and taught to use language and to take part in our various epistemic practices and is thus already fully conceptual and a competent epistemic agent. If, then, there is still room for instinct here, it is one concerning our so- called second nature, not our merely first and animal one. (ibid: 174-5)
So, ‘animal certainty’ is really not the focus of On Certainty, though it is a precondition for being drilled to take part in our various language games. What On Certainty centres on are rather those propositions which, as a result of our upbringing within a community that shares a language and a form of life, we can reflectively identify as being exempt from verification and control as well as from doubt. This makes them play the role of norms, either of language or of evidential significance. Moreover, with respect to them, we do practically (as opposed to epistemically) accept them – that is to say, we behave in accord with them, in ways which know no doubt – where our doing so is, in its turn, constitutive of epistemic rationality. (ibid: 175)

So the picture is one of a background of animal certainty upon which, through education and development of a McDowellian second nature, conceptually articulated propositional certainties can be built. These are thus the object of propositional attitudes though not epistemic propositional attitudes. Various questions arise such as the nature of the attitude and how the hinges’ propositionality is realised.

With respect to the former. in the passages just quoted, Coliva sketches an initial analogy between hinges and pragmatic acceptance. But she adds that the relevant attitude to hinges is not merely a pragmatist acceptance - due to an evaluation of its expected practical utility - but is rather constitutive of epistemic rationality.

So what is the limited positive aspect of the analogy? We behave in accord with pragmatic norms and also with hinges and would reproach those who don’t. But the hinges also play a non-contingent role in the constitution of rationality. What is this role? I’m not sure. But it seems to have something to do with using – if that is the right verb – the propositional hinges for normative rather than descriptive purposes. We instruct people using hinges and we accept them as the normative standards that establish the epistemic language game, I think.

By contrast, by defending the view that hinges are propositions, though normative rather than descriptive in nature, and that our certainty with respect to them is a kind of acceptance which displays itself in our acting in accord with them, we make both certainties and certainty with respect to them effable. Of course, I think Moyal-Sharrock is right to claim that when we utter hinges qua hinges we mostly do so with heuristic purposes in mind of the kind she correctly identifies. Yet, by acknowledging their propositionality hinges become indeed sayable as such – that is to say, as norms. (ibid: 177)

The second comment – about when we utter hinges qua hinges – connects a heuristic purpose, which I think Coliva accepts, with the propositionality and hence sayability of hinges as such. Utterances can have propositional contents.

Earlier she expresses this thus:

On the contrary, I hold the view that while failing at bipolarity, they are still propositions, albeit with a normative function, rather than a descriptive one, and that we do indeed express them on various occasions: either to teach them to someone who ignored them or to remind someone of them were they to violate them, as philosophers such as Moore and a sceptic do. Contrary to other framework interpreters, most notably Moyal-Sharrock, I do think that at least the former context in which hinges are actually said is a genuine language game, by Wittgensteinian lights. (ibid: 10)

So the normative use is connected to heuristic purposes and is part of a genuine language game, not a misfiring piece of nonsense. That gives us one place for hinges: in instructing people how to play the game of giving and asking for reasons, which is based on certainties. The proposition is the content of the instructional utterance. But what is our attitude to them when they take a role in propositional attitudes which display themselves in our acting in accord with them? It seems: pragmatic acceptance. But that seems odd. It seems prima facie odd to model the certainty of hinges on mere pragmatic acceptance.

Another line of thought may help. Coliva contrasts her view with Moore’s.

when taken in those very circumstances, Moore’s propositions don’t have an empirical role, but a normative one. In the twofold sense that they are both linguistically paradigmatic judgements – that is to say, judgements that must be agreed on if the meaning of the words in them is to be determined – and epistemically paradigmatic ones. That is to say, judgements that can’t be called into question on the basis of contrary evidence, for they must stay put – however in context that might be – in order for a subject to be in a position rationally to gather any kind of evidence for other, genuinely empirical propositions. (ibid: 80)

The first part of this seems to characterise an instructive use of an utterance rather than a propositional attitude. (There is a second aspect reflected by the phrase epistemically paradigmatic to which I'll return.) But the instructive use looks to be meta-linguistic. It’s something like: call this! a ‘hand’, linking mention of a word type and a demonstrative. The related propositional attitude would seem to be an attitude to the connection between the look of a hand and the word ‘hand’. But now, surely the right attitude is knowledge? I know the meaning of the word ‘hand’. I know that this is called a ‘hand’. But perhaps this is not enough because pragmatically accepting a norm here suggests not only knowing the standrd meaning or use of ‘hand’ in English but deciding to bind oneself to that norm. I'll return to this shortly.

Coliva, however, suggests that things run deeper than either knowledge of meaning or adoption of a norm by quoting a famous paragraph from the Investigations.

If language is to be a means of communication there must be agreement not only in definitions but also (queer as this may sound) in judgments. This seems to abolish logic, but does not do so. – It is one thing to describe methods of measurement, and another to obtain and state results of measurement. But what we call ‘measuring’ is partly determined by a certain constancy in results of measurement. (PI §242)

I think that this gives content the idea that judgements about instances of hands play a role in underpinning the meta-linguistic point. (I also think that this links to the saying-showing distinction.) For Coliva, the fact that we do just judge in accord with the normative standard governing ‘hand’ is part of the logic of judgement.

To judge thus-and-so, in certain circumstances, is said, in OC, to be part of ‘our method of doubt and enquiry’. Now, everything which is part of method does in fact belong to ‘grammar’ and ‘logic’ too, in the extended, not merely linguistic sense that those terms came to have for Wittgenstein at the time of On Certainty. To judge that there is a hand in the circumstances of Moore’s proof therefore belongs to the logic of our epistemic practices because it is what must stand fast if we want to test other things – for example, the reliability of our senses – which we do in turn need to trust in order to go about forming specific empirical judgements in circumstances where it is an open question whether what we see in front of us is really a hand. So, that judgement is itself part of logic and therefore comes to have a normative role, rather than a genuinely empirical one. (ibid: 81-2)

I imagine a case in which one uses one’s hand to estimate the size of a spider – “It was as big as this hand!” – taking for granted the identity of the hand. But now I’m unsure about the nature of the propositional attitude. The hand, by contrast with the spider, is not an object of scrutiny. But still it seems bizarre to think of our attitude as being analogous to a pragmatic attitude, such as agreeing to stop at red traffic lights. We might take that towards the metalinguistic fact that we call hands ‘hands’ in English. Thus, I think we know and additionally and distinctly endorse as a practice for ourselves for successful communicative intent. As well as knowing that ‘hand’ means hand in English, we might also agree to be bound by the norm of using ‘hand’ in just this way for pragmatic reasons. We can also make sense of adopting a different policy. 

But what of the unreflective, animal-based but second nature, attitude towards this thing on the end of my arm being a hand? Although I may adopt a policy of speaking in accord with English norms, it does not seem that the prior recognition of my hand as a hand - or recognising it as the same thing over time - is a matter of policy. I don’t just ‘accept’ that. No other policy seems available. 

Instead it seems to be forced on one by an appreciation of one’s predicament. Other things may then follow such as the use of hands as comparison with spiders, for example, or the decision to follow regular English usage in their labelling. But we seem to be passive in the face of acknowledging what the world shows us. Why is it not simply knowledge?

Ontological and Epistemological Bases of Person Centered Medicine

Abstract

Person Centred Medicine is a substantial and contentious view of healthcare that carries both ontological and epistemological presuppositions. This chapter examines two key aspects: that the person is a central, basic irreducible element in ontology and that person-level knowledge is both important and possible. Some reasons for holding both of these are sketched.

10 key words

epistemology, normativity, ontology, persons, reductionism, rationality, self, space of reasons

Introduction

The precise nature of Person Centered Medicine (PCM) is contested. What are its implicit contrasts? Person versus patient or person versus sub-personal body part, for example? What are its essential features? Does it presuppose a specific set of person-level values? Such potential choices and conflicting claims, addressed in other chapters of this book, have consequences for articulating the bases of PCM.

‘Base’ itself suggests two meanings. It may mean the explicit justification or rationale for advancing PCM. Here, I offer a more minimal reading and leave the main work of justification for other chapters. I take the ‘bases’ of PCM to be its presuppositions: specifically, the kinds of ontological and epistemological claims it presupposes to be true. As will become clearer, however, this does offer some partial account of its rationale, too.

I assume that, however its precise nature is articulated, PCM assumes the following broad claims. Ontologically, the level of the person is an irreducible and significant feature of ontology and a proper focus for healthcare. Epistemologically, not only is knowledge of the human person (human beings, people) possible and significant in healthcare, there are also irreducible forms of person-level knowledge which are important to healthcare. A commitment to PCM is thus a substantive commitment to ontological and epistemological claims. I will examine these commitments in turn.

Objectives

My aim is to clarify the implicit conceptual or philosophical commitments (in ontology and epistemology) of subscribing to PCM. I take it as a premiss that to subscribe to PCM is to assume the genuine existence of persons, for example. A fully worked out account of that commitment might require a completely satisfactory philosophical analysis of ‘person’ and refutation of all rival accounts. But that is an unrealistic account of what is required to support PCM. In this short chapter I will restrict myself to the sort of claims presupposed for PCM. A full philosophical defence of PCM might be possible but would also require narrowing down a precise specification of what PCM is. My aim is more modest but therefore of broader application to a range of views of what PCM involves.

Approaches to fulfil the objectives and knowledge base #1: The ontological presuppositions of PCM

At the very least, PCM presupposes the existence of persons. Further, it assumes that the ‘level’ of the person is important and irreducible in healthcare. That is, truths about persons are not reducible without loss to truths at a more basic level, such as the biochemical functioning of the body and its parts. If such truths were reducible, there would be no need to complement or contrast conventional biomedical approaches with something distinct. PCM would be subsumed by a biomedical view of healthcare.

PCM need not reject the importance of bio-medical medicine so much as complement it. A proper knowledge of the functioning of bodily systems seems to be an essential feature of anything recognisable as general medicine by contrast, for example, with healthcare disciplines that focus solely on specific forms of mental pathology or distress, such as psychotherapy. On the other hand, to count as person centred, PCM must resist the claim that the concept of the person reduces without loss into a set of component bodily systems.

Given the success of modern science in explaining larger systems by decomposing them into the behaviour of smaller scale, simpler systems, what would rationalise the presupposition that the person is a basic feature of ontology and irreducible to smaller scale biology?

One once influential answer – and a helpful illustration here – is provided by Cartesian substance dualism. Descartes’ own account of the bulk of the natural world was that of a mechanical ‘plenum’: a packed world of direct causal pushes and pulls. Responding to the rise of mechanical natural philosophy – corresponding with the rise of modern science – Descartes assumed that mechanical models would apply very generally. At the same time, however, he exempted the mind from this domain. His dualism divides the world into two realms of different sorts of substance: res extensa – the domain of direct causal interaction within a spatial realm – and res cogitans, the non-spatial mental realm. Despite this distinction, the mental realm appears to be modelled on the mechanical philosophy in one sense: mental states are free-standing states, acting as though akin to causal factors [McDowell 1998a: 237-243]. This is one of the features that makes accounting for everyday mental phenomena difficult: for example, the capacity for thoughts to be relational rather than free-standing, about things, to possess ‘intentionality [ibid: 242-3]. If thoughts are free standing items in an inner realm, how can they be about anything, in the outer realm? Another is the problem Descartes himself recognised of accounting for the apparent interaction of the mental and extended realms.

If we put those objections to one side for the moment, however, Cartesian substance dualism would provide a rationale for PCM by explaining one of its presuppositions. Substance dualism implies that persons – possessors of both mental and physical attributes – cannot be entirely made of extended matter. The mental belongs to a distinct non-bodily realm. But subscription to what now seems an outmoded approach to the mind would be a high price to pay for subscribing to PCM. So if not that, why else might one take the concept of the person to be irreducible?

One lesson of academic philosophy of mind since the 1970s is that there are many (apparently or epistemically) possible models of the relation of mind and body [Fulford et al 2006: 653]. At one end of a spectrum is substance dualism. At the other is eliminativism: the view that there are no mental states because the mental is a failed theory of the physical and should be eliminiated. Between are varieties of forms of property dualism, more or less closely tethered by supervenience (an asymmetric relation of dependence), and reductionist physicalism (the view that the mental can be reduced without loss to physical descriptions). Thus, a commitment to PCM requires a rejection of eliminativism and reductionist physicalism but leaves open a variety of other ontological positions. But what might motivate that choice however precisely it might be realised?

Within analytic philosophy of mind, two main lines of argument have been stressed. One concerns the irreducibility of the qualitative aspects of mental states and experiences: their qualia. One such argument is Frank Jackson’s thought experiment concerning Mary the neuroscientist, locked in a black and white room but knowing the full physics and neurophysiology of colour vision [Jackson 1986]. Surely, runs the line of thought, she learns something new when presented for the first time with a red object? But if so, there is at least one fact to be learnt – what red looks like to the conscious mind – that cannot be captured within physical and neurophysiological theory. So reductionism of the mental to the physical is false.

A second line of argument, associated with Donald Davidson, concerns the irreducibility of the structure of rationality to mere lawlike relations between natural events [Davidson 1980: 229-44]. On the twin assumptions that the mental is essentially tied to rationality, and that rationality cannot be codified into any structure of laws and hence captured in physical theory, then the mental is irreducible to physical properties.

Such arguments – or the premises of such arguments however precisely formalised: the appeal to qualia or to rationality – supply plausible motivations for subscribing to a view of the irreducibility of the mental to something physical of bodily. But that is not yet to say that the notion of a person is specifically of importance. What of the centrality of the person?

There is a line of thought in philosophy dating back to David Hume which would motivate scepticism about its importance, even while conceding the importance of the mental. Hume presents an argument that focuses on the nature of the self as something mental able to unify (mental) experiences as the experiences of a particular subject. Hume suggests that an introspective search for such a self, as the subject of thoughts and experiences, yields nothing.

For my part, when I enter most intimately into what I call myself, I always stumble on some particular perception or other, of heat or cold, light or shade, love or hatred, pain or pleasure. I never can catch myself at any time without a perception, and never can observe anything but the perception. . . . If anyone, upon serious and unprejudiced reflection, thinks he has a different notion of himself, I must confess I can reason no longer with him. All I can allow him is, that he may be in the right as well as I, and that we are essentially different in this particular. He may, perhaps, perceive something simple and continued, which he calls himself; though I am certain there is no such principle in me. [Hume 1978: 252]

Hume’s final comment is clearly meant to be ironic. Introspection, Hume suggests, reveals nothing that could stand in the sort of relation to one’s mental states that a self is supposed to do. This leads him to advocate a minimalist ‘bundle theory’ of mind. The self is identified simply with the mental states encountered in introspection and not with an ego which stands in some ownership relation to them. Philosophers since Hume have adopted a variety of responses that concede the basic point. Daniel Dennett argues that the self is an abstraction: a narrative structure of mental states. ‘A self is also an abstract object, a theorist’s fiction.’ [Dennett 1992]. Others have denied the existence of self in favour of underlying neurological structures [Hofstadter 2007; Metzinger 2003; Taylor 1999]

There is, however, a conflicting line of thought dating back to Kant that grants an important basic status to the person. The philosopher Peter Strawson offers an explicitly Kantian account [Strawson 1959, 1966]. To earn the right to the idea that experiences are unified as the experiences of a particular subject (a person), there has to be some way to specify or identify that subject. Without some such criteria, the idea of a single subject is vacuous. But as Hume’s description of introspection reveals, conscious experience does not yield any criteria to identify a subject (or owner) for one’s experiences. It reveals only the experiences themselves. From this, Hume concludes that there is no substantial self. But there are criteria for the identification of a subject available elsewhere: third-person criteria for the ascription of experiences to fellow human beings on the basis of what they say and do.

Strawson suggests that these can provide substance to the idea of a self even though they are not appealed to in self-ascriptions of experiences. This is because, while self-ascription of experiences is made without any appeal to these (or any other) criteria to identify a subject, it is still made in accord with them. As Strawson puts it, ‘The links between criterionless self-ascription and empirical criteria of subject-identity are not in practice severed’ [Strawson 1966: 165]. Thus, it is because we are identifiable from a third person perspective as embodied subjects located within the world that we can also self-ascribe experiences without appeal to, but still in accord with, those criteria. The third-person criteria substantiate the idea of a subject.

Strawson goes on to argue that the person is a basic feature of ontology. Persons have, essentially, both physical and mental predicates. It is this combination that underpins the kind of subjective perspective to which Hume appeals but which cannot, by itself, constitute a self. As the contemporary philosopher John McDowell puts it:

The alternative [to a purely mental construal of the self as subject of experience] is to leave in place the idea that continuity of “consciousness” constitutes awareness of an identity through time, but reject the assumption that that fact needs to be provided for within a self-contained conception of the continuity of “consciousness”. On the contrary, we can say: continuous “consciousness” is intelligible (even “from within”) only as a subjective angle on something that has more to it than the subjective angle reveals, namely the career of an objective continuant with which the subject of the continuous “consciousness” identifies itself. The subjective angle does not contain within itself any analogue of keeping track of something, but its content can nevertheless intelligibly involve a stable continuing reference, of a first person kind; this is thanks to its being situated in a wider context, which provides for an understanding that the persisting referent is also a third person, something whose career is a substantially traceable continuity in the objective world. [McDowell 1998b: 363]

I do not wish to suggest, in this brief chapter, that a Kantian account of the nature of the person and a Strawsonian justification of its ontologically basic status is a necessary presupposition of PCM. But it provides a worked example of the kind of account to which PCM is committed: to the existence and importance of persons as a basic feature in ontology.

Approaches to fulfil the objectives and knowledge base #2: The epistemological presuppositions of PCM

Just as PCM presupposes that the person is a proper part of ontology – an irreducible level of description of the natural world – so it also carries epistemic presuppositions. Centrally, it is possible to have knowledge of persons. To clarify this point, think of the more normal English plural. It is possible to have knowledge of people. Well of course it is! But a biomedical perspective that explicitly rejected the principles of PCM would still claim knowledge of the bodies, of their functions and dysfunctions, of people. Thus, to arrive at a presupposition that marks PCM out as a distinct substantive and potentially contentious approach, it is necessary to say something more. It is not just that knowledge of persons is possible, for example, of their bodies, but that knowledge of persons or people as persons is possible. What might be the characteristic content of such person-specific knowledge?

The previous section, however, mentioned one way to substantiate just such a claim. Descriptions of mental phenomena answer to a distinct constitutive principle that ‘finds no echo in physical theory’: the Constitutive Ideal of Rationality [Davidson 1980: 223]. To adopt a different metaphor: even without subscribing to a dualism of substances (mental and physical), one might still recognise a distinction between two conceptual spaces or modes of intelligibility: the space of reasons and the realm of law [Sellars 1997]. The former has application at the level of the person and captures a normative or evaluative character in the assessment of reasons for belief or action. One of the features that mark out persons or people from other objects of scientific scrutiny is that people, unlike planets or atoms, act for reasons or motives or to further goals or interests and they can be successful or fail in the attempt. This introduces a normative dimension – a dimension of correctness or incorrectness, good or bad – that is missing from basic physical sciences. Thus, part of the way in which PCM earns the right to claim a sui generis level of knowledge of persons as persons is to commit to the importance and irreducibility of placing subjects in the ‘logical space of reasons’.

This link opens up connections to other areas often taken to be part of PCM when less minimally approached. (Recall that this chapter has adopted a minimal approach to what PCM requires in order to explore the central ontological and epistemological presuppositions of any plausible view of PCM.) The space of reasons is also the space of values. Thus, any version of PCM that argues for the moral and ethical consequences or presuppositions of treating patients as persons will have to trade in this space: the space of evaluating the Good and the True.

But while sketching the logical space of knowledge of persons as persons helps show the nature of the ambition for PCM it does not address one specific worry that, while philosophically-influenced, can occur in reflective moments inspired by everyday life. It is the worry that, desirable that knowledge of other people – as persons – is, it is strictly impossible. One can never achieve good enough evidence to justify claims about another’s mental life. Such is the worry. Here is a way to seem – misleadingly! – to ground it. Consider again the Cartesian substance dualist picture of the relation of mind and body. If mind and body occupy different dimensions – the physically extended and the thinking – then it seems that no form of perception based on causal receptivity in the physical realm can yield awareness of other minds because minds are simply not in that realm. How therefore is knowledge of others as persons so much as possible? Surely one can never bridge the gap between one’s own experience of another person and their actual thoughts and feelings? This worry then seems to float free of the specifically Cartesian dualist background. Even if the mind is software running on the hardware of brains – as philosophical functionalism claims – how is it possible to infer from someone’s behaviour to their underlying software state?

During the last 30 years, there have been two dominant philosophical answers to this question. One approach argues that such knowledge is akin to scientific theoretically mediated knowledge of unobservable entities: ‘theory theory’ [Davies and Stone 1995a]. Its main rival starts from the idea of empathic projection: one imaginatively places oneself in the position of the other and imagines one’s thoughts and experiences: ‘simulation theory’ [Davies and Stone 1995b]. It is worth noting in practice how unsatisfactory either is to ground the idea that one can ever have genuine knowledge of how another person – a patient or service user or even a loved one, perhaps – is feeling. We do not seem to know the theory presupposed by the former approach while the act of imagination outlined by the second seems inadequate for knowledge.

PCM need presuppose no particular account of how person-level knowledge of persons as persons is possible. Its commitment is not to any specific explanation of how but to the more generic claim that it is possible. However, it is worth noting that the very idea that there is a problem to be solved may be more philosophical – albeit longstanding – artefact than common sense.

A helpful alternative view stems from the same account of the basic role of persons highlighted in the previous section which is both essentially mental and physical. If one starts from that perspective, rather than the dualistic separation of mind and body, then there is no need to deny the common-sense idea that human minds can express themselves in human behaviour and hence be known by others through that expressive behaviour. This contrasts with the ‘alienated’ conception of our relation to others that underpins a Cartesian view of human bodies where bodies are brute machines at best merely controlled by minds that inhabit a different dimension. On the non-Cartesian picture, one can have a form of almost direct knowledge of another’s mental states. It is direct knowledge of the expression of the mental state. As John McDowell argues, experience of other people is not limited to their bare behaviour, with mentality hidden behind it. The idea of almost direct knowledge can be applied:

in at least some cases of knowledge that someone else is in an “inner” state, on the basis of experience of what he says and does. Here we might think of what is directly available to experience in some such terms as “his giving expression to his being in that ‘inner’ state”; this is something that, while not itself actually being the “inner” state of affairs in question, nevertheless does not fall short of it in the sense I explained. (McDowell 1998a.: 387)

Although one person’s inner states do not themselves fall within the direct perceptual experience of another person (hence ‘almost’), the fact that they express them can. This idea of 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 meaning and expression.

One way to think about this alternative to the Cartesian picture is to think about how one might describe another person’s smile. We naturally reach for apparently epistemically risky and mind-presupposing words over the supposedly more basic purely physical descriptions. A smile is relaxed, ecstatic, forced, brave etc. Such descriptions are easier to offer than the purely geometric and non-mental descriptions that the Cartesian picture of the relation of others’ bodies and minds would suggest.

This particular philosophical ‘diagnosis’ of the implicit error behind the thought that it can seem that direct person-level knowledge is impossible provides one rationale for thinking that epistemological strand of PCM is fully justifiable. But it is not necessary to accept this to subscribe to PCM. The epistemological mark of PCM is merely that there is an available form of knowledge, couched at the level of the person, that is a key component of healthcare alongside more basic knowledge of bodily functions and dysfunctions.

Practical Implications

The practical implications of adopting a PCM approach will be explored more directly in other chapters of this book. The purpose of this conceptual and theoretical chapter is to clarity the presuppositions and suggest the logical space for such a distinctive view. Only if some things are ruled out by it does PCM have any content. I have argued that what is ruled out is the idea that person-level claims can be reduced without loss to lower level bio-medical claims and that there is no distinctive person-level knowledge. I have also offered a brief route map to escape the pessimistic thought that it is simply impossible to have knowledge of other people’s mental states.

But some practical implications are immediately apparent. If person level knowledge exists and is irreducible and assuming that it is important to healthcare (a claim for which I have not offered argument here for reasons of space but is apparent elsewhere in this book) then the pursuit of person level knowledge requires the right kind of inquiring stance. Since the most obvious way to find out how things stand with another person is to ask them, and to listen to what they say, and to watch what they do, then these forms of inquiry must be available in doctor-patient, or specialist-client, or practitioner-service user relations.

Discussion and conclusions

Person Centred Medicine is a substantial and contentious view within the philosophy and practice of healthcare. The mark of its substance is that it rules some things out. It is incompatible with some other views of nature and hence healthcare. In this chapter, I have explored its main broad presuppositions concerning ontology and epistemology. Its commitment to the existence of the person as a basic and irreducible element within ontology stands in opposition to views that deny that by, for example, promising to reduce the concept of the person to more basic phenomena. Thus, it stands opposed to various reductionist views. Its commitment to there being a form of person level knowledge and it being achievable stands in opposition both to claims that there is no such irreducible level or sceptical claims that it is impossible to attain. Although advocates for PCM need not have a fully worked out philosophy of the person or person-level knowledge, I have sketched the nature of this sort of commitment and made some suggestions for how they might be supported.

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