Tim Thornton

Decision-making depends on bringing evidence together with values: decision theory for example employs probabilities and utilities; health economic decisions employ measures such as quality of life. The hypothesis guiding this chapter is that bringing evidence together with values in clinical decision-making requires an exercise of phronesis. Our aim however is not to justify our guiding hypothesis. It is rather to outline an account of phronesis that is in principle fit for the purposes of clinical decision-making if our guiding hypothesis is correct. The chapter has three sections. Section 1 describes the growing gap between evidence and values in clinical decision-making: the missing link, we suggest, required to bridge this gap, is an appropriate account of phronesis. Section 2 provides an initial characterisation of the required account of phronesis via Michael Polanyi’s twin stipulation on the nature of tacit knowledge. Section 3 then fills out the required account using John McDowell’s characterisation of phronesis as a situation specific but at the same time conceptually structured form of practical discernment. A McDowellian account of phronesis, we argue, in satisfying Polanyi’s twin stipulation, provides an in-principle bridge between evidence and values. We conclude with a note on some of the further requirements if the gap is to be bridged not only in principle but in practice too.

It seems obvious that one of the harms that dementia does is to undermine the person’s identity. One reason for thinking this is that personal identity has long been associated with continuity of a subjective perspective on the world held together by memory that that memory is severely curtailed in dementia. Hence dementia seems to threaten an individual’s identity as a particular person, gradually undermining it. But the necessity of the connection has been criticised by a number of philosophers and healthcare professionals who subscribe to a narrative account of personal identity. If personal identity is constituted through a personal narrative rather than, for example, a memory connection, then while the capacity to author a self-narrative also seems to be threatened by dementia, that need not undermine personal identity providing that the narrative that constitutes identity can be co-constructed. In this paper I set out the danger of any such view, explore its motivations and provide a minimal account of the role of narrative in dementia making use of the Wittgensteinian notion of secondary sense.

According to the recovery model, mental healthcare should be aimed towards a conception of recovery articulated by a patient or service user in accord with his or her own specific values. The model thus presupposes and emphasises the agency of the patient and opposes paternalism. Recent philosophical work on the relations between respect, self-respect, self-esteem, shame, and agency suggests, however, two ways in which mental illness itself can undermine self-respect, promote shame and undermine agency, suggesting a tension within the recovery model. I argue, however, that this is a tension rather than a fatal flaw by distinguishing between paternalist and non-paternalist clinical responses to this failure of agency.

In response to the concern that criteriological psychiatric diagnosis, based on the DSM and ICD classifications, pigeon-holes patients, there have been calls for it to be augmented by an idiographic formulation [IDGA Workgroup, WPA 2003]. I have argued elsewhere that this is a mistake [Thornton 2008a, 2008b, 2010]. Looking back to its original proponent Wilhelm Windelband yields no clear account of the contrast between idiographic and nomothetic judgement. Abstracting from Jaspers’ account of understanding an idea of idiographic judgement based on the contrast between singular and general causal relations also fails. I argue, however, that Windelband does provide a helpful clue in his remark that ‘every interest and judgement, 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: 182]. This suggests a role for the idiographic not as the content of a particular kind of judgement but rather as characterising its aim. I argue that this connects to the issue of the generalisability of small scale qualitative social science research and to the critique of ‘looking away’ in moral philosophy.

Wittgensteinian Themes gathers together 14 previously published essays written towards the end of Malcolm's life. The majority of essays provide exegeses of Wittgenstein's thought. It is arguable that both Wittgensteinian exegesis and Wittgensteinian philosophy run the risk of parochialism. This collection makes a commendable effort to escape that charge. Even in the exegetical essays, issue is taken with conflicting contemporary philosophers whilst four essays are direct attacks on opposing philosophical perspectives, albeit using Wittgensteinian methods.

The paper begins by asking, in the context of McDowell's Mind and World, what guides empirical judgement. It then critically examines David Bell's account of the role of aesthetic judgement, or experience, in Kant and Wittgenstein, in shedding light on empirical judgement. Bell's suggestion that a Wittgensteinian account of aesthetic experience can guide the application of empirical concepts is criticised: neither the discussion of aesthetic judgement nor aesthetic experience helps underpin empirical judgement. But attention to the parallel between Wittgenstein's discussion of understanding rules and the question of how empirical concepts can be applied to particulars suggests how to dissolve the felt need for an answer. This in turn helps shed light on McDowell's conceptualist account of experience.

Psychiatric diagnosis depends, centrally, on the transmission of patients’ knowledge of their experiences and symptoms to clinicians by testimony. In the case of non-native speakers, the need for linguistic interpretation raises significant practical problems. But determining the best practical approach depends on determining the best underlying model of both testimony and knowledge itself. Internalist models of knowledge have been influential since Descartes. But they cannot account for testimony. Since knowledge by testimony is possible, and forms the basis of psychiatric diagnosis, its very existence is a factor in support of an externalist model of knowledge in general. Internalist and externalist models of knowledge also suggest different ways of responding to the practical challenges of basing psychiatric diagnosis on testimony. Thus the argument in favour of externalism also supports a potentially empirically testable hypothesis about interpretation of non-native speakers for accurate psychiatric diagnosis: interpretation of non-English speakers should be as transparent and unhindered by specialised medical knowledge as possible

The World Psychiatric Association has emphasised the importance of idiographic understanding as a distinct component of comprehensive assessment but in introductions to the idea it is often assimilated to the notion of narrative judgement. This paper aims to distinguish between supposed idiographic and narrative judgement. Taking the former to mean a kind of individualised judgement, I argue that it has no place in psychiatry in part because it threatens psychiatric validity. Narrative judgement, by contrast, is a genuinely distinct complement to criteriological diagnosis but it is, nevertheless, a special kind of general judgement and thus can possess validity. To argue this I first examine the origin of the distinction between idiographic and nomothetic in Windelband’s 1894 rectorial address. I argue that none of three ways of understanding that distinction is tenable. Windelband’s description of historical methods, as a practical example, does not articulate a genuine form of understanding. A metaphysical distinction between particulars and general kinds is guilty of subscribing to the Myth of the Given. A distinction based on an abstraction of essentially combined aspects of empirical judgement cannot underpin a distinct empirical method. Furthermore, idiographic elements understood as individualised judgements threaten the validity of psychiatric diagnosis. In the final part I briefly describe some aspects of the logic of narrative judgements and argue that in the call for comprehensive diagnosis, narrative rather than idiographic elements have an important role. Importantly, however, whilst directed towards individual subjects, narratives are framed in intrinsically general concepts and thus can aspire to validity

In lieu of an abstract, here is a brief excerpt of the content:The Ambiguities of Mild Cognitive ImpairmentTim Thornton (bio)Keywordsclassification, disease, mild cognitive impairment, normative, valuesCorner and Bond's paper (2006) raises some key ethical questions about the classification and diagnosis of mild cognitive impairment (MCI). In this commentary, I wish to revise some of the general issues about the classification of mental disorder raised by this particular classificatory concept. The central issue raised is the connection between the pathologic status of a condition and what I term the plain facts about the frequency and nature of its symptoms.There are a number of ethical questions raised by applying the label of MCI. Centrally, perhaps, is the concern, illustrated by the case vignettes, that a diagnosis carries negative repercussions that might outweigh the more narrowly medical advantages of an early diagnosis. But although that concern may be appropriate, such ethical complications are a danger of any psychiatric classification or diagnosis, even the most well grounded. Any psychiatric diagnosis can carry a danger of stigma, for example.What seems to make such ethical concerns more serious in this case—at least to a philosopher outsider—is the implicit further concern that MCI is not a real, objective, or, to use a more medical term, valid category or classification. If it is not valid, then any negative connotations of the diagnosis will not be outweighed by medical technological achievements. In other words, the further ethical issues are given much greater weight if the question of validity is not satisfactorily resolved.The question of the reality, objectivity, or validity of MCI can be divided into two issues:1. Is MCI a real, objective, or valid feature of psychological phenomenology?2. Is MCI a real, objective, or valid psychological illness, disease, or pathology?A condition might be a real, objective, or valid feature of psychological phenomenology without being a real illness. It might be some other aspect of human living. Szasz (1960) suggests that this is the case with mental illness (he might more properly say "so-called mental illness") as a whole. But, less controversially, the unusual ability to calculate, mentally and in a flash, the date of future Easter Sundays is a genuine feature of human living—some people possess the ability even if most do not—without either it, or its lack, being an illness. Being real as an illness is a very specific kind of being. It is this, I suggest, that raises difficulties in the case of MCI by contrast with the easier question of whether something is a genuine feature of human living in some other way. [End Page 21]From "normal" and "normative" to "correct" and "incorrect"Corner and Bond (2006) usefully suggest that the question of whether MCI is real is made more difficult by an ambiguity in the sense of the word normal. They suggest that although "physiologic and cognitive decline is assumed to be a normal experience" this still leaves "boundary problems" about "distinguishing normal aging from disease" (Corner and Bond 2006, 3–4). Thus, if the symptoms of MCI are continuous with the ordinary phenomena of physiologic and cognitive decline, then they might also be merely normal. But this does not settle the status of MCI because normal can mean either "normative, that is, usual; or it can mean nonpathologic" (Corner and Bond 2006, 4).On the assumption that MCI is at least continuous with phenomena that are normal, then its symptoms might be normal in the sense of usual but nevertheless pathologic: an inevitable illness. Or they might be usual and nonpathologic, that is, merely a feature of aging that, although regrettable, lacks the connotations of illness (e.g., the appropriateness, if not the possibility, of treatment). (In principle on the assumption in play—that the symptoms of MCI are normal—they might be unusual but nonpathologic akin, for example, to an improved ability to solve crosswords with age that might affect a small lucky proportion of the population. Perhaps such a crossword puzzler might be reassured by their doctor: "Well that is very unusual but there is no need to worry: it is not a symptom of any illness. You are perfectly normal.")Thus the question "Is MCI normal...

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.4 (2003) 361-367 [Access article in PDF] Psychopathology and Two Kinds of Narrative Account of the Self Tim Thornton Keywords self, narrative, reductionism, embodiment, Dennett, Strawson, McDowell The self plays an important role in psycho pathology. Conditions such as dementia raise the question of how much loss of memory and awareness there can be before there is, if ever, also a loss of the self. Syndromes such as Dissociative Identity Disorder (DID) or Multiple Personality Disorder (MPD) raise the possibility of a fragmentation of one self into a number of selves. Depersonalization disorder suggests a kind of diminution both of the sense of self and the reality of the world. Symptoms such as thought insertion suggest a different kind of fragmentation of the coherence of thought within a self.At the same time there is something prima facie paradoxical about the very idea of the fragmentation or loss of self. It seems to be one thing for a self to suffer loss, quite another to think of the self as being lost. Although the experiences or beliefs had or entertained by a self might be disordered or chaotic, how can a self be anything other than whole and seem real and whole to itself?The narrative approach to the self looks like a tool purpose built to shed light on some aspects of psychopathology. The papers in this issue have examined its application to four revealing case histories and questioned its effectiveness in accounting for features of psychopathology. But in this short note I wish to stand back from the particular cases discussed in previous papers and to shed light on the general approach by setting out two contrasting versions of it. Crudely put, the first forges a connection between the concepts of self and personality; the second between the concepts of self and person. I will use the contrast between these two to draw some general lessons for the philosophy of psychopathology. Dennett's Austere Narrative Account I will start with Dennett's influential version of a narrative account of the self. His central idea is that the very idea of a self should be understood as dependent on a particular kind of interpretative strategy. Roughly, this contrasts with the idea that it is a more basic datum calling out for notice prior to adopting a specific theoretical perspective.Dennett suggests an analogy with centers of gravity both to outline the consequences of this view for the reality of selves, and the connection between the self and the interpretative strategy involved. [End Page 361] A center of gravity is just an abstractum. It's just a fictional object. But when I say it's a fictional object, I do not mean to disparage it; it's a wonderful fictional object, and it has a perfectly legitimate place within serious, sober, echt physical science. (Dennett 1992) The concept of a center of gravity is deployed within a branch of physics to describe and predict the behavior of physical systems acting under physical forces. It is the theoretical context that determines the nature of centers of gravity; at the same time, they contribute to that broader context. Dennett stresses that they are abstract or calculation-bound theoretical objects to contrast with objects that are also theoretically posited but causally interactive, such as microphysical particles (Dennett 1987, 53).Dennett has also used the analogy with abstracta to account for mental states such as beliefs, desires, and other propositional attitudes, which he suggests are ascribed using a particular interpretative strategy: the "Intentional Stance" (Dennett 1987, 13-42). The suggestion is that by showing the necessity of adopting that stance to make sense of human behavior he can defend a form of objectivity about mental states even while rejecting the industrial-strength realism that requires identifying mental states with physical, and thus causally interactive, internal states.Selves are given similar treatment. Like centers of gravity or mental states, they are theoretical, even fictional, entities articulated within an interpretative theoretical stance: A self is also an abstract object, a theorist's fiction...

The two main psychiatric taxonomies set out codifications of psychiatric diagnoses via lists of symptoms with the aim of maximizing the reliability of diagnostic judgements. This approach has been criticized, however, for failing to capture the precise connection between diagnostic judgements and symptoms as detected by skilled clinicians. Assuming that this criticism is correct, this chapter offers two related accounts of why this might be so. First, skilled diagnostic judgement may be an exercise of tacit knowledge: a practical skill the exercise of which requires the presence of the patient. Second, the conception of criteria implicit in the DSM and ICD is based on a mistaken view of how what people say and do connects to their mental states. On an alternative account, in an overall gestalt diagnostic judgement the various criteria are abstractions from a whole that directly expresses the underlying psychopathological state of patients or clients.

This chapter contrasts the recent emphasis on operationalism as the route to reliability in psychiatry with arguments for an ineliminable role for tacit knowledge. Although Michael Polanyi popularized the idea of tacit dimension, the chapter argues that two clues he offers as to its nature-that we know more than we can tell and that knowledge is an active comprehension of things known-are better interpreted through regress arguments set out by Ryle and Wittgenstein. Those arguments, however, suggest that tacit knowledge is not inexpressible but merely inexpressible in context-free terms. The chapter suggests instead that tacit knowledge is best understood to be context-dependent practical knowledge. So understood, the regress arguments suggest that the operational approach to psychiatric diagnosis can never free itself from a tacit dimension. Given that claim, then Parnas' opposing view of diagnosis can be seen as a way to embrace, rather than deny, the importance of tacit knowledge and skilled clinical judgment for psychiatry.

In Paradoxes of Delusion, Sass aims to use passages from Wittgenstein to characterize the feeling of “mute particularity” that forms a part of delusional atmosphere. I argue that Wittgenstein’s discussion provides no helpful positive account. But his remarks on more everyday cases of the uncanny and the feeling of unreality might seem to promise a better approach via the expressive use of words in secondary sense. I argue that this also is a false hope but that, interestingly, there can be no interesting or substantial explanation of this failure

Psychiatry is unique in medicine in being on the border between science and the humanities. Science provides insight into the 'causes' of a problem, enabling us to formulate an 'explanation', while the humanities provide insight into its 'meanings' and helps with our 'understanding'. The new interdisciplinary field of 'philosophy of psychiatry' has developed to explore the range of issues relevant to this border country. The Oxford Textbook of Philosophy and Psychiatry is a unique textbook which provides a detailed introduction to the field, a framework for study and skill development, and an overview of current research. It focuses on case studies in 5 key topic areas. Each case study is supported by selected readings from both philosophy and mental health, thinking skills exercises, self-test questions, key learning points and detailed guides to further reading

I believe that Wright’s constructivist account of intention is funda- mentally flawed [Wright 1984, 1986, 1987a, 1987b, 1988, 1989a, 1989b, 1991, 1992]. To understand why it fails it is necessary first to locate the account in its broader strategic context. That context is Wright’s response to Wittgenstein’s account of rule following. When so located the diagnosis of the account’s failure is clear. Wright’s account of intention is a species of the interpretative approach to mental content which is explicitly rejected by Wittgenstein.

Introduction. Whatever its underlying causes, even the description of the phenomenon of thought insertion, of the content of the delusion, presents difficulty. It may seem that the best hope of a description comes from a broadly cognitivist approach to the mind which construes content-laden mental states as internal mental representations within what is literally an inner space: the space of the brain or nervous system. Such an approach objectifies thoughts in a way which might seem to hold out the prospect of describing the ''alienated'' relation to one's own thoughts that seems to be present in thought insertion.1 Method. Firstly, I examine the general structure of cognitivist accounts of intentional or content-laden mental states. I raise the general difficulty of explaining how free-standing, and thus world-independent, inner states can still have bearing on the outer world. Secondly, I briefly examine Frith's model for explaining thought insertion and other passivity phenomena by postulating a failure of an internal monitoring mechanism of inner states. I question what account can be given of non-pathological cases and raise two specific objects. Results. Cognitivist accounts of the mind face a general, and possibly insuperable, challenge: explaining the intentionality of mental states in non-intentional, non- question-begging terms. There have so far been no satisfactory solutions. Cognitivist accounts of passivity phenomena in terms of a failure of internal monitoring face two objections. Firstly, accounting for non-pathological cases generates an infinite regress. Secondly, no account can be given of the paradoxical nature of utterances of the form of Moore's paradox: ''it is raining but I do not believe it''. Conclusions. A cognitivist approach presents an alienated account of thought in normal, non-pathological cases and is no help in accounting for thought insertion

Jaspers’s binary distinction between understanding and explanation has given way first to a proliferation of explanatory levels and now, in John Campbell’s recent work, to a conception of explanation with no distinct levels of explanation and no inbuilt rationality requirement. I argue that there is still a role for understanding in psychiatry and that is to demystify the assumption that the states it concerns are mental. This role can be fulfilled by placing rationality at the heart of understanding without a commitment to the attempt to use rationality to shed light on interpretation and mindedness as though from outside those notions. Delusions still present a significant challenge to philosophical attempts at understanding, but this merely reflects the genuine clinical difficulties such states present.

Idiographic understanding has been proposed as a response to concern that criteriological diagnosis cannot capture the nature of human individuality. It can seem that understanding individuals requires, instead, a distinct form of ‘individualised’ judgement and this claim receives endorsement by the inventor of the term ‘idiographic’, Wilhelm Windelband. I argue, however, that none of the options for specifying a model of individualised judgement, to explain what idiographic judgement might be, will work. I suggest, at the end, that narrative, rather than idiographic, understanding is a more promising response to the limitations of criteriological diagnosis

Tacit knowledge is the form of implicit knowledge that we rely on for learning. It is invoked in a wide range of intellectual inquiries, from traditional academic subjects to more pragmatically orientated investigations into the nature and transmission of skills and expertise. Notwithstanding its apparent pervasiveness, the notion of tacit knowledge is a complex and puzzling one. What is its status as knowledge? What is its relation to explicit knowledge? What does it mean to say that knowledge is tacit? Can it be measured? Recent years have seen a growing interest from philosophers in understanding the nature of tacit knowledge. Philosophers of science have discussed its role in scientific problem-solving; philosophers of language have been concerned with the speaker's relation to grammatical theories; and phenomenologists have attempted to describe the relation of explicit theoretical knowledge to a background understanding of matters that are taken for granted. This book seeks to bring a unity to these diverse philosophical discussions by clarifying their conceptual underpinnings. In addition the book advances a specific account of tacit knowledge that elucidates the importance of the concept for understanding the character of human cognition, and demonstrates the relevance of the recommended account to those concerned with the communication of expertise. The book will be of interest to philosophers of language, epistemologists, cognitive psychologists and students of theoretical linguistics.

In lieu of an abstract, here is a brief excerpt of the content:Evidence-Based Medicine and EvaluativismTim Thornton (bio)KeywordsPhilosophy, psychiatry, values, causalThe rise of evidence-based medicine (EBM) in psychiatry has brought, in its train, a concentration on the validity of psychiatric taxonomy to augment the previous focus on reliability (in the medical sense of inter-subject agreement). This is not surprising. If EBM is to be a trustworthy guide to future events, such as patient recovery, it must be based on projectible predicates (Goodman 1983). Not all the predicates that apparently fit past observations would produce true predictions for the future. Furthermore, there is reason to think that employing projectible predicates goes a long way to satisfy the (widespread if contested) aim of being based on a nomological science (Papineau 1986). Thus, the successful implementation of EBM within psychiatry requires the successful articulation of a valid psychiatric taxonomy.This connection helps to explain why fears about the application of EBM to psychiatry often turn on fears about the application of the criteriological model of diagnosis to individuals. In her commentary in this issue, Gloria Ayob has examined some of the arguments concerning the application of EBM to individuals. In this brief commentary, I examine a different potential source of disquiet focused on the underlying nature of psychiatric taxonomy.Dimensions for Psychiatric TaxonomyIn their recent paper, Peter Zachar and Kenneth Kendler suggest a number of different dimensions according to which rival conceptions of psychiatric taxonomy can be mapped. These include (1) causalism–descriptivism, (2) essentialism– nominalism, (3) objectivism–evaluativism, (4) internalism–externalism, (5) entities–agents, and (6) categories–continua (2007, 557). At the heart of the objectivism-evaluativism dimension is the question:Is deciding whether or not something is a psychiatric disorder a simple factual matterY (objectivism), or does it inevitably involve a value-laden judgment (evaluativism)?(Zachar and Kendler 2007, 558)Objectivists argue that the concept of disorder is a simple or plain factual matter by contrast with an evaluation. The apparently evaluative connotations of disorder, they argue, can either be reduced to, or explained away in, more basic terms, which are not themselves essentially evaluative. Thus, for example, the attempt to explain disorder in statistical terms is a form of objectivism. The more plausible attempt to explain disorder through the idea of a biological or proper function is also usually presented as a form of objectivism. (The most famous proponent of a biological approach, however, Jerome Wakefield, adds to an objectivist-aspiring core an explicit value in the form of harm [End Page 175] [Wakefield 1999].) Whether or not it can be successful as a form of objectivism, in addition to whether an analysis in biological terms is possible, depends on whether the account of function can fully discharge any initial evaluative or normative assumptions.There seems to be good evidence that current psychiatric taxonomy, at least, contains values. John Sadler, for example, makes a powerful case for this in his substantial work Values and Psychiatric Diagnosis (2005). Sadler, furthermore, addresses in some detail a further set of questions concerning the kinds and nature of the values involved. I outline just one further question about the nature of values involved.Zachar and Kendler contrast the presence of values with objectivism. Objectivity has at least two relevant senses reflecting contrasts with two senses of subjectivity. It—objectivity—might mean requiring no special subject for the conception and framing of relevant judgments. (This mirrors primary, by contrast with secondary qualities, and Williams' idea of an absolute conception [Williams 1978]). Or, it might mean disciplining and providing a contrast between correctness and incorrectness, or truth and falsity, for the relevant judgments. This contrasts with subjective whimsy.Although it seems relatively straight forward that the conception and framing of value judgments requires that subjects have a particular kind of mind, that still leaves open the other issue. Are value judgments disciplined by anything or does the "truth" of a value judgment collapse back into its being sincerely made?Evaluativism in Psychiatric Taxonomy and EBMThis question relates to the application of EBM to psychiatry in this way. On a disciplined account, psychiatric taxonomy can aim to get right the mixture or, better, the compound of simple facts and values...

The paper outlines the role that tacit knowledge plays in what might seem to be an area of knowledge that can be made fully explicit or codified and which forms a central element of Evidence Based Medicine. Appeal to the role the role of tacit knowledge in science provides a way to unify the tripartite definition of Evidence Based Medicine given by Sackett et al: the integration of best research evidence with clinical expertise and patient values. Each of these three elements, crucially including research evidence, rests on an ineliminable and irreducible notion of uncodified good judgement