Tim Thornton

Values based practice (VBP) is a radical view of the place of values in medicine which develops from a philosophical analysis of values, illness and the role of ethical principles. It denies two attractive and traditional but misguided views of medicine: that diagnosis is a merely factual matter and that the values that should guide treatment and management can be codified in principles. But, in the work of KWM (Bill) Fulford, it goes further in the form of a radical liberal view: that the idea of an antecedently good outcome should be replaced by that of a right process. That however leads to a dilemma as to whether it can account for its own normative status. Given that difficulty, why might one adopt the radical version? I sketch a possible motive drawing on Rorty’s rejection of authoritarianism which replaces objectivity with solidarity as the aim of judgement. But I argue that, nevertheless, this does not justify the rejection of the more modest particularist version of VBP.

Essential Philosophy of Psychiatry is a concise introduction to the growing field of philosophy of psychiatry. Divided into three main aspects of psychiatric clinical judgement, values, meanings and facts, it examines the key debates about mental health care, and the philosophical ideas and tools needed to assess those debates, in six chapters. In addition to outlining the state of play, Essential Philosophy of Psychiatry presents a coherent and unified approach across the different debates, characterized by a rejection of reductionism and an emphasis on the ineliminability of uncodified skilled judgement. The first part, Values, outlines the debate about whether diagnosis of mental illness is essentially value-laden and argues that the prospects for reducing illness or disease to plainly factual matters are poor. It also explains the important role of skilled contextual judgement, rather than a principles-based deduction, in ethical judgement. The second part, Meanings, examines the central role of understanding and a shared first person perspective, both against attempts to reduce meaning to basic information-processing mechanisms and to explain away the difficulties of understanding psychopathology in recent models of delusion. The third part, Facts, shows the importance of uncodified clinical judgements, both in assessing the validity of psychiatric taxonomy and in the application of Evidence Based Medicine. Despite advances in the codifaction of practice and operationalism of diagnosis, an element of judgement remains in the assessment both of what, at one level, is good evidence for diagnosis and treatment and what, at a higher level, is good evidence for the validity of classification overall

The idea that psychiatry contains, in principle, a series of levels of explanation has been criticised both as empirically false but also, by Campbell, as unintelligible because it presupposes a discredited pre-Humean view of causation. Campbell’s criticism is based on an interventionist-inspired denial that mechanisms and rational connections underpin physical and mental causation respectively and hence underpin levels of explanation. These claims echo some superficially similar remarks in Wittgenstein’s Zettel. But attention to the context of Wittgenstein’s remarks suggests a reason to reject explanatory minimalism in psychiatry and reinstate a Wittgensteinian notion of level of explanation. Only in a context broader than the one provided by interventionism is the ascription of propositional attitudes, even in the puzzling case of delusions, justified. Such a view, informed by Wittgenstein, can reconcile the idea that the ascription mental phenomena presupposes a particular level of explanation with the rejection of an a priori claim about its connection to a neurological level of explanation

In this paper, I relate values-based practice (VBP) to clinical judgment more generally. I consider what claim, aside from the fundamental difference of facts and values, lies at the heart of VBP. Rather than, for example, construing values as subjective, I argue that it is more helpful to construe VBP as committed to the uncodifiability of value judgments. It is a form of particularism rather than principlism, but this need not deny the reality of values. Seen in this light, however, VBP is part of a broader conception of clinical judgment that can be compared with Kant’s conception of reflective judgment. This is a useful way of marking similarities between a number of issues raised in philosophy, which can inform a better understanding of clinical judgment

This paper examines the account offered by Bolton and Hill (1996) of how reasons can be causes, and thus how symptoms of mental disorders can be both caused and carry meaning. The central problem is to reconcile the causal and rationalizing powers of content-laden mental states. I draw out these two aspects by putting them in the context of recent work in analytical philosophy, including Davidson's token identity theory and his account of mental disorder. The latter, however, can be used to emphasize in a novel way what is becoming a familiar charge: that Davidson does not show how mental content, as opposed to the physical bearers of that content, can itself play a causal role. (edited)

Harry Collins’s Tacit and Explicit Knowledge characterises tacit knowledge through a number of antonyms: explicit, explicable, and then explicable via elaboration, transformation, mechanization and explanation and, most fundamentally, what can be communicated via “strings”. But his account blurs the distinction between knowledge and what knowledge can be of and has a number of counter-intuitive consequences. This is the result of his adoption of strings themselves rather than the use of words or signs as the mark of what is explicit and, I suggest, it may stem from his earlier response to Wittgenstein’s rules regress

The notion of capacity implicit in the Mental Capacity Act is subject to a tension between two claims. On the one hand, capacity is assessed relative to a particular decision. It is the capacity to make one kind of judgement, specifically, rather than another. So one can have capacity in one area and not have it in another. On the other hand, capacity is supposed to be independent of the ‘wisdom’ or otherwise of the decision made. (‘A person is not to be treated as unable to make a decision merely because he makes an unwise decision.’ Department of Constitutional Affairs 2005, section 1). One may have capacity even if the decision one arrives at is seen as unwise by one’s doctor. In this short note, I explore this ..