Tim Thornton

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...

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.

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...

There has been a recent growth in philosophy of psychiatry that draws heavily (although not exclusively) on analytic philosophy with the aim of a better understanding of psychiatry through an analysis of some of its fundamental concepts. This 'new philosophy of psychiatry' is an addition to both analytic philosophy and to the broader interpretation of mental health care. Nevertheless, it is already a flourishing philosophical field. One indication of this is the new Oxford University Press series International Perspectives in Philosophy and Psychiatry seven volumes of which (by Bolton and Hill; Bracken and Thomas; Fulford, Morris, Sadler, and Stanghellini; Hughes, Louw, and Sabat; Pickering; Sadler; and Stanghellini) are examined in this critical review

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

John McDowell's contribution to philosophy has ranged across Greek philosophy, philosophy of language, philosophy of mind, metaphysics and ethics. His writings have drawn on the works of, amongst others, Aristotle, Kant, Hegel, Frege, Russell, Wittgenstein, Sellars, and Davidson. His contributions have made him one of the most widely read, discussed and challenging philosophers writing today. This book provides a careful account of the main claims that McDowell advances in a number of different areas of philosophy. The interconnections between the different arguments are highlighted and Tim Thornton shows how these individual projects are unified in a post-Kantian framework that articulates the preconditions of thought and language. Thornton sets out the differing strands of McDowell's work prior to, and leading up to, their combination in the broader philosophical vision revealed in "Mind and World" and provides an interpretative and critical framework that will help shape ongoing debates surrounding McDowell's work. An underlying theme of the book is whether McDowell's therapeutic approach to philosophy, which owes much to the later Wittgenstein, is consistent with the substance of McDowell's discussion of nature that uses the vocabulary of other philosophers including, centrally, Kant.

Medicine involves specific practical expertise as well as more general context-independent medical knowledge. This raises the question, what is the nature of the expertise involved? Is there a model of clinical judgement or understanding that can accommodate both elements? This paper begins with a summary of a published account of the kinds of situation-specific skill found in anaesthesia. It authors claim that such skills are often neglected because of a prejudice in favour of the ‘technical rationality’ exemplified in evidence-based medicine but they do not themselves offer a general account of the relation of practical expertise and general medical knowledge. The philosopher Hubert Dreyfus provides one model of the relation of general knowledge to situation-specific skilled coping. He claims that the former logically depends on the latter and provides two arguments, which I articulate in the second section, for this. But he mars those arguments by building in the further assumption that such situation-specific responses must be understood as concept-free and thus mindless. That assumption is held in place by three arguments all of which I criticize in the next section to give a unified account of clinical judgement as both practical and conceptually structured and thus justified in the face of a prejudice in favour of ‘technical rationality’

One of the tasks that recent philosophy of psychiatry has taken upon itself is to extend the range of understanding to some of those aspects of psychopathology that Jaspers deemed beyond its limits. Given the fundamental difficulties of offering a literal interpretation of the contents of primary delusions, a number of alternative strategies have been put forward including regarding them as abnormal versions of framework propositions described by Wittgenstein in On Certainty. But although framework propositions share some of the apparent epistemic features of primary delusions, their role in partially constituting the sense of inquiry rules out their role in helping to understand delusions.

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

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)

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

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 ..

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

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

Introduction. 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

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.

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

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.