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...

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...

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.

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

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 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

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)

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

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