Grant Gillett

Entrepreneurship and broader business literature show a growing interest in sustainability issues, illuminating the critical role that entrepreneurship can play in addressing the issues facing economic development in diverse socioeconomic settings. This study undertakes a selective systematic literature review and synthesizes co-creative entrepreneurship research with Foucault's conceptualizations of ethical power and human relationships to deepen our understanding of the roots of sustainability issues. It offers insights into addressing sustainability challenges in diverse social settings and provides reflections and directions for future research. As such, this study provides a philosophical ground for the further development of sustainable entrepreneurship.

The idea of freedom of the will seems to conflict with the principle of causal efficacy implicit in many theories of mind. The conflict is normally resolved within a compatibilist view whereby the desires and beliefs of the agent, replete with a respectable if yet to be elucidated causal pedigree, are taken to be the basis of individual freedom. The present view is an alternative which erects mental content on a framework of rule following and then argues that rule‐following is conceptually distinct from causally produced activity. The normative aspect of rule‐following defies reduction to descriptive or dispositional terms. According to this view we cannot get beyond the agent as a self‐determining rational individual in formulating a theory of mind and action. The theory is neo‐Kantian in that it identifies rules or conceptions of laws as central in human thought. It, follows Wittgenstein's treatment of rule‐following and generates a plausible (but non‐causal) account of mental explanation and weakness of the will.

ABSTRACT AIDS raises the moral problem of confidentiality because those in sexual contact with the patient may contract a life‐threatening and incurable disease. Medicine has a tradition in which a patient's condition is regarded as confidential information held by the doctor alone. In this case there is a clear moral inclination to inform those at risk from the disease. In most cases no problem will arise but when it does the moral justification for a violation of confidentiality comes into question. Confidentiality is important because of our respect for certain human values and their importance to our patient. Where that patient acts so as to disregard the welfare of others with whom they are in close relationship, those values are lacking. This lack warrants a departure from our normal canons and provokes a suspension of normal moral privileges. The contention that any transgression, however slight, could be held to justify such a response posits a slope down which we, in fact, have no tendency to slide.

Grant Gillett argues that to understand mental illness fully requires more than a study of biological models of mental processes and pathologies. As intensely social animals, he argues, we need to look for the causes of human mental disorders in our interactions with others; in social rule-following and its role in the organization of mental content; in the power relations embedded within social structures and cultural norms; in the way that our mental life is inscribed by a cumulative life of encounters with others. Gillett uses material arising in the study of philosophy of mind, epistemology, post-modern continental philosophy, and philosophy of language to try to elucidate the nature of psychiatric phenomena involving disorders of thought, perception, emotion, moral sense, and action. Within this framework, a series of chapters analyse important psychiatric disorders such as depression, attention deficiency, autism, schizophrenia, and anorexia. Along the way, Gillett explores the nature of memory and identity; of hysteria and what constitutes rational behaviour; and of what causes us to label someone a psychopath or deviant. This fascinating book will provide readers with important insights into the causes and nature of psychosis. In addition, Gillett's arguments have considerable implications for the way in which we understand and treat people suffering from psychiatric disorders. The Mind and its Discontents will be read by researchers and postgraduate students in a range of academic areas, including psychiatry, bioethics, philosophy of mind, social theory, and clinical psychology. It will also be of considerable interest to practising psychiatrists.

Harré’s Discursive psychology located human beings in their proper ecological niche—a setting of relationships and conversations. Within the exchanges to be found there they form themselves according to the values they espouse and help to make real in themselves and others through praxis. That view, developed from the philosophy of Wittgenstein and others situates a Person in a context which has a profound effect on him or her. Reductive neuroscientific models and analyses based on computation are now being transcended by Neural networks theory such that Harré’s ideas can take on scientific Realism not anticipated in an age of computational models of mind and physicalism masquerading as scientific Realism. The role able to be given to discourse and its complexity as the real essence of mental life makes Harré’s work more insightful now than it has often been depicted to be in “scientific” psychology and a “fuzzy” neural network account allows its ethological complexity to be understood anew.

A nervous system configured by intersubjectivity and a grasp of the distinction between truth and falsity shape our neural function so that we sense, perceive, cognise, and act in ways that elaborate sensori-motor activity to fit us for cognitive function under norms of truth and falsity conveyed by and linked to speech or “propositionising.” The resulting self-formation fits us for a world in which meaningful symbolism and normatively constrained communication imposes truth and falsity and depth as the basis of a well-organised intellect. Thus our sensori-motor and language-related neural functions are fitted for the joint demands of the natural world and the socio-political (or discursive) world through triply responsive neurocognitive assemblies shaped in human cognitive development and underpinning human consciousness, thought, and action.

Neo-Aristotelian accounts of the human psyche incorporate our meaningful contact with the world such that complex connectivity within the brain and between brain and world is the basis of consciousness and mental function (a “contact view”). Intelligent contact with things shapes human consciousness and cognition in ways reflecting truth-related thought and talk about the world in a context of communication, judgement, and knowledge. Human intersubjectivity thus allows us to triangulate on the objects we encounter and configure our dealings with them in communicable ways grounded in truth and falsity. Aristotle’s naturalistic view of the soul as an active, self-organising system implies that distinctively human life corresponds to a progressive integration of neural functions, enabling us to tell (in both senses) what is happening and what things really are.

Second nature is what we create in ourselves on the basis of natural capacities comprising first (biological) nature. The self-configuration doing that creative work is an enactive version of what we do all the time. We think of a way things are not but might be (with a little bit of this and a little bit of that) and we make it so. The human will as an origin of what is not but could be brings forth out of thought—the active links we forge between things based on our forms of life—new things. This bringing forth is a creative force in the world that we call the human will. It is always going beyond what is and making what is not (the imaginary) into something real.

The dissolution of the highly evolved and complex triply responsive and profoundly intersubjective human cognitive system produces neurological and psychiatric disorders. The neurological disorders can be identified in terms of sensori-motor functions that have become faulty, but the psychological disorders are more subtle and set us apart from the shared milieu of meaning and relationships that we are adapted to in highly integrated ways not easily analysed in functional or physiological terms. Psychological disorders alienate us from the distinctively human milieu of agreed meanings and shared understanding and therefore go beyond isolated sensory or motor breakdowns and concern the higher integrative functions linking our lives together. The resulting conditions—psychological disorders—embed failures, reflecting distinctively human adaptation to a shared intersubjective world, and are analysed by “alienists.”

Human consciousness emerges from neural evolution as a complex and densely woven whole in which doing and perceiving things and the use of language combine to open up the world for human engagement. That integrated whole can be disrupted by breakdowns in its neurological fabric or in its psychological weaving together through human communication and the shared use of symbols and our relationships with each other. When it functions well, that woven whole engenders certain values—the value of crafted things whose purposefulness can be discerned and contemplated but not fully subsumed by functional considerations and the value of our jointly constructed ethos of mutuality, cooperation, and achievement. Those values respectively inform and emerge from the discourses of art and morality.

The human soul and consciousness are active in the world of nature as part of the origins of things and situations informed by human symbolism and propositionising. Therefore the soul introduces human creativity, relationships, reasoning, and imagination into a world of contingency and brute causality, turning it into a partly humanly constructed world. That transformation changes everything through a special kind of non-linearity in which human meanings inflect what happens in our adaptive niche and embeds us in symbolism, culture, and flows of life that transcend causal mechanisms and put human relationships and imagination at the heart of the world shaping us. We therefore become enchanted, storied beings realising forms of life that do not require mystifying varieties of metaphysics to explain their richness.

Aristotle’s account of the soul differs from Cartesianism; while it holds that the soul denotes a conception of a human being as not merely a physical or material thing, the division is conceptual and not in terms of a different metaphysical substance and it concerns the form of human life as self-organised, rational, and moral beings in a shared world using shared cognitive tools. The human soul animates and gives coherence to our lives and it develops, in part, through education to create a second nature developed out of the (first) nature human beings are born with. The account is extended by Kant and the phenomenologists who examine how human beings train their children as cognitive apprentices.

The first chapter outlines George Engel’s proposal of a new biopsychosocial model for medicine and healthcare in papers 40 years ago and reviews its current status. The model is popular and much invoked in clinical and health education settings and has claim to be the overarching framework for contemporary healthcare. On the other hand, the model has been increasingly criticised for being vague, useless, and even incoherent—clinically, scientifically and philosophically. The combination of these two points signifies something of a crisis in the conceptual foundations of medicine and healthcare. We outline some of the emerging evidence implicating psychosocial as well as biological factors in health and disease, and propose the following solution to the vagueness problem: that the scientific and clinical content of the model relates to specific conditions and stages of conditions, so that there is, for example, a biopsychosocial model of cardiovascular disease, diabetes or depression. Much the same point applies to the narrower biomedical model. However this raises the question: what is the point of having a general model? Our response is that it is needed to theorise biopsychosocial interactions in health and disease. In the light of historical prejudices against psychosocial causation deriving from physicalist reductionism and dualism, recognised by Engel and current commentators on the biopsychosocial model, this is a non-trivial task that occupies subsequent chapters.

This chapter continues from the previous chapter on themes in biopsychosocial conditions of health and disease, picking up some core questions familiar in the theory and philosophy of medicine. We argue that the concepts and boundaries of health and disease are themselves biopsychosocial. Controversies about whether such-and-such a condition is or is not a medical matter, as opposed to difference or lifestyle choice, the consequences of being which involve benefits such as access to healthcare and/or harms such as stigma, and the terms in which such debates are conducted—are all thoroughly biopsychosocial-political. Core defining features of illness—activity limitations, pain and distress—likewise involve our psychology and social life as well as our biology. On the theme of causation, we endorse scientific method as the route to identifying causal mechanisms, note the major role of chronic stress in models of causal mechanisms linking psychosocial factors with biological damage, and spell out that chronic stress is a quintessential biopsychosocial concept. We consider the Research Domain Criteria (RDoC) proposed recently by the N.I.M.H. as a framework for research in mental health as an illustration of a biopsychosocial research framework, potentially extendable to cover physical health and biomedicine. Physical and mental health conditions are brought together in the new biopsychosocial model rather than being axiomatically separate—as they were in the old context of reductionism and dualism.

As Engel saw, we will never make sense of psychosocial factors and their influence on health and disease while there is an underlying assumption that only physical causes are real. We believe the place to unpick this assumption is in biology and biomedicine itself, especially in the relation between biological processes and physics and chemistry. Ernst Schrödinger’s insight that biological processes run locally counter to the general direction of the second law of thermodynamics is now mainstream biophysics, as is his proposal that this is originally achieved by genes exercising information-based regulatory control of energetic processes. Information-based regulatory control mechanisms are a new and distinctive form of causation compared with conformity to the energy equations of physics and chemistry, most clearly evident in the fact that they can break down. This serves to argue against physicalism and is consistent with recent innovations in the philosophy of causation. The new concepts and principles of regulatory control apply in biology, but they also run through the psychological and social domains. This enables a more unified science, and one that has foundational differences between life and death, health and illness.

Moving on from biology to psychology, we propose that the core function of the psychological is agency. This conception of the psychological in the new reworked biopsychosocial theory is consistent with current psychology and neuroscience, for example the so-called 4 Es model of cognition as embodied, embedded, enactive and extended. Agency has conditions in the social and political domains—signified by concepts of autonomy and recognition—the failure of which can jeopardise the perception and exercise of agency and hence psychological health. The third component of the biopsychosocial—the social—is defined within this framework as essentially to do with control and distribution of the resources necessary for biological and psychological life. The main theme of biopsychosocial interactions threads through the chapter, including theorising the notorious (for reductionism) ‘top-down’ causal pathways. This chapter aims to provide a framework to understand how factors involved in health and disease, particularly in the contexts of public health, and managing with long-term conditions, are increasingly seen to extend beyond the internal biological environment into the psychological, social, economic and political conditions of living.

The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or ‘rescue’ procedure for a young person with a severe traumatic brain injury provides a good example of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are likely to remain severely disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other ‘rescue situations’, the utility of the procedure cannot be rationalised on a mere cost–benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation

Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled; a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case.