Introduction to the Institutional Logics Perspective -- Precursors to the Institutional Logics Perspective -- Defining the Inter-institutional System -- The Emergence, Stability and Change of the Inter-institutional System -- Micro-Foundations of Institutional Logics -- The Dynamics of Organizational Practices and Identities -- The Emergence and Evolution of Field-Level Logics -- Implications for Future Research.

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. (shrink)

Education as identity formation in Western-style liberal-democracies relies, in part, on neutrality as a justification for the reproduction of collective individual identity, including societal, cultural, institutional and political identities, many aspects of which are problematic in terms of the reproduction of environmentally harmful attitudes, beliefs and actions. Taking a position on an issue necessitates letting go of certain forms of neutrality, as does effectively teaching environmental education. We contend that to claim a stance of neutrality is to claim a position (...) beyond criticism. In the classroom this can also be an epistemically damaging position to hold. To further explore the problem of neutrality in the classroom, and to offer a potential solution, we will look to the philosophical community of inquiry pedagogy, and advocate for the addition of place-based education; a form of experiential education that promotes learning in local communities in which the school is situated, each with its own history, culture, economy and environment. However, how we understand ‘place’ is fundamental to understanding the potential of place-based education in giving students a ‘sense of place’—how they perceive a place, which includes place attachment and place meaning. To this end, we look to Indigenous understandings of Place and social reconstruction learning to inform place-based pedagogies. Doing so, we hold, opens a pathway to ethical education. (shrink)

Un amer constat paraît traverser l’air du temps, peut-être même le constitue-t-il. Les alertes et l’urgence face aux problèmes constitutifs de notre modernité se redoublent et se démultiplient, aussi bien quantitativement que qualitativement, fruits d’une interdépendance qui appelle des catastrophes en chaîne, sans que semble pouvoir pointer, même à l’horizon, ce spectre de réponses capables d’apaiser la détresse environnante, actuelle et à venir. Non pas que ces réponses soient impossibles :...

Mass literacy, mass communication, and the Internet have all increased the amount of information available. But false knowledge still abounds. Taking cues from Sir Thomas Browne, the English Renaissance skeptic, this title examines a host of contemporary errors in thinking and offers a powerful explanation of why they occur.

I propose a novel metaphysical explanation of identity and distinctness facts called the Modal Proposal. According to the Modal Proposal, for each identity fact – that is, each fact of the form a=b – that fact is metaphysically explained by the fact that it is necessary that the entities involved are indiscernible, and for each distinctness fact –that is, each fact of the form a≠b – that fact is metaphysically explained by the fact that it is possible for the entities (...) involved to be discernible. I argue that the Modal Proposal has greater payoffs at less cost than any of its competitors. It gives simple, uniform, and intuitive explanations of identity and distinctness that conserve longstanding philosophical insights about identity that go back to Leibniz. It does this while making our fundamental base more parsimonious, determining whether controversial cases of identity or distinctness are possible, and expanding our understanding of these central philosophical relations. It does all this while avoiding controversial ontological commitments. (shrink)

The closing chapters of Aristotle’s Nicomachean Ethics x are regularly described as “puzzling,” “extremely abrupt,” “awkward,” or “surprising” to readers. Whereas the previous nine books described—sometimes in lavish detail—the multifold ethical virtues of an embodied person situated within communities of family, friends, and fellow-citizens, NE x 6-8 extol the rarified, god-like and solitary existence of a sophos or sage (1179a32). The ethical virtues that take up approximately the first half of the Ethics describe moral exempla who experience fear fighting for (...) their communities, are sensitive to the esteem and recognition of others, and feel love for a desire to live together with a wide variety of kinds of friends. Such good people take pleasure in prudently expending sums to improve their communities—communities in which they exchange goods and participate in ruling and being ruled in a cooperative fashion. The exemplum of x 7-8, by contrast, is a person whose activity consists almost entirely in exercising his or her mind (nous)—a part of one’s soul that Aristotle explicitly notes is disconnected from human emotions and that can be exercised, insofar as one as wise, in a wholly solitary fashion (1178a15-16, a19-20; 1177a33-34). Although Aristotle’s claim that a “life in accord with the mind” is best and most pleasant (1178a6-7) may jar the intuitions of many people—he himself endorses Anaxagoras’ claim that the happy person will appear as “someone who is absurd” (atopos, 1179a15) to most people—it is false to claim that his conclusions in NE x 6-8 are unexpected or unanticipated, or that the text is in any way discontinuous with what precedes it. The Nicomachean Ethics exhibits aspects of ring-composition both within the work as a whole and within book 10. In NE i 5 Aristotle introduces his rendition of a trope that he inherits (most immediately) from Plato, viz. that the problem of the good can be considered like a contest between three different kinds of life—the life of enjoyment (apolaustikos), the life of politics (politikos), and the life of contemplation (theôrêtikos). NE x 6-8 returns to that contest, rendering a verdict about which life takes first, second, and third place. As the opening lines of NE x 6 note, that verdict presupposes central claims articulated between the first and last books of the Ethics, specifically about the nature of the virtues, the nature of friendship, and the nature of pleasure. NE i 5 and x 6-8 thus serve as “bookends” which encase arguments and proposition located between them. Book 10 exhibits a similar ring-composition. NE x opens with methodological reflection on the gap between the theoretical positions that thinkers articulate and the way they live their lives (especially in the case of scolds who simultaneously criticize pleasure on a scientific level but seek it on a practical level [1172a33-b8]). Chapter 8 concludes with an explicit reiteration of the methodological point, a reiteration that underscores how Aristotle’s treatment of the contest of lives incorporates central aspects of the discussion of pleasure in NE x 1-5. Aristotle’s reiteration of the problem of a gap between theory and practice also draws attention to the centrality of his treatment of pleasure in his adjudication of the three lives. Although the life of pleasure takes a distant third in the contest of lives, the contemplative life wins the contest in part because it itself is the most pleasant form of life. The central philosophical problem looming behind Aristotle’s treatment of the contest of lives concerns the relationship between the notion of activity (energeia) and the notion of a way of life (bios). In the last four decades, much of the scholarship on NE x 6-8 has sought to address the question of what activities a certain way of life includes or excludes. “Monistic” or “dominant” end interpretations of the best life have viewed it as including only contemplative activities whereas “inclusivist” end interpretations of the best life have viewed it as including non-contemplative activities. Although this chapter largely side-steps this debate—partially because there are ample recent first-rate introductory treatments of the debate, partially because I have addressed the question elsewhere in my own writing —I argue that focusing solely on the contest between the two best ways of life overshadows the way that Aristotle incorporates insights from the third way of life into the best way of life. Although the notion of a contest among different kinds of lives presupposes that the lives are mutually exclusive, Aristotle has no problem saying that the contemplative life trumps the life of pleasure because the contemplative life is more pleasant. I proceed in two parts. In the first part I examine what I will call the “outer” ring of the Ethics, namely the relationship between the contest of lives proposed in NE i 5 and its overall resolution in x 6-8. I show how i 5 and x 6 establish the framework for the contest, how x 7 adjudicates that contest in large part by relying upon premises articulated in the interim between books 1 and 10, and how x 6 and x 8 determine the second and third place positions in the contest. In the second part I focus on what I will call the “inner” ring of NE x. More than half of NE x struggles with the nature of pleasure, its role in a happy life, and the methodological problems of examining pleasure within a practical science. I show how x 1 and x 8 are “bookends” that underscore the methodological problem of examining pleasure and how the contest of lives draws upon the proximate conclusions concerning the nature of pleasure in NE x 1-5. (shrink)

Aristotle’s discussions of natural slavery, ‘barbarian kingship’, and the natural characteristics of barbarians or non-Greeks are usually read as calling into question the intellectual, ethical, and political accomplishments of non-Greeks. Such accounts of non-Greek inferiority or inability to self-govern also appear to presuppose a climatic or environmental account that on the whole would imply severe limitations on the possibility of political flourishing for peoples living outside the Greek Mediterranean basin. In light of such accounts, it is somewhat astounding to find (...) Aristotle praising the social and political institutions of Carthage within his discussion of the best constitution in the second book of the Politics. In the 4th century BCE, Carthage (modern day Tunis) was a Phoenician commercial empire that culturally and linguistically was Semitic and clearly non-Greek. That Aristotle contrasts Carthage, a non-Greek polis, favorably with both Sparta and Crete undermines both the claim that Aristotle embraced a categorical opposition between Greeks and non-Greeks and the claim that he was dismissive of the achievements of non-Greeks. (shrink)

Degradation of eukaryotic RNAs that contain premature termination codons (PTC) during nonsense‐mediated mRNA decay (NMD) is initiated by RNA decapping or endonucleolytic cleavage driven by conserved factors. Models for NMD mechanisms, including recognition of PTCs or the timing and role of protein phosphorylation for RNA degradation are challenged by new results. For example, the depletion of the SMG5/7 heterodimer, thought to activate RNA degradation by decapping, leads to a phenotype showing a defect of endonucleolytic activity of NMD complexes. This phenotype (...) is not correlated to a decreased binding of the endonuclease SMG6 with the core NMD factor UPF1, suggesting that it is the result of an imbalance between active (e.g., in polysomes) and inactive (e.g., in RNA‐protein condensates) states of NMD complexes. Such imbalance between multiple complexes is not restricted to NMD and should be taken into account when establishing causal links between gene function perturbation and observed phenotypes. (shrink)

Selon différentes conceptions du genre et des parcours de transition, toujours singulières mais empreintes d’attentes sociales, l’enveloppe corporelle du sujet transgenre se métamorphose. Lors d’entretiens de recherche et d’épreuves projectives (Rorschach et tat ), deux jeunes adultes transgenres aux profils psychopathologiques névrotiques présentaient une sensibilité marquée aux normes, à la morale et aux attentes sociétales. La légitimité, la culpabilité et la honte étaient des problématiques redondantes. Différents temps de transitions subjectives, familiales, sociales et corporelles se sont trouvés en jeu : (...) le passage à l’âge adulte, une vie étudiante hors du giron familial. Ces deux situations illustrent une discussion sur les transitions du corps et des enveloppes chez des sujets transgenres, entre seconde peau et moi-peau corsets. (shrink)

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. (shrink)

At first glance, it looks like Aristotle can’t make up his mind about the ethical or moral status of non-human animals in his ethical treatises. Somewhat infamously, the Nicomachean Ethics claims that “there is neither friendship nor justice towards soulless things, nor is there towards an ox or a horse” (EN 8.11.1161b1–2). Since Aristotle thinks that friendship and justice are co-extensive (EN 8.9.1159b25–32), scholars have often read this passage to entail that humans have no ethical obligations to non-human animals. By (...) contrast, although the Eudemian Ethics denies that non-human animals can participate in “primary” friendships, EE 7.2 claims that “the other kinds of friendship are also found among animals; and it is evident that utility is present to some extent among them both in relation to humankind, in the case of tame animals, and in relation to each other” (EE 7.2.1236b3–11). Does the Nicomachean account of non-human animals contradict that of the Eudemian Ethics? Ultimately, I believe the Nicomachean account is consistent with the Eudemian account. Nonetheless, I argue that Aristotle’s treatment of non-human animals differs significantly in the two texts. My chapter explores this difference in greater detail and considers the ramifications of such a difference for our understanding of Aristotle’s place in the philosophical tradition concerning the ethical status of non-human animals. (shrink)

Time is a critical issue for organizations, especially for healthcare organizations. In the last three decades, concerns over the transformation of healthcare organizations have increasingly gained attention in the literature, indicating how task duration has been reduced to improve clinical-workflow efficiency. This article seeks to raise questions about the experience of acceleration and the ways in which this brings ethical implications to the fore for health professionals within healthcare organizations. Current approaches to acceleration fail to place ethical considerations as their (...) central concern. This article, drawing on the theory of social acceleration and dynamic stabilization of Hartmut Rosa, offers a deeper analysis of ethical perspectives concerning acceleration. To do so, we draw on an in-depth case study, ethnographic immersion, and 48 semi-structured interviews with professionals within a French public hospital. We also carried out 20 telephonic interviews with directors in different hospitals of various sizes. We contribute to the literature by critically exploring the intersection between the experience of acceleration and ethics. We identify four broad categories of ethical implications for health professionals: the expected flexibility of directors facing uncertainty; the erosion of the ethics of care; the process of mechanistic dehumanization; and the adverse effects of speed on emotional work and workers’ well-being. (shrink)

Topical bibliography of Aristotle's Nicomachean Ethics, organized by books/subjects within the Ethics. Includes editions and lexica for the study of Aristotle's Eudemian Ethics and Magna Moralia.

Food systems are made of a myriad of actors, visions and interests. Collaborative governance arrangement may foster their transformation towards greater sustainability when conventional means, such as state-oriented planning, technological developments or social innovations provide insufficient impetus. However, such arrangements may achieve transformative results only under certain conditions and in specific contexts. Despite an abundant literature on participatory schemes, the success for collaborative governance arrangements remains partially understood and deserves academic attention, in particular in the field of food systems reform. (...) This article provides an in-depth analysis of an empirical case study in the Walloon Region (Belgium), where the administration for sustainable development initiated a six-month participatory process to collectively construct a roadmap towards a sustainable regional food system. The article explores the extent to which the process has allowed transformative voices to emerge, and assesses whether the outcome provides a promising tool for adopting a transformative policy at the regional scale. It argues that the facilitation process insufficiently attenuated existing power relations and highlights key underlying factors (including time, resources, expertise and coalition building) that, like in classical negotiation settings, strengthen or weaken specific actors. It discusses the link between the results of the participatory process and the potential for policy-makers to build upon these to guide further the region’s food system towards a sustainable future. (shrink)

Il est communément admis, aussi bien par les spécialistes que les non-spécialistes de la Grèce antique, qu'Aristote considère le barbaros ou l'autre Non-Grec comme radicalement distinct des Grecs (peut-être même racialement) et intrinsèquement inférieur à eux. Cette idée puise sa source dans ses remarques sur l'esclavage, sur les institutions politiques non grecques, sur les caractères naturels ou ethniques. Mais l’idée la plus répandue manque de nuance, et est souvent affirmée à tort en faisant l’économie d’un examen attentif des bases textuelles. (...) Cet article, qui est une sous-section d'un essai plus vaste sur les institutions politiques non-grecques (comme le traitement par Aristote de la politeia de Carthage dans Politique 2.11), soutient qu'Aristote ne distingue pas catégoriquement (et encore moins racialement) les Grecs et les Non-Grecs, ni n’approuve l’assertion selon laquelle les Grecs sont supérieurs aux non-Grecs. En effet, Aristote s'appuie régulièrement sur des institutions politiques non-grecques dans sa propre formulation de la meilleure constitution. (shrink)

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... (shrink)

Aristotle’s claim that poetry is ‘a more philosophic and better thing’ than history (Poet 9.1451b5-6) and his description of the ‘poetic universal’ have been the source of much scholarly discussion. Although many scholars have mined Poetics 9 as a source for Aristotle’s views towards history, in my contribution I caution against doing so. Critics of Aristotle’s remarks have often failed to appreciate the expository principle which governs Poetics 6-12, which begins with a definition of tragedy and then elucidates the terms (...) of that definition by means of a series of juxtapositions. The juxtaposition between poetry and history is one such instance which seeks to elucidate what sort of plot exemplifies a causal unity such that the events of a play unfold with likelihood or necessity. Within that context, Aristotle compares history and poetry in order to elucidate the object of poetic mimesis rather than criticize history as a discipline. Viewing Aristotle as antagonistic towards history fails to appreciate the expository structure of the Poetics and obscures the resource which history provides to the poet, a point which I explore by considering what Aristotle would have thought of an ‘historical’ tragedy like Aeschylus’ Persians. (shrink)

In her “Saving the Appearances in Plato’s Cave,” Dr. Adriel M. Trott argues that “the philosopher’s claim to true knowledge always operates within the realm of the cave.” In order to probe her claim, I challenge her to make sense of “politics in the cave,” namely the status and practices of two categories of people in the cave: “woke” cave dwellers (namely, those who recognize shadows as shadows but have not left the cave) and “woke” puppeteers (namely, philosophers ruling within (...) the cave). (shrink)

Despite its authors’ intentions, the four principles approach to medical ethics can become crudely algorithmic in practice. The first section sets out the bare bones of the four principles approach drawing out those aspects of Beauchamp and Childress’s Principles of biomedical ethics that encourage this misreading. The second section argues that if the emphasis on the guidance of moral judgement is augmented by a particularist account of what disciplines it, then the danger can be reduced. In the third section, I (...) consider how much the resultant picture diverges from Beauchamp and Childress’s actual position. (shrink)

The author attempts a "correct analysis of what 'the moral point of view' is only in so far as it is necessary to do this in order to discuss the problem of its 'justification'." he discusses the views of kurt baier and philippa foot. He concludes that foot and baier have not been able to answer "the so-Called fundamental question of ethics" because it is a "pseudo-Question"; that the rationality of a decision between "moral duty and enlightened self-Interest" rests on (...) whether the "agent accepts or rejects the moral point of view"; and that it is "what a person most wants to do," not what is in his or her best interest, "that provides the ultimate basis for the rational justification of an action." (staff). (shrink)

For good or for ill, we have animal bodies. Through them, we move around, eat and drink, and do many other things besides. We owe much – perhaps our very lives – to these ever-present animals. But how exactly do we relate to our animals? Are we parts of them, or they of us? Do we and these living animals co-inhere or constitute or coincide? Or what? Animalism answers that we are identical to them. There are many objections to animalism, (...) and a dizzying array of rival views. In this article, we do not propose to evaluate those objections and rivals. We will instead present a new argument for that view. The argument begins with the fact that we have emotions. (shrink)

Person Centred Medicine is a substantial and contentious view of healthcare that carries both ontological and epistemological presuppositions. This chapter examines two key aspects: that the person is a central, basic irreducible element in ontology and that person-level knowledge is both important and possible. Some reasons for holding both of these are sketched.

Résumé D’une multiplicité inhérente à la pratique de la danse contemporaine, nous dessinerons les contours de l’interprète, les graphies d’un danseur, des deux dimensions du papier aux trois dimensions du corps et du plateau. De l’écriture à l’interprétation, de la composition à la réception en passant par des notions de transmission ou de traduction et au sein de quelques réalisations chorégraphiques, nous analyserons des processus, par le biais de la description kinesthésique, relative à la sensation et la construction du mouvement (...) dansé. (shrink)

KEYWORDS: Validity, reliability, values, taxonomy, clas- sification, McDowell.

THE AUTHOR ARGUES THAT THE HUMEAN "A PRIORI" ATTACK ON MIRACLES IS INTENDED TO SHOW THE INCOHERENCE OF THE NOTION OF A WELL-ATTESTED MIRACULOUS EVENT (NOT THE INCOHERENCE OF THE CONCEPT OF A MIRACLE). THOUGH THIS TYPE OF ATTACK CAN BE PRESENTED IN A POWERFUL FORM, IT SUFFERS FROM AN UNDULY NARROW ASSUMPTION CONCERNING THE NATURE OF EVIDENCE AND EXPLANATION, FOR IT "IS" POSSIBLE TO DESCRIBE CIRCUMSTANCES IN WHICH IT WOULD BE REASONABLE TO CONCLUDE THAT A MIRACLE HAS OCCURRED. HOWEVER, (...) WE CAN KNOW ON "A POSTERIORI" GROUNDS THAT THE PROBABILITY OF THESE CIRCUMSTANCES EVER HAVING OBTAINED IS EXTREMELY REMOTE. FINALLY, IT IS ARGUED THAT (UNLESS THE DESIGN ARGUMENT IS SOUND) WELL-ATTESTED MIRACLES ARE, NEVERTHELESS, THE ONLY POSSIBLE GROUNDS WHICH COULD JUSTIFY A REASONABLE BELIEF IN THE EXISTENCE OF A PERSONAL GOD. (shrink)

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... (shrink)

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... (shrink)