This article is an attempt to evaluate the Oregon plan from the perspective of a Scandinavian national health care system. The Nordic welfare states are marked by a strong emphasis on equality. As an example of an egalitarian system we present the Norwegian health care model in part one. In part two, the arguments in favor of a one tier system in Norway are presented and compared to Oregon's two tier system. Although we argue, in part three, that a comparison (...) of the degree of explicitness in the prioritization process shows that Norway has much to learn from Oregon, we do believe that the Norwegian system has some attractive elements that may function as an important corrective. In part four we present the Norwegian Guidelines for priority-setting and discuss the weight assigned to the severity of disease criterion. It is argued that the exclusion of information about the severity of disease partly explains the counterintuitive ranking of treatment-condition pairs in Oregon's initial method based on the principle of health maximization. A normative analysis of the conflicting norms of efficiency and equality of results is called for. The final part of the paper is devoted to the problem of rigidity. Henry J. Aaron has argued that the Oregon system is insensitive to inter-individual variations within each diagnosis-treatment pair. This objection is a severe one, since the system might end up treating patients unfairly on the individual level. To overcome this problem, we suggest a selection rule that should be more capable of dealing with the problem of rigidity. (shrink)

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. (shrink)

This chapter introduces the edited volume, The Oxford Handbook of Philosophy and Psychiatry. Published in 2013, the centenary of Karl Jaspers' General Psychopathology, the chapter draws lessons from the last hundred years for the coming century. No predictions are made. Instead, five 'conditions for flourishing' are set out: 1) Particular Problems - the importance of focussing on well-defined particular problems rather than general theory building, 2) Product- orientation - remaining always responsibly product oriented in the specific sense that both sides (...) put in the work necessary to 'go deep' with each other's fields, 3) Partnership - working in partnerships of one kind or another, 4) Process - constant reflection on process based on peer review but leaving scope for the occasional rogue voice to cut innovatively against the grain, and 5) Q - a condition of a different kind, Q is an empirically derived measure of the balance between in-group cohesion and out-group openness required to support creativity. Illustrations are given of how these five conditions for flourishing have underpinned the rapid expansion of philosophy and psychiatry in the closing decades of the twentieth century, and, correspondingly, are also reflected in the Handbook as a whole. Overviews and commentaries on individual contributions to the Handbook are given in extended editorial introductions to each of its eight sections. (shrink)

This “open letter” to Christopher Boorse is a response to his influential naturalist analysis of disease from the perspective of linguistic-analytic value theory. The key linguistic-analytic point against Boorse is that, although defining disease value free, he continue to use the term with clear evaluative connotations. A descriptivist analysis of disease would allow value-free definition consistently with value-laden use: but descriptivism fails when applied to mental disorder because it depends on shared values whereas the values relevant to mental disorders are (...) highly diverse. A part-function analysis, similarly, although initially persuasive for physical disorders, fails with the psychotic mental disorders because these, characteristically, involve disturbances of the rationality of the person as a whole. The difficulties encountered in applying naturalism to mental disorders point, linguistic-analytically, to the possibility that there is, after all, an evaluative element of meaning, deeply hidden but still logically operative, in the concept of disease. (shrink)

In this paper some of the general issues surrounding recently published guidelines for the practice of research ethics committees are outlined, concentrating in particular on the difficulties raised by research with psychiatric patients. Research is distinguished from ordinary clinical practice by the intention to advance knowledge. So defined, research with psychiatric patients should be governed by the same four principles as research with any other group--knowledge, necessity, benefit and consent. In applying these principles, however, particularly the principle of consent, many (...) acute difficulties are raised by psychiatric patients. A number of proposals for addressing these difficulties are discussed. It is suggested that, notwithstanding the value of published guidelines, and the help that may be available from research ethics committees, the primary responsibility for maintaining high standards of practice in research rests with research workers themselves. (shrink)

In the current climate of dramatic advances in the neurosciences, it has been widely assumed that the diagnosis of mental disorder is a matter exclusively for value-free science. Starting from a detailed case history, this paper describes how, to the contrary, values come into the diagnosis of mental disorders, directly through the criteria at the heart of psychiatry's most scientifically grounded classification, the American Psychiatric Association's DSM (Diagnostic and Statistical Manual). Various possible interpretations of the prominence of values in psychiatric (...) diagnosis are outlined. Drawing on work in the Oxford analytic tradition of philosophy, it is shown that, properly understood, the prominence of psychiatric diagnostic values reflects the necessary engagement of psychiatry with the diversity of individual human values. This interpretation opens up psychiatric diagnostic assessment to the resources of a new skills-based approach to working with complex and conflicting values (also derived from analytic philosophy) called 'values-based practice.' Developments in values-based practice in training, policy and research in mental health are briefly outlined. The paper concludes with an indication of how the integration of values-based with evidence-based approaches provides the basis for psychiatric practice in the twenty-first century that is both science-based and person-centred. (shrink)

Couples should not be allowed to select either for or against deafnessRecently, a US couple deliberately attempted to ensure the birth of a deaf child via artificial insemination.1 In opposing this action, I wish to focus on one argument they employ to support it, namely that in trying to have a deaf child, the women see themselves as no different from parents trying to have a girl. Girls can be discriminated against the same as deaf people and “black people have (...) harder lives”, one of them argues. They compare themselves to a minority group.2In using this argument to justify their attempt to secure the birth of a deaf child, they make four claims: It is not wrong to deliberately try to have a child who is expected to experience harm when the harms the child will experience are socially imposed. As a group experiencing socially imposed harms, the deaf are to be understood as a minority group. Women and people of colour also experience social harms, and are to be understood as minority groups. Because the deaf, women, and people of colour are all groups experiencing socially imposed harms, distinctions should not be made between attempts to have a child who will be a member of one of these groups.In reply, I will advance two arguments. First, I will argue that this couple’s decision is inherently just. Here I will acknowledge that this couple’s position draws a great deal of strength from its appeal to the experiences of women. My second argument will contend, however, that despite the reasonableness of this choice, the intentional selection of deaf children is indefensible. Granting this couple’s contestable assertion that the deaf ought to be understood as a minority cultural group, allowing individuals to secure the birth of deaf …. (shrink)

This article sets out a manifesto for the development of an international values-based practice fully engaged with the diversity of cultural values and implemented through the resources of the international movement in philosophy and psychiatry. Anticipated by mid-twentieth century ordinary language philosophy of the “Oxford School,” the last three decades have witnessed a remarkable flowering of cross-disciplinary work between philosophy and psychiatry. The article indicates the scope and scale of this work and then describes the emergence of contemporary values-based practice (...) as its philosophy-into-practice cutting edge. Values-based practice although originating in philosophy and psychiatry is currently being developed mainly in areas of bodily medicine such as surgery. As such, it has been criticized for focusing, as contemporary health care has largely focused, on the individual at the expense of cultural values. Hence arises the need for extending values-based practice internationally. The resources available from international philosophy and psychiatry for so extending values-based practice are outlined and some of the challenges are indicated. The article concludes with the hope that psychiatry in supporting the development of international values-based practice will by the same token take poll position in the development of contemporary science-led clinical care. (shrink)

This article sets out key contributions to the long-running debate about mental disorder from the ordinary language philosophy of the ‘Oxford School’. The distinction between definition and use of concepts underpinning ordinary language philosophy reframes the debate as a debate not just about mental disorder but about disorder in general, bodily as well as mental. The field work of ordinary language philosophy (focusing on the use of concepts as a guide to their meanings) shows that, attempts at elimination notwithstanding, there (...) is an essential evaluative element in the meaning of disorder, bodily as well as mental. The concept of disorder in the debate thus reframed presents a double challenge for analysis: to explain why disorder has evaluative connotations used of mental conditions but descriptive connotations used of bodily conditions. Philosophical value theory, derived by applying ordinary language philosophy to the language of values, provides a rich resource of ideas for meeting this double challenge. It meets the double challenge at the level of theory by allowing both aspects of the double challenge of disorder to be derived from a logical property that disorder shares with all other value terms. It meets the double challenge at the level of practice by supporting the development of a new approach to working with values alongside evidence in healthcare called values-based practice. Ordinary language philosophy, notwithstanding these several contributions, is no panacea. It helps us to make a start, no more and no less, in understanding mental disorder. (shrink)

From the perspective of values-based practice, there is much of interest in Lorenzo Gilardi and Giovanni Stanghellini's "I am a Schizophrenic." Their dialogue exhibits many of the key elements of VBP, it exemplifies the particular challenges presented by VBP in mental health, it illustrates the power of phenomenology in meeting these challenges, and it points by extension to an insight into contemporary psychiatry's professional identity as a medical profession.VBP is a resource for working with values—with what matters or is important (...) to those concerned—in healthcare. Avoiding preset answers, it offers instead a process that supports those concerned in a given situation... (shrink)

This paper employs the methodological framework of linguistic analytic philosophy to explore the conceptual issues arising from a study of the different models of disorder implicit in five groups of stakeholders concerned in the community care of people with a diagnosis of long-term schizophrenia. Linguistic analysis, gives a precise fix on the nature of the practical difficulties presented by such models, suggests a powerful heuristic for displaying and comparing models, is the basis of a methodology which is neutral as between (...) users and providers of services, provides an intuitively powerful way of understanding the results of work of this kind, and facilitates the translation of research into practice. (shrink)

Philosophers have hitherto only interpreted the world in various ways; the point is to change it.Karl marx’s distinction between interpreting the world and changing it points by extension to the state of contemporary philosophy and psychiatry. The 1990s resurgence of interdisciplinary work in this area was driven equally by phenomenological scholarship and by initiatives in analytic philosophy. The former reflected the focus in phenomenology on ‘what it is like’ to experience a given mental symptom with the aim of reconstructing the (...) life-worlds of people experiencing mental disorders, while the latter reflected directly or indirectly the influence of J. L. Austin and others from... (shrink)

I wish to discuss symbols concerned with the way we feel about the world and the way we conduct our lives in consequence of those feelings. Our conduct is guided by commands and instructions which for some reason we have to obey. We are guided by our knowledge of the world. The symbols I wish to discuss express and excite desires and preferences and that is how they affect our conduct.

These are exciting times for philosophy and psychiatry. After drifting apart for most of this century, the two disciplines, if not yet fully reconciled, are suddenly at least on speaking terms. With hindsight we may wonder why they should have ignored each other for so long. As Anthony Quinton pointed out in a lecture to the Royal Institute of Philosophy a few years ago, it is remarkable that philosophers, in a sense the experts on rationality, should have had so little (...) to say about the phenomena of irrationality. There have been partial exceptions, of course. Descartes and Kant both touched on madness; and there were, notably, important philosophical influences on the development of modern psychiatry in the late nineteenth and early twentieth centuries. Yet even John Locke, who was a doctor as well as philosopher, confined himself to a fair-l y superficial distinction between what we should now call mental illness and mental defect—those with, in Locke's view, respectively too many ideas and too few. (shrink)

Ten years ago the Royal Institute of Philosophy marked the establishment of the Society for Applied Philosophy with a series of public lectures, published in an earlier book in this series, under the title Philosophy and Practice. Looking back it i s hard to believe this was only ten years ago. Applied philosophy still has its critics. But it is now so pervasive, so much the norm, that it seems to have been with us always. Law, medicine, education, nursing, the (...) environment, politics, economics … almost it seems, no subject is quite respectable nowadays without its philosophy and its philosophical exponents. (shrink)

Originally published in 1938, this book examines the meaning of the word 'intuition'. Wild considers many different applications of the word in a variety of poetic and philosophical sources, and questions whether or not such a faculty truly can be said to exist. This book will be of value to anyone with an interest in intuition and the implications of such a word's usage.