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Esssential Philosophy of PsychiatryReview - Esssential Philosophy of Psychiatry
by Tim Thornton
Oxford University Press, 2007
Review by Neil Levy, Ph.D.
Jul 8th 2008 (Volume 12, Issue 28)

The title of Tim Thornton’s short book suggests that it is an introduction to central debates in the philosophy of psychiatry. In fact, it is better thought of as a defense of a certain approach to philosophy of psychiatry (and, indeed, mind more generally): a Wittgensteinian approach, which is opposed to the naturalistic standpoint that dominates the mainstream. It does provide extensive coverage of some major debates, but it moves too rapidly to be suitable as an introduction. It is both too difficult and too unusual in its view to be suitable for beginners. Instead, it casts an unusual light on some familiar debates.

Thornton has three themes: the role of values in diagnosis and treatment, the limits of understanding and the scientific underpinnings of psychiatry. He approaches all from the perspective of his non-naturalism (he calls it a relaxed naturalism, and he has some grounds for this terminological innovation, but in the reigning nomenclature it is a non-naturalism). He is opposed to views that attempt to take a bottom-up approach to meaning and to value; that is, which attempt to show that meaning and value are constructed out of elements that are not themselves meaningful or valuable. On his account, meaning and value are irreducible to naturalistic components; instead, they are independently components of the universe.

For Thornton, to be a human being is to live in a space of reasons. This has implications, as he sees, for some perennial debates in the philosophy of psychiatry. In part one, for instance, he reviews the debate over whether mental illness can be defined in a value free manner, for instance by giving an account in terms of (evolutionary) proper function. Since Thornton believes that we live in the space of reasons, he believes that only a normative account can explain our nosology. It is at this point, however, that a curious feature of the book emerges: the arguments that are advanced are so general that, if they succeed, they threaten to prove too much. Suppose it is true, for instance, that because we live in a space of reasons, a non-normative account of mental illness cannot be given. In that case, however, there are no non-normative accounts of anything to be had. Most participants in the debate over nosology take themselves to be debating features that are (allegedly) peculiar to medicine or to psychiatry, not the general metaphysical questions to which Thornton addresses himself. Of course, he may welcome this upshot, but we are left wondering whether there are, or whether Thornton believes there are, any features of medicine that make it especially value-laden.

Similar thoughts are prompted by Thornton’s chapter on normative ethics. He rejects all principalisms, deontological or consequentialist, on the basis of arguments drawn from Wittgenstein’s rule-following considerations. He argues that Wittgenstein demonstrated that rules depend for their application on our grasp of their shape, which depends, ultimately, on our form of life, and that therefore good judgment is indispensable for ethical decision-making. It follows, he claims, that morality cannot be exhausted by codifiable principles. Perhaps so, but the argument is perfectly general: if it shows anything, it is that nothing is entirely codifiable. Is morality uncodifiable, just like arithmetic? Or is there something special about it, which makes it less susceptible to principalism? Particularists typically believe the latter, but it is unclear whether Thornton does.

One is left with the impression that Thornton’s real target, in this book, is not a particular conception of philosophy of psychiatry, still less particular theses, so much as an entire metaphysics and philosophy of mind; estranged epistemology, or epistemology committed to the so-called myth of the given, on the one hand, and a philosophy of mind committed to the view that mental states are internal to the minds of subjects, on the other (oddly, Thornton nowhere mentions that mainstream philosophy of mind has a lively debate over both content and locational externalism, attention to which would have at least complicated his neat picture). Sample views -- about delusions, or about classifications, for instance -- are read as exemplifications of these positions and dismissed on quite general grounds. There is nothing wrong with that, of course, given that these underlying views are his target, but what is lost is a clear sense of anything specific to philosophy of psychiatry.

Nevertheless, Thornton’s unusual perspective is forcefully argued, and his views deserve a hearing in a debate that is dominated by a physicalist perspective at odds with his. Let me close, however, by briefly sketching two problems for his view. First, there is the difficulty of squaring it with an evolutionary perspective on human beings. Suppose that values (to focus only on them) are part of the furniture of the universe, quite independently of human beings. Then how and why did we evolve to grasp them (if we did)? Grasping independent values has no apparent survival value (at least, there are no good arguments extant showing that it does). Hence why would we have come to grasp them? If there are values independent of us, we have no reason to think that what we take to be values actually are. It is only on a naturalism about values that value skepticism of this kind can be avoided.

The second problem is more internal to Thornton’s position. He argues in several places (against Millikan’s proper function account, for instance) that since we live in the space of reasons we cannot give accounts of significance according to which they are built up from non-significant elements. Such accounts overlook the fact that it is only because we are in the space of reasons that we find such accounts meaningful in the first place. But a bottom-up theorist need not deny Thornton’s claim: there is no inconsistency in offering an explanation of the elements in virtue of which we find that very explanation meaningful. For his argument to succeed, Thornton owes us a further argument, as to why we can’t use the engaged perspective which (we are supposing) we find ourselves with to understand some of the non-significant elements of that perspective.

© 2008 Neil Levy

Neil Levy, Ph.D., Senior Research Fellow Program Manager, Ethical Issues in Biotechnology, Centre for Applied Philosophy and Public Ethics, University of Melbourne

Tim Thornton sent the following response to Neil Levy's review.  (Published August 18, 2008)

I am grateful to Neil Levy for engaging with the underlying philosophical themes of my book even if not with the details of its arguments.

To take one example of this lack, Levy ascribes to me the argument that since 'we live in a space of reasons, a non-normative account of mental illness cannot be given'. This is merely a caricature of the discussion of chapter 1 which turns on the question of whether biological functions can be used to reduce the normative notions particular to illness, especially mental illness. Having, it seems, more faith than I have in evolutionary theory to defend reductionism, Levy must disagree with my conclusions but it is a pity he has not engaged more closely with the arguments.

In order to set up one of his two challenges, he ascribes to me the same kind of brisk dismissal of reductionist accounts of meaning: 'since we live in the space of reasons we cannot give accounts of significance according to which they are built up from non-significant elements'. But again this ignores my actual arguments, [eg the 5 page discussion ibid: 129-133] (against what I concede in the text is still a live research project [ibid: 129]) which look, inter alia, to the problems reductionists have answering the 'disjunction problem' or showing how causal theories of reference are of the right form to explain intentionality.

Levy likewise merely parodies my argument for moral particularism. I cannot claim originality for this line of thought (I cite John McDowell) but the argument [ibid: 68-71] starts from the prima facie appearance that such value judgments cannot be codified and then considers why this appearance is often disregarded in philosophy. The discussion of codified judgments is meant to challenge a deep-seated prejudice about rationality which can blind us also to the nature of uncodified judgments. Thus when Levy ascribes to me the view that arithmetic also is uncodifiable he simply ignores the text itself which says:

Thus even in the case of a judgement that can be codified – by the axioms of Peano arithmetic, for example – the principle itself has to be applied through a kind of practical judgement. Whatever principles can be used to encode such practice their application relies on practical judgements which are not themselves codified. Wittgenstein's discussion should undermine the prejudice that wherever there is a rational judgement it must be encoded in a principle, since principles themselves cannot govern judgement unaided. Without the prejudice, however, there is no reason to doubt the appearance that value judgements are made without a close framework of principles. [ibid: 71]

Levy suggests that the main target of my book is 'an entire metaphysics and philosophy of mind' rather than an engagement with particular views within philosophy of psychiatry. Whilst he is right that I oppose reductionism, his description is again an unhelpful way of presenting the way the general and particular inform each other. To take just one area, my discussions of the different accounts of delusion offered by Jaspers, Maher, Frith, Sass, Campbell, Davies and Bolton and Hill turn on the particular details of their theories and models. There can be no one size fits all response. The overall argument for a relaxed (non-reductive) naturalism emerges out of piecemeal discussion of key authors and key issues within the philosophy of psychiatry.

This is not the place to attempt to resolve the longstanding debate about the prospects of reductionist naturalism but let me suggest a way to respond to Levy's remaining challenge. He asks how we could have evolved to grasp real values, worrying that 'If there are values independent of us, we have no reason to think that what we take to be values actually are'. If, however, one takes seriously the idea of values as genuine features of the world then there might well turn out to be an evolutionary account of grasp of them. (Since we have no wish to explain values in other, eg evolutionary, terms, this issue is not pressing for non-reductionist, relaxed naturalists. Reductionists face a bigger challenge.) But if so it had better not eliminate the potential gap between being right and merely seeming right that characterizes any judgment that aims to track real features of the world. Levy's skeptical worry is both under motivated and misplaced.

In addition to misrepresenting my book, I fear Levy also misrepresents the abilities of those with an interest in the philosophy of mental health and psychiatry. My ten years' experience of teaching psychiatrists, mental health nurses and service users, with a passionate interest in the fundamental issues surrounding mental healthcare but without a philosophy background, has in turn taught me that such students thrive by getting stuck into the complexities of the real debates and real figures, from Jaspers to EBM. Understanding my little book should be no problem at all, to them at least.

© 2008 Tim Thornton

Tim Thornton, Professor of Philosophy and Mental Health, The Centre for Ethnicity and Health, University of Central Lancashire, UK

Neil Levy sent the following response to Tim Thornton's reply to his review.  (Published August 18, 2008)

Tim Thornton's chief complaint against me is that I have not engaged with the details of his arguments. On this point, he is entirely right: I haven't. Were I to try to do so, in any way that would not be vulnerable to his charge, I would devote an entire, relatively lengthy, paper to just one of his many claims with which I take issue: the codifiability thesis, or the claim that intentionality cannot be given a reductive account, or the essential normativity of illness, and so on. I did not attempt to do his arguments justice, because a book review is not the forum in which to undertake such an enterprise. Instead, I aimed to give an overview of the book. I took myself to achieve the following goals: give the (potential) reader some sense of the flavor of the book, outline the ways in which it is distinctive, and hint at the burden that it must shoulder to make its non-reductive case in the current physicalist climate. I did not say, and I do not now say, that Thornton's position is clearly wrong, or that his arguments are failures. I pointed to what I took to be difficulties in the view. The accusation that I ascribe to him 'brisk dismissals' of views, and not detailed arguments, seems to me out of place: given that the context is a book review the reader would, I take it, assume that I merely sketch the author's position, not do it justice.

So I agree that I have not done the book justice, inasmuch as I have only given brief and inadequate sketches of the views presented. I deny only that I could reasonably be expected to do more in the context. Thornton's other substantive charge against me is that my worry that his non-reductive moral realism being difficult to square with an evolutionary account of the emergence of morality is 'under motivated and misplaced'. Here again I think the complaint ignores the context; I could not hope to adequately motivate the problem in the space of a book review. Were I to do so, I would refer the reader to Sharon Street's well-known 'Darwinian dilemma'; Street presents compelling arguments for the claim that the supposition that evolution has brought us to track independently existing moral properties is far less plausible than the more parsimonious hypothesis, according to which the tracking mechanism is also a constituting mechanism.

The disagreements I have with Thornton go deep. They reflect disagreements about fundamental issues in metaphysics, mind and morality. In this forum, neither of us can hope to do any more than indicate our sense of where the characteristic strengths and weaknesses of each other's positions lie. What I hope these deep disagreements do not conceal is my sense that his work is important. I think it is important not because it is likely to succeed in its aim – though I do not rule out that possibility entirely – but because the reductive program needs sensitive and robust critics, and sustained arguments like those on display in Thornton's book, if it is to succeed in its aims. What I think we both share, among other things, is the belief that we can best hope to discover truths by pursuing these issues in dialogue and debate.

© 2008 Neil Levy


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