A Philosophy of Nursing Forum

2011-09-22T12:06:00.002-04:00

Hello all! Greetings from the great South. As a part of a class assignment. My doctoral students will be answering the following questions on the blog. Please help me guide them and critique their response. Many thanks!

1. Do you agree or disagree with Pesut and Johnson’s assertion that “philosophical inquiry has yet to be positioned as contributing substantially to the field of nursing’s inquiry.” Why or why not?

2. Do you think that ignoring philosophy in nursing “puts nursing at risk”? Why or why not?

3. What can the historical roots of nursing add to the scientific advancement of the profession?

2010-01-16T23:58:00.002-05:00

Bear:

First, let's consider your point, in the first three paragraphs of your comment, about penectomy. It is correct that penectomy involves transecting the urethra, whereas FGM ordinarily will not. It is not similarly correct to say or suggest that penectomy has no history, and that it would result in death absent modern medical intervention. In fact, penectomy has been performed for thousands of years under circumstances remarkably similar to those attending FGM, as a part of the eunuch process, and it still occurs infrequently in India. See the article in Indian J Urol. 2007 Jul–Sep; 23(3): 317–318 for the grizzly details, along with the accompanying picture. It is instructive, I think, to compare THAT picture to some of the available pictures of female genitalia post FGM, and then compare both of THOSE to one of the innumerable pictures available on the WWW of a circumcised penis. I think my analogy is apt indeed, although like all analogies, it does not achieve a perfect correspondence.

Now, on to your final paragraph. The first two sentences are:

FGM and male circumcision are both barbaric practices with little to justify them. A classic case of culturally defined stupidity and irrational justification in both western and non-western cultures and clear violations of the rights of the victims.

These two sentences make the following claims about MNC: 1) male neonatal circumcision is an elective “cultural” phenomenon or practice not COMPELLED by medical necessity; 2) MNC is stupid and/or irrational; 3) purported justifications of the practice of MNC are “irrational”; and 4) and election by a parent to have a male neonate circumcised violates that neonate's “rights”. I think claim number 1 is true. In Ireland, for example, I gather that a parent will only rarely elect circumcision for a newborn son (Irish readers can correct me if I am wrong about this), and this decision is not irrational. I think it is perfectly rational to elect MNC or to decline MNC. However, I do not think this is true of FGM. A decision to have a daughter “circumcised” is never rational.
Circumcision, a reply to Bear's objections
I flatly deny claims 2, 3, and 4. I suspect the purported truth of #2 depends on the purported truth of #3. That is, I think that if #3 is false, and there are good reasons for a parent to elect MNC, then a fortiori MNC is then neither “stupid” or “irrational”.

I don't see anything in your comment which justifies claim #3, other than characterizations of the research on the topic as just 1) “appearing” to show that MNC confers some benefit, and 2) “thinly veiled rationalizations.” I have, to date, reviewed over 400 published, peer reviewed studies relating to MNC, as did Benatar and Benatar. I have studied research methods, at the graduate level, under the tutelage of one of the best scientists in her field, and am quite sure that I can tell the difference between rational, responsible inquiry and “thinly veiled rationalization.” I am confident Drs. Benatar and Benatar can as well. The corpus of scholarly, scientific study of the practice of MNC is voluminous, and is published in journals that are not in the habit of publishing articles which either a) merely “appear” to show something, or are merely 2) “thinly veiled rationalizations”.

As regards claim #3, I agree with Benatar and Benatar: the evidence supports the following conclusions: men who are circumcised as neonates are at slightly less risk than uncircumcised men of contracting syphilis, gonorrhea and HIV AIDS (if in a high risk group), and at slightly greater risk of contracting canker and non-gonococcal urethritis; they are at a reduced risk for the most invasive forms of penile cancer; and at reduced risk for UTI. Actually, I think most MNG opponents concede that the evidence DOES show what I claim it does. This is especially clear in light of a careful review of the responses to the Benatars' original target article. None of the respondents, even those which were clearly hostile to the practice of neonatal circumcision, argued that there was NO warrant for believing that neonatal circumcision provides (minimal) medical benefits. All of them focused, instead, on whether such benefits were sufficient to justify the practice in light of what various respondents took to be clear contra-indications associated with the practice. Here, I think, absence of evidence equals evidence of absence. Credible arguments against the position that there are minimal medical benefits to neonatal circumcision simply do not exist.

I assume, then, that those who oppose MNG are claiming that there are contra-indications associated with neonatal circumcision which unequivocally and significantly outweigh any medical benefits of the practice that we might have warrant for accepting as real. And, further, that these contra-indications are so significant that the practice should not be permitted. Bear's next to last sentence alludes to one such purported contra-indication – pain.

Pain is yet another informal fallacy – the red herring. Pain is NOT an argument against the circumcision of male neonates. It isn't even a valid argument against FGM, for that matter. It IS an argument against either practice when they are not accompanied by truly effective anesthesia and post-operative analgesia. But pain can be effectively controlled for far more serious operations – it can hardly be an insurmountable obstacle in this instance.

So what other “contraindication” could there be? The only one on offer is that the procedure somehow leaves the individual harmed, or diminished, in some way, and this usually takes the form of one or more versions of the “less pleasure” thesis I have already criticized. Until, and unless, I am offered ARGUMENTS against the position I have outlined regarding the “less pleasure” thesis, and the research which supports my position, I remain unmoved.

I suppose that it is possible that someone might think that only surgery which is medically necessary, as opposed to “in some way desirable”, should be permitted. I cannot imagine why. In fact, surgery is performed all the time for reasons other than “medical necessity.” Here is an example: otoplasty, or ear pinning. The procedure is almost never a medical necessity, since kids with large ears can ordinarily hear perfectly. It is, instead, elected for cosmetic reasons, and to help children avoid inevitable adolescent ridicule. The same is true for cleft palate and other maxillofacial surgery. These are procedures which are not, strictly speaking, medically necessary, but do confer benefits upon those who undergo them. The “not necessary” argument is less than compelling.

Finally, we come to the last sentence, the one about neonatal “rights”. I would argue that neonates do not have “rights” - what they have are interests that adults have a duty to protect and further. For the reasons I have already adduced, I fail to see that any male has an “interest” in either having, or not having, a foreskin, any more than they have an “interest” in having an appendix or tonsils. That is, whether their lives go well or badly in not going to depend to any degree on the presence of these tissues. And this marks the dramatic contrast between FGM and MNC, since every woman has an interest in having a clitoris, and their lives will go less well without their clitoris than they otherwise would.

2010-01-16T09:15:00.002-05:00

Why No Mention of Neonatal Circumcision back in June?

The redoubtable “Bear” Cox has asked why I excluded male neonatal circumcision in my June “capabilities approach” post. I did so for a number of reasons, but let me just mention a few.

First, to equate the two procedures trivializes the horror of FGM. Male
neonatal circumcision (hereinafter MNC) is in no way as invasive as FMG.
The homologous equivalent to female genital mutilation would be amputation
of the entire penis. I assure all reading this post that I am just as
opposed to THAT procedure as I am to FGM. I love my "Mr. Happy," who has been my friend through many adventures. However, penile amputation is almost never performed, whereas FGM happens to millions of young women every year. Since it almost never happens in our patriarchal world, there is no reason to mention it.

Second, I am persuaded that ALL of the COMPETENT peer reviewed studies
regarding MNC, individually and collectively, establish that the procedure
produces a modest medical benefit, to be balanced against modest medical
risk, usually in the form an undetected bleeding disorder. If anyone,
anywhere, is aware of a similar study or studies coming to the same
conclusion about FGM, often termed clitorectomy, please let me know.

An excellent summary of the state of the SCIENTIFIC literature regarding MNC may be found in Benatar and Benatar, "Between prophylaxis and child abuse: the ethics of neonatal male circumcision"; The American Journal of Bioethics - Volume3, Number (2), Spring 2003, pp.35-48. It is magisterial, and much can be gleaned from reading it, along with the decidedly adversarial responses to it from anti-MNC camp.

This leads to my third reason. I am convinced that those who oppose neonatal
male circumcision (in contrast to those who would simply PREFER not to elect
it for their sons) are either uninformed or intellectually dishonest. Here
is an example in the form of a comment on the Benatar study, noted above, by
an individual named "Rio Cruz":

"Benatar and Benatar (2003) conclude that amputating ... protective, and
sexually important tissue from a nonconsenting infant does not constitute
abuse but is rather a matter for parental discretion."

I have never, in 60 years of life, seen a more egregious example of begging
the question. And this is not an isolated instance; every single article I
can find which criticizes the practice contains an example of either the
"strawman" fallacy or the "begging the question" fallacy (usually both),
coupled with a willful refusal to examine the peer reviewed evidence on the
topic with anything remotely resembling an open mind.

Now, to another reason - my main one, actually. Look carefully at what this
"Rio Cruz" person says. He calls the foreskin "sexually important".
Channeling my inner G.E. Moore, I want to know what, exactly, that is
supposed to mean. The anti-MNCers never clearly say, which, following Moore
again, leads me to conclude that they mean nothing whatsoever. But, let's
apply the principle of charity to that statement, and try to say something
meaningful on their behalf. Perhaps what they have in mind is a claim that
the procedure of MNC produces "negative" sexual sequela in later life. I
call this the "Less Pleasure" thesis. Let's take a look at it.

The literature surrounding the possible sexual sequela of neonatal
circumcision focuses on the tactile stimulation that males receive during
sexual activity. Of chief concern is the role that the male foreskin might
(or might not) play in the "sexual pleasure" a sexually active male
experiences, and so the debate seems couched in terms of the "stimulation"
that foreskin tissue might provide, and what loss of "sensitivity"
maturation without a foreskin might cause. This is why one finds so much
discussion (and disagreement) about, for example, how "keratinized" the
glans is, how "sensitive to touch and pressure" the glans is, and how much
"highly erogenous tissue" is removed by circumcision (By "highly erogenous
tissue," I take those using the expression to mean "tissue within an
erogenous zone of the body," and by "erogenous zone" to mean a part of the
body that is associated with sexual pleasure). It is at this point, I
think, that the discussion "jumps the track," and leads to conceptual
confusion.

The discussion "jumps the track" because the analysis seems focused on
"sensation," in the sense of peripheral nerve receptor stimulation, as the
primary focus of investigation and analysis, whereas I maintain that our
best science, and scientifically informed philosophy, suggests that this is
the wrong way (albeit the "folk psychological" way) to think about sexual,
or indeed any other kind, of pleasure.

There is a surprising dearth of recent philosophical analysis on the general
topic of pleasure. Rather, pain seems to be the usual topic of interest.
The great bulk of the modern philosophical literature on the subject of
pleasure generally centers on the work of Gilbert Ryle, produced in the late
1940's and the early 1950's, and the responses of other philosophers to
Ryle's work. This work was done when psychological research was, for the
most part, either strictly behavioristic or, alternatively, introspective.
Psychology at the time had little in the way of research findings to offer
philosophers which could shed light on the subject, so it is perhaps not
surprising that philosophical reflection and analysis on pleasure soon
faded. However, Psychology has advanced considerably in the succeeding
decades, and philosopher Mayat Aydede has revisited the subject fairly
recently and produced a splendid paper, "An Analysis of Pleasure Vis a Vis
Pain," to be found in Philosophy and Phenomenological Research, 61 (3):
537-70, 2000 (hereinafter "Pleasure Analysis.")

The language of the current discussion on the sexual sequela of neonatal
male circumcision leads one, naturally enough, to think about the issue in
terms of some relationship between the number of nerve endings in the penis,
plus or minus the foreskin, and the quantity and intensity of "sexual
pleasure." I maintain that this is the wrong way to conceptualize the issue,
in light of what Dr. Aydede, and the scientific work he cites, can tell us
about how it is that pain and pleasure happen to happen.

Aydede argues that, from a general understanding of the gate control theory
and the phenomenon of reactive dissociation, some clear conclusions can be
reached about pain. We can best understand pain, he argues, in the
following way (as drastically simplified by me.) We "feel" pain, or are "in
pain" when: 1) pain stimuli from peripheral nociceptors (pain specific
receptors, located primarily in the skin and viscera) arrive at the
somatosensory cortex and at various limbic system structures; 2) in the
somatosensory cortex, these nocioceptor generated stimuli (noxious stimuli,
for short) are identified as pain, and measured in terms of intensity and
the spatio-temporal location of the originating nociceptors; and 3)
simultaneously, in the limbic system, affective response to the noxious
stimuli, in the form of an aversive reaction, is generated. That, in a
nutshell, is how pain happens to happen, when all goes as "nature intends."

Contrast this picture, Aydede suggests, with physical pleasure. It some
ways, the process is parallel, in that the "experience" of "feeling physical
pleasure" usually begins when stimuli from receptor sites arrive at the
somatosensory cortex and the limbic system. However, a marked difference is
already at work. The arriving stimuli do not include any "pleasure" stimuli,
for the simple reason that the human body apparently has no "pleasure"
receptors, as such. We have lots of receptors, including proprioceptors,
thermal receptors, pain receptors, receptors for touch, taste, light and
smell; but no "pleasure receptors." Thus, the somatosensory cortex does not
identify anything as "pleasurable." When we "experience" pleasure, the
somatosensory cortex is busy identifing stimuli, but identifying them as,
for example, touch, taste, pressure, smell, sound, or motion; not as
pleasure. So "physical pleasure" simply is, on Aydede's model, the affective
response to those particular stimuli.

To simplify even further, we do not have pleasure experiences; rather, we
have experiences we find pleasurable. Pain is different; we have pain
experiences that we usually find, well, painful, unless someone gives us
morphine. Aydede helps us here by simplifying even further: "Put crudely,
the suggestion is not that we feel...pleasure and then desire it. It is
rather that the very feeling of pleasure metaphysically consists of our
desiring whatever...sensory information we are simultaneously processing or
reacting to." Works for me. How else can we explain what goes on in certain
nightclubs in San Francisco? How else do we explain all of that "birching"
business going on on British television (see several episodes of "Midsomer
Murders" for examples)? My goodness how they carry on over there!

Thus, if either circumcised William or uncircumcised James experiences "less
pleasure" than the other, we are not going to be able to tell by counting
the number of their respective "erotogenic receptor sites," assuming,
without deciding, that there even are such things. Instead, we will have to
determine which of them is most strongly "desiring...whatever sensory
information" they typically process/react to when engaging in sexual
activity. And this sort of study, I am afraid, is not something opponents
of MNC ever cite.

There are some peer reviewed studies which do provide some information about circumcision's sexual sequela in adults. But this evidence, such as it is,
does not reflect negatively, on balance, on male circumcision in general.
There is a study which indicates that men who have been circumcised in
adulthood find sexual activity more satisfying, overall, roughly 70% of the
time, studies which conclude that circumcised men engage in a greater
variety of sexual activities than do uncircumcised men (specifics available
upon request - email me off post, ladies), and studies which conclude that
circumcised men are less prone to erectile dysfunction than uncircumcised
men, especially in later life (more good news!). To me, these studies hardly
provide warrant for characterizing the sexual sequela of neonatal
circumcision as "negative", but I leave the reader to draw her or his own
conclusions in this particular.

Let's end by returning to the capabilities approach. It is entirely clear
to me that women undergoing FGM are deprived of a "capability" needed for a
fully "human" life. Joyce's Molly's "YES" is absolutely never going to
happen for them. In the case of circumcised males, however, YES happens for
them as least as often as it does for their uncircumcised cohorts, and all
of the evidence we have suggests that they yell "Oh My God", or words to
similar effect, at least as loudly, when "knocking boots". So, while MNC in
the USA is indeed a cultural phenomenon, an expression of an aesthetic
preference on the part of middle and upper class protestant women, it
deprives no one of a meaningful capability necessary to enjoy a fully
"human" life. The same cannot be said for FGM.

So I did mention FMG, but didn't mention MNC. Hope this answers Bear's question.

2009-10-08T19:00:00.002-04:00

Ok now that Professor Newsom has kicked off our discussion on realism, let's keep it going.

Realism versus anti-realism

Revolutionary ideas

READINGS:

Read: Rosenberg C 6.

Bergin, M., Wells, J., & Owen, S. (2008, July). Critical realism: a philosophical framework for the study of gender and mental health. Nursing Philosophy, 9(3), 169-179.

Hansen-Ketchum, P., & Myrick, F. (2008, July). Photo methods for qualitative research in nursing: an ontological and epistemological perspective. Nursing Philosophy, 9(3), 205-213.

1. Based on your understanding of Kuhn’s assertion that “we are no nearer the truth about the nature of things nowadays than we were in Aristotle’s times,” (pp 145-146) what are some examples from our profession of accepted paradigms? In applied disciplines, this usually relates to generally accepted practice guidelines.

2. What is your definition of realism as compared to anti realism? In your own words…

3. How do Hansen-Ketchum and Myrick justify the use of photography as a research method based on ontology and epistemology?

4. Select an article in nursing scholarship, which reflects or refutes Kuhn’s ideas. Share your critical assessment of author’s perspective.

2009-10-02T11:05:00.003-04:00

THEORY AND REALITY

This last week's discussion about science and epistemology has impressed me. I gather that the class is quite diverse in terms of how much philosophy the participants have taken, but folks appear to be picking up on many important concepts and ideas right out of the starting gate. Good job!

Let me suggest something further to think about. Caveat: what I am about to say is opinionated and contentious, and would not necessarily meet with widespread agreement by “paid up” philosophers of science. Still it might get the discussion rolling in useful directions.

ONE way to think about the big issues in philosophy of science is to organize the discussion around “realism” versus “anti-realism”, and see how that relates to the empiricism versus rationalism versus pragmatism debate. When we organize our thinking in that way, at least initially, we find an argument going on about the status of “theoretical” entities and forces which we cannot see. Take electrons as a simple example. We don't “see” electrons (or do we?). We take eggs to be “real” because we see them, hold them, eat them, etc. But we don't see, hold, taste or eat electrons in the same way. So why take them to be real?

And, why stop with electrons? What about “causes”? Logical positivists read Hume, famously, as being dubious about any claim of the sort “putting poison in his wife's tea caused her death”. Ayer and the positivists thought Hume would allow that we observed the act of putting poison in the tea, and that we observed the death of the little missus thereafter. He would allow that this same sequence of events has been observed many times in the past. He would allow that, so far, this sequence has been “exceptionless”, that is, that every time we have seen poison put in tea, death has followed on the part of the person drinking the tea. He would allow that we expect that death will follow putting poison in the tea if we do that tomorrow. Moreover, he would allow that expecting death to follow poisoning is perfectly natural on our part. It is a “habit of thought”. But that is ALL he (Hume) would allow, because what we see is the events; we don't SEE the cause. Note, please, that not everyone reads Hume this way. Strawson, Craig and Blackburn offer alternate readings. But, for this discussion, let's stick with the “Hume a la Ayer” version, because it is illustrative.

Illustrative, because we can use it to see what was bugging empiricists “back in the day”, and why empiricism classically can lead to anti-realism in science. “Empiricism” writ large is just the idea that “sense experience is the ultimate source of all our concepts and knowledge”, as contrasted with “rationalism”, which holds that “there are significant ways in which our concepts and knowledge are gained independently of sense experience.” As regards “causes”, or “electrons,” the classical empiricist position might be that, since we never actually see them, there is no reason to treat them as “real”.

Kant thought that, at least as to concepts like “cause”, he had put an end to the debate, arguing that “cause” was a “category of understanding”, a sort of operation that the human mind performed upon experience, thereby constructing the “phenomenal world”. We know, then, that putting poison in the tea causes death, but this is knowledge of the phenomenal world, not knowledge of the “noumenal” world, that is, the world not comprehended through the categories of human understanding. De Pierris and Friedman put it this way: “Kant agrees with Hume that neither the relation of cause and effect nor the idea of necessary connection is given in our sensory perceptions; both, in an important sense, are contributed by our mind. For Kant, however, the concepts of both causality and necessity arise from precisely the operations of our understanding—and, indeed, they arise entirely a priori as pure concepts or categories of the understanding.”

Not everyone agrees that Kant succeeded here, or even what all of that meant, exactly. But, even if he did succeed when it comes to “cause”, where does that leave “electrons”, or germs, or...? THEY aren't “categories” or “operations of the mind,” but rather, according to realists, putative “objects”, or things that (allegedly) exist whether there is any “experience” going on or not. So how does Kant have anything to do with this? How does this HELP? Let's take a brief detour through a bit of medical history and and then return to the question. Much of what follows is inspired by Dr. Marc Lange's article “Salience, Supervenience, and Layer Cakes in Sellars's Scientific Realism, McDowell's Moral Realism, and the Philosophy of Mind”, in Volume 101, Numbers 2-3, of Philosophical Studies. However, he might not agree with some, or much, of this, so don't blame him.

Consider Dr. Semmelweis, the Viennese obstetrician who was horrified to discover that, in the Doctors ward of the hospital, women were dying like flies of Puerperal fever, whereas, over in the nurse midwife ward, women got Puerperal fever less than half as often. And, he wasn't the only one to notice. Here in the good old USA, poet and physician Dr. Oliver Wendell Holmes, Sr. (Justice Holmes' father – a distinguished family) had noticed too. He wrote, years before Semmelwies, that
“. . . in my own family, I had rather that those I esteemed the most should be delivered unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease."

Folks back then understood that diseases could be spread from person to person. They also presumed that bacteria existed, since Antony Van Leeuwenhoek's 1674 observations of “animalcules” through a microscope had been repeated many times for over 150 years. Some even guessed that “disease” could inhere, somehow, on physical objects like blankets, thus giving General Jeffrey Amherst the bright idea of giving native Americans blankets that had been used by small pox victims. Charming. No one, though, thought that “animalcules” could kill you, since they were so tiny. Thus, there was no “germ” theory of disease.

Semmelweis had before him a classic researchers' problem – discover why two groups, “Doctors' patients” versus “Nurses' patients” had different rates of death due to Puerperal fever. So he made Baconian “observations.” Observations of the organs of someone who had died of "cadaverous fever”; observations of the organs of women who had died of Puerperal fever; observations of Nun midwifes and what they did; observations of Doctors and what they did; observations about ward location, temperature, population and crowding; ton-o-observations, in other words, and he wrote these down methodically. Let's call what he wrote down “observation level” statements.

Not everything he observed, though, had anything to do with Puerperal fever. Semmelweis needed to figure out which observations were clues. He needed for some observations to “stand out”. Salience, per cognitive scientist Dr. Laurent Itti is that “which makes some items in the world stand out from their neighbors.”

In the event, the “right” observations were made “salient” for Semmelweis; that is, the right ones “stood out” for him, for the most part, and he ignored those observation level statements of his that didn't matter. What stood out for him were things like “the nuns wash their hands before and after touching the sick,” “the nuns don't go from cutting up corpses to examining women in labor,” “the nuns have clean clothes on that haven't been in contact with rotting corpses,” “the internal organs of people who have died of cadaverous fever look like the organs of women who die of Puerperal fever,” etc. Equally important was what didn't stand out – things like the color of the nuns' habit, the color of the doctors' trousers, the prayers the nuns said, the temperature in the ward.

What made some observation statements salient and others not? How about the THEORETICAL statements (thoughts, conceptual schemes?) in Semmelweis's noggin? His THEORIES, in other words. Note that they weren't the best of all possible theories. In fact, they were pretty much WRONG, consisting as they did of mostly of the stuff he had been taught – the “wisdom” of his day. The theoretical entities in his noggin were things like “miasmas”, and “vapors”, neither of which, in fact, exist. Still, they were good enough, close enough to how things are, to make the RIGHT observations salient for him, after postulating the existence of a new “theoretical entity”, the “cadaverous particle,” which, while not exactly a bacteria, is a step closer than a “miasma”. Based on his theories, he was able to utilize his observations to formulate some “laws of obstetrical ward hygiene”, which are, roughly, the same ones we subscribe to these days.

These laws of obstetrical ward hygiene can be expressed entirely in the terms used in Semmelweis's “observation level” statements. The only “terms” we need are soap, water, hands, wash, etc. So, once we have them, and we confirm the laws inductively – new moms don't get Puerperal fever when we adhere to them – what else is needed? Wouldn't the right thing for nurses to have done back then be to reason as follows: “we nurses will follow the 'laws of obstetrical ward hygiene' as long as they are inductively confirmed, but we will remain agnostics about vapors, miasmas, and cadaverous particles”?

At first glance that SEEMS right – agnosticism would keep researchers from refusing to look at better theories when they came along, like a theory that substitutes pathogenic “animalcules,” or bacteria, for “cadaverous particles”, say. Viewing science historically, with the benefit of hindsight, agnosticism might look sound. There are even respected philosophers of science who counsel something like this attitude today. Constructive empiricists, for example, allow that one can USE theorizing in order to formulate hypotheses and “observation statement” type laws, but are still of the opinion that it is okay to be skeptical, or at least agnostic, about entities and forces which cannot be directly observed by the senses. Perhaps, they say, today's “electron” is tomorrow's “miasma”, and anyone who is not at least open to that possibility is a pig-headed, lab-coated intellectual fascist.

Plausible as this seems, there are problems with it. For one thing, it assumes that there is some principled distinction between that which is “seen” with the naked eye, and that which is “seen” with a microscope, or by means of some other method which augments our senses. Harvard philosopher John Hall finds this highly suspect. It would mean, for example, that some tiny creature that can “see” a bacteria should “believe” in them, whereas we should be agnostic about them because we need microscopes to spot the little rascals. Or what about the moons orbiting the outer planets? Does this mean that we can be agnostic about them as long as we only “see” them through telescopes, but we can “believe” in them after astronauts “see” them through the spaceship's window?

A second problem is this: absent an assumption concerning the truth of our theories, how do we arrive at explanations? We want good laws of obstetrical hygiene, of course, but we also want an explanation for why they “work”. The philosopher Willfrid Sellars used the example of Boyle's law. Why does the equation P=VT work? BECAUSE (theory) heat = molecular motion, and (theory) gases are itty bitty moving particles. If confined, then, as they heat up they move faster, so they bump in to each other more often, so they exert more force on the confining vessel, so pressure rises. COOL!

A true theory, aided by an ASSUMPTION that the fundamental laws of the universe will be the same tomorrow as they are today, permits us to stop relying on inductions from observational statements, and start actually “deducing” things, as J. S. Mill noticed a while back. When our deductions don't work in terms of the observations we make, we go back and revise the theory, expecting (reasonably enough) that it will EXPLAIN not only the observations we do make, but why the old theory SEEMED to work as well as it did.

The miasma theory of disease is a good example to use here. According to that theory, disease was spread by noxious, vaporous things called “miasmas”, which contained tiny bits of rotting stuff called “miasmatas”, and this was the standard theory of disease in the mid 1800's. Nightingale accepted it, for example, at least at the beginning of her career. Accepting it as true lead to changes in public behavior. People started washing stuff that smelled bad (including themselves, thank God), covering sewers, inventing toilets and digging outhouses, and draining swamps so that the bad stinky air wouldn't blow in to town (eliminating the mal aria, in Latin. Isn't that an interesting tidbit?)

The miasma theory wasn't all that great, but it seemed to work. Malaria, for example, virtually ceased to exist in many parts of the industrial world. Public health visibly, measurably, improved. Observations seemed to confirm the theory. It began to be modified/abandoned only when anomalous phenomena were observed, and/or its explanatory power proved inadequate. And, our newer theories of disease explain the successes the miasmatic theory did enjoy. Drained swaps don't harbor mosquitoes, and so malaria disappears. Washed bodies are far less at risk for septicemia than unwashed ones are, due to a lower bacteria count. Cholera is less frequent when people stop throwing poop in to gutters, where it washes in to streams and shallow wells, because fewer vibro cholerae are getting in to the drinking water. In fact, one can go so far as to say that we wouldn't ACCEPT the germ theory of disease if it COULD NOT explain the successes of the miasmatic theory.

So where does this leave us? I think it ought to leave us back with Kant, at least in spirit, if not in detail. Nick Fearn and others have suggested that we think of Kant's BIG idea about categories of understanding as analogous to eyeglasses that we cannot take off, operations that the mind automatically and unceasingly performs on the information it receives, and indispensable to us, since without them we could not THINK at all. Similarly, we might think of theories and the entities and forces they postulate as indispensable eyeglasses which render certain observations salient. Without them, and the presumption that they characterize reality accurately, we cannot proceed.

The late and very much missed philosopher Jay Rosenberg put it much better than I ever could:

“...stories that postulate “theoretical entities” are not merely manageable second-class surrogates for more complicated and unwieldy stories about entities that we have good, i.e., observational, reasons to believe actually exist. Theoretical entities, rather, are those entities we warrantedly believe to exist for good and sufficient theoretical reasons. On this understanding, scientific theories explanatorily “save the appearances” precisely by characterizing the reality of which the appearances are appearances.”

So, don't forget to wash you hands, empiricists. They REALLY have animalcules on them.

2009-09-24T01:58:00.002-04:00

Our first official class discussion blog with Professor Bob Newsom! Let's get started...

We will be discussing scientific theory and epistemology this week.

Discussion Questions:

1. Scientific explanations should be testable, according to Rosenberg. Explain your understanding of the statement in chapter 4 (p 84):

…”almost from the onset science has explained by appeal to a realm of untestable entities, processes, things, events and properties. As far back as Newton, physicists and philosophers have been uncomfortable about the fact that such things seem both necessary and unknowable.”

2. Discuss critically: “Lots of scientists pursue science successfully without any regard to epistemology. The idea that science has an ‘official one’, and that empiricism is it, is wrong-headed.”

2009-08-12T12:39:00.003-04:00

Some readers of this blog have, perhaps, been watching the United States try to devise a rational health care system. I imagine reactions around the globe have varied along a spectrum, from amusement on one end to the sort of pity, mixed with horror, that a classic Greek tragedy produces, on the other. The most vocal opponents over here of any sort of systematic health care planning and reform are being labeled “deathers.” Deathers claim that, under any sort of nationally mandated health care scheme, a lot more old peopled will die a lot sooner than they otherwise would. Those who have been watching from (lucky you!) afar will enjoy this bit of “tongue in cheek” about the “deather” position from the U.S.A. Blogosphere:

'When Obama and the Democrats try to explain how America's health care crisis can be fixed, they often point to our neighbors to the north.

"Canada provides health care to all its citizens, we can too," say the optimists.

Sounds good until you consider this scary fact: at some point after Canada instituted its national health care program, everyone in the country died.

This startling truth emerged today when a group known as the "Deathers" -- sponsored by a consortium of health insurance companies and endorsed by Senator Mitch McConnell (R-KY) -- held a press conference exposing a surprising statistic: according to the most recent census reports, Canada's population is currently zero.

"Near as we can tell, some of them dropped dead right away and some of them were horribly disfigured and stumbled around for awhile and then died," Jordan Gipple, a spokesman for the Deathers, reported "but the bottom line is, from Newfoundland to British Columbia, there's not one single person up there. It's like The Omega Man only without Charlton Heston."

A reporter asked why it was that so many Canadians do seem to be alive and perfectly healthy today. Wayne Gretsky, Seth Rogan and Nelly Fertado were cited as examples. Mr. Gipple responded that these so called "Canadians" actually reside outside of Canada in places like Arizona, Los Angeles and New York. "They're like refugees from the Titanic. Sure, every once in awhile you'll find one floating around, but I bet you five bucks not one person here has seen a real Canadian in the past 24 hours. They've all gone to the great beyond. And you can thank national health care for that!"

"Canada's not the only place. There used to be plenty of people in Norway and Sweden and France. There were even some people in England. But then they went and instituted national health care. And now they're gone too."

Mr. Gipple ended with an impassioned plea that brought tears to the eyes of the press members present, "Yes, America's health care costs are spiraling upwards. Yes, 46 million Americans are uninsured. And yes, about 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs. But seriously, what are the options? Just look at what happened to these other countries when they tried to "fix" the system. I know I speak for all Deathers when I say we must keep the system we have, absolutely. Don't touch it. We don't want to wind up like Canada or Holland or Denmark or Germany. They're all gone. Now it's up to us, us fortunate few, to keep the candle of mankind burning." '

Recently, a U.S. reichwing opinion writer stated:

“People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.”

Of course, other bloggers jumped on this, and one of them pointed out the blindingly obvious:

... "Stephen Hawking was born and raised in the UK and has lived there all his life. He teaches at Cambridge. That's in the UK. This ranks up there with the French not having a word for entrepreneur."

In sum, the combination of galactic ignorance, Harry Frankfurt Bull Shit, and out and out thuggery (our own Kay Lundy's apt and pithy term) going on over here is truly astounding, until you remember that this is happening in America, where knife fights on the floor of state legislatures happened once upon a time, today's college freshmen can't find Wales on a map, and Sarah Palin thinks she can see Russia when she opens her front door.

Sooner or later, it will occur to someone to look at statistics. The following numbers come from our CIA, so they must be pretty good, right? Canada =81.23 years, Norway =79.95, UK=79.01,USA = 78.11. The US only beats Albania, hands down the poorest country in Europe, by a few months.

So, how are you perfidious Cannucks, Norskies and Brits managing this? Do you come up with a closely guarded secret “target” age, fixed upon by NHS gnomes, to keep the “life expectancy” numbers up to a level that reassures the gullible public, and THEN do granny in? Or, could it be that here in the US of A we are, in fact, doing granny in ourselves, in various and sundry (and often unpleasant) ways, but just lying to ourselves about what really goes on here?

Perhaps, for example, we make routine care out of reach for Granny for most of her life, so that her type II Diabetes, and hypertension, go undetected for years. Then, when we finally do detect it, we prescribe expensive meds she can't begin to afford, when over the counter Humulin R and Lasix, coupled with some patient education, would have done very nearly as well. Or even better. Then, when her kidneys fail, we put the tax payers (and Granny) through the oiive press with dialysis. The cost of the dialysis, it should be noted, will far exceed what a lifetime supply of Humulin R, generic brand Walmart insulin syringes, a few home health visits, and generic lasix would have cost.

After months of this misery, Granny refuses dialysis and dies. Painfully. This happens. In 15 years as a long term care nurse, I have held "Granny's" hand, under exactly these circumstances, more times than I care to remember. I cry each and every time it happens. Sometimes, the Director of Nursing has to send me home. “Pay no attention to the man behind the screen, Dorothy.” Could it be that “deathers,” heaven help us, are right to look, but are looking in the wrong direction?

2009-06-27T20:56:00.002-04:00

This list is in danger of suffering from disuse atrophy, which is a bad
thing, as I have reason to know.  So I decided to post something.

I just received an announcement that Martha Nussbaum will be coming to the
southern part of heaven (otherwise known as UNC-Chapel Hill) next spring to
make a presentation (title TBA) to the philosophy department.  I can't pass
up a chance to meet another philosophical rock star.  So, in anticipation of
the coming event, I sat down and read Nussbaum's "Sex and Social Justice,"
one of several of her books that relies on what she calls the "capabilities
approach" to ethical and political theorizing.

Nussbaum writes beautifully, with the goal of engaging not just
philosophers, but all thoughtful people.  Commendably, she doesn't just
theorize in a philosopher's study, but often descends in to the messy world
of day to day life as ordinary people around the world must live it, and, as
one Jesuit reviewer put it, "if you are looking for wisdom, her books are
full of the stuff."

Much of the "wisdom" is derived from her encyclopedic knowledge of the
ancient world, particularly Aristotle and the stoics.  Of course, not
everyone agrees that she "gets them right." I am not competent to
adjudicate, so I just think of it as a case of "Aristotle and Aurelius as
She Understands Them", or AASUT for short (sounds sort of like the "AHH
S..T!" that working nurses exclaim when the vein they are trying to puncture
for a blood sample blows up).

In any event, informed by AASUT, and the work of the economist Amartya Sen,
Nussbaum offers us the notion of "capabilities."  The goal here is to
specify "a life in which fully human functioning, of a kind of basic human
flourishing, will be available."  She attempts, in other words, to meet a
big challenge for eudamonian based ethical theories, that of specifying what
counts as a "good life."  Problems rush in here, for doesn't the very idea
of "basic human flourishing" smack of dreaded "essentialism"?  "Good life"
for me might be a whole different kettle of fish from "good life" for
Hitler.  In fact, I am pretty sure I would mean something different by the
term than he would.

What counts as a good life ought to matter to nursing if anything does,
especially in light of the love affair nursing has had with virtue ethics
over the years.  But, you don't have to be in nursing  very long to discover
that there are differing conceptions of the "good life"  amongst the patient
population. Some nursing scholars are lead to conclude, by the diversity of
views on the subject, locally and globally, that there is simply no such
thing as THE "good life," and any attempt by some
old-fat-white-man-ex-lawyer-now-a-nurse (like, say, me) to define the term
would be an exercise in "colonialism"; a LITTLE better than yelling "bash
the WOGs and Fuzzies, let's have another gin" - but not MUCH better.
Attempting to define "good life" for other folks turns me, apparently, into
a sort of intellectual neo-Clive let loose upon the world once more,
opressing everyone from Dublin to the Ganges (well, not Dublin - I love
Dublin.  Let's abuse them last).  Bob the nabob, minus the opium and dancing
girls (damn it, I was born too late!).

Nussbaum is not unaware of these difficulties, and gamely tackles them.  Her
efforts are impressive, and even the likes of Simon Blackburn (who does not
suffer fools lightly) admires them.  The approach is supposed to be (mostly)
culture neutral because it addresses capabilities as opposed to practices,
and so at some level or another supposedly doesn't  involve telling other
people what to do. Consider the list:

life; bodily health and integrity; senses, imagination and thought;
emotional expression; practical reason; affiliation; play; other species;
and, control over political and material environments.

The idea has initial plausibility - take, say, control over the political
environment.  It doesn't rule out of court an Islamic republic, for example,
provided the folks living there want to live in one and have some say in
choosing that form of life.  But not every "post-colonialist" is likely to
be persuaded.  For instance, some cultures are not too ginned up about
giving women even certain "capabilities."  There are societies which deny
women substantial capabilities viz. affiliation, bodily integrity, thought
and environment.  The capabilities approach would declare them illegitimate,
and therefore is, arguably, "colonialist".

To this criticism from the left flank, there are at least three replies.
First reply: who speaks for the culture in question - the girls who want to
go to school, or keep their clitoris, but who are not allowed to, or the
(male) mullahs, elders and/or warlords who won't let them?  Maybe what the
culture "really" wants IS compatible with the "capabilities" approach.

Second reply: maybe these silly savages are just ignorant.  Maybe they don't
know that women are actually smarter than men, on average, and so OUGHT to
go to school if anyone does, or they've misunderstood their own scripture,
or they don't understand enough about human physiology to comprehend that
eumenorrhea is normal and healthy and occurs for homeostatic reasons, or
that it is a bad idea to mutilate female genitalia with or without antsepsis
and anesthesia for any number of reasons, or ... I could go on for while,
but you get the general idea.  Sort of a Millian style argument, like the
one he gave against Bentham's "equality of pleasures" position.

Third reply: this provides a repugnant conclusion/reductio ad absurdum
refutation of post-colonialist arguments. Simply put, IF post-colonial
theory countenances, in any shape, form or fashion, stuff like female
circumcision, obligatory suicide of widows, "honor" killing of women, etc.,
then so much the worse for post-colonial theory.  What's wrong with the idea
that cultures, like individuals, make mistakes?

Assaults could be mounted from the right flank as well.  While emphasizing
"capabilities" is not AS blatantly egalitarian/redistributionist as say, a
Rawlsian program of equal distribution of all social "goods", it is still
going to involve some "taking from the rich" and "giving to the poor".
Noziak-style libertarians will, therefore, still object.  First reply: a
capabilities approach is consistent with unequal distributions of wealth so
beloved by libertarians - it just assures equality of opportunity to the
fullest extent possible, not equality of achievement. You get to keep, in
other words, what you fairly earn; capabilities approaches are simply trying
to give everyone, to the extent possible, the same chance you have.  It
can't give everyone a great voice and a lucrative concert career, for
example, but it can make it possible for everyone who has a great voice to
have music lessons. After the lessons it's up to you.  How could even Mrs.
Thatcher or Ronald Regan object to that?

Second reply: All the "capabilities approach" is doing is assuring some sort
of compliance with the "Lockean proviso", which says that you, or Bill
Gates, or Madonna can take as much of the world's riches as you want, so
long as you do so fairly and leave "enough and as good" for everyone else.
Most libertarians accept the Lockean proviso.  It is hard to know exactly
what that proviso comes to, in today's world, but maybe some sort of
"capabilities approach" captures the spirit of what Locke had in mind.

Interesting stuff.  But what, one asks, has this got to do with Nursing?
Nothing, if Nursing affords no valuable and unique perspective on questions
such as how should healthcare resources be distributed, o what constitutes
"disease" or "disability".  But, if it does have such a perspective, this
might be one way to articulate it that is in some meaningful sense
"transcultural."

Also, it seems to me that this sort of analysis of social justice and human
flourishing mirrors, in some interesting ways, the ways in which various
nursing processes analyze the individual's health.  The parallels with
Orem's theory are especially striking.  Perhaps Plato was on to something in
suggesting that the healthy person and the healthy society are structurally
similar.

One VERY bright young Don in the UK, Lorella Terzi at Roehampton University,
is doing some interesting work on this approach in the context of education
and learning disability.  See, for example, her ‘Beyond the Dilemma of
Difference: the capability approach on disability and special educational
needs’ in Journal of Philosophy of Education , 39 (3), pp.443-459.

I don't think it is absurd to think that there may be parallels between
questions surrounding  the delivery of educational services to the learning
disabled and the delivery of nursing services to the physically disabled, or
to the care of the sick in general.

Thoughts, anyone?

2008-11-12T10:21:00.002-05:00

This Blog has been moribund for quite a while, as most of the folks who are interested in this subject matter at present have made use of the nursing philosophy listserv, kindly maintained by our UK friends. I hope, though, to resurrect it in the near future.

The blog has proved to be quite useful for philosophy in some ways, permitting scholars who work in (relatively) narrow areas to communicate with each other, and providing a vehicle for those new to a field, or just wanting to explore it, to easily access ongoing discussion. And, unlike listserv-type communication vehicles, a blog does not contribute to e-mail inbox overcrowding.

Let's see if we can give this another go.

2007-03-12T09:20:00.000-04:00

IS 21% CORRECT?

The health issues news service I use, care2.com, had an article posted today that claimed the UK has had a 21% increase in maternal childbirth deaths over the past year. It also claimed that the average salary for physicians in the UK is now higher than in the US, thanks to a new agreement between physicians and the NHS, whereas there is a hiring FREEZE for midwifes.

As the late David Falk would have said, interesting, if true. My problem is that I have found it unwise to take press reports(even those vetted by well-meaning folks like those at care2.com) at face value. After all, the much admired New York Times assured us a few years ago that Iraq possessed weapons of mass destruction.

Are these statistics accurate? Are there interesting issues here (along with the usual costly bout of Humean sympathy I am so prone to) for consideration under the topic of, say, "justice in the distribution of health care resources?" Will this be the occasion on which I loose those rose colored glasses through which I view all things "English?"

Bob Newsom

2007-02-14T16:55:00.000-05:00

Nursing Ethics and Pedagogy

Many community colleges in North Carolina require nursing students to take introductory ethics as one of their humanities courses. My institution, Guilford Technical Community College, does not. It, and several others like it, choose to satisfy the Board of Nursing's requirements for ethical instruction by incorporating "ethics modules" in specific nursing courses. Nevertheless, after much tireless missonary work, I feel like I am making SOME headway, and each semester that I teach the subject, I have 3 or 4 nursing students in both sections. Not enough, to be sure, as I consider it to be self-evident that every human being who claims to be truly educated should have (at least) one general survey course on the history of philosophy, and one introductory ethics couse. Still, progress is being made. Enough progress that a pedagogical question arises.

As I survey (via the internet) various approaches to providing people (and especially nurses) with an introduction to the subject of ethics, there is a growing trend in the US to "specialize" the subject, even at the introductory level. Courses entitled "healthcare ethics," "business ethics (an oxymoron?)," and the like, abound. None of them have prerequisites, so it is NOT the case that these courses constitute a more focused, "in depth," look at some narrow issues of special interest to one particular profession or another. Instead, these courses are the FIRST, and often the ONLY, courses of the field that these students will take. I see this as an unfortunate trend.

First, if the published syllabus for the typical course is any guide, these courses rarely "survey" the field. Some philosophers of vital importance are often left out entirely (Hume and Adam Smith come to mind), and others are often marginalized and their views traduced (Kant especially). In other words, after completing the class the student remains uninformed or, worse, misinformed.

Second, as a dogmatic moral realist (or, at least, quasi-realist), the idea that 'the right and the good" might somehow be different in the case of, say, nurses, as opposed to doctors, lawyers or indian chiefs, is something I find highly suspect.

Third, these specialized approaches seem to involve a good deal of "rules of the profession" instruction, the discussion of which takes the students no where near "the right and the good." For example, in a "legal ethics" course in the USA (another oxymoron?) one will learn that, in a criminal case, if the defendant wishes to testify in his own behalf, his counsel ought to call him to the stand even when counsel knows the defendant intends to testify falsely (our UK cousins have a different rule, I hope and believe). Little, if any, discussion time will be devoted to the question of whether or not this OUGHT to be the rule, whether counsel as a moral agent has a duty to disobey the rule and accept the consequences (and there will be some - see my Vita if you think there won't be), etc.

In sum, the very notion a profession specific "ethics" at least SUGGESTS a form of ethical relativism I find repugnant. This is NOT to say that a member of a profession does not have special obligations that others do not. I would argue, on broadly kantian grounds, that they often do, inasmuch as the acceptance of a professional role can amount to a promise to perform certain acts, or undertake to do certain things, that other people are not, in general, obliged to do. A blunt illustration: most people are not obliged to wipe someone else's bottom after an episode of bowel incontinence, but nurses on duty are. Still, I think this sort of example is not contrary to my general point. Nurses, lawyers, plumbers and politicians all inhabit a single moral universe; one in which, per Kant, it is always wrong to, say, tell a lie or subourn one. If members of a special profession have special duties, they are surely grounded upon, or arise from, the same considerations of "right and good" that should guide the conduct of everyone.

I have another source of unease, as regards the notion of "nursing ethics" as a distinct area of inquiry. Nursing, it seems to me, still suffers a bit from "ghettoizaton" in the American academy. Even at the community college level, the students and their faculty spend most of their time over in their own building doing "nursing stuff." They venture "outside" only when they must. As a nursing student, I have taken nursing, and nursing related, courses at two different community colleges and two (very good) 4 year universities. In each case, interdepartmental activities were notably absent. Four schools is not enough in the way of data points to reach any firm conclusion, but I can't help but wonder if things are much different anywhere else. A study of ethics, at least, could be a shared experience.

Here's a thought - good "transcultural" nursing is going to necessitate, on the part of nurses, the development of something like the "kosmos polis" of the stoics - a sense of world citizenship, and a sense of identity with all that is "human." It is difficult for me to see how we can care for humanity if we decide there is no such THING as "humanity," or that "humanity" is a social construction we somehow "make up" which fails to somehow pick out any real features of an objective world. One way to START developing that "sense" is to participate in a learning experience which at least explores the possibility that all human beings inhabit the same universe - the MORAL one.

2006-11-16T01:33:00.000-05:00

Kitcher Said: "Read 'Madness and Civilization,'" So I Did

There are few projects in recent philosophy that I admire more than Phillip Kitcher's defense of a correspondence role for the concept of truth (although I admire Fred Sommers' treatment of the same subject as well), and I think his "Science, Truth and Democracy" is a VERY important book that everyone involved with health care policy and analysis needs to read and reflect on. So, when he said I should read Foucault's "Madness and Civilization," I did.

The book makes a LOT of claims (I'm assuming the English translation I have is accurate - I can't read French). Here are my thoughts on ONE of the claims I think Foucault is making.

Claim - We should view mental illness as "culturally constructed," and therefore individuals who lived in different cultural contexts than we do today just COULD NOT HAVE the same mental illnesses that we do today.

The first thing to say about this claim is that it is an egregious case of either a) begging the question, or b) hasty generalization, or both. IF he means that some behaviors that were thought to be "mad" 400 years ago would not be thought "mad" today (and vice versa), he is clearly correct, but then he has just provided us with another of P.F. Strawson's "non sequitur(s) of mind-numbing grossness."

To take a simple example, 300 years ago you could announce, in Salem, MA, USA, that you had been bewitched, and the town would burn some poor old lady alive. Make that pronouncement today in the same location and YOU will be thrown in the looney bin and be started on Zyprexa, or at least be prevented from handling sharp objects, puppies (remember what happened last time, Lenny!), or your own money. The list of beliefs that counted as delusionary in 1656, and a list of beliefs that count as delusionary in 2006, is not EXACTLY the same list. Wow! Will they really award tenure in France for noticing something like that?

Point being, it still might be the case that some (perhaps many) beliefs would be on BOTH lists. In which case, we have a hasty generalization, and have established, well, nothing.

But, perhaps Foucault means something else. Maybe he means that, for example, while two people might have had Folie a Deaux (otherwise known as shared psychotic disorder) in 1985, people just COULD NOT HAVE HAD Folie a Deaux in 1685, because the cultural contexts are different. But this, surely, begs the question - it isn't an argument. Moreover, it seems wildly implausible.

Whether it is something exotic like Folie a Deaux, or something pretty mundane, like depression, we often come across descriptions of patients from the past that are sign and symptom identical to contemporary patients with these conditions. But are we supposed to believe that something different was wrong with great great great great grandpa than was wrong with cousin Elmer last month, in spite of the fact that they both wet the carpet, howled at a full moon and ended up blowing their own brains out, because they are embedded in different "cultural contexts?" Sorry, I am unpersuaded.

In fact, I am not just unpersuaded that Foucault is right; I am persuaded that he is just wrong as regards at least some (perhaps most) of the conditions we identify today as "mental illness." Comparisons with other forms of illness might be instructive.

I presume that Foucault would NOT deny that we can examine the historical record and determine that, 400 years ago, lots of people died of an acute, diarrheal illness. I would also presume that he would not be concerned to deny that today, people die of cholera, that "cholera" is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae, and that people presenting with cholera exhibit the identical symptoms of those unfortunates we read about in the historical record. So, did they have "cholera" 400 years ago, that is, an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae, or is acute, intractable diarrhea "culturally constructed," and cannot have the same cause this year as it did 400 years ago?

Let's return to great great great great grandpa (hereinafter GGGGGp) and cousin Elmer. Suppose we do a bit of historical detective work, and consult the family bible (the ultimate repository of family lore in rural North Carolina). Therein we learn that GGGGGp wet the floor, howled at the moon and blew his brains out after a year of drinking a quart of moonshine every day. We learn from Elmer's wife, Becky Lynn, that Elmer wet the floor, howled at the moon and blew HIS brains out after a year of drinking a quart of moonshine every day. We learn from the medical examiner down yonder in Chapel Hill, where all those intellectuals and scientific types are, that Elmer had brain damage from drinking all that moonshine, and that any number of Tar Heels over the years who had wet the floor, howled at the moon and blown THEIR brains out after a year of drinking a quart of moonshine every day had damaged brains too.

All of this information reveals a pattern; perhaps their are Kripkesque, "de re necessities" built into the very nature of brains and their interactions with moonshine. Perhaps, while the activity of making and drinking moonshine is in some sense dependent on, or a product of, cultural context, the EFFECTS on the human brain of drinking a quart of the stuff every day for a year are not.

Perhaps some (many?) instances of "madness" and/or "mental illness" are like "Tar Heel moonshine/brainbecomesmush" syndrome. That is to say, perhaps the behaviors some madman is exhibiting today are a consequence of something being wrong with his brain - lesions on the prefrontal cortex, perhaps, or whacky neurotransmitter imbalances. And, if those same things were wrong with someone's brain 400 years ago, that person would exhibit "mad" behavior too. But, if that is so, then at least sometimes, today's mental illness just metaphysically IS yesterday's "madness," and Foucault is wrong.

2006-11-05T10:25:00.000-05:00

Nursing's Love Affair with Phenomenology: The Intellectual Version of
“What Does She See In Him?"

Whenever a cousin or family friend would bring a new beau by to meet our family, my mother would be the gracious southern lady. Juleps or sherry were served, along with country ham biscuits (sort of tastes like British bacon, but with lots of hickory smoke, sugar, pepper and salt), cantaloupe, and other delectables. Polite probing concerning educational achievement, social status, and net worth would be conducted that had to be, for the victim, about as pleasant as "waterboarding." No sooner were the poor souls out the door than she would turn to my father and ask: "What does she see in him?" He never had a satisfactory answer of course, but he wasn't expected to in any event. The American South is, after all, a matriarchy. There is some information, the nuclear secrets of the human experience, that southern men a not permitted access to, and such questions are asked only to remind us that we don't have an answer, and are, in a way Marx never imagined, "everywhere in chains."

I am in the same predicament when it comes to Phenomenology, at least as Husserl propounded it. One reason might be my "philosophical upbringing;" my philosophical mentors have been, broadly and variously, logicians, pragmatists, process philosophers, Humeans, and neo-Kantians. None of them were particularly "phenomenology friendly." However, I deny that my cluelessness about the virtues of phenomenology is only blind prejudice, acquired in the philosophical cradle, or through Skinnerian conditioning. I think I have good reasons for believing that a phenomenological approach is of only (very) limited value to the intellectual life of nursing today. Moreover, I feel exactly the same way about that line of thought, beginning with Kierkegaard, running through Nietzsche and ending (blessedly) with Sartre, which is labeled as "existentialism" for the sake of convenience. Let's leave existentialism for another post. And, this blog isn't a good vehicle for detailing all of the reasons why I don't think phenomenology is particularly valuable to nurses, or anyone else for that matter (except, perhaps, MA candidates in Sociology who want to justify getting a degree based on a thesis that really amounts to a mediocre autobiography). Instead, I'll just provide a sketch of one such reason, and wait for the fallout.

What, exactly, is phenomenology supposed to do for us? What makes it big news? Supposedly, if I am recalling Husserl correctly through the mists of time, it is supposed to 1) tell us how the mind works, and 2) provide a way to reach apodictic conclusions (conclusions which are indubitable in some way or another). Leaving aside the discussion of #1 for now, how does a phenomenological approach, per Husserl, accomplish feat #2? A follows: by setting aside any assumptions about the existence of an external world and studying only the way things seem, we reach conclusions about which we cannot be mistaken. Or so the story goes. We're all transcendental idealists now!

It isn't hard to see a particular reading of Kant (of which Kant himself might not approve) at the heart of this, admixed with a regrettable dose of Descartes and his attempt to beat the skeptical demon from the first person point of view (the wrong tactic, as far as I am concerned). Phenomenology, as thus described, is a sort of transcendental idealism, making its philosophical living on the supposed distinction between phenomena and noumena. The phenomenal, "lived" world; that world we can "know" about no matter what tricks Descartes' Demon, or mad alien scientists who have "envatted" us, are trying to pull. However, the noumenal, "external" world, the world of the "thing in itself," the world as it is from no particular point of view, is either 1) forever "out of bounds," something that it makes no sense (but only SEEMS to make sense) to even talk about, even though we are compelled in some way to do so, or 2) something which we somehow posit, or infer, on the basis of what we KNOW in virtue of the study of phenomena, or 3) something our minds construct (via mechanisms to be explained at some future, conveniently unspecified, date). On any of these interpretations, the possibility of error is supposedly excluded.

The initial plausibility of the first step in such a project is easy enough to sympathize with. It certainly seems that, as I type this, I am experiencing a seeming of "Stonewall the old black and tan coon dog snoozing on a mat in the corner," and that this is, indeed, apodictic. But, as I recollect, even Husserl would agree that this bit of information is neither particularly interesting nor useful. But there are lots of potentially useful and interesting things I DO want to know; things like: who will read this post, and what will they think of it? Will the Democrats regain control of Congress next week? Do I have any Wild Turkey left in the decanter?

These concepts of IPONS subscribers, fellow citizens, and Wild Turkey, in other words, are concepts of an objective reality; I do not conceive of them as appearances in my mind, but as features and fellows in a world I am happy I share with them. In the case of IPONS list subscribers, for example, my concepts are concepts of a real John Paley, John Drummond, Janet Holt, Catherine O'Neill, Geralyn Hayes, Helen Kohlen, Drerek, Sarah, et. al. My concepts of IPONS members are concepts of persons with bodies existing in an objective reality, extended in time and space, having minds and separate identities, offering handshakes and hugs, and existing outside of my (maybe envatted) brain and in no way dependent on it (fortunately for them - who in their right mind would want to be dependent on my mind for their existence? Or does the question beg the question?)

If the aforementioned memory serves, Husserl wasn't oblivious to this. To grossly oversimplify here, I read Husserl as attempting to demonstrate that we naturally, based on apodictic experience (or perhaps even prior to it), posit, or theorize, or just naturally assume the existence of, other "I's," who also experience a world of seemings, and this in turn gives rise to the conception of an objective world. For these reasons, it is open to Husserl to argue that the fact that my concepts are concepts of objectivity is just what I should expect. The difficulty here is that, the minute we start talking about naturally tending to posit other "I's," the certainty that was the desiderata of this project has disappeared. Why is it not possible that this "natural tendency" is systematically mistaken and misleading? How is it a better guide to the really real than "clear and distinct ideas," and, therefore, how are we any better off with Husserl than we were with Descartes?

Turning to the question of insights into the mind, here too phenomenology may not be really offering us what we need. We want to know not only how the mental seems to us, but also how minds (yours, mine, Stonewall's, George Bush's, our patients, etc) work in terms of interacting with this objective world Husserl claims to have shown that we cannot help but conceptualize. I recall nothing helpful in Husserl when THAT question is posed. Actually, it is less than clear that Husserl would even acknowledge that our minds DO interact with an external, objective reality; rather, I recall him saying at some point that the mind "conditions the possibility of the world," whatever that is supposed to mean.

Notice how most of these problems just go away when we stop goofing around in the philosophical first person, and start our inquiry from the third person point of view. Rather than solipsistically musing about my own seemings, I can begin inquiry when I behold Stonewall on the trail of that ancestral enemy of his blood, the raccoon, and undertake a study of this remarkable creature's truly wonderful capacities to know and act upon his world. Tom Nagel and his misdirected musings about bats notwithstanding, I can learn many things about what it is like to be Stonewall, and others of his brave and noble kind, and come to know how he is able to accomplish the truly amazing feats of which he is capable. There seems to be no conceptual barrier to doing the same thing with others of MY kind, as well, and no good reason to believe that what is true in their case is not also true in mine, and vice versa.

But, if the first person is the wrong place to begin, then phenomenology generally is the wrong tool to use. So, asks my Mom, "what does she see in him?"

2006-10-25T12:44:00.000-04:00

A Weekend at “The Hill”

Every October for the last 40 years, The University of North Carolina at Chapel Hill has hosted a wonderful philosophy colloquium. It is certainly one of the most prestigious colloquia in the world of analytic philosophy - NO ONE turns down an opportunity to present there, or to be a commentator on an invited presentation. This year, presenters and commentators included Daniel C. Dennett, Hilary Putnam, Ruth Baron Marcus, Patricia Kitcher and Gideon Rosen. This is about as notable a collection of “heavy hitters” and philosophical “rock stars” as one could gather.

This year produced a unique opportunity for me- the chance to spend an hour on a Saturday evening standing around in Geoff Sayre-McCord’s kitchen, listening to Dan Dennett and Phillip Kitcher talk philosophy (and occasionally get a word in myself). The conversation was fascinating, and there were features of it, and one other conversation, that I think would be of considerable interest to the subscribers to this list.

Although I didn’t realize it at the time, since I hadn’t read the book, talk centered on issues surrounding Kitcher’s 2001 “Science, Truth and Democracy” (hereinafter STD). Needless to say, I came home and bought it immediately, and stayed up most of he night reading it.

Broadly speaking, the first part of STD is an elaboration and defense of Kitcher’s “moderate scientific realism,” and his heroic defense HERE

( http://www.columbia.edu/~psk16/correspondence_truth.htm)

of a correspondence theory of truth. For Kitcher, “realism” must be “moderate” because any scientific enterprise, with its particular aims, experiments, methodologies and classificatory systems, is undertaken for particular purposes, and to advance particular interests. When we do science, we inevitably construct models, or maps, of the world and pick out for inclusion in/on the model/map certain features of the world, and leave others off, and this process of inclusion/exclusion is governed by judgments about what is “significant.” Continuing with the map analogy, Kitcher thinks that “the ideal Atlas is a myth.”

Still, Kitcher argues, none of this is incompatible with realism. All that realism is committed to, on his account, are claims that the features selected for mapping can be represented more, or less, accurately; and, in addition, that these features exist independently of those individuals who are mapping them.

Kitcher’s realism may be moderate, but it is still realism. He continues to characterize claims by “creationists, romantics, feminists, postcolonialists and critical theorists” that science is only one of many possible, equally defensible, systems of belief fixation as “Luddites’ laments.” He is clearly committed to the view that, as against the “Luddites,” science at its best is the best way to find out about our world.

If Kitcher is right about all of this, though, at least some of the so-called Luddites have a point, even if it not precisely the point they hoped to make. Kitcher concedes that 1) “We divide things into kinds to suit our purposes,“ 2)there is no “ideal Atlas,” and 3) for any given scientific enterprise, there are particular interests (besides the production of knowledge) being advanced, purposes being fulfilled, and implicit judgments being made about what is, and is not, “significant.” So, even if it is perfectly sensible to say that some scientific enterprise has produced an accurate model, or map, of some features of external reality, it has chosen what features to map relative to particular interests, and those with other interests could have selected different features, significant for them, which would lead to an entirely different map or model of reality.

Well, at least in some cases. Science varies in terms of how “value laden” particular research projects are. Dividing things into “kinds” when the subject matter is, say, atomic particles, seems somehow less “value,“ or “purpose” driven than an enterprise like dividing humanity into “races.“ Stll, even if finding out about electrons is a result of knowledge obtained for the sake of knowledge, the project of learning about what we can DO with electrons, and what electrons can do to us, becomes VERY value laden VERY quickly. The fact that improvements in the electric chair outpaced improvements in the light bulb, at least for a while, speaks volumes on behalf of the “Luddites” complaints about the human condition, if not their diagnosis about what, exactly, has produced it.

Thus, even on Kitcher’s account, it is still a case of “them as has the gold, (mostly) makes the rules.” The evil patriarchy (or whoever) may not be “constructing reality,” exactly, but they are in various ways controlling what we can and do learn about it, and to what uses that knowledge is put, and this has approximately the same effect as “constructing reality“ would have. Indeed, the difference may only be of interest to metaphysicians and other pedants (like me). And, of course, Kitcher is perfectly well aware of this. What to DO about it, (how to address the perfectly justifiable complaints of those pesky “Luddites,” in other words, without sounding like Schopenhauer or Derrida) is the subject matter of the second half of his book.

Kitcher’s solutions in STD are, modestly, advanced only as a starting point for dialogue rather than as a final, magisterial answer. Still, as one would expect from a philosopher of his ability, they are sophisticated and plausible. Without getting deeply into the details (to vastly oversimplify his views, in other words), I would describe his approach as generally “Rawlsian,” with the idea being that what we need is a “well ordered” science, one in which research reflects the values established by a process of democratic deliberation somewhat like that which goes on in Rawls' “initial position” thought experiment in “A Theory of Justice,” but with a special role for those possessing expertise.

Whether or not Kitcher's suggestions are, in the end, workable is a subject that is worthy of years of debate, and probably will be kicked around in journals for quite some time. For what it is worth, I think the general idea has some considerable merit, but I also think it is subject to some of the same general objections that have been leveled at the overall “Rawlsian” position over the last 35 years – the most trenchant one being that the description of the “initial position” is a set up, engineered to produce conclusions about a just society that would be certain to appeal to an East Coast, Ivy League liberal intellectual like, say, John Rawls. Of course, I happen to LIKE the outcome Rawls produces, but that is no defense to the charge that he subtly begs the question. The suspicion would be that the Kitcher proposal could end up as a question begging enterprise in analogous ways. One way in which this could occur, which gives me special pause, is the role of “expert” in the deliberative process, and the question of whether “Nursing Expertise” would count.

It gives me special pause because of another conversation I had at the colloquium. I spent some time chatting with a VERY good woman philosopher who writes in the area of bioethics, and generally publishes in medical journals. She seemed amazed to learn that a) that there was a Journal entitled “Nursing Philosophy,” b) that nurses would read it, or that c) a philosopher would find anything interesting to publish in such a journal. As she thought all of this over she said “but they're (nurses) so submissive!"

I just let the comment go, figuring that she simply hadn't met any of the subscribers to this list. In fact, I think she must not have met very many nurses, period. I can't think of any I have worked for or with in the last 12 years that I would call “submissive.” Still, the comment was both surprising and disconcerting, since it came from a very bright, otherwise liberal and progressive woman thinker who should know better. And if SHE doesn't quite get the emerging role of nursing in health care policy and analysis, what are the chances that anyone else will? Where would nurses sit at Kitcher's deliberation table? Would they be entitled to an “expert” chair?

2006-04-03T08:13:00.000-04:00

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