Thursday, 12 March 2015

‘The co-production of what?’ Notes for a workshop at Keble College, Oxford

I am giving a talk at a workshop in Oxford next week called Therapeutic Conflicts: Co-Producing Meaning in Mental Health. I suspect it’s a closed mulling-things-over event as I’ve not noticed any publicity for it. The background is:

‘Therapeutic Conflicts: Co-Producing Meaning in Mental Health’ is a year-long project involving Edward Harcourt (Principal Investigator), Anita Avramides, Bill Fulford, Matthew Broome (Co-Investigators), Toby Williamson, David CrepazKeay (Partners, Mental Health Foundation) and Elianna Fetterolf (Post-Doctoral Research Fellow). The project grows out of three interdisciplinary half-day workshops in 2012-13 organized jointly by the Oxford Faculty of Philosophy and the Mental Health Foundation, and starts with a problem in the delivery of mental health services - roughly put, the problem of ‘shared words, unshared understandings’ - which (we think) is why some recent mental health initiatives have achieved less than intended. We then bring to bear some philosophical tools – for example from the philosophy of language and from epistemology – to theorize this problem and to propose ways in which it might be addressed.’

My own thoughts are, sadly too obviously, very preliminary and rough.

The co-production of what?

Ground rules: ‘Co-production’ implies something more than joint discovery. Joint constitution, perhaps. If so, it carries conceptual costs. Philosophy as accountancy (rather than determining what one should think on an issue, it counts the philosophical costs in terms of necessary other supporting commitments of the various options). But even joint discovery deserves investigation if it is not merely an accidental matter.

I will sketch four possible options although there is no reason to think them exhaustive. Co-production might apply to any of the following (in the reverse order of the clinical process)
  • Recovery
  • Idiographic formulation
  • Criteriological diagnosis
  • Diagnostic categories / taxonomy
1: The co-production of recovery

More precisely, the co-production of an individually tailored conception of recovery. However ‘recovery’ is a contested notion lacking agreed meaning. See for example:

The term ‘recovery’ appears to have a simple and self-evident meaning, but within the recovery literature it has been variously used to mean an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth. [Roberts and Wolfson 2004: 38]

There is an increasing global commitment to recovery as the expectation for people with mental illness. There remains, however, little consensus on what recovery means in relation to mental illness. [Davidson and Roe 2007: 450]

It seems to me that there are two broad senses of recovery. The first reflects a conventional view of getting better. The second is the modification applied within mental healthcare in the last 20 years or so.

Recovery1: a return to statistical normality (from a position which may, or may not, be evaluatively characterised, depending on the account of illness).
Recovery2: a move (from a position which may, or may not, be evaluatively characterised, depending on the account of illness) to an evaluatively characterised endpoint, eg.: a conception of a valued form of life.

The latter fits some views of recovery in mental healthcare.

Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems. Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness. Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward. [Shepherd, Boardman & Slade 2008]

Does this latter notion of recovery fit co-production, is it apt for it? One, after all,  might think that recovery should be, solely, patient-or subject-produced rather than co-produced. But it depends on which of two conflicting views one takes. Contrast this views:

There can be no recovery without self-determination… Mental illness may pose an obstacle to the person’s achievement of the kind of life he or she wishes to have, may make it more difficult to live that life, and, at its most extreme, may even deprive the person of life altogether. In none of these cases, though, does mental illness fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency, nor does it deprive them of their fundamental civil rights. [Davidson 2009: 4-1]


Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed. Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility. [Hopper 2007: 877]

The latter view sustains co-production because the subject may need a second view of what is available by way of a flourishing life. Contra Davidson, mental illness may rob people of their agency (though not their civil rights). It may, however, look a matter of mere co-discovery. But the point of recovery is to adopt a view of a way of living, to determine it to be one’s conception of flourishing.

2: Co-production of idiographic formulation

The WPA initiative Psychiatry for the Person calls psychiatric diagnosis or, more broadly, psychiatric formulation to include an idiographic element. A comprehensive model or concept of diagnosis to include as Idiographic (Personalised) Diagnostic Formulation.

This comprehensive concept of diagnosis is implemented through the articulation of two diagnostic levels. The first is a standardised multi-axial diagnostic formulation, which describes the patient’s illness and clinical condition through standardised typologies and scales... The second is an idiographic diagnostic formulation, which complements the standardised formulation with a personalised and flexible statement. [IDGA Workgroup, WPA 2003: 55]

Could idiographic formulation require co-production? Three possibilities strike me.

i: The co-production of the meaning of the account. Cf the social constructionist view of meaning of discursive psychology.

In keeping with the discursive approach to psychology, this study is based on the principle that meanings are jointly constituted by participants in a conversation.
From the discursive point of view, psychological phenomena are not inner or hidden properties or processes of mind which discourse merely expresses. The discursive expression is… the psychological phenomenon itself…
Personhood can be an interpersonal discursive construction, a property of conversations...
‘The mind’ is no more than, but no less than, a privatised part of the ‘general conversation’. Meanings are jointly constructed by competent actors in the course of projects that are realised within systems of public norms’
[Sabat and Harre 1994: 144-146]

But constructionism about meaning comes at a high philosophical price. (For the literature, see discussions of Wittgenstein on rules and especially responses to Kripke’s interpretation of Wittgenstein.)

ii: The requirement for the re-shaping of the subject’s narrative of a formulation by a clinician.

Giving voice to the WPA approach to an idiographic formulation, the psychiatrist Jim Phillips wrote this:

In the most simple terms, a narrative or idiographic formulation is an individual account with first-person and third-person aspects. That is, the patient tells her/his story, with its admixture of personal memories, events, and symptoms, and the story is retold by the clinician. The latter’s account may contain formal diagnostic, ICD- 10/DSM-IV aspects, as well as psychodynamic and cultural dimensions not found in the manuals. The clinician’s account may restructure the patient’s presentation, emphasizing what the patient didn’t emphasize and deemphasizing what the patient felt to be important. It will almost certainly contextualize the presenting symptoms into the patient’s narrative, a task which the patient may not have initiated on her own. Finally, the clinician will make a judgment (or be unable to make such a judgment) regarding the priority of the biological or the psychological in this particular presentation, and will structure the formulation accordingly. [Phillips: 2005: 182]

But this seems to subsume formulation under criteriological diagnosis. That is, it is refashioned not as a thing in itself but in the terms of a conventional diagnosis. Further, the priorrty of the clinicians editorial role looks paternalistic.

iii: The need to augment self-knowledge with external therapeutic insight

Cf psychotherapeutic approaches.
Cf Hopper’s view of recovery.
One may not be the best interpreter of one’s own life. A self-narrative may benefit from an interaction with a therapist. If so, however, this interpretation of co-production looks merely epistemic. The co-production of the narrative, of the selectional decisions, perhaps, but not what is narrated.

3 Co-production of criteriological diagnosis

The co-production of diagnosis assuming fixed diagnostic categories. However, holding constant that diagnostic category, there does not seem to be much space for the co-production of say a cancer diagnosis except in the sense of epistemic achievement. Diagnosis is fixed by the biomedical facts.

But some, at least, putative mental illnesses seem to permit variation depending on the distress of, or harm to, or social dysfunction of the subject. (NB this sense of dysfunction is not meant to be Wakefield’s biological dysfunction which is meant to be purely factual.) Not a decision of the subject, perhaps, but their being ill turns on their reaction to the phenomena. The co-production is of the joint interaction of the phenomenological facts and the subject's reaction to them.

4: Co-production diagnostic categories

This turns on the broader question of the difference between difference and pathology exemplified in the debate about the status of deafness as either a disability or as an identity. The same is disputed with respect to voice hearing, for example.

I think that Zachar and Kendler’s distinction between objectivism and evaluativism helps:

Is deciding whether or not something is a psychiatric disorder a simple factual matter (“something is broken and needs to be fixed”) (objectivism), or does it inevitably involve a value-laden judgement (evaluativism)? [Zachar & Kendler 2007: 558]

Objectivism suggests no space for co-production as the facts, alone, fix the illness status. So co-production presupposes evaluativism: Whether something is a pathology, rather than a mere difference, is a value-judgement.

But how do values affect co-production? Again, a clue from Zachar and Kendler:

How do we respond to historical claims that slaves who had a compulsion to run away [drapetomania] and advocates for change in the former Soviet Union were mentally ill? An objectivist would claim that those classifications contained bad values and progress was made when those values were eliminated. Their opponents would claim that the elimination of bad values is not the same as becoming value-free, and progress has been made by adopting better values. [ibid: 558 underl;ine added]

Evaluative progress implies value judgement is disciplined. Contrast undisciplined subjective preferences. So co-production either as an unconstrained exercise of preference.
Or: a merited response to external moral particulars.

Well sadly I don’t really have any. Each of these options comes at a philosophical cost of squaring one’s other conceptual commitments.

Davidson, L., Ridgway, P., Wieland, M., & O'Connell, M. (2009). A capabilities approach to mental health transformation: a conceptual framework for the recovery era. Canadian Journal of Community Mental Health (Revue canadienne de santé mentale communautaire), 28(2), 35-46

Hopper, K. (2007) ‘Rethinking social recovery in schizophrenia: What a capabilities approach might offer’ Social Science & Medicine 65: 868–879

IDGA Workgroup, WPA (2003) ‘IGDA 8: Idiographic (personalised) diagnostic formulation’ British Journal of Psychiatry, 18 (suppl 45): 55-7

Phillips, J. (2005) ‘Idiographic Formulations, Symbols, Narratives, Context and Meaning’ Psychopathology 38: 180-184

Sabat, S.R. and Harre, R. (1994) ‘The Alzheimer’s disease sufferer as a semiotic subject’ Philosophy Psychiatry and Psychology 1

Zachar, P. and Kendler, K. (2007) ‘Psychiatric Disorders: A Conceptual Taxonomy’ American Journal of Psychiatry 

Monday, 9 March 2015

Mind and Society 2.0: workshop on philosophy and ethnomethodology

Here is a flier for a workshop on philosophy and ethnomethodology at MMU on 30-31 March.

“a symposium on the interface between ethnography, ethnomethodology and post-analytic philosophy

this symposium marks the return of mind and society, an annual symposium that ran for 15 years between 1993 & 2008, in manchester and cambridge UK.

mind and society served as the foremost forum for wittgensteinian philosophy. speakers included avner baz, jim conant, jeff coulter, giuseppina d’oro, john dupre, juliet floyd, warren goldfarb, adrian haddock, lars hertzberg, phil hutchinson, john hyman, kelly jolley, gavin kitching, ivan leudar, mike lynch, marie mcginn, denis mcmanus, mathieu marion, ray monk, katherine morris, stephen mulhall, dewi phillips, anne rawls, rupert read, wes sharrock, charles travis, meredith williams, michael williams & dawn wilson. 

mon 30th- tues 31st  march 2015

Prof. Michael Lynch, Cornell University
Prof. Elizabeth Stokoe, Loughborough University
Prof. Tim Thornton, UCLAN
Dr Simon Summers, University of Durham
Dr Anna Bergqvist
Mr Scott Biagi

Other speakers to be confirmed.

venue: seminar room 5.02 new business school, all saints campus,
manchester metropolitan university,

free of charge, mandatory registration: marie.chollier@...

Friday, 6 March 2015

On not being the subject of one's dreams

As I’ve got older I have been increasingly aware how my ‘take’ on the world is mediated by emotions. When I was younger, it seemed that such a ‘take’ was purely epistemic. I’m now sure it wasn’t but that is how it seemed. Then I wouldn’t have needed to use a dreadful word like ‘take’ to describe what was surely merely having the world in view. Now I reach for that odder word to allow for the possibility that more is going on: a blurring of my emotions and the external facts.

Pushing perhaps the limits of what I want to record on a public blog, let me record a disturbing dream. I’ve realised that because my parents will not live on in nursing care I will, much to my surprise, inherit a little money. Perhaps, I fantasized as I fell asleep this week, it would be possible to buy a small run down flat above a shop in my favourite town, Keswick, in the North Lakes, a possibility that would have pleased my parents. In my dream, both of them were alive although frail and ill, dying in my mother’s case. As the action of the dream began, we had been having tea and scones, a very occasional formal Sunday event, and had clearly been discussing this possibility. My mother asked me when, if we’re possible, I might buy such a place and I realised, in the dream, that this presupposed or anticipated her death. In the sense that one sometimes has about the narrative of a dream that it has been designed to present a particular moment, this was the moment of the dream.

(I sometimes have the sense that a dream is akin to the creationist idea that the earth’s dinosaur history is a myth and that the whole of time is really a brief instant: there is just a single moment and fake memories.)

(I seem to recall that I have reason to believe that the construction of a moment was how Ian McEwan used to write. Wanting to write a scene about what it was to saw up a body, lose a child in a supermarket, let slip a balloon, he would construct a narrative that allowed this to have been written. That certainly seems a way to think about the Innocent. But I may have dreamt this idea.)

In the dream, I struggled with what to say and ended up saying, awkwardly, "Well I will have to inherit some money". I woke with the burden of working through my real responses to thoughts and emotions with which I had merely been saddled. As my ex IAS Durham colleague Bill D remarked, dreams raise questions of authenticity and responsibility of the subject, the dreamer. Sometimes, though perhaps not as often as might happen, I dream of doing or saying dreadful things. If my own experiences can be generalised, waking from such dreams presents the ex-dreamer with something which is more disturbing than seeing a film presented as though from the (visual) perspective of a subject or agent who acts in ways we, the viewers, would disavow. (Though even that is rather a disturbing phenomenon.) It is as though some responsibility carries over from the first person perspective of the dream to the now awake subject. Or rather, the memory of the dream seems to suggest this and the task of equanimity is to feel as well as think the rejection of this.

After a discussion of Freudian dream work at Wednesday’s MMU workshop, in response to a paper by Dr Lene Auestad (University of Oslo), the question if whether we could understand the deviant ‘logic’ of dreams was raised. A possible contrast was between being given a list of the kind of swaps and inversions as a method then to decode dreams without seeing any intrinsic sense in the code versus having a more direct grasp of why the code works as it does. Understanding is not endorsement of course (as UK politicians never seem to have grasp in discussions of trying to understand terrorists). But it does require, I think, a kind of internal response in a way that explanation does not (cf explanations of the quantum mechanical word). On one picture, that comes only with the results of the decoding in particular cases. In the other, the code itself has a kind of graspable meaning, an intuitive logic. On both, the dream is itself understandable.

But it now seems to me that there is an extra complication. I could easily make sense of why the subject in my dream felt saddled with his/my embarrassment. But whereas the subject in the dream had been monstrously tactless, that hadn’t actually happened. So awake, I ought merely to have had a contingent understanding: had I been so tactless then I would feel terrible. But the dream pushed an unconditional version: having done that, I did and do feel terrible. A proper reaction to this unbidden thought seems the opposite of understanding: a willed resistance to the identification that comes naturally with the dream’s subject.

Thursday, 5 March 2015

Ur and the unsayable

Just a quick comment on a couple of aspects of the Philosophy and Psychotherapy Workshop I attended at MMU, Manchester yesterday.  

Richard Gipps gave an intriguing paper called ‘Ur’. I see that he has put the notes for it on his blog so I’ll just borrow a couple of quotes to support the strand that struck me most. The presentation and the blog entry have rather more going on, as well as this strand, including an interesting diagnosis of the various motivations for the position he opposes. (I’m also going to construe the blog entry and the talk as the same abstract entity.)

The question addressed runs thus:

Posits and Poiesis: Is the core understanding of psychoanalysis a scientific model? Do our articulations of the being of the unconscious amount to inferential posits, explanatory of human thought and action? Is their role fundamentally one of explanation, or is it one which provides us with a new form of comprehension revelatory of a new dimension of our existence?

On Richard’s view it is a mistake to offer a justification for the existence of the unconscious. With the assumption that such a justification needs to be offered, it is offered via inference to the best explanation.

Thus Freud on the unconscious: we need to posit unconscious desires, emotions and motivations, he says, to make sense of the observable phenomena of dreams, slips, suggestion effects, and symptoms. It is the best explanation we have of such phenomena.  

Such a need starts from an assumption that it is possible to grasp the concept of the unconscious and then ask whether that concept is instanced in the world. This is akin to the idea that one might understand the concept of the Loch Ness Monster, understand what it would be, and can then question whether such a monster exists (put aside Kripkean worries about unicorns). The previous quote continues directly:

The separability of essence and existence, this ‘logical gap’, allows us to stand back from and put a question to nature without it having already been answered; the resultant answer will then be the central understanding of 'psychoanalysis'.  

Presupposing that the unconscious is like the Loch Ness Monster, it stands in need of a positive answer to the questin of whether it is instanciated and inference to the best explanation is the route. But, Richard suggests, this is a mistake.

By contrast with this I urge that the central understanding of the unconscious etc., is not an answer to an already articulable question, but rather a revelation which affords us the possibility of asking new questions.

One reason that the former strategy fails is that the explanatory gain cannot be neutrally described. The world available with the description of the unconscious is richer than that before and cannot simply be presented backwards into the previous, impoverished terms. Further, the supporting evidence offered for inference to the best explanation suggests a misunderstanding of its own status.

[P]sychoanalysis gets offered as a ‘theory of how the mind works’. It is said that its concepts ‘pick out patterns’ in human behaviour. It supposedly helps us to 'understand' what couldn't otherwise be understood. However these truths are, I believe, actually disguised truisms, and so the philosophical discussion therefore too readily runs the risk of an unwarranted ‘smugness’ (this again is the 'narcissism' I mentioned above). The truth of the propositions gets proffered as having a justificatory significance for the psychoanalytic endeavour. However psychoanalysis simultaneously adjusts our understanding not only of the explanans but also of the explananda. What is meant by mental, what now counts as an understanding, what a pattern amounts to here, and what now is to count as intentional behaviour, all subtly change in their meanings. Thus it won’t do to say that the extensions of folk psychology offered by psychoanalysis can be warranted in terms of their explanatory payback, since psychoanalysis is also extending our sense of what here counts as legitimate explanation. Psychoanalysis articulates new experiential gestalts, new objects, and new modes of comprehension.

As I understood the argument, it might be akin to the following contrast. We can grasp the concept of the Loch Ness Monster in such a way that we are prepared for uses of either of the following form:

1: Scientists have today confirmed the Loch Ness Monster exists!

2: Scientists today confirm, after an exhaustive search, that the Loch Ness Monster does not exist.

By contrast our grasp of the concept of animal does not prepare us for a sentence like:

3: Scientists today confirm, after an exhaustive search, that animals do not exist.

And I guess, and in accord with much discussion of OnCertainty, we are not prepared for the converse:

4: Animals exist! Scientists confirm.

By saying ‘we are not prepared’ I mean: much additional contextualisation would be needed for us to know what to do with either of these sentences, though such additional contextualisation may not be impossible (again, modulo Kripke on unicorns).

The former pair show the gap that Richard calls that between essence and existence. The latter closes that gap. All of that seems fine to me. But I would want to account for this distinction by suggesting that the closest we can come to 4 would be something implicit in the expression of a rule governing the explanation of the meaning of ‘animal’. Perhaps Little Ludwig might say to me, after a happy day of me pointing out sheep and cows and cats and dogs, but not birds or fish, as example animals “Ah, so there are lots of animals” and hence there are animals.

But Richard is sceptical of this as already too close to the version of truth as adequation:

It’s tempting to articulate the above critique of a representational conception of central psychoanalytical truth claims simply by using a Wittgensteinian discourse of language games, rules, framework propositions, etc. Charles Elder does this and suggests at times that psychoanalysis offers us new ways of describing what we already know. The trouble with this way of trying to spell out the inadequacies of the view of core analytical concepts as posits is, it seems to me, that it ends up reinstating a dualism of ‘not always the facts, but rather sometimes how we describe the facts’. It supposes, one could say, that either we have to do with representations of what is or with rules of representation; in both cases we are firmly in the representation game. There is something right, as I see it, in the impulse to resist the urge to assume it is intelligible to ask ‘but are dreams really wish fulfillments?’ or ‘are symptoms really compromise formations?’ But this, I want to suggest, is not because we meet here with rules for representing what we otherwise know, but rather because we have to do with a more founding notion of truth as an unconcealment in which there is, as such, no room for adequation - i.e. no room for the question ‘does what is said correspond to what actually obtains?’

I would like to domesticate the analogies and disanalogies (connecting animals and the unconscious and disconnecting the unconscious from a kind of posit) within a kind of understated natural ontological attitude in which, for example, truth is a simple univocal notion given by a minimal disquotational approach. I can imagine that dividing truth into a more fundamental revealing notion and something that governs truth as disquotation would be sufficient for the distinction Richard wants but I’m not sure it is necessary. One potential line of reapprochement was a conversation, on the way to lunch, that the same sort of factors that govern ‘animals’ might also cover ‘sacrifice’. I tend to suggest that a way to grasp what the latter words means would be to steep oneself in the Tarkovsky film of that name. To grasp the rule for that word, though, requires a profound change in one’s own character. Rules for the use of words, for the articulation of concepts, may require profound change, opening one’s eyes to new tracts of the space of reasons. (Richard has responded to this worry here.)

One small point from the final paper: ‘The Unsayable in Philosophy and Psychoanalysis: Some Notes on Wittgenstein and Bion’ by Prof. Victor Krebs connected back to this. In a dense and wide ranging paper, Victor stressed the idea that the standing possibility of saying more when one tries to express something or describe something merited the name ‘unsayable’. The non-linguistic world provided a ground for saying things – for example, descriptions of it – and its very inexhaustibility suggested that it was unsayable. This might have resonance with Richard’s more profound sense of truth: a kind of ontological ground for mere judgement. But I’m not sure. (I asked Victor if it would matter if we swapped the word ‘sayable’ for the constantly articulable or describable or sayable features of the world rather than ‘unsayable’, in a spirit of glass half full rather than a spooky glass half empty. He looked at me sadly and said it might not matter but that would be to try to deflate what he wanted to say.)  

Tuesday, 3 March 2015

Why should nurses aim to have knowledge of their subject?

This is a reworked first section of a chapter for a nursing textbook. I am trying to say something general about knowledge without stumbling into an account of the last 50 years of anglo-american epistemology. This version mentions Gettier’s criticism of the traditional model of knowledge (as justified true belief) but does not draw the obvious conclusion (that the JTB analysis is false). In the context, I hope this works, is not too misleading.

The value of knowledge

Why should nurses aim to have knowledge of their subject? What is the value of knowledge?

Exercise: Think about this question before reading on. One clue might be to think about possible opposites to knowledge. If nursing practices were not based on knowledge, on what might they be based? Write down some ideas.

Answering the question of the value of knowledge is difficult. We will approach it in this section via a preliminary question: what is knowledge or what does ‘knowledge’ mean? Now there might not be a very helpful or informative answer to this question. Imagine that someone asks what stickiness is or what the word ‘sticky’ means. One might reply by offering a word that means more or less the same: such as ‘tacky’. But this does not help explain the concept of stickiness so much as swap one word for it for another. Alternatively, one might offer a more substantial explanation of the concept such as ‘a tendency of a body to adhere to another on contact’. Such an explanation may more or less equate to the concept but it isn’t obvious that a speaker who understands the word ‘sticky’ should be able to offer such a formal paraphrase nor that hearing the formal paraphrase will teach the meaning of sticky since it raises further questions such as what the word ‘adhere’ means. But despite these difficulties in defining it, there is generally no difficulty in learning, understanding and teaching how to apply the word ‘sticky’. So we should approach the question of what knowledge in general is with some caution. There may not be a very helpful definition available.

Some general features of knowledge can, however, be learnt from particular examples. Suppose that Sandy knows that, because it is 5pm, Mr Smith is due for medication. If so, she must hold it to be, or take it to be, true that it is time for his medication. That is, she must at least believe it. (‘At least’ because we often use the word ‘believe’ when we are not sure we do know something. “Do you know that?” “Well I believe it.”) Second, if Sandy does know that Mr Smith is due for medication, then he must really be due for medication. If she has knowledge, what she believes must be true.

Third, her belief cannot merely be accidentally true. Suppose Sandy believes that it is time for Mr Smith’s medication because she knows that he takes medication every day at 5pm and she believes that it is now 5pm. But suppose her belief about the time is based on the normally reliable ward clock which has, in fact, stopped the day before. By chance, however, it is now nearly 5pm. If so, although Sandy has a true belief about the need, now, for Mr Smith’s medication she does not know it. Her belief is merely true by luck. (Earlier in the day she would have formed the false belief that it was 5pm.) Being lucky will make no difference to how things seem to her (since she does not realise the clock has stopped) but an observer might say that she didn’t know the time, she was right only by luck.

These constraints on knowledge have motivated a definition which dates back 2,000 years to the Greek philosopher Plato: knowledge is justified, true belief. The idea is that needing a justification for a belief (for it to count as knowledge) should rule out merely lucky true beliefs. But this prompts a question: in the example of Sandy and the stopped ward clock, does that work?

Exercise: Think about this question for a moment. Does the traditional analysis give the correct account of Sandy? Here is a clue: ask whether Sandy has a justification for thinking the time is 5pm and also ask whether her true belief is lucky. If the answer to both is ‘yes’ then the traditional account does not address the problem of luck. If it does not, could some modification could be made to the definition?

As well as trying to rule out merely lucky true beliefs, justification also plays a second role which is relevant for thinking about the challenge of generating nursing knowledge. It provides a way or a method, or a route, to aim at true beliefs. It is one thing to worry that one’s beliefs about the latest medication for mental illness may not be correct, but quite another to work out how to avoid error.
Suppose some hospital authority issued an instruction that all nursing staff should replace any false beliefs they hold with true beliefs. On the face of it, this seems a good aim. But would the instruction help? Could one act on it? The problem is that ‘from the inside’ true beliefs and false beliefs seem the same. To hold a belief is to hold it to be true. (To believe that something is not true is precisely not to believe it.) Thus beliefs which are, in fact, false are not transparently so to someone who holds them. So the imagined instruction from the hospital authority is not helpful.

By contrast, the following instruction would help: replace any beliefs that one holds without a justification with beliefs that do have justifications. One can tell whether one believes something for a reason, or with a justification. And further, by aiming at having only justified beliefs, one should in general succeed in reaching true beliefs since justification is, in general, conducive to truth. (Any ‘justification’ which did not increase the chances of a belief being true would not be a justification for it after all.)

Although justification can play this second, helpful role of providing a concrete way of aiming at true beliefs it is not so successful in the first role mentioned above: ruling out being merely true by luck. As the example of Sandy and the stopped clock illustrates, Sandy does have a justification for believing that it is 5pm: she can point to the clock. Nevertheless, her belief is only true by luck because, as the narrator of the film Withnail and I says: even a stopped clock is right twice a day. So she has a justification for a belief and the belief is true but no one would say that she knows the time.
Although the definition that knowledge is justified true belief dominated philosophy for 2,000 years since Plato, the problem that one might have a justified, true belief but still not have knowledge was first pointed out in the 1960s by the philosopher Edmund Gettier using an example like this one [Gettier 1963]. What follows?

It seems at first that, as a definition of knowledge, ‘justified, true belief’ must fail (because Sandy has justified, true belief but not knowledge). But a better response is to argue that what the example really shows is that Sandy does not really have a proper justification, a good enough justification for knowledge. Knowledge can still be correctly understood as justified, true belief but not everything that one might think of as a justification (in the example, looking at the ward clock) really is a justification (because the clock has stopped). If so, it is a little like the definition of stickiness from earlier: ‘a tendency of a body to adhere to another on contact’. Just as only someone who understands the concept of stickiness will understanding the concept of adhering, so only someone who can understand the concept of knowledge can understand the kind of justification it needs. Knowledge and justification are a pair of concepts that one learns, in learning a first language, at the same time. The definition, whilst not explaining knowledge to someone who does not already understand it, highlights the essential connection between knowledge truth and justification. If so, nursing knowledge has to have the right kind of justification. The route to knowledge to underpin nursing practice will be, as suggested above, through suitable justification.

We will end this section by returning to the question we first raised. Why should nurses aim to have knowledge of their subject? What is the value of knowledge? In the light of the discussion so far part of the answer is this. Because knowledge, unlike say mere rumour or public opinion on which nursing might otherwise be based, is by definition true, aiming at knowledge is aiming at truth. Now it may seem obvious in a theoretical or contemplative discipline why one should aim at truth in one’s thinking. Cosmologists, for example, want to understand how the universe works just for the sake of understanding it. And hence they should aim at true beliefs just for their sake. But there is a further reason to aim at truth for nursing.

This is because nursing is a practical discipline. It aims not just to understand health and illness (as a merely theoretical or contemplative discipline) but, for example, to make a difference, to change people’s states of illness to health. And in general, actions – for example, medical interventions, or acts of caring – based on true beliefs are more likely to succeed than those based on false ones. So nurses should aim at having true beliefs in order that their practical interventions in the lives of their patients are more likely to be successful. But because there are no intrinsic signs or symptoms of true beliefs that mark them out from false beliefs, the route to this is via a suitable justification which forms part of the conceptually rich idea of knowledge.

In this section, we have raised a fundamental question: why should nurses aim at knowledge. By ‘unpacking’ the concept of knowledge we have suggested answers which connect to the value of truth, the role of justification as a way of aiming at truth and the practical ambitions of nursing to intervene in patients’ lives. There are further, complementary reasons we could have explored. For example, to identify someone, such as a particular member of a multiple disciplinary team, as knowing a patient’s history is to mark out what he or she says on the matter as reliable. Knowledge can be used to mark out whom to trust in cooperative disciplines like nursing.

But although we have talked about the knowledge which underpins nursing practice or ‘nursing knowledge’, there are reasons to think that the diversity of forms of knowledge that nurses need to know makes the phrase ‘nursing knowledge’ misleading. Towards the end of the chapter we will provocatively suggest that there is no such thing as ‘nursing knowledge’ and that nursing is as much an art as a science. But in the next three sections, we will discuss some broad divisions of kinds of knowledge and suggest that nursing straddles each divide. Hence in each case, the generation of new knowledge to underpin practice has to draw on distinct methods and approaches which adds to the challenge of being a modern nurse.