The clinical surround: Values and versions

Julian C. Hughes

in Thinking Through Dementia

Published on behalf of Oxford University Press

Published in print February 2011 | ISBN: 9780199570669
Published online February 2013 | e-ISBN: 9780191754654 | DOI:

Series: International Perspectives in Philosophy & Psychiatry

The clinical surround: Values and versions

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We shall return to the principles of VBM at various points in the course of this book. But now we need to take stock. Epidemiological facts about dementia expose the need to make value judgements about such things as treatment and research. More than that, facts are value-laden. As Hilary Putnam has suggested, the distinction between facts and values, ‘is at the very least hopelessly fuzzy because factual statements themselves, and the practices of scientific inquiry upon which we rely to decide what is and what is not a fact, presuppose values’ (Putnam, 1981: 128).

So we see the world according to the versions of reality that we tell or hold dear. Our view of the world is always from somewhere, so that what we see has a particular background or surround.

Definitions of ‘dementia’, therefore, that place cognitive function centre-stage, give us one view. But there are also social and personal views of dementia.3 And there are arguments that the word itself is too stigmatizing, so that even if the construct needs to survive, the nomenclature needs to change. ‘Acquired diffuse neurocognitive dysfunction’ could be the syndromal diagnosis, with individual categorical diagnoses being picked out by terms that suggest pathology. At this point, however, we run up against the problem that the pathology itself does not provide clear-cut categories. There is, indeed, no clear line to be drawn between normal and abnormal; not unless, that is, we move away from the pathology back into the world in order to accommodate our background evaluative judgements. What we encounter in the world, especially as scientific understanding increases, is values diversity. Then we are left with differences: different versions, different views, different backgrounds, different contexts from which will emerge different evaluative judgements. (Remember it was Wittgenstein who once suggested he might use a line from King Lear as a motto for Philosophical Investigations: ‘I'll teach you differences’ (Rhees, 1981: 171).) We seem, therefore, to be in an uncertain world, which is strange, given that acquired diffuse neurocognitive dysfunction—at one level—is such a concrete construct.

And this takes us back to the poet Keats, who (in a letter to his brothers in December 1817) praised the idea of ‘negative capability’: ‘… that is when man is capable of being in uncertainties, Mysteries, doubts, without any irritable reaching after fact & reason …’ (Keats, 1990: 370).

Poetic expression of this is famously found at the end of his Ode on a Grecian Urn: ‘Beauty is truth, truth beauty’,—that is all Ye know on earth, and all ye need to know. (Keats, 1990: 289)

Perhaps, then, the place we have arrived at is this: thinking through dementia will involve something that is (at least) akin to aesthetic judgement, where we shall have to accept a degree of uncertainty and doubt. The surround, we might say, suggests something more mysterious, because the questions raised will be about human life in the human world. The dilemma of acquired diffuse neurocognitive dysfunction concerns our response to the uncertainty: whether we can live with it in the way we might live with a valued aesthetic experience, or whether we need to interrogate it in the search for its underlying factual basis.

Truth, we might have thought, should be the impetus to scientific work, the value that underpins it. But against this position, which he describes as a ‘strawman’, Putnam asserts: ‘… truth is not the bottom line: truth itself gets its life from our criteria of rational acceptability, and these are what we must look at if we wish to discover the values which are really implicit in science’ (Putnam, 1981: 130).

In Part III of this book, I shall discuss in some detail different models of dementia. In essence, the question will concern the ‘criteria of rational acceptability’ for each of the models. To anticipate, I shall find the models wanting, because what is required is something more mysterious (in one sense) than any model can give us. What is required, according to the Wittgensteinian analysis I shall offer in Chapter 4, is a transcendental account. Recall Wittgenstein writing in his early work: ‘Ethics is transcendental’ (TLP: §6.421); but we shall come to this in Chapter 2. For now we are left with the conclusion that thinking through the facts of dementia reveals a host of evaluative concerns and uncertainties. It is not apparent that further facts will clear away these uncertainties. Keats's negative capability is what is required as we contemplate the context of dementia. If the ethical dilemmas with which we started looked as if they might be susceptible to bureaucratic, procedural, or legal solutions, this is because of a failure to grasp the mystery raised by acquired diffuse neurocognitive dysfunction. It is a mystery that arises not from within the brain, but from the surroundings that situate the person qua person. And so it is to the concept of the person that we shall now turn.

Chapter.  13825 words. 

Subjects: Psychiatry

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