Marcus Aurelius: reflection good enough for an emperor but is it good enough for medicine?

Sati Heer-Stavert very kindly asked my permission to link to the paper I wrote a while back on Marcus Aurelius, stoicism and reflective practice – here is the post that has resulted which I am very impressed by! Certainly Sati has provided an excellent framework to prompt students and learners to reflect on what reflection means and what the obstacles to it are….


Reflection is an important part of training, appraisal and revalidation for doctors based in the UK. However, for many doctors the very thought of reflection can cause feelings of frustration, non-engagement or even rejection. Where did we go wrong?

Learning objectives

1. Consider the definition of reflection used in medicine

2. Understand how reflection can be assessed

3. Encourage you to read Meditations by Marcus Aurelius

Oh no! A patient has complained about your refusal to supply antibiotics for a cold. Wow! This would make a really good entry in your learning portfolio:

“That men of a certain type should behave as they do is inevitable. To wish it otherwise were to wish the fig-tree would not yield its juice. In any case, remember that in a very little while both you and he will be dead, and your very names will quickly be forgotten.”

You have to respond to…

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Vampirism as Mental Illness: Myth, Madness and the Loss of Meaning in Psychiatry

This  is certainly the academic paper I have been involved with which has garnered the most media attention. Brendan Kelly and myself intended to write a nuanced paper on how psychiatry conceptualised vampirism, when it occurred as a clinical presentation, and how this changed over time. This reflected wider changes in psychiatry (and probably, though this wasn’t part of the paper, society itself) in that the meaning ascribed to symptoms was increasingly devalued in favour of a “checklisting” approach. Something similar has happened to dreams, in the psychiatric context.

Did we succeed in this? Here is the abstract :


Vampirism, as a clinical presentation, was formerly much discussed in psychiatric literature. In recent years this has not been the case. This article begins by exploring the history of vampiric phenomena and the various medical theories of vampirism. It discusses the change in emphasis in psychiatry from a psychotherapeutically-influenced exploration of the meaning of a particular symptom to a more ostensibly evidence-based, checklist approach. This reflects a wider shift in psychiatric culture. Articles from the psychiatric literature dealing with vampirism are reviewed in depth. The article argues that the clinical interpretation of vampirism may be useful as an indicator of shifting attitudes within psychiatric discourse.

And here is how The Sunday Times covered the article:


Perhaps not that surprisingly, this provoked a backlash from the online vampyre community, none of which seemed based on actually reading our article but on the Sunday Times and Irish Central’s even more misleading take. (most of the links to the vampyre forums where we were attacked seem to have broken.

Brendan has talked further about the paper in various forums such as here , and has discussed this media and online reaction.

I know How Journalism Works. I know that the headline is chosen by a subeditor, not the author of the article. I know that “Doctors write nuanced article on changes in how psychiatrists see vampires over time” is not a headline.

In a way, this coverage illustrates that for the media as well as in day to day a life, a psychiatrist is character with a somewhat predetermined role and that, if a psychiatrist is writing about vampirism, it must be through the prism of mental illness and of treatment. Even in cases where the psychiatrist is trying to do the direct opposite. Alasdair MacIntyre wrote (quoted in the blog post linked immediately above):

Contrast the quite different way in which a certain type of social role may embody beliefs so that the ideas, theories and doctrines expressed in and presupposed by the role may at least on some occasions be quite other than the ideas, theories and doctrines believed by the individual who inhabits the role.



Sophistry, the Sophists and modern medical education. Medical Teacher Volume 32, Issue 1, 2010. Part 2.


One of the direct ways in which the Sophists are relevant to today is that they were the first to put a monetary value on education; they were the first professional educators. In Plato’s Hippias Major Socrates remarks that Gorgias ‘by giving exhibitions and associating with the young, he earned and received a great deal of money from the city’ and that Prodicus ‘in his private capacity, by giving exhibitions and associating with the young … received a marvellous sum of money.’
The Sophists’ innovation of seeking payment for tuition is the first appearance of an idea now all pervasive. Today it is taken almost entirely for granted that teachers require payment, and with it in the modern age come sick leave, maternity leave, pensions and other payments.
The professionalisation of education in general is therefore a legacy of the Sophists. The whole apparatus of modern university teaching, for good and ill, has its root in this idea. Despite a long gestation, it is only in recent years that a professionalisation of medical education has taken root, and it still faces cynicism and opposition today even in recent times (Peterson 1999). There has been concern at the standard of clinical teaching in medicine internationally for a number of years (Wall and McAleer 2000). In the United Kingdom, partly under the influence of the National Committee of Inquiry into Higher Education (Dearing 1997), in the number of departments of medical education attached to medical schools has grown, and a proliferation of masters level programmes and postgraduate certificates in medical education (Pugsley et al. 2008). The whole apparatus of modern academic discourse — peer-reviewed journals, associations, national and international conferences and other scholarly paraphernalia — has grown up around the subject. The subtitle of Peterson’s article cited above — Tomorrow’s doctors need informed educators not amateur tutors — gives a flavour of this new emphasis on professionalisation in medical education.


The second great sense in which the Sophists are still relevant is their case that virtue was not inborn or innate, but could be taught. Their ‘most revolutionary innovation was, precisely, that, faced with nature, they set up teaching to counteract it and considered that virtue could be learned by attending their classes’ (de Romilly 2002), and the problem of nature versus nurture, as it is invariably dubbed today, is a very old one that troubled the Athenians with a peculiar intensity. We see it in Thucydides, in the comparison between the courage of the Athenians — described by the historian as deriving from reason, from expertise and from experience — and that of the Spartans, portrayed as ‘natural’ and traditional. We see it in Euripides’ play, Hecabe, when Hecabe (wife of King Priam of Troy) learns of the slaughter of her daughter. After a few rather perfunctory expressions of grief she launches into a meditation on this very question:
How strange, that bad soil, if the gods send rain and sun,
Bear a rich crop, while good soil, starved of what it needs,
Is barren, but man’s nature is ingrained—the bad
Is never anything but bad, and the good man
Is good: misfortune cannot warp his character,
His goodness will endure.
          Where lies the difference?
In heredity or upbringing? Being nobly bred
At least instructs a child in goodness; and this lesson,
If well learnt, shows him by that measure what evil is.
(Vellacott 1963, lines 593–603)

Plato’s dialogue Protagoras is devoted to the dispute between Socrates and Protagoras on this particular issue, the teaching of virtue. Although both agree that virtue can be taught, Socrates doubts Protagoras’ self-confidence on the issue. This is an issue that has huge implications not only for education but also for wider political economy. Improved knowledge of genetics in the last hundred years has given the problem a new acuity. Nevertheless, in this as in many fields one can get the impression from contemporary media coverage that all this is a new problem, which only our time has had to face. Nothing could be further from the truth, as the example of the Sophists illustrates.

Whatever ones own beliefs on the issue of nature-nurture, and whatever science may or may not tell us about it, one must concede that the Sophists have, from a practical point of view, won the argument. That education should be available for all is such a commonplace in Western society that to suggest otherwise would be social and (for an elected official) political suicide. Prior to the Sophists, the idea that arete was inborn and therefore unteachable was widely held. Therefore aristocratic birth alone qualified one for rule. If Protagoras’ self-confidence in his ability to teach virtue seemed dubious to Socrates, who was after all sympathetic to the essential point, imagine how shocking it must have been to Athenians more in thrall to notions of aristocratic virtue.
This parallels the reaction medical educators often receive from colleagues. While it is often not directly articulated, the claim that communication skills, for instance, or attitudinal aspects of medical practice, cannot be taught but are innate is frequently encountered. With the exception of ethics teaching (discussed below), medical educators may not consider themselves as teaching ‘virtue’, per se, but overall professionalism and attitudinal aspects of medical practice are explicitly incorporated into curricular design and structure. For instance Harden et al. (1999) describe a concentric circle model of learning outcomes, with an inner core of task focused outcomes defining the technical competency of a doctor, a middle section of ‘approach to practice’ outcomes defining understanding of the context of illness and evidence-based and ethics-based approaches to clinical work, and finally an outer circle of outcomes focused on the overall role of the doctor and ongoing personal development. The term ‘personal development’ itself implies that character can be changed by training.
This debate is particularly relevant to ethics training. A tension has been described (Eckles et al. 2005) between proponents of the view that ethics training should be aimed at the formation of virtuous physicians (for instance, Pellegrino and Thomasina,1993) while others have argued that the moral character of medical students is formed at arrival in medical school (Glick1994). This latter viewpoint is expressed as a belief that the goal of ethics training is to impart of body of ethical knowledge and provide a set of skills for application by medical graduates, whose underlying virtue has been established prior to admission to medical school. Eckles et al. identify this dichotomy as making it ‘difficult to find a consensus regarding the goals of medical ethics education’ and suggest that further theoretical work is needed to delineate the core content, processes and skills relevant to the ethical practice of medicine. The antiquity of this debate is not acknowledged.


A theme of this article is that what the Sophists really thought, and what their influence on Western thought really was, is very different from the broad caricature often presented. Before discussing the final trend in medical education which is prefigured in Sophist thought, I wish to examine the thought of a specific Sophist figure and link with modern medical education theory. The thought of Protagoras (circa 490-420 BC) described as ‘the first and greatest of the Sophists’ (Waterfield2000) is known from a seven fragments and the reports of others, especially his appearance in the Platonic dialogue Protagoras. Both Socrates and Protagoras believe that virtue can be taught, although to differing degrees (and Plato will later have Socrates definitively oppose this view in the dialogue Meno), but Socrates is sceptical of Protagoras’ confidence on this issue.
The surviving fragments of Protagoras’ thought indicates the seriousness with which he thought about education (Lavery2008). The most famous, ‘man is the measure of all things’, is often cited as a key motif of relativist thought. Debate continues as to whether this was an example of ‘strong’ or ‘weak’ relativism – in other words whether this is a general statement about humanity or is about the individual human being’s ability to accurate perceive the world. However the underlying relativist thrust of this aphorism is not in doubt. Constructivist theories of learning, which are influential in medical education today, are clearly influenced by this approach.
Other Protagorian mottos directly related to education are ‘teaching needs endowment and practice. Learning must begin in youth’ (cited as Fragment 2 in Lavery, 2008). ‘Art without practice, and practice without art, are nothing’ (Fragment in Lavery,2008) and ‘education does not take root in the soul unless one goes deep’ (Fragment 8 in Lavery, 2008). All of these are relevant to medical education – the emphasis on practice and on deep learning, and on lasting attitudinal and behavioural change particularly so. As can be seen, these aphorisms are far in spirit from the caricature of the Sophists as promoting a superficial, purely rhetorical education.


Another characteristic of contemporary medical education theory prefigured in the thought of the Sophists is an evidence-based approach. The Sophists championed empirical knowledge and direct enquiry, which as well as marking them out as early pioneers of the scientific method, also suggests their place as exemplars of evidence-based practice.
The pre-Socratic philosophers of the centuries before both Socrates and the Sophists are often called both the first philosophers and the first scientists. This, of course, is due to their inquiring minds, and readiness to challenge explanations that depended solely on divine action — thus we have the atomic theory of Democritus, or the postulate of Thales that all matter is water (Waterfield 2000). Nevertheless, a modern reader often finds the Sophists more familiarly ‘scientific’ than the pre-Socratics. This is due to the pre-Socratics’ tendency to expand speculation into explanation, and to engage in metaphysics. The Sophists are more recognisable ancestors of modern scientific method because of their scepticism, their refusal to accept simple explanations, and their pragmatic bent. Defining the scientific method is a hugely problematic enterprise, but an attempt at the unprejudiced search for alternative explanations for any given event or observation is one of its cardinal features.
‘Making the weaker argument the stronger’, a taunt of Aristophanes in The Clouds, is one of the phrases with which the Sophists were most often abused. At first glance, it suggests a sort of confidence trick, a justification for wrongdoing. Yet on reflection, ‘the weaker argument’ may conceal the best answer. The querying approach of the Sophists forces one to examine apparently sound arguments and justifications, and thereby perhaps discover their soundness to be illusory. Richard Feynman described the scientific method as ‘a kind of scientific integrity, a principle of scientific thought that corresponds to a kind of utter honesty–a kind of leaning over backwards. For example, if you’re doing an experiment, you should report everything that you think might make it invalid—not only what you think is right about it: other causes that could possibly explain your results; and things you thought of that you’ve eliminated by some other experiment, and how they worked—to make sure the other fellow can tell they have been eliminated’ (Feynman 1974). So openness to alternative explanations, and a willingness to accept that the ‘weaker argument’ (or initially less persuasive or attractive hypothesis) may be closer to the truth, is a characteristic not of rhetorical chicanery, but of any empirical approach to knowledge and practice.
Best evidence medical education enshrines this empirical approach. Mirroring definitions of evidence-based medical practice, it is defined by Harden and Lilly (2000) as the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. This means integrating individual educational expertise with the best available external and internal evidence from systematic research. Best evidence medical education approaches mean that the assumptions of medical educationalists are themselves open to question. Our fondness for a particular innovative means of teaching should be as suspect as the stubborn retention of every aspect of traditional teaching. In Western thought, the Sophists were the great intellectual gadflies, the questioners – pointing out social assumptions and prejudices for what they were. Medical educators owe a debt to these intellectual precursors.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.


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Sophistry, the Sophists and modern medical education. Medical Teacher Volume 32, Issue 1, 2010. Part 1.

I’m sure on a Friday evening what the world is waiting for is the reposting of a paper on  (possibly) unfairly maligned Ancient Greek philosophers and the parallels between their thought and modern medical education theory. I fully expect this one to go viral. Re-reading it I am quietly happy with my discussion of the (mis)use of the term “sophistry” in the educational literature…. less admirably, I barely mention any of the Sophists themselves. Original is here

Sophistry, the Sophists and modern medical education


The term ‘sophist’ has become a term of intellectual abuse in both general discourse and that of educational theory. However the actual thought of the fifth century BC Athenian-based philosophers who were the original Sophists was very different from the caricature. In this essay, I draw parallels between trends in modern medical educational practice and the thought of the Sophists. Specific areas discussed are the professionalisation of medical education, the teaching of higher-order characterological attributes such as personal development skills, and evidence-based medical education. Using the specific example of the Sophist Protagoras, it is argued that the Sophists were precursors of philosophical approaches and practices of enquiry underlying modern medical education.


The term ‘sophist’ has become a term of intellectual abuse in both general discourse and that of educational theory. However the actual thought of the fifth century BC Athenian-based philosophers who were the original Sophists was very different from the caricature. In this essay, I draw parallels between trends in modern medical educational practice and the thought of the Sophists. Specific areas discussed are the professionalisation of medical education, the teaching of higher-order characterological attributes such as personal development skills, and evidence-based medical education. Using the specific example of the Sophist Protagoras, it is argued that the Sophists were precursors of philosophical approaches and practices of enquiry underlying modern medical education.

The Sophists and Medical Education


The Sophists

The Sophists were among the earliest philosophers of the Western world. Their name is now generally used as a term of intellectual abuse. ‘Sophist’ means a clever cheat, a casuist, a spin doctor, an insincere practitioner of misleading rhetoric. This is because what little we know about the Sophists comes from their opponents, especially Plato. Plato portrayed Socrates as a man of truth, seeking wisdom, as opposed to the quick-witted but superficial Sophists. They were also accused of being mercenary as they took payment for their teaching. Modern perceptions of the Sophists derive mostly from Plato’s depiction and Aristophanes’ comedy The Clouds. In this play, an Athenian father sends his son to a parodic academy of unworldly philosophers so he can learn how to win law cases. However ultimately his son questions and overthrows (literally) paternal authority using the rhetorical skills he has learnt. It suggests that young men would be distracted from dutiful, honest dreams of martial glory by a world of, at best, useless speculation and, at worst, logical hair-splitting that would allow them, literally and figuratively, to beat their betters (Sommerstein, 1973). This negative image of the Sophists has passed into both general discourse and educational philosophy. In this article I wish to discuss what the Sophists actually thought, insofar as we can elucidate it, and draw parallels with modern medical education theory and practice. Some of the most fundamental principles of medical education theory have their origins in the work of the Sophists.
There are three main strands of Sophistic thought which find parallels in the modern discourse of medical educationalists. Firstly, the whole idea of education as a professional enterprise requiring structured attention and of monetary recognition. Secondly, the idea that what are often seen as innate qualities can in fact be taught. Thirdly, an empirical, evidence-based approach to receive opinion and practice.

Who were the Sophists? The word is derived from the Ancient Greek sophos meaning ‘wise’, ‘skilful’, ‘clever’. In early Greek literature, a Sophist was a teacher, poet and wise man. This is how ‘Sophist’ is used by Homer and Hesiod in the seventh centuries BC (O’Grady 2008). A laudatory meaning was attached to the word when used by Homer. In the works of Herodotus (c. 490–420 BC), ‘Sophist’ is employed neutrally to mean ‘teacher’. The ‘Sophists’, as a term, now generally refers to philosophers of the fifth and fourth century BC. They were freelancers, mostly non-Athenian, independent teachers who travelled from city to city throughout Ancient Greece, charging for their services and making their living from a demand for education (O’Grady 2008). Kerferd (1981) identified distinguishing attributes of Sophists – they were paid for teaching, they were patronised by the wealthy, were mainly non-Athenian as well as itinerant, claimed to teach political arête (excellence) and how to be a good citizen, and emphasized the art of speaking. It was this focus on the art of speaking, and a delight in rhetorical innovation and, above all, a constantly questioning stance, which earned the Sophists their reputation. Although a later group of philosophers in the second century A.D. were also dubbed Sophists, ‘the Sophists’ generally refers to these fifth century B.C. intellectuals.
The Sophists brought tremendous intellectual excitement to Athens. This excitement brought with it anxiety, as is evident in The Clouds. All was up for grabs for the Sophists, from the nature of reality itself to the nature of the good to the existence of gods. For traditionally minded Athenians, this was a threatening stance.
The history of ideas is sometimes seen as a series of reactions and counter reactions — Reformation and Counter-Reformation, Romanticism and Neo Classicism, Postmodernism versus modernism. In educational theory, we see parallel dichotomies of behaviourist and constructivist paradigms. The Socratic movement and the Sophists can be seen as being in a similar opposition. Of course, all these developments derive from the other and each depends upon the other. Socrates and the Sophists were not mutually exclusive camps. Aristophanes’ portrayal of Socrates in The Clouds, for instance, is very clearly of a Sophist. And the intellectual excitement which the Sophists kindled in Athens surely had much to do with Socrates setting himself up as a philosopher, and with Plato, at later date, writing his dialogues.
Later generations have been harsh to the Sophists. They were described by the classicist Henry Sidgwick in 1872 as ‘a set of charlatans who appeared in Greece in the fifth century, and earned an ample livelihood by imposing on public credulity; professing to teach virtue, they really taught the art of fallacious discourse, and meanwhile propagated immoral practical doctrines’ (Sidgwick 1872). Right up to the present day, ‘Sophist’ carries this meaning, as can be seen in the words of the contemporary Catholic apologist Peter Kreeft: ‘Socrates made a point that he never took a fee for his teaching. (Neither did Jesus.) This proved that he was not one of the Sophists, who sold their minds as a prostitute sells her body’ (Kreeft 2002).

‘Sophistry’ in modern educational theory

In educational theory and philosophy, similar views prevail – Socratic and Sophistic approaches to education are often contrasted, usually unfavourably to Sophistic ones. For instance Furedy and Furedy (1982) propose a Socratic-Sophistic continuum, positing that Socratic approaches are characterised by enquiry while the Sophistic approach is characterised by persuasion and a focus on rhetoric. Elsewhere, the same authors (1986) argue that Socratic approaches are conterminous with critical enquiry and that Sophistic influences have been mainly implicit and manifested in tendency towards instrumentalism and affective learning as well as in the choice of curricula and curricula development. The title of this latter paper — On Strengthening the Socratic Strain in Higher Education — strongly suggests where the authors’ sympathies lie. As Furedy and Furedy acknowledge, the Sophistic–Socratic dichotomy, like all dichotomies, is overly simplistic, and in this ariticle I will argue that when we look at what the Sophists themselves thought and taught, we find a strong commitment to critical enquiry and the questioning of assumptions.
Boyles (1996), writing from the perspective of teacher training, collapses the Socratic–Sophistic dichotomy in his analysis of the Socratic dialogue Meno – but in a way unfavourable to both schools. He argues that Socratic dialogue is an example of coercive Sophistic rhetoric rather than disinterested enquiry. Hall (1996) in his commentary on Boyles’ paper takes the view that ‘sophistry is deficient insofar as it panders to the desire of the unwise, untutored, and unreflective for quick acquisition of knowledge. If one had enough money, one could with great speed acquire knowledge about, for example, political affairs together with the ability to speak persuasively on virtually any subject’ (Hall 1996) This statement, coming as it does within a sophisticated discussion of a Socratic dialogue, summarises the dominant view of the Sophists within educational philosophy. Stabile (2007), in his analysis of the clash between ‘virtue’ and ‘Sophist’ trends in education, depicts Sophist approaches as synonymous with utilitarian ones. In educational discourse, ‘Sophist’ has become a pejorative term in a more specific way then the general pejorative usage. These negative views are counterbalanced by a modern awareness of the importance of the Sophists, and awareness that their thought was more subtle and less focused on persuasion by any means necessary than their critics wrote.

What makes “a new mental illness”?: The cases of solastalgia and hubris syndrome. Cosmos and History, 2009. Part 2

The concept of mental illness: psychiatrists and philosophers

Defining what psychiatry is and what mental illnesses are can often seem a circular process. One indisputable fact is that psychiatry, as it is currently constituted, is a branch of medicine. While contemporary psychiatrists tend to aspire to practice using a “biopsychosocial approach” (Clare, 1999, p. 109), their training and the structure of the vast majority of psychiatric practice fits a medical model. People present with symptoms and exhibit signs which are examined. If these symptoms and signs are deemed to provide evidence of pathology, they lead to a diagnosis of an illness. Investigations and treatments are ordered. Medications and other interventions are prescribed to treat the illness. The cessation of the symptoms and signs marks recovery from the illness. This is, on the surface, similar to how an ophthalmologist would approach cataract, or a respiratory physician chronic obstructive pulmonary disease. Dictionary definitions of psychiatry describe it as the medical specialty concerned with mental illness (Oxford English Dictionary, 2007) Psychiatry textbooks too generally gloss over the actual meaning of mental illness but assume it has a readily understood and commonly accepted meaning.

A key paper from within the psychiatric establishment on the definition of mental illness is Robins and Guze (1970) on the establishment of diagnostic validity in psychiatric illness, with regard to schizophrenia. This paper’s approach has had a strong influence on the development of DSM-IV, the American Psychiatric Associations classification of mental illnesses which is used in clinical practice (although it was developed primarily to enable researchers to communicate with each other rather than as a clinical tool) for diagnostic purposes.Robins and Guze describe a five step method for achieving diagnostic validity in psychiatric illness is described, consisting of five phases: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study. The method was applied in this paper to patients with the diagnosis of schizophrenia, and it was shown by follow-up and family studies that poor prognosis cases can be validly separated clinically from good prognosis cases. The authors conclude that good prognosis “schizophrenia” is not mild schizophrenia, but a different illness.

“Diagnostic validity” means that a diagnosis of schizophrenia is in fact a case of schizophrenia. It differs from a related concept, reliability, which describes how well diagnoses match each other—a reliable diagnosis of schizophrenia means that other clinicians would come up with a diagnosis of schizophrenia given the same case. It is possible for a diagnostic process to be reliable but not valid, although validity implies reliability.It does not, however, address the question of what schizophrenia is.

Validity implies that one is describing an entity whose existence and nature is not disputed. It does not address fundamental questions of what this entity actually is. Solastalgia may well fit the Robins and Guze framework very well. Clinical description has already been carried out. “Laboratory investigation” is mirrored in the development of the Environmental Distress Scale. Exclusion of other disorders could, arguably, involve showing that the distress experienced by the person is due to environmental change and no other factor.

Hubris syndrome also fits this framework very well. Already clinical description and exclusion criteria are provided by Owen. Owen suggests possible avenues for laboratory study, referring to neurotransmitters. Although the rarity of hubris syndrome may make this study and follow-up studies challenging, it may be that analogues to hubris syndrome in less eminent persons will be developed. Family studies would be more problematic, although cases such as the two Bush Presidents and the Nehru-Gandhi dynasty in India would suggest that this could be overcome. Follow-up and family studies, in any case, refer to activities psychiatric researchers undertake, and implicitly assumes that the diagnosis is an entity in itself.

And this points to the essential circularity of mainstream psychiatry’s definitions of mental illness. Robins and Guze’s formulation of mental illness is made up of five steps that refer entirely to medical and psychiatric activity itself. Psychiatry is the medical specialty concerned with mental illness, and mental illnesses are conditions which are the concern of psychiatry.

As outlined in the statement of the Focus & Scope of this journal, a tension between “cosmology, conceiving the cosmos as an immutable, timeless order, and history, concerned with actions, intentions, conflicts and the rise and fall of individuals and communities, has been at the core of virtually all intellectual and political oppositions throughout the history of European civilization.” This tension is particularly germane to psychiatry. Psychiatrists spend much of their time trying to improve the image of psychiatry within medicine by insisting it is a scientific enterprise, characterised by the assumptions of expertise, specialist knowledge and greater objectivity that (it is assumed) are possessed in full by other medical specialties. However psychiatry, as shall be seen, is also intimately concerned with values and the concerns of the humanities. The tension between the worldviews of ethical and political philosophy on the one hand and the traditional scientific view on the other is particularly acute in psychiatry.

Any attempt at any overarching, definitive definition of what philosophy is will be even more contested than that of psychiatry. Just as with medicine and medical practice, there are very many disciplines subsumed within philosophy, and while the medical model described above is generally accepted within most medical specialties, there is no such consensus within philosophy as to what philosophers do, what “the business of philosophy” should be, or how philosophers should approach the problems that come under the heading of “philosophy.” Of the many things that philosophy is, it is perhaps safest to say that philosophy questions assumptions and encourages critical thinking about things taken for granted.

The concept of “mental illness”, which as we can see from the above can be considered an assumption in common usage within the psychiatric profession (and, perhaps, in wider society), has been subjected to a thoroughgoing critique from philosophers, psychiatrists, psychologists, social workers, political scientists, feminists and many other figures. This critique has taken five main approaches:

  • a psychological model, as exemplified by the British psychologist Hans Eysenck, arguing that mental disorders are in fact learned abnormalities of behaviour (Eysenck 1968)

  • a labelling model, as exemplified by the American sociologist Thomas Scheff, who argued that the features of mental disorder are in fact a response to the labelling of an individual as “deviant” (Scheff 1974)

  • a “hidden meaning” model, postulating that the apparently irrational, harmful or meaningless behaviour associated with mental disorder is in fact meaningful. The Scottish psychiatrist R.D. Laing, for instance, argued that “madness” was a sane response to an insane society. (Laing, 1960)

  • an “unconscious mind” model, influenced by psychoanalysis, which postulates that, again, the apparently irrational can be comprehended, this time with reference to the unconscious mind

  • political control models—this critique of psychiatry sees it as a legitimising the social status quo and allowing those who dissent from it to be labelled mentally ill. The practice of psychiatry in the former Soviet Union exemplifies this. Another example is the feminist critiques of post-natal depression, which feminists would argue reflects society’s treatment of mothers rather than being a disease per se. Thus legitimate distress at the unfair structure of society is pejoratively labelled an illness. Similarly, the Franco-Algerian psychiatrist Frantz Fanon argued that psychiatry was a tool of colonial control and part of the hegemonic order of industrial capitalism.

This questioning, much of which has been posed by psychiatrists, has forced psychiatry to scrutinise its own concept of what constitutes mental illness. Many of it is more about the role of various psychological, social and political factors in the development of mental illness, rather than being an attack on the basic concept of mental illness. Other critiques have not so much been of psychiatry as a discipline or practice, but on the cultural significance of a therapeutic ethos, for instance that of Philip Rieff in “The Triumph of the Therapeutic.” (1965) For Rieff, the rise of psychotherapy and the “psychological man”—marked a turning point in human culture, being the death-knell of a Western culture whose ideals had lost their power to deeply pervade the characters of its members. In a therapeutic ethos, truths are contingent and negotiable, and commitments or faiths only survive as therapeutic devices easily discarded in the interests of therapy. For Rieff, this is a symptom of Western cultural decadence and decline.

Much of the “antipsychiatry” critique has been absorbed into mainstream psychiatric thinking and practice. Psychiatry is generally practiced in the community in a multidisciplinary, biopsychosocial fashion, and psychiatrists themselves lobby for extra resources to achieve this. Government policies enshrine the concept of patient-centred care that meets holistic needs and aim for “recovery” that goes beyond the simple alleviation of symptoms (Expert Group on Mental Health, 2006.) Compulsory treatment of those diagnosed as mentally ill is surrounded by tight regulatory control in Western societies.

However, for the most thoroughgoing anti-psychiatrists, this is not enough. They favour not tighter controls on compulsory admission, but the complete abolition of the phenomenon.One of the most influential critiques is that of Szasz (Szasz, 1960). Szasz disclaims the label “antipsychiatrist” and also insists he is not a philosopher, however his work could be seen both as the quintessence of “antipsychiatry” and as having a strong influence on philosophical approaches to mental illness. Throughout his career he has stated emphatically that illness requires the presence of a physical lesion which causes disease. With mental illnesses, there is no identifiable physical lesion. Therefore “mental illness” is a myth. This is not to say that the phenomena described as mental illnesses are not actually happening, but that they are not illness. “Mental illness” involves a value judgement, whereas the diagnosis of bodily illness does not. What has formerly been termed mental illnesses are in fact “problems of living.” This leads Szasz to a radical and continuing critique of psychiatry as a discipline (Schaeler, ed, 2004.) Other critics of psychiatry (for instance Eysenck, 1968) have argued that many, if not most, patients presenting with mental illness are in fact experiencing problems of living, but have generally conceded that some at least are experiencing a biologically based mental illness. Szasz, however, has consistently maintained what could be called a “hard” position denying the validity of mental illness and, from this position, attacking both psychiatric coercion (involuntary admission and treatment) and “psychiatric excuses” (the insanity plea) Szasz has not argued for the abolition of psychiatric practice, but that psychiatric practice should only be between two consenting adults (what he calls “contractual” psychiatry), that psychiatrists should have no powers to compel treatment or admission, and that courts deliver verdicts of either guilty or not guilty with no acceptance that insanity can be a mitigating circumstance. Over the course of his career he has compared “institutional” psychiatry (contrasted to “contractual” psychiatry) to the Inquisition, the slave trade and the Holocaust. (Szasz 2002)

Szasz has never stated that the phenomena described as mental illnesses do not exist—that people who are diagnosed with depression are not suffering from distress, or that people who are diagnosed with paranoid schizophrenia are not reporting persecution without a basis in real events. Szasz simply states that these presentations are not illnesses, and their treatment as such is not simply an intellectual error but has lead to massive violations of human rights on a worldwide scale.

There have been many “pro-psychiatry” counterparts to the work of the antipsychiatrists. Kendell (1975) described the ‘biological disadvantage’ criterion of illness, based on the work of Scadding (1967), a chest physician who described a disease as ‘the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for the species in such a way as to place them at a biological disadvantage.” Kendell used this criterion of “biological disadvantage” to argue that, in fact, a value-free concept of illness was possible, and also that it applied to mental illness, as it shortened life expectancy and reduced reproductive advantage.Later, Kendell changed his position and came to believe that value judgements were inescapable with regard to any illness (Kendell 2002). Kendell’s original argument was directly intended as a response to Szasz and the other antipsychiatrists. So, where Szasz defined bodily illness as cellular dysfunction, Kendell defined it as a process leading to “biological disadvantage.”

Kendell and Szasz share, however, a view that defining bodily illness is uncomplicated compared to mental illness. Their debate is framed in terms of comparing mental illness to bodily illness, and arguing that mental illness is illness in so far as it is more or less like bodily illness. Many critics of Szasz since have taken the same basic approach—for instance, that there are in fact biological pathologies associated with mental illness, or that as medical science progresses we will identify these pathologies. To which Szasz replies that, if this indeed turns out to be the case, these conditions will become bodily illnesses to be treated by bodily physicians, as Alzheimer’s Disease and General Paralysis of the Insane (tertiary syphilis) did in the late nineteenth century.

Many later respondents to Szasz have argued that his concept of illness is narrow, and that bodily or purely physical illness or disease is not to be defined as simply as he suggests. Szasz himself has continued to hold to his original position, writing that “I use the terms disease and illness interchangeably” (Szasz, 2000, p. 3.) Szasz has continued to insist that bodily illness is an uncomplicated concept and mental illness an unjustifiable extension of that concept. One of his supporting references is the introductory material for pathology textbooks, which (in a way analogous to the simple definitions of mental illness that are used in psychiatry text books) generally simply state that disease is due to cellular damage. Whether the authors of these textbooks, any more than those of psychiatric textbooks, have taken a philosophical approach to the underpinnings of their specialty could perhaps be questioned.

Boorse (1976) has also described the distinction between illness and disease, with disease referring to dysfunction (which, Boorse argues, can be used to describe cognitive and perceptual as well as purely physical domains) and illness referring to the social consequences of disease. “Disease” is a value-free, objective entity—“illness” is a value-laden, socially determined process or consequence of disease. Boorse argues that a disease becomes an illness when it becomes incapacitating for the person experiencing it. In social terms, it must be undesirable for its bearer, “a title to special treatment” and “a valid excuse for normally criticisable behaviour” Boorse argued that the fact that mental illness is value-laden relative to physical illness was not because physical illness was value free—for the whole concept of illness is value-laden. Mental illness is seemingly more value-laden because the sciences that underlie mental illness are not as well developed as those underlying other medical specialties, but this is simply a historical factor which will be rectified over time.

Boorse’s disease/illness distinction—an attempt to retain value-free evaluation of pathology while accepting the value-laden nature of diagnosis, treatment and the sick role—brings us to one of the pivotal work of the French epistemiologist and physician Georges Canguilhem. Canguilhem, author of one of the key texts in the philosophy of medicine, The Normal and the Pathological (Canguilhem, 1989), challenged the dominant “scientific” paradigm of pathology based on statistical norms of supposed immutability, which defined boundaries on a continuum between normal and abnormal. For Canguilhem, health and disease were properties of a total organism, with health being the capacity to withstand change and to establish new norms—the ability to fall sick and recover,  or normativity—and disease the lack of this capacity. Anomalyper se was not abnormality, and a list of symptoms and signs or deviations from a statistical norm did not define disease.

Canguilhem’s work was rooted in an approach to the history of medicine that looked at the evolution of conceptual rather than factual knowledge (Horton, 1995). For Canguilhem, as for many other philosophers of science as the twentieth century progressed, the positivist view of science as based on observations made in language entirely independent of theory was untenable.The dominant positivist view of medicine reflected the influence of  physiologists such as Claude Bernard, who championed an approach to understanding disease based on laboratory experimentation separated from clinical conditions. Against this, Canguilhem argues that a purely “scientific”, lab-based understanding of illness divorced from clinical experience or understanding the conditions of disease is impossible—“it is first and foremost because men feel sick that a medicine exists. It is only secondarily that men know, because medicine exists, in what way they are sick.” (Canguilhem, 1989, p. 229)

A futher key of Canguilhem’s approach was that the history of medicine had shown a gradual movement from concepts of health and disease as qualitatively different entities, to one in which there is only a quantitative difference. For Canguilhem, the pathological state is qualitatively different from health because of its implications for the organism’s survival and ability to flourish. It is this factor that  purely positivist accounts of sickness cannot account for, but cannot ignore. The implications of Canguilhem’s writing for mental illness have been discussed by Magree. (Magree, 2002)

Arguments continue about definitions of mental illness. As outlined above, Szasz has kept very strongly to his original position over the years, in the face of all critics. However the debate has moved on to other terms. Christopher Megone, for instance, describes illness both bodily and mental as incapacitating failure of bodily or mental capacities to fulfil their functions (Megone, 2000). He traces this concept of functional impairment back to Aristotle.Fulford, meanwhile, focuses on the actual experience of illness as a basis for thinking about illness (Fulford, 1993). This is influenced by the work of the philosopher J L Austin and the sociologist David Locker (Austin, 1961 and Locker, 1981). Austin was a philosopher associated with the Linguistic Analytic move in philosophy, which emphasised examining how a concept is used in ordinary usage as a way of finding out its is meaning. One of the approaches to “doing philosophy” which was seen traditionally as leading to clear thinking was to “define your terms.” In other writings Fulford has discussed how the assumption that “defining your terms” is a necessary condition for clinical utility has become so prevalent within medicine has lead to the belief that concepts are only clinically useful if they can be so clearly defined (Fulford, 2001). Austin suggested that “philosophical fieldwork”—exploration the use of concepts in everyday language and usage—may be a better means of approaching the meaning of concepts, rather than concentrating on definitions per se.

Austin also described the complexity of actions. Philosophers had previously tended to focus on particular aspects of action—intention, voluntariness and so on—and to unpick them by defining them. Austin focused on “the machinery of action” which involves a wide range of processes and activities—“we have to pay (some) attention to what we are doing and to take (some) care to guard against (likely) dangers; we may need to use judgement or tact; we must exercise sufficient control over our bodily parts; and so on.” (Austin, 1961)Fulford utilises this as a way of approaching the medical concept of illness, as “action-failure.” “The machinery of action” has a wide range of elements, and this breadth gives Fulford a wide range of approaches to understanding illness experiences, both physical and mental.

The work of  Locker on those features of experiences that people identify as marking out these experiences as illnesses helped suggest this approach.Four relevant features were identified—the experience is negatively evaluated,  has a certain intensity and duration,  is not “done to or happens to” the person undergoing it, and  is not “done by the person” themselves.

Fulford has built on Austin and Locker’s work to describe the importance of “action failure” in defining illness. At first sight, “action failure” does not seem too different from the “dysfunction” of Boorse’s thought. Action and function are closely related, but are also more distinctthan one might think. Individual people (as agents) perform actions; particular physiological systems or body parts function. Fulford uses this distinction to draw a parallel with the distinction between the patient’s experience of illness and a doctor’s knowledge of illness. Fulford has described a “full field” model of mental illness. Going beyond purely medical models, focusing on disease and failure of function, it combines the social, value-based concept of illness with corresponding failure of action.

To the objection that unpleasant experiences such as pain or psychological distress are often involved in illness experiences (and that these do not immediately obviously fit into the concept of action failure, Fulford replies that pain is integral to “the machinery of action”, as is psychological distress, and therefore action-failure analysis can be applied.

Eels and alcohol – Two letters to Alcohol and Alcoholism (May 2010, May 2014)

OK, for the first time on this blog I will post something I originally posted under my nom du medicine , Seamus Mac Suibhne. Or sort of did, since it is credited to a mysteriously named Seamus Mac Suibhne (Sweeney).

Both letters, appropriately enough, had serendipitous origins. In some compendium of random facts I came across the first, attributed to Culpeper. Later, in J C McKeown’s Cabinet of Roman Curiosities I came across the same advice, attributed to Isidore of Seville. Isidore’s work was itself a compendium of more ancient medical texts, so presumably this advice is even older. I am unaware of any actual clinical trials.

First Letter

Nicholas Culpeper (1616–1654) was an English physician, herbalist, botanist and astrologer. He lived at a time when these fields overlapped to a considerable extent, and unlike many of his contemporaries he took an empirical approach to the healing enterprise, cataloguing medicinal plant and their effects for himself rather than appealing to tradition. Recent commentators have placed Culpeper in the context of a radical democratization of medical knowledge and authority (Woolley, 2004).

Culpeper’s works have all been immensely influential, being consulted regularly by complementary/alternative practitioners to this day. ‘Culpeper’s Herbal’, the popular name given to his 1653 work ‘The Complete Herbal’, contains the following advice under the section on the medicinal use of living creatures: ‘Eels, being put into wine or beer, and suffered to die in it, he that drinks it will never endure that sort of liquor again’ (Culpeper, 2006 [1653]).

To an early twenty-first (or late twentieth) century medical reader, this is extremely reminiscent of the use of disulfiram as an aversive treatment in problematic alcohol use. Disulfiram has been used in the manufacture of synthetic rubber since the 1800s, and while its range of unpleasant physical reactions to alcohol ingestion in those exposed to it in the process were well known within the rubber industry, it was the mid-1930s before a medical researcher noted the fact (Williams, 1937). The use of disulfiram for aversion treatment of alcohol dependency dates from 1948, when it was serendipitously rediscovered by two Danish researchers who were experimenting with disulfiram as a possible treatment for helminthic parasites (Hald and Jacobsen, 1948; Steffen, 2005). A Danish psychiatrist, Martensen-Larsen, subsequently developed the chemical as a treatment for alcoholism (Martensen-Larsen, 1948).

Naturally occurring substances with analogous action to disulfiram are known—the most prominent being the ink cap mushroom (Broadhurst-Zingrich, 1978), Culpeper’s reference to allowing eels to die in alcoholic beverages and using the resulting concoction to induce aversion to alcohol is suggestive of a similar approach to the aversive pharmacotherapeutic one of disulfiram, one which given his empirical approach Culpeper may have tried himself. Even more suggestively, eel skins have themselves been used to manufacture rubber-like materials. Given the serendipitous route by which disulfiram entered the pharmacopeia of alcohol addiction treatment, it is important that contemporary researchers maintain an alert mind attuned to possible therapeutic strategies of the past.
↵Broadhurst-Zingrich L. Ink caps and alcohol. BMJ 1978;6111:511.
↵Culpeper N. The Complete Herbal. Carlisle: Applewood Books; 2006 [1653].
↵Hald J, Jacobsen E. A drug sensitizing the organism to ethyl alcohol. Lancet 1948;2:1001-4.Medline
↵Martensen-Larsen O. Treatment of alcoholism with a sensitizing drug. Lancet 1948;2:1004.Medline
↵Jenkins R, Jessen H, Steffen VSteffen V; Jenkins R, Jessen H, Steffen V, editors. Managing uncertainty: ethnographic studies of illness, risk and the struggle for control. Challenging Control: Antabuse Medication in Denmark Copenhagen: Museum Tusculanum Press; 2005:173-196.
↵Williams EE. Effects of alcohol on workers with carbon disulfide. JAMA 1937;109:1472-1473.
↵Woolley B. The herbalist: Nicholas Culpeper and the fight for medical freedom. Toronto: Harper Collins; 2004.

Second Letter

Isidore of Seville, Eels and Disulfiram
Seamus P.M. MacSuibhne (Sweeney)

In 2010 I corresponded with this journal (Mac Suibhne, 2010) about intriguing parallels between a comment made by the 17th Century English botanist, physician, astrologer and herbalist Thomas Culpeper in his ‘Complete Herbal’ and the use of disulfiram. Culpeper’s specific words were ‘eels, being put into wine or beer, and suffered to die in it, he that drinks it will never endure that sort of liquor again’ (Culpeper, 2006 [1653]).

I wish to the journal readership’s attention to an even earlier citation of the same advice, in Isidore of Seville’s (c. 560–636) encylopaedia Etymologiae. Compiled towards the end of his life, Etymologiae was the first attempt by a Christian writer to produce a compilation of the knowledge of antiquity. It serves as the only remaining source of much classical learning.

Chapter 12 of this work deals with animals; at section 6, verse 41 we find the following: ‘Eels originate from mud; hence, when one is caught, it is so slippery that the tighter you hold it, the more quickly it slips away. They say that the river Ganges, in the East, produces eels 30 feet long. When eels are killed in wine, whoever drinks it then develops a distaste for wine (Isidore of Seville, 2006 [c. 630]).

As this work is a compilation of ancient sources, many of which are lost, it is clear that this advice has an even older origin. In my previous correspondence I outlined the serendipitous discovery of disulfiram as an aversive agent, its derivation from the rubber industry, and linked this naturally occurring disulfiram analogues (Broadhurst-Zingrich, 1978) and with the use of eel skins to produce rubber-like products. It is possible that this form of aversive therapy has even older roots.
↵Broadhurst-Zingrich L. Ink caps and alcohol. BMJ 1978;6111:511.
↵Culpeper N. The Complete Herbal. Carlisle: Applewood Books; 2006 [1653].
↵Isidore of Seville. Etymologiae. (Barney, Lewis, Beach, Berghof, trans). Cambridge: Cambridge University Press; 2006 [c. 630].
↵Mac Suibhne S. Commentary: Nicholas Culpeper, eels and disulfiram. Alcohol Alcohol 2010;45:589.