: Social Constructivism about the disease concept has generally been taken to ignore the fundamental biological reality underlying diseases, as well as to fall foul of several apparently compelling objections. In this paper I explain how the metaphysical relation of grounding can be used to tie a socially-constructed account of diseases and their classification to their underlying biological and behavioural states. I then generalise the position by disambiguating several varieties of normativism, including a particularly strong version of social constructivism, and showing that the grounding approach is available to each. I go on to provide what I believe to be the first attempt at a full semantics for disease-talk and disagreement, before showing on that basis that the most troublesome objections to these positions can be avoided.

Grounded Disease: Constructing the Social from the Biological in Medicine

This new workbook, produced by the Sainsbury Centre for Mental Health and written by a distinguished philosopher of psychiatry plus an expert on values in mental healthcare, is aimed at mental health practitioners of all kinds, as well as service users and carers. It provides a series of exercises

/pdf/whose-values-a-workbook-for-values-based-practice-in-mental-1x08diurzm.pdf

Whose Values? A Workbook for Values-Based Practice in Mental Health Care

Values based practice is a radical view of the place of values in medicine which develops from a philosophical analysis of values, illness and the role of ethical principles. It denies two attractive and traditional views of medicine: that diagnosis is a merely factual matter and that the values that should guide treatment and management can be codified in principles. But it goes further in the adoption of a radical liberal view: that right or good outcome should be replaced by right process. I describe each of these three claims but caution against the third.

/pdf/radical-liberal-values-based-practice-56gpazziqp.pdf

Radical liberal values-based practice

I am grateful to the editors of JECP for the opportunity to respond to the commentaries on my target paper on values-based practice in an earlier edition of the journal [1]. I am also grateful to the commentators in that same edition for the many positive things they have to say about values-based practice, but also for highlighting a number of key issues: these include, Thornton [2] on particularism and the writ of values-based practice (why anyone should feel bound by it); Gupta [3] on the extent of overlap between values-based practice and other approaches to working with values in health care (notably, the emerging field of clinical ethics); Brecher [4] on the two closely related questions of the definition of ‘value’ and precisely ‘whose values?’ valuesbased practice is all about; and Hutchinson [5] on philosophical foundations. In my target paper, I focussed mainly downstream as it were, on the practical products of values-based practice particularly in mental health: Thornton (p. 988), Gupta (p. 994) and Hutchinson (p. 999) all generously acknowledge the influential nature and practical impact of values-based practice. The issues raised by the commentators, however, invite us to take a step back from practice and to look rather at the theory supporting values-based practice and at its overall character as an approach to working more effectively with values not just in mental health, but across health care as a whole. Given the significance of the commentators’ points, I will not have space here to do full justice to each of them considered separately. Summing across the commentaries as a whole, however, three themes stand out: ‘liberal’, ‘unclear’ and ‘dangerous’. Values-based practice, the commentators say (severally and in different ways) is a liberal approach to working with values in health care, it is unclear on a number of issues, and it is dangerous. Well, in brief, I agree. Values-based practice, I will argue, is indeed liberal (strategically so), it is indeed unclear (electively so), and, yes, it is indeed dangerous (hopefully so). Values-based practice is (strategically) liberal

Values‐based practice: Fulford's dangerous idea

Contemporary neoliberal reconfigurations of statutory mental health services involve significant organisational
changes. Based on findings from twelve months fieldwork within a community mental health team, the thesis
examines the effects of this new service landscape on the way conceptualisations of mental distress are utilised
and articulated.

The thesis combines critical realist epistemology and reflexive ethnographic method to produce a contextually situated understanding of the field capturing the dynamic relationships between concepts, agents and the context of action. This draws on and extends Rhodes’ ‘pentimento’ (1993) as a conceptual framework for understanding mental health practice. It argues the mental health team is a ‘differentially sedimented structural institution’ in which practitioners and service users navigate a field of contradictions defined by four strata: the custodial system of the asylum; the biomedical treatment system of the hospital; community care within the Keynesian welfare state; and neoliberal welfare reconfigurations. These are conceptualised as ideological positions that coexist within practitioners as alternative modes of thinking and operate in a relationship of mutual tension. Practice should be understood as a process shaped by mechanisms at different levels of scale from micro to macro, and involving movement between these overlapping and co-existing strata of historically sedimented meaning.

'The Business End': Perspectives on mental distress in the context of neoliberal restructuring of community mental health services

The central idea of values-based practice is that clinical judgements should accommodate 'dissensus' by concentrating on right processes rather than good outcomes. Dissensus, however, has a philosophical history in political theory, especially liberal political theory, which may provide further tools for values-based practice. But it is not without difficulty. Rawlsian political theory aims to limit dissensus by presupposing rational consensus. Agonistic liberalism, although more promising, still leaves the problem of how conflicting views can be understood without presupposing some basic shared agreement.

Political Liberalism and Values-Based Practice: Processes Above Outcomes or Rediscovering the Priority of the Right Over the Good

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Political Liberalism and Values-Based Practice: Processes Above Outcomes or Rediscovering the Priority of the Right Over the Good