All medical procedures, be they therapeutic or investigative, touch on the issue of consent – that is a measure of willingness on the part of the patient to undertake the procedure proposed. In this, ECT is no different to other therapeutic interventions. However, ECT has a particular status both within psychiatry and within the law that makes specific discussion of issues with regard to consent necessary.
General issues regarding consent
Electroconvulsive therapy is unusual in that consent obtained is for a course of treatments rather than for an individual procedure. It is also customary that the person seeking the consent will not be the person giving the treatment. The fact that the person receiving treatment has a psychiatric disorder sufficiently severe for ECT to be considered raises questions about their capacity; this makes it particularly important that consent is properly obtained and valid. It is unlawful and unethical to treat a patient who is capable of understanding the nature of any procedure, its purpose and implications, the anticipated benefits and any reasonably foreseeable adverse effects without first explaining it. The patient must then agree. Even if patients choose not to be informed of the full details of their diagnosis and treatment, they must be given the option of receiving this information. Guidance on good practice in consent can be found in publications from the Department of Health in England and Wales (2009), the Department of Health, Social Services and Public Safety in Northern Ireland (2003) and the Scottish Executive (2006), as well as from the General Medical Council (2008).
Obtaining valid consent should be considered a process rather than an event and it is necessary for patients to be given an adequate length of time to consider the benefits and drawbacks of the proposed treatment before making an informed decision. Patients should be informed of the risks and unwanted effects of ECT (Chapters 7–9) and they need to realise that a general anaesthetic is involved. If there are specific anaesthetic risks, the anaesthetist should explain these and obtain the necessary consent.
It is helpful for patients and carers to be provided with information obtained from different sources. Written information sheets may be useful (e.g. Appendix V); these need to be accompanied by the opportunity to discuss issues with members of the therapeutic team, family members, carers, advocates, etc.
Inferences of reason
I have so far avoided Kant's theory about how reason generates the problems which are treated in the Dialectic. This theory, which is expounded in the Introduction, Book I and the Appendix to the Dialectic, is a bad one, and the Dialectic's main content is independent of it. Still, the theory of reason is sometimes invoked in discussions of specific problems; and it is also supposed to generate the architectonic – the over-all shape – of the material in Book II, explaining why the proper concerns of the Dialectic are exhausted by psychology, cosmology and theology. This architectonic is a clumsy attempt to rationalize a set of problems which reflect not the structure of reason but the preoccupations of German academic philosophers at the time when Kant was writing. Where the theory has an effect, it is by tempting Kant into a brutal and insensitive forcing of his material into unnatural shapes, and never by genuinely illuminating it. Still, the theory must be attended to.
What sort of faculty does Kant think reason to be? His main explanation, given in two sub-sections of the Introduction, is that reason is a faculty of making logical deductions. The understanding can also be used deductively, Kant says, but only with one premiss at a time, whereas reason's deductive task is the drawing of conclusions from pairs of premisses. He puts it like this:
If the inferred judgment is already so contained in the earlier judgment that it may be derived from it without the mediation of a third representation, the inference is called immediate… – I should prefer to entitle it inference of the understanding. But if besides the knowledge contained in the primary proposition still another judgment is needed to yield the conclusion, it is to be entitled an inference of the reason.
That is ambiguous. It is supposed to distinguish (a) arguments with one premiss from (b) arguments with two, but it could easily be taken instead to distinguish (a′) arguments in which the conclusion follows immediately from the premiss(es) from (b′) arguments in which the conclusion can be derived from the premiss(es) only with the aid of an intermediate lemma. Kant's central concern is with (a)/(b), but his use of ‘mediation’ and ‘immediate’ strongly suggests (a′)/(b′).
The antinomies chapter
In Kant's usage, an ‘antinomy’ is a pair of good-looking arguments for apparently conflicting conclusions. In the chapter on the Dialectic to which I now turn, he offers four antinomies, each purporting to exhibit a conflict which can be resolved only with help from Kantian philosophy. Sometimes Kant suggests that his principles discredit the questions to which the antinomal arguments offer answers, but he also suggests that in the first two antinomies each of the opposing conclusions may be false, while in the third and fourth both conclusions may be true. Indeed, no one account will do. The chapter is in fact a medley, and the several sorts of unity claimed for it are all spurious.
For one thing, the ostensible topic is cosmology, or ‘the world-whole’ (434); but only the first antinomy, about the age and the size of the world, clearly has such a topic. The second antinomy concerns the infinite divisibility of matter, and is ‘cosmological’ only in a stretched sense. The third concerns the first event that ever happened, but Kant rapidly moves on from that into a perfectly uncosmological problem about human freedom. The fourth antinomy, about the existence of a ‘necessary being’, is cosmological enough, but it heavily overlaps the discussion in the theology chapter of the ‘cosmological argument’ for the existence of God.
Kant's poor selection of material for the antinomies chapter may be partly due to his bad theory, to be discussed in my final chapter, about how all the Dialectic's troubles arise from reason's inherent tendency to error. Although most of the Dialectic's serious content can be grasped without reference to this theory, it does make its presence felt in the antinomies chapter, among other things by providing the setting for Kant's feeble account of why there are exactly these four antinomies (442–3). I do not know whether the theory of reason actually constrained Kant to select these four, or merely helped him to rationalize a selection he had made on other grounds.
In expounding the alleged fault-line running through the faculty of reason, Kant speaks of ‘a natural and inevitable illusion’, a ‘dialectic’ which is ‘inseparable from human reason, and which, even after its deceptiveness has been exposed, will…continually entrap [reason] into momentary aberrations ever and again calling for correction’.
The realism argument
Kant has a certain line of argument which, though adumbrated in the Transcendental Deduction in A (see §33 above), appears explicitly only in B, under the heading ‘Refutation of Idealism’. In the Preface to B Kant rightly calls it ‘the only addition, strictly so called’ which he has made to the content of the Critique.
The Refutation of Idealism is Kant's chef d’œuvre of compressed obscurity: no-one could claim that its one brief paragraph constitutes, as it stands, an achieved argument. If we are to take it seriously, we must speculate about what is supposed to be happening in it. Clearly, its target is anyone who denies or casts doubt on the existence of an objective realm; and the opening sentences give an impression of what the line of attack will be:
I am conscious of my own existence as determined in time. All determination of time presupposes something permanent in perception. This permanent cannot, however, be something in me…
This seems to say: ‘According to the first Analogy, a self-conscious being must have experience of something permanent. I shall now show that the latter must be objective or other-than-oneself.’ Although most commentators have taken Kant at his word here, there are powerful reasons for not doing so.
For one thing, the Refutation of Idealism could hold little interest if it presupposed the untruth which is the first Analogy, i.e. if it were a rider saying : ‘…and, furthermore, these sempiternal items must be objective’. Also, such verbal overlaps as it has with the ‘proof’ of the first Analogy pertain to the latter's least comprehensible part—not to the analysis of existence-change but rather to the obscure doctrine that time is permanent and unperceivable. Most important of all: if the Refutation of Idealism presupposes the first Analogy, then the ‘proof’ of the latter must be taken as offering, in support of the conclusion that self-consciousness requires experience of something permanent, an argument which is neutral as to whether the ‘something permanent’ is inner or outer. This is an impossible reading of the first Analogy, which is clearly stated in both editions as a thesis about the division of ‘appearances’, i.e. of the objective realm, into substances and properties.
The second antinomy concerns divisibility. It pits the Thesis that every ‘composite substance’ has indivisible parts against the Antithesis that extended things cannot have indivisible parts. The reference to extension is essential: the divisibility of matter is being inferred from that of space, and Kant's occasional hints that the antinomy concerns the simplicity of the soul are just wrong.
In this section I shall discuss the Thesis-argument, the Antithesis-argument will be the topic of §53, and most of the remainder of the chapter will explore the conflict between them.
Deprived of its useless and confusing reductio ad absurdum form, the Thesis-argument goes as follows (462–4). From any composite substance ‘remove in thought all composition’, that is, think about its raw materials without any thought of how they are assembled to constitute the composite substance. As a crude analogy: one might ‘remove in thought all composition’ from a house by thinking of its constituent bricks – as a jumble, not as assembled in any particular fashion. But the analogy is crude, for a brick also has parts, so that if we had removed in thought all composition from a house we would not be thinking of ordinary space-taking bricks. Now, the argument continues, if upon removing in thought all composition from a composite substance we still have something to think about, some elements which are not themselves composed of anything still smaller, then those elements will be simple or non-composite or indivisible, and to that extent the Thesis will be satisfied. To complete the argument, then, Kant has only to rule out the possibility that when we remove in thought all composition from a composite substance there is nothing left for us to think about. In his own words, he has to show that it is always ‘possible to remove in thought all composition’ from a composite substance.
The Kant–Frege view
After psychology and cosmology, Kant has a final chapter on theology. This treats three traditional arguments for God's existence, starting with the so-called ontological argument, which goes somewhat as follows.
If the word ‘God’ means, in part, ‘being which is omnipotent, benevolent, omniscient…’, then anyone who says ‘God is not omnipotent’ either contradicts himself or is not using ‘God’ with its normal meaning. Now, ‘God’ means, in part, ‘being which is existent, omnipotent, benevolent…’ That implies that anyone who says ‘God is not existent’ either contradicts himself or is not using ‘God’ in its normal meaning; whence it follows that ‘God is existent’, normally understood, is guaranteed as true just by the meaning of its subject-term.
Kant rejects this argument because, he says, ‘existent’ has no right to occur in a list of terms purporting to express what an item must be like in order to qualify for a certain label. Existent things are not things of a kind; existence is not a state or quality or process; ‘existent’ is not a predicate. ‘“Exist”… is a verb, but it does not describe something that things do all the time, like breathing, only quieter – ticking over, as it were, in a metaphysical sort of way.’
Kant puts this by saying that ‘existent’ is not a ‘real predicate’ or a ‘determining predicate’. It and its cognates can behave like predicates in a sentence, he admits, as when we say ‘Unicorns don't exist’, which may seem to report something that unicorns don't do. But that only qualifies it as a grammatical or ‘logical’ predicate:
Anything… can… serve as a logical predicate; the subject can even be predicated of itself… But a determining predicate is a predicate which is added to the concept of the subject and enlarges it… ‘Being’ is obviously not a real predicate; that is, it is not a concept of something which could be added to the concept of a thing.(626)
Recall that a thing's ‘determinations’ are its properties or qualities. To ‘determine’ something is to discover or report detail about it.
The sensory/intellectual continuum
Two philosophical traditions – the rationalist and the empiricist – came together in Kant's philosophy, not in an inconsistent jumble but in a coherent synthesis of truths drawn from each. Underlying this positive achievement is a crucial negative one, namely Kant's avoiding of a certain error which was common to the empiricists and the rationalists. I shall chart this error in the present section and the next, and Kant's correction of it in §§6–8. Topics related to this will occupy the rest of the chapter.
The error is that of assimilating the sensory to the intellectual aspects of the human condition. No one would fail to distinguish seeing a man from thinking about men, hearing a whistle from understanding a lecture about whistles, feeling running water from drawing a conclusion; but the philosophers I am concerned with put all these matters on a continuum, representing as a difference of degree what is really one of kind.
A common vehicle for this mistake is the word ‘idea’. Some philosophers have said that ‘ideas’ are what one has or is confronted with in ordinary sense-experience, in hallucinations, in some kinds of imagining and so on, and that they are also involved in thinking and understanding – so that having a meaning for a word is associating it with an ‘idea’, and thinking through a problem is mentally manipulating ‘ideas’. Descartes clearly commits himself to using ‘idea’ as widely as that. He takes the term ‘idea’ to stand for ‘whatever the mind directly perceives’, and he says explicitly that ‘perception’ covers ‘sense-perception, imagining, and even conceiving things that are purely intelligible’. Descartes’ detailed procedures also show him allowing ‘idea’ to sprawl across the whole realm of the mental. On the sensory side, for example, he says: ‘If I now hear some sound, if I see the sun, or feel heat,…I can perhaps persuade myself that these ideas are adventitious’, where ‘these ideas’ are clearly items of sensory intake that occur in hearing, seeing etc. But there is nothing sensory about Descartes’ ‘idea’ of God, when he asks what there is ‘in that idea’, and bases his answer on the fact that ‘By the name God I mean a substance that is infinite, eternal, immutable, independent, omniscient, omnipotent…’.
The third antinomy
Both sides of the third antinomy assume that whatever happens is caused to happen. The Antithesis says that the only causality is the causality of nature, in which an event is caused by something earlier. The Thesis denies this, in the interests of an alleged causality of freedom, in which the cause does not ante-date the effect. The Thesis-argument is a genuine reductio ad absurdum: it offers no positive doctrine of freedom, but rather presents an alleged difficulty in the Antithesis. I shall now examine this.
The Thesis-argument starts by arguing, quite cogently, that in the causality of nature every cause must be an event or happening. If it were a ‘preceding state’ which ‘had always existed’, its effect ‘also would have always existed, and would not have only just arisen’. This is important, for it implies that if every event is caused through the causality of nature then every event is caused by an earlier event which is caused by … and so on, without beginning. So no causal-explanatory chain can be completed, or, as Kant says, there can be ‘no completeness of the series on the side of the causes’.
What is the difficulty about that? Kant seems poised to raise a problem about infinity, but in fact he does no such thing. The argument concludes thus:
The law of nature is just this, that nothing takes place without a cause sufficiently determined a priori. The proposition that no causality is possible save in accordance with laws of nature, when taken in unlimited universality, is therefore self-contradictory; and this cannot, therefore, be regarded as the sole kind of causality.
The whole weight falls on the phrase ‘sufficiently determined a priori’, which Kant, typically, does not explain. Here is Kemp Smith's account of what Kant means:
The vital point of this argument lies in the assertion that the principle of causality calls for a sufficient cause for each event, and that such sufficiency is not to be found in natural causes which are themselves derivative or conditioned [or caused].
According to this, the Thesis-argument claims that we have not assigned a sufficient cause for an event if we have merely adduced something which in turn needs explanation but is not explained.
The Cartesian basis
We now start on the Dialectic, beginning with Book II (see §1 above). The first chapter of this, to which my next three chapters will be devoted, is called ‘The Paralogisms of Pure Reason’. Its topic is the soul – i.e. one's mind when considered independently of any beliefs about anything else whatsoever. In this use of ‘soul’, the word has no religious connotations.
I shall use the phrase ‘the Cartesian basis’ to refer to the intellectual situation in which one attends to nothing but one's mind and its states. Descartes worked his way down to the Cartesian basis by ‘feigning doubt’ of everything which did not meet a certain standard of indubitability. That left him with an indubitable residue which he embodied in the statement ‘Cogito’, which I take to stand for any first-person, present-tense statement about one's own mind. Descartes’ standard of indubitability is unattractive, his reason for interest in it is even more so, and his reconstruction on the basis of ‘Cogito’ is lax and self-indulgent. What makes his endeavour still interesting is its representing one's knowledge of one's own states of mind as the foundation for all one's other knowledge. Even if I cannot doubt that I have a body while not doubting that my mind is thus and so, still all my beliefs about bodies somehow rest on what I know about states of my mind. So I am sympathetic to the adoption of the Cartesian basis, i.e. to the position sometimes called ‘methodological solipsism’.
The following evident truths, I submit, show that the Cartesian basis is basic:
(1) Any intellectual problem which I have must, for me, take the form ‘What should I think about x?’
(2) The decision as to what I am to think about x must be taken by me.
(3) My decision as to what to think about x must be based upon data which I have.
(4) How I use my data in reaching my decision must depend upon the concepts, or the intellectual capacities and dispositions, which I have.
These are almost trivial, and yet taken together they imply that the Cartesian basis is the foundation of all knowledge.
Jonathan Bennett's Kant's Dialectic is a landmark work in modern scholarship. Its appearance in 1974 was one of the first expressions of a confluence of three major trends that for fifty years now have played a major role in philosophy. The first trend is the general re-emergence of metaphysics as a source of positive attraction for the best and the brightest in the field. A second surprising trend has been the renaissance of studies in the history of philosophy. Whereas earlier, history and philosophy were often contrasted as two different fields, a historical turn has now taken the form of an avalanche of detailed studies of major modern figures (e.g., Bennett's Locke, Berkeley, Hume: Central Themes, 1971), as well as an incorporation of historical considerations directly in the content of significant systematic argumentation. A third trend is the rehabilitation of Kant's philosophy, and a reconsideration of all aspects of his system as relevant to contemporary thought. Along with P. F. Strawson and Wilfrid Sellars, Jonathan Bennett was a prime analytic instigator of this movement already in the 1960s, with his first book on Kant, Kant's Analytic (1966). This book made Bennett famous as a practitioner of an approach that favours reconstructing a concise and interesting form of argument that seems to be present in the text, and then not hesitating to mercilessly expose its apparent shortcomings, all for the purpose of leading to more satisfactory arguments on the important topics under discussion. Kant's Dialectic employs a somewhat similar approach but expresses a broader perspective, one enriched with considerably more historical detail and reference to relevant predecessors. After an extremely helpful review, in the first three chapters, of the general themes of the ‘Analytic’, that is, the first major section of Kant's Critique of Pure Reason, Kant's Dialectic launches into a path-breaking and detailed treatment of the key metaphysical terms of the second major section of the Critique: substantiality, simplicity, identity, infinity, limits, divisibility, freedom, God, and reason. The mere fact that this part of Kant's text – which had for so long been ignored because of its seemingly old-fashioned themes: rational psychology, cosmology, theology – received such careful attention by Bennett was already a revolution in its time.
The object/process argument
The second Analogy says: ‘All alterations take place in conformity with the law of the connection of cause and effect.’ Kant's ‘proof’ of this is sometimes said to be a sequence of six arguments with no acknowledged breaks between them; while Weldon calls it a single argument with an introduction and a postscript. I think that the ‘proof’ is too much of a jumble for either of these descriptions to be apt. Here, even more than usual, respect for Kant's genius requires an irreverent approach to his text.
A dominant theme in the ‘proof’ of the second Analogy is the relationship between causality and objectivity. Kant has two arguments about this. One of them argues that since self-conscious creatures must have outer experience, they must have experience of a realm which is causally ordered:
If we enquire what new character relation to an object confers upon our representations, what dignity they thereby acquire, we find that it results only in subjecting the representations to a rule, and so in necessitating us to connect them in some one specific manner.
This point was illustrated in §12, where sensory chaos was turned into experience of objective sound-sequences by means of a primitive causal law associating non-master with master sounds; and again in §13, where the sound-sequences were allowed to move and alter, but at a rate limited by yet further causal laws so that the auditory world should not revert to a non-objective chaos. These examples point to Kant's central insight that objectivity is a certain kind of order.
An objective realm must indeed obey causal laws, but the obedience need not be perfect. The physical world would not be shown to be a figment of my imagination just by the occurrence in it of occasional flurries of disorder, occasional happenings which—so far as I could tell—fell under no causal law. Kant, therefore, is still short of his conclusion that all alterations conform to ‘the law of the connection of cause and effect’.
One would hardly expect him to concede this.
Objectivity and ‘what solipsism means’
I want now to justify Kant's preoccupation with the first-person singular case in his treatment of mental identity, and also to introduce an important new aspect of the Transcendental Deduction. These two aims are linked by the concept of an objective state of affairs, which Kant, not quite happily, calls the concept of an object. This is the concept which marks the difference between ‘I have a sensation of warmth’ and ‘There is something hot in my vicinity’, and between ‘I have a visual field as of seeing something red’ and ‘There is something red which I see’.
A good part of Kant's account of this concept can be found in the four paragraphs on A 104–6, but it is also scattered throughout the Transcendental Deduction in both versions: see for example the paragraph on A 128–30, and the two on B 140–2. It is an account which I, like Strawson, have assumed to be fundamentally correct throughout §§11– 13; but it must now be subjected to scrutiny.
Kant's analysis of the concept of an objective state of affairs rests squarely on his phenomenalism. He says that when we think we have knowledge about objects,
the object is viewed as that which prevents our modes of knowledge from being haphazard or arbitrary, and which determines them…in some definite fashion. For in so far as they are to relate to an object, they must necessarily agree with one another, that is, must possess that unity which constitutes the concept of an object.
Thus, if I employ the concept of an object by saying ‘I see something which is red’, I do not merely report my visual field but also commit myself to something about what other intuitions I should have if I were to change my position, close my eyes, etc. That is, I bring my visual field ‘under a rule’ which relates it to other intuitions which I have had, do have, shall have or might have. If the rule is not obeyed, then I have either applied the concept of an object wrongly or erred in introducing it at all.
I have discussed two attempts to derive from the premiss that the outer world must be spatial the conclusion that it must be perfectly Euclidean. In one of these, ‘spatial’ is equated with ‘exactly geometrizable’, and Euclid's is assumed to be the only possible geometry; while in the other, only our actual physical space is considered, and what is said about that is restricted to what could be learned about it from single glances. I want to turn now from the over-discussed conclusion of these two derivations to their common premiss, namely that outer experience must pertain to things in space—in a space, not necessarily in our space or even our kind of space.
I accept this premiss, and shall support it with arguments which I draw not from Kant but from the chapter ‘Sounds’ in Strawson's Individuals. My debt to this chapter is great. If I supply details which Strawson omits, or take his argument in directions which he does not explore, this is because my central concerns are not his.
If we ask, say, what makes a glimpse of a horse-race ‘outer’ and a certain buzzing sound ‘only inner’, we shall have to handle too many differences at once. We must therefore simplify, e.g. by considering one sense only. Smell, taste and sensitivity to temperature are too ill-organized; and sight and touch are too closely linked to physicality, and thus to the familiar contingencies of our kind of space, to be safely used. Strawson therefore adopts the heuristic fiction of a creature—I shall call him ‘the hearer’—whose sensory intake is all auditory.
Suppose that the hearer's sensory history consists in a chaos about which nothing general can be said except that it is auditory and chaotic. Can he find work for the distinction between ‘only inner’ and ‘outer’, i.e. between experiences which are just his auditory states and ones which are hearings of sounds that, independently of him, are there to be heard? Strawson's negative answer is right, of course, but I want to show in detail why.
The form of inner sense
Kant says that time is the form of inner sense, as space is the form of outer sense: all experienced things outside oneself must be spatially ordered, and all experience whatsoever must be temporally ordered.
Here is an analogue. A submarine captain wears sun-glasses all the time and sees beyond his submarine only through a slightly defective periscope: everything he sees looks green, and everything he sees outside his vessel looks blurred as well. This analogue, like the piano one in §5, is inadequate and dangerous. Still, it illustrates Kant's view of the formal relationship between inner and outer sense; and its very defects serve to remind us that Kant, in offering his doctrine of inner sense as synthetic, may have to construe inner sense as a noumenal mechanism which stamps temporality upon its products.
A preliminary point:– I have not spoken of outer experience as itself being spatial or Euclidean, because I do not think that spatial terms can be applied in their ordinary meanings to experience, i.e. to sensory states or sense-data. Those who think that spatial concepts are rooted in visual considerations, and who treat visual sense-data as though they were thin coloured pictures, will cheerfully apply spatial terms to visual sense-data: ‘The green patch is to the left of the red patch and a little larger than it.’ Wishing to avoid this kind of talk, I have spoken of outer experience not as Euclidean but as Euclid-confirming, or as of something Euclidean—or, in the weaker version, of something spatial. The situation changes, however, when we come to the inner-sense theory. It is not satisfactory to express Kant's thesis in the form ‘All inner experience must be of something which is temporal’, for some inner experience is not in any plain sense ‘of’ anything at all. (I here reject Kant's unhappy notion that, just as outer experience is one's encounter with an objective realm, inner experience is one's encounter with oneself.) But we can speak of experience as being itself temporal in a way in which we cannot speak of it as being itself spatial.
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