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PHARMACY MANAGEMENT
ESSENTIALS FOR
ALL PRACTICE SETTINGS
 Notice
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PHARMACY MANAGEMENT
ESSENTIALS FOR
ALL PRACTICE SETTINGS
FIFTH EDITION

David P. Zganick, PhD, FAPhA Ldicia R. Moczygemba, PbannD, PhD

Professor Associate Profussor
Sc:hoolofPhannacy Health Outcomes Division
Bouve College of Health Sciences The University ofTeus College of Pharmacy
Northeastem University .Associate Director
Boston, Massachusetts Tew Center for Health Outcomes .Research.
and Education
Greg L. AI.ton, PharmD
Professor and Associate Dean
South Univcnity Savannah Campus Shane P. Deuelle, RPb, PbD, FAPhA
Savmnah, Georgia Professor, College of Pharmacy
Touro Univenity California
Vallejo, California

New York ChiQ&O San Francisoo Ad=. London Madrid Mexico City
Milan New Dclh.i Singapore Sydney Toronto
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DEDICATION

To Michelle, Seamus, Zoe, and Fiona (D.P.Z.)

To Travis and Ashton (L.R.M.)
To June (G.L.A.)
and
To Deborah and Brittney (S.P.D.)
CONTENTS

Contributors I ix
Preface I xiii
Acknowledgmcnts I xvii

I. WHY STUDY MANAGEMENT IN PHARMACY SCHOOL? 1

Chapter 1 The "Management" in Medication Therapy Management 3
Chapter 2 Management Functions 21
Chapter 3 Leadership in Pharmacy Practice 35
Chapter4 Ethical Decision-Making, Problem-Solving, and Ddegating Authority 55
Chapter 5 Creating and Managing Value 75

II. MANAGING OPERATIONS 89

Chapter6 Strategic Planning in Pharmacy Operations 91
Chapter? Business Planning for Pharmacy Programs 109
Chapter 8 Operations Management 127
Chapter 9 Managing Technology that Supports the Medication Use Process 141
Chapter 10 Ensuring Quality in Pharmacy Operations 161
Chapter 11 Risk Management in Contemporary Pharmacy Practice 187
Chapter 12 Preventing and Managing Medication Errors: The Pharmacist's Role 205
Chapter 13 Compliance with Regulations and Regulatory Bodies 233

III. MANAGING PEOPLE 253

Chapter 14 Managing Yourself for Success 255
Chapter 15 Negotiation Skills 275
Chapter 16 Organizational Structure and Behavior 293
Chapter 17 Human Resources Management Functions 325
Chapter 18 The Basics of Employment Law and Workplace Safety 347
Chapter 19 Pharmacy Technicians 367
Chapter 20 Performance Appraisal Systems 391

IV. MANAGING MONEY 415

Chapter 21 Financial Reports 417
Chapter 22 Budgeting 437
Chapter 23 Third-Party Payer Considerations 455
vii
viii CONTENTS

v. MANAGING TRADITIONAL GOODS AND SERVICES 481

Chapter 24 Marketing Fundamentals 483
Chapter 25 Marketing Applications 513
Chapter 26 Customer Service 535
Chapter 27 Supply Chain Management 557
Chapter 28 Merchandising 585

VI. MANAGING VALUE-ADDED SERVICES 607

Chapter 29 Value-Added Services as a Component of Enhancing Pharmacists'
Roles in Public Health 609
Chapter 30 Implementing Value-Added Pharmacist Services 625

VII. MANAGEMENT APPLICATIONS IN SPECIFIC

PHARMACY PRACTICE SETTINGS 655
Chapter 31 Entrepreneurship and Innovation 657
Chapter 32 Applications in Independent Community Pharmacy 671

Index I 695
CONTRIBUTORS

Jennifer L. Adams, PhannD, &ID

Clinical Associate Professor and Associate Dean fur Academic .Affitlrs, College of Pharmacy, Idaho State University,
Sam and Aline Skaggs Health Science Center, Meridian, Idaho

Greg L Alston, PhannD

Professor and Associate Dean, South University Savannah Campus, Savannah, Georgia
Chief Value Officer, Pharmacist Success Academy

Mitch Hamett, PhannD, MS

Associate Professor, Touro University California, Vallejo, California

John P. Bentley, PhD

Professor and Chair, Department of Pharmacy Administration, School of Pharmacy, University of Mississippi,
University, Mississippi

Steve Boone
Pharmacy Insurance Practice Leader, Heffernan Insurance Brokers, Chesterfield, Missouri

Peter T. Bulatao, PharmD, MS, MMAS, BCPS, BCACP

Associate Professor, Pharmacy Practice, South University Savannah Campus, Savannah, Georgia

Leigh Ann Bynum, PhD

Associate Professor, Pharmaceutical Sciences, Belmont University College of Pharmacy, Nashville, Tennessee

I.amen M. Caldas, PharmD, BCACP

Assistant Professor, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia

PatrickJ. Campbell, PharmD

Director of Measurement Outcomes Research, Pharmacy Quality Alliance, Alexandria, Virginia

Antoinette B. Coe, PharmD, PhD

Assistant Professor, University of Michigan College of Pharmacy, Ann Arbor, Michigan

Edward Cohen, PhannD

Executive Vice President, Pharmacy Advocacy, Michael JHennessy Associates, Inc., Plainsboro, New Jersey

Michael R. Cohen, RPh, MS, Sc:D

Founder and President, Institute for Safe Medication Practices, Huntington Valley, Pennsylvania

ix
x CONTRIBUTORS

Shane P. Desselle, RPh, PhD, FAPhA

Professor, College of Pharmacy, Touro University California, and President, Applied Pharmacy Solutions,
Vallejo, California

Andrew J. Donnelly, Pha.nnD, MBA

Director, Pharmacy Services, University of Illinois Hospital and Health Sciences System, Clinical Professor
of Pharmacy Practice and Associate Dean for Clinical AfFairs, University of Illinois at Chicago, College of
Pharmacy, Chicago, Illinois

Brent I. Fox, PhD, Pha.nnD

Associate Professor, Department of Health Outcomes Research and Policy, Harrison School of Pharmacy,
Auburn University, Auburn, Alabama

PerryL Fri
Executive Vice President of Industry Relations, Membership and Education, Healthcare Distribution Alliance
(HOA} and Chief Operating Officer, HOA Research Foundation, Alexandria, Virginia

Eric Fromhart, PhannD

Co-founder and President, Secure340B.oom, Philadelphia, Pennsylvania

Caroline M. Gaither, PhD

Professor, Department of Pharmaceutical Care and Health Systems, Senior Associate Dean, Professional
Education Division, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota

David Gettman, MBA, PhD

Professor, D'Youville College School of Pharmacy, Buffalo, New York

Matthew Grissinger, RPh, FISMP, FASCP

Director, Error Reporting Programs, Institute for Safe Medication Practices, Huntington Valley, Pennsylvania

Dana P. Hammer, RPh, PhD

Faculty Lead for Student Professional Development, Skaggs School of Pharmacy and Pharmaceutical Sciences,
University of Colorado, Denver, Colorado

Karl M. HC5S, PharmD, APh, CTII, FCPhA, AFfM RCPS (Glasg)

Associate Professor of Pharmacy Practice, Director, Community Pharmacy Practice Innovations,
Department of Pharmacy Practice, Chapman University School of Pharmacy, Harry and Diane Rinker
Health Science Campus, Irvine, California

Susan E. Higgins, MBA

Independent Management and Strategy Consulting Serving the Health Care Industry
 CONTRIBUTORS xi

Kenneth C. Hohmeier, PharmD

Associate Professor of Clinical Pharmacy and Translational Science, Director of Community Affairs,
University ofTennessee Health Science Center College of Pharmacy, Memphis, Tennessee

Erin R. Holmes, PhD, PharmD

Associate Professor, University of Mississippi School of Pharmacy, Oxford, Mississippi

Jan M. Keresztes, PhannD, F.ASHP

Senior Educator, Pharmacy, Talent First PBC, Orland Park, Illinois

Michael L Manolakis, PhD

Vice President, National Pharmacy Practice Group, Aon Consulting, Charlotte, North Carolina

Ema Mesic, MPH

Manager, Retail and Pharmacy Projects, Walgreens, Deerfield, Illinois

Leticia R. Moaygemba, PhannD, PhD

Associate Professor and Associate Director, Texas Center for Health Outcomes Research and Education,
Health Outcomes Division, The University of Texas College of Pharmacy, Austin, Texas

Rashid Mosavin, PhD

Dean and Professor, College of Pharmacy and Health Sciences, Texas Southern University

Md L Nelson, PhannD
Director of Research and Academic Affairs, Pharmacy Quality Alliance, Alexandria, Virginia

Jacob T. Painter, PharmD, MBA, PhD

Associate Professor, Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical
Sciences, Little Rock, Arkansas

Evan T. Robinson, PhD

Dean and Professor, College of Pharmacy and Health Sciences, Creighton University, Omaha, Nebraska

Meagan Rosenthal, PhD

Assistant Professor, Department of Pharmacy Administration, University of Mississippi School of Pharmacy,
Oxford, Mississippi

Thad Schumacher, PhannD

Pharmacist and Owner, Fitchburg Family Pharmacy, Fitchburg, Wisconsin

Glen T. Schumock, PhannD, MBA, PhD

Dean and Professor, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
xii CONTRIBUTORS

Mark H. Siska, BS Phann, MBAfTM

Chief Pharmacy Informatics Officer, Mayo Clinic, Rochester, Minnesota

Todd D. Sorenson, PharmD, FAPhA, FCCP

Professor and Associate Head, Department of Pharmaceutical Care and Health Systems, College of Pharmacy,
University of Minnesota, Minneapolis, Minnesota

Rachel Sullivan
Project Manager, HDA Research Foundation, Alexandria, Virginia

Benjamin S. Teeter, PhD

Assistant Professor, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Kyle M. Turner, PharmD, BCACP

Assistant Clinical Professor, University of Utah College of Pharmacy, Salt Lake City, Utah

Benjamin Y. Urick, PhannD, PhD

Research Assistant Professor, Center for Medication Optimization, Eshelman School of Pharmacy, University of
North Carolina, Chapel Hill, North Carolina

Julie M. Unnie, PhD

Associate Professor, University oflowa College of Pharmacy, Iowa City, Iowa

Terri L Warholak, PhD, RPh

Professor and Assistant Dean of Academic Affairs and Assessment, University ofArizona College of Pharmacy,
Tucson, Arizona

Wdliam Wynn, PharmD

Assistant Professor, Experiential Education Coordinator, and Director of lnterprofessional Education,
South University Columbia Campus, Columbia, South Carolina

David P. z.gamck, PhD, FAPhA

Professor, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
PREFACE

• WHY DID WE CREATE THIS TEXTBOOK?

Pharmacy remains a very exciting profession; in fact, more opponunities are available for pharmacists, pharmacy
students, and educators than ever before. The roles of pharmacists in interprofessional health care teams continue
to evolve, as does their recognition by payers and policy makers. Pharmacists continue to transform the delivery
of their services to accentuate the critical nature of publlc health and proactive health care. But with new oppor-
tunities also come challenges, including the challenge of how to manage the personal and professional resources
necessary to succeed in today's ever-changing environment.
Educators must not only keep up with changes in pharmacy practice, but also anticipate and prepare our
students for opponunities and contingencies that will arise throughout their professional careers. In our efforts to
best prepare students, pharmacy management educators have increasingly had to gather teaching materials from
a variety of textbooks, journals, and other educational resources. This is due to the fact that many resources only
focus on a specific management function (marketing, personnel, accounting, and finance) or a specific practice
setting (independent pharmacies, hospital pharmacies). We believed that there would be value in a comprehen-
sive pharmacy management textbook that covered many content areas and gathered a variety of resources into
one text. We also aimed to develop a text that uses "evidence-based management"; that is, material derived from
the best and most contemporary primary literature, but that which at the same time focuses on the appllcation
of knowledge into skills that pharmacists will use every day.

• NEW CONTENT IN THIS EDITION!

In planning for a fifth edition of this text, we sought input from faculty who teach pharmacy management, as
well as from pharmacy students and pharmacists who apply management principles in their daily practice. We
llstened carefully to users also while scanning the latest advances in teaching strategies to produce the fifth edi-
tion. Of course, we also considered the many changes in pharmacy practice, management, and health systems
reform that have occurred during the past few years.

• Every chapter has been updated to reflect the fluid nature of its respective management topic.
• New trends in the management literature are reflected in each of the chapters, including management trends
within and beyond pharmacy.
• Some chapters have been revised substantially and with new authors to provide users of the text with the most
relevant information. Examples include the following:
• Sustaining medication therapy management services through implementation science as well as other mod-
els of care delivery, such as continuous medication monitoring (CoMM).
• Leveraging leadership skills into practice by guiding change management, establishing a culture of employee
self-motivation, extracting the most from your resources and infrastructure, all while advocating for your
profession and the patients you serve.
• Broadening our views of how pharmacists manage the supply chain, particularly to ensure that they can
access safe and effective medications and other resources that are needed by their patients.
xiii
xiv PREFACE

• Maintaining compliance with laws, rules, and regulations which impact a pharmacy manager's ability to
care for patients and manage their practice.
• Developing new ways of organizing and managing our time for our own success and the success of others,
particularly given the challenges and opportunities provided by social media and other forms of technology.
We have also added new chapters commensurate with contemporary pharmacy practice in anticipation of
continually evolving models of care. These include:
• Ethical Decision Making, Problem Solving, and Delegating Authority, where pharmacists utilize appropriate
judgment processes when faced with decisions of how to optimize care in the face of budgetary constraints
and preferences of various stakeholders in the medication use process.
• Negotiation Skills, a skill needed through various components of practice, ranging from encouraging treatment
adherence from patients, to requesting a change from the prescriber in a patient's medication regimen, to
adjudicating a fair contract with a third-party payer for the services renders to covered enrolees.
• Pharmacy Technicians, the persons to whom pharmacists are increasingly delegating more responsibility and
greater numbers of tasks that pharmacists used to perform so that they can now spend more time in direct
patient care activities.

• NEW FEATURES IN THIS EDITION!

Management education encompasses a broad constellation of knowledge, skills, abilities, and attitudes required
to become an effective leader. It is difficult for instructors to possess the breadth of experience across all aspects
of pharmacy management to intuitively design structured lesson plans to effectively educate their students. With
that in mind, the editors of the fifth edition have developed tools to assist instructors with teaching the concepts
covered in this book. Instructors who adopt the textbook will have full access to these resources which include:
(1) PowerPoint~ slides that cover the core content of each chapter; (2) lesson plans built on the Understanding
by Design model developed by Jay McTighe and Grant Wiggins. These plans guide the course leader through the
three stages oflesson design: (1) focusing on the big ideas within the content; (2) crafting fair, valid, and reliable
assessments of the desired results; and (3) creating an effective and engaging learning unit.

• WHAT WILL THE READER FIND IN THIS TEXTBOOK?

This textbook is organized to reflect all of the major management functions performed by pharmacists in any
practice setting. The book is divided into sections representing each function, and is further divided into chapters
that detail the various components of each function.
Our experience as educators has taught us that students are the most effective learners when they are "ready"
to learn. Many students selected pharmacy as a major in part from the desire to help people, but also due to
their fascination and intrigue with how such small amounts of various medicinal substances have such profound
effects on the body. Many of these students also believe that they only need to learn about management after they
graduate, and then only if they take on a managerial or administrative position at their pharmacy. The first sec-
tion of this book makes the case that management skills are imponant for all people and pharmacists, regardless
of their position or practice setting. In an environment of increasingly scarce resources and higher accountability,
we also help the reader to understand and create the value proposition for themselves, their services, and their
 PREFACE xv

organization. After establishing the need for management in both our personal and professional lives, the next
four sections describe the management functions and resources that are common to all pharmacy practice set.-
rings (operations, people, money, traditional pharmacy goods and services). Chapters within each section focus
on important aspects of each function or resource.
As pharmacy practice moves from a product orientation to a patient orientation, there are unique challenges
that arise in managing the value-added services that pharmacists are devdoping to meet patient needs in medic~
tion therapy management. A section of this book is dedicated to the planning, implementation, and reimburse-
ment of these new patient care services offered by pharmacists.
Several chapters are dedicated to describing the risks inherent in pharmacy practice and the impact that
laws, regulations, and medication errors have on pharmacy management. The final section describes how man-
agement functions are applied by entrepreneurs and intrapreneurs in settings ranging from independently owned
community pharmacies to those devdoping new goods, services, and ideas in any setting to meet needs related
to medications and their use.

• HOW EACH CHAPTER IS ORGANIZED?

Each chapter is divided into several sections to facilitate the reader's understanding and application of the mate-
rial. Chapters begin with a list of learning objectives that outline the major topics to be addressed. A brief sce-
nario is used to describe how a pharmacy student or pharmacist may need or apply the information described
in this book in their daily lives or practice. Questions at the start of each chapter provide direction and assist the
reader in understanding what they can expect to learn.
The text of each chapter provides comprehensive coverage of the content and theory underlying the major
concepts. References to the management and pharmacy literature are commonly used to provide readers with
links to additional background information. Explanations and applications are also used to hdp readers better
understand the need to master and apply each concept. Questions at the end of each chapter encourage readers
to think about what they have just learned and apply these concepts in new ways.

• WHAT WE HOPE YOU WILL GAIN FROM THIS BOOK?

If you are a pharmacy student, we hope that using this book will help you gain an appreciation for the roles of
management in pharmacy practice, regardless of your future position or practice setting. This book will also
provide you with a variety of management theories and cools that you can apply in your daily life.
We realize that many pharmacists have not had much management coursework in their formal education
or professional training. We hope that this book serves as a valuable guide to pharmacists who may require some
assistance in dealing with matters they did not anticipate when embarking on their careers. For those pharmacists
with formal management education and experience, we hope that this book serves as a valuable reference or as a
source of new ideas that can be applied in daily practice.
For educators, this book has been designed as a comprehensive pharmacy management textbook. As a
whole, it is meant to be used in survey courses that cover many areas of pharmacy management. The section
format also allows the book to be used in courses that focus on specific pharmacy management functions or top-
ics. The sections and content of each chapter are meant not only to provide valuable information that is easy for
students to understand but also to stimulate further discussion and motivate students to learn more on their own.
xvi PREFACE

• WE WOULD LIKE TO HEAR FROM YOU!

The creators of each chapter have put a great deal of time and effort into getting their final outputs ready for
consumers, but it rarely can be considered a "finished product." Textbooks are "works in progress" that can always
be improved. The best way to improve these products is to seek input from our users. As you use this book,
we would like to learn what you like about it, what could be improved, and what topics or features you would
like to see included in the future. Please feel free to share your thoughts at any time by contacting us through
pharmacy@mcgraw-hillcom. We plan to improve this book over future editions by listening to your feedback and
continuing to reflect changes in the management sciences and pharmacy practice.

For Ancillaries, please go to the Pharmacy tab at:

https://www.mhprofessional.com/desselle5e
ACKNOWLEDGMENTS

We would like to thank the colleagues who have played provided an environment that makes this type of
an important role in our development throughout our endeavor possible. We would also like to thank all of
undergraduate, professional, and graduate studies, as the students we have taught who have inspired us to
well as at our institutions. In addition, as our careers continue to strive to become better educators.
have advanced, we also have come to know many We would like to thank everyone at McGraw-
great academicians in other disciplines and other Hill Education and, in particular, our editor, Michael
leaders in pharmacy who have greatly influenced our Weitz, for working with us to improve this compre-
careers and provided keen guidance. We have learned hensive pharmacy management textbook.
so much from all these people and feel fortunate that Finally, we would like to acknowledge the efforts
they have been willing to share their knowledge and of each of our chapter authors. We chose our authors
experience with us. not only because of their expertise but also because
Thanks must also go to all the faculty, staff, and of their dedication to teaching and the professional
administrators at Northeastern University, University development of pharmacy students and pharmacists.
of Texas College of Pharmacy, South University There is no way in which we could have completed
Savannah Campus, and Touro University who have this textbook without their efforts.

xvil
SECTION I

WHY STUDY MANAGEMENT IN

PHARMACY SCHOOL?
THE "MANAGEMENT" IN
MEDICATION THERAPY
MANAGEMENT
Shane P. Desselk, Leticia. R Moczygemba, DaviJ P. Zgarriclt, and Grtg L. Alston

bout the.Auihon: Dr. Desselle is a professor of Social, Behavioral, and Admin.istrative

A Pharmacy at Touro University California College of Pharmacy. His rcsean:h program

focuses on optimizing mles fur pharmacy technicians, development of mentorship
programs, and in promoting healthy organizational cultures and citizenship bchaviors in pro-
fessional settin~. He is a Fulbright Specialist Scholar having completed a project to develop
a Center of Assessment for the University of Pristina in Kosovo. Dr. Desselle is a Founding
Editor-in-Chiefof the international peer-reviewed journal, Research in Social and Administra-
ti~ Pharmacy with graduate students and collaborations worldwide on various projects such
as medication safety and medication adherence issues with informal cazegivers. Dr. Desselle
also is a primary author for the Pharmacy Management Tips of the Week on .AccessPharmacy
that accompany this te:lttbook.
Dr. Moczygemba is an associate professor and associate director of the Texas Center
for Health Outcomes Research and Education at The University ofTaas College of Pharmacy.
Her reseuch program focuses on working with communities and health S}'3tems to mitigate
health disparities by developing patient-ccntered interventions to optimize medication-related
health outcomes. She has worked to advance the health care of homeless individuals, older
adults, and those living in rural areas through. the development, implementation, and evalu-
ation of care models that integrate pharmacists with health care team&. She teaches in the
health care systems course in the Doctor of Pharmacy (PharmD) program and is engaged. in
interprofe&sional education initiatives with a focw on quality improvement and patient safety.
Dr. Zganick is a professor in the School of Pharmacy at North.eastern Univenity's Bouve
College of Health Sciences. He received a BS degree in pharmacy from the University of
Wisconsin and a MS and PhD in pharmaceutical administration from the Ohio State Univer-
sity. He has practice experience in both independent and chain community pharmacy settin~.
He has taught courses in pharmacy management, business planning for professional services,.
and drug literature evaluation. His scholarly interests include pharmacist workforce research,
pharmacy management and operations, pharmacy education, and the development of post·
graduate programs.
Dr. Alston is Associate Dean and professor, Savannah Campus, South University School
of Pharmacy. He has over 30 years of experience in community pharmacy management, both
3
4 WHY STUDY MANAGEMENT IN PHARMACY SCHOOL?

as a chain pharmacy administrator and an independ- and The Ten Things A New Manager Must Get /Ught
ent pharmacy owner. He earned a Doctor of Phar- From the Start, and Own Your ~lue- The Real Future
macy degree from the University of the Pacific and ofPharmacy Practice. His passion lies in teaching the
has published three best-selling management books, next generation of pharmacists how to create value for
The Bossho/e Effect-Managing People Simplified the stakeholders they serve.

• LEARNING OBJECTIVES
After completing this chapter, readers should be able to
1. Identify changes in the roles of pharmacists since the early 1900s.
2. Describe how pharmacy practitioners and educators viewed the need for man-
agement skills as the roles of pharmacists evolved.
3. Identify principal domains of pharmacy care.
4. Describe how management skills and functions fit within the context of provid-
ing medication therapy management services.
5. Identify myths surrounding the practice of pharmacy and health care as a business.
6. Evaluate the need for a management perspective to better serve patients and
improve outcomes to drug therapy.
7. List the managerial sciences and describe their use as tools to assist pharmacists
in practice.

• SCENARIO students having already completed the course, she is

concerned. "What do I have to take this course for?
Stephanie Chen has just completed the first 2 years of I did not come to pharmacy school for this. I'm very
a PharmD curriculum. Despite many long hours of good at science. If I liked this kind of stuff, I would
hard work and a few anxious moments preparing for have majored in business. How is this going to help
examinations, she has been pleased with her educa- me to become a better pharmacist?" she asks hersd£
tional experience. She perceives that as she continues After some thought, she comes to realize that, at
progressing through the curriculum, the upcoming worst, taking this course will not be the end of the
courses will be more integrated and directly appli- world, and even better, it simply might be a mod-
cable to pharmacy practice. She is especially excited erate intrusion in her Monday-Wednesday-Friday
about taking courses in pharmacology and therapeu- routine. She begins to focus on other issues, such as
tics so that she can "really learn about how to be a her part-time job at Middletown South Pharmacy.
pharmacist." As she glances down at her schedule and Lately, she has been dreading each day she goes to
sees that she is enrolled in a required course in phar- work there. The staff consistently seems rushed
macy management, her enthusiasm becomes some- and impatient. There always seems to be conflict
what tempered. She immediately consults with fellow among the employees, and as soon as one fire has
students on what they have heard about the course, been put out, another larger one begins to burn. She
and they tell her that the course is about "finance, regrets her decision to quit her job at Middletown
accounting, personnel management, and market- North Pharmacy 3 months ago, even though it took
ing." Despite some positive comments provided by 20 minutes longer to get there. Things always
 The "Management" in Medication Therapy Management 5

seemed to run smoothly at Middletown North. and empathic and seek personal reward and self-
Mary even noticed that the patients at Middletown actualization through the helping of others (Meyer-
North seemed happier and healthier than those at Juncol., 2015, Pohontsch et al., 2018; Warshawski et
Middletown South. al., 2018). Finally, many pharmacy students also con-
sider the relatively high salaries of their chosen profes-
sion prior to choosing a college major and a career
• CHAPTER QUESTIONS pathway. While few fields guarantee graduates a job,
and certainly not one with entry-level salaries in the
1. How have pharmacists' roles in delivering goods
six figures, pharmacy srudents take comfort in know-
and services evolved over the past few decades?
ing that employment in their profession will provide
What roles and functions do pharmacists perform
them with a generous and steady stream of income.
today?
It comes as no surprise that pharmacists and pharmacy
2. What is the significance of management within
students have been shown to be risk-averse individuals
the context of the profession's movement toward
who do not deal with uncertainties particularly well
the provision of direct patient-care services such as
(Latif, 2000; Leung et al., 2018). This further explains
medication therapy management? Why has its sig-
their gravitation toward science-oriented courses that
nificance typically been overlooked by pharmacists
offer straightforward solutions to problems.
and pharmacy students?
Unbeknown to many pharmacy students is that
3. What are some of the myths surrounding the con-
the actual practice ofpharmacy does not present a suc-
fluence of business practices and the provision of
cession of problems that can be resolved in such a lin-
patient care by pharmacists?
ear manner. While the sequential processes involved
4. What evidence exists that a business perspective is
in community pharmacy practice have remained the
critical to provide effective pharmacy services to
same-patients present with prescriptions, pharmacy
patients?
personnel fill them, and the necessary counseling
5. What are the managerial sciences, and how can
is offered or provided by the pharmacist-a careful
pharmacists use them effectively?
introspection reveals that the profession has under-
gone a rapid, head-turning transformation over just
• INTRODUCTION the past few decades. Pharmacists now are increas-
ingly involved with providing direct patient-care ser-
The preceding scenario, though perhaps overly sim- vices in addition to dispensing medications, and are
plistic, captures the feelings of many students who taking greater responsibility for patients' outcomes
select pharmacy as a major. They generally are inter- arising from drug therapy. Pharmacists have become
ested in science, have a desire to help people in need, more integrated into health care delivery teams that
and prefer a career offering long-term financial secu- coordinate patient care through the implementation
rity. Given that the pharmacy curriculum consists of of evidence-based guidelines and treatment algo-
courses that apply knowledge from physics, chem- rithms. This has been even further accelerated by
istry, anatomy, physiology, and therapeutics, most recent changes in states' pharmacist scope of practice
pharmacy students achieved success in science and regulations, collaborative practice agreements, reim-
math courses throughout their pre-pharmacy studies bursement incentives from payers, and the reorganiza-
(Keshishian et al., 2010). Second, students select- tion of health care delivery into medical home models
ing pharmacy as a major typically are attracted to and accountable care organizations (George et al.,
health care fields and may have contemplated nursing, 2018; Isasi & Krofah, 2015; McConaha et al., 2015).
medicine, or other health professions. Research has For students to better understand the way that
demonstrated that people in health care are caring pharmacy is practiced today, time should be devoted
6 WHY STUDY MANAGEMENT IN PHARMACY SCHOOL?

to understanding the major forces that have shaped Pharmacy was, at best, a "marginal" profession.
the profession. This chapter begins with a brief his- Most practitioners entered the occupation through
tory of the evolution of pharmacy practice in the 20th apprenticeships rather than formal education. The
century. This history, coupled with a snapshot of con- pharmacist's principal job function was described
temporary pharmacy practice, will make it clear that as the "daily handling and preparing of remedies in
the past and current pharmacy practice models are as common use" (Sonnedecker, 1963, p. 204). Phar-
much about management as they are about clinical macists, or "apothecaries," were often engaged in the
pharmacy practice. The chapter proceeds by pointing wholesale manufacture and distribution of medici-
out myths about the exclusivity of the pharmacy busi- nal products. Pharmacists' roles during this time
ness and patient outcomes and by providing evidence were considerably different than they are today. In
that what is best for the operation of a pharmacy busi- the early 20th century, pharmacists' primary roles
ness is often also best for the patients and other stake- were to procure raw ingredients and extemporane-
holders that it serves. The chapter concludes with a ously compound them into drug products for con-
brief discwsion of the managerial sciences-tools sumer use. While pharmacists had yet to achieve
that every practitioner will find weful at one point or recognition as health care professionals, they often
another regardless of the practice setting. This chapter had considerable autonomy in their practice. There
and all other succeeding chapters we an evidence-based was no dear distinction between "prescription" and
approach to discuss pharmacy management, relying "nonprescription" drugs. Although physicians were
on recent literature and research findings to describe engaged in the process of writing prescriptions,
and explain what is happening in practice today. pharmacists were not precluded from dispensing
Students are encouraged to explore readings of inter- preparations without a physician's order. Consum-
est among the references cited throughout the text. ers commonly relied on their pharmacists' advice
on minor ailments, and often entrusted the nick-
name of "doc" to their neighborhood pharmacist
• A BRIEF HISTORICAL (Hepler, 1987).
OVERVIEW OF PHARMACY Pharmacists had little choice but to have sharp
PRACTICE bwiness acumen to survive. Since few of the products
they dispensed were prefabricated by manufacturers,
There have been several noteworthy efforts to describe pharmacists had to be adept at managing inventories
the evolution of pharmacy practice. Some have of bulk chemicals and supplies wed in compound-
described the process within the context of "waves," ing the preparations they dispensed. They also had to
or shifts, in educational and indwtrial forces (Hepler, have a keen sense of how to manage time and people
1987), another through identifying stages of profes- to accomplish a series of complex tasks throughout the
sional identity (Hepler & Strand, 1990), and still workday.
another through describing activation of pharmacists' A series of studies commissioned by the US gov-
setvices as stewards of public health in a medical care ernment in the early 1900s produced what became
system increasingly challenging for patients to navi- known as the "Flexner reports" in 1915. These reports
gate (Blanchard et al., 2017). While these approaches were critical for health care professionals and their edu-
appear quite different, their descriptions of the princi- cation, including pharmacists. The reports questioned
pal drivers of change closely mirror one another. the validity and necessity of pharmacists as health
care professionals. Shortly thereafter, the American
Pharmacy in the Early Twentieth Century Association of Colleges of Pharmacy (AACP) com-
Pharmacy in the United States began in the 20th missioned a study directed by W. W. Charters that
century much like it existed in the latter 1800s. ultimately served as the basis for requiring a 4-year
 The "Management" in Medication Therapy Management 7

baccalaureate degree program for all colleges of phar- and content driven. A fifth year of education was
macy (Hepler, 1987). These and other forces led to added to the 4-year baccalaureate degree by colleges
dramatic changes in pharmacy in the coming years. and schools of pharmacy during the late 1940s and
early 1950s following the AACP Committee on Cur-
Pharmacy in the Middle of the riculum report entitled, "The Pharmaceutical Cur-
Twentieth Century riculum" (Hepler, 1987). It was during this time
The 1940s through the 1960s often have been referred that pharmacology, pharmaceutics, and medicinal
to as the "era of expansion" in health care (Smyrl, chemistry matured as disciplines and became the
2014). The Flexner reports paved the way for a more core of pharmacy education. Pharmacy students were
scientifically sound, empirically based allopathic required to memorize an abundance of information
branch of medicine to become the basis by which about the physical and chemical nature of drug prod-
health care was practiced and organized. The federal ucts and dosage forms. Courses in the business aspects
government invested significant funds to expand the of pharmacy took a secondary role, whereas education
quantity and quality of health care services. The in patient care (e.g., communications, therapeutics)
Hospital Survey and Construction (Hill-Burton} Act was for all intents and purposes nonexistent.
of 1946 provided considerable funding for the reno- With the APhA Code of Ethics suggesting that
vation and expansion of existing hospitals and the pharmacists not discuss drug therapies with patients,
construction of new ones, primarily in underserved the profession lost sight of the need for pharmacists
inner city and rural areas (Torrens, 1993). to communicate effectively with patients and other
Ironically, pharmacists began to see their roles health care professionals. As the number of hospital
diminish during this era of expansion in health care. and chain pharmacies expanded, resulting in pharma-
Among the factors responsible for this decline were cists being more likdy to be an employee than a busi-
advances in technology and in the pharmaceutical sci- ness owner, the importance of practice management
ences, coupled with societal demands that drug prod- skills was not stressed in schools of pharmacy. Ironi-
ucts become uniform in their composition. These cally, studies such as the "Dichter report" commis-
brought about the mass production of prefabricated sioned by the APhA revealed that consumers regarded
drug products in tablet, capsule, syrup, and dixir dos- pharmacists more as merchants than as health care
age forms, thus significantly reducing the need for professionals (Maine & Penna, 1996).
pharmacists to compound prescription orders. The
passage of the Durham-Humphrey amendment to
the Food, Drug, and Cosmetic Act in 1951 created a Pharmacy in the Latter Part of the
prescription, or "legend," category of drugs. Pharma- Twentieth Century
cists did not have the ability to dispense these drugs The era ofexpansion slowed in the 1970s when society
without an order from a licensed prescriber. Finally, began to question the value obtained from the larger
pharmacy's own "Code of Ethics" promulgated by the amount of resources being allocated toward health
American Pharmaceutical Association (APhA) stated care. Congress passed the Health Maintenance Act of
that pharmacists were not to discuss the therapeutic 1973, which helped to pave the way for health main-
effects or composition of a prescription with a patient tenance organizations (HMOs) to become an integral
(Buerki & Vottero, 1994, p. 93). This combination of player in the ddivery of health care services. Govern-
forces relegated the role of the pharmacist largely to a ments, rather than the private sector, took the lead
dispenser of pre-prepared drug products. in attempting to curb costs when they implemented
The response of schools and colleges of pharmacy a prospective payment system of reimbursement for
to these diminishing professional roles was the crea- Medicare hospitalizations based on categories of
tion of curricula that were more technical, scientific, diagnosis-related groups (Pink, 1991).
8 WHY STUDY MANAGEMENT IN PHARMACY SCHOOL?

In 1975 the Millis Commission's report, Pharma- pharmacists willing and knowledgeable enough to
cists for the Future: The &port ofthe Study Commission provide patient-oriented clinical services face signifi-
on Pharmacy (Millis, 1975), suggested that pharma- cant barriers when practicing in a community phar-
cists were inadequately prepared in systems analysis macy environment (Blalock et al., 2013; Kennelty
and management skills and had particular deficien- et al., 2015; Schommer & Gaither, 2014). In addi-
cies in communicating with patients, physicians, and tion, the growth of mail order services in the outpa-
other health care professionals. A subsequent report tient pharmacy setting virtually excludes face-to-face
suggested incorporating more of the behavioral and consultation with patients. Mail order pharmacy has
social sciences into pharmacy curricula and encour- become a significant channel for the distribution of
aged faculty participation and research into real prob- pharmaceuticals and is used by the Veterans Admin-
lems inherent in pharmacy practice (Millis, 1976). istration system and many pharmacy benefits managers.
Prior to these reports, the American Society of Many brick-and-mortar pharmacy operations now
Hospital Pharmacists had published Mirror to Hospital have a significant mail order component to their
Pharmacy stating that pharmacy had lost its purpose, business as well. While providing consumers with a
falling short of producing health care professionals convenient way to obtain drug products, this form
capable of engendering change and noting that frw- of commerce has the potential to further remove the
tration and dissatisfaction among practitioners were pharmacist from patients and others who could ben-
beginning to affect students (Hepler, 1987, p. 371). efit from their clinical services. Moreover, this trend
The clinical pharmacy movement evolved in the has continued; at the time of writing this chapter,
1970s to capture the essence of the drug use control the massive e-retailer Amazon had begun its foray
concept forwarded by Brodie (1967) and promoted into the prescription drug market initially through
the pharmacist's role as therapeutic advisor. The clini- the purchase of a company (PillPack) that delivers
cal pharmacy movement brought about changes in medication to patients through the mail in packag-
pharmacy education and practice. After being intro- ing aimed to improve patient adherence (LaVito &
duced in 1948, the 6-year PharmD degree became the Hirsch, 2018). With Amazon's advantages in supply
only entry-level degree offered by a small number of chain and operational cost-savings (see Chapter 27),
colleges of pharmacy as early as the late 1960s and this could provide for a momentous disruption in the
early 1970s. The additional year of study was devoted prescription drug market. However, as described fur-
mostly to therapeutics or "disease-oriented courses" ther in this chapter and in many places throughout
and experiential education. The PharmD degree the text, sometimes challenges such as this can end up
became the entry-level degree into the profession in being a boon to practice and with the proper manage-
the early 2000s, with colleges of pharmacy phasing ment and leadership can be among a number of phe-
out their baccalaureate programs. nomena that could result in a greater opportunity for
These trends toward a more clinical practice pharmacists to become more highly involved in direct
approach may at first glance appear to be an ill- patient-care activities.
conceived response given recent changes in health
care delivery. These changes placed a heightened
concern over spiraling costs and have resulted in the • PHARMACEUTICAL
deinstitutionalization of patients and the standardiza- CARE AND MEDICATION
tion of care using tools such as protocols, treatment THERAPY MANAGEMENT AS
algorithms, and disease-based therapeutic guidelines. MANAGEMENT MOVEMENTS
Adoption of a clinical practice approach may also
appear to fly in the face of changes in the organiza- With these changes in mind, adopting pharmaceuti-
tion of the pharmacy workforce and current mar- cal care as a practice philosophy in the 1990s would
ket for pharmaceuticals. Studies have suggested that have appeared "a day late and a dollar short" for both
 The "Management" in Medication Therapy Management 9

the profession and the patients it serves. And indeed, "domains" in which these standards could be classified
that might have been the case had the concept of (Desselle & Rappaport, 1995). These practice domains
pharmaceutical care been entirely clinical in nature. can be found in Table 1-1. Figuring prominently into
The originators of the concept fervently stressed that this classification was the "risk management" domain,
pharmaceutical care was not simply a list of clini- which included activities related to documentation,
cally oriented activities to perform for each and every drug review, triage, and dosage calculations. However,
patient but was, in fact, a new mission and way of the contributions of the managerial sciences do not
thinking that takes advantage of pharmacists' accessi- stop there. The remaining four domains connote sig-
bility and the frequency to which they are engaged by nificant involvement by pharmacists into managerial
patients-a way of thinking that engenders the phar- processes. Two of the domains ("services marketing"
macist to take responsibility for managing a patient's and "business management") are named specifically
drug therapy to resolve current problems and prevent after managerial functions.
future problems related to their medications.
It has been argued that the focus on preventing
and resolving medication-related problems is simply From Pharmaceutical Care to Medication
an extension of risk management (Heringa et al., 2016 Therapy Management and Other Paradigms
see also Chapter 11). Risks are an inherent part of While the pharmaceutical care movement made an
any business activity, including the provision of phar- indelible mark on the profession, its use in the mod-
macy services. Common risks to a business include ern lexicon describing pharmacists' services is fad-
fire, natural disasters, theft, economic downturns, ing. It has been replaced with terminology that more
and employee turnover, as well as the fact that there accurately reflects pharmacists' growing roles in the
is no guarantee that consumers will accept or adopt provision of public health services and reorganization
any good or service that the business offers. The prac- of care into medical homes. In recognizing the mor-
tice of pharmacy involves additional risks, specifically bidity and mortality resulting from medication errors
the risk that patients will suffer untoward events as as a public health problem, the profession embraced
a result of their drug therapy or from errors in the the concept of medication therapy management
medication dispensing process. These events are sig- (MTM). MTM represents a comprehensive and pro~
nificant because they may result in significant harm active approach to hdp patients maximize the ben-
and even death to a patient. They can also harm phar- efits from drug therapy and includes services aimed
macists and their businesses. Risk management sug- to facilitate or improve patient adherence to drug
gests that risk cannot be avoided entirely, but rather therapy, educate entire populations of persons, con-
it should be assessed, measured, and reduced to some duct wellness programs, and become more intimately
feasible extent (Flyvbjerg, 2006). involved in disease management and monitoring. The
The idea that pharmaceutical care should be MTM movement has been strengthened by language
viewed strictly as a clinical movement was called into in the Medicare Prescription Drug. Improvement
question (Wilkin, 1999). Evidence that pharmaceuti- and Modernization Act (MMA) of 2003 (Public Law
cal care existed in part as a management movement Number 108-173, 2010), which mandates payment
was provided in a study that sought to identify stand- for MTM services and proffers pharmacists as viable
ards of practice for providing pharmaceutical care health professionals that may offer such services. The
(Desselle, 1997). A nationwide panel ofexperts identi- place of MTM in health care delivery was advanced
fied 52 standards of pharmacy practice, only to have a even further in the Patient Protection and Affordable
statewide sample of pharmacists judge many of them Care Act, which established pilots for integrated care
as unfeasible to implement in everyday practice. Of delivery, comprehensive medication review for Medi-
the practice standards that were judged to be feasible, care beneficiaries, and grants specifically for MTM
the researchers constructed a system of "factors" or programs (Public Law Number 111-148, 2010). As
Another random document with
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identical with my own, to the interesting discussion of Mr. W. R. B.
Gibson in Personal Idealism, p. 144 ff.
166. Compare Bradley, Appearance and Reality, chap. 23, note 2
to p. 331 (1st ed.); Lotze, Metaphysic, bk. ii. chap. 7, pp. 209, 210
(Eng. trans., vol. ii. p. 89 ff.); Ward, Naturalism and Agnosticism, vol.
i. pp. 84-91 (Conservation of Mass), 170-181 (Conservation of
Energy).
167. If we merely desired to fix the sense of the term mass without
introducing the concept of constant mass, we might of course
mass of B
consider two bodies only, A and B. Then the ratio ——— =
mass of A
acceleration of A in presence of B
————————————— See Mach, Science of Mechanics, p.
acceleration of B in presence of A.
216 ff.; and Pearson, Grammar of Science, p. 302 (2nd ed.), on
which the above account is based.
 BOOK IV

RATIONAL PSYCHOLOGY:
THE INTERPRETATION OF LIFE
 CHAPTER I

THE LOGICAL CHARACTER OF PSYCHOLOGICAL

SCIENCE
§ 1. The various sciences which deal with the interpretation of human life all avail
themselves of the fundamental categories of Psychology. Hence we must ask
how the concepts of Psychology are related to actual experience. § 2.
Psychology is a body of abstract descriptive formulæ, not a direct transcript of
the individual processes of real life. It presupposes the previous construction
of the physical order. § 3. The psychological conception of conscious life as a
succession of “mental states” or “images” is a transformation of actual
experience devised primarily to account for the experience of other subjects,
and subsequently extended to my own. The transformation is effected by the
hypothesis of “introjection.” §§ 4, 5. The logical justification of the
psychological transformation of facts is twofold. The psychological scheme
serves partly to fill up the gaps in our theories of physiological Mechanism,
and also, in respect of the teleological categories of Psychology, to describe
the course of human conduct in a form capable of ethical and historical
appreciation. Psychology may legitimately employ both mechanical and
teleological categories. § 6. The objections sometimes brought against the
possibility of (a) psychological, (b) teleological description are untenable.

§ 1. The net result of our brief examination of some of the most

important cosmological concepts has been to confirm us in the
“idealistic” or “spiritualistic” interpretation of existence to which our
first two books in principle committed us. The reader who has
followed us so far with acquiescence will now be fully prepared to
admit that we shall at least be nearer the truth in conceiving the
universe as composed of sentient and purposive subjects of
experience, akin in principle to the members of human society, than
as constituted, entirely or in part, of mechanically interacting and
interdependent elements. The acceptance of an idealist
interpretation of the universe, however, still leaves us face to face
with a number of problems of the gravest philosophical import. We
have still to ask how in particular we can most truly conceive the
systematic unity which is formed by the whole multiplicity of
apparently more or less independent subjects of experience, what
degree of permanence and individuality, so far as we can judge,
belongs to ourselves as members of that system, and what light is
thrown by our ethical, religious, and æsthetic aspirations and ideals
on the concrete character of the whole system and on our own place
in it. Again, before we can attack these momentous problems with
any reasonable hope of success, we shall need to know which
among the categories employed by the various sciences dealing with
mental life are of fundamental significance, and what is the logical
relation of those sciences to the concrete realities of immediate
experience, and to the constructions of physical science. Only on the
basis of a rational theory as to the purposes subserved by the
various mental sciences, and the possible limitations imposed by
those purposes on the use of the corresponding categories, can we
decide how far the interpretation of existence as a whole in terms of
Psychology, Sociology, or Ethics, is legitimate.
It is clear that the complete execution of the programme indicated
in the previous paragraph would involve a systematic philosophical
interpretation of the significance of human life for which some such
name as the Metaphysics of Society or Metaphysics of History would
be a more adequate designation than the traditional title of Rational
Psychology. I have, however, retained the ancient name for this
subdivision of our task, mainly on the ground that our own
elementary discussion will be primarily concerned with those most
simple and universal psychological concepts of which the various
more concrete social and historical sciences make the same
constant use as chemistry and the other physical sciences do of the
mechanical concepts of mass, energy, velocity, etc. Whatever view
we adopt of the precise degree of connection between Psychology
on the one side and the various social and historical sciences on the
other, it is at least manifest that Ethics, Sociology, History, and the
rest all involve the constant use of such psychological categories as
those of self, will, thought, freedom, and that thus any sound
metaphysical interpretation of history and society must begin with
investigation into the logical character of the science to which these
concepts belong, just as a sound Metaphysic of nature had to start
by an examination of the postulates of Mechanics. I suppose that
there is no need to utter more than a passing word by way of
reminder to the reader, that such an investigation presupposes the
previous creation of a purely empirical science of Psychology. The
business of Metaphysics with Psychology is not to dictate in advance
how it must construct its view of the world, but to ascertain the
logical character of the completed construction, and its relation to the
general system of human knowledge.
§ 2. The Place of Psychology among the Sciences.—From the
metaphysician’s point of view, it is of the utmost importance to
recognise clearly and constantly that Psychology, like the other
sciences, deals throughout not with the actual experiences of real
subjects, but with “data” obtained by the artificial manipulation and
transformation of actual experience into a shape dictated by certain
special interests and purposes. This is a point upon which the
idealist metaphysician, in particular, is peculiarly liable to go wrong
when left to himself. Starting with the conviction that the key to the
nature of existence as a whole is to be found in our own direct
experience of our sentient and purposive life, he almost inevitably
tends, unless he has given particular attention to the methodology of
psychological science, to take it for granted that the concepts and
hypotheses of the psychologist afford a description of this
experience in its concrete directness, and may therefore be treated
without misgiving as a fruitful source of certain knowledge about the
inmost structure of the absolute or infinite individual itself. And even
the reiterated demonstration that one or another of the current
categories of Psychology cannot be predicated of the absolute whole
of reality without flagrant contradiction, frequently fails to produce
conviction where it is not accompanied by direct proof of the
artificiality and remoteness from concrete actuality of the
psychologist’s data. Hence it would be worse than useless to discuss
such questions as, whether the infinite individual can properly be
thought of as a “self” or an “ethical person,” or again as a “society of
ethical persons,” or again whether finite “selves” are “eternal” or only
transitory constituents of the world-system, without first arriving at
some definite view as to the way in which these psychological
concepts are derived from the concrete actualities of experience, the
special interests which lead to their formulation, and the restrictions
imposed by those interests on the sphere of their valid application.
That Psychology, like all descriptive science, deals throughout with
data which are not concrete experience-realities, but artificial
products of a process of abstraction and reconstruction, should be
sufficiently clear from the very consideration that, like the other
sciences, it is a body of general descriptions of typical situations. An
actual process of knowing or acting, like every actual event, is
always individual, and because of its individuality defies adequate
description. It is only in so far as a situation admits of being
generalised by the selection of certain of its aspects or qualities as
representative of its whole reality, that it is capable of being
described at all. Even History and Biography, in which the
teleological interpretation of a series of events as internally united by
the singleness of the purpose underlying them takes the place of
external connection in accord with mechanical laws of sequence as
the ideal of explanation, are only possible on the condition that such
transformation of the concrete realities of life as is implied in such a
degree of abstraction and reconstruction can be carried out without
detriment to the special interests of the historian and the biographer.
And Psychology is unreal and abstract even as compared with
history. It provides us with general formulæ which are, or should be,
valuable as affording a means of describing certain universal
features of the processes of willing and knowing which it is desirable
to study in isolation, but it is of itself as incapable of adequately
tracing the actual course of a real process of willing or thinking, as
Mechanics is of following the actual course of a real individual
process in “external” nature. In this respect the concepts and
formulæ of scientific Psychology stand on precisely the same
footing, as regards their relation to the individual and actual, as do
those of scientific Physics. Their truth and validity means simply that
by substituting them for concrete actualities we can get answers to
certain special questions which we have an interest in solving, not
that they are unaltered transcripts of the actualities themselves.
 This is perhaps most strikingly shown by observing that the very
existence of Psychology as a distinct branch of science presupposes
that artificial severance of the unity of direct experience into a
physical order and a non-physical realm external to that order, of
which we have already investigated the origin. Psychology has no
subject-matter at all until we have first, for the practical reasons
already discussed, constructed the physical order by the inclusion in
it of all those experience-contents which are equally accessible
under specified conditions to the observation of a plurality of
subjects, and then gone on to assign to the realm of “psychical” or
“mental” existence whatever experience-contents fall outside the
system so defined. And this whole separation of the physical and the
psychical or mental, as we have already seen, has no place in the
direct experience of actual life. In actual life, until we come to
reconstruct it in thought for the purposes of description and
calculation, there are neither material bodies nor “immaterial minds”
or “consciousnesses” which are “in” them or “animate” them; there
are simply sentient and purposive beings and the environment of
things to which they have to adjust themselves in the execution of
their purposes. How and for what reasons this naïvely realistic view
of existence comes to give place to the dualistic conception of a
physical world and a plurality of non-physical beings in relation with
it, we have already seen in our study of the methodology of the
physical sciences. We have now to follow the development of the
dualistic line of thought somewhat further, before we can see
precisely what is the character of the logical reconstruction of actual
experience presupposed by the existence of a science of
Psychology.
§ 3. As we have already learned, our recognition of the actuality of
our own and our fellow-men’s life of unique and incommunicable
feeling compelled us to admit the existence of much that, from its
incommunicable nature, falls outside the sphere of physical reality.
We have now to see how Psychology, in taking this non-physical
existence as its subject-matter, conceives of its mode of existence
and its relation to the subject-matter of the physical sciences. In
recent years, much light has been thrown upon the methodological
problem in question by the labours of Avenarius and his followers,
from whom the substance of our account will be largely drawn. What
Avenarius has for the first time made perfectly clear is, that the
psychological interpretation of our own experience is throughout
based upon reading into that experience a theory originally devised
to meet a difficulty suggested by the existence of our fellow-men.
We have already seen, in dealing with the subjectivist’s fallacy,
what this difficulty is. So long as I am concerned only with the
analysis of my own experience, there is nothing to suggest the
distinction between a physical and a psychical aspect of existence.
All that I require, or rather all that I should require had I any interest
in analysing my own experience independent of the need for
intercommunication, is the simpler and more primitive distinction
between myself as one thing in the world and the other things which
form my environment. But the case is altered when I come, after the
creation of the concept of a physical order, to analyse the experience
of my fellow-men. My fellow-men, on the one hand, belong to the
physical order, and, as belonging to it, are known to me as objects
cognisable through my senses. On the other hand, it is necessary for
all the purposes of practical intercourse to credit them with the same
kind of sentience and feeling which I directly know in myself. This
sentience and feeling are, of course, inaccessible to the perception
of my own senses; I can see my fellow’s eye and can hear his voice,
but I cannot see that he sees or hear that he hears. My fellow thus
comes to be thought of as having a double existence; besides that
aspect of him in which he is simply one among other things
perceived, or in principle perceptible, by my senses, he has another
aspect, not directly perceptible but necessarily presupposed in all
social relation with him. On the side of his body he belongs entirely
to the physical order; but there is, associated with this bodily
existence, another side to him which I call his psychical aspect. Now,
how must this “psychical aspect” be supposed to be constituted
when once it has come to be thus artificially separated in thought
from the physical side of my fellow’s existence? It is here that the
theory of “introjection,” as worked out by Avenarius, comes to our
aid.
When I perceive any object directly, without sophisticating myself
by devising psychological hypotheses about the process, what I am
aware of is, on the one side, the thing as a constituent of my
environment, and, on the other, a variety of movements or impulses
to movement in myself, marked by a peculiar tone of satisfied or
dissatisfied feeling, and determined by the relation in which the thing
in question stands to my various interests. But when I come to
explain to myself what is meant by my fellow-man’s assertion that he
also perceives the same object, a difficulty seems to arise which
renders this simple analysis inadequate. The perceived object, the
sun for example, appears to belong to my world of sensible things,
for I too see the sun. Not so my fellow-man’s perception of it; as I
cannot “see him seeing the sun,” so to say, I find it hard to
understand how the sun, which is a thing in my sensible world, can
be an object for his perception, which is not in my sensible world.
Hence I draw the inference that while I see the actual sun, the
content of my fellow’s perception is an image or idea of the sun (cf.
p. 81).
By the extension of this process of inference I come to think of the
non-physical aspect of my fellow’s existence as consisting, as a
whole, of a vast complex of successive ideas or images, attended
with their characteristic tone of satisfied and dissatisfied feeling; as
this series of “mental states” or “ideas” has now to be represented as
in some way related to the sensible physical reality I call my fellow’s
body, I imagine it as going on “within” his skin somewhere, and thus
arrive at the conception of my fellow as a dualistic compound of a
physical factor, perceptible by my senses, his body, and a non-
physical factor, composed of a stream of “mental images,” and
imperceptible to sense, his mind. One further step remains to be
taken and the work of “introjection” is complete. That step is the
artificial re-interpretation of my own experience in terms of the
distinction I have been led to establish for the case of my fellow. I
come to think of my own conscious life in terms of the distinction
between body and mind, and to analyse what as originally
experienced was the direct reaction of a unitary self upon the things
which formed its environment into a succession of “mental states” or
“images” going on “within” a body, their relation to which will yet form
a prominent scientific problem.
 Now, it is only when this process of “introjection” has reached its
final issue, and the actual life of sentient purposive intercourse with
the other actual things of our environment has been replaced in
thought by the conception of a mental succession of “images” or
“contents of consciousness,” taken to “refer” to “things” which are
themselves “outside consciousness,” while the felt unity of
experience has given way to the radical sundering of human
existence into a physical and a psychical aspect, that we have
reached the point of view from which psychological science takes its
departure. Only when the actualities of experience have been
artificially transformed into “mental states” or “images” of actualities
by the hypothesis of “introjection,” and thus definitely constituted into
a non-physical order, have we the materials for the construction of a
special science of the “psychical side” of our nature. Psychology, in
fact, presupposes “psychical states” as the material of its studies,
and “psychical states” are not data of immediate experience, but
symbols derived from and substituted for the actual data of
experience by an elaborately artificial method of transformation.
Hence we should be committing a grave fallacy in Logic if we were to
argue that since subjects of experience are the sole real things, the
hypotheses of Psychology must be the final metaphysical truth about
the world.
When we attempt to criticise the logical validity of the process of
“introjection,” and the scientific constructions of a Psychology built up
on an introjectionist foundation, we cannot fail to observe certain
apparent gross breaches of logic which affect it. In the first place, the
fundamental assumption that my fellow’s “mental life” is composed of
“images” of the actual things of my own experience, is clearly at
variance with the principle previously implied in the construction, for
purposes of co-operation, of the physical order as composed of
things equally accessible to the perception of a plurality of
individuals. This discrepancy is once more done away with, when the
process of introjection has been completed, by the reduction of my
own mental life to a succession of images or states of
consciousness, but only at the cost of forgetting that the original
motive to “introjection” was a supposed disparity between my own
and my fellow’s relation to the physical things of my environment.
 Hence it is not strange that Avenarius should apparently hold the
whole introjectionist transformation of the “naïvely realistic”
standpoint to be essentially fallacious, and should close his
discussion of the subject with the proposition that all attempts to vary
the “natural view of the world” lead to superfluities or contradictions.
[168]
It does not, however, seem necessary to follow him in this
unfavourable judgment. Indeed, if we reflect that such a thorough-
going rejection of all the results of introjection must involve as a
consequence the repudiation of the whole science of Psychology, a
science which may fairly be said to be at present about as fully
justified by its successful growth as most of the physical sciences,
we shall probably be inclined to hold that a process so fruitful in
results must have its logical justification, however artificial the
assumptions upon which it rests.
§ 4. What, then, is the logical justification for that elaborate
transformation of experience which is necessary to bring it into the
form presupposed by psychological science? In principle the
question is not hard to answer. The “ideas,” “mental states,” and so
forth, of Psychology are, as we have seen, symbols which we
substitute for certain concrete actualities, and, like all symbols,[169]
they only partially correspond to the material they symbolise. But,
like other symbols, they are admissible as substitutes for the things
symbolised on two conditions: (1) that the individual symbol
corresponds to that which it symbolises according to a definite and
unambiguous scheme, and (2) that the substitution of the symbol for
the thing symbolised is required in order to make the latter amenable
to such manipulation as is necessary for the solution of some
particular class of problem. Now, there can be no doubt that the first
of these conditions is fulfilled by the translation of our actual
experience into the introjectionist symbols of Psychology. For in the
external or “physical” events which correspond to a “mental state,” I
possess an unambiguous means of recognising the actual
experience for which the mental state in question stands in the
symbolism of Psychology. If the various physical “conditions” and
forms of “expression” of the mental state are indicated with sufficient
fulness and accuracy, they enable me to identify the corresponding
actual experience when it occurs in my own life, or even to produce it
experimentally for the express purpose of interpreting the
Psychologist’s symbolism. The only question, then, that can
reasonably be raised as to the legitimacy of psychological
symbolism, is the question whether such a transformation of the
actualities of immediate experience is demanded for the attainment
of some specific purpose or interest.
It seems, I think, that the transformation is really required for more
purposes than one. In the first place, one obvious use of
psychological hypotheses is that, like the hypotheses of physical
science, they assist us to calculate the course of events, in so far as
it is independent of purposive interference of our own, and thus to
form prudential rules for our own guidance in so interfering. This
seems to be the principal use of those parts of Psychology which
deal with the more mechanical aspects of mental life, e.g., the laws
of the formation of fixed habits and associations by repetition, the
gradual passing of voluntary into involuntary attention, and so forth.
We are interested in studying the laws of habit and association, just
as we are in formulating mechanical laws of physical nature,
because we require to guide ourselves by such knowledge whenever
we directly and intentionally interfere in the life of our fellows for
educational, punitive, or general social purposes. Unless we can
forecast the way in which our fellow will continue to act, so far as his
behaviour is not modified by fresh purposive initiative, we shall be
helpless to decide how we must intervene in his life to produce a
given desired effect. Similarly, the direct moulding of our own future
in a desired direction would be impossible apart from such
knowledge of what that future is likely to be without intentional
direction.
It may be said, of course, with justice, that, so far as Psychology
presents us with such routine uniformities of succession, it is a mere
supplementary device for making good the defects in our anatomical
and physiological knowledge. If our physiological science were only
sufficiently extensive and minute, we might reasonably expect to be
able to describe the whole course of human action, so far as it is
amenable to mechanical law, and exhibits routine uniformity in purely
physiological terms. Instead of talking about the “association” of
“ideas” or the production of a “habit” by repetition, we should then,
for instance, be able to describe in physiological terminology the
changes effected in a cerebral tract by the simultaneous excitement
of two nervous centres, and to write the complete history of the
process by which a permanent “conduction-path” arises from the
reiteration of the excitement. Such a definite substitution of
physiological for psychological hypotheses is pretty evidently the
goal which the modern “experimental Psychology” has set before
itself, and which it is constantly trying to persuade itself it has
reached, in respect of some parts at least of its subject.
Nor does there seem any reason to doubt that, since the
physiological counterpart of a routine uniformity of mental sequence
must itself clearly be a routine uniformity, all psychological laws of
uniform mechanical sequence might be ultimately replaced by their
physiological equivalents, if only our knowledge of the structure and
functions of the nervous system were sufficiently advanced. Hence
Professor Münsterberg is perfectly self-consistent in arguing from the
premisses that the sole function of psychological science is to
provide us with mechanical uniformities of sequence by the aid
whereof to calculate the future behaviour of our fellows, in so far as it
is not modified by fresh purposive initiative, to the conclusion that the
whole of Psychology is a temporary stop-gap by which we eke out
our defective Physiology, but which must sooner or later cease to be
of use, and therefore cease to exist as Physiology advances.[170]
It would, of course, remain true, even if we were to accept this
view of the case without reservation, that Psychology is, in the
present state of our knowledge, an indispensable adjunct to
Physiology. For, while our knowledge of the physiology of the
nervous system is at present too fragmentary and vague to be of
much practical use in enabling us to forecast even the simplest
sequences in the behaviour of our fellows, Psychology is,
temporarily at least, in many respects in a more advanced condition.
Thus, if it were necessary, before we could infer the probable effects
of exposure to a particular stimulus on a man’s behaviour, to frame a
workable hypothesis as to the physiological occurrences in the
nervous system between the first reception of the stimulus and the
issuing of the ultimate bodily reaction, we should still be waiting
helplessly for the means of framing the simplest general judgments
as to the probable effects of our actions on our social circle. This is
because the nervous changes intervening between the reception of
the stimulus and the reaction can only be rendered accessible to
observation by devices which postulate for their invention an
extremely advanced condition of physical science in general and of
Physiology in particular. There is no direct method of translating the
actual processes which we experience into an unambiguous
physiological symbolism, or, vice versâ, of testing a physiological
hypothesis by retranslating it into facts of direct living experience. On
the other hand, when we have given the assumed conditions of the
occurrence of the stimulus, it is comparatively easy to observe what
follows on them in actual life, and to translate it into the introjectionist
Psychology, or, vice versâ, to test a theory couched in terms of that
Psychology by comparison with the actualities of experience.
For this reason psychological hypotheses are, in the present state
of knowledge, an indispensable mediating link between actual
experience and physiological theory, and if ever they should come to
be finally superseded by purely physiological descriptions of human
conduct, we may be sure that the triumphant physiological theories
will themselves first have been won by the process of establishing
psychological formulæ and then seeking their physiological
analogues. This is illustrated in the actual history of contemporary
science by the extent to which the cerebral physiologists are
dependent for their conception of the structure of the nervous system
on the previous results of purely psychological investigation. We
might present the mutual relations of concrete experience,
Psychology and nervous Physiology, in an epigrammatic form, by
saying that the connecting link between the subject of experience
and the brain of Physiology is the “mind” or “consciousness” of
Psychology.
§ 5. It is, I think, questionable whether such a view as Professor
Münsterberg’s does full justice to the interests which prompt us to
the construction of the psychological symbolism. On his theory,
Psychology, it will be seen, is essentially a science of routine or
mechanical uniformities of sequence, just like the various branches
of mechanical Physics. According to him, teleology must be
ruthlessly banished from scientific Psychology. In other words,
though all the actual processes of direct experience are pervaded by
teleological unity of interest or purpose, yet in substituting our
psychological symbols for the actualities we must deprive them of
every vestige of this teleological character. Nor is this demand that
Psychology shall translate experience into a series of non-purposive
routine sequences an arbitrary one on Professor Münsterberg’s part.
If the sole function of Psychology is to facilitate calculation and
prediction of the course of events, so far as it is not controlled by
purposive interference, Psychology must, of course, either follow
rigidly mechanical lines in its descriptions, or fail of its object. But I
would suggest that over and above this function of facilitating
calculation and prediction at present fulfilled by Psychology as locum
tenens for a perfected Physiology, Psychology has another and an
entirely distinct function, in which it would be impossible for it to be
replaced by Physiology or by any other branch of study. This function
is that of affording a set of symbols suitable for the description, in
abstract general terms, of the teleological processes of real life, and
thus providing Ethics and History and their kindred studies with an
appropriate terminology.
It is manifest enough that neither the ethical appreciation of human
conduct by comparison with an ideal standard, nor the historical
interpretation of it in the light of the actual ends and ideals which
pervade it and give it its individuality, would be possible unless we
could first of all describe the events with which Ethics and History
are conceived in teleological language. Apart from the presence
throughout those events of more or less conscious striving towards
an ideal end, there would be nothing in them for the moralist to
applaud or blame, or for the historian to interpret. Thus, if Ethics and
History are to have their subject-matter, there must be some science
which describes the processes of human life and conduct in terms of
teleological relation to an end. Now, to what science can we go for
such descriptions? From our previous examination of the postulates
of physical science, it is clear that the requisite material cannot be
afforded by any branch of physical science which remains rigidly
consistent with its own postulates. The nature of the interests in
response to which the concept of the physical order was
constructed, as we saw, required that the physical order should be
thought of and described in terms of rigid mechanism. Hence no
science which describes the processes of human life in purely
physical terminology can indicate their purposive or teleological
character in its descriptions. The purposive character of human
conduct, if recognised at all in our descriptions, must find its
recognition in that science which describes the aspect of human
experience that is in principle excluded from the physical order. In
other words, it is Psychology to which we have to go for such a
general abstract conception of teleological unity as is necessary for
the purposes of the more concrete sciences of Ethics and History.
This function of Psychology is indeed quite familiar to the student
of the moral and historical sciences. In Ethics, as Professor Sidgwick
has observed, the whole vocabulary used to characterise human
conduct, apart from the specially ethical predicates of worth, is
purely psychological. All the material which Ethics pronounces
“good” or “bad,” “right” or “wrong”—“acts,” “feelings,” “tempers,”
“desire,” etc.,—it has taken over bodily from Psychology. And so,
too, History would have nothing left to appreciate if a record of
merely physical movements were substituted for accounts of events
which imply at every turn the psychological categories of “desire,”
“purpose,” “intention,” “temptation,” and the rest. Universally, we may
say all the teleological categories of human thought on examination
prove to be either avowedly the property of Psychology, or, as is the
case with the concepts of biological evolutionism, thinly disguised
borrowings from it.
If this is so, we seem to be justified in drawing certain important
inferences. (1) It will follow that of the two distinct offices which
Psychology at present fulfils, one belongs to it, so to say, in its own
right and inalienably, while the other is exercised by it temporarily,
pending the majority of Cerebral Physiology. While, as we have
seen, those parts of psychological doctrine which are concerned with
the more mechanical aspects of conduct may ultimately be replaced
by Physiology, the parts which deal with the initiation of fresh
purposive adjustments, such as the psychology of attention and of
feeling, are in principle irreducible to Physiology, and must retain a
permanent value so long as mankind continues to be interested in
the ethical and historical appreciation of human life.[171]
 (2) It will also follow that, at present and for long enough to come,
Psychology is bound, pace Professor Münsterberg, to use both
mechanical and teleological hypotheses and categories. Such a
mixture of two different logical standpoints would no doubt be
intolerable in a science which owed its existence to the need of
satisfying a single interest of our nature. For the kind of interest
which is met by mechanical hypotheses is baffled by the introduction
of teleological modes of thought, and vice versâ. But, according to
our view, the interest to which Psychology owes its creation is not
single but double. We have an interest in the mechanical forecasting
of human action, and an interest in its ethical and historical
interpretation, and Psychology, as at present constituted, has to
satisfy both these conflicting interests at once. Hence the
impossibility of confining it either to purely mechanical or to purely
teleological categories. If, indeed, our Physiology had reached the
point of ideal completeness, so that every routine uniformity at
present expressed in psychological terminology as the establishment
of an “association” or “habit” could be translated into its physiological
correlate, we should be able to dispense altogether with
psychological hypotheses as aids to the calculation of the course of
events, and to restore logical unity to Psychology by confining it
entirely to the task of providing Ethics and History with the
teleological categories they require for the description of their
subject-matter. But such a reform of method would be most
premature in the present condition of our physiological knowledge.
[172]

§ 6. There are two points of difficulty which our discussion has so

far failed to deal with, but must not leave entirely unnoticed. We have
allowed ourselves to assume (a) that description in psychological
terms, and (b) that description in teleological terms, are possible.
Both these assumptions have been questioned, and it is clear that if
the first is unsound there can be no science of Psychology at all,
while, if the second is unsound, Psychology cannot use teleological
conceptions. Hence it is absolutely necessary to attempt some
justification of our position on both questions.
As to (a), it has been argued that since only that which is
accessible on equal terms to the perception of a plurality of subjects
can be described by one subject to another, and since all objects so
accessible to the perception of a plurality of subjects were included
in our construction of the physical order, description can only be of
physical objects. A “mental state” must be in principle incapable of
description, because it can only be experienced by one subject.
Now, if Psychology claimed to be the direct description of
immediate experience, as it is experienced, this contention would
certainly be fatal to its very existence. But, as we have seen,
Psychology makes no such claim. Its data are not the actualities of
immediate experience themselves, but symbols derived from those
actualities by a certain process of transformation. And though what
Psychology calls its “facts” cannot, of course, like physical facts, be
directly exhibited to the sense-perception of a plurality of subjects,
we have in the physical conditions and concomitants of a “mental
state” assignable marks by which we may recognise when it occurs
in our own life, the actual experience of which the psychologist’s
“mental state” is the symbol. Thus, though I cannot directly produce
for inspection a sample of what in Psychology I call “the sensation of
red,” I can indirectly, by assigning the upper and lower limits of the
wave-length corresponding to the sensation, make every one
understand what actual experience I am thinking of when I use the
term.
(b) The second difficulty need not detain us long. The view that all
description must be exclusively mechanical, rests upon the
assumption that no other kind of description will answer the purpose
for the sake of which we set out to describe things. Now, so far as
description is undertaken for the purpose of establishing practical
rules for intervention in the course of occurrences, this assumption is
perfectly justified. If we are to lay down general rules for meddling in
the course of events, we must of course assume that, apart from our
meddling, it goes on with routine regularity. And we have already
seen that for this very reason the mechanical interpretation of Nature
is a fundamental postulate of physical science, so long as it confines
itself strictly to the work of formulating “laws of Nature,” and does not
attempt the task of historical appreciation. But, as we have also
seen, the historical appreciation of a series of events as marked by
the progressive execution of an underlying plan or purpose, is only
possible when the events themselves have been described in
essentially teleological terms as processes relative to ends.[173]
Hence we have no right to contend that all scientific descriptions
shall be of the mechanical type, unless we are also prepared to
maintain that the only purpose they subserve is that of the
formulation of general rules for practice.
If the historical appreciation of events is a legitimate human
interest, the description of events in terms of end and purpose must
also be a legitimate form of description. Now, in point of fact, even
the “physical sciences” themselves, when they come to deal with the
facts of organic life, largely desert the primary scientific ideal of the
formation of general laws for the historical ideal of the detection of
lines of individual development, and if our previous conclusions are
correct, it is much more for the latter than for the former purpose that
we are interested in the construction of a science of Psychology.
What a human being wants Psychology for, in the main, is not so
much to help him to forecast the behaviour of other men, as to assist
him to understand how the successive stages of his own individual
development and that of his “social environment” are knit into a unity
by the presence of all-pervading permanent interests and ends. The
contention that psychological description must, on grounds of logical
method, be of the mechanical type, seems therefore to repose on
misconception as to the uses of Psychology.
The preceding discussion may perhaps appear somewhat arid and
wearisome, but it was indispensable that our subsequent
examination of the metaphysical problems suggested by the
recognition of the psychical realm of existence should be based
upon a definite view as to the connection between psychological
conceptions and the actualities of experience, and such a view, in its
turn, presupposes a positive theory of the interests to which
psychological construction ministers and the logical procedure by
which it is affected. The general result of our investigation has gone
to show negatively that Psychology is not a direct transcript of real
experience, but an intellectual reconstruction involving systematic
abstraction from and transformation of experience, and positively
that the reconstruction depends for its legitimacy upon its
serviceableness for the special purposes, partly of the practical
anticipation of events, but principally of their historical and ethical
appreciation. The significance of those conclusions will be more
apparent in the course of the two following chapters.

Consult further:—R. Avenarius, Der Menschliche Weltbegriff; F. H.

Bradley, “A Defence of Phenomenalism in Psychology” (Mind,
January 1900); H. Münsterberg, Grundzüge der Psychologie, vol. i.
chap. 2 (The Epistemological Basis of Psychology), 11 (Connection
through the Body); J. Ward, Art. “Psychology” in Encyclopædia
Britannica, ad init. (“The Standpoint of Psychology”); Naturalism and
Agnosticism, vol. ii. lect. 16.

168. See Avenarius, Der Menschliche Weltbegriff, p. 115 ad fin.

169. Or rather, like all symbols which are not identical with the
things they represent. In the latter case, as when, e.g., for any
purpose I count the numbers of the natural number series
themselves, beginning with 1, there may appear to be complete
correspondence. But the usefulness of the process depends on the
fact that the 1 which I count and the 1 by which I count it are at least
numerically distinct—how much more distinction this implies I do not
stay to discuss here—and hence, I take it, it is by an abuse of
language that the process is called “representation of a thing by
itself.”
170. See Grundzüge der Psychologie, vol. i. chap. 11, pp. 415-
436.
171. This is strikingly illustrated by the procedure of Professor
Münsterberg himself. He expels selective interest from his
psychological account of attention, in obedience to the principle that
teleological ideas must be kept out of a descriptive science, and
then, when confronted with the problem what it is that does decide
what presentations shall actually be attended to, makes the selection
a function of the sub-cortical motor-centres in the brain, thus
reintroducing into biology the teleological categories previously
declared inadmissible. See Grundzüge der Psychologie, vol. i. chap.
15, pp. 525-562. I may once more note, for the benefit of the reader
who is interested in methodology, that whereas the processes of the