Self-Rule in Sick Selves

Exploring the Limits of Personal Autonomy in Contemporary Philosophy and Psychiatric Practice

Floor Cuijpers Student number:10135839 Name supervisor: dhr. dr. T. R. V. (Thomas) Nys Name reader: dhr. dr. H.W.J.M. (Henri) Wijsbek

Master Thesis submitted in partial fulfilment of the requirements for the degree of Master of Philosophy

Date: 24-07-2017 Word count: 20.0049

Self-Rule in Sick Selves

This is a painting by Michaël Borremans: The Advantage, 2001.

Self-Rule in Sick Selves

Preface

Exactly one year ago, I decided to quit my studies in medicine and start a master in philosophy. While studying medicine, it was the field of psychiatry that mostly intrigued me. What are the presuppositions when we say that someone shows ‘dysfunctional behavior’, or ‘lacks the requisite ability to be a self-governing individual’? Moreover, what do such statements reveal about our implicit intuitions considering ‘normal’ or ‘functional behavior’? Such questions highly interest me, yet the medical curriculum does not leave much time to elaborate on these issues. Fortunately, studying philosophy allowed me to engage with similar questions. During my ethics course, for instance, I was introduced to the work of Susan Wolf and Harry Frankfurt, who both critically reflect on some of our most basic assumption on what it means to be an autonomous person. This led me to presume that these philosophical theories might also aid in clarifying what disputes regarding the autonomy of psychiatric patients (or the implicit ideal of what it means to be a functioning person) are all about. I soon realized however, that characterizing this relationship between mental conditions and personal autonomy introduces many puzzles. Here, I would like to thank Thomas Nys for our inspiring meetings, his support in guiding me trough this, at times complex, process of writing a thesis and the many interesting theories and philosophers he introduced me to.

Self-Rule in Sick Selves

Table of Contents Introduction ...... 6 Research Question ...... 7 Outline ...... 8 PART I: AUTONOMY IN MENTAL HEALTH CARE ...... 9 1. Autonomy & Competence in Psychiatric Practice ...... 10 §1.1 Informed Consent & Competence ...... 10 §1.2 Competence in Psychiatry ...... 11 §1.3 Competence Assessments: Two Approaches ...... 14 §1.4 Conclusion ...... 18 PART II: AUTONOMY CONCEPTIONS IN PHILOSOPHY ...... 19 1. Procedural Accounts of Autonomous Agency ...... 20 §1.1 Structural Versions: Frankfurt’s Higher-Order Desires ...... 20 §1.2 Criticizing Frankfurt’s Account: The Regress-Problem ...... 25 §1.3 Historical Versions: John Christman & Gerald Dworkin ...... 27 §1.4 Criticizing Historical Accounts: The Ad-Hoc Problem & Oppression ...... 31 §1.5 Conclusion ...... 35 2. Substantive Accounts of Autonomous Agency ...... 37 §2.1 Wolf’s Substantive Element: The Sanity Condition ...... 37 §2.2 Wolf’s Sanity Condition & Psychiatric Practice ...... 40 §2.3 Criticizing Wolf’s Notion of Normative Competence ...... 43 §2.4 Tensions and Paradoxes ...... 48 §2.5 Conclusion ...... 49 PART III: THE PARADOX OF SELF-CREATION ...... 51 §3.1 ‘The Ab Initio Requirement’ ...... 52 §3.2 The Gradual Rise of Autonomy ...... 55 §3.3 New Selves versus Existing Selves ...... 56 § 3.4. What About Sick Selves? ...... 57 Conclusion ...... 59 Bibliography ...... 61

Self-Rule in Sick Selves

Introduction

Despite the fundamental value our present day society attaches to the notion of ‘personal autonomy’, the meaning of the term differs greatly depending on the context in which it is used (Dworkin, 1988). In health-care settings for instance, contemporary medical ethics dictates that patients ought to be treated as autonomous agents, i.e. they need to be allowed to make decisions about their treatment for themselves. By contrast, those who suffer from ‘diminished autonomy’ due to illnesses or disabilities are entitled to protection (Beauchamp & Childress, 2011). This reveals that autonomy is not only understood as an individual right to self-governance that others should respect; autonomy is also interpreted as a capacity, where only those who fulfill certain criteria are entitled to this right. Yet what exactly does it mean to say that a subject has or lacks the requisite capacity to be treated as an autonomous agent? And how can this be capacity be assessed? These challenging questions are central to the theory and practice of psychiatric health-care. The intuition often expressed in psychiatric health settings is that sufferers from mental disorders make choices that they would have never made prior to the onset of their conditions. Put differently, “he or she is not ‘autonomous’ or ‘self-governing’, but is ‘governed’ by the illness’’. The justification for imposing treatment would then be “respect for the right for autonomy, expressed as the attempt to restore autonomy to someone who presently lacks it’’ (Matthews, p. 67, 2000). This argument is based on the premise that a patient’s action or choice should only be recognized as autonomous if it is a true expression of oneself. Thus, considering what justifies infringing on patients’ autonomy requires addressing questions such as “What is the nature of the self who is choosing?”. Such questions are not only central to debates in psychiatric practice, on the contrary, they also play a crucial role in philosophical theories of personal autonomy. Interestingly, philosophers regularly invoke the example of the mentally ill, where the absence of autonomy is presumed, in order to explicate, conceptualize or demarcate different notions of autonomy (Wolf 1987, Christman, 1991). Thus, the relationship between autonomy and mental illness concerns both philosophers and practitioners of clinical psychiatry. However, the approaches of these two fields differ. Whereas current debates in psychiatric practice revolve around the question if,

Self-Rule in Sick Selves and how, psychiatric illnesses might impinge on the mental capacities required for autonomous agency; theorists of personal autonomy at times refer to mental illnesses to illustrate how we could better understand the notion of autonomy in the first place.

Research Questions

In this thesis, I will investigate the link between mental illnesses and the concept of autonomy as it appears in psychiatric practice, as well as how this link is described in contemporary philosophical theories on personal autonomy. Such an exploration might at first glance be understood as a project belonging to the field of ‘Philosophical Psychopathology’ (Murphey, 2017). Philosophers writing in this tradition attempt to incorporate empirical results from psychiatry in order to open up new ways of thinking about contemporary theories of autonomy (Graham & Stephens, 2007), or conversely reflect upon the philosophical literature on autonomy in order to better understand why illnesses such as compulsive disorders and addiction might infringe on patients’ autonomy (Prinz, 2007). In this thesis however, I will take on a different approach. Rather than trying to illuminate one concept by turning towards the other discipline, I will follow the path proposed by Gerald Dworkin and “study how the term personal autonomy is connected with other notions, what role it plays in justifying normative claims, how the notion is supposed to ground ascriptions of value’’ (1988a, p. 11). In doing so, I will first focus on practical issues regarding autonomy, by scrutinizing the debate around informed consent and competence assessments in psychiatric patients. What does this debate tell us about the underlying assumptions regarding autonomous agency guiding contemporary psychiatric practice in Western societies? I will then turn towards contemporary philosophical literature on personal autonomy. In this literature, mental illnesses are frequently introduced to exemplify impairments to autonomy, perhaps guided by the idea that we can understand the notion of autonomy better if we understand its (presumed) failure. What, however, are the underlying assumptions autonomy theorists make when reflecting upon impaired autonomy in those living with mental illnesses? And do these assumptions relate to those that guide psychiatric practice?

Self-Rule in Sick Selves

Outline In the first part of this thesis I will reflect upon the difficulties that arise when physicians attempt to evaluate whether sufferers from mental illnesses are competent for autonomous decision-making. More specifically, I will critically examine the various ‘competence tests’ which have been introduced: ‘objective’ instruments which aim to assist psychiatrists in judging whether patients should be considered capable of clinical decision-making, and therefore, autonomous. There is an ongoing debate on what type of criteria should be included in these tests. A critical reflection on this discussion shows that what might initially appear to be a practical issue - a dispute over the effectiveness of these tests- soon reveals more fundamental disagreements within psychiatric practice on what it should mean to be an autonomous agent. Whereas the first section of this thesis focuses on practical contexts in which autonomy is at issue, in the second part of this project I will turn to a number of important works in the philosophical literature on personal autonomy. I observe that, despite the fundamental differences in these approaches to personal autonomy, many theorists seem to share an important underlying intuition: to achieve the status of autonomy, one’s acts or desires need to flow in some way from what can be considered one’s true self. In other word, an agent acts autonomously when ‘an authentic expression of his or her will’. There are a number of difficulties with such requirements. In the third and final part of this thesis, I will consider the requirement of authenticity for autonomy. More specifically, I will explore how Robert Noggle (2005) problematizes the notion of authenticity as a condition for autonomy.

Self-Rule in Sick Selves

PART I: AUTONOMY IN MENTAL HEALTH CARE

“Why do you assume to have the right to decide for someone else? Don’t you agree it’s a terrifying right, one that rarely leads to good? You should be careful to. No one is entitled to it, not even doctors.’’

But doctors are entitled to the right – doctors above all’’, exclaimed Dontsova with deep conviction. By now she was really angry. Without that right there’d be no such thing as medicine!’’

Solzhenitsyn, Cancer Ward,Autonomy and informed consent, Gerald Dworkin (1988) p. 100

Self-Rule in Sick Selves

1. Autonomy and Competence in Psychiatric Practice

§1.1 Informed Consent and Competence

Directing our life in accordance to a self-chosen plan, based on what we regard as valuable is of crucial importance in today’s liberal society. In health-care settings, this value is reflected in patients’ right to make their own choices considering their physical and mental health, a right safeguarded by the principle of ‘Informed Consent’. According to this principle, medical interventions can only be performed on patients who are firstly, fully informed about the type of treatment they might receive, and secondly, have given their permission for the treatment at stake (Beauchamp & Childress, 2011). As such, this principle should protect patients against potential manipulation, coercion or other forms of maltreatment in medical settings, in this way safeguarding their right for ‘self-governance’ (Dworkin, 1988c, p. 100). Moreover, it is also in accord with the liberal ethos, which states that no person ‘not even a doctor’, has the right to impose his or her (medical) values on those who do not share them (Taylor, 2010). However, not every patient is entitled to this right of Informed Consent. Indeed, the liberal ideal of self-governance rests on the condition that the individual is capable of exercising self-governance; in other words, one needs to be considered ‘competent’ (Beauchamp & Childress, 2011). Within medical contexts, this notion of competence is often defined as the “capacity to make (health-) choices’’ (Beauchamp & Childress, p. 70).1 At times, physicians fear that their patients lack the capacities that are required to make the decision at stake. In order to safeguard the patient from any harm, he or she can be declared ‘incompetent’, in which case someone else decides for the patient. Such “non-

1Much debate exists around this formulation of competence. It has been argued, for instance, that competence is not a categorical principle- something that is fixed, but should rather be understood as a dynamical concept that changes with every decision. Following this line of thought it might be better to speak of “ competence for some task, competence to do something’ (Buchanan & Brock 1989, 84). This task might differ, and with that, someone’s competence. In this regard, someone might be competent of deciding between pulling a tooth or not, yet would be incompetent when this decision encompasses her heart surgery. The term ‘decisional relativity’ now emphasizes that the evaluation of competence needs to be directly tied to a particular decision, for a particular patient, at a specific place and time.

Self-Rule in Sick Selves consensual treatments” (Matthews, 2000, p. 59) occur for instance in individuals who are in a coma and therefore physically unable to express their wishes, but also in patients who suffer from severe psychoses, treatment can sometimes start without firstly obtaining the patient's’ approval -even when this goes against his or her direct will.2 In the Dutch health care system the term ‘wilsbekwaamheid ’ is frequently used to refer to the notion of competence (Ruissen, Meynen & Widdershoven, 2011). This notion should, according to the ‘WBGO-wet’, be understood as “a patient who is rendered capable of fairly appreciating those issues which are at stake’’.3 This formulation can be interpreted in many ways though, an issue I will come back to. In the following sections, I will use the term competence as well as ‘wilsbekwaamheid’, where in both cases I refer to “the state in which a patient's decision-making capacities are sufficiently intact for their decisions to be honored” (Grisso & Appelbaum 1998, p.11).

§1.2 Competence in Psychiatry

Within psychiatric health care, the terms competence and self-governance play a special role. Whereas in somatic health-care, physical barriers such as a paralysis or a coma might prevent patients from expressing their will- thereby rendering them incapable of decision-making, in psychiatric patients something different is going on. Frequently, sufferers from mental illnesses are still capable of expressing a will, yet it is exactly the genuineness of this ‘will’ which is sometimes questioned by their treating psychiatrists. The intuition giving rise to these doubts is that in some cases, psychopathological changes interfere with the mental life of a patient to such an extent “that he or she is no longer self-governing, yet is instead “governed’ by the illness’’ (Matthews, p. 67, 2000). The will or choice expressed might then not be truly belonging to the patient, yet is merely the result of pathological disturbances.

2 These forms of coerced treatment are only accepted when there is a risk for severe damage to the patient’s health or when there is a danger other people might be harmed. An additional requirement is that the treating physician has looked for alternative treatments. Rijksoverheid (2017). Informatiepunt Dwang en Zorg. WBGO- wet. Wilsbekwaamheid (Accessed May 2017)

3 “[E]en meerderjarige patiënt die in staat kan worden geacht tot een redelijke waardering van de belangen ter zake’’. Rijksoverheid (2017). Informatiepunt Dwang in de Zorg, WBGO-wet. Wilsbekwaamheid (Accessed May 2017)

Self-Rule in Sick Selves

Such deliberations take place, for instance, in cases of euthanasia requests. According to a new proposed law “[E]uthanasie bij Voltooid Leven’’, elderly people who consider their life as “accomplished’’ should be allowed to receive euthanasia, provided that their wish is not the result of either external pressures (by for instance medical staff or family members) nor the effect of mental disturbances which render them incompetent, such as a depression or psychosis (Rijksoverheid, 2016).4 As such, prior to any intervention, psychiatrists need to distinguish between a ‘competent’ and ‘incompetent’ request, and examine whether the will expressed belongs to the patient, or in fact, derives from mental changes due to a psychiatric illness. In practice, this is not an easy task. Important to note is that a psychiatric diagnosis does not automatically renders a patient incompetent (WBGO-wet). 5 Different mental diseases can influence a person’s behavior in various ways. Moreover, a similar mental illness might manifest itself very differently in one patient compared to another. As such, declaring a patient incompetent solely based on his or her psychiatric diagnosis would be stigmatizing as well as discriminating. To safeguard patients from such unfair treatments, there is consensus that “every individual should be regarded as competent, until proven otherwise’’.6 What however, does this ‘proven otherwise’ exactly mean? And how does one determine this? These questions have shown to be very difficult. As stated before, the definition of ‘wilsbekwaamheid’ as a state in which one is “capable of fairly appreciating those issues that are at stake’’, can be interpreted in many (conflicting) ways.7 Is it, for instance, the physician or the patient who determines what these ‘issues at stake’ are? And what level of ‘appreciation’ is sufficient for a patient's’ choice to be respected? In short, although patients’ right to self-governance is premised on the condition that a patient is ‘competent’ for such exercise, how we should precisely understand what it means to be competent is unclear.

4 Rijksoverheid (2016). Rapport Adviescommissie. ‘Voltooid leven’.(Accessed April 2017)

5 Rijksoverheid (2017). Informatiepunt Dwang in de Zorg, ‘Wilsbekwaamheid’. (Accessed May 2017)

6 Rijksoverheid (2017). Informatiepunt Dwang in de Zorg. ‘Wilsbekwaamheid’ (Accessed May 2017)

7 Rijksoverheid (2017). Informatiepunt Dwang in de Zorg. ‘Wilsbekwaamheid’. (Accessed May 2017)

Self-Rule in Sick Selves

This lack of consensus on the term (in)competence is remarkable however, when we consider the radical impact this assessment can have on a patient's’ life. For not only can an ‘incompetent’ statement lead to a denial of a euthanasia request (such as in the situation sketched above) at times this declaration might also result in coerced treatment or even an involuntary commitment to a psychiatric ward.8 Bearing in mind these drastic consequences, it would be troublesome if a patient’s competence assessment (and consequently, his or her right for autonomous decision making) would depend on the type of psychiatrist he or she happens to have. Ideally then, psychiatrists would adhere to a shared idea of what it means to be competent when they assess this capacity in their patients. Not only would such an agreement on this notion assist psychiatrists in judging their patients’ competence whenever they are in doubt, more importantly, an equal evaluation would be more fair towards the patient whose right for self- governance is at stake. Roughly said, it would be in line with what Beauchamp & Childress define as the principle of justice in health-care, “the obligations of fairness in the distribution of benefits and risks’’ (Beauchamp & Childress 2011, p. 64). For these reasons, various competence ‘tests’ have been developed: tools established to help psychiatrists in evaluating their patients’ competence (Grisso & Applebaum, 1998). Ever since these tests came into being however, they have been criticized for different reasons (Charland, 1998) and the debate around these competence tests still continues (Meynen & Widdershoven, 2012). In general, we could state that this discussion revolves around two conflicting approaches to this idea of ‘measuring competence’, a procedural and a more substantive approach. In the next section I will provide an example of these two approaches, as well as an analysis of the various ways in which they have been criticized.

8These forms of coerced treatment are only accepted when there is a risk for severe damage to the patient’s health, or when there is a danger that other people might be harmed. An additional requirement is that treating physicians have looked for alternative treatment the patient does agree with. Rijksoverheid (2017). Informatiepunt Dwang en Zorg. WBGO-wet. Wilsbekwaamheid (Accessed May 2017)

Self-Rule in Sick Selves

§1.3 Competence Assessments: Two Approaches

1.3.1. A Procedural Approach: The MacArthur Competence Assessment Tool

The most widely used competence test, the MacArthur Competence Assessment Tool (developed by Grisso & Applebaum, 1998), aims to evaluate a patient’s competence by means of four criteria: his or her ability to communicate a choice, to understand the relevant information, to appreciate the medical consequences of the situation, and to reason about treatment choices, where this reasoning is usually said to include the ability to weigh risks and benefits With these four criteria, this test focuses on the patient's ‘cognitive functions’ which are thought to be required for the process of reaching a certain decision, but leaves out the material (the values, beliefs and convictions) individuals use whilst deciding, and does not evaluate the actual outcome of the decision either. As such, this test is characterized as ‘content-neutral’ or ‘procedural’ (Hermann et al. 2016). It is stated that this latter characteristic make this test well suited for liberal societies. The argument expressed here is that since assessments of competence take place against a background of a pluralistic culture, in which all people involved (whether they are nurses, psychiatrists or patients) hold on to different values, and since the imposition of certain values on other people is unwanted, “a test for competence must leave enough space for persons to choose which (irrational) values to adhere to, and consequently, which courses of actions to follow’’(Taylor, p. 64, 2010). Procedural tests, like the MacArthur-test, are considered to fit these demands, since they “refrain from judging the lifestyle, value system, viewpoint, or reasons underpinning a decision as more or less appropriate. As long as these procedural demands are met, people are allowed to make decisions on whatever grounds they choose- rational or irrational’’ (Hermann et al. 2016. p. 7).

1.3.2 Problems with the MacArthur Test: The Role of Values

Not everyone agrees with this exclusion of values and emotions in competence assessments. Louis Charland, for instance, states that “values figure among the reasons that patients 14

Self-Rule in Sick Selves actually use in reasoning when they weigh the risks and benefits of proposed treatment options’’ (2006, p. 283). In a similar vein, Buchanan and Brock have argued that making a decision necessitates “a conception of what is good” against which to weigh and evaluate alternative courses of action (1989, p. 24). From this follows that a method that excludes these components in evaluating competence, fails to capture what it aims to evaluate: a patient’s capacity to make a choice. Based on this argument, Charland concludes that the MacArthur test lacks “empirical validity”(2006, p. 284). Moreover, at times it are precisely patients’ values and emotions, which cause psychiatrists to question their competence (Meynen & Widdershoven, 2012). In explaining their concerns, Meynen & Widdershoven refer to a large empirical study by Tan and colleagues (2007) in which the MacArthur tool was used to evaluate whether anorexia patients were competent enough to refuse treatment. According to the MacArthur test, the patient’s cognitive functions were fully intact (i.e. they were able to reason about treatment options and to explain and communicate their choice for refusing treatment in an adequate way), as such; all of these patients were considered competent. However, this outcome shows exactly why there is a foundational problem with the MacArthur test, according to Meynen & Widdershoven (2012), for in fact, all of these patients should not have been judged as competent. After evaluating these patients according to the MacArthur tool, Tan et al. (2007) asked them why they wished to refuse treatment. As it turned out, most of them based their decisions on the value of ‘staying thin’. This value, however is a direct a result of the pathology anorexia nervosa, the illness they should be protected against, according to Meynen & Widdershoven (2012). In short, Meynen & Widdershoven argue that the MacArthur test sets the threshold for competence too low, for even though patients cognitive reasoning processes might be intact, due to these value disturbances they should still be considered incompetent. These clinicians therefore propose a model of competence that not only focuses on cognitive capacities, but also incorporates an evaluation of patients’ values.

1.3.3 A Substantial Approach: Pathological versus Authentic Values?

Despite the fact the MacArthur-test is praised for its content-neutrality, not judging the desires or values that could motivate a person to make that decision, critics consider this 15

Self-Rule in Sick Selves aspect a major weakness of the test, bringing in that it are exactly value disturbances which might render patients incompetent (Charland, 2007, Meynen & Widdershoven, 2012). These critics promote what has been defined as a more ‘substantive approach’ to competence (Hermann et al 2016), by proposing to include an evaluation of potentially pathological values as well. Yet, this account raises questions as well, for how should we understand this notion of a ‘pathological value’? The answer to this question is not straightforward. As stated before, a psychiatric diagnosis does not automatically render someone incompetent. In a similar vein then, a value cannot be considered ‘pathological’ solely because it belongs to someone with a mental disorder. Rather, according to Meynen & Widdershoven (2012), sufferers from mental illnesses should be assessed as incompetent with regard decision-making when certain ‘pathological values’ start to inflict upon this patient’s ‘authentic self’. Shortly, they express the argument that in order to be deemed competent and hence, enjoy one’s right to autonomous decision-making, patients must base their decisions on ‘authentic’, rather than ‘pathological’ values. This however, raises another, potentially even more challenging question, for how do we differentiate between a person’s ‘authentic’ and ‘pathological’ values? To illustrate this complexity, we might turn to a fictional case. Imagine a man who, after spending ten days in Nepal, decides to drastically change his diet. Whereas his family and friends would characterize him as a true ‘bon-vivant’, enjoying good company, his daily steak and glass of wine, he now only eats one plate of red beets a day (he only allows himself to eat purple food) and prefers to stay at home. Not only did the traveler drastically change his diet, while standing on the Mount Everest, he also decided to quit his job at a prestigious law office in order to meditate all day. It is these sudden changes which made his family question whether the man’s wish to quit his job is truly autonomous. Indeed, apparently, the man acquired a novel set of values and goals that highly contrasts with his previous way of living. Yet, declaring this man incompetent to make health decisions would be odd. What is it about the traveler which, despite the intrusion of these novel (bizarre) values, leaves him to ‘act authentically’, while the anorexic patient is no longer considered authentic? Clearly, it cannot be the fact that the anorexic patient makes decisions that conflict with his or her own well-being, since in both cases, the newly acquired

Self-Rule in Sick Selves values lead to serious health problems. However, the mere fact that the anorexia patient suffers from a mental condition is not enough either, as discussed before, in declaring a person incompetent and thus, not autonomous. Some psychiatrists have elaborated on the link between pathological values and authenticity by stating that:

One implication of them [anorexic values] being pathological is that these values do not represent the true or authentic views of the person. In respecting the autonomy of the person it is her ‘authentic’ views that should be respected – that is the views that she would have (or did have) if she did not suffer from the mental disorder (Tan et al. 2006, p. 280).

In this regard, if we were to question ‘which values are authentic?’ The answer would be; those that are not inflicted upon by pathological values. However, if we then wonder ‘what types of values are pathological’? The answer would be: those that do not represent authentic views. Thus, based on these latter explanations, we cannot distinguish between a ‘novel bizarre value’ and a ‘pathological value’. What is actually stated here is that some values are pathological because they are not authentic, and authenticity is acting without the influence of pathological values. Hence, such a definition of authenticity is begging the question. In short, more substantive approaches to testing competence, such as those by Meynen & Widdershoven, propose to include an evaluation of patients’ values as well. The argument is based on two propositions. Firstly, that choosing authentically is a necessary requirement for competence and thus for autonomy, and secondly, that there exist certain pathological values that hamper one’s authentic decision-making processes. The example above however, revealed that if we were to use this approach in evaluating competence, we also have to explain how and why certain new values are pathological and render choices inauthentic, whilst others do not, without referring to the patient’s diagnosis (this would be discriminating).

Self-Rule in Sick Selves

§1.4 Conclusion

In this chapter, we looked into the controversies regarding the assessment of patients’ competence, for even though this notion of competence forms a fundamental condition for patients’ right to autonomy, how we should understand or operationalize this term is unclear. This fuzziness around the notion of competence is reflected in the debate around the type of criteria that are relevant for such an assessment. On the one hand, it is argued that competence tests should focus only on patients’ cognitive skills, not judging the underlying values, in this way allowing for a variety of lives patients can lead (Grisso & Applebaum, 1998). Opponents of this apparent ‘neutral approach’ to competence bring in that not only does decision-making require a set of values, at times it are exactly value disturbances which compromise a patient's’ competence. Since content-neutral approaches such as the MacArthur-test do not take into account these (potential pathological) values, critics state that this test is not suitable for assessing competence in patients (Meynen & Widdershoven, 2012). In short, there seems to be a tension between constructing a test that is ‘thin enough’ to allow space for patients’ irrational decisions, yet ‘thick’ enough to safeguard those patients who should be entitled to protection. Moreover, analyzing the clinical issue of competence assessments revealed that this debate is also guided by different assumptions about what it means, or what it should mean to be a competent agent. We have seen that the apparent content-neutrality of the Mac-Arthur test of competence differs highly from substantive approaches to competence, on which patients cannot endorse certain values if he or she is to be considered competent, and therefore autonomous. This latter account is guided by the assumption that only patients who make their decision based on ‘authentic values’ are competent, and hence, suitable for the right to autonomy. How to understand or define these types of values though, is left unanswered.

Self-Rule in Sick Selves

PART II: AUTONOMY CONCEPTIONS IN PHILOSOPHY

In the first part of this thesis, we explored practical contexts in which autonomy is at issue by analyzing the notion of autonomy within psychiatric practice. More specifically, we shed light on how various notions of ‘competence’; the condition for autonomous decision- making, take shape in different clinical tests developed to assist psychiatrists in evaluating this capacity in psychiatric patients. With a practical background in place, I will now examine different perspectives on autonomy as they appear in contemporary philosophical theories. What stands out in this discussion is that despite their different ideas about what autonomy is or what it ought to be, many theorists refer to a similar group of examples to demarcate this notion: in sufferers from mental illnesses, it is stated, autonomy is often undermined. Especially addictions and compulsions form popular examples in philosophical literature to illustrate how certain influences on our behavior prevent us from governing ourselves. How can these similar examples serve the same purpose in different- and at times even competing- theories of autonomy? And what are the underlying assumptions guiding such descriptions? With these questions in mind, I will shed light on several contemporary approaches to autonomy, adhering to the distinction introduced by Catriona Mackenzie between procedural and more substantive autonomy accounts (2000, p.12). In general terms, those who follow procedural models believe that an agent's’ autonomy depends on their critical reflection of their values as “his or her own”, instead of feeling “indifferent or external towards these desires” (p. 13). Mackenzie further divides between structural and historical versions of procedural theories, which according to her, have different opinions on what kind of critical reflection processes are necessary for autonomy. On the other hand, more substantive approaches to autonomy claim that “internal reflection on one’s values and desires is not enough to secure autonomy”, and propose to add more constraints on the type of values an autonomous agent is guided by (Mackenzie, 2000, p.14).

This part of the thesis is divided into two chapters. In the first chapter, I will engage with procedural theories of autonomy, focusing first on one of the most well-known structural accounts, introduced by Harry Frankfurt and grounded in the notion of higher-order desires 19

Self-Rule in Sick Selves

(1988). Secondly, I will turn to more historical versions of these procedural theories, brought forward by Gerald Dworkin (1988) and John Christman (1999). Subsequently in chapter two of this part, I shall outline the critiques of these procedural theories of autonomy, which leads me to discuss more substantive approaches, focusing on one by Susan Wolf.

1. Procedural Accounts of Autonomous Agency

§1.1 Structural Versions: Frankfurt’s Higher-Order Desires

One of the most influential approaches to autonomy, introduced by Harry Frankfurt, is based on the notion of “second-order desires” (1988a, p.11). In his famous essay Freedom of the Will and the Concept of a Person, Frankfurt makes a distinction between two types of human desires. First-order desires constitute the wish to perform certain types of action, such as watching reality TV all day long. Second-order desire constitutes a type of attitude towards this first order desire, for instance, the desire to no longer be guided by the desire to watch reality TV all afternoon (instead to be productive and write a thesis proposal). On Frankfurt’s account, to have freedom of will (or to be an autonomous agent9) we need not only the ability to “translate our desires into action” (1988a, p.20), but also to “identify” with these desires (1988a, p.18). In this sense, identifying means distinguishing between desires that an agent considers “one’s own” from those desires that one is either indifferent to or regards as “external” to oneself (Frankfurt, 1988b, p.170). To illustrate this account, Frankfurt asks us to consider two types of agents who, according to him, lack autonomy. Interestingly, he refers to a psychiatric condition in order to explain his point. The first type of agent who does not act autonomously is someone who does not have any second-order desires at all. Frankfurt calls such agents “wantons’’ instead of persons (p. 16), listing small children and animals as well as individuals who are addicted to drugs and constantly desire to take this drug, without having any type of attitude towards this desire (1988a, p. 17). As Frankfurt sees it, even though these individuals might have

9 Frankfurt's view is not exactly a theory of autonomy, yet rather an account of freedom of the will. Nevertheless, “the account has been absorbed into the literature on autonomy as a model of that notion.” (Christman, John, "Autonomy in Moral and Political Philosophy", The Stanford Encyclopedia of Philosophy (Spring 2015 Edition)

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“freedom of action”, they lack the capacity to identify with this desire (the ability to accept or disregard the desire at stake as ‘one’s own’) and hence, do not have freedom of will (Frankfurt, 1988a, p. 16). Merely having second-order desires is in Frankfurt’s view not enough for autonomy either; an autonomous agent also needs to satisfy a second condition. Again, Frankfurt asks us to consider a drug addict who does possess a second-order attitude towards his drug cravings-he wishes to no longer desire heroin-yet is unable to act upon this second order desire and continues shooting heroin. Even though this “unwilling addict” (p.17) has a clear aversive attitude towards his daily drug cravings (he wants them to go away), the fact that he is unable to act upon this second-order desire (and stop using heroin) still prevents him from having freedom of the will (1988a, p. 17). Both examples reveal that in Frankfurt’s account, someone acts autonomously when there is match between this person’s second-order desire (a desire as to which first-order desire should move one to action) and the first-order desire, which does in fact move this agent to action (Frankfurt, 1988a, p. 18). Otherwise stated, an autonomous agent is someone who is not just guided by the desires one ‘happens to have’, but rather acts on the basis of those desires one identifies with, those one regards one’s own. As such, Frankfurt’s account of identification opens up new ways of thinking about the practical issues regarding autonomy in mental health practices, discussed in the previous chapter. Within such contexts, imposing treatment (which might violate a patient’s right to self-governance) is sometimes justified by the argument that sufferers of mental disorders make decisions that they would not have made prior to the disease. Consequently, “he or she is not ‘autonomous’ or ‘self-governing’, but is ‘governed’ by the illness’’ (Matthews, 2000, p. 67). Frankfurt’s account of identification sheds a different light on this debate. In fact, we have seen that Frankfurt handles the own attitudes of agents towards their desires as the ultimate determinants with regard to the assessment of whether or not they are autonomous, where acting in accordance with the desires one identifies with constitutes autonomous action (1988a, p.18) From this perspective, even patients who suffer from severe addictions might still be considered autonomous, provided that they identify with the desire (they should have

Self-Rule in Sick Selves accepted this desire to use the substance at stake as ‘their own’). To illustrate this better, Frankfurt characterizes such a “willing addict” in the following way.

(H)e is altogether delighted with his condition. He is a willing addict, who would not have things any other way. If the grip of his addiction should somehow weaken, he would do whatever he could to reinstate it; if his desire for the drug should begin to fade, he would take steps to renew its intensity. (Frankfurt 1988a, p. 24)

In short, the willing addict both wants to want the drug, and is also moved by this desire. In contrast to what this quote might suggest, Frankfurt is not claiming that the willing addict enjoys control over his (first-order) desire to take the drugs. Just like the unwilling addict, he argues, the willing addict is “physiologically addicted” and “his will is out of his control”. What differentiates these two agents though, is that the willing addict identifies with his drug cravings, in other words, “by his second-order desire that his desire for the drug should be effective”, he, “made this will his own”. Frankfurt states that “given that it is therefore not only because of his addiction that his desire for the drug is effective, he may be morally responsible for taking the drug” (1988a, p. 25). It should be clear that Frankfurt’s notion breaks with the idea that mental illnesses automatically diminish a patient’s autonomy, and hence brings in a new perspective to the debate around autonomy in mental illnesses. Indeed, following Frankfurt’s approach, even though mental illnesses such as addiction might govern patients’ will (or first-order desire), the potential presence of second-order desires might turn this addictive desire into these patients’ ‘own will’, in which case they still act out of their free will, and their autonomy is not undermined. Though this model opens up new ways of thinking about autonomy and addiction (leaving enough space for the idea that autonomy should be related to making up one’s own mind), Frankfurt’s account of the willing addict also led to resistance. Mark Leon for instance, argues that this willing addict does not use the drugs because he is drawn to it and

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“identifies” with this desire, he uses drugs because he is “irresistibly addicted’’ (Leon, 2001, p. 437). More specifically, he states “given that the willing addict’s desire for the drug is an irresistible desire, he would still continue to use the heroin ‘even if he no longer desires to do so’”. Consequently, Leon claims that just like Frankfurt’s unwilling addict, this agent is “merely a passive by-stander to the operation of the addiction’’ and ’the willing addicts does not have free will” (p. 438, 2001). James Taylor (2005) claims that the idea that the addict does not have freedom of will because he would continue using heroin regardless is based on a questionable assumption. Namely, “ for a person to act out of one’s free will, he or she needs to be able to act other than he or she did’’. Frankfurt has convincingly argued against exactly this latter assumption that dominated “moral intuitions”, a notion he famously called the “principle of alternate possibilities” (Frankfurt, 1988b, p.2). To understand the consequences of Frankfurt’s willing addict argument, we will have to take a small detour and investigate why Frankfurt states that the principle of alternate possibilities is false. In what follows, I shall reflect upon the way he argued against this principle, subsequently returning to our debate by reflecting upon Taylor’s ideas of what this means for the willing addict. Briefly, according to Frankfurt, the principle of alternate possibilities does not hold. He states, “a person may well be morally responsible (or have freedom of will) for what he has done even though he could not have done otherwise” (Frankfurt, 1988b, p.2). Frankfurt‘s arguments are based on the following thought experiment.

Suppose someone -Black, let us say- wants Jones to perform a certain action. Black is prepared to go to considerable lengths to get his way, but he prefers to avoid showing his hand unnecessarily. So he waits until Jones is about to make up his mind what to do, and he does nothing unless it is clear to him (Black is an excellent judge of such things) that Jones is going to decide to do something other than what he wants him to do. If it does become clear that Jones is going to decide to do something else, Black takes effective steps to ensure that Jones decides to do, and that he does do, what he wants him to do. Whatever Jones's initial preferences and inclinations, then, Black will have his way. However Black never has to show his hand 23

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because Jones, for reasons of his own, decides to perform and does perform the very action Black wants him to perform. (Frankfurt,1988b, p.7).

In short, Frankfurt claims that because Jones performs the action for ‘reasons of his own’, even though he could not have done otherwise, neither free action nor free will requires that a person needs to be able to do anything other than what he did. How does this notion relate to freedom of will in the willing addict? According to Taylor, we can say something similar of the willing addict. Even though there was no other way for the addict than to take the heroin due to irresistible desire, similar to Jones “the willing addict's act of taking the drug flowed from his own motivational set and he was moved to perform it by a desire that he volitionally endorsed” (p. 241, 2005). Following Frankfurt’s line of reasoning, Taylor concludes that “the fact that there was no other option for the addict than to take the drug to which he is addicted does not undermine the claim that he acted both freely and of his own free will’’(2005, p. 241). In short, according to Taylor, the argument that the willing addict had no other option than to take the drug does not undermine Frankfurt’s statement that the willing addict acted of his own free will when he took the drug that he was addicted to. That is not to say, however, that Taylor fully agrees with Frankfurt’s account of freedom of will, grounded in the notion of identification. On the contrary, Taylor is skeptical regarding approaches to autonomy that adhere to a “subjective analysis of what it is for a person to identify with her desires” (p. 253, 2015). For how do these theories account for the possibility that a person’s attitude towards his or her first-order desire might have resulted from manipulation? (Taylor, 2005) Or, to refer to the example of the willing addict, what ensures us that this addict’s second-order desires were not also a result of the addiction? It seems that on Frankfurt’s account, to answer this question we would need another desire (a third-order desire) to determine whether the patient truly identifies with this second- order desire. Yet this solution does not seem to solve the problem. In fact, as we will see in the following section, by raising this question, Taylor touches upon what is often seen as the most problematic part of Frankfurt’s account of identification.

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§1.2 Criticizing Frankfurt’s Account: The Regress-Problem

In the previous section, we observed how in Frankfurt’s analysis identification with one’s desires is sufficient for autonomy. Moreover, following his account, even those individuals who appear to behave out of their own control (i.e. due to a severe addiction) might still be rendered autonomous provided that they have a second-order desire that is in line with their first-order desire and behavior. Such examples illustrate that there is some sort of “hierarchical structure” (Mackenzie, 2000, p.14) in Frankfurt’s approach to autonomy: second-order desires belong more truly to the agent compared to first-order desires. In other words, “second-order desires reveal what one ‘really’ wants, that they are the side of one’s “true self” (Anderson, 2008, p. 10). This argument is met with skepticism. Critics of such hierarchical approaches, such as Gary Watson, raise that the mere fact that human beings have different types of desires does not yet provide hierarchical orders to them (1975, p. 218). Indeed, what is it about this second-order desire that makes it a more ‘true expression of the self’, than the first-order desire? Moreover, as Taylor argued, these second-order desires might have themselves resulted from manipulation or indoctrination (Taylor, 2005). To refer to the willing addict, what prevents us from claiming that the addict’s identification with the desire to use drugs was in fact a result of the addiction, rather than at the side of the patient’s ‘true self? It seems that in Frankfurt’s terms, in order to determine whether this was the case and make sure that the patient truly identifies with this drug craving, there is need of another (third-order) desire. However, it is exactly this point where Frankfurt’s theory of identification falls short. Gary Watson, for instance, states that “since second-order volitions are themselves simply desires, to add them to the context of conflict is just to increase the number of contenders” (Watson, p. 218, 1975). In a similar vein, Robert Noggle claimed that such a solution would merely “move the problem back a step’’ (2005, p.90), for what ensures us that this third-order desire is more authoritative of a person’s will and grants it the autonomy status? In summary then, it seems that Frankfurt’s approach runs into difficulties when it comes to determining which desire in the potential infinite chain can be can be regarded as truly autonomous, a problem famously articulated by Gary Watson as the “regress problem’’ (Watson, 1975, p.

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217). To account for this regress problem, different strategies have been introduced. Frankfurt himself also acknowledged the deficiencies in his account of higher-order desires. In his later essay ‘Identification and Wholeheartedness’, he states that “the mere fact that one desire occupies a higher level than another in the hierarchy seems plainly insufficient to endow it with greater authority or with any constitutive legitimacy” (Frankfurt, 1988c, p. 166). To end this possible infinite regress, Frankfurt introduces a second criterion; for someone’s desires to be autonomous, this person should also be “satisfied” with them (1988, p. 166). How we should understand this notion of satisfaction becomes clear when Frankfurt’s writes: “to be satisfied with something does not require that a person have any particular belief about it, nor any particular feeling or attitude or intention”. Rather, he writes elsewhere, we might see it as a state of the will which is “untroubled by doubts or desires to change”, and compares it to “being or becoming relaxed” (Frankfurt, 1999, p.105). Applying this revised account including the condition of ‘satisfaction’ to the willing addict leads to the following: if the drug addict forms second-order desires about her addiction (she wants to want the drugs), and is at that current moment not troubled by conflicting desires nor any desire to change, then there should be no reason to deny that this addict is an autonomous agent, as per Frankfurt. It is questionable however, whether Frankfurt’s account of satisfaction really ends the regress problem. For how do we know when we are in a state of satisfaction? If “satisfaction” consists of an absence of any particular feelings or beliefs towards one’s state (as Frankfurt claims), then how does this fit with Frankfurt’s own theory of second-order desires, in which an autonomous agent not only acts on the basis of his or her will, but also forms (active) attitudes towards this will? Bas Peeters expressed this criticism by asking “if the satisfied agent has no active interest in bringing about a change, why then should the agent still be considered a genuine person? After all, if he simply does not care about his psychic condition, then being satisfied seems to come very close to the indifference of the wanton.” (2015, p. 23). In short, it is questionable whether Frankfurt’s revised account of satisfaction really solves the regress problem, an issue I will return to later. At this point, we have seen that Frankfurt’s original, as well as his revised account of identification as satisfaction are both neutral with respect to evaluating the content of an

Self-Rule in Sick Selves agent’s desires as well as to the origin of these desires. It is precisely this latter aspect of Frankfurt’s theory, which has led to much resistance. John Christman states that this view “accepts that 'a person's desires can be determined to be autonomous or not by taking a time- slice of the person and asking what her attitude would be about the desires she has at the time” (Christman 1991, p. 9). Yet, he concedes, “how the agent evaluates the desire in itself may have little to do with the process of desire-formation” (p. 9). Rather, exactly during this process of acquiring desires and beliefs is where Christman suspects autonomy might be hampered. In a similar vein, Gerald Dworkin, argues that “second-order reflections cannot be the whole story of autonomy. For those reflections, the choice of the person one wants to become may be influenced by other persons or circumstances in such a fashion that we do not view those evaluations as being the person’s own” (Dworkin, 1988, p. 18). Thus, for both Dworkin and Christman, the fact that Frankfurt’s account does not include the way an agent came to the desires at stake creates a pitfall to his approach. More specifically, their objection against this ‘time-slice’ approach is grounded in the concern that reflection on one’s desires might have been influenced by certain forms of manipulation or brainwashing, in which case the idea that these desires are the most authoritative basis of one’s ‘own will’ becomes questionable. To account for such scenarios, both critics developed a notion of autonomy that also incorporates the processes and circumstances leading up to an agent’s desires at stake. In the following section, I will shed light on these so called “historical approaches” to autonomy (Mackenzie, 2000, p. 11).

§1.3 Historical Versions: John Christman & Gerald Dworkin

In the previous section, we observed how Frankfurt’s notion of autonomy has been criticized for introducing a ‘time-slice-model’. Such criticism is guided by the belief that certain types of processes lead to autonomous desires and beliefs whilst other kinds do not, something that such a ‘time-slice approach’ cannot check for (Christman, 1999). To secure that agents’ autonomous desires “arose in the right way” (Dworkin, 1988), theories that also account for the circumstances under which an agent is reflecting have been developed (Christman 2009,

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Dworkin, 1988). In these conceptions, autonomy is not only determined by an agent’s desires at a given moment in time, but also evaluates the processes and circumstances leading up to these desires. To understand the main differences between Frankfurt’s account and these so called “historical approaches” (Mackenzie, 2000, p. 11) it might be insightful to analyze how both theories would deal with the case-study introduced in the first chapter of this thesis. To briefly recall, in the previous chapter we discussed the case of a man who, after returning from a ten-day holiday in Nepal, decided to drastically change his life. He began to meditate for more than six hours a day, changed his diet (he now only eats purple food) and is now considering quitting his job as a lawyer to meditate even more. In combination, it seems that during these ten days, the man acquired new desires and beliefs that highly contrast with his previous manner of living, which made his family question whether the man’s wish to quit his is job is truly autonomous. Applying Frankfurt’s account of identification and satisfaction, whether or not we should perceive of the man’s decisions as truly autonomous can be determined by the traveler’s point of view alone. In short, if the man both wants to desire to eat purple food and meditate all day, and if he is untroubled by doubts or desires to change, then according to Frankfurt we have no reason to think he is not autonomous. John Christman and Gerald Dworkin argue that these conditions would not be enough to guarantee that the traveler acts autonomously. They are concerned that such an account fails to check whether the process of desire-formation was free of influences by other people or circumstances, which would hamper one’s autonomy. What if during his trip in Nepal, the traveler joined a cult that indoctrinated him to adopt the desires of his cult leader (meditation, eating purple food) through a series of highly spiritual sessions? Therefore, according to Christman, the way in which the traveler came to these novel desires and beliefs would be most troubling, rather than how the man evaluates these desires at the given moment in time. Following this intuition, Christman proposes that “the key element of autonomy is the agent's acceptance or rejection of the process of desire formation or the factors that give rise to this desire formation, rather than the agent's identification with the desires” (1991, p.2), and also “whether any factors are present during these evaluations which effectively undercut a person's ability to make these judgments about her past” (1991,

Self-Rule in Sick Selves p.10). Dworkin would agree with a Christman reading that checking the traveler’s current state would not be enough to ascribe him autonomy. Yet, whereas Christman emphasizes that this process of reflecting on one’s desires should not be interfered by “Illegitimate External Influences” (1987, p. 291), Dworkin develops a slightly different notion. More precisely, Dworkin attempts to ensure that this critical reflection is not influenced by autonomy undermining circumstances, by requiring that this process occurs under the conditions of “procedural independence”. In his words, “if a person’s reflections have not been manipulated, coerced, and so forth and if the person does have the requisite identification [i.e. if the person has formed second-order desires] then they are, on my view, autonomous” (Dworkin 1988a, p. 20). Following these historical approaches to autonomy, Frankfurt’s conditions of identification and satisfaction do not suffice to consider the traveler autonomous. To evaluate whether the traveler’s desires are autonomous, we would also need to make sure the way he came to these desires was not manipulated or constrained in any way. Concretely, we would need to know what happened during his time in Nepal. There are a number of attractive features to these historical conceptions of autonomy. Firstly, in contrast to structural versions, these accounts support our intuition that the way in which a person came to the beliefs that he or she holds is also an important feature of autonomous agency. According to Joel Anderson (2008) there is another advantage of historical approaches over structural accounts. Interestingly, Anderson’s criticism of Frankfurt’s approach brings us back to the issue with which we began this exploration: autonomy ascription in sufferers from mental illnesses. According to Anderson, in everyday life autonomy is something that is always “ascribed and contested’’ to others (2008, p. 9). He illustrates this by writing that “in the practical contexts in which autonomy is at issue – for example, a patient’s request for assisted suicide, the relevance for autonomy-ascriptions is undeniable” (2008, p. 9). For these reasons, Anderson claims that “it is a desideratum of any theory of autonomy that its account of what autonomy entails provide at least the basis for an account of the pragmatics of how autonomy is to be ascribed and contested’’ (2008, p.9). It is of course up for debate whether a theory of autonomy should capture our

Self-Rule in Sick Selves everyday and practical uses of the term. However, if we follow Anderson’s rationale that an account of autonomy should assist in autonomy ascriptions, Frankfurt’s account provides little support. This approach treats agents’ own evaluations of their desires as the sole and ultimate determinants of autonomy. As such, Frankfurt’s account of identification seems to better suited for ‘self-ascription’ of autonomy, rather than ascribing this quality to others.10 Moreover, Anderson suggests that even if we were to evaluate whether our desires are autonomous from a first-person perspective, Frankfurt’s model leaves us without resolve (2008, p. 13). We have seen that for Frankfurt, the condition for autonomy, being satisfied, is understood as a first-person, reflexive state of the will in which someone is untroubled by doubts or desires to change. In this regard, the question whether one’s desires are truly autonomous is quite paradoxical. Indeed, as Anderson’s nicely states it “from the perspective of the deliberating agent, the question of one’s autonomy is supposed to answer itself by not being asked” (2008, p. 13). Historical versions, on the other hand, are according to Anderson much better suited to deal with the “dynamics of autonomy-ascription” (Anderson, 2008, p. 15). He states that “particularly for those working in contexts of applied ethics, there is much that is attractive about the apparently straightforwardly public criterion introduced by Dworkin: if a person’s reflections have not been manipulated, coerced, and so forth and if the person does have the requisite identification, then they are, on my view, autonomous” (Anderson, 2008 p.15). In short, according to Anderson, autonomy is something that is (in everyday life) mainly contested and ascribed to others. Based on this observation, Anderson holds that a theory of autonomy should at least include a basis of how to assign such a quality in someone else. In comparison to Frankfurt’s account, historical versions are in Anderson’s view better

10 It should be noted that both philosophers are on a different mission. Whereas Frankfurt spells out certain conditions for an agent to have freedom of will at a certain moment in time (1988a), not intending to analyze any ethical or practical matters, Anderson emphasizes that a theory of autonomy should do just that. In specific, he wants to focus on the “practical use of such an autonomy theory” and argues that in daily life autonomy is something that is always ‘’ascribed and contested’’(2008, p. 9). It is of course up for debate whether a theory of autonomy should indeed capture our everyday uses of the term.

Self-Rule in Sick Selves in meeting this demands, since the way he sees it, such theories spell out more concrete and practical conditions required for autonomy. But do they really?

§1.4 Criticizing Historical Accounts: The Ad-Hoc Problem & Oppression

In the previous section we have seen that theorists who follow historical approaches emphasize that autonomous desires should not only be properly assigned to someone’s current state and reflections, yet that these also originated in the ‘right way’. Consequently, the challenge for these theorists becomes to explain what this ‘right way’ entails. More specifically, they need to distinguish certain circumstances or processes that safeguard or encourage, someone’s self-governing, from those that infringe on this capacity. We have seen that Dworkin specifies this by emphasizing that autonomous reflection should occur under the conditions of “procedural independence” (1988, p. 18). Yet, how do we know that these conditions of procedural independence are met? According to Dworkin, “spelling out the conditions of procedural independence involves distinguishing those ways of influencing people’s reflective and critical faculties which subvert them from those which promote and improve them” (p. 18). This however, is only part of the answer, for it still requires a specification of what ‘critical faculties’ are necessary for autonomy. Other procedural theorists sometimes explain a lack of autonomy by referring to instances of psychological conditioning, manipulation or mental disorders and then argue that such influences “interfere’’ with the capacity of self-governance (Watson, 1975, p. 205). Yet this is also only a partial explanation, for it leaves the question why these influences hamper autonomy, unanswered. Sarah Buss expresses this criticism stating that “insofar as accounts of autonomy stipulate that certain influences on an agent’s intention-forming process “interfere with”’ or “pervert”, this process, these accounts are incomplete, for they leave it mysterious why certain, and not others, are a threat to self-government” (2008). Moreover, we could even argue that such explanations resemble the ad-hoc argument we analyzed in chapter one, brought forward within psychiatric practice. To recall this, in the context of mental health-care, it is sometimes suggested that in order for patients to be rendered competent (and therefore autonomous), he or she needs to act authentically, i.e. a 31

Self-Rule in Sick Selves patient needs to make authentic choice (Tan et al. 2007, Meynen & Widdershoven, 2012). Yet, when it comes to defining what renders such a choice authentic, this approach seems to be begging the question. Acting authentically, so it is stated, means to act without the interference of pathological values, where pathological values are understood as those who do not express the authentic views of the patient. Now, it seems that specifying the conditions for procedural independence runs the risk of expressing a similar circular argument.11 According to these procedural theories too, someone acts autonomously if he or she acts in the absence of any ‘autonomy-undermining’ influences, such as brainwashing, manipulation or certain mental conditions, leaving the question why such influences and circumstances interfere with one’s capacity for self- governing unanswered. In short, the challenge for procedural theorists becomes to explain what makes such an influence ‘external’ and autonomy undermining, and to do this without begging the question. Christman proposes an historical approach that is slightly different and hence, his account might avoid these conceptual difficulties. For even though Christman also emphasizes that the way in which an agent’s desire originate is crucial to autonomy, unlike Dworkin, he argues that this depends on someone’s own attitudes towards the historical processes leading up to their current desires. Indeed, Christman states “a person is autonomous with respect to her values and higher-order identifications only if, upon becoming aware of the historical process through which she acquired them, she does not resist this process, or she would not resist it were she to become aware of it” (Christman, 1999, p.65).12

11 As a matter of fact, Dworkin also acknowledges the difficulties that arise in explaining procedural conditions in a way that is not circular, when he states that specifying these conditions “involves distinguishing those influences such as hypnotic suggestion, manipulation, coercive persuasion, subluminal influence, and so forth, and doing so in a non ad hoc fashion.” (1988, p. 18).

12 In a more recent writing, Christman introduces a slightly different criterion in order to test for autonomy. Here, he argues that a person is autonomous with respect to some belief or desire if upon becoming aware of the processes leading up to these beliefs, he or she would not feel alienated, where alienation should be understood as having “neither a negative judgment about, or a negative emotional reaction to the desire (Christman, 2009, p.144).

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This condition however, also raises questions, for what if the agent’s attitudes towards the processes leading up to his desires, are in fact a product of these circumstances? Consider again the traveler. It might be the case that he has been so thoroughly indoctrinated due to these cult rituals that even becoming aware of these indoctrination processes, the traveler does not lead him to feel any resistance. Otherwise stated, what ensures us that the man’s current lack of resistance against such processes is not in fact also a result of these indoctrination rituals? Christman himself also acknowledges this possibility and therefore introduced a second requirement: in addition to the condition that an autonomous agent should not feel resistance when reflecting upon the origins of his desires, this contemplation should neither occur under conditions that hamper such reflection altogether (Christman, 1991). Combining these two conditions, he argues that autonomous reflection should not be interfered by “Illegitimate External Influences” (Christman, p. 289) More specifically, he defines such an interference as “External” in case it originated outside the individual and interferes with normal cognitive processes of reflection, and “Illegitimate” if this person wants to revise these desires after becoming aware of their origins (Christman, 1987. p. 290) Here we see that Christman developed a theory in which he combines a subjective aspect, the condition that an agent should not feel resistance in the process of reflection, with a more external criterion, the fact that such reflection should not be hampered by interferences with cognitive processes of reflection. This however, does not avoid the problem we run into when trying to specify Dworkin’s conditions of procedural independence. On the contrary, on Christman’s account as well, conceptual difficulties arise when it comes to specifying what kinds of influences interfere with “normal cognitive processes of reflection’, for it are precisely these processes that needed a clarification in the first place. In short, whereas historical approaches emphasize that autonomous agency involves critical reflection on whether one’s motives are truly one’s own instead of the result of external interferences, specifying such inferences seems to be difficult. This issue becomes especially puzzling when we turn to the processes of socialization. More specifically, how do historical theories allow for the fact that our

Self-Rule in Sick Selves desires, motives and life-choices are heavily shaped (if not determined) by the society we grow up in? Should we regard such societal influences also as a type of historical processes that interfere with our capacity of critical reflection, or do they rather promote this capacity? In this regard, since historical accounts require that an autonomous agent evaluates and acts on those motives that belong to one’s self, such theories might have difficulties accounting for the fact that this self is in fact shaped by numerous societal influences, such as our education, upbringing and social class. Moreover, these questions become particularly problematic for historical theories, when we analyze forms of socialization that are oppressive. This is convincingly demonstrated by Paul Benson who, in order to illustrate such an oppressive force, introduces the example of “socialization of feminine appearance” (Benson, 1991, p. 389). In a few words, Benson asks us to consider a girl who grows up in a male-dominated society that highly values women’s physical appearance. Due to the constant pressure by the media, the fashion industry and her peers, this girl internalizes the desire to look attractive and feminine for men to such an extent that, as a young woman, her sense of self-worth is completely determined by the way she looks (Benson, 1991, p.389). Intuitively, we would feel troubled considering this woman a full autonomous agent. Historical approaches, however, do not support such intuitions. Conforming to Christman’s notion of autonomy, for instance, we should check whether such desires are illegitimate (whether the girl feels resistance whenever she realizes they are a product of the sexist society she lives in) or external (whether they interfere with the girls’ ‘normal cognitive processes’). Yet, Benson argues, it is exactly here where Christman might have overlooked an important aspect. For it is very likely that the young woman is so “accustomed to thinking of herself from an internalized male point of view” (p. 394) that even becoming aware of the fact that the desire to be attractive were a result of the oppressive and sexist society she lives in, would not lead her to adjust this desire (Benson, 1991). Natalie Stoljar makes a similar point when she states that merely articulating an internalized norm would by itself not likely lead to resistance “precisely because the habits of deference and the internalized norms, that is, the values that govern the agent’s motivational structure, would themselves justify holding the relevant desire” (2000, p. 101).

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Moreover, according to Benson, this girl’s desires could potentially not even be considered as an ‘external influence’, for the majority of people growing up in such a society might have been so accustomed to these norms of feminine appearance, that the girl’s desire to fit in this ideal, would never be regarded as interferences with normal cognitive processes (1991, p. 395). To summarize this, Benson objects to Christman’s approach by arguing that someone might be so thoroughly socialized to internalize oppressive norms as their own desires and beliefs, that becoming aware of their origins would not lead to any revisions. Moreover, some of these beliefs are actually part of what some societies take to be ‘normal cognitive processes’. It is here, Benson states, where historical accounts such as Christman’s fail to detect the oppressive, sometimes autonomy-undermining processes in a person’s history.

§1.5 Conclusion

In this chapter, we looked into procedural conceptions of autonomy, which emphasize that autonomy involves critical reflection on one’s desires. More specifically, an autonomous agent acts on the basis of desires he or she regards as one’s own, instead of being guided by motives one feels indifferent or repelled by. We have seen that structural versions of these procedural accounts, such as those defended by Harry Frankfurt, differ from historical versions, introduced by John Christman and Gerald Dworkin, in their different ways of spelling out what kind of critical reflection is needed to secure autonomy (Mackenzie, 2000). According to Frankfurt, autonomous reflection consists in being guided by those desires one identifies with, rather than by those one merely ‘happens to have’. Identifying in his account, means being moved by desires one - on a higher-order level - wants to be moved by. Additionally, an autonomous agent should during this process not be bothered by any doubts or desires to change. Since Frankfurt’s treats agent’s own judgments of their desires as the final determinants of autonomous agency, his conception of autonomy is often characterized as a model of ‘internal self-reflection’ (Mackenzie, 2000). Even though Frankfurt’s idea of higher-order desires left important traces in 35

Self-Rule in Sick Selves contemporary theories of autonomy, his account has also received much criticism. Firstly, some bring in that Frankfurt’s model fails to meet what these critics consider an important desideratum for a theory of autonomy, the fact that in everyday life this quality is often ascribed to others (Anderson, 2008). Indeed, this approach treats agents’ own evaluations of their desires as the only, and ultimate determinants of autonomy. As such, Frankfurt’s account of identification seems to better suited for ‘self-ascription’ of autonomy, rather than ascribing this quality to others. Secondly, opponents argue that reflecting upon one’s desires at a single moment in time is not enough to secure autonomous behavior, since those reflections and desires might have been influenced by processes in such a way that we should no longer consider them to be an expression of the agent’s real self. Following these concerns, critics such as John Christman and Gerald Dworkin propose to add a second constraint: in order to consider desires as autonomous, it should also be secured that the historical processes leading up to these desires occurred under the ‘right conditions’. In the attempt to specify these conditions, however, conceptual difficulties arise. Indeed, even though historical approaches have sometimes been praised for their practical nature when compared to structural notions (Anderson, 2008), it seems that they as well, depend to a great extent on deeper (undefined) intuitions about what type of influences undermine autonomy, while it are exactly these influences which needed interpretation in the first place. Lastly, difficulties regarding procedural theories arise when we turn to the widespread idea that a major part of our selves is formed through various types of socialization processes. For if a theory of autonomy requires that choices and values belong to our ‘true self’, then how should we account for the fact that most of these choices and values are heavily depend on the social environment we grow up in? Moreover, critics argue, an adequate theory of autonomy should also be able to explain why those moving within repressive institutions and structures suffer from a lack of autonomy, something procedural approaches fail to achieve. In the following chapter, I shall provide an outline of an autonomy account that wishes to achieve just this.

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2. Substantive Accounts of Autonomous Agency

The previous chapter revealed that procedural accounts run into problems when it comes to the assessment of autonomy in oppressive societies. More specifically, we discovered that even those who adhere to beliefs which result from oppressive norms (i.e. socialized feminine appearances) can in fact meet all the procedural conditions - such as (retrospect) identification- sketched out by such accounts and hence, still be considered as autonomous. Opponents, however, claim that an adequate account of autonomy should also be able to account for these autonomy-impairing effects of the internalization of oppressive norms (Wolf, 1987, Benson, 1991). Since such oppressive norms can be internalized and hence not be tracked by the conditions of ‘procedural independence’, it must be in the content of these norms and beliefs that we can reveal those forms of internalized oppression that hamper autonomy. Following this line of thought, these critics argue, satisfactory theory of autonomy should also evaluate the substance (or content) of agents' decisions and beliefs, reason why these theories are commonly called “substantive accounts’’ (Mackenzie, 2000). Susan Wolf introduces such a substantive account in her in her essay “Sanity and the Metaphysics of Responsibility” (1987). In this work, Wolf firstly argues why according to her, procedural accounts such as those by Frankfurt are insufficient to secure autonomy, and subsequently proposes to add an additional substantive requirement. On Wolf’s revised account, an autonomous agent should not only act on the desires he or she regards as one’s own, this agent should also be ‘sane’. In the following section, I will provide an outline of her theory, subsequently turning to different ways in which it has been criticized. Interestingly, this criticism brings us back to the example we started our exploration with in the first place: the debate on relevant criteria for competence in mental health care.

§2.1 Wolf’s Substantive Element: The Sanity Condition

In her essay “Sanity and the Metaphysics of Responsibility”, Susan Wolf describes an important similarity between the procedural theories brought forward by philosophers such as Harry Frankfurt and Gary Watson. What these theories have in common, she states, is that they are all grounded in the belief that “responsible agents are those for whom it is not just

Self-Rule in Sick Selves the case that their actions are within the control of their wills, but also the case that their wills are within the control of their selves in some deeper sense” (p. 367, 1987). This observation leads Wolf to classify such autonomy theories as ‘Deep-Self Views’. According to Wolf, however, the conditions provided by deep-self views are not enough to secure autonomy. For it might well be the case, she states, that an agent performs an action that is expressive of this agent’s deep self, without this person being morally responsible13 for the action at stake (p.379). In fact, as we will see in the following example, similar to the way Paul Benson objects to historical accounts, Wolf’s criticizes deep-self views for their inability to deal with the ways in which certain socialization processes hamper autonomy. In order to clarify why deep-self views overlook an important facet in autonomy assessments, Wolf asks us to consider the case of a young man JoJo, who is raised by his father, a cruel dictator, and consequently ends up with the same, evil will as his sadistic dad. Due to this twisted childhood, JoJo not only desires to behave sadistically, he also identifies with these desires; he regards them as his own. Hence, according to deep-self views, JoJo would count as morally responsible. Yet, according to Wolf, such a conclusion would be off the mark. Even though JoJo’s sadistic acts might be a true expression of his deep self, the fact that “his deepest self is not up to him” yet merely a product of his wrongful upbringing, should prevent us from considering JoJo morally responsible for his acts. For, according to Wolf, "it is unclear whether anyone with a childhood such as his could have developed into anything but the twisted and perverse sort of person that he has become" (p. 380). However, Wolf concedes, if JoJo is not autonomous because his deepest self is not up to him, then how can we ever say that we are autonomous? Indeed, just like the son of a

13 Actually, Wolf is in this essay not defending a theory of autonomy but one of moral responsibility. It would therefore be a bit unreasonable to interpret and discuss her conception of moral responsibility as one of autonomy. However, similarly to what happened with Frankfurt’s notion of freedom of will, Wolf’s notion of moral responsibility “has been taken up by the literature” as a model of autonomy (Taylor, 2005). Moreover, since Wolf is contrasting her ideas with those who do explicitly defend a theory of autonomy (Watson, Taylor), in this thesis, I will also regard her notion of moral responsibility as one of autonomy and use these two interchangeable.

Self-Rule in Sick Selves dictator, we have also been brought up in circumstances that heavily shaped our motives, desires and opinions, in other words, our deeper selves. Thus, similar to the case of JoJo, Wolf states, our deepest selves are ‘not up to us’ either. In other words, if we regard JoJo as not responsible based on the fact that it was not in his hands to become this specific person, it follows that “responsibility would be impossible for anyone to achieve”, because we simply “cannot have created our deepest selves” (p. 380). According to Wolf, however, the idea that literal self-creation is necessary for moral responsibility, is flawed, she states “not all things necessary for freedom and responsibility must be types of power and control” (p. 380). In fact, Wolf argues, there is something else at stake, an important difference between JoJo and us that explains why the son of an evil dictator is not responsible for his acts, while we are. It is at this point that Wolf introduces a substantive element to her theory of autonomy; besides the condition that an autonomous agents should act in accordance with one’s deeper self, this person also needs to “be a certain way” (p. 380). This ‘being a certain way’, is according to Wolf fulfilled by the criterion that one is “sane” (p. 380). Interestingly, in order to explain her condition for sanity, Wolf refers to the M'Naghten Rule, a rule used in legal settings to determine whether a person who violated the law was responsible for the act at stake, by checking whether this person is sane. This rule states that someone is sane if (1) this person agent knows what one is doing and (2) this person knows that what he or she is doing is, as the case may be, right or wrong. When we apply this condition to the conditions of the deep-self view, the following picture emerges. For Wolf, autonomy not only consists in acting according to desires that derive from one’s deep self, such an agent should also have the ability to distinguish between those values that are right or wrong. It is for these reasons that Wolf’s theory is often characterized as an autonomy approach that is grounded in the idea of “normative competence” (Mackenzie, 2000, p. 19). Now, applying Wolf’s additional criterion to the case of JoJo reveals that even though the dictator’s son satisfies the conditions proposed by deep-self views, JoJo does not fulfill this additional requirement of sanity. Indeed, it was due to the violent environment he grew up in that he never acquired “the ability to know the difference between right and wrong’’ and hence, we should not consider him responsible for his desires to torture and manipulate

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(p. 381). In summary then, whereas deep-self views emphasize the way in which desires should flow from one’s deeper self, yet leave the content of such desires unexamined, Wolf now also puts a constraint on the substance of such desires. In her words, an autonomous agent should at least desire that “one’s values be controlled by processes that afford an accurate conception of the world’’ (p.381). This however, raises another question. For what does it mean to have one’s values be controlled by an accurate conception of the world? In her book “Freedom Within Reason”, Wolf elaborates on this question. In a nutshell, she claims “an individual is responsible if and only if she is able to form her actions on the basis of what is True and Good” (1993, p. 75). Yet how does one do this? In short, Wolf argues that in order to act in accordance to the True and the Good, we should be guided by our Reason. Consequently, someone lacks autonomy if this person does not have the ability to respond to the dictates of Reason, for Reason is inclined to lead us to the True and the Good (1993). Here we see that for Wolf, the “demands of morality are equivalent to the demands of Reason” (Mackenzie, 2000, p. 19). In short, by adding this substantive condition, Wolf extends the issue of autonomy from a notion of internal self-reflection (such as those sketched out by procedural accounts), to a world that is shared with other people, where one’s ability for responsibility should be tested against the background of values and beliefs.

§2.2 Wolf’s Sanity Condition & Psychiatric Practice

Interestingly, by directly addressing the topic of (in)sanity in connection to autonomy, Wolf’s theory seems to be closely tied to the clinical issue that formed the starting point of this exploration: the notion of autonomy in mental-health contexts. To briefly recall this clinical issue; in current psychiatric practices it is unclear how to define and assess whether a patient is capable of autonomous decision-making. Consequently, the challenge becomes to think of a conceptual framework which specifies those aspects of human functioning that are required for autonomy, and to explain in what ways they can be affected by mental disorders. In fact, in this work, Wolf introduces (at least in broad terms) a more concrete perspective on this issue. We have seen that according to Wolf, agents can only be considered

Self-Rule in Sick Selves autonomous when they are sane, where sanity is understood as the having “the ability to distinguish right from wrong.” Another way of saying this is that in order to be considered autonomous, one’s values should “be controlled by processes that afford an accurate conception of the world’’ (p.381). Consequently, ‘wrong acting’ agents such as JoJo are in Wolf’s view not autonomous, not only because they cannot help but have such (evil) values, but also because such values do not correspond to the world in the appropriate way, their values are mistaken. In this respect, how should we make sense of the values of those living with psychiatric conditions? Are the values of anorexic patients, for instance, mistaken in the same way as JoJo’s desire to torture? Wolf might answer this question by arguing that a person who highly values ‘staying thin’, such as the anorexia patient, is not “controlled by processes that afford an accurate conception of the world’’ (p.381). Put differently, such patients might “acts in a way that is not in accordance with acceptable standards of rationality and reasonableness” (p. 387, 1987). Yet would this also imply that the traveler who now only eats purple food and meditates all day, is no longer controlled by ‘accurate conceptions of the world’? If so, then it seems that Wolf’s theory faces another problem. Different cultures around the world, or even within our own society, will often have divergent opinions of what count as the correct moral values or reasonableness. Since Wolf proposes to evaluate autonomy based on our current interpretation of what is morally correct, following her theory we might have to render those who lived before, or agents who grow up in very different cultures, as no longer autonomous. Also within mental-health care contexts, applying this condition raises questions. In the first chapter of this thesis, we observed how in health-care settings, it is frequently argued that in order to adhere to the ideals of a liberal, pluralistic society, testing a patient on the ability of autonomous decision-making must “leave enough space for persons to choose which (irrational) values to adhere to, and consequently, which courses of actions to follow’’ (Taylor, p. 64, 2010). Since Wolf’s condition of autonomy depends on external, widespread judgments on what counts as the True and Good, it is questionable whether het theory allows for the fact that patients can make unpopular choices, even ones that are judged as highly irrational by others.

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Besides the fact that Wolf’s theory might contrast with this desideratum of a clinical test for autonomy, trying to apply her account to psychiatric practice introduces another puzzle. We have seen that according to Wolf, agents lack autonomy not only when they exhibit the ‘cognitive failure’ to distinguish right from wrong, they must also (just like JoJo) cannot help but have such inabilities. In the case of JoJo, Wolf explains his incapacity to respond to the True and Good, by referring to his upbringings; it is because JoJo never encountered any moral sensibilities, she argues, that he now has mistaken values and is therefore “unable to understand and appreciate that an action fell outside acceptable bound’’ (p. 387). Now, how should we make sense of this latter requirement in regards to individuals with psychiatric conditions? Are those who suffer from anorexia, just like victims of twisted upbringings, also examples of agents who cannot help but have mistaken values? Or do they rather have this capacity to distinguish right from wrong, yet fail to exercise it due to different reasons? Combined, these questions reveal that Wolf introduced a very loose definition of sanity. As such, her theory leaves some of our questions, such as these regarding autonomy in anorexic patients and the traveler, unanswered. Moreover, by stating that an autonomous agent must be sane, Wolf expresses the exact notion the psychiatrists wanted to challenge: the (discriminating) idea that a psychiatric diagnosis will automatically exclude patients from achieving the status an autonomous agent. Thus, even though Wolf’s theory directly addresses the connection between autonomy and mental illnesses, a close analysis of her account does not bring new perspectives to this clinical debate. It should be noted, however, that Wolf did not introduce her sanity condition to an account of autonomy, intending to clarify such practical issues. On the contrary, she explicitly states that her notion of sanity is an “implausibly broad construction of the term”. Moreover, she writes “there are problems with this definition of sanity… that make it ultimately unacceptable either as a gloss on or an improvement of the meaning of the term in many of the contexts in which it is used ”(p. 381). With this in mind, it would be unfair to apply her account to the context of psychiatric healthcare. In what follow, I will therefore focus on a different aspect of her theory and compare this account to those provided by procedural theorists.

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We have seen how, unlike procedural theories, Wolf’s theory of normative competence does provide us with tools to explain why someone who has been subject to oppressive institutions, such as the young woman in the sexist society, or violent upbringings, such as JoJo, should not be considered morally responsible. Indeed, to be evaluated as an autonomous agent, one must have acquired the ability to distinguish between right and wrong. Since oppressive socialization processes or very violent environments prevent the development of such capacities, we now understand why these agents are not autonomous. Thus, whereas procedural accounts have approached autonomy by focusing on agents internal beliefs and desires, Wolf now extends this issue to a world that is shared with other people, where one’s ability for responsibility should be tested against external criteria. However, it are precisely these ‘external criteria’ that Wolf introduces to her theory of autonomy, which have been highly criticized. Some, for instance, bring in that Wolf’s notion of competence specifies the conditions of a virtuous, rather than an autonomous agent (Jennings, 2000) others fear that adding such external criteria sets the bar for autonomy too high, in which case only a few of us would count as autonomous (Christman, 1991). The more general concern underlying these objections seem to be that adding substantive elements to a theory of autonomy might shift the notion of autonomy away from what critics think should be its base: self-governance. In the next pages, I will outline these three objections to Wolf’s account in more detail, which in fact, brings us again back to the issue we started this exploration with in the first place; that of autonomy in mental health care.

§2.3 Criticizing Wolf’s Notion of Normative Competence

First, according to Richard Double, Wolf’s account seems to spell out those criteria under which one can be called a ‘good person’, more than an autonomous person (Double, 1992). In order to explain his point, Double asks us to imagine someone who is capable of distinguishing right from wrong, yet doesn’t see the fact that something is wrong as enough reason for not doing it. To refer back to Wolf’s own example, imagine that JoJo was in fact fully aware that torturing others was a morally bad thing to do, however, this JoJo (let’s call him JoJo II) does not see the fact that torturing is wrong as a reason for not doing it. In other

Self-Rule in Sick Selves words, even though JoJo II appreciates the moral reasons (he has the ability to tell wrong from right), these reasons do not move him. Would Wolf consider this JoJo II as an autonomous person? According to Jennings, it is at this point that Wolf faces a dilemma: if she argues that JoJo II is indeed autonomous, Wolf may also have to regard some psychotic victims of traumatic childhoods, or those who grow up in sexist societies, as morally responsible and consequently encounters the same problems deep-self views face - the inability to defend our intuition regarding the lack of autonomy in these individuals. On the other hand, if Wolf denies that this JoJo II is morally responsibly, her account would be one of virtuous behavior rather than a theory of autonomous behavior (Jennings, 2000, p. 152). As a matter of fact, Wolf herself already anticipated this criticism. Indeed, in the final section of “Sanity and the Metaphysics of Responsibility”, she elaborates on this “potential objection” (p. 387). Here, Wolf defines sanity as the ability to cognitively and normatively appreciate the world for what it is, however, she concedes, “having this ability is one thing, yet exercising it is another” (p. 387). To clarify her point, she asks us to consider a student who performs badly on a math test: even though there is always the opportunity that the student was just not intelligent enough, “other explanations will be possible too” (p. 387, 1987). The testee might have been too lazy or too occupied with other things, for instance, to study sufficiently. In a similar vein, Wolf states, such considerations also apply to those who act wrongly. For indeed, just as in the case of JoJo II described before, having the ability to do the right is one thing, yet exercising it is another. It is here where we actually touch upon another fundamental issue in Wolf’s perspective on moral responsibility. More specifically, in her essay “Asymmetrical Freedom” (1980), Wolf points towards a feature in our moral intuitions “which has generally been overlooked” (p. 151). Consider again the student who takes the math test and JoJo, the son of the evil dictator. Our moral intuition regarding these two agents is very similar: we only blame JoJo and the student for their acts, in case they could have done otherwise. Indeed, we intuitively refrain from blaming JoJo in case his evil acts are the inevitable result of his twisted upbringings, and similarly, would not get angry at the student who is just not intelligent enough to perform well on the test at stake. Thus, when it comes to blaming those who perform a bad action, we require that someone could have done otherwise (Wolf, 1980).

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At this point, however, Wolf points towards a striking irregularity in our moral intuitions (Wolf, 1980, p.157). For when we think of a person who cannot do other than what is morally right, our intuitions follow a very different path. To illustrate this, Wolf asks us to consider a boy who has been educated in such a proper manner that he cannot do anything else but what is right. Consequently, as an adult man, he buys a book for his friend because he just “couldn’t resist it” (p. 157). In this case, is very unlikely that we withhold this man from praise, even though he had no other options. On the contrary, we would rather see the fact that he had no other choice than to buy this book as a proof of “’a good friendship”, or moreover, as a sign of how virtuous his character is (p. 157). In any case, we would not withhold praise from this agent who performs a good act, even though this person is determined to act this way. In a similar vein, Wolf states, our everyday expressions such as “I cannot tell a lie” and “he couldn’t hurt a fly” are not exemptions from praiseworthiness but testimonies to it” (1980, 157). These cases reveal an “asymmetry in our moral intuitions when it comes to assigning praise and blame” (p. 158). Indeed, we only blame those agents in case they could have done other than they did, however, when we ask whether an agent’s action deserves to be praised, it seems we do not require that this person could have done otherwise. In other words, “determination is compatible with an agent’s responsibility to perform a good action, but incompatible with response to an agent’s bad actions” (1980, p.158). In this regard, how should we deal with moral wrongdoers such as JoJo II? We have seen that according to Wolf, autonomous agents must have been able to be guided by Reason. Now, if an agent does act in accordance with Reason, he or she can be praised for one's actions, independently of whether this agent was determined to act this way. Contrarily, agents who fail to act in accordance with Reason can only be blamed if they were in fact capable of acting in accordance with Reason (Wolf, 1980, p.160). This however, still leaves us a bit unsettled. For what does it mean to be ‘capable of acting in accordance with reason’? Unlike JoJo, we have seen that JoJo II knew in fact that torturing others was a bad thing. This knowledge however, did not prevent him from stopping these evil acts, in other words, he was not moved by this knowledge. Now, is the fact that JoJo II did not act upon these moral reasons, also a proof of him not being capable to act in accordance with reason? If so, then just like JoJo, JoJo II did not have any other options than

Self-Rule in Sick Selves to act badly and hence, he does not deserve to be blamed. In fact, Wolf also admits, “it is hard to know whether an agent who did one thing, could have done another instead” (1980, p. 164). However, she continues, “we decide such questions now on the basis of statistical evidence”, which means that “we decide that an agent could have done otherwise if others in his situation have done otherwise”, or, she concedes, whenever “’he himself has done otherwise in a situation which is like this in all apparently relevant ways” (p. 164). Now, in this case, the only comparable case we have is JoJo the first, and since JoJo also acted wrongfully in a similar situation, following Wolf’s line of reasoning, we might have to derive from this that JoJo II is not autonomous and should not be blamed for his wrongdoings either. As such, Jennings does seem to have a point when he argued that Wolf provides an account of a virtuous, rather than an autonomous agent. In summary then, it seems that Wolf’s account supports our intuitions regarding those who suffer from twisted upbringings or oppressive societies. However, her theory does not allow us to differentiate between those who are really unable to distinguish between right and wrong, and those culpable agents such as JoJo II, who simply fail to do so. Besides the concern that Wolf provides an account of virtuous, rather than autonomous behavior, also other aspects of her theory have been criticized. John Christman, for instance, objects to the fact that her substantive theory depends on ‘objective’ moral values that are external to the person. More specifically, according to Christman, introducing such conditions runs the risk of making “the property of autonomy divergent from the idea of self-government that provides its intuitive base” (1991, p. 21). To quote him at length:

On the view that only rational, fully informed selves are autonomous, it follows that the fiercest interferences with a person’s value judgments, desire formation, or thought patterns are not interferences with autonomy at all if those values, desires or thoughts are irrational ones. As long as the interfering agent has beliefs that are better supported by the objective evidence, then no loss of autonomy is suffered from any form of manipulation for the sake of more reasonable beliefs and desires (Christman, 1991, p. 21)

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In short, Christman criticizes substantial theories for being too demanding, in which case the notion of autonomy might be hampered in safeguarding agents in different contexts from unfair treatment, including paternalistic interferences. Indeed, if we agree that a theory of autonomy should enable agents (also marginalized ones) to defend themselves from different types of paternalistic interventions, theories that require that one’s values should be linked to the world in some proper way, might no longer be able to fulfill this job. In fact, we have seen a similar worry expressed before, when we looked into the notion of autonomy in mental health. To recall this dispute, in health contexts, the principle of Informed Consent was designed to protect patient’s autonomy, by safeguarding them from those who might want to impose (medical) values on them, values they might not necessarily adhere to themselves. This right to Informed Consent, however, rests on the condition that a patient is competent, he or she needs to have decision-making capacity. Now, some have proposed that having this decision-making capacity requires an absence of pathological values (Meynen & Widdershoven, 2012). Opponents, however, bring in that this would exactly go against the notion of autonomy reflected in Informed Consent. More specifically, they argue, if the goal of requiring Informed Consent before treatment was to protect patients against other people’s values, then “it can hardly be a presupposition of that requirement that patients have the capacity to make decisions that accord with the values held by others” (Whitening, 2009, p. 343). This reveals that in both the field of philosophical literature, as well as the context of psychiatric practice, there is a concern that supplementing a theory autonomy with substantive elements, shifts this notion away from what many theorists believe should be its base: self-governance. I interpreted the following quote, by Tom O’Shea, as clearly articulating this wariness; “however interesting or worthy an ideal of self-government built around the merits of rationality and successful practical and theoretical activity is, it cannot fail to foreground the crucial normative contribution of the self which is doing the governing” (2015, p. 633).

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§2.4 Tensions and Paradoxes

It is here where we touch upon a crucial conflict between substantive and procedural theorists. Roughly stated, this involves the tension between on the one hand respecting the ‘self’ as an independent, governing agent, while also acknowledging that this ‘self’ is formed through all kinds of socialization processes, some of which we intuitively regard as autonomy-undermining. We have seen that unlike procedural theories, Wolf’s theory allows us to rescue some of these latter intuitions; indeed, it is because agents subjected to oppression are unable to respond to the True and the Good, that they lack autonomy. Now, even though I think it would be highly desirable if agents hold on to reasonable beliefs and values that correspond to what we regard as morally correct, I disagree that this feature should be included in our conception of autonomy. In line with the criticism raised by Tom O’Shea and John Christman, I hold the opinion that adding such substantive elements to a theory of autonomy runs a serious risk of putting too much constraint on what this ‘self’ should look like, in this way no longer foregrounding what I take to be its most important ideal, that of self-governance. However, if we agree with the criticisms raised against Wolf’s account and return to a conception of autonomy that locates this property in the way an agent evaluates his or her desires and beliefs, without putting any constraint on the content of these beliefs, we will soon be faced with the same difficulties procedural accounts are confronted with. Indeed, since oppressed norms can be internalized in an agent’s system of beliefs, theories that emphasize that autonomy depends on how an agent evaluates his or her desire, rather than on the content of these desires, fail to take into account oppressive forms of socialization. Additionally, defending a theory in which autonomy consists in being guided by motives that are truly my own, rather than anything else, seems to introduce another puzzle. For if autonomy consists in being guided by beliefs that I consider to be my own, how then should we deal with the fact that my beliefs are essentially the product of circumstances which happened long before I even thought about what person I wanted to become? Roughly stated, there seems to be a tension between being guided by beliefs one regards as one’s own, while also acknowledging that these values and beliefs are not really the consequence of our own choice. Gerald Dworkin phrases this as the “conflict between self- 48

Self-Rule in Sick Selves determination and notions of correctness and objectivity” (1988, p. 12). Let me quote him at length:

In all three areas- moral, political, social, we find that there is a notion of the self which is to be respected, left un-manipulated, and which is, in certain ways, independent and self-determining. But we also find certain tensions and paradoxes. If the notion of self-determination is given a very strong definition – the unchosen chooser, the uninfluenced influencer – then it seems as if autonomy is impossible. We know that all individuals have a history. They develop socially and psychologically in a given environment which a set of biological endowments….How then, can we talk of self-determination? (Dworkin, 1988, p. 12)

In short, Dworkin’s quote reveals that if we abandon substantive elements, such as the sanity condition proposed by Wolf, and return to subjective accounts in which autonomy does not consist in what we believe or desire, yet only that these beliefs are expressive of our true self, other challenges arise. In fact, such a move requires us to deal with the issue Wolf already raised when she argued that “self-creation is not only empirically, also logically impossible”, for indeed, “we simply cannot have created our deepest selves” (1980, p. 380).

§2.5 Conclusion

This chapter shed light on substantive theories of autonomy, focusing especially on Susan Wolf’s theory of normative competence. We have seen that her approach to autonomy is grounded in the idea that in order to be considered competent for autonomy, one has to be ‘sane’, which Wolf understands as having the ability to distinguish between right and wrong. At first glance, her theory seems to be closely tied to the issue of autonomy in psychiatric practice. A closer analysis however, revealed that by stating that an autonomous agent must be sane, Wolf expresses the exact notion the psychiatrists wanted to challenge, the idea that a psychiatric diagnosis will always exclude patients from achieving the status

Self-Rule in Sick Selves an autonomous agent. However, by adding this substantive element, Wolf’s theory does allow us to explain something procedural accounts fail to achieve: it clarifies our intuitions regarding the lack of autonomy in individuals who are subject to certain socialization processes. Indeed, it is because those exposed to traumatic childhoods or oppressive societies never acquired the ability to know the difference between right or wrong, that they lack autonomy. In any way, by including this sanity condition, Wolf extends the property of autonomy from internal reflection on one’s beliefs and desires, to a world that is shared with other people, where one’s ability for autonomous behavior should be tested against external criteria and moral values. It is exactly this part of Wolf’s theory, however, which led to much resistance. Whereas some bring in that Wolf s notion of normative competence provides an account of virtuous, rather than autonomous behavior (Jennings, 2000), others argue that this substantive requirement puts too much constraints on what autonomous agency constitutes (Christman, 1991). More generally, these critics are afraid that adding the condition that an agent’s values should in some way respond to external criteria shifts the notion of autonomy from what they believe should be foregrounded: self-governance. Roughly stated, there is a dilemma between on the one hand respecting the self as an independent, governing agent, while also acknowledging that this self is formed through all kinds of socialization processes, some of which we intuitively regard as autonomy- undermining. Now, if we go along with the criticism raised against Wolf’s objective criteria (and I think we should), and strive for a more subjective theory of autonomy, we do not only reintroduce the socialization problem, such a move also presents us with another puzzle. Indeed, if autonomy consists in actions that are an expression of the true self, then how do we account for the widespread belief that this self is in fact shaped by factors we did not control, nor choose for? This question will be the topic of the following, final chapter. More specifically, I will introduce the work of Robert Noggle, who addresses this issue in his famous work “The Paradox of Self-Creation” (2005).

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PART III: THE PARADOX OF SELF-CREATION

In the previous chapter, we outlined a number of important objections against Wolf’s substantive theory of autonomy. However, we have also seen that rejecting such substantive elements in a theory of autonomy, reintroduces a number of difficulties. Indeed, if we stress that a theory of autonomy should somehow secure that one’s values and beliefs relate to one’s true self in the ‘right way’, without examining the content of these beliefs, then it looks like an agent who has been subjected to oppression would enjoy the same kind of autonomy as anyone else. There is another challenge that comes into focus when we return to subjective theories that focus on agents’ own appraisals to secure autonomy. The previous chapters revealed how procedural theories, such as those by Harry Frankfurt and John Christman, require that an autonomous desire should somehow be an expression of someone’s ‘true self’. Whether a desire is expressive of the agent’s true self then, depends on the way it which it relates to some other psychological element in the agent’s motivational set, for instance a higher-order desire (Frankfurt, 1988a) or the agents own attitudes towards the processes of their formation (Christman, 1991). Thus, desires are autonomous if they are expressions of one’s true self, and we can find this out with the help of our own, reflective faculties. Yet what if my critical reflections on these desires were somehow installed by something else? Evidently, this would distort this process and we would no longer be sure whether my desires are really expressions of my true self. Consequently, in order to secure that a desire or belief is an expression of my own, true self, it seems that these reflections themselves also have to be an expression of my true self. However, as we will see in the following pages, it is exactly this latter requirement that causes subjective theories to run into problems. The outline of this chapter is as follows; I will start by elaborating more on this latter requirement, firstly described by Christman as the “ab initio problem” (1987). Subsequently, I will introduce the work of Robert Noggle, who in his essay “The Paradox of Self-Creation” (2005) tries to come up with a solution to this ab initio problem. I will then shed light on Noggle’s alternative account of autonomy, which is grounded in the difference between ‘existing selves’ and 51

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‘new selves’. Finally, with the help of Noggle’s considerations, we will reflect back on the issue that formed the start of this exploration: autonomy assessment in those who suffer from mental illnesses.

§3.1 ‘The Ab Initio Requirement’

In order to explain why subjective theories run into a difficult dilemma, we have to turn back to an issue we discussed in the beginning of this work. In the first chapter of this thesis, we analyzed Frankfurt’s account of identification, which is grounded in the idea of higher-order desires. More specifically, we observed how Frankfurt’s approach runs into problems when it comes to determining which desire in the potential infinite chain can be can be regarded as truly autonomous, a problem firstly articulated by Gary Watson as the ‘regress problem’. According to Robert Noggle, the origins of this regress problem can be found in a widespread assumption. This is the belief that if we want to explain autonomy by referring to some aspects of an agent's mental state, then these further aspects must themselves be autonomous.14 Christman calls this ‘the ab initio requirement’, which he clarifies by rhetorically asking “how can a desire be autonomous if it was formed or evaluated by a process that was not itself autonomous?” (1989, p. 12). To briefly illustrate this, if my desire to finish this thesis was in fact the result of a group of neuroscientists who secretly experimented with a new method of deep brain stimulation, then I would certainly not regard this desire as belonging to my own. Thus, it would be weird to assume that some non-autonomous process can render a desire autonomous. We have seen that Christman and Dworkin tried to account for this regress problem - induced by the ab initio requirement- by arguing that what is more important for autonomy

14 Noggle does not use the term autonomy; he instead refers to this notion as “authenticity”, which he argues, “is commonly applied to elements of the person’s psychology that are part of or produced by this true or real self.” (p. 88). However, since we are in this chapter dealing with (subjective) autonomy theories that define this notion as precisely that; “being an expression of this true self”, I will here substitute the term autonomy for authenticity. Moreover, Noggle himself also mentions “some philosophers refer to what I am calling authentic desires as “internal” desires. Sometimes the phrase “autonomous desire” is used to mean the same thing”. (Noggle, 2005, p. 109, first footnote)

Self-Rule in Sick Selves is the way in which someone came to have these novel desires and beliefs, rather than how I evaluate them at this current moment in time. More specifically, if I do not feel resistance against my desire to write this thesis, even after knowing that it was induced by deep brain stimulation, then my current desire to write would be autonomous. At first glance, we might say that adding these historical components to the conditions for autonomy avoids the regress problem. Indeed, if autonomy depends on the historical processes that already occurred in my own history, it seems that we do not need any further evaluations that are also autonomous; we just need to make sure that these past events were free of the types of influences that are inconsistent with autonomy. Thinking this through, however, reveals that these historical conditions are not “regress-proof” after all (Noggle, p. 96). Indeed, adhering to the ‘ab initio requirement’, we also have to make sure that my current processes of reflecting on these processes are autonomous. In other words, whether my acceptance of this deep-brain stimulation is an actual expression of my true self. Yet, in order to answer that question, we would have to move further back in time and see whether there were any processes I resisted to that led to my current acceptance. This, however, reintroduces the regress-problem. Moreover, it will eventually lead us to a certain moment in time at which I was too young to evaluate any type of processes of desire-formation. In Noggle’s own words, moving back, “we eventually reach a point at which our psychological configurations no longer even exist. And well before then…we find psychological causes that involve conditioning, role model imitation, the internalization of socially-endorsed behavioral norms, and the acceptance of claims on the basis of adult authority” (p. 97). It is now starting to become clear why the ab initio requirement is so problematic. For if we want to validate that a certain desire is an expression of my true self, then whatever is doing the validating also needs to be an expression of my true self. This however, leads us to an infinite regress until we eventually run into the problem Susan Wolf already pointed at, which is that the self cannot be the cause of its own creation (1987). Noggle also elaborates on what he calls the “Paradox of Self-Creation” (p. 97) by stating that the notion of self-creation would require “the truth of two contradictory propositions: first, that the self-creating thing exists, which seems to be necessary for it to do anything, such as create something, and second, that the thing does not exist, which must be true in

Self-Rule in Sick Selves order for it to require to be created” (2005, p. 99). In short, it seems that this ab initio requirement is ultimately based on an implausible idea of self-creation. Now, where to go from here? If we agree that the self cannot be the cause of its own creation, what then should we do with this ab initio requirement? Noggle’s own answer to this question is rather clear-cut; according to him we should reject it (p. 99). In the following section, I will investigate the consequences of this solution.

Self-Rule in Sick Selves

§3.2 The Gradual Rise of Autonomy

Up until now we have seen that an important requirement underlying procedural theories, the ab initio requirement, is based an implausible idea of self-creation. For this reason, Robert Noggle proposes to abandon it. Such a move, however, introduces a new puzzle. For how then can we explain that autonomy comes into being from circumstances that we do not regard as autonomous? In fact, Noggle’s answer to this is not very shocking. In illustrating how autonomy can emerge from non-autonomous circumstances, he asks us to consider the way a child slowly evolves into an adult. In his words, “out of a seemingly unpromising beginning…the child’s self gradually emerges as her cognitive and motivational systems develop the kind of structure and stability, and the rational and reflective capacities, necessary for the existence of a coherent and stable self…” (2005, p. 105). Thus, autonomy emerges in the same, gradual manner as the way a child’s upbringings lead this child to acquire those desires and beliefs that will eventually form a stable “core self” (p. 105). Yet what if these children were raised in very twisted environments such as in the case of evil JoJo, or the girl who grows up in the sexist society? Do they also develop into autonomous agents? Noggle admits that his theory might “bruise” (p. 105) our intuitions when it comes to these cases. For even though we would be inclined to say that both agents’ desires are far from autonomous, according to Noggle, they are. In order to see why, it is important to understand that Noggle perceives the gradual emergence of autonomy as something that goes hand in hand with those processes of socialization and upbringing leading to the development “stable core self’ (105). From this it follows that autonomy is always a “two place relation”, which means that a value, desire or belief is always authentic to a particular person. Moreover, Noggle states, any type of upbringing or socialization process has the ability to implement its beliefs and norms into a developing self, even if such norms are “morally defective” (p. 107) Combining these two notions we see why it is meaningless to ask whether the selves of JoJo and the oppressed girl are autonomous. Indeed, in Noggle’s words, “it is not that the earliest socialization of a child into an evil or oppressive world-view imprisons some better self. For there is no self at all before the socialization that initially creates it” (p.

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107). From this Noggle concludes that if the question of autonomy is a question of whether certain motives are really someone’s own, then we cannot claim that desires such as those of JoJo and the oppressed girl are not autonomous. At this point it becomes clear why Noggle’s account of autonomy, in contrast to Wolf’s, does not allow us to argue against oppression on the base of one’s lack of autonomy. Indeed, even though Noggle states that “better selves” could have emerged from other types of socialization processes, such a self does not now exist, “nor did it ever exist” (p. 108). In short, no matter how oppressive or malicious their content, once socialization processes managed to insert certain norms and values into a child’s ‘core self’; these norms and values will be autonomous for that agent.

§3.3 New Selves versus Existing Selves

We have seen that on Noggle’s account we cannot criticize oppressive or violent upbringings on the grounds of autonomy. Indeed, whatever his or her type childhood was like, a person at one point turns autonomous. That is, however, not to say that Noggle believes that such oppressive forces do not have any destructive effect on our abilities for autonomous behavior. On the contrary, he argues that desires such as those of JoJo and the oppressed girl “did arise through processes that we normally think of as having the capacity to undermine autonomy”. However, he concedes, it makes great difference whether these processes are used to “build an initial self, or whether they are being used to implant psychological elements in an already existing self”’ (p.108). How does this work? In order to see the difference between these scenarios, we might reintroduce the example of the traveler we discussed earlier. To recall this, in the beginning of this thesis we introduced the case of a man who, after returning from a ten-day holiday in Nepal, decided to drastically change his life. Not only did he begin to mediate more than six hours a day, he also changed his diet (he now only eats purple food) and is now considering quitting his job as a lawyer in order to meditate even more. It is for this reason that some question whether his new desires are truly autonomous. Now, les us imagine that the traveler in fact did join a particular cult where he was subjected to a number of indoctrination processes. How should we regard the autonomy of this traveler, according to Noggle? Firstly, in contrast to the cases of JoJo or the oppressed 56

Self-Rule in Sick Selves girl, in this scenario it does make sense to ask whether the traveler’s desires are truly are autonomous. This is so, Noggle states, because we are now talking about the effects of certain processes on a person who “already has an existing self” (p. 108). Indeed, whereas in the case of JoJo and the oppressed girl there was no ‘core self’, prior to the twisted socialization that originally created it, in the case of the traveler, we can ask whether these processes – i.e. the traveler’s experiences at the cult – “preserved the self that is already there” (p. 108). This said, how should we deal with the question regarding the autonomy of the traveler, are his desires to eat purple food and meditate truly autonomous? In fact, Noggle, argues, this depends on “what self we are talking about” (p. 108). For it might be the case, that the indoctrination processes that the man underwent, were “sufficiently thorough to count as the implantation of a new self into this man’s “psychological make-up”. In this case, these desires might indeed be no longer autonomous to the man’s initial self, yet are now autonomous to this novel (cult) self (p. 108). Following this, Noggle claims, “there seems to be a big difference between the application of brainwashing and related techniques to person with a fully formed self and the application of very similar techniques during the early stages of child rearing. In both cases, we create a self. But in the former case, we create a self by destroying an already existing one” (p. 109).

§ 3.4. What About Sick Selves?

I would now like to take a step back and see how Noggle’s ideas regarding autonomy (or on his terms, authenticity) relate to the issue which formed the motivation for writing this thesis: autonomy assessments in psychiatric health-care. We have seen that in psychiatric practice, dilemmas arise in evaluating whether someone is competent for decision-making, and thus, autonomous. Now, some psychiatrists propose that the capacity for decision-making requires the absence of pathological values. Pathological values, they state, are those that fail to be ‘authentic to a person’ (Meynen & Widdershoven 2012, Tan et al. 2007). Yet what does it mean to say that a value is not ‘authentic to a person’? These psychiatrists do not answer this question. 57

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Reflecting on this issue using the account of Noggle might help to disentangle some of these issues. Firstly, as Noggle stated, authenticity is really a “two place relation”, which means that some value, desire or belief is always is “authentic to a particular person” (p. 107). Moreover, we have seen how he claims that only those who are old enough to have a “stable core self”, can have the capacity for autonomy. From this it follows, according to Noggle, that asking the question whether a value is authentic (or not authentic) to a person only makes sense in agents who already have an existing self. Now, let us for a moment assume that patients in psychiatric health care are above the age of children we normally consider heteronomous, and hence, that these patients have an already existing ‘core self’. Having established that in this case, it does make sense to ask whether a pathological value is (or is not) authentic to a patient, we can return to the question. For what then, does it mean to say that someone possesses a value that fails to be authentic? One potential answer might be that this patient does not really possess this value, yet that this value belongs to the pathology. This seems implausible though, for how can an illness be in possession of a value? In fact, as we have seen in Noggle’s reflections, there might be another more sensible answer. Just as in the case of the traveler described before, we might state that this value is no longer authentic to the person’s self, because this self no longer exist. Indeed, similar to the effects of the indoctrination processes that occurred to the traveler, the effects of the mental illness might have been “so thorough that they implemented a new self into his “psychological make-up”, which replaced the older self ”(Noggle, 2005, p.108). As such, we could argue that the ‘healthy self’ of this person is now replaced by the ‘sick self’ of this person (a terminology which is in fact quite frequently used in these contexts). Following this line of thought, these values might indeed be no longer authentic to an agent's ‘healthy self’, yet are now authentic to his or her new ‘sick self’. This however, seems to conflict with the proposed conditions for decision-making capacity. For in fact, the purpose of competence assessments was to judge whether the patient (our in our terms, the ‘sick self’) was capable of decision-making and acted on the basis of authentic values, and as we have seen here, these pathological values are in fact authentic to this patient. In short, it seems that conceptual problems arise in arguing that a patient lacks competence, based on the fact that he or she acts on values that are not authentic to that person.

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Conclusion

In the field of mental health-care, as well as in the discipline of contemporary philosophical literature on autonomy, it is often assumed that psychiatric patients suffer from a lack of autonomy. Rather than being governed by their true self, it is frequently argued, these patients are governed by their mental illness. In this thesis, I investigated this assumption. To begin with, I observed that these two disciplines approach the link between autonomy and mental conditions from opposite sites; whereas current debates in psychiatric practice revolve around the question if, and how, psychiatric illnesses might inflict on mental capacities required for autonomous agency, theorists of personal autonomy at times refer to mental illnesses in order to explain how we could better understand this notion of autonomy in the first place. Despite these different starting points, I found that theorists in both areas frequently run into similar difficulties in their attempt to express the intuition regarding the autonomy impairments in psychiatric patients in a unified theory of autonomy. Firstly, in both fields, mental illnesses are often characterized as a type of ‘external’ influences that that somehow ‘interfere’ or ‘inflict’ on an agent’s autonomy. Conceptualizing this relationship in this way, however, runs the risk of expressing a circular argument, for it was exactly the question what makes such a factor external, rather than autonomous to a person, which needed an answer in the first place. Secondly, in psychiatric practice and contemporary philosophical works, there is tension between on the one hand, defending a theory of autonomy that foregrounds agents’ self-governance, rather than any other property such as mental well-being, rationality or good character, while on the other hand acknowledging that this self might be hampered in many different ways and therefore unable to fully exercise this self-governance. Lastly, in both areas, in order to be considered autonomous, an agent has to make decisions of a kind that are expressive of their true, or authentic, self. This requirement becomes problematic however, when we turn to the widespread belief that this self is essentially shaped by processes that occurred outside this person, long before this agent had any clue what type of person he or she wanted to become. To conclude, there exist a wide variety of intuitions regarding the lack of autonomy of individuals in many different contexts. As much as we want to defend the intuition that

Self-Rule in Sick Selves individuals in oppressive societies, victims of twisted upbringings, or sufferers from mental illnesses are in some way hampered in their capacity for self-governance, doing so on the grounds of a unifying theory of autonomy, seems to be very challenging.

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