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 2 Self-Rule in Sick Selves This is a painting by Michaël Borremans: The Advantage, 2001. 3 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. 4 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 5 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, 6 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