Chapter

Mental disorder and the value(s) of ‘autonomy’

Jane Heal

in Autonomy and Mental Disorder

Published on behalf of Oxford University Press

Published in print April 2012 | ISBN: 9780199595426
Published online February 2013 | e-ISBN: 9780191754739 | DOI: http://dx.doi.org/10.1093/med/9780199595426.003.0011

Series: International Perspectives in Philosophy & Psychiatry

Mental disorder and the value(s) of ‘autonomy’

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‘Autonomy’ is a word which indicates an area where important things are felt to be at issue but where much is also complex and disputed. As to its broad shape the notion has both a descriptive and a normative face. It is taken that ‘autonomous’ specifies descriptively a way a person or decision may be and which (many) people and decisions actually are, at least to some extent. But use of the notion also brings with it (at least for many users) acknowledgement of a normative requirement to respect autonomy and an acknowledgement of the value of promoting more autonomy. There is, however, much debate as to how both the descriptive and the normative elements of the notion are to be articulated.

One area where the complexities and disputes manifest themselves is in considering how things should go for the mentally disordered. The need for decisions may arise, for the person him- or herself and for carers, clinicians, and others, concerning what treatment to have, where to live, how to dress, what activities to take up, etc. In making these decisions it is accepted that we should seek, as far as possible, to realize in the lives of the mentally disordered those value(s) we gesture at with talk of autonomy. But in practice we find that, in many cases, we do not know what this requires of us.

Often in a situation of this shape, i.e. one where one has getting G as a goal, but is unclear about the details of what G is and hence how to get it, then the sensible thing to do is discover more about G before setting out on one’s project. For example, suppose we think that it is a good thing to avoid ingesting any prussic acid, but we don’t know exactly what the chemical constitution of prussic acid is and we know that its presence, although sometimes obvious, is also sometimes difficult to detect. In this situation the sensible thing to do would be to analyse further what prussic acid is so that we know exactly what to look for and can devise better tests for it. It may seem that analogously given that we want to treat the mentally disordered with respect for their autonomy, we need first to work out by philosophical reflection what autonomy is and then apply that insight to seeing what we should look for to find whether autonomy is or is not present in the varying situations of the mentally disordered. And this is the form of thought which is implicit in some discussions of how to respect autonomy in dealings with the mentally disordered.

But what I shall suggest in this paper is that this form of thought may be methodologically inappropriate given the particular kinds of unclarity and dispute we have about autonomy. A pattern of thinking which proceeds on the assumption that there is some one thing which is real or true autonomy, and that we can identify it by philosophical discussion, may well be in order, particularly in some contexts of constructive and hopeful ethical or political debate. But in the context of other debates, particularly ones about how in practice things should go for the mentally disordered, the pattern is, I shall argue, potentially unhelpful.

Accepting this suggestion does not mean that there can be no fruitful interchange between philosophical speculation about the nature of autonomy and practical thought about how to treat those suffering from mental disorder. Each kind of thinking can and should influence the other. The claim defended here is only that a more realistic sense of the shape of the concepts used, in particular ‘autonomy’, and hence what issues are really in play at various points, could be helpful in preventing various styles and strands of thought from getting confusingly intertwined.

The structure of the paper is as follows. Section 1.2 will discuss the shape of the concept of ‘autonomy’. It will sketch the agreed surface of its logical form, consider some of the disagreements lurking beneath that surface, and suggest an explanation of these things in terms of our historical context. Sections 1.3, 1.4, and 1.5 will then explore some implications of that account for the use of the word ‘autonomy’ in discussions of right interaction with the mentally disordered. The argument will proceed via consideration of three recent papers by philosophers—Silver (2002), Jaworska (1999), and van Willigenburg (2005) —all of which concern, in one way or another, the idea of respecting autonomy in the treatment of the mentally disordered. The aim in discussing these papers is not to take issue with what I take to be the central ethical recommendations advanced by these authors. On the contrary, there may well be much of value in what they say. The aim is rather to consider how certain ways of proceeding in those discussions, in particular the practice of using the word ‘autonomy’ as if there were one right account of it to be given, may not be the best way of presenting those ideas.

Chapter.  8859 words. 

Subjects: Psychiatry

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