Chapter

Three challenges from delusion for theories of autonomy

K.W.M. (Bill) Fulford and Lubomira Radoilska

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/9780199595426.003.0018

Series: International Perspectives in Philosophy & Psychiatry

Three challenges from delusion for theories of autonomy

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The main ambition of this chapter is to identify and explore a series of challenges that the phenomenology of delusions poses to our systematic thinking about autonomy. For the sake of the argument, we shall understand autonomy in terms of intentional agency over time (see, for example, Bratman 2007) and will not expand on the possible interactions between this and alternative conceptions, which either take an ahistorical perspective and define autonomy as a distinctive relationship to one’s motives at the time of action (Frankfurt 1971), or integrate further criteria, such as responsiveness to reasons (Watson 1975) and accordance with particular values (Hill 1991). An implication of this methodological choice is that the challenges at issue will have no immediate bearing to emancipatory accounts which define autonomy as a particular social-relational status and therefore have no apparent reason to take delusions as likely failures of autonomy per se, independently of specific institutional contexts (Mackenzie and Stoljar 2000). In other words, the following discussion is primarily aimed at theories which conceive autonomy as an agency rather than a status concept. The central claim is that in order to avoid circularity, such theories should be able to address the subsequent challenges from delusion. This becomes clear if we consider the compelling intuition according to which ‘insanity’ is an obvious case where autonomy as just specified has broken down (see, in particular, Wolf 1987). What seems to be implied in it, however, is that ‘insanity’ is definable independently of whether it compromises autonomy or not. Psychosis as a central mental disorder and delusion, its central symptom, seem to provide the required theoretical leverage. The thought is that, unless delusion is conceived as theoretically independent from autonomy, we would end up with a vicious circle: defining ‘insanity’ as lack of autonomy and then turning back to clarifying autonomy as a state where autonomy is not lacking.

Yet, as we shall argue drawing on (Fulford 1989) the following challenges from delusion suggest that delusions are implicitly understood in terms of various kinds of breakdowns of intentional agency. Hence, in order to avoid circularity both in defining autonomy and delusions, we need to explicitly address the putative failures of autonomy as presented by the logical topography of delusions, encompassing: their centrality (Challenge 1), their diverse logical range (Challenge 2), and non-pathological instances (Challenge 3). We take these challenges in turn, first setting out and illustrating the relevant features of delusions and then expanding on the implications for theories of autonomy. We conclude by spelling out several caveats that emerge from the discussion and briefly indicating the relevance of the analysis to contemporary policy and practice in mental health.

Chapter.  11615 words. 

Subjects: Psychiatry

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