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Rationality and self-knowledge in delusion and confabulation: implications for autonomy as self-governance

Lisa Bortolotti, Rochelle Cox, Matthew Broome and Matteo Mameli

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/9780199595426.003.0024

Series: International Perspectives in Philosophy & Psychiatry

Rationality and self-knowledge in delusion and confabulation: implications for autonomy as self-governance

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The main purpose of this paper is to explore the implications of the epistemic faults of delusions and confabulations for the autonomy of the people affected by these conditions. The issue whether autonomy is compromised and to what extent is of great practical relevance. Do people affected by psychiatric disorders that manifest with delusions and confabulations have capacity to consent to treatment? More generally, should they be allowed to make, and be deemed responsible for, significant decisions that affect their well-being?

We propose to look at autonomy as self-governance and to make a distinction between (a) whether one has the capacity to govern oneself and (b) whether one is successful at governing oneself. We argue that the capacity for self-governance depends on the capacity to develop a self-narrative which encompasses the capacity to endorse attitudes and actions on the basis of reasons. Success in self-governance depends on the coherence of self-narratives and on their correspondence to real life events.

Our thesis is that, in most cases, people with delusions or confabulations have the capacity for self-governance, but are unlikely to be successful at governing themselves. This is because they are likely to demonstrate failures of rationality and self-knowledge that impact on the coherence of their self-narratives and the correspondence between these narratives and real life events. The notion of rationality we use in this chapter is a comprehensive notion of rationality for beliefs, which encompasses procedural, epistemic, and agential considerations. It addresses whether there is consistency between a person’s beliefs and other intentional states; whether a person’s beliefs are well supported by, and responsive to, the evidence available to that person; and whether a person can defend her beliefs with reasons and act in accordance with her beliefs. By self-knowledge we mean knowledge of one’s own present and past attitudes, dispositions, and actions, based on introspection, testimony, memory, self-observation, and inference from one’s own behaviour.

Although in some cases the very capacity for self-governance may be compromised (e.g. in ‘primary’ delusions where no reasons are offered in support of the delusion or in delusions and confabulations which occur at advanced stages of dementia), our claim is that having delusions and confabulations does not necessarily imply a lack of capacity for self-governance. That said, delusions and confabulations interfere with the exercise of self-governance.

In Section 5.2, we argue that people with delusions and confabulations typically experience failures of rationality and self-knowledge. In Section 5.3, we sketch an account of authorship, a person’s capacity to determine what to believe, intend, and do based on what she thinks are her best reasons for those beliefs, intentions, and actions. This capacity is important as it allows people to take responsibility for their own attitudes and integrate them in a personal narrative that underlies the conception of themselves as autonomous agents. In Section 5.4, we suggest that authorship makes a contribution to self-governance via the construction of self-narratives. The attitudes that can be ‘authored’ (deliberated about or justified on the basis of reasons) are likely to play a significant role in people’s narratives. As a result, breakdowns of authorship can ensue in unsuccessful self-governance. In Section 5.5, we review some attempts to describe delusions and confabulations as unreliable self-narratives. In Section 5.6, we draw some general conclusions about the discussion of self-governance in people with delusions and confabulations, and we think about possible implications for policy.

In the paper we argue that, in most of the relevant cases, the best thing to say is that people with delusions and confabulations retain the basic capacity for self-governance but are unlikely to be successful at governing themselves due to their typical failures of rationality and self-knowledge. Failures of rationality and self-knowledge are also present in people without delusions and confabulations and they interfere with the exercise of self-governance in these cases too. However, the failures of rationality and self-knowledge that occur in delusions and confabulations may have more serious consequences, for instance by impairing social functioning.

Chapter.  8185 words. 

Subjects: Psychiatry

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