Autonomy and Mental Disorder
Whether by intent or accident, each of us, upon making psychiatry our chosen specialty, steps into a philosophical minefield that we are generally unprepared to navigate. Even those psychiatrists who claim no expertise at addressing what constitutes "the good life" face big questions concerning free will and determinism, dualism and holism, virtue, vice, and victimhood. For several decades, medicine as a whole has wrestled with the ever higher premium placed on patient autonomy in health care decision-making. Psychiatry has been particularly challenged in this thorny philosophical/ethical domain, trafficking as it does in civil commitment and the imposition of involuntary interventions upon certain patients. Further, physicians from other specialties frequently turn (sometimes reflexively) to psychiatrists to negotiate their own dilemmas regarding patient autonomy via evaluations of patients’ decisional capacity.
These concerns center on a presumption that mental illness represents an internal threat to individual autonomy. Autonomy and Mental Disorder, an edited text in Oxford University Press’ series, International Perspectives in Philosophy and Psychiatry, critically addresses this presumption and its implications. The editor, Lubomira Radoilska, has recruited a predominantly British team composed mainly of philosophers. As such, American psychiatrists will find the book fresh in at least 2 respects: (1) that it approaches individualistic autonomy from a questioning rather than an idealizing stance and (2) that it departs somewhat from the usual competency/capacity forensic focus that orthodox medical education tends to take on the subject.
Following a substantial introduction by the editor, the book’s 12 chapters are broken down into 4 sections/themes. Truth be told, I sometimes could not tell why a chapter was situated in one section and not another, but these mysteries seemed inconsequential. While this text is digestible enough to be read cover to cover, its contents are not iterative; readers can easily pick and choose the chapters that seem most germane to their practices and curiosities. Regardless, they will find valuable investigations into what it means to be autonomous and what it means to be respectful of others’ autonomy.
It is probably not giving away the ending to say that no consensus conclusions are drawn in these areas. Even basic assumptions about autonomy and disruptive influences from psychopathology fray at the edges, as demonstrated in a chapter posing "Three Challenges From Delusion for Theories of Autonomy." Moving in from the outer margins, limitations of the standard 4-abilities model of capacity assessment come to light in many discussions of how patients’ and providers’ values are derived and come into clinical play. The equating of capacity/competency with autonomy itself is seen, particularly in the chapter "Autonomy, Value, and the First Person," as exerting restrictive force upon beliefs about when and whether to respect not just patients’ decisions, but patients themselves. A dense but cogent argument is put forth that intact "agent autonomy" (the possession of rational agency) is not the sole justification for respecting "choice autonomy" (freedom from coercive intrusion). While this position increases the complexity of certain clinical situations, it also shines a light on some of the otherwise ineffable messiness inherent in psychiatric work.
Likewise, 2 late chapters, "Autonomy, Dialogue, and Practical Rationality" and "How Do I Learn to Be Me Again? Autonomy, Life Skills, and Identity," hone in on mainstream individualist views of autonomy and moral development and articulate relational alternatives. In doing so, they partially decouple interference and coercion, opening avenues for physicians to meaningfully engage, even challenge, patients about their stated values, particularly when those values do not square with patients’ decisions or actions. Patients, of course, hardly have a monopoly on debate-worthy values. In an especially useful chapter on "The Mental Capacity Act and Conceptions of the Good," paternalism’s categories and justifications are discussed, along with various concepts of "best interests." Here, some unspoken assumptions in the care of compromised persons are laid bare and examined, including many providers’ understandable but ungrounded exaltations of physical well-being in any best interests analysis. If I could select only a single chapter from this volume for teaching and self-scrutiny purposes, it would be this one.
For all of its laudable qualities and content, Autonomy and Mental Disorder can sometimes be a difficult, even frustrating, book for the philosophically uninitiated (myself included). In its lesser moments it may seem intellectually self-indulgent and inutile for a volume in a "philosophy and psychiatry" series. For the most part, though, one is driven forward by a comment on the very first page of chapter 1, stating 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" (p 3; italics added). Figuring those requirements out is a worthy personal and professional project well served by this challenging text.
Author affiliation: Harvard Medical School, Boston, Massachusetts.
Potential conflicts of interest: None reported.
J Clin Psychiatry 2013;74(4):e343 (doi:10.4088/JCP.13bk08406).
© Copyright 2013 Physicians Postgraduate Press, Inc.
