oxford handbook of bioethics

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that ‘insane behaviour, no less than sane, is goal directed and motivated’ (Szasz: 113, cited in Moore 1975/1982). Szasz apparently believes that the mere capacity for intentional action is decisive evidence of the autonomy of the actor. This is a very thin account of the conditions of autonomous agency and one that is not shared by many moral philosophers. For, on such an account, young children and even dogs would count as autonomous and so as morally and legally responsible for their actions.4

R. Jay Wallace, in adopting a broadly Kantian account of agency, notes that

to be an accountable agent — an agent who is subject to moral requirements, and who may be appropriately held responsible for failing to comply with such requirements — it is not enough merely to be subject to desires and capable of acting to promote the ends set by such desires. Moral agency requires, in addition, the capacity to step back from one’s given desires and to assess the ends they incline one to pursue in the light of moral principles. (Wallace 1994: 13)

Wallace articulates a widely shared view in insisting that free autonomous agents must possess the powers of ‘reflective self-control’.5 What are these? First, the person must possess moral concepts and have the capacity to recognize and apply moral reasons appropriately in their practical deliberation. Second, they must have the capacity to control their behaviour in accordance with these reasons. These capacities are not all or nothing. They come in degrees, and so responsibility, too, comes in degrees. While most persons with psychiatric illnesses or disorders will have acquired ordinary moral concepts (psychopaths are arguably the exception), disordered thinking, delusions, hallucinations, clinically depressed or elevated mood, and so forth may reduce or remove their capacity to recognize, or to weigh appropriately, relevant moral considerations and to judge accordingly.6 Further,

persons suffer from a mental-brain disease . . . and that ostensibly compassionate – therapeutic attitude towards such individuals justifies our depriving them of their liberty (when they are innocent of crime), and of excusing them of responsibility for crime (when they are guilty of it)’ (Szasz 1998: 205). I take it that by ‘guilt’ here he means only that they performed the action proscribed by the law.

4 Unfortunately the incidence of mental illness and other psychiatric disorders in our prison populations suggests that the view expressed by Szasz — that mentally disordered persons are rightly held responsible for their offences — is not uncommon. A recent New York Times report puts the figure at about 20 per cent of the prison population (‘Study Finds Hundreds of Thousands of Inmates Mentally Ill’, 22 Oct. 2003). This is a time when it is increasingly difficult to mount a successful insanity defense in the United States even for defendants who are clearly severely impaired. Among philosophers, though, there is fairly consistent support for the idea that people with mental illnesses are not, or not fully, responsible for those actions symptomatic of their illness. Discussion here has tended to focus on the case of schizophrenia. See Christian Perring (2002).

5 The idea that autonomous agency centrally involves the capacity to stand back from and evaluate one’s first-order desires is widely shared by philosophers of both a Humean and a Kantian cast. See e.g. Bratman (2000); Kennett (2001); Korsgaard (1996); Watson (1982); Frankfurt (1971); Velleman (1997).

6 For an argument that mentally ill defendants usually do know both what they are doing and that it is wrong, see Schopp (1991). Schopp argues that, nevertheless, such individuals may be substantially

these conditions may impair the ill person’s capacity to exercise control over their actions in accordance with the moral considerations they do accept. Deveson writes movingly of finding desperate notes written by Jonathan to himself, perhaps as reminders or injunctions: ‘Don’t hurt Anne’. But such attempts to control his future actions were always vulnerable to defeat by his symptoms. On standard accounts Jonathan cannot count as an autonomous, responsible agent. He, at least, ought not be blamed for many of his actions. But even where we can make such a clear determination on responsibility for particular harmful actions, it does not determine in full what our attitude should be towards Jonathan or how he should be treated. For that we need to acquire a more substantial understanding of the losses the illness imposes on Jonathan himself.

Unified Agency and Self-Authorship

David Velleman has remarked that the philosophy of autonomy and the philosophy of personal identity seem to intersect at something called ‘the self ’.7 My discussion here is located at this intersection: at the interrelation between effective agency and self-conception. Christine Korsgaard (1988: 101), in providing a Kantian account of personal identity, argues that a person is ‘both active and passive, both an agent and a subject of experiences’. She argues that effective agency requires unity both at a time, in order that we may eliminate conflict among our motives and do one thing rather than another, and over time, since many of the things we do form part of longer-term projects and make sense in the light of these projects and life plans. And she says that in pursuing these long-term projects and commitments ‘we both presuppose and construct a continuity of identity and of agency’ (1988: 113; my emphasis). What does this mean? We do not simply act, as Michael Bratman (2000: 40) points out, from moment to moment. We conceive of ourselves as agents who persist over time, and so we commit ourselves to future directed plans, which we intend should structure and coordinate our more particular decisions and activities. But we can only do so if we can be confident that our future directed decisions will be effective, that we are able to ‘determine today what gets done by us tomorrow’ (Velleman 1997: 45). If we don’t have this ability we lack autonomy here and now. For, as Korsgaard says: ‘to the extent that you regulate your choices by identifying yourself as the one who is implementing something like a particular plan of life, you need to identify with your future in order be what you are even now’ (1988: 113 – 14).

Velleman argues that we achieve diachronic autonomy because the plans we adopt now provide reasons for us into the future, reasons we will then buy into

impaired in their capacities of rational choice. They may have, for example, delusional beliefs of such force that they cannot reason properly about their actions. For further discussion of issues surrounding criminal responsibility and mental impairment, see Kennett and Matthews (2004).

7 Formerly on his website.

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but might not otherwise have had. We identify these plans and commitments as our own and implementing them thus usually makes the best sense of our life stories (Velleman 1997: 45 – 8; 2000). Hence it would seem that autonomous agency depends upon significantly unified agency. Unity is fundamental to the capacity to make, shape, and revise plans and to carry them out: to engagement in those long-term projects and commitments, such as an education, a career, a marriage, or a friendship, which are the sources of our deepest satisfactions. Unity is an essential condition of both the capacity for competent deliberation and the capacity for self-control over time that standard accounts of moral agency and responsibility insist upon. In short, it underwrites our authorship of our lives. While not all aspects of the self, or even, I would argue, all valuable aspects of the self, are subject to agential control, agency is surely central to the self and is a condition of access to a wide variety of important normative goods.

Of course unity of one’s agency does not, on its own, ensure a good life. Successful self-authorship relies on the possession of a variety of fairly sophisticated skills that fall under the rubric of either competent deliberation or self-control. There is the rational requirement of getting one’s projects to cohere, there are means – end managerial skills; there are value judgments about the quality of different projects; there are prioritization skills; and importantly, predictive imagination — ‘If I take that job, then I’ll turn into that kind of person, can I imagine myself as being like that, is that the way I want to be . . . ?’, and so on.

A view of the self as author allows for rational revision of plans in the light of changed circumstances or new information, and so allows for personal development and change over time. Indeed we may have projects that quite explicitly aim at changing our very characters, and so at changing the way we may come to view ourselves, and our projects, in the future. One of my projects may be to write a cookbook, another may be to learn to service my car. Yet another may be to develop a greater sensitivity to the suffering of others and a less judgmental attitude to their misfortunes. If I am successful in this latter character-building project, I may come to see new reasons for action in the future; these lead me to take on new projects, and so by incremental steps I become very different from how I am now. Nevertheless, I retain authorship of the overall process and identify with each stage of it.

But now consider what happens when we undergo dramatic changes — not in our external circumstances, but in ourselves — which we have not chosen. What if we find we can no longer rely, in the normal way, on our future selves being appropriately affected by our present plans and decisions? What if our projects, large and small, were at constant risk of derailment? What if even those traits and dispositions which we might think of as fundamental to our characters — openness, generosity, efficiency, and so forth — were in danger of being masked or reversed? Then it would seem that we would lack authorial control over our lives, and our identity, our self-conception, as well as our autonomy would be gravely

undermined. In cases of serious, recurrent, or chronic mental illness I suggest that this is what happens. The onset of illness is like a grenade or a series of grenades exploding in one’s path. The impact of the repeated failure of one’s plans and one’s hopes for the future must damage one’s self-conception and autonomy in ways that extend beyond the more obvious and direct disabling of the capacities for rational reflection and self-control. As Korsgaard says, we need to see ourselves as agents of our future, we need to identify with our future, to be what we are even now. If mental illness changes a person’s view of their future, and of their ability to shape their future, it changes them now.

Agnetti and Young (1993: 69) argue that, for patients (and their families) with a long-standing psychiatric disorder:

life seems like it has always been dominated by the illness and always will be. The past is seen as the same as the present and the future offers nothing new. . . . If the temporal dimension is lost in one’s view of the world, then the possibility of hope, growth and change is also lost . . . events stand still and individual action is paralysed.8

Repeated experiences of illness, of hospital, of (perhaps coercive) treatment, of failed plans, of other ill people, and of the reactions of others to one’s illness, must all over time profoundly affect the way the agent sees themselves and influence the ways in which they can project themselves into the future. This is vividly illustrated in Jay Watts and Stephen Priebe’s (2002: 447) study of users of assertive community treatment services:

Most of the participants described the psychiatric system and the labelling of diagnosis as an attack on their identity. For example: ‘I get sick, I get cracked up, and this is my life. I can’t keep fighting against it and trying to be someone else . . . I had people that could depend on me. I liked independence . . . To lead, and I am not in a position to lead no more.’

Though people with chronic mental illnesses still wish for the same goods as everyone else, and may hold much the same values as they did prior to illness, a loss of confidence in their power to see through valued plans and projects may mean that they are given up, and the person lives an impoverished life dominated by short-term considerations. They may come to see themselves quite generally as subjects, rather than agents, of their experiences.

There is much more to be said, and much more precisely, than there is room for here, about how the various symptoms of the various illnesses might affect or impair one’s authorial capacities as well as about the possibilities of regaining authorship of one’s life in a way that integrates and organizes one’s experience of illness. I leave further exploration of that to the reader.9 Here I want to focus on one

8 There is also evidence that treating teams are vulnerable to this paralyzing sense of timelessness when dealing with patients or clients with chronic psychiatric conditions. For discussion of this and of ways in which treating teams can ‘restart the clock’ for their clients, see Young (1994).

9 But see Wells (2003); Kennett and Matthews (2003); Phillips (2003); Radden (2003); Velleman (2005).

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particularly central way in which one’s sense of self, and opportunities for effective agency, may be affected when one suffers a mental illness, which has especially strong moral implications for those with social, professional, and institutional contact with persons suffering mental disorders or illnesses.

RE C I P RO C A L IN TER AC T I ON

AND THE VISIBILIT Y OF THE SEL F

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Successful negotiation of the social environment is a condition of success for almost all of our activities and projects, from going shopping to holding down a job. Further, our most central and long-term commitments may be to loving reciprocal relationships. Talking in terms of an individual person’s projects and capacities, as I have until now, may suggest that to the extent to which persons have authorship at all, we are sole authors of our identity and life story. But of course, as social beings, as agents whose actions impact on others and who regularly need the cooperation of others in order to complete action, we are not. Other people contribute very significantly to how we see ourselves, and so to the selves that we become. How do these social interactions and relationships proceed? How do they make their contribution to the self-building and maintenance project? And how does this enhance or impair our agency and autonomy?

Nathaniel Branden (1993: 67), in an essay entitled ‘Love and Psychological Visibility’, argues that it is to a large degree through our interactions with others that we become visible to ourselves. He begins by analyzing the pleasure he gets from playing with his dog:

The key to understanding my pleasurable reaction . . . was in the self-awareness that came from the nature of the feedback she was providing. From the moment I began to ‘box’ she responded in a playful manner . . . Were I to push or jab at an inanimate object, it would react in a purely mechanical way; it would not be responding to me; there would be no possibility of its grasping the meaning of my actions, of apprehending my intentions, and of guiding its behaviour accordingly . . . The effect of Mutnik’s behaviour was to make me feel seen, to make me feel psychologically visible . . . And as part of the same process, I was experiencing a greater degree of visibility to myself ; I was making contact with a playfulness . . . which . . . I generally kept severely contained, so the interaction also contained elements of self-discovery . . .

Branden argues that this experience of visibility to oneself and others is a product of all positive human interaction that reaches its pinnacle in romantic love. He further claims that to do the job of providing visibility, the interaction must be both positive and appropriately responsive to the other and to what is conveyed by the other. Let’s look at some of those interactions.

RECIPRO C IT Y, INTER PRETAT ION, AND THE

REAC T IVE AT T I T UDES

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As social beings we must, necessarily, engage in a wide variety of transactions and interactions with others. Social life is shot through with interpretive practices. Grasping each other’s meaning, recognizing each other’s intentions, guiding our actions accordingly to coordinate with each other, these all involve a degree of interpretation of the other. The interpretation is largely implicit. For the most part we don’t think about the particular messages we give to others: we are skilled at mind reading, at picking up behavioural cues and responding to them appropriately, and many social situations and transactions are governed by rules, roles, or conventions that we have internalized. All social transactions, from getting a haircut, to asking for directions, to having dinner with friends, require a degree of mutual responsiveness and interpretation of the other for success. In these transactions with other our default stance, our natural stance, is what Peter Strawson (1982: 62) has called the participant stance. Within this stance we are exposed to the reactive attitudes of, for example, ‘gratitude, resentment, forgiveness, love, and hurt feelings’. My attitude to you will depend crucially on my picture of your motivations towards me. As Strawson (1982: 63) remarks: ‘If someone treads on my hand accidentally, while trying to help me, the pain may be no less acute than if he treads on it in contemptuous disregard of my existence . . . but I shall generally feel in the second case a kind and degree of resentment that I shall not feel in the first.’ Strawson claims that just in being prone to these kinds of reactive attitudes we manifest respect for each other. In taking up the participant stance, he says, we signal that we regard those with whom we engage as fit for ordinary adult human relationships. So successful social interactions should provide, at least, a basic visibility and affirmation of the self as social participant with rightful expectations of mutual goodwill. Often enough they do more. We might receive more specific feedback on how we’re doing and on how we’re seen, for example a compliment on our good service, thanks for some basic assistance like helping someone pick up the contents of a spilled trolley, or we might share a moment’s camaraderie with a stranger at a football match. Such interactions involve positive reactive attitudes and provide positive reinforcement to the self. They allow us to proceed with confidence. But now consider those of the negative variety.

Whether we stand to the other as friend, lover, colleague, customer, or patient, we expect and indeed demand that their actions where we are concerned reflect good rather than ill will. That we make this demand, and that the attitudes of others matter to us, is evident in our reactions when our ordinary expectations are disappointed. The rudeness of a shop assistant, the brusque dismissiveness of a doctor, each occasions hurt feelings and a degree of resentment that may bear little relation to any actual disadvantage we suffer. The shop assistant rolls her

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eyes at my clumsiness with my purse, ignores my attempts at pleasantries, and displays obvious impatience in answering my queries, but she wraps my purchases efficiently and gives the correct change. The injury here is in the attitude not the action. Attitudes of contempt or indifference are in themselves injurious; attitudes of goodwill and esteem, in themselves, confer a benefit on the recipient. But what is the nature of the injury? I suggest that it is, at least in part, an injury to our conception and presentation of ourselves. When we lose control of how we appear to others, when our self-presentation misfires, we will typically experience some anxiety about who we are. I am trying to be pleasant and cooperative but am coming across as fussy and incompetent. Maybe I am fussy and incompetent. Or maybe she is just rude. In the case of one-off interactions such as with the shop assistant where there is a failure of reciprocity and interpretive charity there is no chance to negotiate or revise the interpretation as there may be in longer-term relationships. I am stuck with the dissonance between the way I thought I was and the picture I gained in seeing myself through her eyes. (Of course I may come to believe that her interpretation of me is correct and I will then modify my view of myself and maybe make an effort to change in order to avoid the negative feedback.) In cases of the worst kind I cannot see myself at all through the other’s eyes. I am simply invisible to them. This is frequently the experience of members of minority or oppressed groups in interactions with members of dominant groups. In these cases the default assumption of mutual goodwill and respect doesn’t even get off the ground. The effect of such invisibility and exclusion from social interaction on the agent’s sense of efficacy, and on their capacity to act, is particularly severe.

FAI L E D RE C I P RO C I T Y A N D FRAG I L E

IDENT IT Y

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I started hearing voices, I started talking to myself, she couldn’t take it any more, the relationship broke up . . . and I ended up on my own.

(quoted in Watts and Priebe 2002: 445)

In cases where the agent suffers a mental illness, the kinds of social misfirings I’ve described above happen more often. Though most people with a mental illness manage well enough with most public social interactions, going to the corner shop, catching public transport, etc., the features of their illnesses can often create the conditions for things to go wrong. Depressed or anxious persons may seek to make themselves invisible, others go the opposite way; their lack of judgment or social disinhibition leads them to press too much personal information on strangers, resulting in withdrawal. Other oddities in behaviour and presentation, for example, talking too loudly or standing too close, can also lead to avoidance. Sufferers may

have difficulty seeing themselves through others’ eyes and so may not make the appropriate modifications to their behaviour: alternatively they may be too ready to adopt a negative self-evaluation on the basis of others’ reactions to them. Thus these experiences will fail to provide visibility of the right kind and may feed back in a negative way to the agents’ conception of themselves.

Of course these kinds of public social interactions are not of a deep, extended, or intimate nature and so they would not normally provide, contribute to, or challenge a deep view of the self. Our close and intimate relationships do, on the other hand, contribute very significantly to the way we see ourselves and to the selves that we become. The more stable, positive, and sensitive interpretations offered in the context of our intimate relationships can counter and resolve dissonant experiences in the public social sphere. The reassurance and affirmation we receive there strengthen and protect the self. Unfortunately these relations too are often weakened or unavailable to the agent suffering a mental disorder, since many such people are impaired precisely in the responsiveness and attentiveness to others needed to form and maintain them.

Since Aristotle it has been accepted that friendship is a central human good and an important source of self-knowledge. In addition it provides a means to self-growth and development. Let’s examine how. In close friendships we engage in the broad interpretive practices outlined above of grasping each other’s meaning, recognizing intentions, coordinating actions. But, ideally at least, these will be more finely tuned and attentive in friendship. One’s close friend will be better able than acquaintances or strangers to read one’s mood, and friends, as I’ve claimed elsewhere, are especially receptive to responding to each other’s wishes and coordinating their activities in accordance with each other’s suggestions.10 So I might notice, where others would not, a slight stiffening in my friend’s demeanour when she is cornered by someone she dislikes but doesn’t wish to be rude to at a social gathering, and will move to rescue her from the situation. If she then says ‘Let’s get out of here’, I will take that as sufficient reason to leave. My responses to her are highly particularized and thus provide a high degree of visibility and affirmation of self.

Beyond this particularized implicit interpretation of her I also, as her close friend, offer explicit interpretations that contribute in a deeper way to her understanding of who she is. I may, for example, point out, after rescuing her, that she quite generally exhibits discomfort with men of a certain status and that perhaps this is colouring her view of the individual who cornered her. I may say that he’s not so bad, that she may have misread his intentions, or I may affirm her own assessment of the situation. Assuming that what I say is, as Branden insists, appropriately responsive, she is likely to take it on board and this will help shape and develop

10 The account of friendship given here draws upon that developed in Dean Cocking and Jeanette Kennett (1998, 2000). See also Dean Cocking and Steve Matthews (2000). The example below originated in a talk given by Dean Cocking, ‘Intimacy and Privacy Online’, at the Australian National University in 2002.