oxford handbook of bioethics

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her view, not just of the situation, but also of herself. Mutual deep interpretation is a central and defining activity of close friendship without which much of its intimacy would be lost. Within friendship we receive and accept input and feedback that importantly contributes to our self-building project, and affirmation, which is vital to its maintenance. This, what we might call, drawing of each other, further enhances the relationship between us: there is a positive and dynamic feedback loop.

Such interpretations may not be taken on board at all, and certainly not in the same way, if made in the context of a different relationship, say by one’s mother or even by one’s therapist. The point is that in close friendship we are especially receptive to such interpretations and so friendship provides an important arena for self-development and the acquisition of self-knowledge that may not be replaceable. Aristotle (MM 1213a10 – 26) says: ‘If, then, it is pleasant to know oneself, and it is not possible to know this without having someone else for a friend, the self-sufficing man will require friendship in order to know himself.’ There is here, as John Cooper (1980) says, recognition ‘of the social bases of a secure self-concept and of the role intimacy plays in providing the means to it’. This supposed necessary base of a secure self-concept is placed at risk when one party develops a chronic mental illness.

The nature of the difficulty that, for example, delusional individuals must face in establishing and maintaining close friendships is obvious when we look at the role reciprocal interpretation plays in friendship. Delusional individuals often have beliefs about themselves and others that are bizarre and resistant to revision. A lack of response or a highly inappropriate response to the interpretations offered by another will constitute a barrier to friendship. Conversely the ill person is often not well placed to offer the kinds of interpretations of others that the other can integrate into their self-conception. So an important mutual activity of friendship that contributes to the intimacy between friends, as well as to self-knowledge and self-development, may be less available to those suffering delusions. More generally the mere presence and expression of the delusion can disturb the friendship since this may lead to wariness on the part of the friend with respect even to non-delusional communication. Other psychiatric conditions will also affect one’s fitness here. For example, deep depression, paranoia, or wild mood swings may so bias interpretations that they are unacceptable to the recipient.

Even the apparently less demanding broad interpretive activities of grasping the other’s meaning and anticipating their intentions, forming joint intentions, and coordinating activities can be more difficult for people with serious mental illnesses. The presence of delusions or obsessions, for example, may dictate activities or routines that cannot be altered and which others cannot understand or share; or the illness may affect the agent’s motivation and planning capacities such that they cannot reliably take part in joint activities, even in the absence of positive symptoms. Poor or absent motivation is well recognized as one of the negative

symptoms of schizophrenia. Further, the loss of confidence in one’s future that comes from repeated interruption of one’s projects does, as we have seen, affect how the agent thinks of themselves in the present and so affects the way they proceed in relationships as in other matters.

The loss of friendships and other close relationships leads to social isolation and contributes to the social invisibility of the ill person, and it is well known that such isolation has a significant detrimental effect. As Watts and Priebe (2002: 446) point out, the literature on chronic illnesses shows that ‘the overwhelming implications of illness on identity is mitigated by intervention from significant others’. But this mitigation was largely unavailable to the psychiatric patients in their study, many of whom had lost significant others ‘early in their psychiatric career’. Without the stabilizing influences that good relations with others provide, psychological function deteriorates further.11 A vicious loop can develop as the feedback from others becomes increasingly impoverished, negative, and defensive, or somewhat artificial and paternalistic, as in many professional encounters.12 It is hard to construct a rich positive sense of self as we become increasingly invisible to others, as they refuse eye contact, turn away at our approach, end conversations abruptly, and show less and less interest in what we say and do.

The argument to this point suggests that the consequences of impaired social interaction and the loss of deep interaction on self-concept and the development and exercise of one’s agential capacities can be severe. What it does not support is the idea of a neat division between the person and the symptoms of their illness that we can use in allocations of responsibility, since the illness can affect the person via its effects on their plans, projects, expectations, and relationships even during periods of quiescence. The person they would have become if they had not become ill is an increasingly distant fiction, and the self they are now is constructed out of experiences of illness and of remission, and of their own responses to these experiences and others’ responses to them. It is not identical either to a set of symptoms or to the self prior to illness.

If the illness now forms part of the person and has shaped their identity, we cannot dismiss it or glide over it in our moral evaluation of the person. Our responses to the person must also be responses to their illness. However, if we accept the claim that in our relations with others we can become, invited, welcomed, or not, part authors of that person’s self-conception and life story, we need carefully to consider the responsibility that is thus placed on us, particularly in our dealings

11Indeed impaired adolescent friendship patterns are a significant predictor of a sustained delusional outcome in persons with schizoaffective disorder (Coryell, Keller, et al. 1990).

12Watts and Priebe outline the therapeutic experiences of their subjects as follows: ‘the approach

focused on medication . . . Relationships were seen as impersonal and paternalistic because of short appointment times and frequent turnover of staff ’ (2002: 448). They quote one subject, Mr B: ‘When you are on the ward, you get staff that think it’s a prison or something. And that you’ve done something and they try and boss you around. Control you, control you’ (2002: 446).

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with those whose identity and agency is already fragile. Given the undermining effects of social failure and withdrawal by others on the self, it may seem obvious that in both professional and personal contexts we should not withdraw, as people often do, from those suffering a mental illness. Simple beneficence dictates that we should actively seek to maintain engagement with the other even where their capacity to reciprocate appropriately is impaired. But there is a problem with this simple conclusion. For mental illness is widely (and properly) seen as exculpatory, and in several influential writings it is argued that reciprocal relations and the presumption of responsibility are not separable.

FAI L E D RE C I P RO C I T Y A N D T H E OB J E C T I VE

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The consequences of the mentally ill agent’s impaired capacity for interpersonal relations and social interaction have deep and troubling implications not only for the development and maintenance of the self and the exercise of agency, but also for the ill person’s moral standing in the community. As we have seen, to the extent that we find someone’s actions odd or unintelligible and unmodified by our reactions to them, to the extent to which they seem incapable of understanding or taking an interest in our interests, or of responding to us as we are, we may decide that our interaction with them is insufficiently rewarding and withdraw from it. Peter Strawson (1982: 66) takes a position at the opposite end of the spectrum to Szasz in suggesting that in the case of the severely mentally ill, the participant reactive attitudes are altogether out of place. When faced with such individuals we move, and should move, to the objective stance. Here is his description of this stance:13

To adopt the objective attitude to another human being is to see him, perhaps, as an object of social policy; as a subject for what, in a wide range of sense, might be called treatment; as something certainly to be taken into account, perhaps precautionary account of; to be managed, handled, cured or trained; perhaps simply to be avoided. . . . The objective attitude may be emotionally toned in many ways, but not in all ways: it may include repulsion or fear, it may include pity or love, though not all kinds of love. But it cannot include the range of reactive feelings and attitudes which belong to involvement or participation with others in inter-personal human relationships; it cannot include resentment, gratitude, forgiveness, anger, or the sort of love which adults can sometimes be said to feel reciprocally for each other. If your attitude towards someone is wholly objective, then though you may fight with

13 The following passage may present Strawson’s view as rather more black and white than it is. Strawson does acknowledge that we may move between the two stances particularly in the case of children. I argue below that there is a distinction between a fitting objectivity of judgment that may inform aspects of our relations with others, including professional relations, and the objective stance as described by Strawson.

him, you cannot quarrel with him, and though you may talk to him, even negotiate with him, you cannot reason with him. You can at most pretend to quarrel, or to reason, with him.

Seeing some one then, as warped or deranged or compulsive in behaviour . . . tends, at least to some extent, to set him apart from normal participant reactive attitudes on the part of one who sees him, tends to promote, at least in the civilized, objective attitudes.

Though the objective attitude, so described, sounds anything but civilized, we may find ourselves moving towards it, in both personal and professional contexts, for the reasons I have given. Disappointed reciprocity and failures of interpretation can lead to feelings of frustration and impotence. Then the objective stance may indeed act as a refuge from the strains of involvement. But further argument is needed to support Strawson’s implied suggestion that we should, normatively speaking, adopt the objective stance when dealing with people suffering severe mental illness. If reciprocal relations are, as Strawson suggests, the ordinary basis even for respect and goodwill, then we would expect to find, what we largely do find, that mentally ill persons are treated with less respect and less goodwill than other adult members of the community including by some members of the helping professions. It does not seem right or desirable that one’s moral entitlements should depend so heavily upon one’s social competence. So what can be said in favour of Strawson’s position?

For Strawson, resentment is arguably the most central of the reactive attitudes, so I will focus on that. Let’s consider the kinds of consideration that allowably modify or remove resentment and the disposition to blame in circumstances where one would normally expect it to be operative; that is, in circumstances where one has suffered some injury or offence at the hands of the other. Strawson suggests that the considerations fall into two kinds, which, following Wallace (1994), I shall call excuses and exemptions.

Excuses do not call into question those capacities of the agent that seem essential for engagement with others and for making and responding to the demand for goodwill and respect. They do not invite us ‘to view the agent as one in respect of whom these attitudes are in any way inappropriate’ (Strawson 1982: 64). Excuses draw our attention to the fact that, for example, the action was performed inadvertently or on the basis of misinformation, or that it was coerced or accidental. ‘I couldn’t help it’, ‘I didn’t know’, ‘I was pushed’, ‘The accelerator jammed’. Resentment is inappropriate here, since the agent’s actions do not signal any lack of goodwill, and the suspension of interpersonal attitudes is also inappropriate, since there is no indication that the agent is unfit for social life. The agent is seen as in general accountable for her actions, but the presence of an excusing condition indicates that the agent did not, on this occasion, do anything deserving of blame.

Exemptions, on the other hand, do invite the suspension of some or all of the reactive attitudes. It is admitted that the agent did do something wrong, but it is suggested that this agent, in particular, is not accountable for it on this occasion. Strawson believes that there are two subgroups to the exemptions. The first points

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to a temporary lack of accountability — e.g. ‘He’s been under a very great strain lately.’ The second suggests a more thoroughgoing lack of accountability. Strawson gives the following examples: ‘He’s only a child’, ‘He’s a hopeless schizophrenic’, ‘His mind has been systematically perverted’, ‘That’s purely compulsive behaviour on his part’. These pleas, Strawson claims, do invite the suspension of our ordinary reactive attitudes. The second subgroup, in particular, invites us to see the agent as ‘psychologically abnormal — or as morally underdeveloped’, as ‘incapacitated for normal human relationships’. He argues that when we see someone in such a light, ‘all our reactive attitudes tend to be profoundly modified’ (1982: 66). It is apparent that Strawson places mental illness in the class of type-2 exemptions rather than excuses and sees the presence of serious mental illness as a reason to suspend or ‘profoundly modify’ our reactive attitudes, rather than to see them as undeserved in just this instance. He argues that ‘the participant attitude, and the personal reactive attitudes in general, tend to give place and, it is judged by the civilized, should give place, to objective attitudes, just in so far as the agent is seen as excluded from ordinary human relationships by deep-rooted psychological abnormality’ (1982: 67).

Strawson believes that holding people responsible for what they do, praising or blaming them, or even excusing them on some occasion for their actions, is something we can only do in so far as we, actually or vicariously, occupy the participant stance with regard to them. Gary Watson (1987: 257) points out that, for Strawson, the reactive attitudes ‘are constitutive of moral responsibility; to regard oneself or another as responsible just is the proneness to react to them in these kinds of ways under certain conditions’. We find a similar position put forward by Christine Korsgaard (1992: 305) in her paper ‘Creating the Kingdom of Ends: Reciprocity and Responsibility in Personal Relations’. There she argues that to hold someone responsible ‘is to adopt an attitude towards him rather than to have a belief about him or about the conditions under which he acts’. It is, effectively, to enter a certain kind of relationship with the other: a relationship of reciprocity. Reciprocity, she claims, involves acting in concert with another, sharing ends and sharing reasons with each other. You will only enter into such a relationship on the expectation that the other will deal with reasons rationally as you would. ‘In this sense’ she argues, ‘reciprocity requires that you hold the other responsible’ (1992: 311). She says:

If my friend fails me in a serious way, and I do not blame her, shrugging it off as I would the misdemeanours of a child or a pet, then I was not holding her responsible after all and probably I was holding myself back. . . . Blame is important . . . as an expression of the tenacity of disappointed respect. At its best it declares to its object a greater faith than she has in herself. Yet it is still not central. The willingness to take a chance on some form of reciprocity is the essence of holding someone responsible. . . . In everyday personal interaction, we cannot get on without the concept of responsibility. (1992: 311 – 12)

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solution rests on a mistake. First, it is not clear that there is the strong conceptual connection claimed by Strawson and Korsgaard between occupying the participant stance with respect to another and attributions of responsible agency. So it is not clear that adopting the participant stance will be unfair to the mentally ill. Second, the participant stance is elastic; it encompasses a wide variety of reciprocal interactions that are commonly adapted to take account of the particular capacities and characteristics of those with whom we engage. It is unlikely that in any but the most extreme cases the participant stance would be wholly unavailable to us.

It seems clear in both Strawson’s and Korsgaard’s accounts that judgments of responsibility made from within the participant stance must presuppose the existence and importance of just those capacities for deliberation, planning, and self-control over time that I earlier described as belonging to autonomous agency. Indeed it is precisely the presence, impairment, or absence of these capacities that Strawson implicitly, and sometimes explicitly, draws upon in distinguishing the varieties of excusing conditions from each other and from those that exempt one from blame and modify or remove resentment. Resentment serves, often, to alert us to the violation of an other-regarding reason. But we may only fairly hold people responsible for such violations if they have both the capacity to recognize the reason and the capacity to conform their conduct to it. Though those capacities are for the most part developed and supported through our relations with others, they are nonetheless conceptually distinct from these relationships. Further, we can make judgments about those capacities and about the degree of responsibility to be borne by the agent without entering, actually or vicariously, into a relationship with them and exposing ourselves to the participant reactive attitudes.

According to what Korsgaard calls the theoretical conception of responsibility, which is the conception familiar in philosophical and legal discussions, a person is responsible for her actions just in case she possesses certain characteristics or capacities essential for responsible agency and is in a condition to exercise those capacities in the circumstances (or to determine the condition she is in). It will be a matter of fact, though perhaps difficult to determine, whether or not the person has those capacities. Korsgaard (1992: 313) believes that this is not the model we adopt in our practical interactions with others. On the practical construal that she favours, she argues that holding someone responsible ‘is adopting an attitude towards her, or, much better, placing yourself in a relationship with her’. On this conception, facts about the agent’s condition at the time of action guide decisions about responsibility but do not determine them. She says:

I do not believe there is a stable relationship between the voluntariness of an action or attitude and the appropriateness of holding someone responsible for it. If a bad action is found to have been involuntary in some straightforward sense we will withdraw blame; we may also do this if a person is under severe emotional stress. But there is neither need nor reason to reduce the second kind of excusing condition to the first and say that people under

high-level, wide-ranging mutual responsiveness as providing a description or a norm for interpersonal relations in general. We are neither forced nor normatively required to move to the objective stance in our dealings with the mentally ill, since not all social interactions must presuppose full autonomous agency and since we can establish or maintain areas of reciprocity with persons whose agency and social responsiveness is underdeveloped, impaired, or intermittent. However, given that it can be difficult to remain in the participant stance without falling prey to misplaced resentment or other harmful reactive attitudes, we might wonder whether anything obliges us to remain, or to try to remain, there, and to pursue engagement when our ordinary expectations of reciprocity and reason sharing are disappointed.

Here I believe that the best argument (though perhaps not the whole argument) is to be found within a Kantian perspective. I’ve argued that a wholesale shift to the objective stance denies the mentally ill person psychological visibility and so further depletes or undermines their picture of themselves and their efficacy as agents. It fails to acknowledge or to support their stake in constructing a unified autonomous self and in regaining authorship of their actions and lives. In moving to the objective stance we deny or ignore the agency of the other. That is what it is to treat someone as ‘an object of social policy . . . to be understood and controlled in the most desirable fashion’ (Strawson 1982: 66). Now, as beings with the goal of autonomy — as beings constitutively concerned with discovering and acting for reasons — Kant believed that persons had intrinsic worth and dignity and as such were never to be used merely as means. To treat a person as an object is clearly to mistreat them. The demand for respect and goodwill in our dealings with each other is, in the first place, the demand that we approach each other from within the participant stance. It is minimally the demand that we do not ignore or undermine each other’s agency. For many latter-day Kantians it is more. They recognize that agency comes in degrees, that autonomy is an achievement, and that respect for autonomy may require our active support for the agency of those in adverse circumstances. Mental illness is such an adverse circumstance. In especially severe cases we may not have any great reason for optimism about the prospects of the ill person regaining control of their lives and achieving the goods conditional upon unified agency; even in less severe cases we may not always be sure to what extent the person’s actions are symptoms of her illness rather than manifestations of her (albeit impaired) agency, and so we may not be sure that our responses are appropriate. But our uncertainty does not counter the moral reason to adopt as far as possible the participant stance and to adapt it in response to the capacities of the ill person. The demand for goodwill from each other is a powerful moral demand and one that mentally ill people are as entitled to make as mentally well people. In the professional context and the broader social context as well as in more personal contexts it is a demand for patience and charity of interpretation of the other’s words and actions particularly as they reflect on the person’s character. It is the demand that we remain receptive to, and promote, opportunities for engagement;