Autonomy, Enactivism, and Mental Disorder

A Philosophical Account

Michelle Maiese

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000609622
• Edition: 1
• Topic: Philosophie
• Subtopic: Esprit et corps en philosophie

This book brings together insights from the enactivist approach in philosophy of mind and existing work on autonomous agency from both philosophy of action and feminist philosophy. It then utilizes this proposed account of autonomous agency to make sense of the impairments in agency that commonly occur in cases of dissociative identity disorder, mood disorders, and psychopathy.

While much of the existing philosophical work on autonomy focuses on threats that come from outside the agent, this book addresses how inner conflict, instability of character, or motivational issues can disrupt agency. In the first half of the book, the author conceptualizes what it means to be self-governing and to exercise autonomous agency. In the second half, she investigates the extent to which agents with various forms of mental disorder are capable of exercising autonomy. In her view, many forms of mental disorder involve disruptions to self-governance, so that agents lack sufficient control over their intentional behavior or are unable to formulate and execute coherent action plans. However, this does not mean that they are utterly incapable of autonomous agency; rather, their ability to exercise this capacity is compromised in important respects. Understanding these agential impairments can help to deepen our understanding of what it means to exercise autonomy, and also devise more effective treatments that restore subjects' agency.

Autonomy, Enactivism, and Mental Disorder will be of interest to researchers and advanced students working in philosophy of mind, philosophy of action, philosophy of psychiatry, and feminist philosophy.

1 Autonomous Agency: Conditions for an Adequate Account

DOI: 10.4324/9781003174103-1

1.1 Introduction

While the term “autonomy” generally connotes self-determination, it has taken on many different meanings in the philosophical literature. One approach, which stems from liberal political philosophy, characterizes autonomy as freedom of the individual to carry on with their affairs provided that this does not interfere with the freedom of others. Such freedom of action requires that individuals be free from coercive interference and have a range of reasonable options from which to choose. This notion of choice autonomy signifies a political, pragmatic approach; within the realm of health care provision, for example, it raises questions about whether it is ever justifiable to subject someone to medical treatment without their consent (Lillehammer, 2012, p. 197). A second approach, obviously related to the first, focuses on what it means to be a self-governing agent, one who can reflect on their beliefs, motivations, and actions, formulate goals, and execute action plans. A self-governing individual who is capable of agent autonomy is a paradigm example of someone who can enter into legally binding contracts, participate in market exchanges, engage in democratic processes, and be held responsible for their actions.

However, the focus of the present project is largely theoretical. In the first half of the book, I aim to conceptualize what it means to be self-governing and exercise autonomous agency. I begin, in the present chapter, by discussing some of the central questions and puzzles widely discussed in the literature on autonomy, and then presenting some conditions for an adequate account. Then, in the latter half of the book, I investigate the extent to which agents suffering from various forms of mental disorder are capable of exercising autonomy. In my view, many forms of mental disorder involve disruptions to self-governance, so that agents lack sufficient control over their intentional behavior or are unable to formulate and execute coherent action plans. However, this does not mean that they are utterly incapable of autonomous agency; rather, their ability to exercise this capacity is disrupted or compromised in distinctive respects. Understanding these disruptions can both help to deepen our understanding of what it means to exercise autonomy, and also pave the way toward more effective, autonomy-restoring treatment methods. To unpack these ideas, I draw upon insights from existing philosophical literature on philosophy of action and autonomy, as well as the enactivist approach in philosophy of mind. Throughout, I operate with the assumption that autonomous agency is diachronic and that it comes in degrees. That is, rather than questioning whether agents are autonomous (where the focus is on personal autonomy) and attempting to provide a clear “yes” or “no” answer, I aim to investigate to extent to which their agency over time is autonomous. During different periods of their lives, all individuals exhibit autonomous agency to greater or lesser degrees. What is notable about mental disorder is that individuals encounter distinctive and recurrent disruptions to agency that make it difficult for them to engage effectively with their surroundings.

Many existing accounts of autonomous agency point to the centrality of self-control and the ability to suppress or modify one’s mental states on the basis of higher order reflection. What Paul Benson (2005) calls “identification accounts” hold that agents act autonomously when they act upon a will that is their own, upon desires that they somehow have endorsed. Such accounts emphasize that what makes a desire or intention truly one’s own is that one identifies with it. According to Harry Frankfurt’s (1988) well-known account, for example, such identification consists in the formation of higher-order desires to the effect that specific first-order desires be effective in action. This emphasis on authenticity, and the notion that autonomous agency flows from the desires of the agent themself, ones that they have embraced, is intuitively very compelling. On the face of it, such accounts do a good job of explaining why instances of addiction or mere impulsive behavior do not qualify as autonomous. However, three central objections that face identification accounts such as Frankfurt’s are the “arbitrariness problem,” the “regress problem,” and the “manipulation problem.” All these worries center around questions concerning what makes acts of identification the agent’s own, rather than being a random whim or an action imposed from the outside. After all, one might identify with certain desires not because they reflect one’s deepest wants, but merely as an expression of adaptive preferences. However, given the extent to which human psychology and action are influenced by social and relational factors, there is a sense in which all preferences are adaptive. Because a human agent is deeply embedded in the surrounding social world, their mental states and actions are very much products of their environment. However, surely this does not mean that all human agency fails to be autonomous. Both from a theoretical and practical standpoint, it is important to clarify just what it means to exhibit authenticity and exercise autonomous agency. Rather than treating autonomous agency as the achievement of individuals, an adequate account needs to acknowledge the important sense in which autonomous agency is fundamentally relational; and it must distinguish between coercive and non-coercive external influences.

In addition, an adequate account of autonomy requires that we examine the sorts of agentic skills that are involved. Traditionally, self-reflection and deliberation have been deemed integral or even necessary for autonomy, and some theorists have failed to acknowledge the important role of other sorts of skills, such as imagination and perspective-taking. While I do not deny the importance of reflection and the endorsement of actions plans, some accounts tend to over-intellectualize autonomous agency and overlook or downplay the important role of bodily experience and emotion. We need an account which emphasizes that for an action to be one’s own, it should be expressive of one’s desires, feelings, or what one cares about, broadly speaking. An adequate account also needs to recognize the way in which autonomous agency involves a responsiveness to changing circumstances, and to acknowledge that this ability to shift course and modify behavior involves a wide range of agentic skills, including but not limited to self-reflection and deliberation. Moreover, an adequate account should acknowledge that autonomous agency is diachronic and unfolds over time, and that it comes in degrees. Because autonomy is not an all-or-nothing affair, determining whether someone’s actions are autonomous requires that we examine the way they unfold and how they relate to other aspects of their psychology and circumstances.

Lastly, and perhaps more controversially, I maintain that an adequate account of autonomous agency should be grounded in naturalistic considerations and engage directly with literature from philosophy of mind. Specifically, I argue that theorizing about autonomy can be enriched by insights from the enactivist approach in philosophy of mind. After all, assumptions about the mind-body relation and the nature of desire, emotion, and cognition shape the way that we think about agency and the nature of human action. In chapter 2, I will argue that the enactivist approach developed by theorists such as Thompson (2007) and Weber and Varela (2002) can provide us with an ontological backdrop and conceptual tools that not only help us to gain an understanding of the workings of autonomous agency and its social-relational dimension, but also allow us to naturalize the concept of autonomy. Enactivist notions of autonomy and adaptive sense-making, in particular, can help us to conceptualize the way in which autonomous agency centrally involves the formation and ongoing modification of habits. Over the course of learning and socialization, human agents become selectively attuned to particular aspects of their surroundings, develop a concerned point of view, and begin to exhibit recurring patterns of engagement and response. Such habits reflect what we care about and allow for us to engage fluidly and meaningfully with our surroundings, often without the need for high-level deliberation or reflection. They develop not in isolation, but rather overlap and become integrated with other habits, so that they form a bundle; and different “bundles of habits” are called upon depending on the specific circumstances and situation.

These organized patterns of behavior and attention can be understood as regional identities that simultaneously allow for both stability and coherence of character, as well as flexibility of response. That is, this dual stability and flexibility enable agents to both (a) form coherent, enduring patterns of behavior and attention, and thereby form an identity or character, and (b) modify the way they engage with their surroundings and other people in response to reasons and evidence. As a result, agents are able to exercise autonomous agency and engage with relevant action-possibilities in their surroundings. In chapter 3, I will propose that these insights from the enactivist approach can be integrated with some of the key insights from the Frankfurt-style, identity-based theory of autonomy, and that the resulting account of autonomous agency meets the conditions of adequacy highlighted in the present chapter.

Then, in chapters 4–6, I examine cases of mental disorder; these are cases in which agents encounter disruptions to autonomous agency, and the stability or flexibility of habit is diminished. Agents with dissociative identity disorder (DID), for example, encounter conflicting regional identities and are unable to form a coherent and stable sense of self. This lack of coherence and stability might be understood as a form of extreme ambivalence that makes it difficult for them to exercise autonomous agency (Maiese, 2016). In depression, agents exhibit diminished plasticity: because they get stuck in particular habits of attention and response, many available action-possibilities seem closed off (Maiese, 2018) and there is a mismatch between what they care about and what they actually do. Lastly, agents with psychopathy exhibit an extremely narrow range of cares or concerns. While ordinary adults have a wide range of regional identities that they fluidly move between over the course of their daily lives, psychopaths are one-dimensional and lack a well-developed character. This one-dimensionality is directly connected to their lack of concern for others and their exclusive focus on their own immediate desires. As a result, agents with psychopathy display impulsivity and are deficient in many of the agentic skills (e.g., imagination and empathy) that are required to exercise autonomy.

In the concluding chapter, I consider some practical implications of my proposed account. My general claim is that while the exercise of autonomous agency is compromised in cases of mental disorder, the general capacity for autonomy does not disappear altogether, and our real-life practices should reflect this. I present some proposals regarding legal accountability and mental health treatment and maintain that one of the central aims of these practices is to cultivate and restore agents’ ability to exercise autonomy.

1.2 Frankfurt’s Identification Account

What it means to exercise autonomous agency has received considerable attention in the philosophical literature. However, my central aim is not to provide a comprehensive review of existing work, but rather to highlight some of the issues that seem to be central to debate, and then develop a new way of approaching them. Autonomy is widely understood in terms of a capacity to guide one’s life from one’s own perspective, and to act in ways that genuinely express one’s point of view. A natural starting point for an account of autonomy is individual self-governance: “self-rule free of controlling interferences by others, and without limitations in the individual that prevent free and informed choice and action” (Beauchamp & Wobber, 2014, p. 118). This general formulation points to two key conditions of autonomy: (1) liberty, or the absence of controlling influences; and (2) agency, or self-initiated intentional action. However, some theorists have emphasized that the satisfaction of these conditions is not yet sufficient for autonomy. Mere causation of bodily movement by a belief or desire that someone repudiates or rejects, for example, does not yield autonomous agency. A person acts autonomously only if they genuinely participate in the operation of their will, as opposed to being estranged from themself or behaving as a passive bystander. Along these lines, identification accounts hold that someone’s actions are their own when they arise from, or are incorporated within, the sphere of what they really care about (Benson, 2005, p. 102). Michael Bratman (1987), for example, holds that persons take ownership of what they do when they identify with associated action-plans; Gerald Dworkin (1988) maintains that autonomy consists in “a second-order capacity of persons to reflect critically upon their first-order preferences, desires, wishes, and so forth and the capacity to accept or attempt to change these in light of higher-order preferences and values” (p. 20); and Frankfurt (1988) famously characterizes autonomous agency in terms of being motivated by psychological attitudes that are somehow authoritatively expressive of one’s psyche.

Here, I focus on the work of Frankfurt to frame the discussion, though many of the concerns I discuss apply to other identification accounts as well. My aim is to examine some of the key objections that have been raised in order to develop some conditions of adequacy for an account of autonomous agency. In my view, the limitations of Frankfurt’s account help to shed light on the central issues that an adequate account of autonomous agency ought to address. The main goal of this chapter is to formulate these conditions of adequacy.

1.2.1 Second-Order Volitions and Identification

To make sense of how an agent takes ownership of their action and will, Frankfurt introduces the notion of second-order volitions and distinguishes between mere desires and effective desires. Some desires, such as idle wishes or preferences, may not be at all likely to play a role in what an agent actually does or tries to do. These are distinct from effective desires, ones that will or would move an agent all the way to action, which Frankfurt characterizes as a person’s will. For example, suppose that I have an effective first-order desire to work on a paper that leads me to go to my computer and begin writing. Frankfurt would say that this is what I have willed, or is my will, on that occasion.

However, this is not the only sort of desire that influences how our lives unfold. Due to our unique capacity for self-reflection, persons like us also are able to form second-order desires with respect to our first-order desires. That is, we are capable not only of wanting (not) to x, but also of wanting to (not) want to x. However, this wanting to have the first-order desire need not entail wanting that the first-...