Morbid Symptoms

"The crisis consists precisely in the fact that the old is dying and the new cannot be born; in this interregnum a great variety of morbid symptoms appear." – Gramsci

On Being One’s Own Father

Whenever I hear the term ‘paternalism’, it strikes me how bad a metaphor it has become for describing the mechanics of authority. Does the figure of the father — individual, domestic, affect-swollen — provide the right frame for thinking about the increasingly diffuse and bureaucratic vectors of power that political, economic, pedagogic or psychiatric actors use? On the whole: no (as I have written about before).

If the prospects of paternalism as an analytical tool are rather dim, then it’s chances as a normative ideal are, of course, even worse. For instance, Corey Robin has recently underlined the way that appeals to fatherly authority act as unifying force in conservative politics:

[C]onservatism is a defense of “the private life of power,” those hierarchies in spheres like the family and the workplace that we often call private. [...] People often wonder how libertarian-ish free market types can come together with cultural and religious conservatives in the GOP. [T]he answer: Both groups value the power of fathers—in the family, and in the workplace.

Nor does it seem too crass to note the association between the valorisation of paternal forms of authority and proto-fascist sympathies. In short: it’s hard to imagine someone telling me that they thought fatherhood was a good way to think about how authority should be used and not immediately thinking they were some kind of reactionary idiot.

Despite these analytical and normative limitations, I wonder whether paternalism can be put to some sort of use in thinking about techniques for legitimating authority in psychiatry and social care. Again, I am usually wary of the concept even in this context, since it’s so ill-fitting in care relationships. When the paradigm form of medical care was the male doctor, practicing alone in a community where he commanded great respect and had cultivated social relationships with most of his patients, then the paternal metaphor seems more apt. But when care is now so often ‘delivered’ by multidisciplinary teams, directed by institutional bureaucracies, which are bound by more aggressive forms of central oversight and control, in the context of huge resource allocation pressures and a tendency toward defensive medicine, then the relationship between father and child looks to be much less illuminating. All metaphors give out somewhere along the line, of course. In this case, however, given how common it is to hear the language of ‘paternalism’ (almost always wielded as a criticism), the mismatch between it and the phenomena described is problematic. We need new metaphors — not least, to stop thinking about authority in care settings getting stale.

This being said, I want to see whether paternalism can be put to work, albeit in an admittedly weird way. Paternalism is an analogical concept: it maps a relation father-to-child onto another relationship, e.g. government-to-citizen, psychiatrist-to-patient, teacher-to-pupil. The relation I want to examine under the concept of paternalism is unusual in that the same person occupies both places. In other words, what if the father-to-child relation is mapped onto a relation of a person-to-themselves? Can you be paternalistic towards yourself?

In its bare-bones form, paternalism is interference with a person’s liberty intended to promote their own good. This meshes with the idealisation of fatherhood as a relation to a child of superior knowledge and power alongside benevolent intentions. This father wants what is best for the child, usually knows what that is better than the child does, and is able to bring it about by imposing his will. Thinking about my proposal, what then would it even mean for you to know what is good for you better than you do yourself? How can your impose your will on yourself? These can seem like contradictions in terms. Thus, paternalism towards oneself threatens to be nonsensical.

There are activities in psychiatry and social care that exemplify this structure, however. For example, making what is called an ‘advance decision’, in which a person who currently has legal capacity to decide for themselves makes a binding judgement about what should happen to them should they be found to lack decision-making capacity. For instance, this person might want to refuse certain medical treatments in advance before their dementia makes it legally and practically difficult to object.

This is possible because you both are and are not the person you once were. In other words, people are temporally extended without being static. In an advance decision, someone takes themselves to be better placed with respect to knowledge, power and self-concern now than they will be in the future.  This might even involve restricting the liberty of their future self in what a person deems to be their own best interest. For example, if the future self lacks mental capacity and wants treatment that the care team would have otherwise given them if not for the advance decision, then current liberty is restricted on the basis of benevolent self-directed intentions. In an immediate sense, the person’s liberty is being restricted by the care team; but the care team are acting as agents of the former self. In this way, the self binds itself in what it takes to be its own best interests.

This structure is also found in some collaborative emergency care plans in psychiatry (where advance decisions are typically not valid). These involve the person themselves in planning the response ahead of time when it’s likely that someone is going to end up ‘losing the plot’  — for instance, before the manic phase of bipolar disorders kicks in. Again, people are being invited to think about how to restrict their future liberty for their own good. (George Szmukler and colleagues have written more about the use of these ‘joint crisis plans’.) Yet another example might be residential care homes for people with Prader-Willi syndrome, which I discuss in this post.

One way to think about what is going on here is to rely on the paternalism metaphor. People are being asked to adopt a similar perspective with respect to themselves as parents often do towards their children. How do you help someone’s life along, or make sure it doesn’t end in disaster, without smothering them with your parochial hangups? In our case, the exercise of power is to be legitimated or at least mitigated in light of a superior knowledge and self-concern that can be made effective through institutional power. The assumption would be that you know yourself and what is in your own good better than anyone else and better than your ill or otherwise incapacitous self. Plus, it supposes that you actually want to bring it about.  Both are contestable, of course, but are prima facie plausible.

If you were your own parent, how would you construct the regime of power in which you are to live? Do you give yourself maximum scope to go your own way, risk making mistakes, and live in the moment, or do you make sure that someone you trust has a firm hand on the tiller, even if that means they sometimes force you to do things you don’t want to? The task is a little like trying to plot your own Bildungsroman, only in reverse — a kind of Verbildungsroman, or story of deformation. Given that parts of your self are going to slip away, either temporarily or permanently, the task is to shape the trajectory of that decline when you seem best able to do so. How to accomplish this isn’t clear: there’s likely to be conflicting impulses to junk as much authority as possible and to micromanage your future in a way that allows no scope for development or changes of mind. At least one approach to this task is to ask what would someone do who cared about you in the way that parents typically care about their children. This might provide some useful initial cognitive traction on the problem. I’m still far from sure this is the best way to think about these ‘Ulysses contract’ structures;  but the concept of paternalism may be more fitting here than in its more familiar uses.

Decision Ecologies

Radical disability organisations have attacked pervasive assumptions about the legitimacy of challenging the legal status of people with significant developmental and mental health issues. One of their main legal victories has been in shaping the drafting and subsequent interpretation of the UN Convention on the Rights of Persons with Disabilities, particularly Article 12, which requires that “persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life”. On more radical construals, this puts the Convention in conflict with much existing law based around mental disorder and mental capacity. In this post, I want to sound a note of caution and make a qualified defence of some aspects of this law — or, at least, offer a way of thinking about it that may go some way to accomodating the intutions driving these radical critics.

Mental health law in England and Wales falls under two main pieces of legislation: the Mental Health Act and the Mental Capacity Act. The Mental Health Act can be used to detain people against their will if they have a mental disorder that adversely effects their health or safety, or the safety of others, when administering treament requires such detention. But here I want to focus on the Mental Capacity Act, which is used to make decisions on behalf of people who have ‘an impairment of, or a disturbance in the functioning of, the mind or brain’ that leaves them without the ability to make the decision themselves. The criteria that the Act specifies for incapacity are inabilities to understand, retain, and use or weigh relevant information, or to communicate a decision.

Proponents of radical disability approaches have claimed that insofar as this makes legal rights to make decisions for oneself conditional upon a test that excludes some persons with disabilities from having their decisions accorded equal status under the law with others, then such legislation must be jettisoned. In Bach and Kerzner’s words: “mental capacity can no longer serve as a proxy for legal capacity.” When someone with a mental disorder or developmental disability has an identifiable will or set of preferences, then these critics maintain that proxy decision-making, such as acting in their stead in line with their legally-adjudicated ‘best interests’,  cannot be countenanced. At most, other people are called upon to help articulate the person’s will. In more abstruse philosophical vocabulary, I tend to think of this as a ‘socially-facilitated voluntarism’.

Can legal and care systems based around mental capacity assessment adequately respond to these pressures? This is a genuinely open question for me; but I shall suggest that to some extent they might insofar as they construe mental capacity in ecological terms. This is an attempt to understand mental capacity in a way that goes beyond the dichotomy between a medical model of individual cognitive deficits and a social model centred on obstacles to exercising rights that arise from societal conditions. The aim is to integrate these perspectives, such that individual impairment and social impediments, as well as the complex relationship between the two, are taken into account in capacity assessment. Indeed, sociality is only one of the salient dimensions of the environment within which the functional capacities involved in decision-making are exercised, which also includes the physical environment.

In using the concept of ‘ecology’ in this way, I am building on attempts by the psychologist Gerd Gigerenzer to develop an ecological conception of rationality. Quoting Herbert Simon, Gigerenzer says:

“Human rational behavior is shaped by a scissors whose two blades are the structure of task environments and the computational capabilities of the actor”. Just as one cannot understand how scissors cut by looking only at one blade, one will not understand human behavior by studying either cognition or the environment alone.

This is part of his wider project to develop an understanding of the kinds of ‘bounded rationality’, and particularly uses of heuristics, which are deployed when solving problems under constraints of time and limited mental resources. But the basic idea which I want to adopt from Gigerenzer’s work is simply that assessing aspects of our mental functioning, such as whether there is an impairment or disturbance of functioning in mind or brain that impedes decision-making, is a matter of relating a narrow kind of individual psychology with aspects of environments it bears upon.

In some ways, a recognition of the ecological dimension of mental capacity—the fact that decision-making abilities depend upon an environment within which they are formed, exercised and assessed in relation to—is already implicit in some of the provisions of the MCA. For example, the Act requires decision-specificity, which ties capacity assessment to specific decisions (or classes of decision) and the conditions which hold at the ‘material time’ that decisions are made. So too, the Act requires that assessment only take place when someone has been provided necessary assistance to support their decision-making capacity. Nonetheless, this dimension of mental capacity assessment should be made more explicit and its potentially revisionary consequences ought to be emphasised.

In spelling this out, I will cover two aspects of what you might call the ‘decision ecology’: first, the physical environment in which decisions are made; and second, the social environment – particularly how we might think about the role of others in supporting decision-making. On a weaker interpretation of the ecological elements of capacity, aspects of the decision-making environment can be said to provide important instrumental supports for decision-making. But we could also understand these ecological elements in a stronger and more metaphysically significant fashion, such that mental capacity is not simply localised in the mind or brain but distributed over the environment.

Let’s start with the physical environment, and particularly the importance of place, which is often a relatively neglected influence on mental capacity. Thinking about where decisions are made, and what material tools are available to help make them, is one way of shifting the focus away from deficits in individual cognitive or evaluative abilities and towards a more synoptic account of decision-making capability. For instance, consider someone who becomes so anxious and confused whenever they are taken from their home and into a hospital that they can no longer retain relevant information that would enable them to make decisions. There is a sense in which this is an individual impairment – after all, other people may be able to cope with non-domestic settings with relative ease, and show no deterioration in their ability to remember or use relevant information. But it only becomes a problem – a genuine deficit – in certain environments; and this can suggest that the proper unit of assessment when thinking about mental capacity is not the mind or brain as ordinarily understood, but a composite of the individual and their environment.

You might approach this thought in a slightly different way instead. The philosophers Andy Clark and David Chalmers have argued that the mind can extend to our physical surroundings, that it is not confined to an individual’s brain. They contrast two people walking through New York to the Museum of Modern Art to meet a friend: Inga relies on her memory, whereas Otto, who has dementia, sometimes consults a notepad with directions when he forgets which turning to take. Clark and Chalmers argue that insofar as the notepad plays the same causal and functional role for Otto as aspects of Inga’s memory do for her, then Otto’s mind extends to the notepad. Similarly, it seems open to us to say that, were Otto’s ability to make decisions about medication or what to do with his money dependent on other physical features of physical his environment — say, the quiet, familiar surroundings of his home, where he has a set routine in place, which frees up some of his scarce mental resources for when he really needs them — then we might start to think that this environment is part of what constitutes his mental capacity, insofar as he cannot make competent decisions anywhere else. This implies that a mental capacity assessment which ignores the setting – which takes Otto alone to be the object of assessment, irrespective of whether he is on a ward, visiting friends, or back at home – could be highly misleading.

Of course, it is not only the material environment that is important for shaping decision-making capacity but also social relationships which people stand in with friends, families, carers and other professionals, as well as prevailing social attitudes in general. Often, it is worries about forms of undue influence that get raised in this respect, particularly in the context of intellectual disability, where the courts have denied aspects of someone’s mental capacity on the basis of the effect of overbearing mothers or abusive partners. But there is now increasing discussion of the role of others in supporting people’s functioning and their decision-making capacity in particular. Again, you might interpret this in weaker or stronger ways. Leslie Francis and Anita Silvers have proposed that we think about this in terms of decision-making trustees who function as a prosthesis for persons with cognitive disabilities. They say, just

as a prosthetic arm or leg executes some of the functions of a missing fleshly one without being confused with or supplanting the usual fleshly limb, so, we propose, a trustee’s reasoning and communicating can execute part or all of a subject’s own thinking processes without substituting the trustee’s own idea as if it were the subject’s own.

The prosthesis model is helpful insofar as suggests how others can generate independence rather than simply take it away; someone can be dependent on their prosthesis for doing certain tasks, but simultaneously, by using this prosthesis, they can be made more independent overall.

However, I am not sure that this prosthetic model is ultimately the best way to think about the relation between people and their social supports. That is because it instrumentalises these relationships, and ends up effacing the person in the supporting or caring role. To put it bluntly, unlike a fibre glass leg, friends and carers talk back! So, it is not so much that people who function as social supports for decision-making are tools or prosthetics that are “operated by the subject” (to use Francis and Silvers’ formulation); rather, they are agents in their own right, but around whose capabilities and actions another person’s decision-ecology can be structured. Their role in this environment might have either a benign or a corrosive impact on it; but, at least some of the time, it will make sense to say that their presence will be constitutive of decision-making capacity, and so will be part of the proper object of mental capacity assessment.

Finally, I want to say something about why it might be helpful to go about capacity assessment with this ecological framework in mind. Firstly, it provides a way of undertaking and communicating the results of capacity assessment in a way that could help to ameliorate the problems of what Winick calls ‘law-related psychological dysfunction’ — the deleterious effects that legal classification as incompetent can have on people’s self-conception and motivation. From an ecological perspective, we no longer have to think of individual persons as the sole objects of mental capacity assessment, but simply as being the locus or most important node in a wider decision-making apparatus. Thus, at least in theory, the problem is less whether you qua isolated individual meet a narrowly psychological set of decision-making criteria or are found to be incompetent; but is, instead, whether the right match between person and setting can be found. The hope is that this will be de-stigmatising and less damaging with respect the way people think of themselves, because incompetence is no longer a matter of individual functional deficit alone. Perhaps, in the end, these sorts of distinction will be cold comfort to people, especially when no changes in their environment are likely to significantly improve decision-making abilities; but it does at least drive home the message that practitioners must exhaust all the different kinds of material and social supports before a finding of incapacity can be made.

Relatedly, an ecological persepctive also attempts to preserve some of the key insights of the so-called ‘social model of disability’, such as that disability is not an asocial but a relational challenge and that both society and our physical environments need to be adapted in order to facilitate decision-making; but it does so within a framework that can accommodate proxy decision-making in those cases when someone does have a clear will and intention which nevertheless seems compromised, such as with medication-induced psychosis or a manic phase of bipolar affective disorder. Whilst it is unlikely to satisfy the most radical critics, thinking about capacity in ecological terms does, I hope, provide a way of foregrounding some of the progressive elements of the current system.

Freedom and Feeding

Food is the focus of numerous psychopathologies — the most familiar being anorexia nervosa (involving a fixation on caloric restriction and bodily control) and bulimia (characterised by binging and purging). Less well-known is the extreme impairment of the satiety response that is found in persons with Prader-Willi syndrome. In this post, I want to consider what Prader-Willi might reveal about freedom in the context of psychopathology, particularly in relation to treatment and care regimes that can be coercive.

Prader-Willi syndrome (henceforth ‘PWS’) is a rare genetic disorder which manifests in around one in twenty-thousand people. It results from the non-expression of genes on chromosome 15, with effects that begin in utero. Babies born with PWS tend to be hypotonic or ‘floppy’ with a poor suck response that necessitates them being tube fed. At this early stage, there is little to no interest in feeding, and parents’ attention and hopes are aimed at ensuring their children eat. Typically within two years, appetite increases and weight is gained to well-above average levels.

Adults with PWS usually (but not invariably) experience significant intellectual disabilities; and emotional difficulties, infertility and suceptibility to diabetes are common. However, I shall focus on appetite here. Despite some variation, people with PWS ordinarily experience excessive and virtually unquenchable appetite that, left unchecked, can lead to life-threatening obesity. For instance, anecdotally, one man who left the controlled environment of residential care died from weight-related complications within 8 months — this being an all-too-common tragedy. Research suggests that the core problem is inhibition of satiety rather than hunger per se. Appetite is barely dented by calorie intake; it becomes literally insatiable.

Prader-Willi is exceptionally difficult to manage in the home, with constant battles over access to food and drink, exerting a huge strain on all involved. Locking consumables away in cupboards is often not enough — persons with PWS have been known to eat cardboard and even soap. Shoplifting is another common problem, and the Erysichthian ache for ever-more food can also leave people open to exploitation and abuse. Specialist residential centres are available for some people who can secure local authority funding, and they represent another route for managing people’s PWS. Meals are strictly regulated, access to food and money heavily policed, and for some residents, outside travel to work placements and recreational activities is supervised by a member of staff in order to prevent binging.

To some, this might seem outrageously paternalistic — an infringement of the basic rights to liberty which adults without disabilities can use or abuse as they see fit. People make all sorts of ‘dumb choices': drinking and smoking themselves to death, throwing away their lives in fucked-up relationships or tumbling into decade-spanning numbed-out hazes of Xbox and weed smoke. Thus, what possible justification could there be for such heavy-handedness in relation to people with PWS?

My understanding of PWS is cursory and second-hand, so I hesitate to make firm judgements about the condition, let alone the lives of people with the syndrome. However, I think that concentrating on structural features of PWS and attendant care settings can be useful in thinking about potential justifications of coercion. This is because PWS illustrates the relation between some different aspects of human freedom in a particularly perspicuous fashion.

To return to our question, is there a reason why coercive measures, like locking away food and restricting access to money, might be legitimate in some situations encountered by people with PWS? One defence could be prior consent. I’ve only spoken to one staff member in a PWS residence, so it’s not clear whether this is standard practice, but where she works, residents sign a contract upon entering, agreeing to certain rules by which the institution operates. Since there has been consensus beforehand, then agreed-upon restrictions on liberty can look to be self-authorised. But given pressure from families and the cognitive and emotional difficulties people with PWS often face, it’s not clear how meaningful any complex future-oriented consent can be in many instances. In this respect, the coercion of persons with PWS in relation to access to food would be different from Odysseus’s efforts to hear the song of the Sirens without harm by commanding his soldiers to tie him to the ship’s mast and ignore his pleas to be unbound. Crudely, the ruggedly independent Odysseus, who hatches the plan himself, seems better placed to know and be accountable for what he is getting in for.

Furthermore, appeals to tacit consent for coercive care regimes look not to be compelling justifications either. For example, and again anecdotally, the Mental Capacity Act has been used as a lever to persuade people considered seriously ‘at risk’ to stay in residential care — them being told that, if they try to leave permanently, they will likely be found to lack decision-making capacity in relation to their living arrangements and that a best interest decision will be made for them. Thus, even when there is prior or tacit consent, it looks to be vitiated in the circumstances under which it would typically be given.

Antiseptic expressions such as ‘restricting a person’s liberty’ can obscure a fraught reality of arguments, resentment, misery and violence. Coercion is no small thing. Yet, PWS engenders situations in which untrammelled individual liberty destroys rather than sustains autonomy. Thus, I think the idea that coercion of some people with PWS in relation to access to food and money can sometimes be justified — even in the absence of prior or tacit consent — is one we should take seriously.

My freedom can potentially be deepened by preventing me from acting on my most intense, enduring and visceral desires. This thought tends to strike people either as soporifically obvious, highly paradoxical, or both. How you respond is likely to be determined by the conceptual framework you bring to the concept of freedom. If negative liberty — freedom from interference and impediment — is foremost in mind, then the thought may appear incoherent. It looks to be similarly implausible if self-governance consists in being recognised to be a self-sufficient agent whose actions should never be directed by others. Even on certain conceptions of freedom as authenticity, then given sufficiently insistent and recurrent desires, being stopped from pursuing them will only diminish freedom. But we ought to reject these understandings of freedom; or rather, the most fruitful way to approach freedom is to subsume these aspects into a more comprehensive structure, such that they are not necessarily decisive factors.

Self-determination requires social scaffolding. Typically, this involves others deferring to someone’s present wishes or giving them a hand in realising them; but at times it is these wishes themselves that warp a person’s psyche, leaving them unable to think, feel or act other than in a deadeningly fixed fashion. When agency is highjacked, becoming unresponsive to reason, its environment and other affects, then freedom and free rein no longer coincide.

PWS looks to be a paradigm case of agency being overridden: without the structure and resistance provided by appropriate institutions, then people are consumed by their appetite to consume. When wracked by an insatiable hunger, which returns with a similar ferocity shortly after eating, then being left to the Sisyphean labour of adhering to it — physically and mentally enervating oneself in the process — amounts to no freedom worth having. Indeed, it is being abandoned to another kind of slavery.

Freedom of whatever kind need not possess lexical priority, and the torrent of pain and frustration involved in battles over food may prove so great that it becomes the decisive factor in determining what to do. Yet, the best that can be said for others stepping back in such situations is that it would offer someone momentary satisfactions and spare them the exhausting and fractious wrangling over access to food. However, the relative success of residential support for people with PWS suggests that this would be the exception rather than the rule. In a controlled environment, where people know that no amount of arguing or emotional pressure will get them extra food, then stress and anguish is partly lessened anyway. Moreover, ‘empowerment’ (another of those sterile words) becomes a tangible reality: the power to act is massively inreased, whether that is a capability to do things one enjoys (because the distractions of food are less present), to work (because a carer stops one being waylaid on the journey), or to visit places (because ill-health does not get in the way of travel). Despite the vexations of the additional constraints involved, such an existence looks to be more autonomous than one without them: self-direction is secured more comprehensively through being subject to extraordinary limits in some specific areas.

It is difficult to draw general conclusions, not least because people with PWS live very different lives. However, I think we should be sensitive to a few basic points: (i) desires can corrode agency as well as express it; (ii) freedom is multifaceted, extending beyond negative liberty and including functioning agency and real capabilities to act; (iii) self-determination relies on scaffolding that can enjoin others to step in as well as step back; and (iv) it is possible to augment autonomy by curbing liberty. The orectic structures fostered by PWS help to exemplify all this, suggesting that there are strong grounds for limited coercive intervention in at least some lives dominated by PWS. Counterveiling considerations soon crowd in, of course, such as demands for normalisation of people with disabilities, equality of respect for persons, and a historically informed revulsion for any psychiatric-led coercion. Thus, no decisive justification emerges and H.L. Mencken’s maxim holds: “For every subtle and complicated question, there is a perfectly simple and straightforward answer, which is wrong.” Yet, the overarching thought here — that institutions can provide structures in which to realise freedom even (or sometime especially) if they close down untrammeled choice — is one which should be more often borne in mind.

More information on Prader-Willi syndrome

The best book on the subject which I have come across is Prader-Willi Syndrome: Development and Manifestations by Joyce Whittington and Tony Holland. Another good introduction is Can’t Stop Eating — a documentary I remember seeing years ago and which is now available on YouTube.

Reassembling Autonomy

Hegel claims that the path of philosophy is not the “common way a man can take in his dressing-gown.” Instead, “[t]rue thoughts and scientific insight can only be won by the labour of the concept [Arbeit des Begriffes].” Concepts, so characterised, are both material and tools: philosophy brings concepts to bear on concepts, tracing their logical structure, interconnections and development. Thus, philosophy can be depicted as conceptual labour. But concepts themselves can also be understood as a kind of labourer [Arbeiter]. Like other workers, concepts do not come ready-made — they must be reproduced and sustained within a suitable environment, and they are only likely to thrive when they stand in fruitful relationships with others in their community. So too, as with other workers, they can become overworked and enervated as a result of the jobs they perform, as well as diseased from noxious working conditions or pestilent co-workers.

Autonomy is in danger of becoming such a fatigued and sickly concept. For one, it is required to do work of Stakhanovite proportions. Even when restricted to personal autonomy, the term has countless meanings — everything from liberty, moral responsibility, self-legislation, non-fungibility, reasons-responsiveness and mental capacity, to name only a handful. This semantic plasticity means that virtually any action, thought, person or social formation can be lauded as autonomous or condemned as heteronomous, thereby making precise analysis very difficult without a continual revalidation or recalibration of the meaning of terms. Like a precarious worker at a temp agency, the concept of autonomy finds itself deployed in all sorts of heterogeneous settings, with little ability to shape the jobs it is tasked with performing, and the expectation that it will not bring any potentially disruptive history or politics with it from its previous workplaces. Indeed, autonomy as an ideal is so frictionless that whatever your cause — radical social justice or tax cuts; national liberation struggles or imperialist military intervention; survivors of psychiatry and disability movements or conservative social policy — then some autonomist justification can be confected for it. But if your rallying cry strikes fear in no-one’s hearts, then it’s worse than useless.

The deeper problem, however, is not merely formal — that autonomy can be co-opted by almost anyone — but that it has been co-opted by some pernicious political and philosophical forces. In short, autonomy’s neighbourhood has been gentrified and most of its friends are complacent liberals. Mired in talk of abstract rights, authenticity, choice and decision-making, it is hard to locate any genuine critical or elucidatory potentiality in the concept. If anything, its predominant philosophical deployments now do little more than reinforce a narcissistic form of individualism. You need only look to the soporific preoccupations of its champions: the merits of ‘life-planning'; how lowly drug addicts are; oppressive communalist tendencies within Islam; the opprobrium that lack of restraint at the dinner table deserves; and so on. Telegraph-fodder, basically.

What then is to be done? The concept of autonomy, or merely the term ‘autonomy’, could simply be abandoned. Similar temptations arise with notions like democracy that have been subject to conceptual capture by forces of reaction, despite the latent radicalism and unadorned beauty of the idea. Autonomy might be jettisoned for being equally tainted and functioning as a dampener rather than a catalyst of thought. But that would be to relinquish important logical and linguistic territory. Losing battles over contested concepts such as freedom is part of the reason why, for instance, markets that immiserate millions of people in underdeveloped economies can so seamlessly acquire honorifics like ‘free'; at the very least, this ground ought not simply be ceded without a fight. Moreover, concern for autonomy already saturates philosophy, medicine, psychiatry, social care, law and political economy, and so can be seen a beachhead as much as a quagmire. In sum, the concept of autonomy ought be revitalised rather than repudiated.

First, and negatively, the elements of authenticity and decision-making capacity that loom so large in its contemporary usage should be offset. The tacit metaethics underlying this usage is one which invariably crowns individual desires and choices as sovereign, such that autonomy becomes a psychological capacity to enact plans for preference-maximisation — which is, in turn, understood as the only thing we could ever have a reason to do. Whilst the struggle for human autonomy should ultimately be oriented by the prospect of achieving a non-alienated affective and volitional relationship to ourselves, establishing this as the primary criterion of autonomy feeds a myopic and conceited individualism which suppresses the possibility that freedom requires a radical change or reassembly of our present self. Autonomy can be neither an affable psychological equilibrium nor cod-existentialist anomic willing nor the pop-therapeutic idiocy of a quest for our ‘real selves’.

Second, and more positively, the concept of autonomy needs to be yoked to more apposite kinds of human independence than those that currently trouble most philosophers, lawyers and psychologists. For Kant, it was ossified institutions like those of traditional religious life which impeded the kind of self-determination that the public use of reason can win for us. Lacking the courage to use one’s own understanding meant relying on a ‘private’ use of reason: one bounded by the parochial assumptions of such an institution. However, in reanimating a concern with the place of the free, rational individual within contemporary social formations, we must look to other structural forces. Most obviously for anyone on the left today, there has to be a recognition of those threats to self-determination that come from outside of the comfortable circle of bourgeois consensus: tyrannous concentrations of capital and the neo-liberal states that are subjugated by them, which together dominate the economic and social landscape; limpened forms of political governance, compounded by structurally typhlotic news media, which are incapable of drawing out and enacting the popular will and interests; and the assault upon the welfare state, including education and basic welfare payments alongside psychiatric, medical and social care provision that foster the capabilities and opportunities that individual self-determination depends upon. Clearly, these are first and foremost political harms, which you do not need a philosophical analysis of autonomy to identify. Yet, these threats should orient a conception of autonomy, which ultimately may be able to sharpen an understanding of what would, concretely, be needed for free human agency to be realised. If the concept of autonomy is rehabilitated in this fashion, then it may once again return to the most useful kind of work.

Paternalism and Anti-Authoritarian Authority

Liberals despise paternalism like nature abhors a vacuum. But despite being lodged in the collective political imaginary, the metaphor of paternal authority is increasingly anachronistic and obfuscatory. In the seventeenth century, Robert Filmer’s identification of patriarchal and political power at least captured the reactionary ideological attractions of a political system notionally founded upon the individual sovereign authority of a monarch. Yet, as a concept of contemporary social analysis and criticism, it’s almost kitsch.

Capitalism’s deterritorialising tendencies — its militant indifference to traditional social structures when they are no longer exploitable for its ends, such that “All that is solid melts into air, all that is holy is profaned” — have catalysed the decline of the father who is sole breadwinner, public face and locus of power over his household. In other words, even paternalism in the family is no longer what it once was. Similarly, at the explicitly political level, economic and institutional globalisation has continued to corrode the power of human agency in general, let alone that invested in any single imperial figure who could act as a ‘Father of the Nation’. Thus, sentimental familialism hardly seems the best framework to understand the present production, structuration and legitimation of power.

Effusive criticisms of paternalism are not simply irrelevant, though. However inapt the vocabulary, the terrain upon which denunciations of paternalism take place is of paramount importance. At our latest Autonomy Project conference yesterday, Mark Fisher stressed the need for the left to think through an anti-authoritarian conception of authority. In this, I think he is absolutely correct; it’s the unconscious equation of authority with authoritarianism common to both anarchism and neo-liberalism which a modernist left-wing form of politics ought to contest.

We need to develop an alternative to both anarchism’s prefigurative politics and neo-liberalism’s institution of a sovereignty of desire. The former is gripped with a squeamishness about even democratic authority, and which coalesces around a paralysing obsession with anti-kyriarchicalism. Organisational mechanisms like consensus decision-making are lauded, but these are (at least, in my experience) liable to be a vehicle for those with the most social capital, bolstered by the very racial, gendered and (particularly) class privilege that they are nominally opposing. Adam Curtis’ recent oneiric documentaries — for all their other flaws — seemed to get this much right: it is no advance to replace formal democratic power with charismatic power which both produces and feeds on ressentiment.

It’d be disingenuous to draw a false equivalence between neo-liberalism and anarchism in their relationship to authority, but there are some convergences. Both are typically unduly suspicious of collective power that is irreducible to individualistic consent. Furthermore, I think that each fails to appreciate the extent to which public friction — blocks on what the individual chooses —  can be productive, and not simply destructive, of freedom and agency. Mark has previously put the point well in relation to neo-liberalism:

Neoliberal “choice” traps you in yourself, allowing you to select amongst minimally different versions of what you have already chosen; paternalism wagers on a different “you”, a you that does not yet exist.

In neo-liberal rhetoric, it is never countenanced that you might not know your own interests or be psychologically inhibited from pursuing them. Desires are sovereign, and any attempt to reshape these desires is  foreclosed — at least, outside of the pre-approved nexus of advertising, self-help and socialisation-porn TV, and the hectoring of an insufficiently ‘aspirational’  working class. To do so would be unduly paternalistic and ‘elitist’ — who are you to tell me what to want? Indeed, the tacit metaphysics of value here threatens to make the very idea of questioning the propriety of a desire not only arrogant but unintelligible. Thus, disastrously, the only legitimate authority is confined within libidinal circuits of the self.

What then is the alternative? Mark has proposed the formulation ‘democratic paternalism’ to name the end for which we should aim. He has been the first to recognise that the vocabulary is not entirely appropriate here, insofar as it symptomatically echoes the moribund form of paternalism which we need to reconfigure. I think the thought is still sound though, namely that we should embrace institutions and practices that can shape and socialise people in progressive ways, yet which are not themselves directed by a Leninist cadre but by the demos as a whole. Dan Hind’s proposals for public commissioning of media is one fruitful model Mark has pointed to. Not only would this avoid the current full-spectrum dominance of the patronising ‘unpopular populism’ of trash TV and endless bloviated newspaper columns, but giving us power is also likely to edify our preferences — if we are choosing what media content is produced then it harder to disavow our consumption of effluent. In my research on mental disorder and autonomy, I’ve been trying to develop similar models with some my Autonomy Project colleagues: if institutions need to make decisions on people’s behalf due to their mental incapacity, then the conditions for a finding of incapacity need to be entirely transparent, contestable and accountable to the populations whose liberty is most at risk as well as wider society.

In sum, we ought to reassemble authority outside of its traditional paternalistic form and within functional institutions — thereby circumscribing the potential for its abuse — rather than abandoning this terrain to impersonal forces or agents with no such scruples. This will require much conceptual and moreover practical work, but it is better than trusting the magical intervention of markets or spontaneous self-organisation.

Morbid Symptoms

“All beginnings are involuntary.”
— Fernando Pessoa, O Conde D. Henrique

I plan to write here about philosophy, politics and psychiatry — especially their intersections.

You may have come across my previous blog, Grundlegung, which I used when I was a graduate student in philosophy working on autonomy and normativity. Currently, I’m part of the Essex Autonomy Project, an interdisciplinary project on self-determination, which has increasingly focused on mental capacity and mental health law. Whilst my doctoral research was pitched at a relatively abstract or even metaetheoretical level, much of my EAP work has been intensely practical: sifting through law reports, social history, policy documents, talking to social workers and psychiatrists, and so on. One of the effects of this has been to catalyse my interest in mental disorder, particularly its social etiology and relation to the emotional and evaluative structures engendered by capitalism. I’m also beginning to learn how to weaponize philosophy more effectively — figuring out how to write about social and political topics with philosophical tools, yet avoiding the intellectual wasteland that most often passes for ‘applied philosophy’. A new blog seems like the best place to do more of this.

These are febrile times, in every sense, yet it’s ever-harder to cognise them. The most vital and effective writing from the radical left at the moment is that which is anatomising the political, economic and psychological architecture of society — in the fashion of Eva Illouz, Nina Power or Mark Fisher. At any rate, it is this kind of work that I cannot stop reading. What I hope to do on the blog is to find a way to start writing it.

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