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.