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  • Autonomy, Well-Being, Disease, and Disability
  • Julian Savulescu (bio)

autonomy, well-being, mental disorder, psychiatric disease, disability, welfare, body integrity identity disorder

Varelius seeks to redefine what constitutes mental disorder or mental illness. (I use these terms interchangeably.) "According to this account, 'a person is mentally disordered when her psychological capacity for autonomy is diminished as compared with that of a typical member of our species of her age-group" (Varelius 2009). This is a stimulating and important paper. Varelius describes fruitfully the relationship between mental illness and autonomy, specifically the ways in which mental disorder can undermine autonomy. This is valuable in understanding the impact of mental illness on the lives of people who suffer from it, which is a serious issue in practical ethics. But is it what constitutes mental disorder or illness? There are logical, conceptual reasons why we should not redefine mental illness in this way.

Incomplete Account of Mental Disorder

There are a family of related concepts: disease, injury, disorder, illness, disability. There are old and entrenched disputes about how we should define these concepts. Varelius' paper is a contribution to the definition of mental disorder and illness.

The primary classificatory category that defines medical practice is that of health and disease. Disease, broadly construed, involves the presence of pathology. Pathology can result from processes primarily or predominantly internal to the organism, such as genetic disease (although external factors affect their expression), or from processes primarily or predominantly external to the organism, such as injuries.

The concepts of disorder and illness relate to the concept of disease. Disorder could be defined in terms of the functional effect of pathology. Illness could be defined in terms of the experiential impact of disease.1 How these terms are precisely defined and related need not concern us at the present. What matters is that the primary category is disease.

Psychiatry has evolved in its use of terminology. What used to be called psychiatric diseases are now often called mental disorders. I now claim, for the purposes of illustration of the argument (though it does not require this claim), that the dominant category is disease. Indeed, what are called mental disorders appear in the International Classification of Diseases.

Disease can be divided into the mental and physical. I believe that the mental will one day be [End Page 59] shown to be shown to be entirely a subset of the physical. That is, that brain pathology will be a cause, if not the only cause, of mental disease. But others may believe the sets of mental and physical disease are intersecting but not coextensive.

What matters is that mental disease is a subcategory of the more general category of disease. It must have the same definitional features as "disease" plus some extra ones specific to the "mental," or mind. (The same points apply if you use "disorder" as the dominant category rather than "disease.")

One problem for Varelius is this: how does this autonomy account of "mental disease" relate to an account of "physical disease," and "disease" in general? If mental disease is defined in terms of its impact on the psychological capacities necessary for autonomy, how is "disease" in general, or physical disease, to be defined? One obvious response is to define these related concepts in a similar way:

Disease: "a person is diseased when her capacity for autonomy is diminished as compared to that of a typical member of our species of her age-group." Physical disease: "a person is physically disordered when her physical capacity for autonomy is diminished as compared to that of a typical member of our species of her age-group."

This interpretation is suggested by the following passage from Varelius:

As contrasted with the actual condition of being autonomous, as a capacity of an individual autonomy means that a person has the psychological and bodily abilities that being autonomous . . . requires.


It would be radical to define disease in general in terms of capacity for autonomy. There is no doubt that disease affects our autonomy, and that is morally significant, but these seem clearly separable concepts. Varelius could respond that he is not defining mental disease but rather the mental component...


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pp. 59-65
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