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  • Paternalism, Autonomy, and the Good
  • Daniel Moseley (bio) and Gary Gala (bio)
Keywords

paternalism, autonomy, voluntariness, competence, anorexia nervosa

Brent Kious presents an important meditation on the relation of paternalism, autonomy, and values in “Autonomy and Values: Why the Conventional Theory of Values Is Not Value-Neutral.” We begin by giving a brief overview of the main argument. Kious claims that if a paternalistic intervention is justified, then that intervention does not impede an agent’s autonomous decision: considerations of autonomy are necessary for justifying paternalistic interventions. He also maintains that considerations of autonomy may focus on either competence or voluntariness. Accordingly, individuals that lack autonomy either lack competence or lack voluntariness. Kious argues that individuals with certain mental illnesses possess competence and therefore it is a lack of voluntariness, and not a lack of competence, that undermines their autonomy. Although many authors agree with Kious that a lack of autonomy in many cases of mental illness is the result of non-voluntariness, they have often tried to give value-neutral accounts of voluntary decision making. Kious proposes a non-value neutral (or as we shall call it ‘normative’) account of voluntariness. Kious maintains that all voluntary actions are motivated by values, where ‘values’ are defined as psychological states that provide the motivational component of action and decision, but value-neutral accounts of autonomy and voluntariness deny that voluntariness requires a voluntary action to meet any standard of objective goodness (or any other standard external to that agent’s goals, preferences, desires, or other conative states). Kious defends a normative account of autonomy because, in the cases of mental illness that he describes, a person’s autonomy is “undermined when a person’s values do not accurately reflect her own objective good.” (2015, 1).

Our evaluation of Kious’s arguments proceeds as follows. First, we raise some worries that psychiatrists may have with Kious’s account. Next, we consider some concerns with the philosophical content of the arguments.

Psychiatric Concerns

From a psychiatric point of view, our main concern with Kious’ account is the general scope of his claims about anorexia nervosa (AN), which, he argues, may undermine one’s voluntary decision making and thereby undermine that individual’s autonomy. Kious tells us: “Although distorted perceptions of her appearance sometimes influence the anorexic person’s behaviors, her non-autonomy cannot be explained by incompetence” (p. 3). We [End Page 13] dispute this claim. There is strong evidence that not only perceptual distortions but also cognitive deficits occur in AN involving memory, set shifting, and central coherence and that the severity of some of these deficits are weight dependent (e.g., Cucarellaa, Tortajadab, and Morenoc 2012; Roberts et al. 2007; Lopez et al. 2008a; Lopez et al. 2008b; Zakzanis, Campbell, and Polsinelli 2010). So we would suggest that for patients with AN, a lack of autonomy due to non-voluntariness only explains a subset of patients with AN and perhaps only a subset of them at certain times in their illness. At other times in the patients’ illness, a lack of autonomy may be explained clearly by incompetence, arising as a result of cognitive deficits that impair understanding.

A second psychiatric concern we have with Kious’s account arises from the discussion of mental illness as the cause of non-voluntariness. Kious explores the relationship between non-voluntariness, competence, illness, and values. He wants to show that illness is essentially evaluative, but that in value-neutral accounts of autonomy many decisions remain autonomous despite the presence of illness and competence. He assumes that individuals with AN are competent, but that their illness “causes the victim to have certain values” and that those values do not reflect their good (p. 5). We agree with Kious’s claim that illness is a value-laden concept. However, the assumption that all individuals with AN are competent and that AN effects a patient’s behavior mostly via a shift in the individual’s values is not supported by the empirical data. There is a persuasive body of literature that suggests that AN primarily involves a perceptual change in body image (a small sample of this literature includes Cash and Deagle...

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