Lubomira Radoilska

This chapter explores four kinds of skepticism about autonomy in general and its applicability to psychiatric ethics in particular. It is argued that although there are valuable lessons to be learnt from each of these skeptical challenges, their overall contribution is best understood in terms of friendly correctives to an autonomy-centered normative and conceptual framework instead of viable alternatives to it. The first four sections each provide a logical reconstruction of a distinct skeptical line of reasoning about autonomy and expand on its implications for psychiatric ethics: skepticism about personal autonomy; skepticism about autonomy as an agency concept; vulnerability-grounded skepticism about autonomy; and paternalism-friendly skepticism about autonomy. The fifth section identifies and explores the underlying presuppositions that motivate the previously discussed forms of skepticism about autonomy, and the sixth reflects on the significance of psychiatric ethics for rebutting skepticism about autonomy and developing a new, more promising positive theory.

Contemporary analytic philosophers tend to see akrasia, or acting against one’s better judgement, as a problem of motivation. On this standard view, akratic actions are paradoxical since akratic agents know that they have a better alternative but nevertheless take up the worse, akratic option. In other words, akratic agents know what they are doing. They do not make any epistemic mistakes but – inexplicably – engage in behaviours that they correctly identify as wrong. The thought that akratic agents are not flawed as inquirers and knowers but only as agents plays a key role in turning akrasia into a textbook example of motivational only, or practical irrationality. This paper will aim to revise the standard view by emphasizing the epistemic dimensions of phenomenon, that is, the ways in which akrasia affects both how agents understand their own involvement and how they handle evidence about their prospects of success. The ambition is to show that akratic agents typically rationalise their akrasia. They do not recognise it as paradoxical or irrational. Instead, they reinterpret it as separate goal-directed actions undertaken under conditions that are not ideal for them. This rationalisation of akrasia is closely related to another epistemically deficient habit: akratic agents pay too much heed to evidence that they are unlikely to succeed. In so doing, they display too little of what philosophers have described as ‘epistemic resilience’, or more simply, ‘grit’.

In a recent Editorial, Kious et al. (2023) put forward the claim that psychiatrists should resist calls to integrate concerns about epistemic injustice into their practice as this concept not only fails to add significantly to the current professional standards but would also lead to deleterious clinical outcomes. We believe their claim is mistaken, as it arises from several misconceptions about both the nature of epistemic injustice, and its clinical relevance. First, epistemic justice is conflated with what the authors term ‘a quest for social justice’ that could ‘sideline principles of good clinical reasoning’ (Kious at al 2023: 4). Second, the claim about the impracticality and/or counterproductivity of epistemic injustice as a critical tool within psychiatric practice reflects a series of misconceptions about the normative framework from which this concept derives, so the standards they evaluate it against are ill-chosen. Pace Kious at al., fostering epistemic justice in any area of knowledge and inquiry could not – unwittingly or otherwise – inhibit the consideration of relevant evidence, restrict sound argument or facilitate the casual treatment of testimonies at face value. Third and final, this claim obfuscates some immediate ways in which a focus on epistemic justice as an integral goal will strengthen psychiatric practice according to its own internal standards.