Jeanette Kennett

Pickard (2012) claims that the neurobiological or disease model of addiction hinders the recovery of people because it undermines their feeling of self-efficacy and agency. Sub- stance users are “not aided by being treated as victims of a neurobiological disease, as opposed to agents of their own recovery” (40).Although Pickard acknowledges that claims of powerlessness or loss of agency can have a functional role in the self-narratives of substance users in excusing them from blame, she primarily focuses on the negative effects of the diseasemodel on the recovery of substance users. Preliminary evidence from in-depth interviews with heroin-dependent participants in our current cohort study on addiction and moral identity supports Pickard’s claims in part: Substance users describe grades of control, psychological distress, and loss of options, and an ambivalent attitude toward their belief in self-efficacy. However the interviews also provide points of critique. While Pickard is right to dismiss the more extreme claims of proponents of the disease model—namely, that drug use in addicts is literally compelled—user responses suggest that an understanding of the neurobiology of addiction might in some respects support rather than undermine a sense of agency. Moreover, there is reason to suppose that the relation be- tween substance use and psychological distress is not as straightforward as Pickard claims. In this respect we believe the debate must become more nuanced and move beyond a simple opposition between the disease model and the rational choice model endorsed by Pickard.

Effective agency, according to contemporary Kantians, requires a unity of purpose both at a time, in order that we may eliminate conflict among our motives, and over time, because many of the things we do form part of longer-term projects and make sense only in the light of these projects and life plans. Call this the unity of agency thesis. This thesis can be regarded as a normative constraint on accounts of personal identity and indeed on accounts of what it is to have the life of a person in the broad, rather than narrowly biological sense. It is also a fundamental condition of social life that persons within society fulfill a range of longitudinal roles: parenthood is one such obvious example, as are teachers, health professionals, engineers, artists, and many others. The fulfillment of these and other valuable social roles requires that agents have the capacity to rationally conceive of themselves as engaged in these roles and subject to the demands of them. To be unable to fulfill any such longitudinal social roles is to have a life deficient in value. The unity of agency is thus, we argue, something we rationally strive for, and something to be morally promoted. Psychiatric states that undermine the unity of agency are morally and rationally disvaluable. Using the example of dissociation, we explain how one such state may have this undermining or disruptive effect on the unity of agency. The therapeutic ends for psychiatry in conditions involving such states are thus seen more globally as the restoration of effective agency, that is, unified agency.

In this chapter I argue that there is a normative aspect to self-control that is not captured by the purely procedural account to be drawn from dual process theories of cognition – which we only uncover when we consider what self-control is for and why it is valuable. For at least a significant sub-group of addicts their loss of control over their drug use may not be due to a lack or depletion of cognitive resources. Rather it may be that they have little confidence in their ability to exert control over their circumstances and shape the life they would value having and the person they would value being.

Mary Walker (2012) argues that the narrative form that self-understanding must take is capable of providing a largely truthful picture of who we are, despite neuropsychological evidence suggesting the contrary. Walker describes three approaches to counter the conclusion of falsity in self narratives: that some truths are fully intelligible only within a narrative structure; that narratives contain non-factual content with a significance and meaning otherwise unavailable; thirdly, and importantly for our purposes, she offers a constraint ‘on what can count as a correct or good self-narrative...to point to ways in which the process of self-narration should be connected to the facts’. In this commentary we elaborate and offer further support to Walker’s claim that ‘continual intersubjective checking’ provides a dynamic and corrective social mechanism for ensuring truth in self narratives.

Mental time travel is the ability to simulate alternative pasts and futures. It is often described as the ability to project a sense of self in the service of diachronic agency. It requires not only semantic representation but affective sampling of alternative futures. If people lose this ability for affective sampling their sense of self is diminished. They have less of a self to project hence are compromised as agents. If they cannot “feel the future” they cannot imaginatively inhabit it and hence their agency is compromised. The extent of such losses and consequent impairments to moral agency can be matters of degree.

Kant claimed both that "moral feeling is the capacity to be affected by a moral judgment" and that moral motivation is motivation by principle. What are the psychological mechanism that could enable principles to motivate? This chapter develops in more detail a suggestion made elsewhere by the author that posits a connection between susceptibility to the discomfort of cognitive dissonance and moral motivation of a broadly Kantian kind. The chapter argues that the possession of principles is constitutively connected to one’s status as a diachronic self and to one’s rational agentive capacities. If psychopaths are insensitive to cognitive dissonance, they cannot have or be motivated by principles. This provides an explanation of the failure of moral motivation in psychopaths that differs from the usual focus on lack of empathy.

Psychopaths have long been of interest to moral philosophers, since a careful examination of their peculiar deficiencies may reveal what features are normally critical to the development of moral agency. What underlies the psychopath's amoralism? A common and plausible answer to this question is that the psychopath lacks empathy. Lack of empathy is also claimed to be a critical impairment in autism, yet it is not at all clear that autistic individuals share the psychopath's amoralism. How is empathy characterized in the literature, and how crucial is empathy, so described, to moral understanding and agency? I argue that an examination of moral thinking in high-functioning autistic people supports a Kantian rather than a Humean account of moral agency.

We argue that companion friendship is not importantly marked by self-disclosure as understood in either of these two ways. One's close friends need not be markedly similar to oneself, as is claimed by the mirror account, nor is the role of private information in establishing and maintaining intimacy important in the way claimed by the secrets view. Our claim will be that the mirror and secrets views not only fail to identify features that are in part constitutive of close or companion friendship, but that they miss the mark quite broadly and fail to capture anything significant and distinctive about the ways in which friendship has an impact on the self. The article will proceed as follows. In the first section we outline our account of the self in friendship. In the next two sections we examine the mirror and secrets views and develop our own view in counterpoint to these. In the final section we defend our own account by showing how it provides the governing conditions which do distinguish friendship from other kinds of relations between persons.

We have argued elsewhere that moral responsibility over time depends in part upon the having of psychological connections which facilitate forms of self-control. In this chapter we explore the importance of mental time travel - our ordinary ability to mentally travel to temporal locations outside the present, involving both memory of our personal past and the ability to imagine ourselves in the future - to our agential capacities for planning and control. We suggest that in many individuals with dissociative disorders, forms of amnesia, or other frontal lobe damage, our capacity for mental time travel is impaired, resulting in commensurate losses to agency autonomy, and a forensic condition essential for holding persons responsible: in legal terms, the capacity for mens rea.

Substance use and misuse occurs at a very high rate among people with mental health problems and the relationship between the two conditions is complex. In this paper we argue that treatment of substance use in dual diagnosis clients must begin from an understanding of the losses suffered by those with mental illness. We outline the fundamental condition of effective agency, unified agency, which is disrupted in mental illness and show how this is needed to secure access to central social and moral goods such as continuing employment and satisfying relationships. We argue that drug use will be disvaluable primarily in so far as it too prevents access to this set of agential goods and focuses the agent on synchronic well-being to the exclusion of diachronic well-being. The goals and methods of treatment for dual diagnosis patients should thus reflect the primary impairment to unified agency.

What is the role and value of pleasure in addiction? Foddy and Savulescu have claimed that substance use is just pleasure-oriented behavior. They describe addiction as "strong appetites toward pleasure" and argue that addicts suffer in significant part because of strong social and moral disapproval of lives dominated by pleasure seeking. But such lives, they claim, can be autonomous and rational. The view they offer is largely in line with the choice model and opposed to a disease model of addiction. Foddy and Savulescu are sceptical of self-reports that emphasize the ill effects of addiction such as loss of family and possessions, or that claim an absence of pleasure after tolerance sets in. Such reports they think are shaped by social stigma which makes available a limited set of socially approved addiction narratives. We will not question the claim that a life devoted to pleasure can be autonomously chosen. Nor do we question the claim that the social stigma attached to the use of certain drugs increases the harm suffered by the user. However our interviews with addicts reveal a genuinely ambivalent and complex relationship between addiction, value, and pleasure. Our subjects did not shy away from discussing pleasure and its role in use. But though they usually valued the pleasurable properties of substances, and this played that did not mean that they valued an addictive life. Our interviews distinguished changing attitudes towards drug related pleasures across the course of substance use, including diminishing pleasure from use over time and increasing resentment at the effects of substance use on other valued activities. In this paper we consider the implications of what drug users say about pleasure and value over the course of addiction for models of addiction. Well don't get me wrong, I love using mate. If I could use successfully I would. I'd still be using. I love using. I just don't like the shit that comes with it.