Amanda Evans

(To appear in Philosophy and the Mind Sciences’ Book Symposium for Neuroethics: Agency in the Age of Brain Science (OUP 2023) by Joshua May). In Neuroethics: Agency in the Age of Brain Science (2023), Joshua May arrives at a cautiously optimistic appraisal of deep brain stimulation (DBS) for brain-based disorders. May does not, however, distinguish between disorders that are properly considered neurological and those that are properly considered psychiatric (or psychopathological). After motivating this distinction, I argue that May’s discussion of DBS fails to account for the added complexities and potential ethical harms of DBS for psychiatric conditions.

Concerns over medical paternalism are especially salient when there exists a conflict of values between patient and clinician. This is particularly relevant for psychiatry, the field of medicine for which the phenomenon of conflicting values is most present and for which the specter of medical paternalism looms large. Few cases are as glaring as that of anorexia nervosa (AN), a disorder that is considered to be egosyntonic (meaning its symptoms are reflectively endorsed by the patient) and maintained by the presence of pathological values. One might think, given this, that an approach to medicine that foregrounds the role of values in clinical encounters would be particularly well suited to address the problem of medical paternalism in treating AN. As it happens, this is precisely the goal of values-based medicine, an approach to medicine that prioritizes the integration of patients’ unique values into the aims of treatment and that has been touted as being particularly applicable to psychiatric conditions such as AN. Although this strategy may initially appear promising, in this paper I will argue that the directive to incorporate patient values (as dictated by values-based medicine) cannot do the work of mitigating medical paternalism in the treatment of egosyntonic disorders such as AN. Rather than chalking this up as a failure due to AN being a particularly challenging case, I will instead conclude that the failure of values-based medicine in this context cuts to the heart of the limitations of rectifying medical paternalism within psychiatry as it currently exists.

Any insights we can hope to gain with respect to what is going on with our mental lives and our agency will almost certainly require a close examination of the “worst-case scenarios”, since it is when things break down that the joints of the phenomena are revealed. This is a philosophical intuition of mine that pervades everything I work on, and the papers that make up this dissertation are no exception. In keeping with this guiding sentiment, this dissertation tackles three philosophical issues related to the so-called “loss of control” that occurs in mental disorder, and it does so in a way that places the phenomenology of agency at the forefront in some way or other. In my first paper on the sense of agency in anorexia nervosa, I try to resolve an apparent discrepancy between the phenomenology of anorexics in the grip of their disorder and the psychological and neurological data that purport to describe what they are undergoing. I provide a solution to this apparent incongruency by offering an account of the sense of agency in AN that grants sincerity to anorexic testimony while also being able to explain why the relevant experiences of agency come to be illusory. Then, in my second paper, I broaden my scope to include not just AN but also substance use disorder. After outlining the debate surrounding the question of whether addiction ought to be categorized as a form of akrasia, I show that the phenomenon at issue is far more complex than either side has supposed. I then propose a “horseshoe model” of loss of control that is able to capture the complexity that is brought in by examining the similarities and differences between SUD and AN. Finally, in my third paper, I pursue a question that arises from the exposition of the horseshoe model introduced in the previous paper. The question is, roughly, “Why is one ‘half’ of the horseshoe model associated with the phenomenology of loss of control while the other “half” is associated with the phenomenology of extreme self-control?”. This line of inquiry ultimately leads to an understanding of how one’s pathological desires can be experienced quite differently depending on the content of one’s self-image. Taken together, it is my hope that these papers can contribute to the philosophical goal of unearthing the realities of our mental lives and our agency by examining the fault lines formed by psychopathology.

This is a preprint draft. Please cite published version (DOI: 10.1111/mila.12385). The aim of this paper is to provide a novel analysis of anorexia nervosa (AN) in the context of the sense of agency literature. I first show that two accounts of anorexia nervosa that we ought to take seriously— i.e., the first personal reports of those who have experienced it firsthand as well as the research that seeks to explain anorexic behavior from an empirical perspective— appear to be thoroughly in tension with one another in their descriptions of anorexic actions. Rather than proceeding at this point by way of disregarding anorexic testimony as meaningless or insincere, I instead offer a positive account of the sense of agency in anorexia nervosa that renders these two depictions compatible. The resultant picture of anorexic behavior is one that accommodates current empirical findings while also providing valuable insight into how it is that anorexics can sincerely report feeling fully in control over their food restriction.