Excerpt from my PhD thesis
This text is an excerpt from the introductory chapter to my yet untitled PhD thesis in philosophy. It explains in brief and simple terms what my research is about, and what the main contributions are. However, please note that my thesis—including this excerpt—is still on an early manuscript stage. Changes will be made to it.
Respect for autonomy is a central moral principle in bioethics. The term autonomy is from the ancient Greek auto, which means “self,” and nomos, which means “law.” Being autonomous means that one is self-governing. In biomedical contexts various concepts are invoked in concern of patients’ autonomy, most importantly decision-making capacity and voluntariness. That is, a patient is less autonomous to the extent that she lacks decision-making capacity and to the extent that she is not acting or choosing voluntarily. Sometimes, authenticity is invoked accordingly in concern of patients’ autonomy; a patient is less autonomous to the extent that her actions or choices are inauthentic.
There are various uses of the term “authentic.” Bialystok identifies three main variations of how the term is used in ordinary English; in the first sense, authentic is synonymous with “original,” as in “being continuous with a historical entity” (2014, p. 275). A fifties-style diner is authentic in this sense if it actually opened in the 1950s, was typical of that era, and has remained unchanged since then. In the second sense, it is synonymous with “real,” as opposed to “fake.” Turtle soup is authentic in this sense if it is actually made of turtle, and not of some cheap alternative (p. 276). In the third sense, authentic means “honest,” “true to oneself,” or “genuine.” When a person is authentic in this sense, her behavior “converges with who she actually is” (p. 278). It is this sense of the term that is of interest here.
My thesis includes four articles related to the notion of authenticity. The first article, entitled “Ten Cases of Possible Inauthenticity in Biomedical Contexts and How They May Be Approached,” collects various cases in biomedical contexts where the notion of authenticity has been or could reasonably be expected to be of moral significance. In what follows, I call the article “the Ten Cases article,” or variations thereof. The second article, entitled “The impossibility of reliably determining the authenticity of desires: implications for informed consent,” collects theories that are intended to explain or conceptualize authenticity.1 In it, I argue that authenticity is difficult to observe in others. I call it “the Determining Authenticity article,” or similar. The third article is entitled “What Justifies Judgments of Inauthenticity?” In it, I formulate a proposal of how judgments that someone else’s desires are inauthentic may be justified. I call it “the Justifying Inauthenticity Judgments article,” or similar. Finally, in the fourth article, which is entitled “A Non-Ideal Authenticity-Based Conceptualization of Personal Autonomy,” I develop a conceptualization of personal autonomy which includes the notion of authenticity. I call it “the Autonomy article,” or variations on that theme.
The aim of the thesis is to make theoretical ideals of authenticity helpful in practical biomedical contexts. This is facilitated by an overview of authenticity-related problems (the Ten Cases article) and an explanation of why theoretical ideals of authenticity are unhelpful in them (the Determining Authenticity article). The thesis succeeds in two respects; it further develops an already established theory of authenticity so that it renders practically observable implications (the Justifying Inauthenticity Judgments article) and proposes an authenticity-based conceptualization of personal autonomy against those implications (the Autonomy article). I elaborate in this section.
The Ten Cases article begins with a citation from a person who reports of her anorexia nervosa: “I wasn’t really bothered about dying, as long as I died thin” (Tan et al. 2006, p. 274). Anorexia sometimes affects how people who suffer from it value themselves, and in turn the values affect the anorectics’ motivational sets with regards to nutrition. Thus, there is sometimes a problematic interaction in play between the disorder and the values that anorectics have. In some cases, anorexia nervosa patients are fully competent to appreciate the nature of their situation and the risks and consequences involved with the various healthcare-related decisions they face; they have what bioethicists and medical practitioners call decisional-capacity (Beauchamp and Childress 2013, p. 118; Grisso et al. 1997). Yet, they hold values that are problematic in the above sense. Some report that they would rather die than gain weight.
Intuitively, there is something deeply distressing about holding such values, and this distress has led some to analyze cases of anorexia nervosa in terms of authenticity (Hope et al. 2011; Sjöstrand and Juth 2014; Tan et al. 2006). One common suggestion is that while some anorectics may have decisional-capacity, they are in a state of inauthenticity and should therefore nevertheless not be allowed to make their own healthcare decisions. That is, they are not themselves, in some qualitative sense.
Similar problems appear also in other medical situations. Untreated syphilis may cause changes in a person’s character that make them or their decisions inauthentic. People suffering from borderline personality disorder (BPD) may, in a short time span, express drastically conflicting opinions on their medical treatment. It may be the case that their condition should be phrased and analyzed in terms of inauthenticity. And so on. The Ten Cases article collects just that—i.e., ten cases—in which the notion of authenticity has been or may be relevant in practical biomedical contexts.
Philosophers that have set out to analyze authenticity in biomedical contexts have proposed various conceptualizations of the notion. There are vast disagreements already in the outset of this debate. First, it is not clear what it is that should be subject to critical scrutiny in terms of authenticity. Some hold that an analysis of authenticity must begin with the concept of what it is to be a real person. Others hold that the notion of personhood is secondary at best, as it is the authenticity of medical decisions that is of interest in clinical practices. Second, philosophers who agree on what should be the subject of the analysis support competing theories of what distinguishes authenticity from inauthenticity. For instance, some theorists who hold that it is the authenticity of desires that should be of interest argue that it is the causal history of a desire that matters most to its authenticity. Others, while agreeing on the focus on desires, instead argue that it is the coherence of full desire-sets that matter.
In the thesis, I have made two choices with regards to these debates, neither of which have been or will be defended at length. The first choice is to focus on the authenticity of desires, rather than persons, lives, or something else. This is because I, as many others in this field, hold desires to be the most basic element in ordinary preference forming and, thus, the most basic element in decision-making (cf., e.g., Taylor 2005). Without further elaboration, and in awareness of that terminologies vary between contexts and disciplines, I here think of desires as an attitude or directedness which influence the decisions that the desire-holder makes. The second choice I have made is to focus on a theoretical tradition of thinking about authenticity that first took form in a set of books and articles in the 1970’s and 1980’s, of which Frankfurt (1971) and Dworkin (1988) are the most noteworthy.2 In this tradition, authentic desires are distinguished from inauthentic desires in that the former would be endorsed, at least hypothetically, by the desire-holder upon informed and critical self-reflection. Here, I call this criterion “affirmative self-reflection.”
There are various problems with this theory. For instance, it can be argued that affirmative self-reflection itself requires affirmative self-reflection, and that the theory therefore results in an infinite regress (Taylor 2005). I do not address such problems in this thesis, i.e., problems concerning whether the theory succeeds in distinguishing between authenticity and inauthenticity. Instead, I focus on problems associated with applying the theory in practical contexts. One major problem is that the theory fails to render practically observable consequences. I elaborate on this problem in the Determining Authenticity article. In short, it is difficult to know whether a desire-holder would endorse her own desires upon informed and critical self-reflection; people’s decision-making takes place in a practically impenetrable “black box” that others do not have access to. Therefore, affirmative self-reflection appears to be an ideal that is unhelpful in terms of action-guidance in practical biomedical contexts.
In the Justifying Inauthenticity Judgments article, I develop a version of the Frankfurt-Dworkean theory that renders practically observable indicators of inauthenticity. Thereby, the gap between theoretical ideals of authenticity and practical authenticity-related problems is bridged. The version is not morally neutral. It is formulated in terms of moral justification, meaning that the problem of determining whether a desire is inauthentic is phrased in terms of when it is morally justified to make judgments of inauthenticity. Among other things, this means that there may be inauthentic desires that observers are not justified to judge as inauthentic, which is mainly due to that observers often work in epistemically unfavorable conditions that do not allow them to make judgments of inauthenticity.
It is important to note that paternalist interventions such as, for instance, force-feeding an anorectic who states that she would rather die than gain weight, are not justified merely because it is (by hypothesis) justified to judge that her desires are inauthentic. Paternalist interventions require their own independent justifications, not least considering the degree of proportionality of the intervention and the degree of epistemic certainty of inauthenticity. This thesis does not include any elaborate discussion of paternalism, or any detailed suggestions of how the present theories could support paternalist interventions.
In the Autonomy article, I incorporate my re-stated and morally loaded version of the Frankfurt-Dworkean theory in Beauchamp and Childress’s account of personal autonomy. Thereby, this thesis constructs a conceptualization of autonomy that manages to take authenticity into account. The principle of respect for autonomy is widened to include judgments of authenticity. Thus, the aim of this thesis, i.e., to make theoretical ideals of authenticity helpful in practical biomedical contexts, is succeeded.∗
1 Published as: Ahlin, J. (2018). The impossibility of reliably determining the authenticity of desires: implications for informed consent. Medicine, Health Care and Philosophy, 21(1), 43–50.
2 The Determining Authenticity article elaborates on three different traditions of thinking about authentic desires.
Beauchamp, T. L., & Childress, J. F. (2013). Principles of Biomedical Ethics(7 ed.). Oxford: Oxford University Press.
Bialystok, L. (2014). Authenticity and the Limits of Philosophy. Dialogue, 53(2), 271–298.
Dworkin, G. (1988). The Theory and Practice of Autonomy: Cambridge University Press.
Frankfurt, H. (1971). Freedom of the Will and the Concept of a Person. The Journal of Philosophy, 68(1), 5–20.
Grisso, T., Appelbaum, P. S., & Hill-Fotouhi, C. (1997). The MacCAT-T: A Clinical Tool to Assess Patients’ Capacities to Make Treatment Decisions. Psychiatric Services, 48(11), 1415–1419.
Hope, P. T., Tan, D. J. O. A., Stewart, D. A., & Fitzpatrick, P. R. (2011). Anorexia Nervosa and the Language of Authenticity. Hastings Center Report, 41(6), 19 –29.
Sjöstrand, M., & Juth, N. (2014). Authenticity and psychiatric disorder: does autonomy of personal preferences matter? Medicine, Health Care and Philosophy, 17(1), 115–122.
Tan, D. J. O. A., Hope, P. T., Stewart, D. A., & Fitzpatrick, P. R. (2006). Competence to make treatment decisions in anorexia nervosa: thinking processes and values. Philosophy, Psychiatry, & Psychology : PPP, 13(4), 267–282.
Taylor, J. S. (2005). Introduction. In J. S. Taylor (Ed.), Personal Autonomy: New Essays on Personal Autonomy and Its Role in Contemporary Moral Philosophy(pp. 1–29): Cambridge University Press.