Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 1 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 Subject: Psychology,	Clinical	Psychology,	Counseling	Psychology Online	Publication	Date: Dec 2014 DOI: 10.1093/oxfordhb/9780198732365.013.28 Rationality,	Diagnosis,	and	Patient	Autonomy	in	Psychiatry Jillian	Craigie	and	Lisa	Bortolotti The	Oxford	Handbook	of	Psychiatric	Ethics,	Volume	1	(Forthcoming) Edited	by	John	Z.	Sadler,	Bill	Fulford,	and	Cornelius	Werendly	van	Staden Oxford	Handbooks	Online Abstract	and	Keywords In	this	chapter,	our	focus	is	the	role	played	by	notions	of	rationality	in	the	diagnosis	of	mental	disorders,	and	in	the practice	of	overriding	patient	autonomy	in	psychiatry.	We	describe	and	evaluate	different	hypotheses	concerning the	relationship	between	rationality	and	diagnosis,	raising	questions	about	what	features	underpin	psychiatric categories.	These	questions	reinforce	widely	held	concerns	about	the	use	of	diagnosis	as	a	justification	for overriding	autonomy,	which	have	motivated	a	shift	to	mental	incapacity	as	an	alternative	justification.	However, this	approach	too	has	recently	been	criticized	from	a	mental	disability	rights	perspective.	Our	analysis	of	the relationship	between	mental	capacity	and	rationality	is	used	to	illuminate	these	concerns,	and	to	investigate	further the	relationship	between	rationality	and	psychiatric	diagnosis. Keywords:	rationality,	diagnosis,	psychiatry,	patient	autonomy,	mental	incapacity,	mental	capacity,	neurodiversity Introduction In	this	chapter	we	focus	on	two	ethical	issues	in	the	practice	of	psychiatry	which	concern	the	role	that	rationality plays	in	the	understanding	of	mental	disorder:	(1)	how	to	draw	the	boundaries	of	mental	disorder;	and	(2)	the implications	of	mental	disorder	for	patient	autonomy.	Rationality	talk	pervades	criteria	of	psychiatric	classification and	diagnosis,	and	this	suggests	that	some	form	of	irrationality	may	be	necessary	or	even	sufficient	for	mental disorder.	In	"The	Role	of	Rationality	in	Psychiatric	Classification	and	Diagnosis"	we	describe	and	assess	different hypotheses	about	the	relationship	between	rationality	and	mental	disorder.	This	issue	is	ethically	significant	in	its own	right	because	of	the	social	stigma	associated	with	a	psychiatric	diagnosis,	and	questions	concerning	the status	and	evolution	of	psychiatry	as	a	branch	of	medicine.	However,	the	relationship	between	psychiatric diagnosis	and	rationality	takes	on	particular	ethical	significance	in	the	context	of	decisions	concerning	a	patient's right	to	autonomy.	"Rationality	and	Patient	Autonomy"	explores	the	ethical	problems	associated	with	diagnosis	as	a justification	for	overriding	autonomy,	and	outlines	an	emerging	challenge	to	a	mental	capacity	as	an	alternative approach.	We	begin	by	mapping	out	a	framework	for	thinking	about	rationality	in	the	context	of	psychiatric	ethics. A	Framework	for	Thinking	about	Rationality At	the	broadest	level-in	the	academic	literature	as	well	as	in	an	everyday	sense-questions	of	rationality	concern the	normative	constraints	on	decision-making:	what	we	should	believe,	or	what	we	should	do	(Kolodny	2005).	The territory	of	rationality	can	be	carved	up	in	many	ways	(Wallace	2014),	but	in	this	chapter	we	will	use	two distinctions.	The	first	is	a	distinction	between	procedural	and	substantive	norms,	where	the	former	are	concerned with	the	deliberative	process	by	which	a	decision	is	reached,	and	the	latter	are	concerned	with	matters	of	value- the	ends	that	should	be	pursued.	The	second	distinction,	which	cuts	across	the	first,	reflects	divergent perspectives	on	why	norms	of	rationality	are	binding-what	makes	these	requirements	required.	One	prominent Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 2 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 explanation	is	that	rational	requirements	are	binding	because	accordance	is	essential	for	the	pursuit	of	our purpose	as	agents	(for	discussion	see	Kolodny	2008).	And	one	way	of	thinking	about	this	purpose	is	in	terms	of getting	the	answers	right-having	true	beliefs	or	choosing	the	right	course	of	action.	We	will	use	the	term	epistemic to	capture	this	perspective.	This	can	be	contrasted	with	a	more	practical	orientation,	focused	on	what	makes things	go	well	for	the	agent,	and	we	will	therefore	refer	to	this	as	a	pragmatic	perspective. There	will	be	considerable	overlap	between	these	perspectives	because	in	many	contexts	getting	the	answer	right will	be	a	good	thing	for	the	agent.	However,	they	will	also	sometimes	come	apart.	We	illustrate	this	in	relation	to procedural	requirements	as	these	are	our	main	focus	in	the	chapter.	From	a	pragmatic	perspective	it	may	not	be rational	for	a	person	to	hold	a	particular	true	belief	if	doing	so	would	be	paralyzing	for	them-a	false	belief	might	be more	helpful	in	achieving	their	chosen	goals	or	promoting	their	well-being. Classic	criticisms	of	utilitarianism- according	to	which	the	requirement	to	maximize	utility	is	self-defeating	because	the	deliberative	process	itself incurs	a	cost	(Sidgwick	[1874]	1907,	pp.	489–490,	Pettit	1991)-might	be	thought	of	as	an	example	where	these perspectives	come	apart.	Further	examples	in	the	context	of	psychiatry	will	come	to	light	throughout	the	chapter. The	Role	of	Rationality	in	Psychiatric	Classification	and	Diagnosis Is	Psychiatry	a	Science? The	project	of	establishing	whether	psychiatry	has	scientific	status	is	made	difficult	by	the	lack	of	agreement	on necessary	and	sufficient	conditions	for	a	human	activity	to	count	as	scientific	research	(e.g.,	Bortolotti	and Heinrichs	2007).	All	the	demarcation	criteria	that	have	been	proposed	so	far,	between	science	and	non-science, and	between	science	and	pseudo-science,	have	been	abandoned	under	the	pressure	of	compelling	counterexamples.	As	a	result,	philosophers	who	are	interested	in	the	status	of	psychiatry	have	stopped	asking	whether psychiatry	is	a	science	and	have	become	more	concerned	with	the	scientific	credentials	of	specific	aspects	of psychiatric	practice,	such	as	classification	(Cooper	2009)	and	explanation	(Murphy	2006). As	we	see	it,	one	of	the	central	problems	with	classification	in	psychiatry	is	that	it	plays	two	important	functions. The	taxonomies	proposed	by	the	American	Psychiatric	Association's	Diagnostic	and	Statistical	Manual	of	Mental Disorders	(DSM)	and	by	the	World	Health	Organization's	International	Classification	of	Diseases	(ICD)	guide research	into	mental	disorders,	but	also	inform	diagnostic	categories,	thus	determining	eligibility	for	treatment	via national	health	or	health	insurance	systems. Potential	conflicts	between	the	aims	of	research	and	clinical	practice	have	become	obvious	in	the	debate	about	the new	edition	of	the	DSM,	published	in	May	2013.	For	the	purposes	of	identifying	mental	disorders	in	a	clinical	setting, criteria	largely	based	on	behavioral	manifestations	may	be	appropriate,	especially	when	no	other	diagnostic	tools are	available	due	to	the	often	complex	and	still	largely	unknown	etiology	of	many	psychiatric	disorders.	But	for	the purposes	of	research,	classification	based	on	symptoms	alone	is	often	deemed	unsatisfactory.	Two	weeks	before the	DSM-5	was	published,	the	director	of	the	National	Institute	of	Mental	Health,	Tom	Insel,	claimed	that	the	institute would	no	longer	fund	research	based	exclusively	on	DSM	criteria	due	to	problems	of	validity	for	DSM	categories. Insel	wrote:	"Unlike	our	definitions	of	ischemic	heart	disease,	lymphoma,	or	AIDS,	the	DSM	diagnoses	are	based	on a	consensus	about	clusters	of	clinical	symptoms,	not	any	objective	laboratory	measure"	(Insel	2013). Subsequently,	Insel	amended	his	evaluation	of	the	DSM	considerably	(Insel	and	Lieberman	2013),	but	it	is	fair	to say	that	his	criticism	about	the	validity	of	its	diagnostic	categories	remains,	and	that	the	current	direction	of	the NIMH	is	toward	casting	mental	disorders	as	primarily	biological	phenomena. Further	questions	are	raised	by	the	social	and	political	pressures	that	shape	classificatory	and	diagnostic	manuals. In	the	1970s	and	1980s,	debates	surrounding	homosexuality	led	to	significant	changes	in	the	DSM.	Homosexuality, which	had	been	listed	as	a	"sociopathic	personality	disturbance,"	was	removed	from	the	DSM	in	1973,	and replaced	by	"ego-dystonic	homosexuality"	(referring	to	distress	caused	by	sexual	orientation),	which	in	1986	also disappeared.	More	recent	debates	have	focused	on	attention	deficit/hyperactivity	disorder	(Koerth-Baker	2013) and	on	depression	(Rottenberg	2013),	with	commentators	claiming	that	the	changes	in	DSM-5	will	lead	to	an unnecessary	pathologization	of	normal	behavior. Controversies	in	Classification	and	Diagnosis 1 Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 3 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 In	addition	to	the	above	complexities,	there	are	further	reasons	why	diagnostic	criteria	are	more	controversial	in psychiatry	than	in	other	medical	specialties.	First,	it	is	more	common	for	psychiatric	patients	than	for	nonpsychiatric	patients	to	reject	their	specific	diagnoses	even	when	insight	is	present	(Szasz	1974).	Second,	empirical evidence	suggests	that	psychiatrists	can	be	easily	deceived	to	diagnose	people	who	report	false	symptoms, raising	concerns	about	the	objective	validation	of	psychiatric	diagnosis,	and	heavy	reliance	on	self-reports (Rosenhan	1973).	Third,	some	disorders	appear	to	be	culturally	bounded	in	that	they	are	diagnosed	more frequently	in	certain	periods	of	time	and	in	certain	geographical	areas.	One	interesting	case	is	that	of	dissociative amnesia	(Pope	et	al.	2007);	another	is	that	of	"apathetic	children"	in	Sweden	(Godman	2013). In	addition	to	these	challenges,	symptoms	do	not	map	onto	disorders	in	a	straightforward	way.	Different	disorders may	share	the	same	symptoms,	and	symptoms	may	be	continuous	with,	as	opposed	to	radically	divergent	from, normal	patterns	of	behavior.	Furthermore,	it	has	been	argued	that	a	concept	such	as	schizophrenia	is "scientifically	meaningless"	because	sharing	the	diagnosis	does	not	mean	having	the	same	brain	disease	(Bentall 2004).	Richard	Bentall	holds	that,	as	such,	general	statements	about	how	a	person	with	schizophrenia	is	likely	to behave	are	not	going	to	be	a	reliable	guide	to	either	research	or	diagnosis.	A	similar	argument	might	be	made	in relation	to	autism	spectrum	disorder	(ASD),	which	has	been	introduced	as	a	unified	category	in	DSM-5.	As	for schizophrenia,	genetic,	environmental,	psychological,	and	neurological	causal	factors	have	been	found	to contribute	to	ASD.	The	diverse	behaviors	that	are	diagnostic	seem	unlikely	to	be	explained	by	a	single	"brain disease." All	of	this	raises	the	question:	How	should	classification	and	diagnosis	work	for	mental	disorders	such	as schizophrenia	and	autism?	According	to	a	strong	interpretation	of	the	medical	model,	we	can	be	alerted	to	the presence	of	a	pathological	condition	by	the	observation	of	a	cluster	of	symptoms,	but	ultimately	we	should	identify the	biological	markers	reliably	associated	with	that	condition;	and	any	such	association	should	be	informed	by	a good-enough	story	about	how	the	biology	causes	the	symptoms	(Taylor	1999;	Andreasen	2001).	But	while	this model	is	often	regarded	as	a	regulative	ideal,	something	to	aspire	to	in	psychiatry,	given	what	we	currently	know about	psychiatric	conditions	it	seems	unrealistic.	As	we	read	in	the	introduction	to	the	DSM-5,	for	many	psychiatric categories,	there	is	insufficient	information	about	the	biological	or	physiological	correlates.	This	may	be	because the	causal	mechanisms	of	the	disorder	are	to	some	extent	unknown,	or	because	the	label	we	use	does	not	capture a	single	biologically	defined	disorder.	Other	possibilities	for	reinterpreting	such	categories	will	be	explored	below	in "Rationality	and	Patient	Autonomy." Irrationality	as	a	Diagnostic	Criterion Box	1 Schizophrenia The	schizophrenic	disorders	are	characterized	in	general	by	fundamental	and	characteristic	distortions	of thinking	and	perception,	and	affects	that	are	inappropriate	or	blunted.	Clear	consciousness	and	intellectual capacity	are	usually	maintained	although	certain	cognitive	deficits	may	evolve	in	the	course	of	time.	(ICD-10, F20,	our	emphasis) Delusional	Disorder Delusions	are	deemed	bizarre	if	they	are	clearly	implausible,	not	understandable,	and	not	derived	from ordinary	life	experiences.	(DSM-5,	297.1,	our	emphasis) Major	Depressive	Disorder Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 4 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 Feelings	of	worthlessness	or	excessive	and	inappropriate	guilt	(which	may	be	delusional)	nearly	every	day. Markedly	diminished	interest	or	pleasure	in	all,	or	almost	all,	activities	most	of	the	day,	nearly	every	day. Diminished	ability	to	think	or	concentrate,	or	indecisiveness,	nearly	every	day.	(DSM-5,	296,	abridged,	our emphasis) Autism	Spectrum	Disorder Persistent	deficits	in	social	communication	and	social	interaction	across	multiple	contexts,	as	manifested	by the	following: Deficits	in	social-emotional	reciprocity. Deficits	in	nonverbal	communicative	behaviours	used	for	social	interaction. Deficits	in	developing,	maintaining,	and	understanding	relationships.	(DSM	5,	299.00,	abridged,	our emphasis) Major	neurocognitive	disorder	(includes	dementia) Evidence	of	significant	cognitive	decline	from	a	previous	level	of	performance	in	one	or	more	cognitive domains	(complex	attention,	executive	function,	learning	and	memory,	language,	perceptual-motor,	or	social cognition).	(DSM-5,	our	emphasis) There	may	be	a	more	fundamental	reason	why	the	medical	model,	in	its	strong	interpretation,	does	not	seem	to	suit psychiatry:	namely,	that	we	can	detect	pathologies	of	behavior	only	if	we	look	closely	at	behavior,	and	find	that	it departs	from	norms	of	epistemic	and	pragmatic	rationality,	and	accepted	norms	of	moral	conduct	(see	Stier	2013). The	main	obstacle	to	the	reduction	of	psychiatry	to	neuroscience	appears	to	come	from	the	role	that considerations	about	rationality	currently	play	in	the	classification	and	diagnosis	of	mental	disorders	(see	Pickard 2009;	Broome	and	Bortolotti	2009	for	some	examples).	The	diagnostic	criteria	in	the	ICD	and	DSM	rely	almost exclusively	on	behavioral	manifestations,	and	many	of	them	are	described	as	deviations	from	rationality.	As Dominic	Murphy	says,	the	DSM	offers	a	picture	of	mental	disorders	as	"a	collections	of	signs	and	symptoms"	which "depend	on	physical	processes	but	are	not	defined	or	classified	in	terms	of	those	physical	processes"	(Murphy 2009,	p.	107).	For	a	variety	of	common	disorders	such	as	depression,	schizophrenia,	autism,	and	dementia,	the symptoms	are	characterized	in	terms	of	deviations	from	rationality,	especially	epistemic	requirements,	or	social norms	(see	Box	1	for	some	examples). Is	Epistemic	Rationality	the	Mark	of	Mental	Illness? The	fact	that	a	variety	of	common	disorders	are	chiefly	characterized	as	breakdowns	of	epistemic	rationality	may suggest	that	there	is	a	very	close	relationship	between	such	deviations	from	rationality	and	mental	disorder,	but	it would	be	hasty	to	conclude	that	epistemic	irrationality	is	sufficient,	or	even	necessary,	for	mental	disorder.	First,	as cognitive	and	social	psychologists	have	insisted	since	the	1970s,	epistemic	irrationality	is	a	feature	of	normal cognition	and	is	not	confined	to	those	who	have	a	psychiatric	diagnosis.	People	systematically	fail	to	test	simple conditional	statements;	are	unable	to	determine	the	relative	probability	of	statements;	and	routinely	exhibit inconsistent	beliefs	and	preferences	(Stein	1996).	These	reasoning	mistakes	and	inconsistencies	are	observed	not only	in	the	lab;	they	are	also	widespread	in	everyday	decision-making,	and	do	not	spare	those	with	professional expertise	in	the	making	of	decisions	involving	deductive	and	probabilistic	inferences,	such	as	statisticians	and medical	doctors	(see,	for	instance,	Garb	1998). We	do	not	need	to	read	the	psychological	literature	to	appreciate	the	extent	to	which	human	cognition	is	plagued Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 5 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 by	irrationality.	According	to	norms	of	epistemic	rationality,	a	belief	is	rational	if	it	is	well	supported	by,	and responsive	to,	the	available	evidence.	There	are	many	instances	of	ordinary,	non-pathological,	beliefs	that	do	not meet	these	standards.	The	racist	belief	that	members	of	a	certain	ethnic	group	are	violent	or	lazy	is	not	obviously less	irrational	than	the	delusional	belief	that	one's	neighbor	is	a	spy	paid	by	the	government	to	follow	one's movements	(persecutory	delusion),	or	that	one's	romantic	partner	is	unfaithful	(delusion	of	jealousy).	Racist	or superstitious	beliefs	share	many	of	the	epistemic	features	of	delusions:	they	are	typically	false;	they	may	conflict with	other	beliefs	the	person	has;	they	are	badly	supported	by	the	available	evidence;	and	they	are	often incredibly	resistant	to	counter-evidence	(Bortolotti	2009,	chapter	3). One	reason	why	racist	and	superstitious	beliefs	come	across	as	less	puzzling	than	delusions	is	that	they	are widespread	in	the	population,	whilst	delusions	are	rare.	Another	reason	is	that	the	content	of	everyday	irrational beliefs	tends	to	be	more	mundane	than	the	content	of	delusions.	One	can	understand	how	racist	beliefs	are formed,	but	it	is	more	difficult	to	make	sense	of	the	formation	of	many	delusions	if	no	specific	reference	is	made	to the	anomalous	experience	people	may	have	had	prior	to	adopting	delusional	hypotheses.	Delusions	such	as Capgras,	where	the	person	reports	that	a	loved	one	has	been	replaced	by	an	impostor,	or	Cotard,	where	the person	claims	to	be	dead	or	disembodied,	seem	so	implausible	as	to	involve	a	different	sort	of	irrationality. But	even	Capgras	and	Cotard	delusions	make	some	sense	to	those	who	are	clinically	trained.	If	we	learn	that	a woman	who	comes	to	believe	that	her	husband	has	been	replaced	by	an	almost	identical	impostor	does	not	feel the	same	affective	response	she	used	to	feel	when	she	sees	her	husband,	then	her	delusion	becomes	more understandable-her	recognition	of	her	husband	is	compromised.	The	delusional	belief	is	still	implausible,	but	it	is not	unmotivated.	Moreover,	whether	beliefs	are	widespread	and	whether	their	content	is	puzzling	to	our	ears	seem to	be	contingent	facts	about	the	assumptions	shared	in	the	society	in	which	such	beliefs	are	reported,	and	do	not seem	necessarily	to	point	to	any	significant	epistemic	difference. Some	authors	remain	unconvinced	that	there	is	continuity	between	familiar	and	more	exotic	forms	of	irrationality, and	argue	that	pathological	irrationality	is	more	persistent	and	severe	(e.g.,	Edwards	1981),	or	is	of	a	different quality	because	it	signals	a	more	dramatic	failure	to	be	in	touch	with	reality	(e.g.,	Gallagher	2009).	But	the epistemic	irrationality	exhibited	in	the	context	of	many	psychiatric	disorders	is	often	not	persistent,	and,	as	we	shall see,	is	not	necessarily	more	severe	than	the	irrationality	found	in	the	non-clinical	population	(Bortolotti	2013). Moreover,	the	assumption	that	familiar	irrationality	does	not	involve	losing	touch	with	reality	should	be	more thoroughly	challenged	in	the	literature.	What	is	the	disanalogy	between	the	irrational	belief	of	the	person	affected by	prejudice	and	the	irrational	belief	of	the	person	affected	by	delusions	of	persecution,	in	terms	of	reality	checks? Insofar	as	the	beliefs	are	irresponsive	to	evidence,	they	signal	a	departure	from	reality.	The	person	with	sexist beliefs	who	refuses	to	acknowledge	evidence	for	the	view	that,	say,	women	make	good	scientists,	shuts	herself	off from	the	game	of	evidential	support	that	all	epistemically	rational	believers	should	play.	These	mundane	failures	to engage	with	reality	may	not	capture	our	imagination	as	bizarre	delusional	hypotheses	do,	but,	from	an	epistemic point	of	view,	they	are	on	a	continuum	with	them. Epistemic	irrationality	is	not	even	necessary	for	mental	illness.	There	is	no	reason	to	suppose	that	mental	illness needs	to	manifest	as	a	failure	of	epistemic	rationality	and,	indeed,	the	diagnostic	criteria	for	anxiety	disorder	and personality	disorders	do	not	include	behaviours	characterized	by	epistemic	irrationality.	Moreover,	in	some specific	tasks,	people	with	psychiatric	diagnoses	that	are	characterized	in	terms	of	deviations	from	rationality	seem to	be	more	epistemically	rational	than	non-clinical	samples.	Studies	investigating	what	has	been	called	depressive realism	suggest	that	people	make	more	accurate	predictions	when	they	are	depressed	(for	a	review,	see Abramson	et	al.	2002).	This	is	because	the	statistically	normal	way	in	which	predictions	are	made	is	characterized by	excessive	optimism.	The	phenomenon	of	depressive	realism	is	controversial	(for	recent	evidence	against	the phenomenon,	see	Baker	et	al.	2011),	but	similar	phenomena	have	been	observed	for	other	diagnoses.	There	is evidence	in	autism	and	schizophrenia	that	the	reasoning	tendencies	partially	responsible	for	the	formation	of pathological	beliefs,	or	underlying	pathological	behavior,	can	also	have	epistemic	benefits	relative	to	those	found in	the	non-clinical	population	(Tateno	2013;	De	Martino	et	al.	2008;	Owen	et	al.	2007).	For	instance,	people	with schizophrenia	have	been	found	to	be	less	vulnerable	to	framing	effects,	and	do	not	exhibit	a	statistically	normal but	procedurally	irrational	increased	tendency	to	gamble	when	faced	with	a	certain	loss	(Brown	et	al.	2013). Therefore,	although	epistemic	irrationality	is	undoubtedly	a	characteristic	of	the	behavior	of	people	diagnosed	with some	mental	disorders,	we	can	have	mental	disorder	without	epistemic	irrationality,	and	epistemic	irrationality without	mental	disorder. Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 6 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 Is	Pragmatic	Irrationality	the	Mark	of	Mental	Illness? The	above	discussion	questions	the	strength	of	the	association	between	epistemic	irrationality	and	psychiatric diagnosis.	We	now	consider	the	role	of	pragmatic	irrationality	in	psychiatric	classification	and	diagnosis.	In	this chapter,	we	use	the	term	pragmatic	rationality	to	refer	to	decision-making	that	promotes	the	agent's	wellbeing	or success	in	pursuing	their	goals.	An	alternative	notion	of	rationality	is	captured	by	the	notion	of	ecological rationality,	which	refers	to	decision-making	strategies	that	promote	genetic	fitness,	measured	in	terms	of	chances of	survival	and	reproduction.	The	distinction	between	pragmatic	and	ecological	rationality	maps	onto	the	distinction between	psychological	adaptiveness	(where	the	goal	is	to	increase	well-being)	and	biological	adaptiveness	(where the	goal	is	to	enhance	genetic	fitness),	which	we	owe	to	Ryan	McKay	and	Daniel	Dennett	(2009).	They	point	out that	some	behavior	can	be	psychologically	adaptive	without	being	biologically	so,	because	the	relationship between	well-being	and	genetic	fitness	is	a	complex	one.	Here	we	focus	on	the	hypothesis	according	to	which pragmatic	irrationality-decision-making	that	compromises	the	well-being	or	success	of	an	agent	in	pursing	their goals-is	the	marker	of	mental	disorder. An	argument	for	the	claim	that	pragmatic	irrationality	is	what	demarcates	mental	disorder	could	be	advanced	as follows.	Depressive	realists	may	have	a	more	accurate	representation	of	reality,	and	may	make	better	predictions about	future	events.	And	people	with	schizophrenia	may	be	less	risk-taking	when	faced	with	a	certain	loss.	But these	epistemic	advantages	apparently	do	not	translate	into	well-being	and	success	from	a	pragmatic	perspective. People	with	these	mental	disorders	struggle	to	flourish.	Mental	disorder,	it	might	be	proposed,	undermines	the rational	capacities	that	enable	agents	to	navigate	their	environment,	pursuing	and	achieving	at	least	some	of	their goals.	Indeed,	this	could	be	the	difference	between	the	person	with	racist	beliefs	and	the	person	with	delusions: maybe	they	are	both	epistemically	irrational,	but	racist	beliefs	as	opposed	to	delusions	are	pragmatically	neutral	or may	even	have	pragmatic	benefits. The	difficulty	is	that	it	is	not	clear,	in	general,	that	everyday	instances	of	epistemic	irrationality	increase	flourishing or	are	at	least	pragmatically	neutral;	nor	that	the	epistemic	irrationality	associated	with	mental	disorder	generally undermines	flourishing.	It	is	true	that	commonplace	over-optimistic	trains	of	thought	have	been	consistently	shown to	impact	positively	on	mental	and	physical	well-being	(Taylor	et	al.	2003).	But	the	case	of	people	with schizophrenia	taking	fewer	risks	as	a	response	to	the	prospect	of	certain	loss	does	not	seem	to	support	the proposal.	This	uncommon	epistemic	rationality	means	that	people	with	a	diagnosis	of	schizophrenia	are	less	likely to	lose	in	gambling	situations	by	choosing	the	less	risky	option,	and	thus	are	likely	to	make	better	decisions, arguably	promoting	well-being	and	success.	Conversely,	while	commonplace	racist	and	superstitious	beliefs	can offer	comfort	and	increase	self-esteem	in	the	short	term,	they	will	often	be	socially	sanctioned	in	the	long	run, leading	to	distress	and	loss	of	self-esteem.	Thus,	the	hypothesis	that	pragmatic	irrationality	is	the	marker	of	mental disorder	deserves	closer	examination.	Some	apparent	counter-examples	include	the	case	of	"successful psychotics"	(who	experience	hallucinations	and	delusions	but	find	meaning	in	life	thanks	to	those	psychotic experiences,	and	function	well),	and	the	notion	of	"successful	psychopaths"	(Board	and	Fritzon	2005).	In	both cases,	it	is	apparently	judged	that	a	psychiatric	diagnosis	is	appropriate-as	indicated	by	the	use	of	diagnostic language	in	these	labels-despite	the	person's	apparent	flourishing	as	an	agent. Interim	Summary So	far,	we	have	discussed	the	role	of	epistemic	and	pragmatic	rationality	in	psychiatric	classification	and diagnosis,	and	considered	whether	either	is	the	distinctive	marker	of	mental	disorder.	We	observed	that	the diagnostic	criteria	of	many	psychiatric	categories	make	reference	to	cognitive	or	affective	impairments	described in	the	language	of	rationality	and	social	functioning.	We	then	asked	whether	mental	disorder	is	demarcated	by reference	to	the	violation	of	epistemic	norms,	and	concluded	that	this	is	implausible,	due	to:	(1)	the	pervasiveness of	epistemic	irrationality	in	the	non-clinical	population;	(2)	the	fact	that	epistemic	irrationality	does	not	have	a different	quality	when	it	is	present	in	people	with	a	psychiatric	diagnosis	(it	always	involves	some	sort	of	departure from	reality);	and	(3)	the	fact	that	on	some	occasions	the	reasoning	styles	and	strategies	of	people	affected	by mental	disorder	are	more	conducive	to	epistemic	rationality	than	the	styles	and	strategies	of	the	non-clinical population-a	theme	that	will	be	picked	up	again	in	the	sections	that	follow.	We	found	it	more	plausible	that	mental disorder	is	demarcated	by	pragmatic	irrationality,	where	decision-making	results	in	diminished	well-being	or compromised	success	in	the	pursuit	of	one's	goals.	However,	we	note	that	there	are	unresolved	issues	and 2 Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 7 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 potential	counter-examples	associated	with	this	proposal	as	well. Rationality	and	Patient	Autonomy The	question	of	when,	if	ever,	a	person's	mental	state	justifies	not	respecting	their	wishes	concerning	some	aspect of	their	medical	care	is	a	place	where	the	interplay	between	psychiatric	diagnosis	and	rationality	is	brought	into sharp	relief.	In	this	context,	judgments	concerning	diagnosis	and	rationality	have	serious	consequences	in	terms	of legal	recognition	and	fundamental	rights	to	liberty	and	bodily	integrity.	It	is	therefore	an	area	where	the	issues discussed	above	take	on	particular	legal	and	ethical	significance. The	problem	is	traditionally	set	up	in	the	following	way.	In	addition	to	a	broad	commitment	to	preserving	an	adult's right	to	direct	the	course	of	their	own	medical	care,	the	law	must	find	a	way	to	accommodate	the	strong	intuition that	sometimes	the	right	thing	to	do	(or	the	least	wrong	thing	to	do)	is	to	infringe	on	decision-making	liberty	in	order to	protect	the	person.	Understood	in	this	way,	the	challenge	is	to	establish	the	appropriate	grounds	for	deciding when	to	intervene.	Typically,	it	is	understood	that	there	are	two	potential	sources	of	justification	for	intervening: mental	disorder	and	mental	incapacity. Mental	Disorder	as	Grounds	for	Interference One	approach	taken	in	many	jurisdictions	holds	that	the	presence	of	mental	disorder	authorizes	intervention merely	on	grounds	of	the	risk	the	person	poses	to	their	own	health	or	safety.	Justifications	of	this	kind	of	approach refer	to	impaired	insight	in	mental	disorder	(Saddichha	2008);	to	mental	disorder	removing	autonomous	control (Doyal	and	Sheather	2005);	to	the	association	of	mental	illness	with	global	irrationality	(discussed	in	Hewitt	2010); and	to	the	idea	that	mental	disorder	undermines	personal	identity	(Edwards	2010;	Matthews	2000)	or	diachronic agency	(Janssens	et	al.	2004).	Whatever	the	underlying	assumptions,	law	that	bases	interference	on	the	presence of	mental	disorder-the	so-called	"status"	approach-holds	that	a	psychiatric	diagnosis	eliminates	the	need	to assess	the	person's	decision-making	ability.	The	diagnosis	alone	is	taken	to	mean	that	the	person	is	not	in	a position	to	decide	for	themselves,	at	least	in	relation	to	psychiatric	treatment,	and	such	legal	structures	have	been widely	criticized	because	of	this	feature	(Department	of	Health	1999;	Szmukler	and	Dawson	2011;	Wildeman 2013). In	addition	to	this	concern,	criticisms	have	focused	on	the	risk-based	grounding	of	intervention	that	is	often	a feature	of	the	status	approach.	This	conflicts	with	a	liberal	understanding	of	the	appropriate	scope	of	the	law, which	requires	that	legal	structures	allow	for	considerable	flexibility	when	it	comes	to	the	different	kinds	of	lives people	choose	to	live	(Plant	2011).	The	law	must	allow	for	controversial	treatment	decisions	to	sometimes	be respected,	on	grounds	that	in	some	cases	the	controversial	nature	of	a	decision	will	be	explained	by	the	person's idiosyncratic	commitments-their	particular	desires,	values,	projects,	what	makes	life	meaningful	for	them.	By focusing	on	the	risk	to	health	and	safety,	such	laws	do	not	allow	for	any	divergence	of	perspective	on	the	question of	what	ends	should	be	pursued.	Health	and	safety	is	what	matters,	whether	or	not	these	are	the	primary	concerns for	the	person	in	question. Mental	Incapacity	as	Grounds	for	Interference In	contrast,	a	mental	capacity	approach	to	the	question	of	when	interference	is	justified	is	held	up	as	a	much	more progressive	answer.	For	example,	in	England	and	Wales,	the	Mental	Capacity	Act	2005	(MCA)	is	understood	to address	both	of	the	above	concerns.	A	medical	diagnosis	is	neither	necessary	nor	sufficient	for	a	finding	of	mental incapacity	(though	the	person's	inability	to	decide	must	be	due	to	an	impairment	in	the	functioning	of	mind	or	brain (s.	2(1);	Department	of	Constitutional	Affairs	2007,	p.	44)).	Rather,	an	assessment	of	person's	ability	to	understand, weigh,	and	use	relevant	information,	and	to	express	their	decision,	grounds	decisions	about	the	right	to	selfdetermination-what	is	known	as	a	functional	test. In	relation	to	the	second	concern,	to	significant	degree	assessments	of	mental	capacity	are	designed	to	be independent	of	the	choice	the	person	makes.	Different	jurisdictions	allow	for	the	seriousness	of	the	consequences to	influence	the	assessment	of	mental	capacity	in	different	ways.	When	the	consequences	are	serious,	the	test may	be	applied	more	stringently,	or	the	threshold	for	mental	capacity	may	be	raised	(Buchanan	2004). However,3 Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 8 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 this	flexibility	is	only	supposed	to	go	so	far.	It	is	generally	understood	that	an	adult's	treatment	decisions	must	be respected	if	they	have	the	mental	capacity	to	make	the	decision,	however	grave	the	potential	consequences,	and there	is	some	evidence	that	in	England	and	Wales	this	principle	is	being	put	into	practice.	In	2007,	Kerrie Wooltorton,	a	young	woman	with	a	history	of	mental	health	problems	and	suicide	attempts,	was	admitted	to	hospital having	deliberately	drunk	a	lethal	quantity	of	antifreeze.	She	refused	life-saving	treatment,	but	assented	to medicine	that	would	help	make	her	comfortable.	Her	wishes	were	respected	on	grounds	that	she	had	the	mental capacity	to	refuse	life-saving	treatment.	She	subsequently	died	in	hospital,	and	the	decision	to	respect	her	wishes was	supported	by	the	coroner	who	investigated	her	death	(David	et	al.	2010;	Richardson	2013). Because	of	these	features,	a	mental	capacity	approach	has	been	held	up	as	a	more	ethically	secure	basis	for overriding	patient	autonomy.	Legal	intervention	aims	to	be	independent	of	medical	diagnosis,	and	largely independent	of	the	person's	choice,	so	allowing	for	divergence	on	the	life-shaping	commitments	people	choose	to pursue.	In	essence,	mental	capacity	law	is	understood	to	make	moral	progress	because	its	focus	is	on	the decision-making	process.	Functional	tests	appear	to	operationalize	procedural	norms	of	rationality,	which, according	to	standard	views,	enable	people	to	pursue	whatever	it	is	they	want	to	pursue	(Craigie	and	Coram	2013; Williams	1981).	Appeal	to	these	norms	is	supposed	to	bring	impartiality	to	mental	incapacity	as	a	basis	for interference,	though	the	extent	of	the	role	they	play	in	practice	has	been	a	matter	of	debate	(see	Owen	et	al.	2009; Holroyd	2012;	Banner	2013;	Freyenhagen	and	O'Shea	2013;	Mackenzie	and	Rogers	2013). However,	recent	developments	in	international	human	rights	law	and	the	disability	rights	literature	have	called	into question	the	legitimacy	of	mental	incapacity	as	a	basis	for	overriding	patient	autonomy.	We	frame	this	challenge	as questioning	the	impartiality	of	the	mental	capacity	approach,	and	draw	on	the	puzzles	explored	in	the	sections above	to	explore	this	idea.	We	begin	by	examining	Ronald	Dworkin's	much-discussed	position	on	what	respect	for autonomy	requires	in	the	context	of	dementia,	which	provides	a	background	against	which	to	consider	this challenge. Respect	for	Autonomy	and	Dementia In	his	book	Life's	Dominion:	An	Argument	about	Abortion,	Euthanasia,	and	Individual	Freedom,	Ronald	Dworkin discusses	the	case	of	Margo,	a	woman	who	at	54	has	advanced	Alzheimer's	disease	(1994,	pp.	220–237).	Margo is	described	as	a	woman	who	reads	mysteries	but	her	place	in	the	book	jumps	randomly	from	day	to	day.	She attends	art	class	where	she	paints	pretty	much	the	same	picture	every	time,	and	enjoys	listening	to	music,	happily listening	to	the	same	song	over	and	over	as	if	for	the	first	time,	though	she	does	smile	at	a	particular	song	which she	says	reminds	her	of	her	deceased	husband.	Despite	her	illness,	one	of	Margo's	carers	describes	her	as	one	of the	happiest	people	he	has	known.	In	his	words,	the	Alzheimer's	was	leaving	her	"carefree"	and	"always	cheerful" (Firlik	1991). Dworkin	asks	what	respect	for	autonomy	requires	if,	before	suffering	any	serious	mental	decline	Margo	had expressed	a	firm	wish,	in	writing,	that	life-saving	treatment	should	be	withheld	once	she	was	in	the	advanced stages	of	the	illness,	allowing	her	to	die.	Should	treatment	be	withheld,	for	example,	if	Margo	contracts	a	respiratory infection	that	is	life-threatening	but	could	easily	be	treated	with	antibiotics?	Based	on	an	analysis	of	what	makes	it the	case	that	we	ought,	generally,	to	respect	people's	personal	choices,	Dworkin	argues	that	life-saving	treatment in	such	a	case	should	be	withheld.	According	to	Dworkin,	it	is	Margo's	prior	wishes	that	should	be	given	legal effect,	because	the	importance	of	respecting	autonomy	"derives	from	the	capacity	it	protects;	the	capacity	to express	one's	own	character-values,	commitments,	convictions,	and	critical	as	well	as	experiential	interests-in the	life	one	leads.	Recognizing	an	individual	right	of	autonomy	makes	self-creation	possible"	(Dworkin	1994,	p. 224). The	right	to	autonomy	rests	on	the	capacity	to	lead	a	life	in	this	sense,	and	in	Dworkin's	view	Margo	no	longer	has this	capacity.	What	is	essential	is	a	person's	ability	to	consider	their	critical	interests:	their	own	ideas	of	what	for them	makes	life	successful,	not	merely	enjoyable	or	not	in	the	moment.	Importantly,	in	adopting	this	position, Dworkin	rejects	the	idea	that	respect	for	autonomy	is	required	because	people	know	best	what	is	good	for	them, and	therefore	that	welfare	considerations	underpin	the	principle.	It	is	clear,	according	to	Dworkin,	that	autonomy requires	that	personal	choices	are	respected	even	when	they	are	against	the	individual's	avowed	interests	(as	in weakness	of	will	and	acts	of	self-sacrifice	for	another). Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 9 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 Among	others,	Agnieszka	Jaworska	challenged	Dworkin's	conclusion	about	respect	for	autonomy	in	the	context	of dementia	on	the	basis	that	he	focuses	on	"peripheral	rather	than	essential"	elements	of	the	capacity	for	autonomy (1999,	p.	129;	for	other	criticisms	see	Dresser	1995;	Wolff	2012).	Jaworska	focuses	instead	on	the	possession	of decision-guiding	values	as	the	foundation	of	the	capacity	that	the	principle	of	respect	for	autonomy	aims	to protect.	She	argues	that	in	all	but	the	most	severe	cases	of	dementia,	the	person	remains	a	"valuer"-an	agent who	endorses	and	eschews	desires,	and	therefore	has	opinions	about	what	is	good	for	them.	In	her	view,	what	are lost	in	dementia	are	primarily	the	capacities	for	means-ends	reasoning	and	planning	that	enable	the	person	to make	decisions	in	accordance	with	these	values;	and	this	loss	does	not	justify	withdrawing	respect	for	autonomy: "An	Alzheimer's	patient	may	be	too	disoriented	to	form	a	life	plan	or	to	choose	specific	treatment	preferences,	but so	long	as	he	still	holds	values,	he	is,	in	the	most	basic	sense,	capable	of	self-governance,	and	this	fact	about	him commands	utmost	respect"	(Jaworska	1999,	p.	134). The	disagreement	between	Dworkin	and	Jaworska	can	be	understood	as	a	difference	on	what	capacities	are necessary	for	a	person	to	have	agency	that	requires	legal	recognition,	and	should	be	given	legal	effect	(at	least	in relation	to	this	kind	of	decision-Wolff	points	out	that	the	answer	is	likely	to	depend	on	the	nature	of	the	decision: Wolff	2012).	According	to	Jaworska,	only	the	capacity	to	value	is	essential.	For	Dworkin,	among	other	things,	the agent	must	have	the	capacity	to	make	decisions	from	a	life	overall	perspective.	This	requirement	is	apparently procedural	rather	than	substantive	in	nature	(it	does	not	specify	what	ends	the	agent	should	pursue).	Nonetheless, Dworkin's	position	appears	to	be	value-laden.	According	to	Dworkin,	it	is	the	importance	of	respecting	a	person's capacity	to	live	their	life	in	their	own	particular	way	that	justifies	non-interference,	and	his	conclusion	therefore entails	that	Margo	is	unable	to	live	life	in	her	own	particular	way.	But	in	a	straightforward	sense	Margo	clearly	is living	life	in	her	own	way.	It's	just	not	a	way	that	is	directed	from	a	life-overall-a	life	with	a	plan-perspective. The	importance	of	the	procedural	requirements	that	Dworkin	holds	are	essential	for	attracting	respect	for	autonomy is	derived	from	his	commitment	to	the	value	of	human	life	being	structured	by	a	plan. His	position	on	Margo's	case therefore	illustrates	one	way	in	which	mental	incapacity	as	a	justification	for	not	respecting	autonomy,	seems, ultimately,	to	have	value-laden	roots. Rationality	and	Legal	Personhood The	disagreement	between	Dworkin	and	Jaworska	has	a	resonance	for	more	recent	developments	in	disability rights	law	and	literature,	which	have	challenged	the	use	of	mental	incapacity	as	a	basis	for	not	respecting	patient autonomy.	The	UN	Convention	on	the	Rights	of	Persons	with	Disabilities,	around	which	these	developments	are focused,	is	said	to	constitute	a	paradigm	shift	in	mental	health	law	(Richardson	2012;	Bartlett	2012;	Wildeman 2013).	According	to	Article	12	of	the	Convention,	persons	with	mental	disabilities,	including	mental	disorders,	must be	recognized	before	the	law	on	an	equal	basis	to	others,	and	must	be	supported	in	the	exercise	of	their	legal capacity.	A	strong	interpretation	holds	that	recognition	as	a	legal	person,	which	includes	the	right	to	respect	for autonomy	in	one's	personal	affairs,	should	not	be	limited	to	those	who	meet	the	requirements	of	functional	tests (Bach	and	Kerzner	2010;	United	Nations	Committee	on	the	Rights	of	Persons	with	Disabilities	2014). In	the	Convention,	this	position	is	set	against	a	background	commitment	to	the	equality,	dignity,	autonomy,	and needs	of	persons	with	disabilities,	as	well	as	a	social	model	of	disability	(preamble,	section	e).	While	medical models	explain	mental	disability	solely	with	reference	to	the	individual's	mental	impairment,	social	models	point	to the	environmental	factors	that	also	play	a	role	in	determining	whether	an	impairment	results	in	a	disability.	The social	model	supports	a	shift	away	from	mental	incapacity	as	a	basis	for	interference,	to	the	extent	that	it	suggests the	concept	of	mental	capacity,	which	is	focused	on	the	individual,	should	be	replaced	with	a	more	socially contingent	notion	of	decision-making	ability,	justifying	the	requirement	of	decision-making	supports.	However,	the de-linking	of	legal	capacity	from	mental	capacity	requires	further	justification,	and	these	arguments	have	been developed	in	the	surrounding	literature. One	central	moral	argument	given	in	support	of	this	position	holds	that	mental	capacity	tests	set	requirements	that, if	strictly	applied,	most	people	would	fail	to	meet-a	view	that	garners	support	from	the	sections	above.	Most prominently,	Michael	Bach	and	Gerard	Quinn	have	questioned	the	degree	to	which	people	generally	understand the	complex	health	care	interventions	to	which	they	consent	(among	other	kinds	of	decision;	Bach	2009;	Quinn 2010).	Bach	and	Quinn	can	be	understood	to	rightly	highlight	that	having	mental	capacity	does	not	require	full procedural	rationality.	It	seems	true	the	most	of	us	will	not	fully	understand	the	probabilistic	results	of	diagnostic 4 Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 10 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 tests	before	making	a	related	decision;	and	most	of	us	place	less	value	than	we	should	on	consequences	in	the	far future	relative	to	those	in	the	near	future,	according	to	theories	of	rationality.	Rather,	functional	tests	are	about having	good	enough-which	in	practice	means	statistically	normal-rational	capacities.	The	threshold	for	mental capacity	is	set	so	that	most	people	have	legal	capacity,	and	therefore	it	is	political	considerations,	as	much	as rationality	considerations,	that	determine	the	requirements	of	mental	capacity	tests	(Buchanan	2004). Framed	in	this	way,	the	argument	against	mental	capacity	as	a	basis	for	interference	is	analogous	to	liberal criticisms	of	dedicated	mental	health	law.	The	proposal	is	that	Bach	and	Quinn	are	essentially	arguing	that	mental capacity	law	is	unfair	because	the	line	determining	whose	decisions	are	respected	is	drawn	on	the	basis	of	how statistically	normal	an	irrationality	is.	From	a	liberal	perspective	it	is	wrong	to	draw	this	line	on	the	basis	that someone	is	not	living	their	life	in	a	normal	way,	which	raises	the	question:	why	is	statistical	normality	justified	as	a way	of	drawing	the	line	when	it	concerns	how	people	deliberate	in	their	personal	decisions? Neurodiversity	and	Mental	Capacity The	emerging	concept	of	neurodiversity,	which	is	being	used	to	reinterpret	certain	psychiatric	categories,	can	be used	further	to	develop	this	idea.	The	central	example	is	autism,	but	wherever	it	is	applied,	a	neurodiversity perspective	seeks	to	redefine	a	diagnostic	category	primarily	as	a	set	of	cognitive	differences.	The	features	that are	used	to	identify	the	category	are	understood	to	be	atypical,	but	not	intrinsically	dysfunctional	(Jaarsma	and Welin	2012). In	relation	to	autism	the	call	for	this	reassessment	has	been	motivated,	among	other	factors,	by	scientific	findings that	suggest	autism	is	more	accurately	described	as	a	cognitive	profile	or	cognitive	style,	which	confers	both advantages	and	disadvantages,	rather	than	straightforwardly	as	a	disorder.	The	idea	can	be	explained	using	the weak	cognitive	coherence	theory	of	autism	(Happe	1999),	though	it	does	not	depend	on	this	particular	theory turning	out	to	be	true.	According	to	the	weak	cognitive	coherence	theory,	while	for	most	people	information	is processed	using	its	broader	context-often	at	the	expense	of	local-level	information,	as	we	will	see	below-for autistic	people	cognitive	processing	is	focused	on	the	local	level,	at	the	expense	of	more	global	and	contextual features.	Global	processing	means	that	for	most	people,	the	words	of	a	sentence	with	meaning	are	easier	to remember	than	a	random	list	of	words	of	the	same	length,	and	the	perception	of	an	object	is	strongly	influenced	by its	context.	This	processing	style	confers	many	advantages,	but	also	disadvantages,	as	seen	in	the	difficulty	that most	people	have	remembering	random	lists	of	words;	in	visual	illusions	induced	by	contextual	features;	and	in framing	effects	that	are	examples	of	epistemic	irrationality	that	is	widespread	in	the	general	population.	On	a	range of	these	kinds	of	tasks	there	is	increasing	evidence	that	autistic	people	tend	to	outperform	non-clinical	controls (e.g.,	De	Martino	et	al.	2008;	for	overview	Happe	1999,	Mottron	2011). In	relation	to	the	arguments	against	mental	incapacity	as	a	basis	for	interference,	this	understanding	of	autism reinforces	the	concern	that	statistical	normality	more	than	rationality	may	be	driving	assessments	of	mental capacity.	Tyler	Cowen	observes	that	in	psychological	studies	where	a	difference	in	performance	is	observed between	an	autistic	group	and	a	non-clinical	control	group,	it	is	often	assumed	that	the	difference	is	explained	by	a cognitive	impairment	associated	with	autism,	even	where	the	autistic	group	clearly	outperforms	controls	(Cowen 2011;	De	Martino	et	al.	2008).	The	concern	is	that	a	parallel	interpretation	occurs	in	the	context	of	mental	capacity assessments	(Mackenzie	and	Watts	2011).	While	both	globally	focused	processing	and	locally	focused	processing confer	mental	incapacities,	it	seems	plausible-likely,	even-that	only	the	incapacities	associated	with	locally focused	(autistic)	processing	will	be	identified	as	such,	and	as	potentially	relevant	grounds	for	mental	incapacity	in the	legal	sense.	The	incapacities	that	are	a	product	of	globally	focused	processing	will	be	accepted	because	they are	statistically	normal,	however	much	epistemic	irrationality	they	involve.	There	may	even	be	a	danger	that	locally focused	cognitive	advantages	that	are	characteristic	of	autism,	conferring	more	epistemically	rational	decisionmaking,	will	be	interpreted	as	an	incapacity	because	of	their	abnormal	rationality	relative	to	the	general	population. Open	Questions	and	New	Directions	for	Research It	has	long	been	understood	that	psychiatric	diagnosis	is	a	morally	problematic	basis	for	not	respecting	patient autonomy,	because	on	this	approach	a	psychiatric	diagnosis	is	automatically	taken	to	mean	that	you	are	unable	to make	a	decision	for	yourself.	Our	analysis	of	the	relationship	between	psychiatric	categories	and	rationality	in	the Rationality, Diagnosis, and Patient Autonomy in Psychiatry Page 11 of 15 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 first	half	of	the	chapter	reinforces	the	point.	The	lack	of	a	neat,	necessary	connection	between	irrationality	and mental	disorder	calls	into	question	the	assumed,	straightforward,	link	between	psychiatric	diagnosis	and	decisionmaking	abilities,	in	both	the	epistemic	and	the	pragmatic	sense. A	mental	capacity	approach	is	seen	as	morally	progressive	because	it	seems	to	focus	on	what	really	matters: decision-making	abilities.	But	recent	developments	in	the	disability	rights	literature	point	to	the	role	that	statistical normality	apparently	plays	in	deciding	what	counts	as	mental	incapacity.	We	believe	that	these	developments raise	new	and	important	questions	about	the	moral	legitimacy	of	the	mental	capacity	approach-questions	that deserve	closer	examination.	We	note	also	that	the	role	played	by	statistical	normality	in	mental	capacity	tests raises	a	question	about	its	role	in	distinguishing	mentally	healthy	behavior	from	behavior	that	attracts	a	psychiatric diagnosis. Assessing	the	strength	of	this	challenge	to	the	mental	capacity	approach	depends	on	the	extent	to	which	mental capacity	tests	are	based	on	statistical	normality	rather	than	epistemic	or	pragmatic	rationality;	and	whether	this	is morally	justified.	It	might	be	argued,	for	example,	that	things	do	in	fact	go	much	worse	for	a	person	when	their mental	capacities	fall	below	a	statistically	normal	threshold.	On	such	a	view,	welfare	considerations	would	play	a more	significant	role	in	justifying	interference	than	is	recognized	on	Dworkin's	account.	Finally,	the	arguments concerning	neurodiversity	depend	on	its	success	as	a	way	of	understanding	categories	such	as	autism.	It	seems to	us	that	the	reinterpretation	of	psychiatric	disorders	primarily	as	differences	will	have	its	limits,	but	where	these are,	and	what	this	means	for	the	mental	capacity	approach	to	justifying	interference,	remains	an	open	question. 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Under the terms of the l icence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy). date: 19 January 2015 the	Convention	on	the	Rights	of	Persons	with	Disabilities.	Journal	of	Law,	Medicine	and	Ethics	41(1):	48–73. Williams,	B.	(1981).	Internal	and	external	reasons.	In	Moral	Luck,	pp.	101–113.	Cambridge:	Cambridge	University Press. Wolff,	J.	(2012).	Dementia,	death	and	advance	directives.	Heath	Economics,	Policy	and	Law	7:	499–506. World	Health	Organization	(2007).	International	Statistical	Classification	of	Diseases	and	Related	Health Problems,	10th	Revision	(ICD-10),	Section	F-Mental	and	Behavioural	Disorders. Notes: ( )	We	note	that	these	are	two	alternative	readings	of	"things	going	well	for	the	agent",	which	will	sometimes	come into	conflict.	An	agent	pursing	their	chosen	goals	will	in	some	cases	undermine	their	well-being,	for	example someone	may	compromise	their	own	well-being	in	caring	for	others	or	in	pursuit	of	a	career. ( )	Another	hypothesis	worth	considering	is	that	the	person	who	is	mentally	disordered	behaves	in	a	way	that	does not	promote	her	chances	of	survival	and	reproduction.	This	is	an	interesting	hypothesis	to	explore,	but	we	will	not discuss	it	here. ( )	For	an	example	of	this	principle	expressed	in	English	case	law:	"What	matters	is	that	the	doctors	should consider	whether	at	that	time	he	had	a	capacity	which	was	commensurate	with	the	gravity	of	the	decision	which	he purported	to	make.	The	more	serious	the	decision,	the	greater	the	capacity	required"	(Lord	Donaldson	in	Re	T (Adult:	Refusal	of	Treatment)	[1993]	Fam	95	at	[28]). ( )	For	a	discussion	of	potential	justifications	for	this	kind	of	requirement	see	Craigie	(2013). Jillian	Craigie Jillian	Craigie,	Department	of	Philosophy,	University	College	London Lisa	Bortolotti Lisa	Bortolotti,	Philosophy	Department,	University	of	Birmingham 1 2 3