Bipolar Autonomy: Excellent Agency and Marginal Agency

This post is by Elliot Porter. Elliot is a lecturer in bioethics at Brighton and Sussex Medical School, and is finishing his PhD at the University of Kent. His research focuses on personal autonomy and mental disorder.  His research involves themes in metaethics, moral epistemology, and epistemic justice.

Elliot Porter

We have largely, but not entirely, moved past the intuition that significant mental disorder constitutes, ipso facto, an injury to an agent’s autonomy. Part of this shift stems from increasingly multidimensional approaches to autonomy that allow us to track, in finer detail, where injuries to autonomy do and do not lie.

We can identify autonomy-threatening influences at a higher resolution than simple ‘mental disorder’ language offers. The movement has also been pushed by the significant and growing literature that articulates the substantive normative and identity claims made by the neurodiversity movement.

The status of minority minds as test cases, to sharpen theories at their edges, is increasingly replaced by status as interlocutors in discussions about what typical and atypical, ordered and disordered, or appropriate or inappropriate workings of the mind involve. Where these influences meet, we have an opportunity to think about autonomy in quite new ways.

The core questions about autonomy are still hotly contested. Is it constitutively social, or only formatively? Are there contexts, such as in bioethics, where procedural conceptions of autonomy are sufficient, or do we need to bring in more substantive content there? Do substantive theories undercut autonomy by imposing values that even apparently autonomous agents are not free to reject? 

An attractive way of framing these disagreements focuses on autonomy’s status as an agency concept, casting these as disagreements about when agency flourishes. Even among theorists who do not share eudaemon approaches to ethics, there is an underlying teleology involved in taking autonomy to be an agency concept. How far we think agency relies on favourable social conditions to meet its teleological end tells us where we lie on the constitutively/non-constitutively social axis. 

Substantive and procedural conceptions of autonomy differ on whether agency is an engine more for making appropriate moves, or producing appropriate outputs. Our position on the substantive/procedural axis is set by how we characterise that teleological end.

What it takes to flourish is hostage to the description under which we are a subject of flourishing. The classical Aristotelian model considers what an excellent example of a man looks like: a political animal with rational capacities, who excels insofar as he exercises those capacities in ways conducive to his living well with others. 

On the far side of this tradition, Philippa Foot takes the subject of flourishing to be an organism; an entity defined in part by a set of biofunctional norms. To flourish is to be an excellent example of the kind of organism one is, and so humans flourish insofar as we reason and pursue goods accordance with a normative structure confined by our biological nature. In both of these cases, excellence in the kind of thing that we are turns on the description of what we are (rational political animal, a sapient organism). On a more or less eudaemon framework, someone can be autonomous when they flourish qua agent.

This is where the freedom to think about autonomy in new ways is liberating. We need an account of agency to understand flourishing if autonomy involves flourishing qua agent, but if agency admits of a plurality of models, as the growing neurodivergence literature indicates, then we can excel as agents under many different descriptions. Whilst we’re used to trading in cases of depression or mania as negative examples, where normal or ideal functioning has gone wrong, or as a test case to clarify the margins of normal agency, these shifts in the literature invite us to consider how depressive, manic, or any other type of mad agency works and what it’s excellent state would involve. 

The problem with bipolar autonomy, to take the example I have focused on in my research, is not that it involves defective agency, but that it extends more and less far in various dimensions in unusual ways. It is a lumpy and strange looking autonomy if we are used to the autonomy we get from neurotypical kinds of agency, but the key claim of the neurodiversity movement is that madness is owed recognition on its own terms. If there are different kinds of agency at work when we are depressed, anxious, manic, or even psychotic, questions of autonomy must address what kind of agency that is, what it looks like when it works as well as it can, and so what autonomy might look like when built on that kind of agency. 

Whilst we will often want our affective or psychotic episodes to end as quickly as possible, these episodes still can’t be written off for a great many people. They will come back over an over again, and so the kinds of agency available during these episodes will make up a significant portion of the tapestry of a life. We can try build autonomy around them, and find a spotty, porous, and inconstant kind of recognisable autonomy. 

Alternatively, we can build a relevant sort of autonomy on top of the agency we have. It will be lumpy, it will vary in its qualities as episodes begin and end, and will look a little foreign to familiar conceptions of autonomy. But if autonomy is a value we should aspire to and support others in achieving, it is still valuable when it is lumpy and built on atypical sorts of agency. Mad agents have as much reason to pursue the kinds of autonomy available to them as do neurotypical peers.