Beyond Mental Competence

Justification for psychiatric paternalism is most easily established where mental illness renders the person mentally incompetent, depriving him of the capacity for rational agency and for autonomy, hence undermining the basis for liberal rights against paternalism. But some philosophers, and no doubt some doctors, have been deeply concerned by the inadequacy of the concept of mental incompetence to encapsulate some apparently appealing cases for psychiatric paternalism. We ought to view mental incompetence as just one subset of a broader justification for psychiatric paternalism. The very basis of liberal limitations on psychiatric paternalism, whether described in terms of rights to autonomy or as respect for differences in values and lifestyles, presupposes a sense of moral persistence, and hence some sufficiently persistent self. Paternalistic intervention is warranted when we are unable to govern our lives in a manner consistent with the goals and values that comprise that ‘self’. One way that can occur is when we lack the mental capacities required for autonomy, such that we are unable to interpret and interact with our environment in order to meaningfully pursue our goals, i.e. mental incompetence. But it can also occur when we are subject to impositions that alter our goals without altering our capacity to pursue them — i.e. when it is our ‘self’ that is impaired rather than our competence.