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Understanding Eating DisordersConceptual and Ethical Issues in the Treatment of Anorexia and Bulimia Nervosa$

Simona Giordano

Print publication date: 2005

Print ISBN-13: 9780199269747

Published to Oxford Scholarship Online: February 2006

DOI: 10.1093/0199269742.001.0001

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Is Pathological Behaviour Caused by Mental Illness ?

Is Pathological Behaviour Caused by Mental Illness ?

(p.58) 3 Is Pathological Behaviour Caused by Mental Illness ?
Understanding Eating Disorders

Simona Giordano (Contributor Webpage)

Oxford University Press

Abstract and Keywords

This chapter considers a widespread argument that behaviour classified as psychopathological is caused by the mental illness. It is common to believe, for example, that patients hear voices because they suffer from paranoid schizophrenia; or that they lose interest in life because they suffer from depression; or that they binge and fast because they suffer from bulimia and so on. It seems to follow that the autonomy of the person with a mental illness is diminished, and therefore paternalism towards mentally ill people can be justified precisely on the grounds that they have a mental illness. This chapter argues that a mental illness does not cause the experiences and behaviours that are regarded as pathological. It shows that it is fallacious to contend that abnormal experiences and behaviours are the result of an underlying mental illness. This has important ethical implications — paternalism cannot be claimed as ethical because the person has a mental illness.

Keywords:   pathological behaviour, mental illness, descriptions, tautologies

1. Introduction

In Chapter 2 I have argued that there is a prima facie obligation to respect other people's actions and choices, provided that these actions and choices are autonomous. Paternalism, at least prima facie, may be justifiable only when self‐harming behaviours are characterized by lack of autonomy (weak paternalism). Although many people agree with the idea that health‐care professionals should respect or even encourage their patients' autonomy, many also believe that this model of patient–professional relationship cannot be applied to the management of mental disorders. The peculiar nature of psychopathology, so the argument goes, makes it impossible to respect patients' autonomy.

The argument may take different forms. One of the most common claims is that mental illness jeopardizes people's autonomy. This argument is very common in ordinary discourse, in discussions within psychiatry, and in law. According to this position, behaviour that we classify as ‘symptomatic’ or ‘abnormal’ is caused by the mental illness—therefore it is necessarily non‐autonomous. A person is diagnosed as having a mental illness when she has abnormal experiences of different types and shows some types of anomalous behaviour. These experiences and behaviour result from an underlying mental disorder. Therefore, those experiences and behaviours are ‘symptomatic’ of the mental disorder. Mental illness is regarded as the cause, the reason, or the explanation of certain experiences, behaviour, and disturbances.

The argument is apparently straightforward and is accepted by many. It is very common to hear people saying, for example, that patients ‘hear voices’ because they suffer from paranoid schizophrenia; or that they lose interest in (p.59) life because they suffer from depression; or that they gamble because they suffer from pathologic gambling; or that they fear open spaces because they are agoraphobic; or that they want to be thin because they suffer from anorexia; or that they binge and fast because they suffer from bulimia. These sorts of arguments are commonplace in ordinary discourse as well as in medical literature and in law.

The ethical implications of these sorts of statements are important. If mental illness causes people to have some experiences, and drives people to behave in a certain way, this means that people do not have much control over those experiences and behaviours. These will be considered ‘pathological’. If pathological experiences and behaviours are the result of a mental illness, the sufferer has little control over them. It follows that the person's autonomy is diminished or compromised in important ways by the mental illness.

Where this is accepted, the diagnosis of mental illness or mental disorder will be considered as one of the criteria that justify coercive interventions. People who have a mental disorder will be regarded by definition as lacking autonomy in some important way. Since the psychiatric patient is regarded as non‐autonomous at least in some way, the issue of respect for her autonomy in those ways simply will not arise. The diagnosis of mental illness will thus provide a justification for paternalism. For example, under the Mental Health Act 1983 (MHA) the statute that regulates assessment and treatment of mental disorders in England and Wales, the diagnosis of mental illness, severe mental impairment, psychopathic disorder, and mental impairment is the first criterion that justifies coercive detention and treatment (s. 2 and s. 3 of the Act).

But is it true that people with mental illness have abnormal experiences and behaviour because of their mental illness? Is it true that mental illness causes some forms of anomalous experiences and behaviour? Is it true that mental illness determines people's behaviour and jeopardizes their autonomy? Is mental illness the ‘causal explanation’ of some people's experiences and behaviour?

This chapter will challenge these types of claims. The claim that people's experiences and behaviours are due to their mental illness involves a logical fallacy, although one that may have a psychological raison d'être, as I now illustrate.

2. ‘That man committed suicide because he was mentally ill’

One of my colleagues, Mr Harry Lesser, tells this story. One day the news reported the suicide of a well‐known British TV comedian. Harry Lesser was (p.60) listening to the news with his young son. The son was very disturbed to hear about the man killing himself and asked why he did that. The father said that the TV personality had killed himself because he was mentally ill. Lesser told me that by saying that the man had killed himself because he was mentally ill, he did not mean to give an explanation of the suicide; rather, as he pointed out to me, that type of answer ‘sets the action into a context’ and ‘makes it more tolerable’ (his words). By saying that the man committed suicide because he was mentally ill, he wanted to make the suicide more tolerable to his son.

Probably, the suicide was rendered more tolerable to the general public as well in the same way. Similarly, saying to people that they have determined experiences because they are mentally ill makes these experiences more tolerable to them.

Moreover, this type of answer (‘because he was mentally ill’) also suggests that the man ‘couldn't help it’. ‘In the absence of a mental illness’, one might expect people to realize that they have alternatives, and to try to control their desires and impulses. The emphasis on the ‘mental illness’ suggests that people cannot be held entirely responsible for their actions, that there is something overwhelming them, which compels them to act in a certain way—that their autonomy is diminished or jeopardized. It is, Lesser says, like the difference between saying that someone is a ‘heavy drinker’ and saying that someone is an ‘alcoholic’. Saying that someone is a heavy drinker leaves space for control over drinking; saying that someone is an alcoholic is to suggest that he or she has lost significant control over him or herself. So, saying that things happen because of mental illness is to suggest that people have no control over certain experiences and behaviours.

But is it true that people have determined experiences because they have a mental illness? Is it true that the comedian committed suicide because he was mentally ill?

It seems to me, and in this chapter I will argue, that saying that things happen to people because they are mentally ill is just a ready‐made answer. The problem with this statement is that it does not explain what it proposes to explain. It is a way of putting it, a way of saying it. As Lesser says, it is a way of putting things into context, and a way of making things more tolerable. Maybe it is also a way of making more tolerable to us the fact that we are unable to explain certain things. But it does not really say what it says. It does not really explain what happens. That because (‘because he was mentally ill’) does not provide an explanation of the action or of the experiences.

(p.61) 3. ‘I had to wash my hair ten times today because voices commanded me to do so’

Here is another story.

One day, while working in a psychiatric unit, I bumped into B I had known B for a long time. B had paranoid schizophrenia and she had been living in the hospital for years. As always, she said hello to me and came towards me to kiss me. I asked how she was and what she had been up to today. She said: ‘This afternoon I had to wash my hair ten times.’ I asked why. She answered very simply: ‘Because some voices ordered me to do so.’

For a long time I have been thinking about this brief conversation, about my question and her answer. She said: ‘Because some voices ordered me to do so.’ What did that word because mean? Was she really explaining her own behaviour? Did she really wash her hair because voices ordered her to do so—was that it?

After having thought about our conversation, I came to the conclusion that her answer was a proper answer, at least in an important way, and probably a better answer than one I could have had from a psychiatrist. She was not trying to provide any further explanation of her experiences and behaviour. She was not trying to explain why she heard voices, or why those voices were irresistible. She was just telling me why she washed her hair ten times—because voices gave the order. It is true, I was unsatisfied with that explanation—because I still did not know why she heard those voices, and why these voices were compelling to her. Of course, I could have asked her why she felt she could not resist that order, or what would have happened to her if she had refused to wash her hair, or whether she believed that the voices were right in asking her to wash her hair ten times, or whether she found it unreasonable to be asked to wash her hair ten times, or whether she found it unreasonable to obey the order, and so on. Indeed I could have asked her many things, but I did not.

I still wonder whether B thought the voices were right, or whether she could have refused to obey them. Although I still do not know many things about what happened to B that afternoon, I think her answer was appropriate in an important way. It was a proper answer to my question. In fact I did not ask her why she heard voices. I just asked why she had to wash her hair ten times. And the answer to that question was: because she heard voices that ordered her to do so.

Another thing that I could have done that afternoon (but I did not do) was to go to one of the psychiatrists in charge and ask why she was hearing voices—a question that is different from the original one ‘why did you wash your hair ten times?’ The reason why I did not ask ‘why does she hear voices?’ (p.62) is that I expected to receive the following answer: ‘because she has paranoid schizophrenia’, an answer that would have told me nothing more than I already knew about B. The truth, it seems to me, is that I do not know why B heard voices that afternoon, neither would a psychiatrist. I know why she washed her hair ten times—because she explained that to me: voices ordered her to do so.1 But the other question—why does she hear voices—remains unanswered.

If I say that B has been washing her hair ten times because voices commanded her to do so, I think I am saying something meaningful. One may wonder why B is unable to resist these voices, but there is nothing tautological in the statement that B has been washing her hair because voices ordered her to do so. There is at most a missing premiss, and the whole argument would go as follows:

  1. 1. some voices commanded B to wash her hair 10 times;

  2. 2. B could not resist (for some unspecified reason);

  3. 3. therefore she washed her hair ten times.

This trilogy properly answers the question: ‘Why has B washed her hair ten times this afternoon?’

If I ask, however: ‘Why does B hear voices?’, what answer can I have? Many would say: because she suffers from schizophrenia.

I will argue here that this sentence amounts to saying: B hears voices because she has hallucinations (= for example, hears voices). It sets B's experiences and behaviour into context; maybe it makes these experiences more tolerable to B; as Harry Lesser put it, it makes our incapacity to understand more tolerable to us; but, ultimately, it is logically fallacious—it is empty. The objection has been made to me that saying, for example, that voices are due to schizophrenia means ruling out other possible causes (such as brain tumours or the effects of drugs). Therefore, saying that the voices are due to schizophrenia is not an entirely empty statement. It is true that when one says, for example, that voices are due to schizophrenia one is implicitly saying that the person does not have a brain tumour or is not under the effect of drugs that produce hallucinations. However, from this it does not follow that the statement ‘voices are due to schizophrenia’ is logically correct. The statement may tell us a number of things about the person and her experiences, and also about how she may be treated, and therefore it may be a useful instrument in practice. However, this statement is still fallacious, from a logical point of view.

(p.63) 4. What do we Mean when we Say that a Person has a Mental Illness?

When we say that a person has a mental illness, all we are saying is that that person manifests some types of experiences and behaviour. For example, B has received the diagnosis of ‘schizophrenia’ because she has manifested some of the many experiences and behaviour that Bleuler listed under ‘paranoid schizophrenia’ (for example, hallucinations and intrusive thoughts).2 The psychiatric diagnosis summarizes in one word a large variety of disturbances (in perception, in language, in motion, and so on). Instead of saying: B has intrusive thoughts, auditory hallucinations, disorganized thought, and so on, we say: B has paranoid schizophrenia. All we mean is that B has intrusive thoughts, auditory hallucinations, disorganized thought, and so on.

The important thing to notice is that the psychiatric diagnosis summarizes these disturbances, but does not explain them. B has received the diagnosis of paranoid schizophrenia because she manifests a pattern of disturbances (for example, hallucinations). When I say that B is a paranoid schizophrenic, all I mean is that B has hallucinations, intrusive thoughts, ideas of reference, and possibly other symptoms. I do not know why she has these disturbances. I only know that she manifests these disturbances. I say that she is schizophrenic because I can see that she has these disturbances, not because I know the cause of her disturbances. I say that she is schizophrenic (= that she manifests hallucinations, intrusive thoughts, or ideas of reference), but I can give no explanation of why she is schizophrenic (= why she manifests hallucinations, intrusive thoughts, or ideas of reference).

The term ‘schizophrenia’ summarizes a number of disturbances, but does not say anything about the cause(s) of these disturbances. The diagnosis has descriptive value, not explicative value (diagnosis is not equivalent to scientific explanation).

The diagnosis certainly has an important predictive value.3 If I am told that B has paranoid schizophrenia, I shall not be surprised when she tells me that ‘voices’ commanded her to wash her hair, and I will probably be able to predict, at least approximately, what is going to happen to her at some point. However good I may be in predicting her behaviour (what may be mistaken for the ability to explain it), I still do not know why she has these disorders.

(p.64) The philosopher Gilbert Ryle noticed that we often make a similar mistake (considering the description as an explanation) when we believe we can ‘explain’ people's behaviour by referring to their ‘personality traits’. He wrote:

On hearing that a man is vain we expect him, in the first instance, to behave in certain ways, namely to talk a lot about himself, to cleave to the society of the eminent, to reject criticisms, to seek the footlights and to disengage himself from conversations about the merits of others. We expect him also to indulge in roseate daydreams about his own successes, to avoid recalling past failures and to plan for his own advancement. To be vain is to tend to act in these and innumerable other kindred ways. Certainly we also expect the vain man to feel certain pangs and flutters in certain situations; we expect him to have an acute sinking feeling, when an eminent person forgets his name, and to feel buoyant of heart and light of toe on hearing of the misfortunes of his rivals. But feelings of pique and buoyancy are not more directly indicative of vanity than are public acts of boasting or private acts of daydreaming. Indeed they are less directly indicative […] When we explain why a man boasts by saying that it is because he is vain, we are forgetting that a disposition is not an event and so cannot be a cause […] The vain man is a man who tends to register particular feelings of vanity; these cause or impel him to boast, or perhaps to will to boast, and to do all the other things which we say are done from vanity. It should be noticed that this argument takes it for granted that to explain an act as done from a certain motive, in this case from vanity, is to give a causal explanation. This means that it assumes that a mind, in this case the boaster's mind, is a field of special causes, that is why a vanity feeling has been called in to be the inner cause of the overt boasting […] to explain an act as done from a certain motive is not analogous to saying that the glass broke because a stone hit it […]4

Ryle also pointed out:

There are al least two quite different senses in which an occurrence is said to be ‘explained’ and there are correspondingly at least two quite different senses in which we ask ‘why’ it occurred and two quite different senses in which we say that it happened ‘because’ so and so was the case. The first sense is the causal sense. To ask why the glass broke is to ask what caused it to break, and we explain, in this sense, the fracture of the glass when we report that a stone hit it. The ‘because’ clause in the explanation reports an event, namely the event which stood to the fracture of the glass as cause to effect.5

Ryle proceeds to discuss in what other ways we may say that an occurrence is explained by this and that, and in what senses we may say that motives and inclinations explain our actions and behaviours. We do not need to get into (p.65) this discussion, because it is not entirely pertinent to our purposes. What is relevant here is to point out that when we ask: ‘Why did someone act in a certain way?’6 and we answer ‘Because he was mentally ill’, we may think we are providing a causal explanation, but we are not. As Ryle points out, saying that the man boasted because he is vain is not like saying that ‘the glass broke because a stone hit it’. All we are saying is that ‘we could have expected that to happen’. We have not established any causal explanation for the experiences and behaviours of that person; we have not given any ‘reason for’ those experiences and behaviours. Saying that ‘B hears voices because she has schizophrenia’ is like saying, as Ryle puts it, that ‘the glass broke because it was brittle’—given that we know that the glass was brittle, we may expect that it will break easily. But what actually did break the glass was the stone, and the glass broke because the stone hit it. In the context of psychiatric illnesses, given that we know that a person is inclined to have certain sorts of experiences, we may expect him to behave in a certain way. But these statements (‘the glass is brittle’—‘the person has had a diagnosis of schizophrenia’) are descriptive statements, with a predictive potential, and not explicative statements, in the same way as ‘the glass is broken because a stone hit it’ is explicative. In the case of mental illness, we are in a similar situation to the one in which we would be if we did not know that the glass was broken by a stone. We do not know what causes the experiences and behaviours that are listed under the psychiatric category. Psychiatry mostly offers descriptive statements (in contrast to physics and neurology as sciences,—if practised as such—that is, as efforts to obtain explanations of why).

To return to B, I think a logically correct way of constructing the situation is to say that B is (classified as, or described as) ‘schizophrenic’ because she manifests a pattern of disturbances (here the clause because is explicative—it explains why psychiatrists gave that particular diagnosis). She does not have these disturbances because she is schizophrenic. We do not know why she manifests these disturbances (unfortunately).

The way the situation of psychiatric patients is constructed in psychiatry is often logically fallacious, as the next section will show.

5. The Fallacy of Psychiatric ‘Explanations’

Box 3.1 contains a schema of the fallacy that often occurs in psychiatry, when people seem to give ‘explanations’ of patients' experiences and behaviours.


I shall focus on schizophrenia and other clinical categories. We shall see later in the chapter that the same fallacy applies to eating disorders. Answer 2b is a tautology.7 This kind of logical error is recurrent in psychiatry. Here there seems to be the tendency to believe that, once we give a name to a phenomenon, then this name explains such a phenomenon.

For example, it is said that people fear open space because they are agoraphobic. However, being agoraphobic means fearing open space. Thus, that statement amounts to saying that people fear open spaces because they fear open spaces—given that being agoraphobic means fearing open spaces. (p.67) Similar arguments are very common. For example: ‘I cannot control my gambling because I suffer from pathological gambling.’ If suffering from pathological gambling means being unable to control gambling, then saying that I cannot control gambling because I suffer from pathological gambling is like saying that I cannot control gambling because I cannot control gambling.

These statements are tautological. These statements point out that ‘we can't help it’. But the logic of the argument is fallacious. The fallacy in these statements consists in taking the description and using it as the explanation.

There are cases in which the fallacy is more difficult to detect. For example, many of us may have heard people saying: ‘She quit her job and now she never goes out, she has lost interest in everything because she suffers from depression.’ These arguments are very much used in ordinary discourse. They also seem meaningful. However, they are also logically fallacious. The term ‘because’ makes them tautological.

The logically correct way of constructing the situation here is: we say that people are depressed because they lose interest in things and have a feeling of unsustainable sadness. We have decided to call a certain pattern of experiences depression and when people manifest that pattern of experiences we say they are depressed. Given that we say that people are depressed because they lose interest in things and have feelings of unsustainable sadness, then saying that a person is sad and loses interest in things because she is depressed amounts to saying that that person is sad and loses interest in things because she is sad and loses interest in things.

Depression refers to a mental state—it is a state of being, not its cause. Saying that people have determined types of feelings and behave in a determined way because they have depression is logically fallacious. As we said above, these statements ‘put the happenings into a context’, as Lesser said, and give us a certain ‘frame of mind’ in dealing with a particular person. They raise a number of expectations in us and make it possible for us to predict a person's behaviour and also to tolerate it—and to tolerate our incapacity to understand and our impotence. These sorts of apparent explanations also make it easier for the sufferers to tolerate their own experiences and the scarce control they have over them. I am not saying that it is by all means ‘impossible’ to understand why people believe in these sorts of explanations—there is probably something positive about them. However, they are not real explanations—as they seem to be. They are psychologically reassuring fallacies.

The same argument can be applied to eating disorders. The argument is outlined in Box 3.2. However often this error occurs in psychiatry, and however ‘positive’ it may be for someone, it is still a logical error. Neither (p.68) the number of times in which this sort of ‘apparent explanation’ is used, nor its positive potential, modifies its tautological nature.

Some people will object that anorexia and other neuroses differ from other psychiatric conditions, such as schizophrenia, in that schizophrenia is determined by biological causes whereas anorexia is ‘mental’. Therefore the category of schizophrenia has an explicative potential that anorexia does not have.

Indeed, there is evidence that some of the disturbances that characterize schizophrenia (in particular, some psychotic disturbances, such as hallucinations) have organic bases. For example, hallucinations seem related to increased dopamine levels. Genetic factors may also be involved in schizophrenia.8 Moreover, brain scans show differences between patients with (p.69) schizophrenia and control groups. Some researchers argue that the brain of the person may have been damaged either by a birth trauma or by an intra‐uterine virus, and the illness, dormant for many years, may make its onset at a later age.9 All these factors, together with family and social stressors, are thought to play a role in the arousal of schizophrenia.10

Of course my arguments do not intend to deny the scientific reliability of these and other studies on schizophrenia. I am not denying that there may be organic factors that contribute to explain the disturbances that characterize schizophrenia. And, of course, the importance of research in this field is great. I am only pointing out a theoretical problem, It seems that, although we may be able to explain why people have some disturbances, the sentence ‘people have hallucinations, delusions, and so on because they suffer from schizophrenia’ is not explicative and is not the equivalent of saying that people have hallucinations because of increased dopamine levels or a birth trauma. What people (or most people) mean when they say that someone has delusions, or hallucinations, or disorganized speech ‘because he or she suffers from schizophrenia’ is not that the person suffers from hallucinations probably caused by increased dopamine levels, or a birth trauma may have caused brain abnormalities, which in turn may be responsible for the disturbances the person manifests. It seems that what most people actually mean is no more than what they say: the person has delusions, hallucinations, and so on ‘because they suffer from schizophrenia’ (= the person has delusions, hallucinations, and so on). This is the argument that I am contesting. When these statements are accepted with these meanings, the description is taken for an explanation. These sorts of statements are similar to the claim that ‘people fast and vomit because they suffer from eating disorders’. These sorts of statements are not explicative. They are logically mistaken, regardless of whether we can also give a proper explanation of the phenomenon.

6. Conclusions

Acknowledging that in most instances the psychiatric diagnosis merely has a descriptive character is to admit that, in the vast majority of cases11, mental illness does not—and cannot—compromise people's autonomy. I have (p.70) argued that it is simply not true that ‘mental illness’ causes a pattern of experiences and behaviour.

Surely the diagnosis sometimes encapsulates the results of scientific data that explain some of the symptoms (for example, the term ‘Alzheimer's disease’ refers to the brain abnormalities that cause loss of memory and other disorders). In these cases, it makes sense to argue that the diagnosis refers to a disease that is responsible for (or that causes) some disturbances. However, this is often not the case for psychiatric diagnoses. In the majority of cases when it is said that a person has a mental illness, what is meant is that she manifests some disturbances. In most cases the psychiatric diagnosis is only a short cut to describe a pattern of disturbances: it has no explanatory value.

In all cases in which the diagnosis merely has a descriptive value (and this is the majority) it is simply not true that ‘mental illness’ jeopardizes people's autonomy. Mental illness is a ‘description of events’, and as such it does not and cannot ‘jeopardize autonomy’.

The psychiatric diagnosis may, of course, refer to a constellation of characteristics that typically indicate that the person may lack autonomy. And, from this point of view, the diagnosis of mental illness may give us an extra reason to investigate the autonomy of the person's behaviour and choices. But this is very different from the claim that ‘mental illness jeopardizes people's autonomy’, and should not be confused with the idea that the fact that a person has a mental illness gives us some sort of entitlement to intervene paternalistically.

This may be seen as an overly logical way of looking at psychiatric diagnoses. However, this has crucial consequences for the ethics of care and treatment of the mentally ill: there is no reason to consider mental illness as ‘something’ capable of destroying people's autonomy and therefore the diagnosis of mental illness should not function as a justificatory criterion for non‐consensual interventions. Diagnosis of mental illness should be regarded in the same way as other types of diagnoses. The mere fact that a person has an illness (whatever that is) does not justify coercion. The diagnosis of an illness justifies treatment, but not coercive treatment, and there is no reason why the psychiatric diagnosis should be treated in a different way. The psychiatric diagnosis, like any other diagnosis, does not justify paternalism. The fact that medical or psychiatric treatment is deemed clinically appropriate or even clinically ‘necessary’ does not make it right or ethical for health‐care professionals to enforce it.

Paternalism towards people with mental disorders—including eating disorders—cannot be justified on the grounds that they have a diagnosis of mental illness. As we shall see in Chapter 11, in the UK there are Mental Statutes that apply to people with mental illness (Mental Health Act 1983 and Scotland Mental Health Act 1984). People with a diagnosis of mental (p.71) illness may be ‘sectioned’ (forcibly hospitalized) and compulsorily treated because of their mental illness. We shall see how the arguments developed in this chapter will be relevant to the discussion of English law on the management of mental disorders. I will explain that the diagnosis of mental illness should not be utilized as one of the criteria that justify coercion towards people.

This, of course, does not mean that we should be indifferent to the destiny of sufferers. In the previous chapter I suggested that paternalism may be ethical when the person is going to harm herself while acting or choosing non‐autonomously (weak paternalism). It is true of those with mental illness, as it is of all other people, that they may be acting non‐autonomously. However, it is mistaken to think that mental illness causes people's experiences and behaviour and therefore that by definition people with mental illness lack autonomy. Statements such as ‘this happens because he has a mental illness’, as I have argued, do not mean what they say. They do not mean that mental illness in effect causes people's experiences and behaviours.

With regard to eating disorders, arguments that people diet and vomit ‘because they have an eating disorder’ are fallacious. Arguments that we are justified in intervening against the eating‐disordered person because her behaviour is ‘the result of a mental illness’ are fallacious. Paternalism should not be based on such fallacious grounds. These arguments, however, have been and are currently used in English law (see Chapter 11).

Some people may believe that there must be ‘an illness’ somewhere in the person, which produces some sort of experiences or which compels the person to act in the ‘symptomatological’ way. These arguments appear no more scientific than the old belief that ‘spirits’ or the ‘devil’ lie inside mentally ill people, possessing them, and determining their behaviour.

A different and more scientific version of this argument is that abnormal experiences and behaviours are caused by some unidentified genetic and/or neurophysiological factor. From this point of view, the distorted experiences and behaviours of mentally ill people are thought to depend on defective physiological or biochemical mechanisms. The issue is to find where the fault lies and in what it consists. Much research is being carried out on the genetics and neurophysiology of mental disorders—including eating disorders. This type of research attracts much attention, in part because finding out ‘the faulted part’ would be the first step towards finding appropriate drug treatments for the disorders. The next chapter will review the most relevant research between 1980 and 2004 on the genetics and neurophysiology of eating disorders. Although this research is beginning to generate interesting results in many mental illnesses, there is as yet no convincing evidence that there is a biological abnormality in the brain of those with eating disorders that causes the abnormalities described as mental illness, as we shall now see.


An early version of this chapter has been published. See Simona Giordano, ‘In Defence of Autonomy in Psychiatric Healthcare’, (Tip Etigi, Turkish Journal of Medical Ethics, 9/2 (2001), 59–66. I am very much indebted to Harry Lesser for discussing the paper and thinking through my ideas with me. I also wish to thank Julian Savulescu for our interesting conversations about this chapter.

(1) I am not saying here that she could not resist the voices because the voices were irresistible. This would be another tautology. I do not know why she could not resist those voices—indeed, I did not ask.

(2) Schizophrenia is a clinical term that refers to a wide spectrum of disturbances. People manifesting such disturbances are called ‘schizophrenic’. Eugen Bleuler used the term ‘schizophrenia’ for the first time. Bleuler called dementia praecox ‘schizophrenia’ ‘because the “splitting” of the different psychic functions is one of the most important characteristics’ of the disorder. In fact, in its etymological meaning, ‘schizophrenia’ means ‘split‐mind’ (from the Greek σχιζο = schizo = split, and φρɛνια = phrenia = mind). See E. Bleuler, Dementia Praecox (New York: International University Press, 1966), 8

(3) I owe this observation to Alan Cribb.

(4) Gilbert Ryle, The Concept of Mind (London: Penguin, 1978), 83–83. I owe this observation to Harry Lesser. We had interesting conversations and he made me think about these issues in a different way.

(5) Ibid. 86

(6) Ibid.

(7) I am not underestimating the importance of diagnostic categories. I am trying to point out logical errors that may lead to overcoming people's autonomy.

(8) Nicky Hayes, Foundations of Psychology (London: Thomson Learning, 2000), 246.

(9) R. M. Murray, P. O. Jones, E. Callaghan, N. Takei, and P. Sham, ‘Genes, Viruses and Neurodevelopmental Schizophrenia’, Journal of Psychiatric Research, 26/4 (1992), 225–35.

(10) Hayes, Foundations of Psychology, 246.

(11) Exception made, as we have just seen, for mental illnesses such as dementia, Alzheimer's disease, Parkinson's disease, and maybe substance‐use disorders, in which abnormal experiences and behaviour are in a proper sense caused by the illness, and in which the illness actually explains those experiences and behaviour.