Can addiction be credibly invoked as an excuse for moral harms secondary to particular decisions to use drugs? This question raises two distinct sets of issues. First, there is the question of whether addiction is the sort of consideration that could, given suitable assumptions about the details of the case, excuse or mitigate moral blameworthiness. Most discussions of addiction and moral responsibility have focused on this question, and many have argued that addiction excuses. Here I articulate what I take to (...) be the best argument for this view, based on the substantial difficulty that people with severe addiction experience in controlling drug-related behavior. This, I argue, may in some cases be sufficient to ground a mitigating excuse, given the way in which addiction undermines agents’ responsiveness to relevant moral reasons to do otherwise. Much less attention has been devoted to a second set of issues that critically affect the possibility of applying this mitigating excuse in particular cases, derived from the ambivalent nature of agential control in addiction. In order to find a fitting response to moral harm, the person with the right standing to blame must make a judgment about the extent to which the agent possessed certain morally relevant capacities at the time of the act. In practice, this will often prove tremendously difficult to assess. The ethical challenge for the person with the right standing to blame is fundamentally one of making a judgment about matters that seem underdetermined by the available evidence. (shrink)

Psychiatric patients sometimes ask where to draw the line between who they are – their selves – and their mental illness. This problem is referred to as the self-illness ambiguity in the literature; it has been argued that solving said ambiguity is a crucial part of psychiatric treatment. I distinguish a Realist Solution from a Constructivist one. The former requires finding a supposedly pre-existing border, in the psychiatric patient’s mental life, between that which belongs to the self and that which (...) belongs to the mental illness. I argue that no such border exists, and that attempts to find it might even render the felt ambiguity worse. Instead, any solution must be constructivist; the patient (and others) should deliberate and discuss what to identify with or not. I further argue that psychiatric patients need not see their mental illness as wholly distinct from themselves to avoid ‘identifying with their diagnoses' in a problematic way. Finally, we can excuse problematic behaviour by mentally ill people – in fact, we can do so in a more nuanced and constructive way – while rejecting the view that the mental illness is wholly distinct from the patient’s self. (shrink)

ABSTRACT‘Self-ambiguity’, we suggest, is best understood as an uncertainty about how strongly a given feature reflects who one truly is. When this understanding of self-ambiguity is applied to a view of the self as having both essential and shapable components, self-ambiguity can be seen to have two aspects: (1) uncertainty about one's essential or relatively unchangeable characteristics, e.g. one's sexuality, and (2) uncertainty about how to shape oneself, e.g. which values to commit to, actions to pursue, or essential features to (...) identify with. We explain how a narrative account of agency can accommodate these forms of self-ambiguity and argue that such an account also reveals another kind of self-ambiguity, namely, (3) uncertainty about whether one's established self-narrative represents who one really is. We illustrate this third form of self-ambiguity in the context of addiction where people's established addiction self-narratives make it difficult to identify with recovery. We argue that recovery will require embracing, especially, our third form of self-ambiguity as a chance for positive self-transformation. Treatment for addiction should, therefore, support people in going through and ultimately narratively resolving the inevitable self-ambiguities of the recovery process. (shrink)

This paper explores how self-identity can be impacted upon by the use of digital and social media. In particular, drawing on a narrative account of selfhood, it argues that some forms of activity and interaction on the internet can support the capacity to be oneself, and foster transformative processes that are self-enhancing. I start by introducing different positions in the philosophical exploration of identity online, critically outlining the arguments of those who hold a “pessimistic” and an “optimistic” stance respectively. I (...) then expand on the narrative identity framework that has been used to support the optimists’ view, arguing that digital and social media use can foster forms of self-understanding that enable us to preserve or develop our identity. More precisely, exploring these dynamics also in relation to the lived experience of mental ill-health, I maintain that internet-enabled technology can support narrative self-constitution in three main ways: (1) by facilitating the processes through which we remember self-defining life-stories; (2) by enabling us to give salience to the stories that we decide should matter the most; and (3) by providing us with opportunities to obtain social uptake for our narratives. I then conclude by dispelling some possible objections to the use of a narrative approach to account for selfhood online. (shrink)

1. Imagine the following hypothetical scenario: Sarah is often called an expert on depression: after all, she graduated from medical school and has a PhD in neuroscience. She knows all theories of...

Losing an intimate other to death belongs to the most uprooting experiences in human life. Not only is it accompanied by a range of negative emotions such as sorrow, longing, anger etc., but profound grief is a limit experience that causes a rupture in the sense of self of the bereaved. This experience is often expressed in identity statements such as ‘I no longer feel like myself’ or ‘I am missing part of myself’. Although such experiences are richly reported in (...) empirical studies on grief and implemented in diagnostic criteria for pathological grief, their experiential meaning is largely left unexplored. In this article, I suggest that being bereaved of an intimate other is self-alienating because our sense of self is a distributed phenomenon relying on daily confirmation through interaction with our habitual environment. When our lives are intertwined with intimate others, this habitual identity become a dyadic structure, relying on a heteronomy. Being bereaved of this intimate other leads to a profound impoverishment of the habituated sense of self, leading to self-alienation. Finally, I discuss the process of returning to a non-alienating state and suggest that this is not exclusively a cognitive process, but equally an embodied process of appropriating a habitual identity. (shrink)

This paper addresses an important yet neglected existential issue sometimes faced by persons with bipolar disorder (BD): confusion about the extent to which what one is like is influenced by BD. Although such confusion is common in psychiatric illnesses, BD raises idiosyncratic difficulties due to its intricate interactions with personality, cognition and behavior. The fluctuating mood phases of BD can generate inconsistency in one's self-experience and sense of self. One way to resolve this confusion would be to coherently account for (...) BD within one's overall self-concept. To facilitate this task, this paper introduces a heuristic taxonomy of different relationships wherein BD can be viewed in light of self-related beliefs. The relationships are as follows: (1) BD contributes to the self, (2) BD scaffolds the self, (3) BD gradually becomes part of the self and (4) BD is not part of the ‘real self’. As the individual presentation of BD varies extensively, the type of relationship one feels holds true depends on one's personal experience of managing and living with the disorder. These relationships act as an organizing framework for one's self-related beliefs about how to account for the effects of BD on personality, behavior, cognitive patterns and other self-expressions. (shrink)

Deep brain stimulation (DBS) uses electrodes implanted in the brain to modulate dysregulated brain activity related to a variety of neurological and psychiatric conditions. A number of people who use DBS have reported changes that affect their sense of self. In the neuroethics literature, there has been significant debate over the exact nature of these changes. More recently, there have been suggestions that this debate is overblown and detracts from clinically-relevant ways of understanding these effects of DBS. In this paper, (...) we offer an alternative approach to understanding the effects of DBS on the self, drawing on John Sadler’s work on self-illness ambiguity. We argue that self-illness ambiguity is a complex concept, with at least three different aspects, and that each of the three aspects we identify also characterizes one kind of DBS-related change. Our analysis also suggests ways of helping patients to adjust to life as a DBS user. (shrink)

Deep brain stimulation (DBS) uses electrodes implanted in the brain to modulate dysregulated brain activity related to a variety of neurological and psychiatric conditions. A number of people who use DBS have reported changes that affect their sense of self. In the neuroethics literature, there has been significant debate over the exact nature of these changes. More recently, there have been suggestions that this debate is overblown and detracts from clinically-relevant ways of understanding these effects of DBS. In this paper, (...) we offer an alternative approach to understanding the effects of DBS on the self, drawing on John Sadler’s work on self-illness ambiguity. We argue that self-illness ambiguity is a complex concept, with at least three different aspects, and that each of the three aspects we identify also characterizes one kind of DBS-related change. Our analysis also suggests ways of helping patients to adjust to life as a DBS user. (shrink)

In their target article, Moore and colleagues offer a valuable overview of the various ambivalence-related phenomena that may impede swift clinical decision-making. They argue that patients...

Self-illness ambiguity is a difficulty to distinguish the ‘self’ or ‘who one is’ from one's mental disorder or diagnosis. Although self-illness ambiguity in a psychiatric context is often deemed to be a negative phenomenon, it may occasionally have a positive role too. This paper investigates whether and in what sense self-illness ambiguity could have a positive role in the process of recovery and self-development in some psychiatric contexts by focusing on a specific case of mental disorder – anorexia nervosa.

The article investigates the concept of self-illness ambiguity (SIA), which was recently re-introduced in the philosophy of psychiatry literature. SIA refers to situations in which patients are uncertain about whether features (symptoms, signs) of their illness should be attributed to their illness or to their ‘selves’. Identification of these features belongs to a more encompassing process of self- definition and -interpretation. The paper introduces a distinction between the notions of self-relatedness, self-referentiality (or: implicit self-signification), self-awareness and self-interpretation. Each of these (...) notions offers a different perspective on SIA, but these perspectives do not exclude one another. A further distinction will be developed between primary, secondary and tertiary forms of self-referentiality. The practical and conceptual relevance of these distinctions will be illustrated with case vignettes. Throughout the paper our findings will placed in the context of other philosophical work on the self, especially in the field of narrative theory (Ricoeur), phenomenology (Ratcliffe) and philosophy of mind. The article closes with a brief discussion about the appropriateness of the term ambiguity and the potential of SIA as concept in the context of clinical psychiatry. Directions for future work will be indicated. (shrink)

ABSTRACT This paper investigates from a phenomenological perspective the origins of self-illness ambiguity. Drawing on phenomenological theories of affectivity and selfhood, I argue that, as a phenomenon which concerns primarily the ‘personal self’, self-illness ambiguity is dependent on distinct alterations of affective background orientations. I start by illustrating how personhood is anchored in the experience of a specific set of non-intentional affects – i.e. moods or existential feelings – alterations of which are often present in mental ill-health. Also through the (...) exploration of the phenomenology of acute and long-term anxiety, I suggest that self-illness ambiguity originates in the presence of moods or existential feelings that are in tension with the ones that structure the person’s experience prior to the onset of the illness or when its symptoms are not experienced. More specifically, I claim that due to their ability to ‘block’ or ‘suspend’ some of the person’s affective and cognitive responses, such affective orientations may unsettle one’s self-defining evaluative perspective, leading to uncertainty and doubting about one’s personal self. (shrink)

Metaphors may present some challenges in cases of self-illness ambiguity, yet they remain necessary to access a person’s perspective on illness and her relationship with it. The paper outlines the main functions of metaphors (i.e., naming, framing, changing functions) to explain why they can be valuable tools for reducing self-illness ambiguity. First, metaphor is presented as a creative way for a patient to (re)claim her ‘self’ through her own speaker’s meaning. Metaphor is not merely a way to name internal processes (...) and make them more communicable to others (compactness and inexpressibility theses), but primarily a way to represent what the mental illness means for herself (for-me-ness thesis). Second, particularly when extended in mental health narratives, metaphor can frame a person’s experiences of illness by offering a specific affective perspective for self-understanding (perspectivalness thesis). Third, the changing function of metaphor offers a new perspective on the experience of self-illness ambiguity in the narrative, allowing to look at the relationship with the illness, without fully identifying with it. The metaphorical functions can facilitate the discovery of new forms of affective coherence in a person’s mental health narrative and serve as crucial tools for clinicians’ understanding in the therapeutic process. (shrink)

In a compelling and provocative paper, ‘Solving the Self-Illness Ambiguity: The Case for Construction Over Discovery,’ Sofia M.I. Jeppsson distinguishes two ways of addressing the self-illness ambiguty problem. The first is the Realist Solution, which postulates a pre-existing border between the self and the illness and frames the goal of treatment in psychiatry as helping the patient ‘discover’ this boundary. Addressing the shortcomings of the Realist Solution, both in terms of its feasibility and possible outcomes, Jeppsson proposes and defends the (...) Constructivist Solution, according to which the patient, through self-reflection and deliberation with others, including the clinicians, decides, which parts of her experiences they identify with themselves and which parts they attribute to their illness. This paper critically evaluates Jeppson’s arguments and addresses some of the shortcomings of Jeppsson’s positive argument, i.e. the Constructivist Solution. (shrink)

ABSTRACT‘If I experience X, is it because of the illness, the medication, or is it ‘just me’?’ (Karp 2009) [Is it me or my Meds? Living with Antidepressants. Harvard University Press]. This issue is known as self-illness ambiguity (SIA) (Sadler 2007) ["The Psychiatric Significance of the Personal Self." Psychiatry: Interpersonal and Biological Processes 70 (2): 113–129]. In her paper Know Thyself: Bipolar Disorder and Self-concept, Carls-Diamante (2022) [“Know Thyself: Bipolar Disorder and Self-Concept.” Philosophical Explorations, 1–17] offers a taxonomy of different (...) ways in which Bipolar Disorder can be related to one’s self and self-concept. In contrast to the essentialist model of mental disorders she seems to adopt, I propose a different outlook on SIA, following an enactive approach to psychiatric disorders as disorders of sense-making. One’s way of making sense of the world and/or oneself can become stuck in a rigid pattern that is stronger than oneself and at odds with how one would want to be. I argue that it is helpful to distinguish between the experiential SIA of specific experiences (Am I over/underreacting?) and the long term concerns of existential SIA (How to live my life in accordance with what matters to me despite/while having certain vulnerabilities?). I conclude that knowing oneself is not an intra-individual matter, nor primarily a matter of reflection: it is rather a relational and material practice of trying to live your life in accordance with what matters to you. (shrink)

Although the concept of self-illness ambiguity is relatively new, the phenomenon is not. It seems likely that people have struggled with the oftentimes ambiguous relation between themselves and the...

Volume 26, Issue 1, March 2023, Page 86-90.

Scholars usually distinguish between testimonial and hermeneutical epistemic injustice in healthcare. The former arises from negative stereotyping and stigmatization, while the latter occurs when the hermeneutical resources of the dominant community are inadequate for articulating the experience of one’s illness. However, the heuristics provided by these two types of epistemic predicaments tend to overlook salient forms of epistemic injustice. In this paper, we prove this argument on the example of the temporality of patients with drug dependence. We identify three temporal (...) dimensions of epistemic injustice affecting drug-dependent patients: the temporal features of their cognitive processes, their individual temporal experience, and the mismatch of social temporality. Notably, the last aspect, which highlights the disparity between the availability of care and its accessibility, does not fit neatly into the categories of testimonial or hermeneutical injustice. (We should note that the International Network of People Who Use Drugs (INPUD) and The Asian Network of People who use Drugs (ANPUD) consider the term “drug addiction” to be associated with disempowerment and negative stereotyping. Instead, they suggest the expression “drug dependence” (INPUD 2020). However, the concept of “drug addiction” is still being used in the current public health, philosophy, and sociology debates that concern the specific field of addiction studies. Replacing the notion of drug addiction with “drug dependence” would not eliminate existing epistemic injustices or allow us to avoid creating new ones, such as those related to ignoring pain claims (O’Brien 2011). Still, for the sake of clarity we will use the notion “drug dependence” when speaking of people while retaining the term “drug addiction” for labelling healthcare practices and the topic for philosophy of healthcare.). (shrink)