Rationality and self-knowledge in delusions and confabulations: implications for autonomy as self-governance more

The main purpose of this paper is to explore the implications of the epistemic faults of delusions and confabulations for the autonomy of the people affected by these conditions. The issue whether autonomy is compromised and to what extent is of great practical relevance. Do people affected by psychiatric disorders that manifest with delusions and confabulations have capacity to consent to treatment? More generally, should they be allowed to make, and deemed responsible for, significant decisions that affect their well-being?

We propose to look at autonomy as self-governance and to make a distinction between (a) whether one has the capacity to govern oneself and (b) whether one is successful at governing oneself. We argue that the capacity for self-governance depends on the capacity to develop a self-narrative which encompasses the capacity to endorse attitudes and actions on the basis of reasons. Success in self-governance depends on the coherence of self-narratives and on their correspondence to real life events.

Our thesis is that, in most cases, people with delusions or confabulations have the capacity for self-governance, but are unlikely to be successful at governing themselves. This is because they are likely to demonstrate failures of rationality and self-knowledge that impact on the coherence of their self-narratives and the correspondence between these narratives and real life events. Although in some cases the very capacity for self-governance may be compromised (e.g., in ‘primary’ delusions where no reasons are offered in support of the delusion or in delusions and confabulations which occur at advanced stages of dementia) our claim is that having delusions and confabulations does not necessarily imply a lack of capacity for self-governance. That said, delusions and confabulations interfere with the exercise of self-governance.