# **TOWARDS AN ETHICS OF AUTISM**

**A Philosophical Exploration**

**KRISTIEN HENS**

**OBP**

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 **KRISTIEN HENS**

TOWARDS AN ETHICS OF AUTISM

TOWARDS AN ETHICS OF AUTISM

*Kristi en Hens succeeds in weaving together experienti al experti se of both people with auti sm and their parents, scienti fi c insights and ethics, and does so with great passion and aff ecti on for people with auti sm (with or without mental or other disabiliti es). In this book she not only asks perti nent questi ons, but also criti cally examines established claims that fail to take into account the criti cism and*

Sam Peeters, author of *Auti sti c Gelukkig* and *Gedurfde vragen;* blog @ Tistje.com

What does it mean to say that someone is au� s� c? *Dynamics of Auti sm* explores this ques� on and many more. Kris� en Hens conducts a though� ul, wide-ranging examina� on of psychiatric, biological, and philosophical perspec� ves on au� sm, as well as its meanings to those who experience it, diagnose it, and research it. Hens delves into the history of au� sm to inform a contemporary ethical analysis of the models we use to understand au� sm and explores the various impacts of a diagnosis on au� s� c people and their families, the relevance of disability studies, the need to include au� s� c people fully in discussions about (and research on)

Rich, accessible, and mul� -layered, this essen� al reading for for philosophers, educa� onal scien� sts, and psychologists who are interested in philosophicalethical ques� ons related to au� sm, but it also has much to off er to teachers, allied

This is the author-approved edi� on of this Open Access � tle. As with all Open Book publica� ons, this en� re book is available to read for free on the publisher's website. Printed and digital edi� ons, together with supplementary digital material,

au� sm, and the signifi cance of epigene� cs to future work on au� sm.

health professionals, and au� s� c people themselves. .

can also be found at h� p://www.openbookpublishers.com

Cover image: Photo by Mika Baumeister on Unsplash at h� ps://unsplash.com/

KRISTIEN HENS

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A Philosophical Exploration

*experiences of people with auti sm.*

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### TOWARDS AN ETHICS OF AUTISM

### Towards an Ethics of Autism

A Philosophical Exploration

*Kristien Hens*

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© 2021 Kristien Hens

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### Contents

This book is the result of ten years of philosophical and ethical explorations of autism. During that period, I spoke to many people, colleagues, students, autism professionals, parents of autistic children, and, last but not least, autistic people themselves. Not only did these conversations help me to think about autism with more nuance, but they also helped me think about philosophy and ethics in a more grounded way. Much of what I now believe to be true, both in ontology and ethics, is the result of my grappling with the many meanings of autism and appreciating the importance of the autistic experience. So my gratitude goes out to all the people I met on the way.

I want to thank the people from Open Book Publishers for their professional handling of this book: Alessandra Tosi, Lucy Barnes, Anna Gatti, Laura Rodriguez. I would also like to thank the anonymous reviewers who read the book's first version: your comments were spot on, and I enjoyed rewriting the book with your suggestions.

I would also like to thank the people from LAuRes (Leuven Autism Research) for welcoming me into their group and giving me a taste of the many aspects of clinical and fundamental research into autism. Thanks also to people from Autism Ethics for exciting workshops and philosophical discussions.

Raymond Langenberg, Susan Langenberg and Fleur Beyers from Campus Gelbergen offered great inspiration and help in writing the Dutch book, of which this book is a rewritten translation.

A special thanks to my colleagues Katrien Schaubroeck, Ilse Noens, Daniela Cutas, Anna Smajdor, Jean Steyaert, and Andreas De Block. You are colleagues in the truest sense of the word!

The ideas in this book formed the gist of my project proposal, which has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme (grant agreement No 804881). This grant allowed me to create my team, *NeuroEpigenEthics*. I could not have developed many of the ideas in this book without the input of all its former and current team members. Eman Ahmed, Jo Bervoets, Delphine Jacobs, Laura Mattys, Lisanne Meinen, Emma Moormann, Gert-Jan Vanaken, Leni Van Goidsenhoven: you are all stars. Thank you for a fantastic experience!

David, Roman, Aaron & Isaak: I spend too much time writing behind my computer, I know. You are what matters.

## Prologue:

#### Dynamics and Ethics of Autism

This is a book about the meanings, experiences and dynamics of autism.

My initial interest in autism began ten years ago. As a bioethicist who had written a PhD on pediatric biobanks, I was interested in the ethics of genetic research and genetic diagnostics of autism. These practices raise several questions in traditional biomedical ethics, such as what genetic findings should genetic counsellors convey to their clients, and are genetic 'risk' factors1 for autism a good reason to opt for reproductive techniques such as in vitro embryo testing? Moreover, back in those days, and still today, public discourse on autism often centred around whether or not there are too many diagnoses of autism. Children with an autism diagnosis, previously scarce, were now to be found in every classroom. Some commentators have argued that this reflects the way that we pathologise and medicalise atypical behaviour. At the same time, parents of autistic children have often criticised this view, as they consider it a denial of the genuine challenges they and their child face. I soon realised that it is impossible to answer these ethical questions without reflecting carefully on the concept of autism itself. It seemed self-evident that when investigating questions about autism, we should first identify precisely what we mean by it. If we suggest that there are now too many diagnoses, this might imply that we think that some of the children currently diagnosed do not actually have autism, and that diagnostic practices should be more stringent. If

1 I have put 'risk' between quotation marks here, as I do not consider autism to be something that you risk. As I shall argue in chapter five, I consider disability to be neutral with regards to its appreciation. In my own writings, I use 'elevated likelihood'.

we argue that autism is something that people can choose to prevent through reproductive techniques, we need to set the record straight on what is being prevented.

When we ask ourselves what it would look like to do good in relation to any subject, and more specifically, what good clinical practice is, we first need a notion of what we are talking about. When thinking about autism and psychiatric diagnosis in general, this is a complex task. The ontological status of psychiatric diagnosis is the subject of fierce debate, and autism in particular is much discussed. However, this is not primarily a book about the history of autism. Scholars have written many books on this topic,2 and those looking for an overview of autism and its history can consult the resources listed in the footnotes.

In this book, I shall draw up an approach to conceptualizing autism that I think has ontological and ethical benefits, without attempting to close down the discussion about the essence of autism. I will use the term autism rather than the official and widely used Autism Spectrum Disorder (ASD), as the latter only covers some of the many meanings of autism. The reader should also be aware that I write this book from a Belgian perspective. In Belgium, diagnosis is still an essential first step in searching for answers and solutions related to autism, both in children and adults. Clinicians here do not often prescribe extensive behavioural therapies such as Applied Behavioural Analysis (ABA), which are contested by many autistic people and which raise ethical questions of their own. I will therefore only dwell on them sporadically. In Belgium, a diagnosis is generally followed by support and services in school or the workplace and psychoeducation about autism. In this book I use the terms 'autistics' and 'autistic persons', rather than 'persons with autism',

2 See for example Roy Richard Grinker, *Unstrange Minds: Remapping the World of Autism* (Basic Books, 2008); Majia Holmer Nadesan, *Constructing Autism: Unravelling the 'Truth' and Understanding the Social* (London ; New York: Routledge, 2005); *The Autism Matrix: The Social Origins of the Autism Epidemic*, ed. by Gil Eyal (Cambridge, UK; Malden, MA: Polity, 2010); Bonnie Evans, *The Metamorphosis of Autism: A History of Child Development in Britain* (Manchester: Manchester University Press, 2017); Mitzi Waltz, *Autism. A Social and Medical History* (Basingstoke: Palgrave McMillan, 2013); Anne McGuire, *War on Autism: On the Cultural Logic of Normative Violence* (Ann Arbor: University of Michigan Press, 2016); Chloe Silverman, *Understanding Autism: Parents, Doctors, and the History of a Disorder* (Princeton: Princeton University Press, 2011); Steve Silberman, *Neurotribes: The Legacy of Autism and How to Think Smarter about People Who Think Differently* (Crows Nest: Allen & Uwin, 2015).

as the former is preferred by autistic people, at least in English-speaking countries.3

Autism professionals often talk about autism as something that is heterogenous, a spectrum. This suggests that autism can manifest itself in many different ways. For example, some autistic people have cognitive disabilities, and others have cognitive strengths. Some autistic people do not use verbal language, whereas others are comfortable with oral communication. Still, 'heterogeneity' or 'spectrum' suggests that autism itself is one thing. Over the years, I have acknowledged that autism is a multi-layered concept. It is polysemous. What a child psychiatrist means when they talk about autism can be something different from what a cognitive scientist means. It may be something different again from what it means for the autistic person.

In order to study the ethics of the genetics of autism, I first talked to several child psychiatrists. From their perspective, one important dimension of autism is that it is a psychiatric diagnosis based on assessing behaviour and functioning. 'To have autism', in this sense, means that you satisfy the criteria of a diagnostic manual, that a qualified diagnostician assesses the behaviour of the person in question through the lens of a behavioural diagnosis and that the person experiences sufficient impairment in day-to-day functioning to receive a diagnosis. The most frequently used diagnostic manual is the DSM (Diagnostic and Statistical Manual of Mental Disorders), currently in its fifth edition. For autism, the main difference between DSM-IV and DSM-5 is the dyad of behaviours in the latter, as shown in Table 1.4 In DSM-IV, this was still a triad: it listed communication and social interaction as separate categories. DSM-5 gathers the earlier diagnoses of Asperger syndrome and PDD-NOS (Pervasive Developmental Disorder — Not Otherwise Specified) and some other conditions under 'Autism Spectrum Disorder'. Moreover, the authors of the DSM-5 have tried to approach the diagnosis in a more multi-dimensional way: different people with an autism diagnosis can exhibit a particular behaviour to a greater or lesser degree. Each characteristic might manifest at different levels of severity.

3 Lorcan Kenny et al., 'Which Terms Should Be Used to Describe Autism? Perspectives from the UK Autism Community', *Autism*, 2015, https://doi.org/10. 1177/1362361315588200

4 American Psychiatric Association, *Diagnostic and Statistical Manual of Mental Disorders (Fifth Ed.)* (Arlington: American Psychiatric Publishing, 2013).

This dimensional approach does not take away from the fact that the diagnosis itself is still categorical: you either have autism or you do not have it; you cannot have it somewhat. We might ask ourselves how far a dimensional approach is compatible with the idea of a spectrum. A spectrum suggests a gradual transition between different types. In contrast, a dimensional system indicates that different people can have various aspects to a greater or lesser degree, and are difficult to pin down on a gradient. The Canadian philosopher of science Ian Hacking, whom we shall meet again in chapter ten, prefers to speak about a manifold.5

In the DSM-5, one of the criteria that must be fulfilled in order to qualify for a diagnosis of autism is that 'Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning'. How much someone experiences such impairment can depend on properties intrinsic to the individual. For example, your IQ can be an asset or it can make certain symptoms more challenging. How much you suffer from sensory hypersensitivity can depend on how your brain functions. The level of dysfunction also depends on the context. For example, a person in a quiet and structured environment may perform better than someone in a chaotic environment.

Moreover, functioning is dependent on the values of both the assessor and the assessed. Specific characteristics of one's life, such as not having many friends or having a preoccupation with certain topics, might be considered dysfunctional from an outsider's perspective. Nevertheless, the person may be perfectly happy. In this book, I do not use the frequently used labels 'high-functioning' (or 'mild') autism or 'lowfunctioning' (or 'severe') autism. These terms, first of all, presuppose that we can quickly grasp the essence of autism and that, based on this essence, you can decide whether it is more or less present. For a phenomenon such as autism, this might never be possible. Moreover, these terms suggest that the challenges of the 'high-functioning' autistic person—often associated with the stereotypical image of the highly gifted person with Asperger syndrome—are less than those of the person with an intellectual disability. If we consider the experiences of autistic persons with a wide range of characteristics, these subdivisions may turn out to be naive and even discriminatory.

5 Ian Hacking, 'Humans, Aliens & Autism', *Daedalus*, 138:3 (2009), 44–59, https://doi. org/10.1162/daed.2<IP_ADDRESS>

If the DSM-5 is strictly followed, someone who satisfies all behavioural criteria but who can successfully integrate these characteristics into their life without experiencing impairments in their everyday life will not qualify for a diagnosis of autism. This implies that, in the context of scientific research, one could screen a population for autistic characteristics, but the appearance of such characteristics would not straightforwardly mean that a person should be diagnosed with autism in the clinical sense. Autism or Autism Spectrum Disorder is therefore a clinical diagnosis based on assessing what is best for a person with a particular need for clinical help.

Besides the DSM, there are other classificatory systems such as ICD-10, the classificatory system for diseases created by the WHO (World Health Organization). The latter also mentions challenges in social functioning and communication, as well as restricted interests, as characteristics of autism. Diagnosticians working with either system use instruments for behavioural diagnoses, such as ADOS-2 (Autism Diagnostic Observation Scale), to measure whether individuals satisfy the diagnostic criteria.6 The DSM further mentions that autistic behaviour has to be present early in development to qualify for a diagnosis, whereas ICD-10 states that autism lasts throughout a person's lifetime. They both mention that there is no cure, but treatment can help. They also state that treatments include behaviour and communication therapies and medicines to control symptoms, and that starting treatment as early as possible is important. The emphasis in ICD-10 on the fact that autism is quasi-innate and lifelong is fascinating: in chapter one, we shall describe how one of the early investigators of autism, Hans Asperger, stated this, but that another early investigator, Leo Kanner, suggests in a 1943 paper that some evolution is possible. Still, this emphasis on the innate and lifelong nature of autism indicates that it is different to—perhaps even more *real* than—a mere psychiatric diagnosis or a clinical presentation that we use to describe the challenges of a child or adult to guide further treatment and support. Autism as an idea seems to refer to a particular neurobiological reality. It looks as if autism is less susceptible to change

6 Johnny L. Matson, *Handbook of Assessment and Diagnosis of Autism Spectrum Disorder* (New York: Springer International Publishing, 2016); Adam McCrimmon and Kristin Rostad, 'Test Review: Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) Manual (Part II): Toddler Module', *Journal of Psychoeducational Assessment*, 32:1 (2014), 88–92, https://doi.org/10.1177/0734282913490916

than a mood disorder such as depression. Maybe autism is even an atypical way of being in the world, which is, in principle, equally as good as what is considered the typical or even normal way. Perhaps, when we think about autism, we more readily conjure up this more essentialist meaning, rather than the clinical meaning.

This second dimension of autism, that of a neurobiological reality, is apparent in the many research projects that seek to find the cause of autism. Taking a clinical diagnosis as a starting point, they seek to find the underlying gene or neurological functioning to explain autistic behaviour. This approach is not only popular with researchers, but autistic people also often acknowledge that they consider autism to have a biological explanation. Around 2016, researcher Raymond Langenberg and I conducted a phenomenological study about the meaning of a diagnosis of autism for adults.7 We interviewed twentyone people about their recent diagnosis. We asked them how they experienced the diagnostic process and their lives before and after the diagnosis. We had noticed how—after a long period of feeling different and often of suffering—they welcomed the diagnosis. Throughout their lives, some of our respondents had received several other diagnoses; for example, borderline personality disorder (this was more common among the women) or obsessive-compulsive personality disorder. Many felt, however, that the diagnosis of autism was the correct one and corresponded to who they were. Some pointed out the importance of finally knowing that their challenges related to how their brain functioned, as this meant these challenges would not be overcome if they simply tried hard enough. This realisation gave them peace of mind: such an effort had cost many of them a great deal of energy without much benefit. At the same time, they sometimes struggled with the reductionist implications of the diagnosis of autism, and its neurobiological status. They often felt that they were more than what was implied by the label and what it caused some of the people around them to assume.

Our conclusion in this study was that autism as a concept worked for the people we interviewed. They experienced autism as real and situated in biology, unlike a personality disorder (such as borderline

7 Kristien Hens and Raymond Langenberg, *Experiences of Adults Following an Autism Diagnosis* (Cham: Palgrave Macmillan, 2018).

personality disorder), as people consider these to be mental disorders. Simultaneously, autism is heterogeneous to such an extent that people who are diagnosed do not have to coincide entirely with the diagnosis. People can pick out those aspects with which they identify. It seems that it is the idea that autism is real, in your brain and your genes, that allows people to accept it as a diagnosis. What we have learned in our research, by talking to people with a diagnosis of autism, with psychiatrists and with other autism professionals, is that autism is indeed real as a shared experience, as something that can be known as a phenomenon.

This book explores three central themes in thinking about autism that are ethically relevant. The approach is inspired by Karen Barad's ethicoonto-epistem-ology: the idea that a phenomenon cannot be separated from how we know and study it. This, in turn, is inextricably linked with ethical practice, which should never be a mere afterthought once the research has been done. This book, therefore, does not give readymade answers to the ethical questions posed in the first paragraph. Instead, I hope to demonstrate that what we know and how we know things matters. I offer a way of looking at autism that may inspire ethical practices.

The first theme is that of the many meanings of autism. In part one, I shall describe different layers of meaning and their implications for the ethics of autism. The aim is not to reduce different dimensions to one true meaning but to engage with uncertainties inextricably linked to autism. Chapter one examines two seminal writings on autism, by Leo Kanner and Hans Asperger, and describes how, even in these writings, autism had different meanings. Chapter two tackles the issue of psychiatric diagnoses and what it means if someone is considered to be ''psychiatrically ill'. Chapter three presents some cognitive explanatory models and their implications for meta-ethics and applied ethics. In chapter four, I examine sociological explanations for the rise and expansion of autism.

In part two, we shall investigate the importance of experience in understanding a phenomenon such as autism. This is inspired by standpoint epistemology, the idea that knowledge arises from a social position. Chapter five explores different models of disability and their application to autism. Chapter six introduces the concept of epistemic injustice and how many people have not taken the accounts of autistic

people seriously for a long time. In chapter seven, I present some ideas from our interview study mentioned above. Chapter eight is an interlude about experiences of time and autism.

A recurrent theme in the book and discussions about autism, in general, is the importance of biology, more specifically of genes and neurology. Biology makes a phenomenon such as autism appear more concrete, less imagined. Simultaneously, associating something with genes or neurology also risks a reductionist and deterministic interpretation, which can lead to stigma. In part three, I pry apart the link between biology and such reductionism and suggest ways to look dynamically at biology. I formulate an alternative to, on the one hand, reductionist biological and cognitive explanations, and on the other hand, approaches that consider autism to be a mere social construct or even a fabrication. Chapter nine describes the dynamics of diagnoses, using, amongst others, the concept of looping effects devised by the philosopher of science Ian Hacking. Chapter ten contains descriptions of dynamic models of biology and human minds. Chapter eleven investigates the impact of ideas of genetics in the context of autism. In the epilogue, I suggest how the ideas presented in this book can shed new light on ethical questions surrounding autism.

#### Table 1: DSM-5 criteria for autism8

**A.** Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history.

**A1.** Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

**A2.** Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

8 DSM-5, p.109–10.

**A3.** Deficits in developing, maintaining, and understandings relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absences of interest in peers.

**B.** Restricted, repetitive patterns of behavior, interests, or activities as manifested by **at least 2 of 4 symptoms** currently or by history.

**B1.** Stereotyped or repetitive motor movements, use of objects, or speech (e.g. simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

**B2.** Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g. extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food everyday).

**B3.** Highly restricted, fixated interests that are abnormal in intensity or focus (e.g. strong attachment to or preoccupation with unusual objects, excessively circumscribed or preservative interest).

**B4.** Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/ temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

**C.** Symptoms must be present in the early developmental periods (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

**D.** Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

**E.** These disturbances are not better explained by intellectual disability (intellectual development disorder) or global development delay.

#### PART I: DIMENSIONS OF AUTISM

*There ain't no answer.  There never has been an answer. That's the answer.*

Gertrude Stein

In February 2020, three doctors stood trial for performing euthanasia in 2017 on Tine Nys, a thirty-eight-year-old woman with severe mental illness. Two months before her death, she had been diagnosed with autism. For the purposes of my account, it is irrelevant whether one approves of euthanasia for unbearable mental suffering, which is, in principle, legal in Belgium. The trial, the media, and the public reactions can shed some light on how autism has many meanings that we cannot merely reduce to one single meaning. For some commentators, many of them psychiatrists, it was bad practice to allow euthanasia to be performed a mere two months after the diagnosis. A psychiatric diagnosis, they said, is meant to provide a clinical image of a person's (dys)functioning, and as such, it is a starting point for clinical care. Two months is far too short to be able to assess the effectiveness of diagnosis and treatment. Others suggested that it is precisely this diagnosis that gave weight to the claim that Tine was suffering incurably and unbearably. Autism is, after all, a lifelong and incurable disorder, they argued. Still others, often parents of autistic children and autistic adults, took issue with the automatic link between autism and suffering. For them, autism is perhaps indeed something that one has from birth and until death, but it is by no means intrinsically and automatically linked with suffering and a worse life. All these different conceptions of autism: from a clinical presentation, a lifelong disorder to a neutral neurological difference, exist simultaneously. Nevertheless, the case of Tine Nys shows us that how we conceive of autism can have far-reaching normative consequences.

In this chapter, I shall investigate how at least three meanings of autism have existed from its inception as a concept and a term: autism as a (child) psychiatric disorder, autism as an innate and lifelong character trait, and autism as a developmental phenomenon. To do

so, I will return to what can be considered the original writings about autism: the English text from 1943 by Leo Kanner (1894–1981), 'Autistic Disturbances of Affective Contact'1 and the German article from 1944 by Hans Asperger (1906–1980), 'Die "Autistischen Psychopathen" im Kindesalter'.2 Both texts shed valuable light on what autism is and how it is seen today: on the one hand, a familial condition that is innate and probably lifelong, on the other hand, a developmental disorder that child psychiatrists can treat. Kanner's text anchored the concept of autism in the clinic, research, and the broader public. However, the word autism had already been used to refer to introverted children. For example, historical educational scientist Annemieke Van Drenth describes the work of Sister Gaudia (full name: Ida Frye (1909–2003). In the 1930s, Sister Gaudia was involved in the case of a boy called Siem.3 She encountered the four-year-old Siem (a pseudonym) at the Paedological Institute in Nijmegen, which she founded. Siem had difficulties maintaining social contact, as well as language difficulties.  Siem remained at the institute for eight years. After that, he was enrolled at a regular school and eventually took up a job as an accountant. However, for the actual origin of the term autism, we have to go back to the Swiss psychiatrist Eugen Bleuler (1857–1939), who used it to denote a specific symptom of schizophrenia: the withdrawal of reality.4 In this context, it was primarily used to describe adults.

Leo Kanner has made history as the researcher who gave child psychiatry a jump-start in the United States with his description of autism. The work of the other founding father of current thinking about autism, Hans Asperger, was less well known for several decades, until Lorna Wing (1928–2014) discovered and translated it in the 1970s.

1 Leo Kanner, 'Autistic Disturbances of Affective Contact', *Acta Paedopsychiatrica*, 35:4 (1968), 100–36.

2 Hans Asperger, 'Die "Autistischen Psychopathen" im Kindesalter', *Archiv für Psychiatrie und Nervenkrankheiten*, 117:1 (1944), 76–136, https://doi.org/10.1007/ BF01837709

3 Annemieke Van Drenth, 'Rethinking the Origins of Autism: Ida Frye and the Unraveling of Children's Inner World in the Netherlands in the Late 1930s', *Journal of the History of the Behavioural Sciences*, 54:1 (2018), 25–42, https://doi.org/10.1002/ jhbs.21884

4 Bernard J. Crespi, 'Revisiting Bleuler: Relationship between Autism and Schizophrenia', *The British Journal of Psychiatry*, 196:6 (2010), 495–95, https://doi. org/10.1192/bjp.196.6.495

Asperger was subsequently discredited in 2018 because of the discovery of his links to the Nazi regime;5 nonetheless, his work is essential to an understanding of the evolution of the concept of autism. It is worth noting that both Leo Kanner and Hans Asperger may have had the same influence for their conceptualisation of autism. Indeed, historical circumstances may have caused Kanner's and Asperger's predecessor, Georg Frankl, and his role in the early history of autism, to be forgotten. In a 2020 article, Filippo Muratori, Sara Calderoni, and Valeria Bizzari describe how Georg Frankl was a senior psychiatrist working in Vienna in the 1930s when Asperger was a postdoctoral researcher.6 Frankl wrote an unpublished work on autism, in which he attributed the phenomenon to a child's poor understanding of the emotional content of words. It is very likely that Asperger knew of this work. Moreover, the authors describe how the well-known Russian psychiatrist Grunya Sukhareva had already published a paper on children with schizoid personality disorders in 1926. The description of the children was remarkably similar to the now famous description of autism by Hans Asperger. George Frankl, being Jewish, was forced to emigrate to the United States. It is certain that Leo Kanner knew Frankl and had read his work. Hence, the authors of the article argue, it is not the case that Frankl brought Asperger's ideas to the United States and to Leo Kanner as it is often believed. Instead, he may well have been the source of these ideas. Below, I will focus on the texts by Kanner and Asperger, because they are the best known in the field, and because they reflect different conceptualisations of autism that are relevant for my account. But the stories of Sister Gaudia, Grunya Sukhareva, and George Frankl should serve as a warning that reading history as a succession of individuals of genius and of founding fathers is wrong: many thinkers contribute to important ideas, and the reasons why some thinkers are installed in the canon cannot merely be attributed to merit. We can only guess how many great thinkers and ideas are forgotten by history because of their gender or because they belonged to a minority.

5 Herwig Czech, 'Hans Asperger, National Socialism, and "Race Hygiene" in Nazi-Era Vienna', *Molecular Autism*, 9 (2018), 29, https://doi.org/10.1186/s13229-018-0208-6

6 Filippo Muratori, Sara Calderoni and Valeria Bizzari, 'George Frankl: an undervalued voice in the history of autism', *Eur Child Adolesc Psychiatry* (2020), http://www.doi. org/10.1007/s00787-020-01622-4 (published online ahead of print).

#### Kanner's Autism: Kick-Starting the Field of Child Psychiatry

Leo Kanner was a psychiatrist of Austrian descent, who founded the department of child psychiatry at the Johns Hopkins Hospital in Baltimore, Maryland, in the 1930s. He thus became the first official child psychiatrist in the United States. The history of autism as a child psychiatric condition starts in 1943 with Kanner's text, 'Autistic Disturbances of Affective Contact',7 in which he describes eleven children who have one specific characteristic in common:

The outstanding, "pathognomonic," fundamental disorder is the children's inability to relate themselves in the ordinary way to people and situations from the beginning of life. Their parents referred to them as having always been "self-sufficient"; "like in a shell"; "happiest when left alone"; "acting as if people weren't there"; "perfectly oblivious to everything about him"; "giving the impression of silent wisdom"; "failing to develop the usual amount of social awareness"; "acting almost as if hypnotised." This is not, as in schizophrenic children or adults, a departure from an initially present relationship; it is not a "withdrawal" from formerly existing participation. There is from the start an extreme autistic aloneness that, whenever possible, disregards, ignores, shuts out anything that comes to the child from the outside.8

Each person interested in autism should read this paper, if only to understand the context in which the discipline of child psychiatry was born. We find many characteristics still associated with autism: the children almost all mix up their pronouns and use 'you' rather than 'I' when they refer to themselves. Echolalia, repeating the words or sentences of an interlocutor, is mentioned several times. Kanner describes insistence on sameness to stress that these children are averse to change, a characteristic that is still frequently associated with autism today. Furthermore, we read that the children described by Kanner often experience sound and noise as disturbing and too intense. This hypersensitivity to sound is a characteristic that autistic persons often use to describe their experiences, but which has only just been taken up as a diagnostic criterion in DSM-5.

7 Kanner, 'Autistic Disturbances of Affective Contact'.

8 Ibid., p. 242.

Kanner wanted to distinguish the phenomenon of infantile autism from childhood schizophrenia. As mentioned before, he did not invent the term autism, but we have to look for its origin in theories about schizophrenia. Kanner, however, introduced a marked difference between what he calls autism and how the term was used in the context of schizophrenia. He suggested that autistic children, unlike children with childhood schizophrenia, do not withdraw from the world but are born with the condition. It is striking how he describes the way that these children, born autistic, in fact gradually come out, from themselves towards the world:

While the schizophrenic tries to solve the problem by stepping out of the world of which he has been a part and with which he has been in touch, our children gradually compromise by extending cautious feelers into a world in which they have been total strangers from the beginning.9

Kanner describes the phenomenon as infantile autism. From this text alone, it is unclear what his prognosis was for the children he examined and what he would call the condition when it manifested in adults. He later described eleven adults that had been under his care as children.10 Some of them had been sent to Devereux schools (schools for special education). Some had overcome some of their previous challenges. About Don, who was first seen by Kanner when he was five years old, Kanner wrote that in a letter from Don's mother, Don was described as working at a bank and having hobbies at age thirty-eight. Kanner and colleagues later researched how some of the children he had examined in his clinical practice fared once they were adults. He described how these children had learned social behaviour during adolescence and how many would earn degrees and find a job, although often they were loners.11 Although Kanner suggested that these children often come from detached and individualistic families, and although he invented the term 'refrigerator mother', a label for mothers of autistic children, whose so-called coldness he considered to be the cause of

9 Ibid., p. 249.

10 Leo Kanner, 'Follow-up Study of Eleven Autistic Children Originally Reported in 1943', *Journal of Autism and Childhood Schizophrenia*, 1:2 (1971), 119–45.

11 Leo Kanner, Alejandro Rodriguez, and Barbara Ashenden, 'How Far Can Autistic Children Go in Matters of Social Adaptation?', *Journal of Autism and Childhood Schizophrenia*, 2:1 (1972), 9–33, https://doi.org/10.1007/BF01537624

their children's predicament, he did not state anywhere in the original paper that parents cause their children's autism. He ended his article by stating that autism is an innate disturbance, hence biological, and not a psychological reaction to suboptimal circumstances. It was only later, in the book *The Empty Fortress* (1967), that the psychoanalyst Bruno Bettelheim (1903–1990) made a causal link between autism and distant parents, more specifically mothers.12 However, eventually Kanner did come to believe, under the influence of psychoanalytic explanations of autism, that there could be psychological as well as biological causes of autism.13

#### Asperger's Autism: A Lifelong Characteristic

Simultaneously, on the other side of the world, the paediatrician Hans Asperger described a similar pediatric phenomenon in his dissertation 'Die "Autistischen Psychopathen" im Kindesalter'.14 In this text, written to obtain the degree of *Habilitation*, a postdoctoral German academic degree, Asperger described in four extensive case studies his ten-year-long observations of children in Vienna's pediatric hospital. Comparable to Kanner's statements, he offered an image of these children as being withdrawn and set apart from others: 'The autistic is only "himself" (hence the word auto), not a lively part of a bigger organism, not constantly influenced by such an organism, and constantly influencing the greater whole.'15 Famously, Asperger describes very bright but odd children, whom he calls little professors. However, in the text itself, Asperger states that the pathology also occurs in children who are less intellectually gifted. Moreover, the level of intelligence influences how well these children

12 Bruno Bettelheim, *The Empty Fortress: Infantile Autism and the Birth of the Self*, illustrated edition (New York: The Free Press, 1972).

13 Brooke Ingersoll and Allison Wainer, 'The Broader Autism Phenotype', in *Handbook of Autism and Pervasive Developmental Disorders: Diagnosis, Development, and Brain Mechanisms, Volume 1, 4th Ed* (Hoboken, NJ: John Wiley & Sons Inc, 2014), pp. 28–56, https://doi.org/10.1002/9781118911389.hautc02

14 Asperger, 'Die "Autistischen Psychopathen" im Kindesalter'. Translation by the author.

15 'Der Autistische ist nur 'er Selbst' (daher das Wort auto), nicht ein lebendiger Teil eines größeren Organismus, von diesem ständig beeinflußt und ständig auf diesen wirkend.' (p. 9)

can adapt: 'Now one does not find the autistic character solely with the intellectually gifted, but also with the less gifted, yes even with the very intellectually disabled. That adaptation with the latter is much more difficult is clear.'16 Indeed, one of the children from the text, Ernst K., seven years old, is explicitly described as cognitively disabled. For Asperger, the 'autistic psychopathy', as he calls the phenomenon, is lifelong and would also impact one's functioning lifelong. Although the condition is permanent, Asperger also thought that the unique gifts and skills that these children demonstrated also had advantages, as long as they ended up in the right place and the right circumstances. Just like Kanner, Asperger identified that the defining area in which the children struggled was their relationships with others. Through his description of the sometimes tricky and, from time to time, even cruel behaviour exhibited by some, he tells a nuanced story about their emotional lives and also recounts how the children sometimes exhibited deep emotions, such as terrible homesickness. Based on the following quote from his paper, I presume that Asperger would not agree with some present-day descriptions of autistic people which suggest that they do not have empathy:

Given these facts, the question about the emotional lives of these children has become very complicated. We cannot merely understand it as a "poverty of emotions" from a quantitative perspective. Instead, it is a qualitatively different way of being, a disharmony of sentiment, of mental state, full of surprising contradictions by which these children are characterised and which causes their disordered adaptability.17

The German term 'Psychopaten' that Asperger uses sounds odd to contemporary ears and reminds us of psychopathy. However, *Autistischen Psychopathen* refers to someone with an 'autistic personality disorder'. Asperger considered autism in the first place as

16 'Nun findet sich der autistische Charakter keineswegs nur bei intellektuell Hochwertigen, sondern auch bei Minderbegabten, ja bei tiefstehend Schwachsinnigen. Daß in diesen letzteren Fällen eine Anpassung noch viel schwerer zu erzielen sein wird, ist klar.' (p. 31)

17 'Angesichts dieser Tatsachen ist uns das Problem der Gefühlsseite dieser Kinder sehr kompliziert geworden. Es ist jedenfalls nicht einfach nach dem Begriff "Gefühlsarmut" zu verstehen, also nach quantitativen Gesichtspunkten, es ist vielmehr ein qualitatives Anderssein, eine Disharmonie an Gefühl, an Gemüt, oft voll überraschender Widersprüche, wodurch diese Kinder charakterisiert sind, wodurch ihre Anpassungstörung verursacht wird.' (p. 56)

something innate and permanent, which is part of one's personality and identity.

The British psychiatrist Lorna Wing rediscovered the work of Asperger: she renamed the phenomenon 'Asperger syndrome' in her article from 1981, which offers a reinterpretation of the original text.18 For Wing, Asperger syndrome is not a personality disorder but a developmental disorder. Since Wing's rediscovery, people have questioned whether Asperger syndrome is a separate entity from autistic disorder. The primary distinction would be that children with Asperger syndrome do not have a delay in language development. Wing herself proposed a spectrum of disorders with a triad of deficits: in social interaction, communication, and imagination. This triad would form the basis for later descriptions in different versions of the DSM. 19 Even today, the concepts of Kanner's autism and Asperger syndrome evoke other images, which might not meet with the complete approval of the authors of the original texts.

#### Autism's Past and Present

There is much more to say about the history of autism. For example, I did not elaborate on the psychogenic explanation by Bruno Bettelheim and the spread of the harmful idea of the 'refrigerator mother'. This idea primarily blamed mothers for their children's autism and resulted in the institutionalisation of many children. In response to (and reaction against) this idea, a new era dawned, ushered in by people such as Bernard Rimland (1928–2006), a psychologist with an autistic son. In this era, autism was primarily understood as being innate and neurobiological.20 This shift in understanding autism led to decades of scientific research into the genes and neurology of autism. Rimland,

18 Lorna Wing, 'Asperger's Syndrome: A Clinical Account', *Psychological Medicine*, 11:1 (1981), 115–29.

19 Kathrin Hippler and Christian Klicpera, 'A Retrospective Analysis of the Clinical Case Records of "Autistic Psychopaths" Diagnosed by Hans Asperger and His Team at the University Children's Hospital, Vienna', *Philosophical Transactions of the Royal Society B: Biological Sciences*, 358:1430 (2003), 291–301, https://doi.org/10.1098/ rstb.2002.1197

20 Bernard Rimland, *Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behaviour* (London: Methuen, 1964).

however, still understood autism as a rare condition, which occurs in children without intellectual disability.

The growth in diagnoses of autism over recent decades is well documented. Many explanations have been given for this, some more plausible than others. Some people argue that the expansion is due to the broadening of diagnostic criteria. Some say that there has been a diagnostic substitution of intellectual disability with autism because people consider the latter to be a less ''severe'' diagnosis and because there are treatments for autism that are not available for intellectual disability. Some point to environmental pollution, whereas others suggest that our society is very autismogenic: today, there is much more stress on autonomous and social functioning and far less tolerance for those who do not fit in easily. Sebastian Lundström and colleagues have suggested that it is not a question of the greater prevalence of autism traits but of diagnoses of autism.21 The reason why such a diagnosis has become more commonplace can be attributed to the fact that doctors are more familiar with the characteristics of autism. However, another explanation may be that society has changed: flexibility and social communication is valued more, which means that people with characteristics of autism stand out more often and experience challenges in their daily functioning. 22

For those wanting to understand autism as a phenomenon, it is essential to read the original texts by Kanner and Asperger. A crucial difference between Kanner and Asperger lies in their perspective on the nature of the condition, not the kind of people they described. Kanner suggested in his first text that infantile autism was innate, but whether it was also lifelong was less clear. He described, from a developmental perspective, how these children gradually acquired more social skills. Although, in his follow-up study, Kanner described the adults as unusual, many of them succeeded in finishing their education and established a place in society. Perhaps Kanner considered these adults

21 Sebastian Lundström and others, 'Autism Phenotype versus Registered Diagnosis in Swedish Children: Prevalence Trends over 10 Years in General Population Samples', *BMJ (Clinical Research Ed.)*, 350 (2015), h1961.

22 Taskforce Autisme, 'Naar Een Autismevriendelijk Vlaanderen. Aanbevelingen van de Taskforce Autisme in Opdracht van Minister Jo Vandeurzen', 2016.

as autistic still. Nevertheless, as a child psychiatrist, he viewed autism primarily as a disorder of development.

However, for Asperger, autistic characteristics were lifelong characteristics of one's personality. Both conceptions are still relevant: autism as a developmental condition, of which the course is not fixed, and autism as an innate neurological ''difference'' with strengths and weaknesses. Of relevance, also, is autism's origins as firmly associated with the birth of child psychiatry.  But what is a psychiatric diagnosis, and what is its relation with neurological development and with biology more generally? The next chapter will delve deeper into these questions.

### 2. The Nature of Psychiatric Diagnoses

In 2016, I attended a two-day conference for researchers of autism in Gent, Belgium. This conference was explicitly geared at autism researchers in the biomedical field. One of the speakers showed videos of a fruit fly and mouse that were supposed to exhibit autistic traits. In both animals, the researchers had changed or switched on or off a candidate gene for autism. The fruit fly exhibited autiform behaviour, so they said, i.e., behaviour that is similar to autistic behaviour, because when the researcher put the male fly in a petri dish with a female fly, he kept to himself rather than exhibiting ''normal'' excessive courting behaviour. Whereas the mouse exhibited extreme digging behaviour: she preferred spending her time digging holes and hiding marbles. I was intrigued about the underlying assumptions of this study: first, that these animals'' behaviour is the direct result of genes. These studies suggest that a genetic explanation is a sufficient explanation for a complex phenomenon such as behaviour. However, in my opinion, behaviour is also a reaction to specific circumstances. Indeed, mice and even fruit flies have reasons for what they do, beyond merely a difference in genetic makeup. Secondly, we may wonder why we call such behaviour autistic: why do we assume that the behaviour of the mouse or the fruit fly is the same as that of autistic children? After all, we do not understand the motivations of these animals, and we may even wonder whether we properly understand the motivations of autistic children for their behaviour.

In what follows, I shall dig deeper into the question of the relationship between our mind and our body, between what is considered biological and psychological. Indeed, the relationship between psychiatric diagnoses and underlying biological essences such as our brains and our genes has been the subject of fierce debate. Let us set aside the nature of autism for the moment and look at how scholars have talked about mental phenomena in general. When we talk about psychiatry, we talk about the clinical discipline with the most family resemblance to philosophy. Psychiatry is not neurology: we do not merely speak about brain diseases but also about mental processes, thoughts and their meaning. Nevertheless, it is not easy to distinguish a cognitive function from a physical process in the brain. We may even wonder whether it makes sense to make this distinction. Some commentators suggest that we are simply our brains1 and that our mental processes are mere illusions. Along the same lines, they argue that psychiatry will eventually turn out to be neurology. Surely, this cannot be the whole truth. We think about ourselves as having a mind and a self. Things have meaning for us.

#### Minds and Brains

If we want to discuss psychiatric diagnoses, we have to briefly discuss the relation between body and mind. It is not my intention here to provide a complete account of the philosophy of mind. However, a brief sketch of the discussion is necessary, as it sheds light on why our biological conceptions of autism exist. Autism seems to sit uncomfortably between the fields of psychiatry and neurology. The question 'are we our brain' has probably occupied human thoughts since the beginning of human self-consciousness. People have always asked how the mental and the corporeal relate. We have asked ourselves whether cognitive processes are merely the results of what happens in our neurons or whether, on the contrary, mental processes can also influence our brains. By the time of the ancient Greeks, people already knew that brain disorders also affect our mental processes, as is demonstrated by a quote from the *The Holy Disease*, attributed to Hippocrates: 'And men ought to know that from nothing else but (*from the brain*) come joys, delights, laughter and sports,

1 Dick Swaab, *Wij zijn ons brein: van baarmoeder tot Alzheimer* (London: Atlas Contact, 2010).

and sorrows, griefs, despondency, and lamentations.'2 The holy disease is epilepsy, and according to Hippocrates, there is nothing sacred about it at all. The delusions that are associated with this disease are the result of biological processes as well. However, the fact that Hippocrates deemed it necessary to point this out to his fellow Greeks already demonstrates that viewing oneself and one's mental processes as functions of the brain was not self-evident even then. Phenomenologically speaking, we are also cognitive functions, despite all neurological images and genetic findings. I shall later argue that the solution to this conundrum does not lie in reducing experiences to biological processes. We will have to concede that many present-day views on biology are too reductionist.

The idea that there is a distinction between body and mind was stressed by René Descartes (1596–1650) in his famous distinction between *res cogitans* (mind) and *res extensa* (matter).3 This distinction brings about a couple of conceptual problems. If *res cogitans* and *res extensa* are genuinely different things, how can they interact? The philosopher Gilbert Ryle (1900–1976) mockingly called the idea of a separate mind the ghost in the machine.4 There are different variants to dualist thinking: one can see mind and body as separate substances and also as the same substance with distinct characteristics. The question of how such separate substances can interact occupies philosophers of consciousness even today. Some take up a radically different perspective and argue that all is matter. To some extent, I agree with the viewpoint that we are our body, and that even mental processes are matter. However, as I will argue in this book, this does not mean we can reduce mental processes to their underlying biological processes.

The challenge seems not to lie in materialism itself but in a reductionist or deterministic conception of what this materialism entails. People with a psychiatric diagnosis may display atypical behaviour. Therefore, it is often implied that dysfunctioning brains and neurons direct this behaviour entirely and in a linear fashion. We only have to look at animal models of autism, such as the mouse obsessively digging holes or the male fruit fly that is not interested in female fruit flies, to see an

2 Hippocrates, *De Morbo Sacro*, Section 1, http://www.perseus.tufts.edu/hopper/text ?doc=Perseus%3atext%3a1999.01.0248%3atext%3dMorb.+Sacr

3 René Descartes, *Discours de la méthode* (Quebec: Collection Résurgences, 1995).

4 Gilbert Ryle, *The Concept of Mind* (Chicago: University of Chicago Press, 1949).

illustration of this. We do not know why these animals behaved as they did and to extrapolate from the behaviour of one animal to that of another (in this case, autistic humans) seems premature. I will come back later to the caveats of genetic research. However, materialist explanations of behaviour do not necessarily have to be causal-deterministic. For example, the physician Roger Penrose, a self-declared materialist, has a theory about our consciousness that builds on quantum physics and explains consciousness based on quantum processes.5 Chapter nine will introduce new materialism, a line of thought that also allows for a nondeterministic view on the matter. Nevertheless, for many, materialism and determinism seem to be concepts that are inextricably linked.

Views on the nature of psychiatric disorders and mental processes are also relevant to our discussion about the ethics of autism and psychiatric diagnosis in general. A mere materialistic-deterministic approach seems to suggest that, in order to understand our experiences and behaviours, we should first look for causal explanations in our brains and our blueprint — our genes. However, this neglects our phenomenological experience that we are more than our neurons. It is almost impossible to imagine ourselves as something different than an 'I'. Is this 'I' merely an illusion? Moreover, such a deterministic-materialistic approach also seems to suggest that free will is an illusion. How can we indeed be free if what we want is merely a function of our brains? This question is hugely relevant to the ethics of psychiatry. It seems to be the case that most psychiatrists, and most human beings in general, do not assume a reductionist and materialistic conception about mind and body but make a distinction between the different psychiatric diagnoses. Wookyoung Ahn and colleagues have discovered that clinical professionals also make such a distinction.6 In their studies, their respondents seem to consider autism as a 'very biological condition'. Moreover, the more people believe that a condition is anchored in biology, the more they deem those with the condition not to be responsible for their behaviour. Marc Miresco and Laurence Kirmayer write, in response to a survey

5 Roger Penrose, Abner Shimony, Nancy Cartwright, and Stephen Hawking, *The Large, the Small and the Human Mind* (Cambridge: Cambridge University Press, 2000).

6 Woo-kyoung Ahn, Caroline C. Proctor, and Elizabeth H. Flanagan, 'Mental Health Clinicians' Beliefs About the Biological, Psychological, and Environmental Bases of Mental Disorders', *Cognitive Science*, 33:2 (2009), 147–82, https://doi. org/10.1111/j.1551-6709.2009.01008.x

they conducted with 270 psychiatrists and psychologists, that the more respondents considered a specific behaviour 'psychological', the more a person was deemed responsible for it:

The more a behavioural problem is seen as originating in "psychological" processes, the more a patient tends to be viewed as responsible and blameworthy for his or her symptoms; conversely, the more behaviours are attributed to neurobiological causes, the less likely patients are to be viewed as responsible and blameworthy.7

Philosopher of science Ian Hacking wrote in this respect that 'biology is exculpating'.8

In our interview study with adults with a recent diagnosis of autism, we also found such mechanisms.9 Some of our female participants had already received a Borderline Personality Disorder (BPD) diagnosis before receiving their autism diagnosis. They accepted the latter diagnosis more readily. They had the impression that when clinicians still considered them to have 'borderline', unreasonable demands were made of them. For example, they had to take part in group therapy which did not work for them. As people consider autism to involve a 'different kind of brain', there was more consideration given to these women's behaviour, and they were less expected to adapt. I could not find any studies that would prove that BPD is more of a mental disorder than autism, although there is more research into the genetic basis of autism. It is difficult to grasp what it would mean for a condition to be more mental or biological. So although these distinctions are readily made and do normative work, their fundamental ontological basis may be flawed.

Biological conceptions about psychiatric disorders also have disadvantages for those diagnosed. Matthew Lebowitz and Wookyoung Ahn describe how biological explanations can have an impact on a clinician's empathy. If one considers a disorder to have a physical cause, people diagnosed with it are seen as less responsible for their

7 Marc J. Miresco and Laurence J. Kirmayer, 'The Persistence of Mind-Brain Dualism in Psychiatric Reasoning about Clinical Scenarios', *The American Journal of Psychiatry*, 163:5 (2006), 913–18, https://doi.org/10.1176/ajp.2<IP_ADDRESS>3

8 Ian Hacking, *Historical Ontology* (Cambridge, MA: Harvard University Press, 2004).

9 Kristien Hens, and Raymond Langenberg, *Experiences of Adults Following an Autism Diagnosis* (Chambersburg: Palgrave Macmillan, 2018).

behaviour. However, they can also count on less empathy being shown towards them. Lebowitz and Ahn suspect that this is because people with a mental disorder that is seen as very 'biological' are considered categorically different from so-called 'normal people'. People with such diagnoses are then looked at more as mechanisms than as individual patients. Moreover, such assumptions also lead to pessimism about the prognosis: it is assumed that 'biologically based' diagnoses are less dynamic and changeable than psychological ones.10

#### The Nature of Psychiatric Disorders

What, in fact, are psychiatric disorders? As we have described above, whether people think something has a biological (rather than psychological) cause is not a sufficient criterion to demarcate psychiatric disorders from somatic illnesses. Dementia, for example, is described in DSM-5, and we assume that this is first and foremost a neurological condition. Let us accept that a psychiatric disorder is something that is described in a diagnostic handbook such as DSM-5. To know which diagnosis suits a specific person, one can use the guide's descriptions and consider to what extent we can apply these to the person who exhibits certain behaviours or who experiences specific challenges. The descriptions in the diagnostic manuals are not directly the result of or the report of scientific findings and are susceptible to changes and societal evolutions.11 Let us, for a moment, look at the description of autism across the decades. We then see, for example, that only the DSM-5, the latest version of the DSM, mentions the idea of 'hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment' as a diagnostic criterion. However, since Kanner, it is considered a part of the autistic phenotype. This late addition presumably has to do with the growing voices of autistic people themselves in autistic research, who think this to be an essential aspect of their experiences. Whether the diagnostic manual describes a disorder has significant consequences.

10 Matthew S. Lebowitz and Woo-kyoung Ahn, 'Effects of Biological Explanations for Mental Disorders on Clinicians' Empathy', *Proceedings of the National Academy of Sciences of the United States of America*, 111:50 (2014), 17786–90, https://doi.org/ 10.1073/pnas.1414058111

11 Trudy Dehue, *De depressie-epidemie: over de plicht het lot in eigen hand te nemen* (Amsterdam: Atlas Contact, Uitgeverij, 2015); Trudy Dehue, *Betere mensen: over gezondheid als keuze en koopwaar* (Amsterdam: Atlas Contact, Uitgeverij, 2014).

For example, an official diagnosis is often needed to receive adequate help and support.

The reasons why a specific manual mentions certain disorders and does not mention others are not always easy to explain. Nevertheless, psychiatric diagnoses and their description become more than a mere report or a guideline for clinical action. In principle, in the DSM or other manuals, diagnoses describe clusters of behaviours and symptoms that often co-occur. Therefore, they are usually reliable, which means that different diagnosticians tend to agree on a diagnosis in an individual, but they are not necessarily valid.12 This means that there is no guarantee that another diagnosed person's' behaviour has the same underlying explanation. However, as these clusters often co-occur, it is suspected that they could potentially represent a 'true' underlying essential disorder and be valid.

Nonetheless, for most disorders in DSM, there is no hard proof that this is the case. Besides this clustering of symptoms, a diagnostician's experience with a treatment, and the treatment's effectiveness play a role. For example, despite lobbying by stakeholders, Sensory Processing Disorder (SPD) was not retained as a separate diagnosis because the American Psychiatric Association (APA) that publishes the DSM was not convinced that this diagnosis could be a guideline for efficient therapy. Many of the children who would qualify for the proposed SPD will now either not get a diagnosis or be diagnosed with ASD or ADHD (Attention Deficit Hyperactivity Disorder) and follow these diagnoses' treatment plans. Diagnostic classification is first and foremost a clinical classification. Although scientific findings related to genetics and neurology will contribute to the categorisation of psychiatric disorders, the DSM's authors do not claim that these categories correspond to underlying biologically delineated entities. They do not claim 'to carve nature at its joints.'13

Still, this cannot be the entire story. We may agree that psychiatric classifications and the diagnoses based on these classifications do not

12 Olivier Lemeire, 'Soortgelijke stoornissen. Over nut en validiteit van classificatie in de psychiatrie', *Tijdschrift voor Filosofie*, 76:2 (2014), 217–46, https://doi.org/10.2143/ TVF.76.2.3030628

13 Tijdschrift Voor Psychiatrie, *Diagnostic and Statistical Manual of Mental Disorders (5de Druk)*, Vol. 5 (2013), http://www.tijdschriftvoorpsychiatrie.nl/en/issues/472/ articles/10181

necessarily correspond one-on-one to underlying biological or natural kinds. Suppose we only look at the many studies that search for the biological causes of exactly these psychiatric classifications. We then realise that they are often interpreted as referring to a fundamental underlying cause. For example, in the search for autism genes, participants are often selected based on diagnostic criteria. We might wonder why we want to use something that has a clinical finality as a basis for research into causes. How can we explain this *Verdinglichung* (reification)? Why do we conceive of human kinds (the diagnostic classifications described in the DSM) as natural kinds (biological kinds with fixed characteristics)?

Pieter Adriaens and Andreas De Block suggest some explanations in their paper 'Why we essentialise mental disorders'.14 People could be, by nature, prone to essentialism. Moreover, the fact that specific medication, such as Ritalin, is helpful to treat someone with a specific psychiatric diagnosis, such as ADHD, suggests that it is indeed a brain disease that can be cured by medication. Trudy Dehue, in her book *Betere Mensen*, also analyses why we tend to essentialise psychiatric diagnoses: we as humans have the urge to consider something that has a name to exist in itself.15 Psychiatric conditions that are considered real tend to work in a deculpabilising manner: they suggest that neither the person diagnosed nor their parents or immediate environment are to blame for the behaviour. However, this essentialising tendency also often leads to the fact that challenges become disorders, something inside an individual. Moreover, the description of the behaviour then transforms into the explanation of the behaviour. If a child is diagnosed with ADHD, this is based on the fact that she has problems concentrating and exhibits hyperactivity. However, ADHD will also function as the explanation for the behaviour ('she cannot sit still because she has ADHD'). By such shortcuts, one risks ignoring the contexts of and reasons for specific behaviour.

People often interpret discussions about the reality of psychiatric disorders as a denial of the reality and the impact of the suffering

14 Pieter R. Adriaens and Andreas De Block, 'Why We Essentialize Mental Disorders', *The Journal of Medicine and Philosophy*, 38:2 (2013), 107–27, https://doi.org/10.1093/ jmp/jht008

15 Dehue, *Betere Mensen*.

experienced by the person diagnosed. Many autistic persons object to the idea that autism is not 'real'. They reject social constructivist conceptions of autism. I will discuss this in more depth in chapter four. However, it must be possible to think beyond the dichotomy of biological disease versus construct-in-language, or natural kind versus humankind. Psychiatrists, parents, children, and adults with a diagnosis testify to the realness of their experiences with autism. We do not need a fixed and straightforward biological truth to acknowledge the reality of experiences. The fact that cultural and familial contexts strongly influence specific experiences, that in a particular era of history a concept of autism may not have been applicable, and that it may not exist or be used in the future, does not take away from this. It is possible to maintain autism as a real and shared experience while at the same time acknowledging that there will probably never be a simple biological explanation. I will return to this possibility later.

#### Concepts of Disease

Why does some behaviour qualify for a psychiatric diagnosis? What does it mean to say that something deviates from the norm? Here we can also distinguish between naturalistic assumptions and constructionist ones. The ideas of philosopher Christopher Boorse have found much resonance in applied ethics. For Boorse, illness is deviance from the statistical mean.16 He believes that we can draw a definite line between disease and health, and that this line is not merely the result of a value judgement. He has laid down the concept of species-typical functioning: a level of functioning that a typical member of a species would exhibit. This species-typical functioning is defined in relation to reference classes based on age and sex. We find this idea in psychiatry as well: diagnoses are often given after extensive examinations, including psychological tests. One can assess whether someone is psychologically deviant from the mean concerning social behaviour or concentration.

There are some problems associated with this approach. We can find examples where deviation from a statistical norm is not an illness, such

16 Christopher Boorse, 'Health as a Theoretical Concept', *Philosophy of Science*, 44:4 (1977), 542–73, https://doi.org/10.1086/288768

as height or intelligence, a fact that Boorse acknowledges. Moreover, it is not clear what it means to function in a species-typical way. Think about social behaviour: in Western societies, eye contact is seen as normal social behaviour, whereas in some other cultures, it is seen as impolite. Still, having 'appropriate' eye contact is part of the diagnostic assessment for autism. Moreover, we may wonder whether a completely value-free concept of disease is possible. Boorse has argued that homosexuality is a disease based on his idea of species-typical functioning. As he considers 'disease' as a value-free concept, this does not imply that it is either something terrible or that we should try to cure it. However, most would intuitively feel that 'homosexuality is a disease' conveys a normative claim and one we should reject.

Psychiatrist Jerome Wakefield takes a naturalistic approach, and he also makes the distinction between mental illness and health by deploying the idea of harmful dysfunction. He explicitly links disease with evolution, but allows value judgements to be part of the analysis through the use of the word 'harmful'. Something is a dysfunction if there is a defect in an internal mechanism that prevents the proper execution of a biological function.17 A fear of spiders, for example, can be explained using the concept of evolution, but it becomes a disorder if it results in a paralysing phobia that severely hampers everyday functioning. The idea of dysfunction is also part of the present-day definition of autism. To receive a clinical diagnosis of autism, one should not merely exhibit specific behavioural characteristics, but, as I have discussed in the prologue, there should also be sufficient impact on the quality of life. We might ask ourselves whether we can ever explain this impact in evolutionary terms. Even today, many psychiatric disorders do not have clear-cut evolutionary explanations.

Furthermore, even the idea of dysfunctioning is not clear. Who gets to decide whether someone is dysfunctioning? Does dysfunctioning involve specific behaviour that is a nuisance to others? Does a child experience challenges if a particular educational system is not a good fit for her? The diagnosis of autism is often given during childhood by child psychiatrists, and this makes it even more challenging to decide whether a particular behaviour can be considered dysfunctional. In this

17 Jerome C. Wakefield, 'The Concept of Mental Disorder: Diagnostic Implications of the Harmful Dysfunction Analysis', *World Psychiatry*, 6:3 (2007), 149–56.

context, Courtenay Norbury and Alison Sparks state that 'the point at which normal variation converges on disorder is largely an arbitrary decision and is highly likely to be influenced by cultural values and expectations.' They note that the vast majority of therapists in Western society are white and female. However, the children with whom they work have a very diverse background concerning language and cultural experiences. For some of these children, playing with dolls is not selfevident, for example. Autism research has primarily focussed on Western culture and reflects only a small minority of the world's population.18 In this respect, the search for evolutionary explanations or statistical means may be a lost cause from the start. Perhaps we should accept that psychiatry will never be neurology, and that value judgments will always play a role in diagnostics.

#### The Values of Psychiatry

The idea that psychiatry is not value-neutral has been elaborated extensively in the writings of Michel Foucault. I do not aim to discuss his arguments in much depth here, but I think it is still helpful to describe some of them. In his *Madness and Civilization: A History of Insanity in the Age of Reason,* Foucault explains that we cannot merely describe psychiatry's history as one of evolving insight: specific historical periods influence how people look at madness. Until the end of the eighteenth century, madness was a social and a moral problem. Only later did it become a medical problem.19 Later on, Foucault discusses, through his description of the panopticon, the function of discipline. Discipline is not the same as oppression, as it is self-imposed, and its relations of power also create productive and valuable knowledge. In later writings, he describes how by opposing and partly assuming imposed identities, alternative forms of subjectivity and identity are possible. We can see these mechanisms at work if we look at how adults come to terms with their diagnosis of autism. Rather than being oppressed by a psychiatric

18 Courtenay Frazier Norbury and Alison Sparks, 'Difference or Disorder? Cultural Issues in Understanding Neurodevelopmental Disorders', *Developmental Psychology*, 49:1 (2013), 45–58, https://doi.org/10.1037/a0027446

19 Michel Foucault, *Geschiedenis van de waanzin in de zeventiende en achttiende eeuw* (Amsterdam: Boom, 1982).

label, autism becomes something with which one identifies. Nevertheless, this identification is not total: autism becomes an explanation for one's functioning, but at the same time, these adults also reject an overly narrow definition of what it is. Someone can identify with autism but, at the same time, say that they are empathic and social. Autism is not only something that is solely shaped by the psychiatric profession, but it acquires a life of its own as an identity.

The birth of the anti-psychiatry movement in the 1960s is, to some extent, influenced by the thoughts of Foucault. However, Foucault himself had a more nuanced view of psychiatric diagnosis. The antipsychiatry movement, with thinkers such as psychiatrists Ronald Laing and Thomas Szasz, asserts that psychiatric diseases do not exist, as they have no biological ground. It characterises psychiatry as an authoritarian system, in which the medical profession suppresses the experiences and identities of patients. People with a psychiatric condition are not ill, and psychiatry only exists to maintain existing conceptions of normality. Hence, according to this view, psychiatry is, by definition, oppression. An oft-cited example is that of drapetomania, a presumed mental illness described in the nineteenth century by the physician Samuel Cartwright (1793–1863): drapetomania is the urge of slaves to run away from their masters. The nineteenth-century concept of hysteria might also be an example of the pathologising of justified frustrations of women in a society that suppresses them. Nowadays, the anti-psychiatry movement has been relegated to the background. Some people even use 'antipsychiatry' as an insult aimed at those in psychiatry who advocate for change within the discipline. Nevertheless, it has led to the insight that psychiatric patients can also actively contribute to their care, rather than the psychiatrist having sole input into their treatment. Moreover, even today, there are psychiatrists and other medical professionals who question the validity of diagnoses. For example, some argue that ADHD is not a real disorder but a means to discipline normal but boisterous children with drugs. Furthermore, in the autism world, some voices want to do away with the label autism altogether. I will return to this in chapter four.

The problem with anti-psychiatry approaches is that they start from the same naive assumption as mere reductionist-biological approaches, namely that discoverable biological essences should support psychiatric classifications to be real. This idea, however, neglects how diagnoses work, and it also denies the fact that shared experiences can also have a claim to the truth. Moreover, we could ask ourselves why we would need a theory about psychiatric disorders or diagnoses. Maybe it is possible to take a pragmatic approach and claim that illness is that what brings people to the medical doctor or the psychiatrist. We could simply say that illness or disorder is that which makes people suffer. Along the same lines, perhaps we can see psychiatric classifications as a clustering of phenomena that we know how to treat. Although I have some sympathy for this pragmatic approach, it is probably insufficient. We need a theory about psychiatric classifications to serve as a legitimisation for treatment plans or medication. For a psychiatric diagnosis to work, people need to experience it as real. A pragmatic solution could then be that psychiatrists and child psychiatrists pretend to their clients that scientists know a lot about the neurological and genetic underpinnings of autism: for many people, the idea of a biological essence or cause is therapeutic. However, given the lack of knowledge about its causes and the physical and social complexity of autism, this seems a dangerous route. We will have to find an approach that does not fall into the trap of a naive-deterministic model or a naive-constructionist model, and which, at the same time, acknowledges the multi-layeredness of the meanings and experiences of psychiatric disorders.

However, first, we shall investigate how mental disorders differ from somatic disorders.

#### Nomy Arpaly and the Nature of Mental Illness

In her paper 'How It Is Not Just Like Diabetes', Nomy Arpaly describes how today, mental disorders are considered more and more to be like somatic diseases.20 According to this view, a mental disorder is fundamentally different from other human conditions, such as love, fear, and hate. We do not consider the latter as diseases. Arpaly thinks this is not correct. She concedes that there are analogies between mental disorders and somatic disorders such as diabetes. For example,

20 Nomy Arpaly, 'How It Is Not "Just Like Diabetes": Mental Disorders and the Moral Psychologist', *Philosophical Issues*, 15:1 (2005), 282–98, https://doi.org/10. 1111/j.1533-6077.2005.00067.x

medication often works very well in treating mental conditions such as depression. Moreover, you cannot decide with willpower alone not to be depressed anymore, just as this is not possible with diabetes.

Nevertheless, the most common reason people think that mental illnesses are equivalent to somatic illnesses is that people assume that mental illnesses are also located in the body. Mental illnesses are disorders of the brain, just as the body causes diabetes by being incapable of producing insulin. However, Arpaly argues, if we assumed such a materialist approach to specific mental disorders, this would apply equally to things like love and hate.   To begin with, you can say about mental conditions that they are justified or not. For example, you can believe that a specific piece of fruit is an apple, and that can be justified or not. We can say something about whether someone's feelings of guilt are justified or unjustified. We cannot say that about purely biochemical states such as diabetes: they just 'are'. Mental states are also about something; they have content efficacy. Arpaly explains this very well using an analogy with coffee:

Consider becoming anxious because of having had too much caffeine vs becoming anxious because there is talk of downsizing in one's company. The first case is "just like diabetes" in a way that the second case is not. This cannot be, as psychiatrists sometimes say, because the caffeineanxiety is "biological" and the downsizing-anxiety is "not biological". Humans are biological entities, anxiety is in the brain, so presumably all anxiety is biological. However, there is still a strong difference: when the thought "I may lose my job" causes anxiety, the content or the meaning of the thought "I may lose my job" is causally efficacious in the creation of the anxiety. Unlike the thought "I may lose my job", caffeine has no content, it is not about anything, and so when it causes anxiety, it is causation that involves no content efficacy.21

This quote is also relevant in the context of autism. It makes clear why the distinction biological/not biological does not adequately elucidate the differences between mental and somatic disorders if we assume

21 Arpaly, 'How It Is Not "Just Like Diabetes"', p. 286.

that what we consider mental is biologically anchored. In the context of autism, it is presumed by some that because it is biological, it is also really almost a somatic disease that we should prevent or cure, and that explaining autism by referring to genetics or neurology is sufficient. Nevertheless, it makes sense to say that autistic behaviour also has content and is about something. It is not merely the result of an infection or mutated genes but a meaningful reaction to context. That does not mean that genes or neurology could not partly explain why people exhibit a particular behaviour, just as with bipolar disorder, for example. However, the behaviour itself is not the direct result of a flaw in genes or brains.

To illustrate her point, Arpaly uses the distinction between narcissistic personality disorder and Tourette Syndrome (TS).  In the case of TS behaviours (tics, involuntary expressions), these are the direct result of failing biology without content efficacy: TS symptoms do not indicate that a person with TS has a desire to insult you or is ill-mannered. However, in my opinion we do not know enough about people's experiences with TS to make an absolute distinction in this way.. A child psychiatrist once told me about a client with a diagnosis of TS. She was Jewish and had a specific tic, the urge to say 'Hitler', which she could suppress only with great difficulty among individual family members. Although we cannot blame her for the tics, of course, it is clear that the tics do have some mental content. We probably do not know enough about the relation between soma and psyche to say, based on diagnosis, something about the extent to which someone's thoughts, experiences, and intentions interact with one's biology. Maybe it is even the case that somatic disorders, to some extent, are *about* something and also have mental content. I shall not elaborate on this thought further here, however.

Arpaly ends the paper by explaining why many people would like mental disorders to be like diabetes. The suggestion that a mental disorder is really like a somatic disorder implies that the suffering caused by the disturbance is real:

I think being told that one's mental troubles are like diabetes satisfies a simple, at times desperate, need: the need to have it recognised that one's problem is real, as painful and debilitating as diabetes can be, and as unlikely to be wished away.22

Nevertheless, she also writes:

Often, one has to pay dearly for the recognition that one's suffering is real. For being taken seriously in one way (being acknowledged as a real sufferer) one risks paying with giving up the privilege of being taken seriously in another way, to be taken as someone whose mental states can be meaningful and warranted. I am not referring here to the oftendescribed experience of stigma, of being regarded as a 'lunatic', but to a type of slight, or dehumanisation, that one can encounter from the most 'enlightened' people, and which is aggravated rather than alleviated by the medical model.23

This is also true for autism. In my research, I have noticed that people who receive a diagnosis of autism often see this as acknowledging that their problems are real, not imaginary. The recognition of one's suffering is often inherently linked to the medicalisation of suffering precisely because the recognition is dependent on the fact that a mental disorder is considered to be biologically real. This idea is supported by the empirical studies I mentioned earlier, which shows that people diagnosed with something that is considered genetic and biological are considered to be less responsible for their deeds than people with a personality disorder.24 Moreover, the more clinicians consider a disorder to be biological, the more often they consider medication to be the best option.25 One study suggests, surprisingly, that clinicians and other professionals may feel less empathy towards those with a diagnosis they

22 Ibid., p. 295.

23 Ibid., pp. 296–7.

24 Stephen Buetow and Glyn Elwyn, 'Are Patients Morally Responsible for Their Errors?', *Journal of Medical Ethics*, 32:5 (2006), 260–62, https://doi.org/10.1136/ jme.2005.012245; Marc J. Miresco and Laurence J. Kirmayer, 'The Persistence of Mind-Brain Dualism in Psychiatric Reasoning about Clinical Scenarios', *The American Journal of Psychiatry*, 163:5 (2006), 913–18, https://doi.org/10.1176/ ajp.2<IP_ADDRESS>3; Daniel Navon and Gil Eyal, 'Looping Genomes: Diagnostic Change and the Genetic Makeup of the Autism Population', *AJS; American Journal of Sociology*, 121:5 (2016), 1416–71, https://doi.org/10.1086/684201

25 Woo-kyoung Ahn, Caroline C. Proctor, and Elizabeth H. Flanagan, 'Mental Health Clinicians' Beliefs About the Biological, Psychological, and Environmental Bases of Mental Disorders', *Cognitive Science*, 33:2 (2009), 147–82, https://doi. org/10.1111/j.1551-6709.2009.01008.x

consider biological rather than psychological.26 According to Arpaly, the trade-off mentioned above is unfortunate: it looks like mental disorders have to be considered as somatically 'real', like diabetes, before the suffering of people with mental conditions is taken seriously. Psychiatric diagnoses, therefore, become a kind of compensation for lack of moral imagination. People seem to have difficulties believing someone if they speak about their psychic suffering unless a diagnosis officially determines this suffering.

Nevertheless, we risk losing an opportunity to understand this suffering better. I think this is also the case with autism. The diagnosis of autism and the accompanying connotations of it being a neurological (and hence quasi-somatic) condition makes the challenges of the autistic person real, for themselves and for others. It is a confirmation that their 'being different' is not imaginary. However, reducing one's own 'being different' to a condition 'like diabetes' increases the risk that mental content, and the person's experiences, are considered less relevant.

To conclude, let us look at different models of psychiatric practice. It is interesting to examine them in light of the distinction between *Erklären* and *Verstehen*, as the philosopher Wilhelm Dilthey (1833–1911) described it.27 *Erklären* (explaining) means looking for causal explanations, as practised by the pure sciences. *Verstehen* (understanding) gives us access to the greater whole: it allows us to understand another person and the context in which they live and function in a network of meaning of which we are also part. Verstehen, according to Dilthey, is practised in the humanities.

The differences between a psychoanalytical approach and a neurobiological approach in psychiatry are well known. Psychoanalysis stresses the importance of language, of the subconscious and early experiences from childhood. Psychoanalytic therapy can take years and

26 Matthew S. Lebowitz and Woo-kyoung Ahn, 'Effects of Biological Explanations for Mental Disorders on Clinicians' Empathy', *Proceedings of the National Academy of Sciences of the United States of America*, 111:50 (2014), 17786–90, https://doi. org/10.1073/pnas.1414058111

27 Wilhelm Dilthey, 'Entwürfe Zur Kritik Der Historischen Vernunft Erster Teil: Erleben, Ausdruck Und Verstehen' in *Der Aufbau Der Geschichtlichen Welt in Den Geisteswissenschaften*, Volume 7 (Göttingen: Vandenhoeck & Ruprecht, 1992), pp. 191–251; Wilhelm Dilthey, 'Ideen Über Eine Beschreibende Und Zergliedernde Psychologie (1894)' in *Die Geistige Welt*, Volume 5 (Göttingen: Vandenhoeck & Ruprecht, 1990), pp. 139–240.

is often concerned with looking for insight rather than finding practical solutions and causal explanations. In some aspects, the psychoanalytical approach is usually not that different from the neurobiological approach. In some schools, finding explanations is at least as important as understanding one's functioning. Autism is an especially good example here: psychogenic explanations of autism have blamed mothers and led to the institutionalisation of children. Still, a psychoanalytic approach has the advantage that clients are considered more than their diagnoses. Such an approach searches for meaning in experiences.

Theoretically, according to a purely neurobiological approach, psychiatric conditions are assumed to be diseases in our brain. Psychiatry becomes a way to understand the world of neurons and genes. I concede that neurology is an essential aspect of understanding psychiatric illnesses. Nevertheless, such an approach may entail situating the disorder merely in the individual and may risk neglecting the context. Moreover, such a neurobiological approach would seem to suggest that medication is the best option. In Belgium, at least, many present-day psychiatrists do not work merely in a psychoanalytic way and do not consider themselves purely neuropsychological psychiatrists either. George L. Engel's bio-psycho-social model tries to think several aspects through together and states that the different mental phenomena are situated on different levels (biological, psychological, social). We have to approach these different levels in an integrated way. This approach has received some criticism as well: it is eclectic and not sustained by a solid theoretical framework.28 I still think that in this approach, understanding is an integral part of treatment.

It is refreshing to consider the ideas of psychiatrist and philosopher Karl Jaspers (1883–1969). He opposed the psychoanalytic approach of his time because he thought that, rather than understanding patients, such a system sought to unmask them and their disorder. His phenomenological-hermeneutic practice of psychiatry championed an empathic understanding of the patient. In his work *Allgemeine Psychopathologie* (1913)*,* he stresses the importance of being able, as a clinician, to take different perspectives, including biological perspectives, and incorporating the greater context of culture as a

28 S. Nassir Ghaemi, *The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry* (Baltimore: JHU Press, 2010).

whole.29 A psychiatrist must search for a comprehensive understanding of phenomena, not merely reduce them to mechanistic explanations. However, he did see a role for *explanation* in psychiatry. According to Jaspers, some mental phenomena, such as psychosis, are so strange and different that they are beyond *Verstehen*. We should explain these phenomena biologically. Jaspers' *Allgemeine Psychopathologie* is a strikingly modern read and should, in my view, be compulsory literature in training for psychiatrists. In a phenomenon such as autism, we can wonder where *Verstehen* ends, and *Erklären* begins. Autistic children and adults are still often considered to be strange and incomprehensible. Nevertheless, it may be the duty of medical professionals, and ourselves, to continue to attempt to understand behaviour that appears bizarre and incomprehensible at first. The autistic person who does not speak and does not score highly on an IQ test has a reason for his or her behaviour, which we must strive to understand.

The first meaning of autism is that it is defined as a psychiatric disorder in a diagnostic manual. In this chapter, we have investigated what a psychiatric disorder is. We investigated the relationship between mind and brain, psychology and biology. We saw how biological explanations for mental disorders can take away feelings of guilt and open up routes towards healing. However, reductionist approaches that merely give a causal biological explanation of mental disorders neglect the importance of understanding the meaning and context in which phenomena occur. To understand this better, let us investigate what kinds of explanations have been given for autism. In the next chapter, I shall describe several theories that have attempted to explain the specific behaviour associated with autism. I shall demonstrate that these theories have normative import as well. Deciding upon the theory that is presumed to underlie certain behaviour is also a moral choice.

29 Karl Jaspers, *General Psychopathology* (Baltimore: JHU Press, 1997).

# 3. Cognitive Explanations of Autism:

#### Beyond Theory of Mind

When I first started to research issues related to autism, way back in 2011, I set out to answer traditional bioethical questions such as 'is a prenatal diagnosis for autism ethically justified?'. Almost a decade later, I consider the idea that we can even predict autism prenatally, based on genes, naive. However, back then, a logical place to start the investigation was the book *The Ethics of Autism*, written by Deborah Barnbaum.1 As she wrote the book in 2008, we may excuse the author for taking the then prevailing explanatory model of autism, a deficit in Theory of Mind (ToM), as a starting point for ethical reflection. Less excusable is that she believes that, given this deficit, autistics are 'among us' but never truly 'of us', to paraphrase the book's subtitle. Hence the use of reproductive technologies to avoid the birth of a child with autism, she states, is permissible. The book is an illustration and a warning sign of how ontological assumptions about autism profoundly influence the ethical conclusions we draw. Assumptions about empathy and autism have tempted many moral philosophers to use autism as an example in a reflection on the nature of morality in general. The way we explain autism also has repercussions for the people diagnosed with autism. Imagine a scholar who argues that an autistic person can discern emotions neither in themselves nor in fellow human beings. Such a scholar has an entirely different starting point from someone who thinks that a person's apparently awkward social functioning results

1 Deborah Barnbaum, *The Ethics of Autism: Among Them, But Not of Them* (Bloomington: Indiana University Press, 2008).

from experiencing an overload of sensory input.2 Therefore we must dig deeper into some of these assumptions and their consequences.

In previous chapters, we have seen how a diagnosis of autism is generally a clinical diagnosis. In consultation with other professionals, in a multidisciplinary team with psychologists and other caregivers, a psychiatrist proposes a diagnosis based on behavioural criteria from the diagnostic manual and based on assessing the person's functioning. A diagnosis is the starting point for services and support, a clinical presentation based on which clinicians can devise a suitable therapeutic trajectory. However, for many people, autism as a concept also refers to something else, a specific neurological and biological reality, a way of being, a different way of thinking, sensing or feeling. Consider the term 'neurodiversity', a name that refers explicitly to a neurologically atypical way of being. Following this, some argue that autism, because it is a neurological or genetic difference, is also a neutral difference or an identity in the same way as homosexuality. Therefore, society should support and accept autistic people rather than try to cure them.3 However, people have also used this emphasis on the neurological basis of autism to defend further research into the genetics and neurology of autism and to look further for medical treatments.

Explanations of autism take place on different levels. For example, we can explain it by referring to genetic factors, or by neurological and cognitive functioning that causes specific behaviour. Often the influence of physical and social environments on the expression of autistic behaviour is also mentioned. Many models seek to integrate these. However, even in such integrative models, some key questions remain: what *is* autism, the behaviour or the cognitive explanation? To which extent does our genetic blueprint steer behaviours, and how can mental models explain particular challenges that autistic people face? I shall postpone discussing the genetics of autism to chapter 11, and I will now sketch the explanatory models that have appealed both to the public imagination and to philosophers and ethicists alike.

2 Nick Pentzell, 'I Think, Therefore I Am. I Am Verbal, Therefore I Live', in *The Philosophy of Autism*, ed. by Jami L. Anderson and Simon Cushing (Lanham: Rowman & Littlefield, 2013), pp. 103–8.

3 Pier Jaarsma and Stellan Welin, 'Autism as a Natural Human Variation: Reflections on the Claims of the Neurodiversity Movement', *Health Care Analysis*, 20.1 (2012), pp. 20–30.

#### Why We Need to Talk about Theory of Mind

Since Kanner and Asperger, researchers have sought to define the origins of the different behaviour of autistics as a deficit of social capabilities. The most widely known theory is that autistic people have a deficient Theory of Mind (ToM), an idea that was first used in 1978 by David Premack and Guy Woodruff. Theory of Mind refers to the capacity to draw conclusions about the mental states of others.4 The ability to judge what others think typically develops in children around the third year of their lives. Whether a young child has a properly functioning ToM can be tested using the Sally-Anne false-belief test. The investigator shows the child a puppet show with the dolls Sally and Anne, a basket, a box, and a marble. Sally puts the marble in the basket while Anne watches. Sally goes outside, and Anne takes the marble from the basket and puts it in the box, without Sally seeing it. The test taker then asks the child where Sally will look for the marble in the basket or the box.

The expected answer is 'basket'. Most children pass this test at around age four. Children with a diagnosis of autism succeed at a later age. This finding led autistic researchers to conclude that autistic people may be unaware of the fact that other people also have thoughts and intentions. In particular, the British researcher Simon Baron-Cohen has further examined this theory and popularised it. Autistic people do not readily look others in the eyes. Eyes are, it is said, the window to the soul, and for someone who seemingly has difficulty understanding that there is a soul behind those windows, it makes no sense to look into them.5 If one begins with the idea that autistic people have a deficient ToM, one might readily conclude that these people have no, or at least less, empathy. To have empathy, you have to be able to imagine what another person feels.

Some people have raised critiques of the ToM hypothesis itself, as well as how ToM is tested, and the idea that autistic people have an empathy deficit. Autistic people themselves claim to have empathy.

4 David Premack and Guy Woodruff, 'Does the Chimpanzee Have a Theory of Mind?', *Behavioural and Brain Sciences*, 4.4 (1978), 515–629.

5 Simon Baron-Cohen, Alan Leslie, and Uta Frith, 'Does the Autistic Child Have A "Theory of Mind"?', *Cognition*, 21.1 (1985), 37–46; Simon Baron-Cohen, *Mindblindness: An Essay on Autism and Theory of Mind* (Cambridge, MA: MIT Press, 1997).

According to the empathy imbalance theory, they may even feel too much, with the result that they have to close themselves off from others.6 Autistic children can pass the Sally-Anne test by researching the correct outcome, if they have the motivation to do so. 7 A very recent theory by Eliane Deschrijver and Colin Palmer states that autistics may not have difficulty inferring mental states in others, but in discerning these from their own mental states.8

Moreover, some researchers claim, autism is something that develops far earlier than their third year, at an age when no child has a functioning ToM.9 A deficit in ToM could merely be the symptom of a development that was atypical far earlier on. In this respect, Shaun Gallagher has stated that the autistic person explicitly reflects on other people's intentions far more than a typically functioning person. They have missed out on something at a more fundamental developmental level: they did not learn how to understand others instinctively in spontaneous interaction (without theory).10 Moreover, specific research demonstrated that although autistic children might score less on ToM tests than their typically developing peers, they often acquire the skill later.11

#### Bridging Minds

Scholars with a background in disability studies and sociology have described autism as a defect that we can localize in the individual or in an individual's inability to interpret someone else's mood and behaviour'. A

6 Adam Smith, 'The Empathy Imbalance Hypothesis of Autism: A Theoretical Approach to Cognitive and Emotional Empathy in Autistic Development', *Psychological Record*, 59.2 (2009), pp. 273–94.

7 Candida C. Peterson and others, 'Children with Autism Can Track Others' Beliefs in a Competitive Game', *Developmental Science*, 16.3 (2013), 443–50, https://doi. org/10.1111/desc.12040

8 Eliane Deschrijver & Colin Palmer, 'Reframing social cognition: Relational versus representational mentalizing,' *Psychological Bulletin*, 146:11 (2020), pp 941–69.

9 R. Peter Hobson, 'Against the Theory of "Theory of Mind"', *British Journal of Developmental Psychology*, 9.1 (1991), 33–51, https://doi.org/10.1111/j.2044- 835X.1991.tb00860.x

10 Shaun Gallagher, 'Understanding Interpersonal Problems in Autism: Interaction Theory As an Alternative to Theory of Mind', *Philosophy, Psychiatry, and Psychology*, 11.3 (2004), pp. 199–217.

11 Yael Kimbi (2014). Theory of mind abilities and deficits in Autism Spectrum Disorders. *Topics in Language Disorders*, *34*(4), 329–43.

good example is the paper 'Minds Between Us: Autism, Mindblindness and the Uncertainty of Communication',12 written by Anne E. McGuire and Rod Michalko. In this paper, the authors challenge the ideas that social and communicative challenges arise from an individual defect. McGuire and Michalko state that people continuously associate autism with mystery. We have to solve a medical puzzle: if we do not understand certain behaviour, we have to explain it by finding a biological origin. If we gather enough knowledge about what autism *is*, what causes it, we can know it and prevent or cure it. Behavioural therapies can then help to alleviate autistic symptoms and improve the behaviour of the autistic child. According to McGuire and Michalko, this interpretation is wrong. Autism is a complex process that takes place in interactions between people. Autism only has meaning in a relational context, and because of that, autism can teach us something about the interactions between people in general. We can never be entirely sure that what another person means with a specific message is precisely the same as how we have understood it. Communication between people is always partial.

If we consider autism a problem of communication by the individual, we assume a standard of problem-free communication in which nonautistic people can participate. This is clear in the Sally-Anne test, where we believe that the correct answer is that Sally thinks that her marble is still in the basket. This 'correct' answer means that you passed the test.  Nevertheless, this is a denial of what communication is. Readily reading someone's intentions based on the look in their eyes seems nice in theory but is not how communication works. We do not just read another's intentions; we must actively work to reconstruct and interpret them, a process that is not always without problems. To go back to the Sally-Anne test: there might be reasons why someone would think that the marble is not in the original place, reasons that do not necessarily relate to reading Sally's thoughts. For example, Sally may know Anne very well and may think that Anne could have played a joke on her. There is more at stake than purely reading the mind of someone else. Nonetheless, in the standard account of autism, part of the puzzle is deemed to be that autistic people

12 Anne E. McGuire and Rod Michalko, 'Minds between Us: Autism, Mindblindness, and the Uncertainty of Communication', *Educational Philosophy and Theory*, 43.2 (2011), pp. 162–77.

have a deficient Theory of Mind, which we can assess using tests such as Sally-Anne.

According to the ToM theory of autism, it is a condition in which something has gone wrong in the individual's natural cause of development. McGuire and Michalko also refer to the ideas of Michael Tomasello and others, which situate what is characteristically human in the possibility of shared attention and the development of shared aims.13 Tomasello and colleagues argue that possessing a greater or lesser number of these characteristics is proof of how 'close to nature' certain people are: primates and autistic children would, in their view, not be able to participate in activities that require shared attention. According to McGuire and Michalko, however, this assumption neglects the idea that there is a moment in all communication in which one has to make an effort to understand the other in a way that makes sense. They use the ideas of Judith Butler and Emmanuel Levinas to argue that the other is someone who breaks through our barriers and questions us. The other is the other in an absolute way: the other forces us to think about who we are and our relation to that other. We are very close to the other but also infinitely far away. The other can not merely be known or resolved. We can all only guess the true intentions of the other. In this way, autism can teach us something about ourselves and how communication always brings uncertainty.

This is one of the great merits of McGuire and Michalko's work. Besides the image of autism as a medical puzzle to be solved, it is also often associated with something completely unusual. Often, images of Martians and other aliens are used to stress this otherness, even by people who have a diagnosis themselves. An unbridgeable gap is thus created between the 'neurotypical' and the 'autistic'. If we follow McGuire and Michalko and conceive of autism as something that unavoidably takes place within communication, it allows us to understand the autistic other better. We can all imagine situations when we have understood something completely differently from how it was intended or when we did not understand a joke. This fact does not preclude the notion that autistic people suffer from such instances more frequently or intensely, but it allows us to understand each other better.

13 Tomasello Michael and Carpenter Malinda, 'Shared Intentionality', *Developmental Science*, 10.1 (2006), 121–25, https://doi.org/10.1111/j.1467-7687.2007.00573.x

#### Beyond the Theory of Mind

Simon Baron-Cohen has championed the association of autism with both a deficit in ToM and with less empathy. Baron-Cohen has sympathy for autistic persons and stresses the talents that these people often have. In his later research, he elaborates on the idea of the extreme male brain.14 According to this theory, specific characteristics that we primarily associate with men are amplified in autism. Autistic people primarily systemise and analyse, in contrast to the more socially interested empathisers. Therefore they have more insight into details. The association of autism with some characteristics that we primarily associate with men looks straightforward: even today, three-fourths of those diagnosed with autism are male.

Moreover, Baron-Cohen gives an additional biological explanation for the origins of autism by linking it to increased exposure to testosterone in the uterus. Anyone who has read up on gender studies intuits that we can contest this theory on several grounds, not in the least the way it is named. Associating specific characteristics with being male or female seems outdated. Moreover, what about autistic girls and women? Do we say that girls in STEM or girls who prefer activities that are not necessarily related to caring have more 'male characteristics'?15 This illustrates that scientists should take care when using specific terms. Still, Baron-Cohen is a big proponent of the idea of neurodiversity: being autistic has certain advantages. For example, it can significantly improve your performance in certain professions to be an analytic thinker and to focus primarily on details. Baron-Cohen has proposed that we should no longer speak of Autism Spectrum Disorder but Autism Spectrum Condition, to stress that we should not always consider the characteristics of autistic people a disorder.16

With the idea of hyper-systemizing — primarily paying attention to analysis and details rather than to interpersonal aspects — we approach

14 Simon Baron-Cohen, 'The Extreme Male Brain Theory of Autism', *Trends in Cognitive Sciences*, 6.6 (2002), 248–54.

15 STEM is an abbreviation of Science, Technology, Engineering & Mathematics.

16 Simon Baron-Cohen, 'Is Asperger Syndrome/High-Functioning Autism Necessarily a Disability?', *Development and Psychopathology*, null.03 (2000), 489–500, https:// doi.org/null; Simon Baron-Cohen, 'Editorial Perspective: Neurodiversity — a Revolutionary Concept for Autism and Psychiatry', *Journal of Child Psychology and Psychiatry*, 58.6 (2017), 744–47, https://doi.org/10.1111/jcpp.12703

the next explanatory model of autism. For Uta Frith and others, the fundamental deficit that can explain the behaviour of autistic people is weak central coherence.17 Central coherence is the ability to integrate different sensory and informational perceptions in a whole. For autistic people, it is a challenge to tie together all these different sensations and feelings into a sensible whole. People with autism get stuck on the details. As such, weak central coherence also explains other challenges that autistic people experience. A focus on details could make it difficult to perceive other people as whole beings with their own thoughts and selves, explaining why autistic children sometimes fail false-belief tests such as the Sally-Anne test. It would also explain why autistic people sometimes have different sensory experiences. Uta Frith and other proponents of this theory would claim that it is not the case that autistic people, for example, perceive certain sounds as louder. Because they cannot integrate them into a greater whole, they only seem louder to them. We should, therefore, take the accounts of autistic people about their sensory perceptions with a grain of salt. Here we also arrive at the most problematic part of her theory: not only do autistic people have a deficient ToM in relation to other people, but also in relation to themselves.

We can represent our self as a little man, a homunculus that is the integrated sum of our experiences. This unified self-experience is thus deficient or fragmented in autistic people. Because of this deficient 'self', we should be cautious when we interpret the experiences that autistic people tell us they have, and we should double-check these with their caregivers. I immediately want to express some concerns here. First, we can contest the idea of the self as a homunculus.18 Philosophers of consciousness disagree about what it means to have a self. It is therefore misguided to deny certain people the ability to speak authoritatively about their own experiences based on this assumption. Moreover, empirical research seems to suggest that autistic people do have a strong sense of self and often question what it means to have a self.19 This self

17 Uta Frith, *Autism: Explaining the Enigma*, 2nd ed. (Malden, MA: Blackwell Pub, 2003).

18 Markus Gabriel, *I Am Not a Brain: Philosophy of Mind for the 21st Century* (Hoboken: Wiley, 2017).

19 David Williams, 'Theory of Own Mind in Autism Evidence of a Specific Deficit in Self-Awareness?', *Autism*, 14.5 (2010), 474–94, https://doi.org/10.1177/13623613 10366314

may be less spontaneous or less subconscious than in an average person. However, we could also state that this is precisely because autistic people are excellent witnesses of their own experiences. In chapter six, I shall return to the problem of epistemic injustice and who can speak for whom.

Ideas about a deficient ToM assume that autism is a problem at a social level in the first place. Competing theories are based on this as well. For example, Peter Hobson has stated that during the early years of autistic children, even before there is any development of ToM, something atypical happens as they learn spontaneous and atheoretical social interaction. These children are, from birth, focused on others to a lesser degree than neurotypical children.20 However, if we look at the DSM-5 definition of ASD, we notice that socialcommunicative problems are only one part of the dyad. Repetitive or stereotypical behaviour is the other part. More recently, theories have been developed that assume that autism is a problem with information processing or sensory processing in the first place, and that social challenges are the result of this, rather than the other way around. For a long time, it has been known that autistic people have problems with executive functioning. Cognitive science defines executive functions as those that play a role in planning, concentration, and working memory. Because autistic people have difficulties with their executive functions, they experience challenges in planning and being attentive to different things simultaneously.21 Therefore, they have a preference for repetitive actions, which also explains the well-known insistence of sameness, an aversion to change.22 If you are unsure of how to take the next step, it is safer if everything remains the same. Explanations that refer to executive functions have an advantage in that they are close to what autistic people tell themselves. They could also explain the overlap of autism with ADHD. Nonetheless, we can still wonder

20 R. Peter Hobson, 'Against the Theory of "Theory of Mind"', *British Journal of Developmental Psychology*, 9.1 (1991), 33–51, https://doi.org/10.1111/j.2044- 835X.1991.tb00860.x

21 Francesco Craig and others, 'A Review of Executive Function Deficits in Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder', *Neuropsychiatric Disease and Treatment*, 12 (2016), 1191–202, https://doi.org/10.2147/NDT.S104620

22 James Russell, *Autism as an Executive Disorder* (Oxford: Oxford University Press, 1997).

whether a deficit in executive functioning is an explanatory model in itself, or the result of a difference on a more fundamental level of information processing.

#### Beyond Deficit Models of Autism

In the last decade, scholars have developed theories that explicitly take into account the experiences of autistic persons. In a 2007 paper, Henry Markram, Tania Rinaldi, and Kamila Markram describe their Intense World theory.23 The problems and challenges that autistic people face, they claim, can be explained by sensory perceptions being experienced much more intensely. They argue that this is because local neuronal circuits in autistic people are hyperreactive and hyperplastic, something the authors have studied in mice. This theory has been much acclaimed by autistic people because it is close to what they experience as their primary challenge. For example, Nick Pentzell, who is autistic himself, writes that this overload explains why children fail the Sally-Anne test. During this test, these children are so busy attempting to maintain their equilibrium while experiencing an overflow of sensory input that everything else becomes a side issue: 'sensory overload inhibits *anyone* from thinking about much more than surviving its barrage'.24

Laurent Mottron is a psychiatrist working at the University of Montréal. He is originally from France and has rejected the psychoanalytic assumptions about autism that are prevalent there. His theory is called Enhanced Perceptual Functioning.25 For Mottron, who also intensively collaborates with autistic researchers (amongst others Michelle Dawson), autism is a different form of intelligence. In his book on early detection, he stresses that autistic people can see wholes and

23 Henry Markram, Tania Rinaldi, and Kamila Markram, 'The Intense World Syndrome — an Alternative Hypothesis for Autism', *Frontiers in Neuroscience*, 1:1 (2007), 77–96, https://doi.org/10.3389/neuro.<IP_ADDRESS>.2007

24 Nick Pentzell, 'I Think, Therefore I Am. I Am Verbal, Therefore I Live', in *The Philosophy of Autism*, ed. by Jami L. Anderson and Simon Cushing (Lanham: Rowman & Littlefield, 2013), pp. 103–8.

25 Laurent Mottron and others, 'Enhanced Perceptual Functioning in Autism: An Update, and Eight Principles of Autistic Perception', *Journal of Autism and Developmental Disorders*, 36:1 (2006), 27–43, https://doi.org/10.1007/s10803-005- 0040-7

not only details, despite what other theories may suggest.26 They just arrive via a different route to the whole. Therefore one should not try to force an autistic child with a delayed language development to learn a language. Autistic children firstly develop a good visual intelligence, which is apparent in the fact that at a young age they can often already read letters ('hyperlexia'). Only after that do they acquire oral language. We should not try to force them to follow more typical development pathways; this might even be considered unethical.

Interestingly, Mottron makes a distinction between 'real' autism and syndromic autism. The latter is autistic behaviour that we can entirely explain by an underlying syndrome such as Fragile-X, a condition with a localizable genetic cause that is associated with autistic behaviours. Although it is possibly correct that different biological causes of autism lead to different types of autism, it seems that the distinction between autism-as-the-result-of-a-syndrome and autism-as-visual-intelligence is artificial and undesirable. Autistic people with a known syndrome behave a certain way because of specific reasons, and they can also have qualities related to their autism. For these people, it is vital that we try to understand their behaviours and not merely explain them via genes.

Moreover, and I think this is a valid criticism of all explanatory models, it seems impossible to find one explanatory model that covers all autistic behaviours. There will be people diagnosed with autism who do not experience much empathy or who score poorly on the visual parts of an IQ test. Autism as a diagnosis connects these people in a way that often makes sense, based on shared experiences. A vision of autism that tries to reduce it to one explanatory model carries the risk that some people will not fit that model, and that we therefore deny them the benefits of identifying and being identified as autistic. We can conclude, however, that we should reject a theory in which no one with a diagnosis recognizes themselves, and which is purely based on speculation about how brains work.

More recent models of autism assume the Bayesian model of predictive coding, the idea that our brain continually generates statistical models of reality and adjusts these based on new information. The High, Inflexible Precision of Prediction Errors in Autism (HIPPEA) theory by

26 Laurent Mottron, *L'intervention précoce pour enfants autistes: Nouveaux principes pour soutenir une autre intelligence* (Brussels: Editions Mardaga, 2016).

KU Leuven researcher Sander Van de Cruys states that autism is related to difficulties in evaluating the weight of prediction errors.27 Our brains build a model based on our observations, and this model is adjusted based on mistakes in our prediction. However, not every prediction error is relevant: some are noise or not appropriate for a specific task. Autistic people's brains put too much weight on all mistakes and do not filter out the noise. Therefore it is more challenging to come to specific predictions, and the brain considers every new situation to be entirely new. This model allows us to view autism not merely as a deficiency. In tasks where the context could lead to mistakes in typically functioning people, for example, in visual illusions, autistic participants often score better.

#### The Ethical Import of Ontological Assumptions about Autism

Let us, for the moment, set aside the discussion about the explanatory models of autism and look at their relevance for ethics. A branch of ethics in which autism has flourished, for example, is that of metaethics. Autism has inspired some philosophers to speculate about the question of why and how we are moral beings. An example of this is the discussion between Victoria McGeer and Jeanette Kennett. In her article 'Autism, Empathy and Moral Agency', Kennett tries to tackle the ageold question about whether David Hume or Immanuel Kant is correct regarding the role of emotions in morality. Autistic people, especially those Kennett describes as 'high-functioning', have a sense of duty and justice. Kennett takes Kant's side: emotions can play a role in morality, but they do not have to. There are other ways to arrive at moral action. According to her, autistic people are Kantians par excellence. Because they do not have direct access to the intuitions and feelings of others, they come to moral insight through reasoning about what is good. She refers to Oliver Sacks and Temple Grandin's meetings, where the latter stated that she would consider for herself how people behaved and what to learn from this. Kennett concludes that, driven by the desire

27 Sander Van de Cruys and others, 'Precise Minds in Uncertain Worlds: Predictive Coding in Autism', *Psychological Review*, 121:4 (2014), 649–75, https://doi. org/10.1037/a0037665