alcohol dependence, philosophy of psychiatry, mental disorder, harmful dysfunction, psychiatric diagnosis, person, moral responsibility
In his paper, Ethical Decisions in the Classification of Mental Conditions as Mental Illness, Craig Edwards grapples with a profound problem: why is it that when we classify a mental condition as a mental disorder, that tends to take the condition out of the sphere of moral responsibility or virtuousness of character? For example, it is not uncommon when someone commits suicide and the question is raised as to why he or she did it, that instead of a reason or character trait that would place the act within a moral calculus, one is offered the explanation "she was clinically depressed" or "he was bipolar," and this tends to terminate discussion and make reasons and moral evaluation superfluous. Why does such a comment have that effect?
As Edwards notes, this can get complicated as the moral and the disordered interact. Certainly people are sometimes morally responsible for acting on their disordered impulses (as in pedophilia), and they are responsible for putting themselves in the way of disorder, as when someone imbibes in a way likely to lead to alcoholism. But at the normal/disorder divide, there seems to be a consistent lifting of some responsibility, reflecting the application of the sick role. For example, the rough equivalent of our current category of post-traumatic stress disorder (PTSD) was recognized as a disorder in earlier wars ("shell shock," "war neurosis"), but often considered an expression of cowardice; the cowardice was morally evaluable as a failure of virtue (even if, like many personality traits, being a coward is not within the person's direct voluntary control) and led to contempt for those with PTSD, but nonetheless—except in cases thought to be malingering—the PTSD that resulted constituted a disorder for which the individual was [End Page 91] not in the same direct sense blameworthy. This moral shift requires explanation.
This topic also has important social ramifications. Relief from responsibility may sound like a good thing, and it is trumpeted by mental health advocates as a reason for supporting the classification of many conditions as disorders. But as Edwards is aware, it is a two-edged sword. Disordered status may allow escape from censure and offer the protections of the sick role, but it also changes the relationship of the agent to his or her own actions and imposes the responsibility of the sick role on the individual to attempt to change ("get better"). The sick role allows for no defense of an idiosyncrasy based on normal variation ("It takes all kinds…") or the individual's eccentric vision or steadfast integrity, for that vision or sense of integrity are now seen as pathological and not morally legitimate. The individual is subjected to endless entreaties to seek help and it is implied that not to do so is irresponsible, so that a decision to embrace one's nature and remain as one is becomes illegitimate. Moreover, the sick role allows for no explanation in terms of the individual's normal defensive response to unjust, deprived, or challenging social or environmental circumstances, thus weakening the motives for social change rather than individual intervention.
In sum, there is an inevitable sense in which being placed in the sick role inherently stigmatizes the "sick" condition in virtue of the special moral attitudes extended to the disordered. Cultures can thus easily exploit the sick role and its much-touted relief from responsibility to extend the reach of social control processes. This is one reason why the distinction between disorder and non-disorder is so important, and why it is crucial to identify when non-disordered conditions are mislabeled as disorders—as when, for example, psychiatry gets it wrong about the distinction between normal and disordered sadness (Horwitz and Wakefield, 2007). Such overpathologization can redefine the boundaries of our moral universe on mistaken grounds.
Edwards offers two provocative answers—not entirely at ease with each other—to the question of why mental disorders relieve the patient from moral responsibility: (1) mental disorders are...