Medical or Moral Kinds? : Moving Beyond a False Dichotomy

I am delighted that Zachar and Potter have chosen to refer to my work on the DSM-IV cluster B personality disorders in their very interesting and ambitious target article. Their suggestion that we turn to virtue ethics rather than traditional moral theory to understand the relation between moral and nonmoral factors in personality disorders is certainly original and worth pursuing. Yet, in the final instance, I am not entirely sure about the exact scope of their proposed analysis. I also worry whether they may have inadvertently presented a slightly inaccurate account of my views on the cluster B personality disorders, as they seek to formulate and defend their own views, which seem to be far wider in scope. I begin my commentary with this question of interpretive accuracy. Then, I briefly examine Zachar’s and Potter’s conclusions on the theoretical status of the personality disorders they discuss; namely, borderline personality disorder (Potter) and narcissistic personality disorder (Zachar). Finally, I close with some warnings about how the term ‘moral’ figures in these discussions, and how it can mislead, particularly in my own work.

Interpretive Issues

The scope of Zachar and Potter’s discussion seems to change as the discussion progresses. This may leave readers with the impression that my arguments in the area are generalizable in a manner that I never intended them to be. To start, in the title of their article, Zachar and Potter refer to ‘personality disorders.’ This is their first stated topic of interest. Not surprisingly, much of their article does in fact deal with personality disorders in this general sense. However, toward the end of their article, the topic changes. By the end of their discussion, we find Zachar and Potter repeatedly referring to ‘psychiatric disorders’ very generally. This is quite a change from personality disorders.

The first reference to my work in Zachar’s and Potter’s discussion occurs in the abstract to their article. There they refer to an alleged claim of mine that ‘personality disorders are moral rather than medical kinds.’ But this is not accurate. In fact, I have never argued for any such general conclusion. My focus is more specific. Zachar and Potter themselves note this very clearly when they allude to my claim that “cluster B personality disorders such as borderline and narcissistic personality disorder are really moral, not medical, kinds” (Zachar and Potter 2010, 101–102). My own topic of interest—the cluster B disorders—is then quite different from, and narrower than, the topics that occupy Zachar and Potter in much of their paper.

These differences in scope are of some consequence. Consider that in the very same article of mine which Zachar and Potter cite, I explicitly state that the cluster A and C personality disorders may actually be genuine medical kinds, with few or no moral dimensions (Charland 2006b). So nowhere do I say or mean to suggest that all the personality disorders are moral rather than medical kinds. Strictly speaking, my conclusion applies to the cluster B personality disorders only, and not personality disorders as a whole. Moreover, I have never intended my argument about the moral status of the cluster B disorders to apply to ‘psychiatric disorders’ in general. Again, my argument concerns the cluster B personality disorders only. More specifically yet, it concerns the cluster B personality disorders exactly as they are described in the DSM-IV.

I wish to emphasize that I have never argued that psychiatric disorders as a whole are ‘medical rather moral conditions.’ For the record, I must insist that I am certainly not an ‘anti-psychiatrist.’ Indeed, I strongly disagree with Thomas Szasz’s claim that mental illness is a myth. Neither do I believe that all psychiatric problems are merely problems in living. I repeat: my arguments are targeted at the cluster B disorders only. Admittedly, in this limited case, my conclusion does bear some resemblance to some of Szasz’s claims. But my arguments are quite different, as are my conclusions.

Let me now turn to another important interpretive...