personality disorders, responsibility, virtue, blame
In “Personality Disorders: Moral or Medical Kinds—or Both?” Peter Zachar and Nancy Nyquist Potter (2010) reject any general dichotomy between morality and mental health, and specifically between character vices and personality disorders. In doing so, they provide a nuanced and illuminating discussion that connects Aristotelian virtue ethics to a multidimensional understanding of personality disorders. I share their conviction that dissolving morality–health dichotomies is the starting point for any plausible understanding of human beings (Martin 2006), but I register some qualms about their discussion of responsibility.
Zachar and Potter target the morality-health dichotomy as it appears in Louis C. Charland’s (2004; 2006) discussions of personality disorders. They might have said more, beginning with Charland’s insights. Building on Carl Elliott’s (1996) work, Charland notes that one group of personality disorders, cluster B (American Psychiatric Association [APA], 2000, 685–686), are defined using moral concepts and can only be successfully treated if the person undergoes a moral change based on moral effort. Most dramatically, antisocial personality disorder is characterized as “a pervasive pattern of disregard for and violation of the rights of others” shown by such things as “deceitfulness,” “reckless disregard for safety of self or others,” and “lack of remorse” for harming others (APA 2000, 706). Similarly, borderline (BPD), histrionic, and narcissistic personality disorders make explicit or tacit reference to lack of moral empathy. “Curing” these disorders requires moral effort and moral transformation, although psychological and pharmaceutical treatments can also be employed. It is essential for clinicians to acknowledge that treating cluster B personality disorders is in part a moral enterprise, for which they might not be fully prepared. This all seems to me right and important.
Charland goes astray, however, when he claims that cluster B disorders are “really moral, and not medical, conditions” (Charland 2004, 64). If anything, his emphasis on how both psychiatric and moral techniques enter into treating cluster B disorders should open, rather than slam shut, the door to an integrated moral–medical perspective. Indeed, many additional disorders in the DSM tacitly employ moral criteria in specifying “maladaptive” behavior and mental states, for example, substance dependency, pathological [End Page 127] gambling, pyromania, kleptomania, and pedophilia. Overcoming these problems typically involves moral transformation, as with cluster B personality disorders. More generally, I regard moral commitment as typically involved in mustering the courage, honesty, and effort required in much psychotherapy. Without collapsing vice into mental disorder, we should acknowledge that moral capacities such as minimal moral empathy and self-control inevitably shape the understanding and treatment of maladaptive habits. And rather than banishing moral assumptions from psychiatry, we should ensure the assumptions are sound (e.g., unlike the bigotry that once classified homosexuality as a mental disorder).
Zachar and Potter illuminate how cluster B personality disorders are simultaneously moral phenomena and fit generic criteria for mental disorders, such as maladjustment, distress, disability, and harm to self. They apply a multidimensional theory of personality disorders that accents lack of empathy and social relatedness and moves us beyond the DSM depictions that Charland rightly finds insufficient. They helpfully invoke John Sadler’s (2005) Moral Wrongfulness Test that warns psychiatrists to take special care (to avoid inappropriate forms of moralism) to be sure health criteria are being employed to define and diagnose those conditions which are popularly condemned on moral grounds. And they remind us that much treatment involves advice and procedures that are simultaneously moral and medical.
Whereas Charland said little about moral responsibility, apart from accepting responsibility as part of moral transformation, Zachar and Potter say considerably more. I find their comments sometimes helpful but often problematic, for three reasons. First, it is important to distinguish (1) evaluating something (e.g., an act or habit) as morally undesirable and (2) assigning moral responsibility for it. We also need to distinguish different senses of moral responsibility, including (3) being morally accountable in general, (4) being morally accountable for meeting specific responsibilities (obligations), (5) blameworthiness for failing to meet obligations, and (6) actually blaming (adopting and expressing negative attitudes toward) someone for their wrongdoing or faults. Rather than sorting out these...