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  • Moral Evaluations and the Cluster B Personality Disorders
  • Nancy Nyquist Potter (bio)
Keywords

moral kinds, medical kinds, Moral Wrongfulness Test, borderline personality disorder, mental disorder, moral responsibility

In the conclusion of her article, Marga Reimer states that the “medicalization of morals is indeed sometimes appropriate. It is appropriate in cases where ‘moral disorder’ is presumed to stem from mental (and ultimately neurological) disorder” (Reimer 2013, 213). Reimer argues that the Cluster B Personality Disorders are medical and not moral on the grounds that a) we can make a diagnosis without referring to moral evaluations, b) treatment is available that is medical (psychotherapy and psychopharmacological), and c) behavioral symptoms are likely to be rooted in brain disorders. Reimer’s framing of the issue, though, is flawed and leads to a faulty conclusion. I start by examining the meaning of the phrase ‘medicalization of morals’ and why we might think it is not appropriate to medicalize morals.

First, let us get clear on the term ‘medicalization.’ To medicalize something is, as John Sadler writes, to take a concept, or a condition, and constrain it with medical instead of other, usually social, meanings (Sadler 2005, 238). Is it ever appropriate to take moral values—socially and culturally inflected phenomena—and reduce them to medical phenomena? I would argue not, if we want the concept of ‘medical disorder’ to have teeth; and if we want the diagnoses of the Cluster Bs to count as scientific knowledge.

I refer to the idea in the definition of the DSM that a mental disorder is ruled out if the source of distress and poor functioning is the result of a conflict between individual and society. Moral values are such a thing. Take homosexuality, for example: Although some people take homosexuality to be a psychiatric condition, it was removed from the DSM on the grounds that objections to it are moral and not medical (cf Sadler 2005, § 6.1 through 6.2. for an analysis on the declassification of homosexuality). Furthermore, moral and social norms vary from culture to culture. What this means for DSM classifications is that, if we were to attempt to medicalize morals, we would need to attend to the contextual nature of moral and social norms. To do so may not mean that we are left with pure relativism in morality and in psychiatry (I resist the dichotomizing of ‘objectivity/subjectivity,’ but a discussion of this matter is beyond the scope of the commentary), but it does greatly complicate the status of psychiatry as scientific knowledge. The push toward evidence-based medicine (and thus evidence-based psychiatry) places randomized, [End Page 217] controlled studies at the top of the hierarchy, but such studies would seem to delegitimize the kind of knowledge gained from intersubjective relations and patient-centered values.1 The point is that the ‘medicalization of morals’ is undesirable both socially and scientifically.

This is not to say that, in good science, moral values never make an appearance in diagnoses. But, as Sadler (2005) argues, the presence of values in diagnoses should give rise prima facie to skepticism regarding psychiatric diagnoses. He proposes that we utilize what he calls the ‘Moral Wrongfulness Test,’ a method of determining whether a diagnosis rests on moral or nonmoral bads (Sadler 2005, § 6.22 through 6.24). As Sadler states:

Disorder status should be based not on moral value-judgments but on nonmoral value-judgments. If a mental disorder is substantively defined in terms of nonmoral value-judgments, the degree of social consensus about the moral evaluations in a putative disorder is irrelevant to diagnosis.

(2005, 216)

Following the Moral Wrongfulness Test, we find that the presence of moral values in the diagnosis of personality disorders is only justified if other, nonmorally bad values undergird it. As Sadler explains, nonmorally bad features must be testable. This kind of evaluative mental disorder contains ‘mostly morally bad conditions with indispensable nonmorally bad features’ (*Sadler 2005, 223).

The idea of reframing the concepts in a disorder to strengthen its legitimacy is reflected, although very briefly, in the comment by Reimer that we could change the language for the Cluster Bs and that this would solve the problem. Reimer writes that...

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