Vice and Viciousness

I am Grateful to Professor Sadler for such a clear and helpful account of how human misconduct (or vice) has been confounded diagnostically with human disease (as defined by the Diagnostic and Statistical Manual of Mental Disorders [DSM] classificatory system); and even more grateful for the chance to offer comment. Professor Sadler’s paper raises questions about the DSM enterprise as a whole; and this is a field in which I have no particular experience to offer for additional discussion. But his other main point is that psychiatrists are constantly invited to distinguish between vice and disease, and he gives three examples, one of which is a clinical case from my own research. I entirely agree with him that this is a good example, and in this commentary, I will explain why.

The argument is about how to distinguish between human behaviors that reflect chosen deviance from prosocial norms and behaviors that reflect a diseased state of mind. Arguments are both legal and political: Aristotle, in the Nichomachean Ethics sets out conditions in which a man should not be blamed for his behaviors, and to some extent these conditions still hold good in the criminal court; ignorance of the meaning of one’s actions, or being forced to act under duress, are good legal defenses. Politically, as Professor Sadler makes clear, the arguments were set out first by Foucault and then Szasz; it is possible for the state to use medical discourse to turn what might be a legitimate social grievance into individual pathology—the ultimate ad hominem argument.

These arguments have not gone away, despite the best efforts of a materialist wing of neuropsychiatry, aided and abetted by pharmaceutical companies, who have a great interest in reductionist arguments in the biosciences. This is particularly so in relation to antisocial behaviors, especially crime. I want to focus on one particular type of antisocial behaviors, namely, the wish to hurt another person. I focus on this because it is my clinical bread and butter: My work as a forensic psychiatrist and psychotherapist requires me to try and understand how and why people want to hurt others. But I think it also makes sense to focus on this because it is the most problematic wish socially and demands understanding. All three of Professor Sadler’s examples involve hurt and harm to others, and it is noteworthy that neuroreductionist or medicalized explanations are rarely sought for theft or tax evasion. This must be in part because socially we think it is normal to try and profit yourself, even illegally, if you can get away with it. (I actually think that such behavior is not all that normal, but that is an argument for another day).

Let us take the clinical example from my own work, cited by Professor Sadler. It is an example of what is called in the DSM “Factitious Disorder by Proxy” (FDP), although it also has an unhelpful eponym of “Munchausen’s Syndrome by Proxy.” As a practicing forensic psychiatrist, it is one of the best examples I know of what has been crudely dichotomized as a “mad or bad?” debate. A mother quite deliberately makes her child ill, and then presents the child to medical services as in need of hospital treatment. In the case I described with Dr. Bluglass, the mother smothered her baby girl and then presented her as having “breathing difficulties” (which was, of course, quite true in one sense). There are two examples of vice here: deliberately hurting your child and lying to others about it; the lies also have the indirect result of potentially causing more harm to the baby. Harming your child, and then lying about it, in a not-for-profit way, are criteria for FDP.

Quite how these actions ever made it into the DSM is puzzling, when they are quite straightforwardly antisocial. If a man in the street were to smother another man to the point of asphyxia, and then lie about it, we might well ask many questions about why he had done it, but we would not say that no offence had occurred. We...