- Vice, Mental Disorder, and the Role of Underlying Pathological Processes
responsibility, virtue theory, cultural norms, psychopathology
The issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an article on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.
Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.
The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]
The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.
If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.
This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).
Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy...