Abstract
Medical professionals, including mental health professionals, largely agree that moral judgment should be kept out of clinical settings. The rationale is simple: moral judgment has the capacity to impair clinical judgment in ways that could harm the patient. However, when the patient is suffering from a "Cluster B" personality disorder, keeping moral judgment out of the clinic might appear impossible, not only in practice but also in theory. For the diagnostic criteria associated with these particular disorders (Antisocial, Borderline, Histrionic, Narcissistic) are expressed in overtly moral language. I consider three proposals for dealing with this problem. The first is to eliminate the Cluster B disorders from the DSM on the grounds that they are moral, rather than mental, disorders. The second is to replace the morally laden language of the diagnostic criteria with morally neutral language. The third is to disambiguate the notion of moral judgment so as to respect the distinction between having morally disvalued traits and having moral responsibility for those traits. Sensitivity to this distinction enables the clinician, at least in theory, to employ morally laden diagnostic criteria without adopting the sort of morally judgmental (and potentially harmful) attitude that results from the tacit presumption of moral responsibility. I argue against the first two proposals and in favor of the third. In doing so, I appeal to Grice's distinction between conventional and conversational implicature. I close with a few brief remarks on the irony of retaining overtly moral language in an ostensibly medical manual for the diagnosis of mental disorders.
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Notes
However, patients can also be harmed when the attributed traits are morally valued traits. Consider the physician whose patient, perhaps someone whom he knows socially, shows signs and symptoms associated with HIV infection. The physician never tests for the presence of the virus because the patient is not “that kind” of woman, the kind of woman who might engage in “risky” behaviors. Within a year, the woman develops full-blown AIDS. It wasn’t the falsity of the physician’s judgment that harmed the patient, it was the fact that he made the judgment at all. For the woman might have gotten the virus from her husband.
All of the foregoing may be symptomatic of a stroke and are more common in women than in men [1].
My use of the term “moral” is to be understood broadly, so as to encompass traits generally regarded as “character flaws.” See Pickard [3] in connection with the idea that the Custer B Personality Disorders involve such flaws.
For recent work on the more general topic of values in psychiatry, see the papers in volume 15 (1) (2009) of Philosophy, Psychiatry, and Psychology.
This initial formulation of the problem does not disambiguate the notion of moral judgment, as the solutions considered first trade on the ambiguity inherent in that notion. In the above formulation, “moral judgment” is to be understood as defined above: as the attribution to an agent of moral traits.
The same is true of those suffering from Cluster A Personality Disorders. In contrast, those suffering from Cluster C Personality Disorders often seek treatment for those conditions [8].
Which is not to say that such actions are actions for which the patient is criminally responsible.
But see Pickard [3], who points out that not all Cluster B diagnostic traits are morally disvalued traits.
More cautiously, neurological disorders might explain some of the characteristic features of so-called “mental disorders.” See Pickard’s [3] “twin earth” thought-experiment involving schizophrenia for details.
While British psychiatrists apparently see things differently, this may be partly because they fail to appreciate the similarities between the Personality Disorders and paradigm mental disorders like schizophrenia [9].
This is not to say that expert consensus is correct or that it might not change.
Because Szasz does not countenance “mental disorders,” he sees the relevant contrast as between moral and medical disorders.
The Cluster B Personality Disorders are also associated with “psychological” as well as “behavioral” dysfunction, thereby satisfying the DSM criteria for “mental disorder” three times over [13].
The other two Cluster B Personality Disorders, Histrionic and Narcissistic, have not been studied as closely by neuroscientists. However, the fact that their diagnostic criteria overlap considerably with the diagnostic criteria for Antisocial Personality Disorder, suggests that they are correlated with similar neurological dysfunction.
“Indicative of” but perhaps not “identical to,” for reasons brought out in Pickard’s [3] “twin earth” thought-experiment.
This would mirror the distinction (drawn above) between “derivative” and “fundamental” senses of “moral.”
A difficult question, not addressed here, is the extent to which the psychopathology presumed to underlie Cluster B traits, impugns autonomy. Here, my focus is on defending the idea that attribution of such traits, in clinical settings, needn’t be accompanied by a morally judgmental attitude on the part of the diagnosing clinician.
Interestingly, Tourette patients often claim to have control over their antisocial vocalizations. However, it has been argued the patients’ moral responsibility is nevertheless diminished, as the urges that lead to such vocalizations are not expressions of the patients’ desires [19].
For arguments to the effect that they might be both, see Pickard [3].
In such settings, the diagnosing clinician is (in effect) both speaker and hearer.
This might explain why clinicians do not seem to mind morally laden diagnostic criteria: they take themselves to be diagnosing mental disorders, not (at least not primarily) moral disorders.
Relatedly, Borderline Personality Disorder is the only Cluster B Personality Disorder whose diagnostic criteria are not strongly suggestive of selfishness and/or disregard for others.
Importantly, this does not necessarily imply that there is diminished legal/criminal responsibility.
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I would like to thank an anonymous reviewer for helpful comments on an earlier draft of this paper. Thanks are also owed to Kent Bach, Rich Reimer, Mark Timmons, to members of University of Arizona’s Undergraduate Philosophy Club, as well as to participants in a recent (2009) workshop on Moral Judgment, held at the University of Arizona in Tucson. Special thanks go to the students in my Fall 2009 Proseminar in Analytic Philosophy of Psychiatry for their many thoughtful comments on earlier versions of this paper.
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Reimer, M. Moral Aspects of Psychiatric Diagnosis: the Cluster B Personality Disorders. Neuroethics 3, 173–184 (2010). https://doi.org/10.1007/s12152-010-9068-2
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DOI: https://doi.org/10.1007/s12152-010-9068-2