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This is bioethics bytes with me, David Edmonds and me Nigel Warburton.

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Bioethics Bytes is made in association with Vox, which we here are Centre for Practical Ethics and made possible by a grant from the Wellcome Trust.

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For more information about bioethics bytes go to WW W Docs Practical Ethics dot oecs docs ac dot UK or to i-Tunes you.

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If someone caught me shoplifting and I was later diagnosed with kleptomania, should I be held responsible?

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Should I be blamed? There's a growing body of knowledge in psychiatry and neuroscience about why

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people think and behave the way they do and according to one school of thought.

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As our knowledge expands. So the space for responsibility contracts.

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Anna Picard is not from that school. She believes we can one in the same time diagnose a disorder and hold the person with that disorder responsible.

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Dr. Picard is an Oxford based philosopher and therapist and the holder of a Wellcome Trust

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fellowship examining the nature of responsibility and morality within personality disorder.

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Hannah Pickett, welcome to Bioethics Bites. Thank you.

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The topic we're going to talk about is personality disorder and responsibility.

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Could we just begin by clarifying what personality disorder is?

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Personality disorder, as the name implies, is a disorder of the personality.

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So if you think of personality as a set of traits that incline you to act and think and feel in a stable set of ways,

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someone with a personality disorder has a personality where those traits cause extreme distress and dysfunction to them in their life.

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Could you give an example of a personality disorder?

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Well, there are almost as many different kinds of personality disorder as there are kinds of personality.

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But clinically, we divide them into three basic types the mad and the bad and the sad.

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And to take just one example from the bad cluster.

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Borderline personality disorder is defined by markedly unstable sense of self and interpersonal

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relationships and is characterised by very dramatic extreme kinds of behaviour like self-harm,

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suicide, recklessness and impulsivity, aggression and violence, eating disorders and substance abuse.

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And this is very different from schizophrenia. Absolutely.

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Schizophrenia is a complicated mental illness, which has multiple components.

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But crucial to the diagnosis is the idea of delusion or cognitive dysfunction in that sense?

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Well, personality disorder is much more on a continuum with how we all sometimes are.

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It's really about the way a person behaves and thinks and feels.

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Why do you think some people develop personality disorder?

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Well, we know that one factor is genetic predisposition, but an equally important factor is early psychosocial adversity.

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People with personality disorder tend to have suffered quite extreme childhood physical, emotional and sexual abuse and neglect.

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There may have been parental psychopathology or violence.

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Death. Institutional care. And then large scale factors like poverty.

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Now, just because you've had that kind of background doesn't mean you go on to develop a personality disorder.

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But most people with personality disorder have had that kind of background.

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This emphasis on early habits and character traits being formed through childhood

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is almost reminiscent of Aristotle's view about how we develop as moral beings.

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This notion that how we brought up somehow affects the cultivation of virtue, we somehow stuck with the way our habits were formed.

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I think that's absolutely right. Aristotle offers a very helpful model for thinking about personality disorder.

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Aristotle thought that children had to learn to be good and they needed a stable and caring environment so that they could

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develop as a person to find a mean between extremes and find a way of being in the world which expressed good regard for others.

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Virtue and stability.

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And people with personality disorders precisely haven't had that kind of early environment, which allows them to find the mean between extremes.

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Their emotional and behavioural responses to particular situations are always wildly out of sync with what we would expect there.

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If somebody had a diagnosis of personality disorder and they behave outrageously, they may be commit a crime even.

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Could we say, well, look, we understand why they're doing this.

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It's to do with their early upbringing. It's to do with the condition that they have.

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And so, in a sense, the medical diagnosis. Reduces any sense of blame there.

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I think that's how we often think about a medical diagnosis, but in this case, it would be a mistake.

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When we work clinically with people with personality disorder,

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we draw a very clear distinction between their responsibility for the behaviour and whether or not we should blame them.

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And because the behaviour is voluntary, it involves actions and omissions over which the person has a degree of choice and control.

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We hold them responsible for that behaviour and the clinical aim is to help them do things differently.

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What we don't do is blame them for it. So what we don't do is treat them with an attitude of derision, of resentment, of anger, of hate.

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Rather, we try to maintain an attitude of compassion. I think we need to clarify this.

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You're saying that we could hold somebody responsible for something in the sense that they had a choice about what they did.

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But at the same time, you're saying it's not right to blame them for what they did.

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If you harm me and you're responsible for harming me, surely it's right for me to blame you.

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Do you think I was weird if I didn't blame you for harming me?

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That kind of situation is something we find ourselves in clinically all the time,

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when patients may act with aggression or violence towards us or to other patients.

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And it is precisely in that context that we try to hold someone responsible for their behaviour and indeed accountable.

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There may be, as part of therapy, negative consequences imposed on the patient, but not blame them.

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It's very difficult. It's not something that clinicians find it natural or easy to do.

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And in the clinical context, we do it because it's essential not to blame patients.

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If you're going to treat them effectively. But I do think that we might all do well to take a page out of the clinical book here and at least begin

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to understand that questions of responsibility are conceptually distinct from questions of blame.

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Responsibility is fundamentally about agency. We attribute responsibility when someone has choice and control over their behaviour.

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When that behaviour does us or someone we care about home, we may be inclined to blame them.

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But that response is something about us. It's about the thoughts and feelings and behaviour that we then choose to adopt towards that person.

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It doesn't follow inevitably, just because we hold them responsible.

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If you think of a case like the murder of Jamie Bolger, a child who was murdered by other children,

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there was a sense in which the children had a choice, but they were themselves victims of terrible abuse.

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Still, many people felt strong emotional feelings of blame of of hatred towards the perpetrators.

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Are you suggesting that should just evaporate, that we should get rid of that, that somehow the wrong emotion to have?

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I think it's very important to distinguish different contexts and what our aim is in different contexts.

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Clinically, the answer is absolutely yes. Our aim is to help.

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We don't do that by hating and blaming patients no matter what they've done.

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From a more societal point of view. I'd want to distinguish two things.

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The first is what it's instrumentally useful for us to do.

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So we would all like to live in a world where there was less violence and less crime.

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And there is increasingly good evidence that societies that practice restorative justice,

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where offenders are given the chance to make amends and to face punishment,

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but also then to be forgiven and reintegrated into society, have lower crime rates.

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So instrumentally, we might have a reason not to blame.

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I also think that as a society, we may have a moral obligation not to blame in certain cases.

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The case you mentioned is a good example because the perpetrators, although they committed terrible acts against another, were also victims.

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They were victims of terrible abuse themselves.

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When you have a perpetrator, as in the case you describe, who is also a victim, and especially when that perpetrator has been a victim as a child,

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we as a society have to ask how we allow children to grow up in such contexts where they are victims of terrible abuse, neglect without intervening.

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Arguably, we have failed all children who grow up in that way, and given that we collectively have some responsibility for that,

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we ought to think about whether it's appropriate to blame them when they then grow up and commit terrible crimes.

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In a sense, everybody's actions can be explained by things that have happened before.

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We can always find an excuse, as it were, in our personal histories, that made us the people that we are and.

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Let us to do what we did. Do you want to draw a strict division between people who have been diagnosed with particular

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personality disorders and the the ordinary person in the streets who has no diagnosis,

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who is considered normal but does something outrageous? Personality disorder lives on a continuum with ordinary personality.

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So there's going to be no strict division between the two.

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That said,

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there are two ways in which personality disorder or diagnosis of personality disorder might affect our response to the person's immoral conduct.

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One, as we've just been talking about, is that we might think that their early psychosocial adversity and our collective

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responsibility as a society for that means that we shouldn't write them off in a blaming,

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stigmatising way, that we owe them some kind of compassion and understanding.

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Another is that we might think that early psychosocial adversity reduces the degree of responsibility that they have.

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And we might think this because they haven't learned certain skills which many of us naturally possess

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through having been brought up in more stable and caring ways and which allow us to behave morally.

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So there are two differences potentially between someone with personality disorder and the rest of us.

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One is whether or not it's right to blame, and the other is the degree of responsibility we attribute to them.

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Everything that happens to us at some level affects our brains.

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There's a physical impact at the molecular level,

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and it's not implausible to think that in the future it'll be possible to treat

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the symptoms of a bad childhood through pharmaceutical or electronic means.

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Do you see that as the way forward? We already use medication to treat certain traits that are part of personality disorder.

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So we might treat someone for their impulsivity or for their depression or for their anxiety.

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And I think there's no doubt that our increasing knowledge of the brain will help us develop further medications that target those traits effectively.

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But that said,

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I think it's equally important to stress that we can now help people through a variety of psychological and social means presently at our disposal,

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much more than we actually do. So it's not the case that the solution to this problem rests simply on future science.

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We could solve it now. We could solve it by developing social programs which intervene early and support parents and children in need.

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And we could also solve it by putting money into psychological services for personality disorder,

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both within mental health and also within the prison population.

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So we can have social programs results in intervention.

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Early on, the Kurds minimise the chance of people developing personality disorders through

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social causes and presumably combining that with pharmaceutical intervention.

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Where we see the early symptoms, we could eliminate the need for therapy.

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I suppose it's possible that in a utopia, if every child grew up with the right start in life, we wouldn't have personality disorder.

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But I don't think that if we do have people who have personality disorder, we can help them just by pharmaceutical means.

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Even when medication for impulsivity, say, is appropriate.

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It's never going to be the only solution for the following reason.

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If you've grown up in such a way that what you really want to do when you're angry is self-harm or harm someone else,

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then unless we medicate you to the point of sedation so you can't act at all, you're going to do that if you decide to do it.

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What we need is to help you learn other ways of managing your anger, and that's something that you can't get from a bottle.

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You need to learn that through therapy or other means. You're unusual in that you're not just a philosopher, but you're also a therapist.

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I wonder if there's anything that philosophers might learn generally from involvement with real cases,

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and also whether there's anything that you in particular have discovered through therapy that would be informative for philosophers.

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I think exposure to real cases is essential to any endeavour that attempts to understand human nature,

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and I hope that's a lot of what we try to do as philosophers.

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So to take a particular example.

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Philosophers often appeal to psychopathology in the free will debate when they want an example of someone who literally can't do otherwise.

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It's impossible, supposedly, for them to behave other than as they do.

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And that is certainly our popular conception of a number of disorders like kleptomania, addiction, personality disorder.

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To some extent, until I worked clinically, I probably wouldn't have felt able to say that that is.

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Quite simply false. But it is from a clinical perspective when someone has that condition and may indeed say that they can't help it,

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that they can't do otherwise, we don't take them at their word.

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Rather, what we take them as expressing is that it's really, really hard for them not to behave in that way,

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and we then work with them constructively to do it differently and to behave in ways that are more functioning and healthy.

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So the clinical presumption in all these psycho pathological cases is that patients can do otherwise.

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We just need to support them to do so.

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So there is a very particular example where psychopathology simply doesn't provide the kind of example that philosophers take it to provide.

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And the free will debate looks different if you acknowledge that kind of picket.

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Thank you very much. Thank you for having me.

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For more information about bioethics bites, go to WW Dot Practical Ethics, Dot Oaks Dot, AC, Dot, UK or iTunes U.