This is bioethics bytes with me, David Edmonds and me Nigel Warburton.
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If someone caught me shoplifting and I was later diagnosed with kleptomania, should I be held responsible?
Should I be blamed? There's a growing body of knowledge in psychiatry and neuroscience about why
people think and behave the way they do and according to one school of thought.
As our knowledge expands. So the space for responsibility contracts.
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.
Dr. Picard is an Oxford based philosopher and therapist and the holder of a Wellcome Trust
fellowship examining the nature of responsibility and morality within personality disorder.
Hannah Pickett, welcome to Bioethics Bites. Thank you.
The topic we're going to talk about is personality disorder and responsibility.
Could we just begin by clarifying what personality disorder is?
Personality disorder, as the name implies, is a disorder of the personality.
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,
someone with a personality disorder has a personality where those traits cause extreme distress and dysfunction to them in their life.
Could you give an example of a personality disorder?
Well, there are almost as many different kinds of personality disorder as there are kinds of personality.
But clinically, we divide them into three basic types the mad and the bad and the sad.
And to take just one example from the bad cluster.
Borderline personality disorder is defined by markedly unstable sense of self and interpersonal
relationships and is characterised by very dramatic extreme kinds of behaviour like self-harm,
suicide, recklessness and impulsivity, aggression and violence, eating disorders and substance abuse.
And this is very different from schizophrenia. Absolutely.
Schizophrenia is a complicated mental illness, which has multiple components.
But crucial to the diagnosis is the idea of delusion or cognitive dysfunction in that sense?
Well, personality disorder is much more on a continuum with how we all sometimes are.
It's really about the way a person behaves and thinks and feels.
Why do you think some people develop personality disorder?
Well, we know that one factor is genetic predisposition, but an equally important factor is early psychosocial adversity.
People with personality disorder tend to have suffered quite extreme childhood physical, emotional and sexual abuse and neglect.
There may have been parental psychopathology or violence.
Death. Institutional care. And then large scale factors like poverty.
Now, just because you've had that kind of background doesn't mean you go on to develop a personality disorder.
But most people with personality disorder have had that kind of background.
This emphasis on early habits and character traits being formed through childhood
is almost reminiscent of Aristotle's view about how we develop as moral beings.
This notion that how we brought up somehow affects the cultivation of virtue, we somehow stuck with the way our habits were formed.
I think that's absolutely right. Aristotle offers a very helpful model for thinking about personality disorder.
Aristotle thought that children had to learn to be good and they needed a stable and caring environment so that they could
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.
Virtue and stability.
And people with personality disorders precisely haven't had that kind of early environment, which allows them to find the mean between extremes.
Their emotional and behavioural responses to particular situations are always wildly out of sync with what we would expect there.
If somebody had a diagnosis of personality disorder and they behave outrageously, they may be commit a crime even.
Could we say, well, look, we understand why they're doing this.
It's to do with their early upbringing. It's to do with the condition that they have.
And so, in a sense, the medical diagnosis. Reduces any sense of blame there.
I think that's how we often think about a medical diagnosis, but in this case, it would be a mistake.
When we work clinically with people with personality disorder,
we draw a very clear distinction between their responsibility for the behaviour and whether or not we should blame them.
And because the behaviour is voluntary, it involves actions and omissions over which the person has a degree of choice and control.
We hold them responsible for that behaviour and the clinical aim is to help them do things differently.
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.
Rather, we try to maintain an attitude of compassion. I think we need to clarify this.
You're saying that we could hold somebody responsible for something in the sense that they had a choice about what they did.
But at the same time, you're saying it's not right to blame them for what they did.
If you harm me and you're responsible for harming me, surely it's right for me to blame you.
Do you think I was weird if I didn't blame you for harming me?
That kind of situation is something we find ourselves in clinically all the time,
when patients may act with aggression or violence towards us or to other patients.
And it is precisely in that context that we try to hold someone responsible for their behaviour and indeed accountable.
There may be, as part of therapy, negative consequences imposed on the patient, but not blame them.
It's very difficult. It's not something that clinicians find it natural or easy to do.
And in the clinical context, we do it because it's essential not to blame patients.
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
to understand that questions of responsibility are conceptually distinct from questions of blame.
Responsibility is fundamentally about agency. We attribute responsibility when someone has choice and control over their behaviour.
When that behaviour does us or someone we care about home, we may be inclined to blame them.
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.
It doesn't follow inevitably, just because we hold them responsible.
If you think of a case like the murder of Jamie Bolger, a child who was murdered by other children,
there was a sense in which the children had a choice, but they were themselves victims of terrible abuse.
Still, many people felt strong emotional feelings of blame of of hatred towards the perpetrators.
Are you suggesting that should just evaporate, that we should get rid of that, that somehow the wrong emotion to have?
I think it's very important to distinguish different contexts and what our aim is in different contexts.
Clinically, the answer is absolutely yes. Our aim is to help.
We don't do that by hating and blaming patients no matter what they've done.
From a more societal point of view. I'd want to distinguish two things.
The first is what it's instrumentally useful for us to do.
So we would all like to live in a world where there was less violence and less crime.
And there is increasingly good evidence that societies that practice restorative justice,
where offenders are given the chance to make amends and to face punishment,
but also then to be forgiven and reintegrated into society, have lower crime rates.
So instrumentally, we might have a reason not to blame.
I also think that as a society, we may have a moral obligation not to blame in certain cases.
The case you mentioned is a good example because the perpetrators, although they committed terrible acts against another, were also victims.
They were victims of terrible abuse themselves.
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,
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.
Arguably, we have failed all children who grow up in that way, and given that we collectively have some responsibility for that,
we ought to think about whether it's appropriate to blame them when they then grow up and commit terrible crimes.
In a sense, everybody's actions can be explained by things that have happened before.
We can always find an excuse, as it were, in our personal histories, that made us the people that we are and.
Let us to do what we did. Do you want to draw a strict division between people who have been diagnosed with particular
personality disorders and the the ordinary person in the streets who has no diagnosis,
who is considered normal but does something outrageous? Personality disorder lives on a continuum with ordinary personality.
So there's going to be no strict division between the two.
That said,
there are two ways in which personality disorder or diagnosis of personality disorder might affect our response to the person's immoral conduct.
One, as we've just been talking about, is that we might think that their early psychosocial adversity and our collective
responsibility as a society for that means that we shouldn't write them off in a blaming,
stigmatising way, that we owe them some kind of compassion and understanding.
Another is that we might think that early psychosocial adversity reduces the degree of responsibility that they have.
And we might think this because they haven't learned certain skills which many of us naturally possess
through having been brought up in more stable and caring ways and which allow us to behave morally.
So there are two differences potentially between someone with personality disorder and the rest of us.
One is whether or not it's right to blame, and the other is the degree of responsibility we attribute to them.
Everything that happens to us at some level affects our brains.
There's a physical impact at the molecular level,
and it's not implausible to think that in the future it'll be possible to treat
the symptoms of a bad childhood through pharmaceutical or electronic means.
Do you see that as the way forward? We already use medication to treat certain traits that are part of personality disorder.
So we might treat someone for their impulsivity or for their depression or for their anxiety.
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.
But that said,
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,
much more than we actually do. So it's not the case that the solution to this problem rests simply on future science.
We could solve it now. We could solve it by developing social programs which intervene early and support parents and children in need.
And we could also solve it by putting money into psychological services for personality disorder,
both within mental health and also within the prison population.
So we can have social programs results in intervention.
Early on, the Kurds minimise the chance of people developing personality disorders through
social causes and presumably combining that with pharmaceutical intervention.
Where we see the early symptoms, we could eliminate the need for therapy.
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.
But I don't think that if we do have people who have personality disorder, we can help them just by pharmaceutical means.
Even when medication for impulsivity, say, is appropriate.
It's never going to be the only solution for the following reason.
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,
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.
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.
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.
I wonder if there's anything that philosophers might learn generally from involvement with real cases,
and also whether there's anything that you in particular have discovered through therapy that would be informative for philosophers.
I think exposure to real cases is essential to any endeavour that attempts to understand human nature,
and I hope that's a lot of what we try to do as philosophers.
So to take a particular example.
Philosophers often appeal to psychopathology in the free will debate when they want an example of someone who literally can't do otherwise.
It's impossible, supposedly, for them to behave other than as they do.
And that is certainly our popular conception of a number of disorders like kleptomania, addiction, personality disorder.
To some extent, until I worked clinically, I probably wouldn't have felt able to say that that is.
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,
that they can't do otherwise, we don't take them at their word.
Rather, what we take them as expressing is that it's really, really hard for them not to behave in that way,
and we then work with them constructively to do it differently and to behave in ways that are more functioning and healthy.
So the clinical presumption in all these psycho pathological cases is that patients can do otherwise.
We just need to support them to do so.
So there is a very particular example where psychopathology simply doesn't provide the kind of example that philosophers take it to provide.
And the free will debate looks different if you acknowledge that kind of picket.
Thank you very much. Thank you for having me.
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