New discoveries in neuroscience challenge our understanding of human responsibility and justice. Recent studies suggest that psychopaths not only exhibit specific behavioral patterns but may also have a distinct neuroanatomical blueprint. Scientists have shown that a significant number of individuals who have demonstrated psychopathic behaviors have reduced volume and other anatomical changes in various regions of the cerebral cortex as well as decreased functional connectivity between different brain areas (i.e., smaller dysfunctional amygdalae). These findings raise ethical questions about how our (...) criminal system deals with these individuals. Should dysfunctional anatomical or diseased features exonerate affected individuals from any responsibility for their criminal activity or the suffering they have caused to their victims? It is estimated that individuals with the signs and symptoms of antisocial personality disorder make up 25% of inmates. Should individuals classified with this disorder be incarcerated with other criminals? In this paper, we summarize the results of the latest brain imaging studies performed on individuals with antisocial personality traits, referred to as psychopaths or sociopaths, and we explore some of the ethical issues concerning psychopathy and the law. (shrink)

I present two philosophical arguments that Antisocial Personality Disorder (ASPD) and Psychopathy can be expected to be culturally variable. I argue that the ways in which people with ASPD and psychopaths can be expected to act will vary with societal values and culture. In the second part of the chapter, I will briefly review some of the empirical literature on cross-cultural variation in ASPD and psychopathy and argue that it is consistent with my philosophical claims. My conclusion in (...) this chapter is that methods of diagnosis will need to be culturally specific. A diagnostic instrument (such as the PCL-R or DSM) should not be uncritically employed in cultures that are very different from those in which it was initially developed. (shrink)

The British National Institute for Health and Clinical Excellence has recently released new guidelines for the diagnosis, treatment and prevention of the psychiatric category antisocial personality disorder. Evident in these recommendations is a broader ambiguity regarding the ontology of ASPD. Although, perhaps, a mundane feature of much of medicine, in this case, ontological uncertainty has significant ethical implications as a product of the profound consequences for an individual categorised with this disorder. This paper argues that in refraining from (...) emphasising uncertainty, NICE risks reifying a controversial category. This is particularly problematical given that the guidelines recommend the identification of individuals “at risk” of raising antisocial children. Although this paper does not argue that NICE is “wrong” in any of its recommendations, more emphasis should have been placed on discussions of the ethical implications of diagnosis and treatment, especially given the multiple uncertainties associated with ASPD. It is proposed that these important issues be examined in more detail in revisions of existing NICE recommendations, and be included in upcoming guidance. This paper thus raises key questions regarding the place and role of ethics within the current and future remit of NICE. (shrink)

Dominic Murphy in several influential publications has formulated and defended what he calls the strong medical model of mental illness. At the core of this project is the objectivist requirement of classifying mental illness in terms of their aetiologies, preferably characterised by multilevel mechanistic explanations of dysfunctions in neurocomputational processes. We are sympathetic to this project and we devise an argument to support it based on a conception of psychiatric kinds. Murphy has, moreover, maintained that there are some open issues (...) concerning the applicability of his program to antisocial personality disorders and psychopathy. We argue that, as a matter of fact, there are already plausible and well-motivated classificatory proposals for these types of disorders that accommodate well within Murphy's strong medical model. (shrink)

Should offenders with psychopathy or those exhibiting extreme forms of antisocial behav- iour be considered criminally responsible? The current debate seems to have reached a stalemate. Several scholars have argued that neuropsychologi- cal data on individuals with psychopathy might be relevant for determining their criminal responsibil- ity. However, relying on such data has not produced a consensus among legal scholars and philosophers on whether individuals with psychopathy should be excused from responsibility. We offer a diagnosis about why this debate (...) has reached a standoff. We argue that part of the problem is that psychopathy, being a syndrome-based category, is too heterogeneous and thus offers low prospects for being integrated with neuropsychological data that might support significant conclusions about the criminal responsibility of individuals with psychopathy. Moreover, the construct of psychopathy was not originally devised to discriminate criminally accountable from unac- countable antisocial individuals. To overcome these difficulties and advance the debate, we extend a currently less discussed theoretical framework for bridging biopsychology and the law that focuses on neuropsychological constructs, domains, and processes that directly measure capacities of offenders that are relevant for criminal responsibility, without necessarily relying on mediating syndrome-based constructs. The novelty of our contribution is that the biopsy- chological bases of exculpation can be further devel- oped and used for determining more fine-grained cat- egorisations of antisocial personality types. We show how this framework provides guidelines for inter- disciplinary research that can significantly advance our understanding of the preconditions for criminal responsibility and help the legal practice of ascribing or withholding it. (shrink)

Psychopaths are often regarded as a scourge of contemporary society and, as such, are the focus of much public vilification and outrage. But, arguably, psychopaths are both sinned against as well as sinners. If that is true, then their status as the victims of abusive subcultures partially mitigates their moral responsibility for the harms they cause. We argue, from the neuroethics of psychopathy and antisocial personality disorder (ASPD), that communities have a moral obligation to psychopaths as well as (...) a case against them. A reflection on the genesis and developmental epidemiology of psychopathy reveals an individualist, attribution-type error evident in much Western psychological and legal thinking—an error that obscures important moral truths about psychopaths. The resulting analysis makes us reconsider the distinction between disorders and moral failings and the ethical significance of the biological or neurocognitive mechanisms underpinning psychopathy. We claim that casting aside the deficit model (based on the presupposition that psychopaths are intrinsically unlike the rest of us) in favor of a relational and holistic view of personality potentiates a more informed and inclusive set of ethical, forensic, and therapeutic attitudes. (shrink)

Individuals diagnosed with conduct disorder (CD) in childhood and adolescence are at risk for increasingly maladaptive and dangerous behaviors, which unchecked, can lead to antisocial personality disorder (ASPD) in adulthood. Children with CD, especially those with the callous unemotional subgroup qualifier (“limited prosocial emotions”/dsm‐5), present with a more severe pattern of delinquency, aggression, and antisocial behavior, all markings of prodrome ASPD. Given this recognized diagnostic trajectory, with a pathological course playing out tragically at the individual, familial, and (...) societal level, and lack of effective remediation via current standards of care, we posit an alternate treatment approach; case‐specific compulsory moral habilitation aimed at rectifying the undeveloped affective domain of adolescents and young adults suffering from these disorders. We begin with a brief historical overview of response to mental illness, review CD and ASPD diagnostic criteria and treatment limitations, and posit a unique neurohabilitative approach that focuses on the absent affective moral development of these populations. Next, we invoke a public health safety argument to justify case‐specific compulsory moral habilitation, discuss neurotechnologies to be considered in treatment, and conclude with ethical considerations and suggestions for further research. (shrink)

This article considers whether psychopaths should be held criminally responsible. After describing the positive law of criminal responsibility in general and as it applies to psychopaths, it suggests that psychopaths lack moral rationality and that severe psychopaths should be excused from crimes that violate the moral rights of others. Alternative forms of social control for dangerous psychopaths, such as involuntary civil commitment, are considered, and the potential legal implications of future scientific understanding of psychopathy are addressed.

Currently, psychopathy and related terms such as antisocial personality disorder are popular yet problematic constructs within forensic psychology and other disciplines. Psychopathy is traced typically to the works of Pinel and Prichard in the early 19th century, and it has even been linked to biblical passages, although there appears to be little or no support for the latter claim. The first use of the term psychopathy in German psychiatry of the mid-19th century referred only to psychological disturbance in (...) general, or ‘personality diseases’, although German psychiatrists such as Kraepelin did propose more specific definitions of the term related to social deviance. Our modern understanding of psychopathy as a psychiatric disorder of an undetermined genetic origin involving antisocial elements and a lack of feeling or concern for others owes much to the clinical work and writings of Cleckley. Antisocial personality disorder appears similarly to derive from the work of psychiatric nosologists like Kraepelin and Schneider, while sociopathy is due more to the work of Partridge in the 1920s and 1930s. (shrink)

English Abstract: The Antisocial personality disorder and several other psychiatric constructs are questioned and deconstructed in this review, that uses psychoanalytic approach to explain the nature of psychopathy and to give recommendations in this respect. -/- German Abstract: In vorliegender Rezension werden psychiatrische Konstrukte psychoanalytischer Bewertung unterzogen und dekonstruiert. Während die Entität „Antisoziale Persönlichkeitsstörung“ aufgrund ihrer Unwissenschaftlichkeit verworfen wird, besteht mentales Konstrukt „Psychopathie“ der Realitätsprüfung. In weiterem Verlauf der Rezension wird Versuch unternommen, das Phänomen der Psychopathie aufzuklären, um (...) sie begrifflich sowie gesundheitlich einzugrenzen. (shrink)

All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. (Article 1, Universal Declaration of Human Rights 1948) This resounding statement encapsulates a number of problematic themes for lawyers with respect to personality disorder, and acutely so for the extremes of personality disorder embraced by designations such as psychopathy or dangerous and severe personality disorder (DSPD). These designations (...) are in themselves contentious; they do not have commonly agreed definitions either across disciplines or across jurisdictions. Morse (2008), for example, argues in a fascinating account that .. (shrink)

Psychopathy presents a difficult challenge to moral and criminal responsibility theorists. Persons with the disorder have an impaired capacity for empathy and other moral emotions, and fail to feel the force of moral considerations. They have some rational impairments, but they reason adequately to manipulate, con, and exploit their victims, and otherwise to engage successfully in antisocial behavior. Is it appropriate to hold them morally responsible for their wrongdoing? Should the law hold psychopaths criminally responsible? This essay discusses philosophical (...) debates involved in addressing these questions. (shrink)

Effective and specifically targeted social and therapeutic responses for antisocial personality disorders and psychopathy are scarce. Some authors maintain that this scarcity should be overcome by revising current syndrome - based classifications of these conditions and devising better biocognitive classifications of antisocial individuals. The inspiration for the latter classifications has been embedded in the Research domain criteria approach (RDoC). RDoC - type approaches to psychiatric research aim at transforming diagnosis, provide valid measures of disorders, aid clinical practice, (...) and improve health outcomes by integrating the data on the genetic, neural, cognitive, and affective systems underlying psychiatric conditions. In the first part of the paper, we discuss the benefits of such approaches in comparison to the dominant syndrome-based ones and review recent attempts at building biocognitive classifications of antisocial individuals. Other researchers, how ever, have objected that biocognitive approaches in psychiatry are committed to an untenable form of explanatory. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.2 (2003) 193-194 [Access article in PDF] A Comment on Christopher Ciocchetti:"The Responsibility of the Psychopathic Offender" Daniel W. Shuman Questions of responsibility for serious harm are complex and potentially divisive. The way in which we frame these questions and the criteria by which we assess answers to them are colored, in part, by the lens though which we view them. I am a law (...) professor whose writings includes issues relating to criminal responsibility of person with mentally disabilities and I come to this commentary from that perspective. For me questions of moral responsibility raise psychological and philosophical, as well as legal, questions.Ciocchetti's (2003) paper addressees the criminal responsibility of the psychopathic offender. Not sure quite what the author meant by this label, I began to try to understand the concept of psychopathic offender by picking up my DSM-IV-TR and found no reference to such a diagnostic category. Absent a handy reference in the DSM, I looked in the paper for some other definition or recognition of the category of psychopathic offender and found no satisfactory grounding in any body of sound research. Left with the author's unsupported assertions that such a category of persons exists and that they behave in ways the author asks me to accept without support, my lawyer instincts cautioned me to proceed carefully. The psychopathic offender the author describes might well exist, but I am not persuaded of that, nor would be my legal colleagues, absent proof.Next, to the author's thesis that "[t]he offender must have the capacities necessary to understand relationships to justify holding that offender responsible" (p. 176) and that because psychopaths lack this capacity they should not be held criminally responsible. Is the author proposing a new test for criminal responsibility? Certainly no test for criminal nonresponsibility based on mental disability (i.e., insanity defense) in Anglo-American jurisprudence, or any other with which I am familiar, makes status (i.e., a diagnostic category) exculpatory for criminal responsibility. Rather, every test addresses the impact of a mental illness or disorder on the cognitive or volitional capacity of the offender at the time of the offense. The author offers no reason to reject the approach taken for the last several hundred years [End Page 193] by Anglo-American jurisprudence. Moreover, to the extent that status or diagnostic category is relevant in the insanity defense in Anglo-American jurisprudence, character or personality disorders (the genus to which I take it that psychopathy belongs) are often specifically excluded from consideration. For example, the Texas Penal Code (Tex. Penal Code Ann. § 8.01 (Vernon 1994)) states that:It is an affirmative defense to prosecution that, at the time of the conduct charged, the actor, as a result of a severe mental disease or defect, did not know that his conduct was wrong. The term "mental disease or defect" does not include an abnormality manifested only by repeated criminal or otherwise antisocial conduct.The federal Insanity Defense Reform Act raises the same issue: The government relies on the legislative history of 18 U.S.C. § 17, which states: "The concept of severity was added to emphasize that non-psychotic behavior disorders or neuroses such as an 'inadequate personality,' 'immature personality,' or a pattern of 'antisocial tendencies' do not constitute the defense.".... The government argues that because Dr. Lorenz would have testified that Salava was not psychotic but suffered from antisocial personality disorder, his testimony was not relevant to either prong of the insanity defense under the statute.... As a general matter, the government's point is well-taken. It seems clear that Congress intended by its inclusion of the modifier "severe" to place certain "disorders" outside the purview of the insanity defense altogether. United States v. Salava, 978 F.2d 320, 323 (7th Cir. 1992) Nowhere in the paper does Chiochetti acknowledge or address these societal judgments of moral responsibility that have already rejected a far more modest version of his proposal in categorically ruling out character or personality disorders from inclusion as... (shrink)

The drift toward behavioral accounts of the cluster of psychological and behavioral traits that were interchangeably referred to as psychopathy, sociopathy and anti-social personality is interesting and well worth exploring. Justman's correct that before the work of the Feighner group and the adoption of Antisocial Personality Disorder in the Diagnostic and Statistical Manual of Mental Disorders -III, the choice of concept did not seem to be vital and in the Mask of Sanity, Cleckley mentions all three terms (...) and does not seem to think much hangs on which term we choose.It seems correct that many held the absence of guilt to be the psychological marker of psychopathy... (shrink)

I argue for two propositions. First, contrary to the common wisdom, we may justly punish individuals who are not morally responsible for their crimes. Psychopaths – individuals who lack the capacity to feel sympathy – help to prove this point. Scholars are increasingly arguing that psychopaths are not morally responsible for their behavior because they suffer from a neurological disorder that makes it impossible for them to understand, and therefore be motivated by, moral reasons. These same scholars then infer from (...) this conclusion that they must also lack criminal responsibility and therefore that our continuing to punish psychopaths for their crimes is unjust. My response is that this inference is entirely fallacious. -/- Criminal responsibility turns out to be quite distinct from moral responsibility. The two kinds of responsibility require very different conditions to be satisfied. In particular, criminal responsibility, unlike moral responsibility, does not require an agent be able to grasp and follow moral reasons; it requires only that the individual be able to grasp and follow criminal laws. Once this point is recognized, it becomes much easier to accept my thesis: while the subset of psychopaths who commit crimes are not morally responsible for their criminal behavior because they cannot understand moral reasons, they are still criminally responsible because they can understand what the consequences will be if they get caught. For this reason, even though I concede that psychopaths are not morally responsible for the crimes that they commit, our practice of punishing them for these crimes is still just. -/- Second, I argue that psychopathy is a mental illness and should be recognized as such. One reason that it should be recognized as a mental illness is simply because it is; it satisfies the main criteria for inclusion in the DSM-IV, the “bible” of mental disorders. The other reason is more practical than conceptual. It starts with two facts: the U.S. Supreme Court has decided that the preventive detention of any individual who is not a criminal suspect is not constitutional unless the individual is not only dangerous but also mentally ill; and psychopathy is not currently considered to be a mental illness. So, as things now stand, we cannot preventively commit dangerous psychopaths – that is, psychopaths who have clearly indicated that they will be committing serious crimes. Instead, we must wait for them to commit the crimes before we can lock them up. Unfortunately, this incarceration always comes too late for the victims. It would therefore be better if we could lock them up before they actually inflict any harm. Once again, then, I propose that the legal and psychological communities classify psychopathy as a mental illness. (shrink)

This paper seeks to determine the extent to which individuals with borderline personality disorders can be held morally responsible for a particular subset of their actions: disproportionate anger, aggressions and displays of temper. The rationale for focusing on these aspects lies in their widespread acknowledgment in the literature and their plausible primary association with blame directed at BPD patients. BPD individuals are indeed typically perceived as “difficult patients” (Sulzer 2015:82; Bodner et al. 2011), significantly more so than schizophrenic or (...) depressive patients (Markam 2003). The “responsibility question” for patients with BPD has already been raised (Martin 2010; Zachar and Potter 2009; Bray 2003), but this paper tackles it from a novel perspective. First, I narrow down the category of things for which the responsibility question is specific to individual with BPD. After that, I argue that some of the diagnosis criteria of BPD such as emotional instability or impulsivity might serve as excusing factors targeting the “control condition” on moral responsibility. Second, this paper also considers another widely accepted condition on moral responsibility: the epistemic condition. The view defended in the paper is that the answer to the responsibility question for individuals with BPD, concerning both the control condition and the epistemic condition, hinges on an understanding of their epistemic profile. (shrink)

In his accompanying article, Dr. Kinscherff has convincingly demonstrated why a categorical exclusion of personality disorders from the definition of “mental disease” in insanity defense adjudication is arbitrary, both conceptually and clinically. He explains his position in the context of a vignette involving a hypothetical defendant, Wilhelmina Sykes, charged with ramming her car into another car obstructing her path, causing serious injury to its driver. Dr. Kinscherff correctly points out that the determinative issue in applying the insanity defense in (...) any case, including the hypothetical case involving Ms. Sykes, is whether the defendant experienced a legally relevant functional impairment at the time of the offense. In many states — and in the hypothetical jurisdiction in which Ms. Sykes is being prosecuted — the relevant functional impairments are those that could have affected her ability “to appreciate the wrongfulness of her conduct” or “to conform her conduct to the requirements of the law. (shrink)

Psychopathy is a personality disorder characterized by emotional deficits and a failure to inhibit impulsive behavior and is often subdivided into “primary” and “secondary” psychopathic subtypes. The maladaptive behavior related to primary psychopathy is thought to reflect constitutional “fearlessness,” while the problematic behavior related to secondary psychopathy is motivated by other factors. The fearlessness observed in psychopathy has often been interpreted as reflecting a fundamental deficit in amygdala function, and previous studies have provided support for a low-fear model of (...) psychopathy. However, many of these studies fail to use appropriate screening procedures, use liberal inclusion criteria, or have used unconventional approaches to assay amygdala function. We measured brain activity with BOLD imaging in primary and secondary psychopaths and non-psychopathic control subjects during Pavlovian fear conditioning. In contrast to the low-fear model, we observed normal fear expression in primary psychopaths. Psychopaths also displayed greater differential BOLD activity in the amygdala relative to matched controls. Inverse patterns of activity were observed in the anterior cingulate cortex (ACC) for primary versus secondary psychopaths. Primary psychopaths exhibited a pattern of activity in the dorsal and ventral ACC consistent with enhanced fear expression, while secondary psychopaths exhibited a pattern of activity in these regions consistent with fear inhibition. These results contradict the low-fear model of psychopathy and suggest that the low fear observed for psychopaths in previous studies may be specific to secondary psychopaths. (shrink)

Psychopathy fascinates. Modernist writers construct out of it an image of alienated individualism pursuing the moment, killing they know not why, exploiting in passing, troubled, if troubled at all, not by guilt, but by perplexity (Camus 1989; Gide 1995; Mailer 1957; Musil 1996). Psychiatrists and psychologists—even those who should know better—are drawn by it to take off into philosophical speculation about morality, evil, and the beast in man (Mullen 1992; Simon 1996). Philosophers succumb to the temptation of attempting to ground (...) speculation in the supposed facticity of psychopathy. -/- Psychopathy is a cultural construct with roots going back to the eighteenth century, but which only came to full flower over the last fifty years (Hare 1998; Lewis 1974). The currently fashionable constructions of psychopathy find wide acceptance among clinicians and academics. The problem is, however, whether the concept has connections that have been established to the behavior, psychopathology, or the structure and function of brain worthy of according even a modest level of scientific status. There is little point in basing an argument on some supposed scientific gold standard if what glitters is iron pyrites (fools' gold). -/- Neil Levy's opening paragraph contains the statement "Yet in other respects they seem quite irrational; so much so that the term moral insanity has sometimes been applied to them" (p. 129). This both asserts that there is a category "them," namely the psychopaths, and connects them to "moral insanity." Moral insanity entered the language of psychiatry when Pritchard chose to use the term to translate Pinel's category of mania sans deliré (Pritchard 1836). Pinel was attempting to conceptualize a range of disorders that bordered on insanity in the sense of severe disturbances of affect, judgment, and behavior, but that were not accompanied by hallucinations or delusions (Pinel 1798/1964). In today's terminology, the cases he described would probably fall into diagnostic groups, including major depression, bipolar disorder, epilepsy, and a range of personality disorders. A number of his more striking case histories involved antisocial and even murderous behavior, which probably reflected Pinel's role in assessing offenders for the criminal courts of Paris. Pritchard's use of the English word "moral" reflected an appeal first to its use at the time to designate something which was like or similar, but not identical (a usage the OED labels "vulgar"), and second moral in the sense of ethical, conforming to virtuous behavior. Anglophones seized on the latter meaning, although Pinel emphasized the former. Forty years later, Henry Maudsley, the most widely read psychiatrist of his generation, could assert that moral insanity was as real as Colour blindness, some people being Colour blind and some moral blind (Maudsley 1879). Moral insanity became connected variously to phrenology with its own bump over the underlying moral cortex, with the twisted genetics of degeneration, with atavistic theories of criminality, and with a range of disorders of brain from epilepsy to frontal lobe damage (Combed 1853; Ellis 1890; Pick 1989). Although it is anachronistic to use the terms "psychopathy" and "moral insanity" together, it is clear they occupied a similar social and psychiatric space, albeit in different era. This should caution against too ready acceptance of psychopathy which may turn out to be as empty and dangerous a conceptualization as moral insanity. Why dangerous? Dangerous to those labeled, because the morally insane and the moral imbeciles were placed in preventive detention in asylums and prisons, and even sterilized in some jurisdictions. Dangerous to society, because it gave a spurious scientific justification for viewing crime not as reflecting the social evils of deprivation, ignorance, and inequality but as the ravages of the born criminals. -/- Psychopaths are not, as Levy asserts, "(causally) responsible for … more than fifty percent of violent crime" (p. 129). A proportion of violent offenders, which varies widely between observers, are labeled psychopaths. This is often on the basis of Hare's psychopathy checklist, which is a subjective, albeit through training aspiring to be reproducible, and to some extent self-sustaining, evaluation system (Hare 1980, 2003). Part of the checklist gathers data on prior antisocial behavior; part constrains the examiner to subjectively estimate such matters as glibness and callousness, part requires judgments about whether the... (shrink)

We have made huge progress in understanding the biology of mental illnesses, but comparatively little in interpreting them at the psychological level. The eminent philosopher Jonathan Glover believes that there is real hope of progress in the human interpretation of disordered minds. -/- The challenge is that the inner worlds of people with psychiatric disorders can seem strange, like alien landscapes, and this strangeness can deter attempts at understanding. Do people with disorders share enough psychology with other people to make (...) interpretation possible? To explore this question, Glover tackles the hard cases—the inner worlds of hospitalized violent criminals, of people with delusions, and of those diagnosed with autism or schizophrenia. Their first-person accounts offer glimpses of inner worlds behind apparently bizarre psychiatric conditions and allow us to begin to learn the “language” used to express psychiatric disturbance. Art by psychiatric patients, or by such complex figures as van Gogh and William Blake, give insight when interpreted from Glover’s unique perspective. He also draws on dark chapters in psychiatry’s past to show the importance of not medicalizing behavior that merely transgresses social norms. And finally, Glover suggests values, especially those linked with agency and identity, to guide how the boundaries of psychiatry should be drawn. -/- Seamlessly blending philosophy, science, literature, and art, Alien Landscapes? is both a sustained defense of humanistic psychological interpretation and a compelling example of the rich and generous approach to mental life for which it argues. (shrink)

How psychopaths and their capacity for moral action are viewed is not only philosophically interesting but is also important and relevant for policy. The philosophical discussion of psychopathy has focussed upon the psychological faculties that are prerequisites for moral responsibility and empirical findings regarding psychopathy that are relevant to philosophical accounts of moral understanding and motivation. However, there are legitimate worries about whether psychopathy is a robust scientific construct, and there are risks attached to reifying psychopathy or other psychiatric constructs. (...) We defend the concept of psychopathy by pointing out the relevance of empirical studies about it for our ordinary practices of ascribing moral responsibility and folk psychological accounts of moral understanding and motivation. (shrink)

ArgumentResearch into the biological markers of pathology has long been a feature of British psychiatry. Such somatic indicators and associated features of mental disorder often intertwine with discourse on psychological and behavioral correlates and causes of mental ill-health. Disorders of sociality – particularly psychopathy and antisocial personality disorder – are important instances where the search for markers of pathology has a long history; research in this area has played an important role in shaping how mental health professionals understand (...) the conditions. Here, I characterize the multiplicity of psychiatric praxis that has sought to define the mark of antisociality as a form of “ontological anarchy.” I regard this as an essential feature of the search for biological and other markers of an unstable referent, positing that uncertainties endure – in part – precisely because of attempts to build consensus regarding the ontology of antisociality through biomedical means. Such an account is suggestive of the co-production of biomarkers, mental disorder, and psychiatric institutions. (shrink)

A criminal offense requires two elements. First, it requires proof of misconduct that is specifically prohibited by law. Second, it requires proof of sufficient intention or recklessness to warrant assignment of moral culpability for the act. For example, a person who kills another person intentionally is typically guilty of murder, while a person who kills recklessly or in the heat of passion in response to provocation may be guilty of manslaughter, and a person who kills accidentally is not guilty of (...) any crime. Even if the elements of the offense have been proven by the prosecution, the actor may not be punishable if the defense proves that his conduct was either justified or excused. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychopathy, Other-Regarding Moral Beliefs, and ResponsibilityLloyd Fields (bio)AbstractIn this paper I seek to show that at least one kind of psychopath is incapable of forming other-regarding moral beliefs; hence that they cannot act for other-regarding moral reasons; and hence that they are not appropriate subjects for the assessment of either moral or legal responsibility. Various attempts to characterize psychopaths are considered and rejected, in particular the widely held view (...) that psychopaths are, in general, incapable of understanding moral concepts. The particular disability proposed here, the incapacity to form other-regarding moral beliefs, is then derived from an analysis of what is required for someone to be a responsible agent. This is illustrated with a detailed case history. A defect of this kind is shown to vitiate moral responsibility, because it renders the psychopath irresponsive to the social pressures which normally ensure respect for moral norms. It is also shown that the psychopath is not a suitable subject for the assessment of legal responsibility, because he lacks the capacity to act from common prudence to avoid sanctions. I conclude that the attempt to characterize particular defects from among the heterogeneity of psychopathic subjects, could lead to better targeted, and hence to more effective, management of particular cases.KeywordsCriminality, mental illness, personality disorder, blame, liability, moral beliefs, guilt, social moralityIntroductionThe term “psychopath” has been used with a wide variety of different meanings and, no doubt, covers a heterogeneous group of subjects (Criminal behaviour and mental health 1992). My aim in this paper is to argue that at least a subgroup of those subjects are characterized by an inability to form other-regarding moral beliefs—and hence, for this particular reason, are not morally responsible agents—and that they also lack the capacity for prudence, and hence are not legally responsible agents.I begin by distinguishing the particular sense in which I will be using the term “psychopathy.” I then consider some suggestions in the literature regarding the defect by which psychopaths might be characterized—that they are mentally ill, or incapable of understanding moral concepts. In rejecting these, I come to the suggestion that the relevant defect is an inability to form other-regarding moral beliefs, a defect which is graphically illustrated by a case report from the literature. I explore the implication of this kind of defect for [End Page 261] moral responsibility as a socially-embedded notion, and the implication of the psychopath’s inability to exercise prudence in relation to legal liability.Nothing in this paper should be taken to suggest that psychopaths are irredeemable. On the contrary, as I argue in an endnote, correctly characterizing the defect from which they suffer leads directly to forms of treatment whose effectiveness has acquired a measure of empirical support.The Nature of PsychopathyPsychopathy is not a homogeneous concept; there are different types of psychopaths. For example, Henderson identified a type of psychopath who he classified as “Predominantly Creative,” exemplified by such figures as T. E. Lawrence and Joan of Arc. In people of this type genius is associated with heightened sensitivity, psychosexual immaturity and emotional instability (Henderson 1939, 108–20; Henderson and Gillespie 1969, 317). Predominantly creative psychopaths do not come within my purview.By “psychopathy” I shall mean the specific form of personality disorder described by Cleckley in his book, The Mask of Sanity (Cleckley 1964). Cleckley’s description forms the basis of Hare’s Revised (20-item) Psychopathy Checklist. The Checklist includes the following personality traits and deviant behaviors:1. Glibness/superficial charm.2. Grandiose sense of self-worth.3. Need for stimulation/proneness to boredom.4. Pathological lying.5. Conning/manipulative.6. Lack of remorse or guilt.7. Shallow affect.8. Callous/lack of empathy.9. Parasitic lifestyle.10. Poor behavioral controls.11. Promiscuous sexual behavior.12. Early behavior problems.13. Lack of realistic, long-term plans.14. Impulsivity.15. Irresponsibility.16. Failure to accept responsibility for own actions.17. Many short-term marital relationships.18. Juvenile delinquency.19. Revocation of conditional release.20. Criminal versatility (Hare 1986, 18). 1This conceptualization resembles in many respects the category of Antisocial Personality Disorder as described in the American Psychiatric... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Key Concepts: Criminal ResponsibilityCarl Elliott (bio)AbstractMentally disordered persons occasionally do things for which we would ordinarily blame or even punish a non-disordered person. We often do not blame mentally disordered persons for these actions, however, because we regard mental disorders, at least in some circumstances, as an excuse from moral responsibility. For moral philosophy and the law, the challenge is to understand the specific circumstances under which a mental (...) disorder should excuse an offender from responsibility for his or her actions. Because different types of psychopathology influence a person’s intentions and character in very different ways, judgments of responsibility crucially depend upon the specific nature of a mental disorder. They also depend on adequate understandings of concepts such as moral understanding, especially in the case of psychopathy, as well as an understanding of the reasons why mental disorders may excuse a person from responsibility.Keywordsintention, M’Naghten Rules, irresistible impulse, personality disorders, psychopathyThe mentally ill often do things for which they are not responsible. This has long been recognized, by both morality and the law. But just which mentally ill persons should be excused, and under what circumstances, is an altogether more complicated affair.In the Nicomachean Ethics, Aristotle distinguishes two types of involuntary actions, for which (by implication) a person might be excused from responsibility: those done in ignorance, and those that were compelled. Both excuses are variations on the theme of non-intention. If a person did not intend to act as he did—either because he did not know what he was doing, or because he could not help acting as he did—then he is not responsible for the action. Intention is also a key point for the law, which traditionally has said that for a crime to have been committed, it must be accompanied by evil intent, or mens rea (literally, “guilty mind.”)The problem comes in saying how these distinctions play out for the mentally ill offender. The most widely used standards for determining criminal (legal) responsibility are based on the M’Naghten Rules, which excuse a person from responsibility for an act if, as a result of a mental disorder, he did not know the nature and quality of the act, or did not know that the act was wrong. This standard works nicely for the paradigmatic cases of mentally ill offenders; it would excuse, for example, the person with paranoid schizophrenia who strikes out violently at a person he falsely believes is threatening his life. However, it is unclear on several other points, the most famous of which relates to Aristotle’s excusing condition of compulsion. How should we regard those people, for example, whose psychosis impairs their ability to control their behavior, or whose mental disorders involve the control of their unusual desires, such as kleptomania, pyromania, pedophilia and voyeurism? Many of the [End Page 305] latter such persons are aware of the nature and quality of what they desire to do, and they are aware that it is wrong, but they find great difficulty in resisting their desires.One well-known effort to remedy this deficiency was the “irresistible impulse” test, which excused those persons who as a result of their condition had acted on desires that were irresistible. Yet the difference between an irresistible desire and a desire not resisted has proven notoriously difficult to distinguish, in practice as well as in theory.Another chronic source of philosophical controversy is the question of responsibility for one’s character. In psychiatry, this debate surfaces most often with patients who have personality disorders. Ordinarily, since persons cannot control whether they incur a mental illness, they can be excused from responsibility for some actions they have taken while they were mentally ill. However, personality disorders are also (in some sense) beyond a person’s control, being the product of genetic inheritance and upbringing. This raises old issues of psychological determinism: if personality disorders are beyond a person’s control, is it just to hold that person responsible for the actions that result from them?On the other hand, even if personality disorders are within the proper domain of psychiatry, they are obviously quite different from... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Bad, the Ugly, and the Need for a Position by PsychiatryLloyd A. Wells (bio)Keywordsvice, psychiatric education, psychiatry-law interface, medicalizationSadler’s paper is thought provoking and will resonate with many psychiatrists who deal with the interface of vice and psychiatric syndromes. This interface and the dilemmas it poses are perhaps most discussed by residents, who are dealing with the issue for the first time and who often debate what is (...) “psychiatric” about these cases. Many residents have their own informal systems of classifying vice, often with a divide between the criminal population and those perceived as avoiding work and responsibility. These unofficial classifications are usually judgmental and often pejorative, but the residents rarely get much help from faculty in this area. Indeed, many of the faculty have equally judgmental and pejorative views, which are neither systematized nor subject to systematic analysis.By clarifying the importance of the issue of the vice–mental disorder relationship (VMDR) to psychiatry, Sadler may move this topic to one that receives Socratic discourse in our training programs and serious consideration in the training of psychiatrists rather than an idiosyncratic lumping of these patients into the broad category of “patients I don’t like.”Sadler asks for comments in several categories: historical intractability, goals of psychiatry, taxonomy, implications for the criminal justice system, implications for the law, and ethical/political implications.Issues of historical intractability are long standing. In A Tour of the Whole Island of Great Britain, written in the early eighteenth century, Daniel Defoe (1724–1727) describes many asylums, often with the comment, “as it is a madhouse, so is it also a house of correction.” Some of the great public hospitals of the seventeenth and eighteenth centuries were built at least as much to get antisocial and homeless people off the streets as to provide care for the mentally ill. The moral treatment of France and Great Britain, which added much to the practice of psychiatry, clearly had punitive “treatments” for patients with vice-laden behaviors, and this was very explicit in the American moral model of treatment of the late nineteenth century with its obsessive need to prevent patients from masturbating. In the nineteenth and early twentieth centuries, there was great debate about the inclusion of Pritchard’s “moral insanity”—now sanitized into “personality disorders”—into the psychiatric domain, and Kraepelin referred to this group as “enemies of society.”Sadler next asks us to consider the goals of psychiatry in regard to “a proper VMDR.” He wonders [End Page 43] whether a strict medicalization account can be defended. I think it is clear from a large literature and from clinical experience that it cannot be defended —now. But it may become defensible in this century, which will pose enormous challenges to psychiatry, lawmakers, and the courts (vide infra). A strict moralization model is defended by many in society, including some psychiatrists, but has severe limitations and seems illogical. It is hard to make a case (though juries have done so) that, for example, a very delusional young woman with postpartum psychosis who murders her children because of the belief that far worse things than death will happen to them imminently if they live, fits the moralization approach. The Dahmer case is especially instructive. Although there was enormous “vice” (and perhaps “evil”), it is hard to make a case that a sane man would make temples out of the body parts of victims and would attempt to commune with the dead through them.He wonders whether a “mixed” version of medicalization/moralization can be developed and defended. I would argue for both a mixed approach and a “shared” approach. A middle adolescent with bipolar disorder burned his house to the ground. (Fortunately, he and family members were injured but not killed.) He was wildly manic at the time and set the fire because he wanted to prove that he was immortal and totally impervious to flames. He was delusional, extraordinarily impulsive, and completely without judgment, and it would be extraordinarily difficult to exclude the medical frame in any consideration of the vice involved. The vice, indeed, may be more involved in his decision while euthymic to stop taking... (shrink)

Patients with borderline personality disorder (BPD) sometimes request to be admitted to hospital under compulsory care, often under the argument that they cannot trust their suicidal impulses if treated voluntarily. Thus, compulsory care is practised as a form of Ulysses contract in such situations. In this normative study we scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacking free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacking decision competence, (4) Ulysses contracts (...) as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergency situations. In our study, we have accepted consequentialist considerations as well as considerations of autonomy. We conclude that compulsory care is not justified when there is a significant uncertainty of beneficial effects or uncertainty regarding the patient’s decision-making capacity. We have argued that such uncertainty is present regarding BPD patients. Hence, Ulysses contracts including compulsory care should not be used for this group of patients. (shrink)

In English law there is a strong (though rebuttable) presumption that life should be maintained. This article contends that this presumption means that it is always unlawful to withdraw life-sustaining treatment from patients in permanent vegetative state (PVS) and minimally conscious state (MCS), and that the reasons for this being the correct legal analysis mean also that such withdrawal will always be ethically unacceptable. There are two reasons for this conclusion. First, the medical uncertainties inherent in the definition and diagnosis (...) of PVS/MCS are such that, as a matter of medical fact, it can never be established, with the degree of certainty necessary to rebut the presumption, that it is not in the patient’s best interest to remain alive. And second (and more controversially and repercussively), that even if permanent unconsciousness can be unequivocally demonstrated, the presumption is not rebutted. This is because there is plainly more to human existence than consciousness (or consciousness the markers of which can ever be demonstrated by medical investigations). It can never be said that the identity of the patient whose best interests are at stake evaporates (so eliminating the legal or ethical subject) when that person ceases to be conscious. Nor can it be said that the best interests of an unconscious person do not mandate continued biological existence. We simply cannot know. That uncertainty is legally conclusive, and (subject to resource allocation questions and views about the relevance of family wishes and the previously expressed wishes of the patient) should be ethically conclusive. (shrink)

Sociobiological explanation requires both a reliable and a valid definition of the sociopathy phenotype. Mealey assumes that such reliable and valid definition of sociopathy exists in her A review of psychiatric literature on the diagnosis of antisocial personality disorder clearly demonstrates that this assumption is faulty. There is substantial disagreement among diagnostic systems (e.g., RDC, DSM-III) over what constitutes the antisocial phenotype, different systems identify different individuals as sociopathic. Without a valid definition of sociopathy, sociobiological theories like (...) Mealey's should be viewed as entirely speculative. (shrink)

This article proposes a formal model that integrates cognitive and psychodynamic psychotherapeutic models of psychopathy to show how two major psychopathic traits called lacks remorse and self-aggrandizing can be understood as a form of abnormal Bayesian inference about the self. This model draws on the predictive coding (i.e., active inference) framework, a neurobiologically plausible explanatory framework for message passing in the brain that is formalized in terms of hierarchical Bayesian inference. In summary, this model proposes that these two cardinal psychopathic (...) traits reflect entrenched maladaptive Bayesian inferences about the self, which defend against the experience of deep-seated, self-related negative emotions, specifically shame and worthlessness. Support for the model in extant research on the neurobiology of psychopathy and quantitative simulations are provided. Finally, we offer a preliminary overview of a novel treatment for psychopathy that rests on our Bayesian formulation. (shrink)

Psychopathy is a developmental disorder associated with specific forms of emotional dysfunction and an increased risk for both frustration-based reactive aggression and goal-directed instrumental antisocial behavior. While the full behavioral manifestation of the disorder is under considerable social influence, the basis of this disorder appears to be genetic. At the neural level, individuals with psychopathy show atypical responding within the amygdala and ventromedial prefrontal cortex. Moreover, the roles of the amygdala in stimulus-reinforcement learning and responding to emotional expressions and (...) vmPFC in the representation of reinforcement expectancies are compromised. The implications of these functional impairments for responsibility are discussed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Commentary on “Psychopathy, Other-Regarding Moral Beliefs, and Responsibility”R. A. Duff (bio)AbstractI make four criticisms of Fields’s account of one type of psychopathy as a responsibility-negating personality disorder which involves an incapacity to form other-regarding moral beliefs. First, his account of what it is to hold moral beliefs (in terms of accepting universal practical principles) actually specifies neither a necessary, nor a sufficient, condition for holding a moral belief. (...) Second, he is too quick to dismiss the suggestion that what psychopaths suffer from is an inability to understand moral concepts and values. Third, he does not show why we should ascribe an incapacity to accept moral beliefs to the psychopath, rather than a culpable failure to do so. Fourth, he suggests too weak a criterion of criminal liability, as requiring only the capacity to act for prudential reasons.KeywordsMoral beliefs, moral understanding, incapacity, criminal liabilityFields argues that we can properly count at least one type of psychopathy as a personality disorder which negates moral responsibility. This is not because, as others have argued, such psychopaths cannot understand moral concepts and moral values, but because they suffer an incapacity to form other-regarding moral beliefs, i. e., to accept practical moral principles; we cannot hold them morally responsible for failing to accept or obey moral principles which they lack the capacity to accept. Nor, he also argues, should we hold them criminally liable, since they lack that capacity to act for prudential reasons to which a deterrent system of law appeals.His paper rightly emphasizes the interdependence of psychiatry and philosophy, in this as in other contexts. A psychiatric account of psychopathy as a disorder involving some kind of moral incapacity must depend for its precise sense on an adequate account of the concepts of moral capacity and incapacity: an account which should draw on the resources of moral philosophy. Philosophers who aim to understand those concepts will do well to attend, as Fields does attend, to psychiatric discussions and case histories: not only because this is necessary if their comments on mental disorder or on psychopathy are to be adequately informed, but also because careful attention to the problematic phenomena of mental disorder can also illuminate our understanding of the rational powers and capacities which are lacking or distorted in the disordered, and which philosophers hope to analyze. Fields is also clearly right to emphasize that the criteria of moral responsibility might not be the same as the appropriate [End Page 283] criteria of criminal liability: that the question of whether psychopaths should be criminally liable cannot necessarily be answered simply by determining whether they are morally responsible.However, I do not think that he has provided an adequate account of psychopathy as a personality disorder which negates moral responsibility and criminal liability. I will comment on four aspects of his discussion.First, as Fields recognizes, one who wants to argue that psychopaths lack the capacity to form moral beliefs owes us an account of what it is to form, or hold, a moral belief. Fields’s account is familiar, but arguable. To hold a moral belief is to accept, and to be motivated by, a universal practical principle: a principle which one regards as providing very strong reasons for action, and breaches of which arouse such responses as (third-person) disapproval or (first-person) guilt. It could be plausibly objected, however, that accepting some universal practical principle is neither a necessary nor a sufficient condition for holding a moral belief.It is not a sufficient condition, partly because not any universal practical principle which an agent treats as being important can intelligibly count as a moral principle. The principle “One should never split an infinitive” cannot, by itself, count as a moral principle; and if someone treated it as if it were a moral principle, we would judge his moral understanding, and his rational capacities, to be seriously impaired. This suggests that a purely formal account of the “moral,” like Fields’s (an account that pays no attention to the content of what could count as a moral principle) cannot be adequate (see Foot 1978). A further, related reason for the... (shrink)

In attempting to explain or deal with negative workplace behaviours such as workplace bullying, the notion of ‘workplace psychopaths’ has recently received much attention. Focusing on individual aspects of negative workplace behaviour is at odds with more systemic approaches that recognise the contribution of individual, organisational and societal influences, without seeking to blame a person(s) for their behaviour or personality disorder. Regarding a coworker as a psychopath is highly stigmatising, and given the relatively low prevalence of psychopathy in the (...) community, is likely to be incorrect. Sources promoting the notion of workplace psychopathy provide lists of diagnostic criteria and appear to encourage the perception that it is common. This research examines how lay persons use behavioural criteria consistent with psychopathy and the label ‘psychopath’ in relation to a coworker. 307 Australian workers completed an online survey concerning their experience of workplace bullying, which also asked them to rate a coworker’s behaviour on a range of scales to assess perceptions of psychopathy. Rates of psychopathy, when using labels and behavioural criteria, were found to be much higher than scientific estimates of prevalence, for both participants who had been bullied and those who had not. A higher proportion of non-bullied participants classified a coworker as a psychopath when using the label ‘psychopath’, compared to when using behavioural criteria. The notion that there are psychopaths in every workplace should be treated with caution to ensure that the potential for ‘misdiagnosis’ and stigmatisation do not cause further harm in situations of unacceptable workplace behaviours. (shrink)

The emerging neuroscience of psychopathy will have several important implications for our attempts to construct an ethical society. In this article we begin by describing the list of criteria by which psychopaths are diagnosed. We then review four competing neuropsychological theories of psychopathic cognition. The first of these models, Newman’s attentional model, locates the problem in a special type of attentional narrowing that psychopaths have shown in experiments. The second and third, Blair’s amygdala model and Kiehl’s paralimbic model represent the (...) psychopath’s problem as primarily emotional, including reduced tendency to experience fear in normally fearful situations, and a failure to attach the proper significance to the emotions of others. The fourth model locates the problem at a higher level: a failure of psychopaths to notice and correct for their attentional or emotional problems using “executive processes.” In normal humans, decisions are accomplished via these executive processes, which are responsible for planning actions, or inhibiting unwise actions, as well as allowing emotions to influence cognition in the proper way. We review the current state of knowledge of the executive capacities of psychopaths. We then evaluate psychopaths in light of the three major philosophical theories of ethics, utilitarianism, deontological theory, and virtue ethics. Finally, we turn to the difficulty psychopath offenders pose to criminal law, because of the way psychopathy interacts with the various justifications and functions of punishment. We conclude with a brief consideration of the effects of psychopaths on contemporary social structures. (shrink)

Since its publication, the Psychopathic Personality Inventory and its revision (Lilien- feld & Andrews, 1996; Lilienfeld & Widows, 2005) have become increasingly popular such that it is now among the most frequently used self-report inventories for the assessment of psychopathy. The current meta-analysis examined the relations between the two PPI factors (factor 1: Fearless Dominance; factor 2: Self-Centered Impulsivity), as well as their relations with other validated measures of psychopathy, internalizing and externalizing forms of psychopathology, general personality traits, (...) and antisocial personality disorder symptoms. Across 61 samples reported in 49 publications, we found support for the convergent and criterion validity of both PPI factor 2 and the PPI total score. Much weaker validation was found for PPI factor 1, which manifested limited convergent validity and a pattern of correlations with central criterion variables that was inconsistent with many conceptualizations of psychopathy. (shrink)

Tankersley has provided an interesting collection of data about various groups of antisocial individuals. Is this a paper about the moral reasoning of psychopaths, or is it an attempt to address a philosophical question—whether moral behavior is primarily driven by emotions (moral sentimentalism) or by reasons (moral rationalism)—empirically? I think it attempts a little of both, although I concentrate on the latter. -/- The trouble with much of the literature on psychopathy is the terminological confusion, and Tankersley has not (...) escaped this. Several disciplines, with their own languages, have an interest in antisocial individuals and use similar sounding words in different ways. It is easy to get confused. Doctors make diagnoses. Antisocial (or dissocial) personality disorder is a medical diagnosis, and has a clear, operationalized definition. By virtue of being a disorder, it must result in some impairment in the functioning of the individual. Psychopathy is a psychological construct, not a diagnosis, and attempts to measure (in a reliable and valid way, using the Psychopathy Checklist) aspects of a person's mind particularly relevant to antisocial behavior. Psychopathy and antisocial personality disorder are different approaches to the same natural phenomenon, but they are not coterminous. There are many individuals with antisocial personality disorder who are not psychopaths. There are some individuals who are psychopaths who do not have any medical diagnosis (e.g., the so-called white collar psychopath). Psychopathy is not a subset of antisocial personality disorder (pace Tankersley 2011, and Herpertz and Habermeyer 2004). (shrink)

Youth antisocial behaviour is frequently considered to be displayed by children and adolescents who suffer from behavioural disorders. Consequently, attempts to reduce ASB have increasingly comprised mental health interventions. Moreover, early signalling of children at risk and early prevention of behavioural problems are regarded as crucial remedies. Critical investigations of these developments, however, are in particular concerned with the consequent medicalization of society and the behaviour exhibited by infants, children and adolescents. Consequently, the new Dutch youth law even refers (...) to demedicalization as a central aim. From an ethical point of view, this article critically discusses the meaning and relevance of the medicalization reproach in the context of ASB. The aim is to show that the term medicalization can reasonably be attached to three different developments: the biomedical turn, an increase in youth mental health care and early signalling and prevention. The ethical implications of these developments, however, are diverse, referring to both risks and benefits. By itself, neither the term medicalization nor demedicalization carries a self-evident normative meaning. Therefore, a careful ethical analysis is needed to reveal which social developments are actually recommendable or disadvantageous. (shrink)

In the aftermath of the Port Arthur shootings, Dunblane or the schoolyard killings in America, communities try to come to terms with private and public trauma and there is a need to understand what kind of person can commit such terrible acts. The problem of how to understand dangerousness often centres on the role of the mental health and criminal justice systems and it is from the intersection of these two institutions that the categorisation of dangerous persons has emerged. This (...) 2001 book traces the history of the category of antisocial personality disorder and shows how it is linked to particular kinds of governing. It examines key legal and institutional developments in Australia, the UK and the US and also parallel developments within psychiatry and psychological medicine. Applying a social theoretical analysis to this material, McCallum challenges our assumptions about the formation and control concepts of dangerousness and personality. (shrink)

In popular culture psychopaths are inaccurately portrayed as serial killers or homicidal maniacs. Most real-world psychopaths are neither killers nor maniacs. Psychologists currently understand psychopathy as an affective disorder that leads to repeated criminal and antisocial behavior. Counter to this prevailing view, I claim that psychopathy is not necessarily linked with criminal behavior. Successful psychopaths, an intriguing new category of psychopathic agent, support this conception of psychopathy. I then consider reactive attitude theories of moral responsibility. Within this tradition, psychopaths (...) are thought to be blameless as a result of their pronounced affective deficits. Psychopaths are considered morally blind because they lack the moral emotions that make us sensitive to moral reasons. I argue that, even if they are morally blind, psychopaths remain open to forms of blame stemming from non-moral reactive attitudes. These reactive attitudes remain appropriate because psychopaths can express hateful, disgusting, or contemptible non-moral values in their judgments. (shrink)

Most clinicians and mental health practitioners are reluctant to work with people with dangerous and severe personality disorders because they believe there is nothing that mental health services can offer. Dangerous and severe personality disorder also signals a diagnosis which is problematic morally. Moral philosophy has not found an adequate way of dealing with personality disorders. This paper explores the question: What makes a person morally responsible for his actions and what is a legitimate mitigating factor? How (...) do psychiatric nurses working with this client group understand the awful things some clients do? What concepts do they need, if they are to know how to explain and how to react? It is suggested that dangerous and severe personality disorder is best regarded as a moral category, framed in terms of goodness, badness, obligation and other ethical concepts. It seems plausible that in important ways the dangerous and severe personality disordered client does not understand morality or understands it differently. The peculiar position of the dangerous and severe personality disordered individual in our system of moral responsibility stems from his apparent inability to see the importance of the interests of others. It might be more helpful to regard personality disordered clients as we do children: partially but not fully reasonable for their actions. We might regard the dangerous and severe personality disordered client responsible for those actions which he most clearly understands, such as causing others physical pain, but not for those with which he is only superficially engaged, such as causing emotional pain. The paper concludes by suggesting that the dangerous and severe personality disordered individual does not fit easily into any conventional moral category, be it criminal, patient, animal or child, and thus an assessment of his moral accountability must take into consideration his special circumstances. (shrink)

BackgroundMedia have increasingly reported on the difficulties associated with end-of-life decision-making in patients with Disorders of Consciousness (DOC), contextualizing such dilemma in detailed accounts of the patient’s life. Two of the first stories debated in the scientific community were those related to the cases of two women, one American, the other Italian, who captured attention of millions of people in the first years of this third millennium.MethodsMuch has been written about the challenges of surrogate decision-making for patients in DOC, but (...) less has been written comparing these challenges across legal systems and cultures. In our paper, we propose a systematic analysis of the final legal documents written by the American and Italian Courts in relation to the two cases, developing our discussion around three areas: the level of certainty/reliability of diagnosis and prognosis, the reconstruction of self-expression, time of illness and time of care. They are examples of the typical issues discussed by legal authors and allow us to understand the link and the difference between the legal and ethical perspectives.ResultsThe legal approach to the two cases has some common elements: the need to be certain about the diagnosis and prognosis and the fact that the clinical criteria are necessary in determining the most appropriate treatments, although these criteria are not sufficient unless they are supplemented by the patient’s will. The issue of relations takes on importance both from a legal and an ethical point of view, but from two different perspectives. While ethics safeguards relationships by guaranteeing their differences and makes them reconcilable, law safeguards relationships by guaranteeing the cold forms of respect, equality, impartiality, symmetry, reciprocity, and irreversibility. In this perspective, the link between the time of care and the decision of the family members assumes importance.ConclusionsThe most interesting point that emerges from our analysis is the issue of relationships and how they affect decisions, both from a legal and ethical point of view. For this reason, during the patients’ hospitalization, it is necessary to identify ways in which they might give their opinion about the moral issues underlying their choices. (shrink)

Psychopathy, as articulated in Hare’s PCL-R, appears to reliably pick out a forensic category of troubled people. This chapter considers the use and utility of PCL-R by focussing upon two interrelated questions. Does philosophical investigation direct attention toward the issues that should interest us about psychopathy? Is being diagnosed as psychopathic or having ASPD clinically useful, as well as for judicial and sentencing purposes? While the research programmes that developed following the attention paid to psychopathy are warranted, more attention could (...) be directed to the varied nature of psychopathy and the presentations of it that Cleckley described in the Mask of Sanity. It is important to understand psychopathy as it affects lives, as well as a forensic problem. (shrink)

Psychopathy is typically characterized as a constellation of deviant personality traits and behavioral tendencies. The link between psychopathic personality traits and pervasive antisocial behavior raises a crucial question concerning the legal accountability of offenders with psychopathy. Some argue that the unique clinical profile and neurobiological peculiarities of individuals with psychopathy mitigate their responsibility, while others maintain that current scientific knowledge does not support the use of psychopathy as an exculpatory condition for criminal offending. Our overview mainly centeres (...) on whether offenders with psychopathy can be considered legally insane. In this regard, our overview suggests that there is still an ongoing debate whether psychopathy should be used as a legally relevant construct for determining criminal responsibility. Moreover, our discussion indicates that careful attention should be put on empirical and conceptual issues surrounding the role of (neuro)scientific data for determining whether individuals with psychopathy should be considered criminally blameworthy for their wrongdoings. (shrink)

In a widely acclaimed study from 2002, researchers found a case of gene-environment interaction for a gene controlling neuroenzymatic activity (low vs. high), exposure to childhood maltreatment, and antisocial personality disorder (ASPD). Cases of gene-environment interaction are generally characterized as evincing a genetic predisposition; for example, individuals with low neuroenzymatic activity are generally characterized as having a genetic predisposition to ASPD. I first argue that the concept of a genetic predisposition fundamentally misconstrues these cases of gene-environment interaction. This (...) misconstrual will be diagnosed, and then a new concept—interactive predisposition—will be introduced. I then show how this conceptual shift reconfigures old questions and raises new questions for genetic screening. Attempts to screen embryos or fetuses for the gene associated with low neuroenzymatic activity with an eye towards selecting against the low-activity variant fall prey to the myth of pre-environmental prediction; attempts to screen newborns for the gene associated with low neuroenzymatic activity with an eye towards early intervention will have to face the interventionist’s dilemma. (shrink)

Background On December 2017 the Italian Parliament approved law n. 219/2017 “Provisions for informed consent and advance directives” regarding challenging legal and bioethical issues related to healthcare decisions and end-of life choices. The law promotes the person’s autonomy as a right and provides for the centrality of the individual in every scenario of health care by mean of three tools: informed consent, shared care planning and advance directives. Few years after the approval of the law, we conducted a survey among (...) physicians working in four health care facilities specific for the care of people suffering from psychiatric disorders, cognitive disorders and dementia located in the North of Italy aiming to investigate their perceived knowledge and training need, attitudes regarding law n. 219/2017 provisions, and practices of implementation of the law. Methods A semi-structured questionnaire was developed on an online platform. The invitation to participate in the survey was sent by email to the potential participants. Information was collected by means of the online platform (Google Forms) which allows to export data in a spreadsheet (Windows Excel) to perform basic statistical analysis (frequency distributions, bar chart representation). Results Twenty-five out of sixty physicians participated in the survey. None of the respondents value their knowledge of the law as very good, 10 good, 13 neither poor nor good, 1 poor and 1 very poor. All the respondents want to learn more about the law (21 yes and 4 absolutely yes). The majority of respondents agrees with the content of the law as a whole (3 absolutely agree, 13 agree), and on each provision. The question on the clarity of the concept of capacity in the law received mixed answers and this impacted on the physicians’ opinion regarding the legitimacy in principle for our groups of patients to realize shared care planning and write advance directives. Thirteen physicians neither introduced the theme of shared care planning nor arranged for shared care planning and the main reason for this was that no patient was in a clinical situation to require it. When shared care planning is realized, a variability in terms of type and number of meetings, mode of tracking and communication is registered. Conclusions Our survey results indicate a need for more clarity regarding the interpretation and implementation of the law in the patient groups under study. There are in particular two related areas that deserve further discussion: (1) the question of whether these patient groups are in principle legitimized by the law to realize shared care planning or write advance directives; (2) the notion of capacity required by the law and how this notion can be declined in real-life situations. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ethics of Surgical Interventions for Body Integrity Identity Disorder and Gender DysphoriaNicanor Pier Giorgio Austriaco, O.P.IntroductionOn May 20, 2009, Fox News featured a report that described the life of a man named "John" who had spent his life struggling with Body Integrity Identity Disorder (BIID).1 In a phone interview, John admitted that he remembers wanting to amputate his leg when he was between seven and eleven years of (...) age, by sticking his leg under the rear wheel of a bus. He never went through with it but continued to experience an intense desire to amputate his healthy limb for the following fifty-plus years. Described for the first time in 1977 as apotemnophilia, BIID was originally thought to be a psychological disorder characterized by sexual arousal associated with the desire to be an amputee. However, it was renamed when Dr. Michael First, a professor of clinical psychiatry at Columbia University, proposed that the primary motivation behind the condition was an issue of identity rather than of sexual desire.2 This proposal is controversial.3 Despite much [End Page 1003] debate, BIID was not included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was published on May 18, 2013.In this essay, we will consider the ethics of surgical interventions for BIID and Gender Dysphoria (GD).4 We begin with a discussion of the principle of totality that distinguishes ethical from unethical modifications of the body. We will refer specifically to the latter category of surgical interventions as "mutilations," though the Catholic moral tradition's use of the term is itself ambiguous.5 This is followed by an extensive moral discussion of (1) amputations of healthy limbs for patients struggling with BIID and (2) sex reassignment surgeries for those who identify themselves as transgender persons. I will propose that an ethical argument can be made to justify the former but not the latter.The Principle of TotalityBecause of the goodness of the human body, its integrity is a good that has to be protected and preserved. The ethical principle that is used to judge the morality of bodily interventions that impinge upon this bodily integrity is the principle of totality.6 It was articulated by St. Thomas Aquinas in his Summa theologiae as follows:Since a member is part of the whole human body, it is for the sake of the whole, as the imperfect for the perfect. Hence a member of the human body is to be disposed of according as it is expedient for the body.... If, however, the member be decayed and therefore a source of corruption to the whole body, then it is lawful with the consent [End Page 1004] of the owner of the member, to cut away the member for the welfare of the whole body.7Over the centuries, Catholic moral theologians appealed to the principle of totality to justify three different scenarios that involved the sacrifice of a bodily organ for the sake of the whole human organism. The first case involves a diseased organ that has to be removed to save the life of the soldier wounded on the battlefield—say a gangrenous, decaying limb as in the example of Aquinas. The second case involves the healthy foot of a man who is trapped on a railroad track that has to be amputated to save his life from a collision with a train, and the third case involves the healthy limb of an individual that has to be amputated in response to a tyrant who orders him to cut off his own hand or lose his head to the executioners instead. In these cases, the sacrifice of the part would be morally permitted as a necessary means of preserving the life of the individual. As Fr. Gerald Kelly, S.J., points out, this final case is particularly significant because it involves a healthy limb whose very presence—and not its diseased or trapped condition—becomes a source of vital harm for the organism.8How does one justify the principle of totality? In 1944, Pope Pius XII explained it this way: "Man's power over his... (shrink)

This book examines core issues related to legal insanity, integrating perspectives from psychiatry, law, and ethics. Various criteria for insanity are analyzed and recommendations for forensic psychiatric and legal practice are offered. Many legal systems have an insanity defense, in one form or another. Still, it remains unclear exactly when and why mental disorders affect a person’s moral or criminal responsibility. Questions addressed in this book include: Why should insanity be a component of our legal system? What should be the (...) criteria for an insanity defense? What would be the reasons for abolishing it? Who should bear the burden of proof? Furthermore, the book discusses the impact neurosciences may have on psychiatric and psychological evaluations of defendants as well as on legal decisions about insanity. (shrink)

A pressing and difficult practical problem concerns the general issue of the right social response to offenders classified as having antisocial personality disorder. This paper approaches this general problem by focusing, from a philosophical perspective, on the still relevant but more approachable question whether psychopathic offenders are morally responsible. In particular, I investigate whether psychopaths possess moral understanding. A plausible way to approach the last question requires a satisfactory philosophical interpretation of the empirical evidence that appears to show (...) that psychopaths fail to draw the distinction between conventional and moral norms. Specifically, I will consider a recent philosophical debate polarized between supporters of rationalist and sentimentalist accounts of moral understanding. These opponents have discussed whether the case of psychopathy offers empirical support for their account and undermine the rival view. I will argue that the available empirical data leave the outcome of this discussion indeterminate. However, this implies that both these principal theories of moral understanding, if independently motivated, would imply that psychopaths have certain deficits that might affect their moral understanding and, consequently, their moral responsibility. (shrink)