“At the end of the day, it's all about food and sex,” writes David Rubinow in Philosophy and Psychiatry (p 262). In case you are wondering, his chapter is about the roles of genetic predisposition and the endocrine system in mood disorders. Like the other 20 contributions to this book, a product of the Philosophical Issues in Psychiatry Research Group at the University of North Carolina at Chapel Hill, Rubinow's chapter is one of a pair, which seems appropriate. If Rubinow is right about what it's all about, it is likely to be more fun with company.
With a couple of exceptions, one of each of the paired chapters is written by a clinician and the other by a philosopher. The arguments of Rubinow, a psychiatry department Chair, are juxtaposed with those of Valerie Hardcastle, a philosopher who points to the effects of disparities in service provision on the health of those who live in poor neighborhoods. Among them, the 10 pairs of chapters cover some big questions. How are mental illnesses different from other illnesses? How does mental illness affect the relationship between free will and moral responsibility? How and when is the coercion of the patients of mental health services justified? What does it mean to be human?
I have an interest in classification and was drawn to the description of “scrupulosity” (p 164), which two philosophers, Jesse Summers and Walter Sinnott-Armstrong, regard as a variant of obsessive-compulsive disorder. The symptoms of scrupulosity apparently include moral perfectionism, chronic doubt, and “moral thought–action fusion” (p 164), a feeling that merely having an intrusive thought (a loved one coming to harm, perhaps) makes the feared outcome more likely. The question that the authors ask is at what point it becomes justified to treat someone who has such a condition over his objection.
The authors argue that the answer depends on the characteristics of the mental disorder that the person is suffering from. I am not sure I agree. I suspect, instead, that the same criteria should apply whatever the condition, and this is the usual legal position. The authors conclude that a distressed person with scrupulosity can be treated against his will when his thinking demonstrates one or more of three types of incoherence: an inability to defend the moral standards that he is endorsing, an inability to distinguish what is ideal from what is required, and a fixation on one element of the broad picture.
Hanna Pickard, in her paired chapter, takes issue with the lack of attention, in the arguments of Summers and Sinnott-Armstrong, to any risk of harm to the person. After all, in most jurisdictions the criteria for treatment over objection include a risk of harm to self or others. One could question also the lack of reference, in the criteria for diagnosis or treatment over objection, to a person's level of function. I think that the degree to which one's scruples prevent one from undertaking the tasks of everyday life should be relevant to both whether one can properly be said to have a mental disorder and whether one should be treated against one's will.
What struck me most, however, was the similarity of incoherence to what might otherwise be called irrationality. Because of this, it seemed to me that the arguments presented here could inform the longstanding discussion of what does and does not amount to “incapacity” to make treatment decisions. Pickard is convincingly insistent that this criterion is key to preventing future abuses of psychiatry's coercive power. Not surprisingly, given the title, incapacity, along with irrationality, appears at numerous points in the book. The arguments of Summers and Sinnott-Armstrong are not taken up by others, however, which is a shame. Their analysis goes to the heart of what it is that justifies coercing some people who have mental disorders and not others.
A defendant's ability to reason in the abstract about right and wrong becomes less important to our ascriptions of responsibility as we learn more about his ability to reason about the particular act in which he engaged. The reasons are complicated. Chandra Sripada argues persuasively that it is always the reasons in relation to the particular act that interest us. She acknowledges that there are times when we do use a person's ability to complete successfully a broader range of mental tasks as evidence of his ability to reason in relation to the criminal act. But, she argues, we use such evidence only in the absence of anything better and allow it to be “superseded” (p 121) when evidence of reasoning in relation to the particular act becomes available.
The volume has been well produced by Routledge and the index is good. The pairings of philosopher with clinician frequently produce more than the sum of their parts. The editors are to be commended for showing that, even if it is all about food and sex, there may be some other interesting diversions along the way.
- © 2016 American Academy of Psychiatry and the Law
