Wednesday, April 1, 2009

PPP Issue on Vice and Disorder

In the latest issue of PPP, John Sadler has put together a "philosophical case conference" on vice and the classification of mental disorders, which will be a great resource for future discussion of the area.
His target piece features discussion of some of the issues of classifying vice, by which he means criminal behavior and immoral attitudes. He sets out three cases. The first is a 12-year-old boy who is disobedient and troublesome, defying authority and lying. He gets diagnosed with conduct disorder. The second is of a mother who presents her mother who presents her child as ill and having breathing difficulties. It turns out that the mother smothered her child. She has a complicated case history, with a troubled past. The third case is Jeffrey Dahmer, who received diagnoses of Asperger's, paraphilias, alcohol abuse, depressive disorder not otherwise specified, and personality disorder not otherwise specified. The rest of the paper sets out some of the issues in dealing with the vice-mental disorder relationship in DSM-UV-TR, under the headings of "Inconsistencies in How Wrongful Conduct is Classified," "Impoverishment of Some Criteria Sets for Vice-Laden Disorders," "Hierarchical and Comorbidity Issues," and "Metaphysical Ambiguities." The main theme is that DSM-IV-TR is not consistent and is not clearly formulated when it comes to the relation between vices and disorders. The paper does not set out a theory of what this relation should be.

There is an unusual number of peer commentators for this target paper:
Jeffrey Geller (U Mass Medical School)
Gwen Adshead
Nancy Nyquist Potter and Peter Zachar
Christopher Heginbotham, University of Central Lancashire
Michael First
Christopher Williams
Lloyd Wells (Mayo Clinic)
Stephen Morse
It is a diverse collection of responses. I'm a little disappointed that there was not more discussion of the cases. Geller writes about some of the history of the topic. Adhead expands on the discussion of Case 2, which was her example in the first place. Potter and Zachar give a rather general discussion. Heginbotham gives a brief discussion of the cases and proposes an approach rooted in the social model of disability. First gives a more extensive discussion of the topic and the cases, allowing that vices can also be indicative of disorders. Williams sketches some issues in identifying the causes of behavior. Wells endorses an approach that mixes medicalization and moralization, and discusses this in several cases of his own. Morse emphasizes the difficulty of examining the issues in the absence of quite well developed theories of what counts as a mental disorder and a theory of morality.

Adshead complains about the "muddling" of social, psychological, and legal discourses, as if it were possible to keep them separate, but she is open to the possibility that vice and disorder need not be mutually exclusive. Yet even here, she seems to think that the mental disorder itself could not explain violence to others completely, and that one needs other elements in the explanation. She is especially sensitive to the danger that explaining an action with a diagnosis would take away a person's sense of agency. Adshead gives the impression that she needs a more fully fledged theory of action and mental disorder in order to avoid conceptual problems. Most of the other authors embrace the fact that the moral and the medical overlap, and that people can responsible for their symptomatic behavior even when they have mental illness.

With this and all the other commentaries, it is clearly impossible for them to set out a detailed view about such a complex area. So they are able to raise a few points but one does not get a strong sense of deep engagement with issues raised by the target article, and none of the authors sets out anything like the robust theories that Morse says are needed. This is all to the good, meaning that there is still plenty of work to be done in this area. Sadler ends with the suggestion that it might be possible to do without some theories, by taking a pragmatic stance. This is an idea that I'm sympathetic with, but I'm not sure that it is possible to bypass the theories altogether, and justifying the pragmatic stance without the theory is going to take lots of discussion, if not theorizing.

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