My impression is that people who are neither moral philosophers nor psychiatrists or psychologists tend to think that there's a sharp line between "vice" and "psychiatric disorders" - or, colloquially, between the bad and the mad (note, I don't know of any empirical research that investigates this very matter, this is really just my impression). My impression is also that people are quick to assume that there's a limit to how bad someone can be without also being mad. But perhaps not the other way around.
Philosophers who work on moral responsibility and moral agency tend to assume this as well. I think all this drawing of lines and placing people in neat boxes is a fundamentally misguided way of looking at moral responsibility, but it's nevertheless the common and traditional way. Neurotypical people are morally responsible agents. Psychiatric and neuropsychiatric diagnoses, on the other hand, frequently undermine moral responsibility, and place people in the "exempted" box. Some philosophers like to divide moral responsibility into different subkinds, and play around with what kind of responsibility you can have with this or that diagnosis, even as you're exempted from the other kinds.
The moral landscape would certainly be a neater place to navigate if there really were sharp lines between the mad and the bad. Sharp lines out there, so to speak, in nature - but alas, there aren't. And that's the main topic for Sadler's book.
More than half of the book is taken up by a loooong journey through time, and also, to some extent, through different cultures and different parts of the globe. People have struggled with the mad-bad distinction everywhere and for ages. And they still do! We still don't have a scientifically and philosophically well-grounded theory! This isn't because the mad-bad border is hard to find, and our science and/or philosophy isn't sufficiently well developed yet. It's because there isn't a sharp border. Sure, lots of people may be categorized as purely mad, or as purely bad (though as the reader of the book will see, the latter has, in modern times, been more controversial), but we'll remain stuck with a big grey area.
Sometimes, this grey area has given rise to "vice-laden" DSM diagnoses, like Conduct Disorder, Oppositional Defiant Disorder or Anti-Social Personality Disorder. Sadler calls these "vice-laden", because the diagnostic criteria is moralizing in a way that the criteria for, say, Schizophrenia or Major Depression are not. At other times, after discussions and debates, behaviours remain "just bad" rather than "bad and mad": Intolerant Personality Disorder, Behavioural Addictions (apart from gambling) such as addiction to sex, shopping, or social media, Political Apathy Disorder, and Paraphilic Rapism never made it into any diagnostic manuals. Sadler, only half-jokingly, suggests that White-Collar Antisocial Disorder, or, as we might call it, the Bernie Maddoff syndrome, could be a psychiatric diagnosis - why should only criminals from the lower social classes be pathologized?
Way too many moral philosophers assume that the business of coming up with psychiatric diagnoses and applying them to individuals is a much harder science than it actually is. If someone has a bona fide diagnosis which includes descriptions of moral vices and vicious behaviour, it goes to show that it's not the person's fault, and they can't be morally responsible. If there's no diagnosis that covers their character traits and behaviour, they are responsible and blameworthy. Or so many philosophers seem to think.
Some people also like to appeal to neurological findings - people with this or that diagnosis have different brains! But every mental difference must have some corresponding brain difference - regardless of which mind-body theory we subscribe to, regardless of whether the mind is identical to the brain or if it supervenes on what happens in the brain or even if we're fancy old-fashioned dualists who think it's just correlation, it follows that every mental difference has some corresponding brain difference. You can't just point to "a brain difference" as evidence of undermined moral responsibility. Nor can you point to "a brain difference" as evidence that people with this or that diagnosis can't help their vices, unlike undiagnosed vicious people.
In our world, you can have Oppositional Defiant Disorder, but not White-Collar Antisocial Disorder. In a nearby possible world, in which human psychology works exactly the same, but psychiatry had a somewhat different development, it's the other way around.
So, let's admit that psychiatric diagnoses and the mad/bad distinction is a huge bloody quagmire. What are we supposed to do? Sadler ends his hefty brick of a book with no less than forty theses of what ought to be done, society-wise, in light of this realization. He very nicely divides these theses into stuff we could do immediately and more distant, long-term goals.
As I said, it's a huge book, and I can't even begin to do everything justice in a blog post. But an overarching theme of the forty final theses is to ditch the attempt to find a neat mad/bad divide. Psychiatry should admit and discuss more explicitly than has hitherto been the case how value-laden it is, and how value-laden it must be. An open discussion allows for scrutiny and criticism of underlying values, instead of implicit acceptance. Also, we shouldn't divide criminals into the bad who deserve punishment and the mad who should go to forensic psychiatry (though very few perpetrators of serious crimes do so in the USA, the insanity defense is rarely invoked and even more rarely successful). We should rehabilitate as many as possible so they can be released back into society, and permanently dangerous people should be kept in humane confinement. The mad/bad distinction is ultimately irrelevant.
This is obviously extremely controversial. I'm not sure what I ultimately think of this idea. Let's say I'm somewhat sympathetic, because Sadler is so very aware of all the problems and pitfalls that come with this suggestion, and discusses them at length.
Both psychiatry and criminal justice institutions in various countries and time periods have played thought police, and have locked people up under the guise of either punishment or treatment/rehabilitation because they have the "wrong" ideas, dare to challenge old social norms, and so on. This is a serious danger, though it exists even when psychiatry and criminal punishment are kept separate. The goal of any rehabilitative program must be people that aren't dangerous to others, not to turn everyone into "normal" people who think the "right" thoughts.
Perhaps there is even a greater risk for abuse when the systems are kept separate - it's so easy to justify abuse of prisoners by painting them as evil and thus deserving of everything they get, and simultaneously justify abuse of psychiatric patients by painting them as so irrational and confused and utterly different from normal people that what would count as horrible violations of a normal person is okay, or at least not all that bad, when done to "those people". Also, no need to listen to any complaints they have, since they don't know what they're saying anyway.
Generally, Sadler shows so much more awareness of potential problems with treatment and rehabilitation than many philosophers who write about these matters. Way too many philosophers are acutely aware of how harmful punishment can be, while utterly oblivious to the horrors that often befall people after they have been declared incompetent and exempt from responsibility.
Regardless of whether one agrees with Sadler's radical conclusions, everyone should agree about the importance of an open discussion about these matters. There's no dividing line between the mad and the bad "out there" for us to discover. And history shows how difficult it is to construct a non-arbitrary line.
So, this is a positive review. I recommend the book to all philosophers working on these topics, and to everyone else who researches or is simply interested in psychiatry and criminal justice. Or more broadly human nature.
After the recommendation, a reservation: Sadler contrasts common "folk-psychological" explanations of behaviour in terms of beliefs and desires with proper scientific explanations. Then he compares this distinction to the distinction between Newtonian physics and later scientific theories like special relativity and quantum mechanics. Folk psychology and Newton work well in everyday life, but when there's lots at stake and we need to be extra careful, they sometimes need to be replaced with more detailed and complicated theories.
Now I'm in deep water here since I'm not an expert on physics. Nevertheless, all physical explanations seem to me, ultimately, the same kind of explanation. They're all purely causal, tell us what causes what. Now, purely causal explanations may or may not conflict with each other. A biological explanation in terms of cellular events, a biochemical in terms of molecules, and a physical that zooms in on atoms need not conflict, since they take place on different levels of explanation. But causal explanations can conflict with each other. I take it that Newtonian physics actually conflict sometimes with relativity and quantum mechanics. When it does, we may say that Newtonian physics is less detailed but still has its place in everyday contexts where it's sufficiently precise for the purpose at hand, whereas we might need more detailed theories in other contexts.
Reasons explanations, on the other hand, are a different kind of explanation to causal explanations. "Folk psychology" is a loose term, and may involve more than reasons, but insofar as reasons are what we focus on - reasons may justify or not, show that you're action was rational or not, show whether it was moral or not ... Reason explanations are a different kind of explanation. They differ from all causal explanations, whether these causes are understood within a psychological, sociological, neurological, or other framework.
If I explain why I did what I just did by referring to my reasons for doing it, while a bunch of empirical scientists who study me provide causal explanations, the difference isn't that I give a rough and sloppy explanation whereas their explanations are detailed. We're looking at my action from completely different angles.
However, I might over-interpret the point that Sadler wanted to make with his Newton-relativity-quantum comparison. It's possible he agrees with everything I write here, in which case it's more of a comment than a reservation.
Now, I'm gonna nitpick.
Sadler discusses - and obviously, he's not alone in this, these discussions are common - whether to say, e.g., "I have schizophrenia" or "I'm schizophrenic". The "am" vs "have" debate, "people first" vs "identity" language. He contrasts how people often say "I am" with regards to psychiatric diagnoses, with the "I have" language we use for physical health problems like cancer or a broken bone. Then, he says that this isn't all that weird, considering how intertwined a psychiatric condition may be with one's personality.
But
a) it's not true that we say "I have" about all physical health problems, it differs from condition to condition, and
b) it's also not true that "I am" language, generally, implies that something is an important part of who I am.
Obviously people don't say "I am cancer" because "cancer" is a noun, you can't say that unless you're the personification of cancer itself, some kind of disease god or other supernatural entity. Similarly, people don't say "I am schizophrenia" or "I am depression". Now, with cancer, people don't usually say "I'm cancerous" either, but there are other physical health problems where "I am" language is common. "I'm diabetic", "I'm HIV-positive", "I'm lactose-intolerant", etc. In English, we say "I have a cold", but in Swedish, we say "jag är förkyld" - roughly, "I'm over-chilled".
Also, if we look at features other than health problems, we habitually use "I am" language about tons of things that aren't important parts of our personalities or who we are. "I'm medium blond", "I'm 169 cm tall", "I'm a Star Trek fan", and so on. In both English and Swedish, people are this or that number of years old and they are hungry if they haven't eaten for some time, whereas in Spanish and French, people have their years and have hunger. Surely these are random language differences that don't matter for how speakers conceive of their ages and states of hunger in relation to their personalities and identities.
And yet, in mental health contexts, people suddenly make a big deal out of "I am" vs "I have", as if these expressions have all these linguistic implications. Well, I guess "I am" vs "I have" have strong linguistic implications in the specific context of mental health now, because so many people have made such a big deal out of it for so long. But why did this come up in the first place? Given that "I am" vs "I have" don't have any interesting implications in language in general?
I can only assume it's because lots of people think it's horrible-horrible-horrible-shameful to have a mental health condition, and therefore they suffer intense second-hand shame every time they hear someone openly say, e.g., "I'm schizophrenic". If you're gonna talk about it, could you at least try to distance yourself from that horrible condition as much as possible?
If this was a peer-reviewed paper rather than a blog post, the imaginary peer reviewer would have this to say:
"That doesn't make any sense. You claim that there's no interesting distinction between 'I am' language vs 'I have', outside of mental health contexts and the special norms that have been created there by people who 'make a big deal out of it'. But if you're right about this, saying 'I have schizophrenia' wouldn't have signaled more detachment than saying 'I'm schizophrenic' until these special mental health language norms were already in place."
Fair enough, imaginary peer reviewer.
Anyway, it's weird. This entire insistence on "have" over "am" in mental health contexts is hella weird, let's just leave it at that.
Finally, philosophers who read this book may find some little annoyances here and
there, where Sadler's terminology doesn't align with ours. For instance,
at one point, he talks about adherents of retributivism who are "couching the concept in the context of utilitarian ethics".
This reads as somewhat philosophically confused. Utilitarianism is the view that
an action (including the act of punishing a criminal) is right if it
maximizes utility (traditionally understood as happiness) and wrong
otherwise. "Desert" has no place in utilitarian theory, except, perhaps,
as a derived and pragmatically used term. Utilitarians since Jeremy
Bentham and onwards have focused on the role that punishment allegedly has in
deterring criminals from re-offending and deterring potential criminals
from offending in the first place (something Sadler also recounts in his book). Retributivism is a different theory, according to which criminals should be punished because they deserve it.
Now, it's possible to hold a mixed theory, according to which we have
several different reasons for punishing criminals; they deserve to be
punished, and it's great if we can deter people from crime.
Stephen Morse and others have pointed out that real-life politicians
often freely mix appeals to an alleged deterrence effect and appeals
to desert when they argue for harsher punishments. Nevertheless,
claiming that we have both deterrence reasons and retributivist reasons
to punish criminals is very different from saying that deterrence is a
reason for retributivism.
Still, this was a very minor nitpick. Overall, I recommend this book. Agree with Sadler or not, he does raise some really important questions.
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