“There is a system in lunacy”: morality and normativity in mental disorders

Leonardo Vaiana

1 Normativity/normality in health mental sciences

The general question to be addressed involves primarily the “normativity”, which is not so much - or simply - a great philosophical theme: it is, rather, the essence of philosophy from Plato to contemporary philosophy until W.V Quine (1969) gave rise to the naturalistic turn. Yet, it is curious that, in the last years, platonic normality has been taken into account within the philosophy of medicine (Chadwick, 2017: 19). On the other hand, Ian Hacking (1990: 160), while reporting that in the early 1820s the word “normality” was coined to signify “a way to be ‘objective’ about human beings”, also underlines that “it uses a power as old as Aristotle to bridge the fact/value distinction, whispering in your ear that what is normal is also right”.

Understandably so, within the sciences of mental health, which are the starting point of this study, after the influential Hempel’s (1965) paper recommending the use of a scientific language supported by observational terms, the core concept became that of “normality”. Adopting this term, psychiatrists and other mental health professionals generally aim to define the mental disorders by an alleged free-value concept. Yet, it is argued by some authors (Wachbroit, 1994; Catita et al., 2020) that sciences as biology and medicine treat the concept of normality as a supposed ideal to which refer the standard accounts of biological or physiological functions. Still it should be reminded that this ideal and its normative function applying to psychiatry were criticized not only by an eccentric historian of thought as M. Foucault (1961), but also by an influential psychiatrist as T. Szasz (1960), both protesting the ‘normalizing’ function of psychiatric practices and their grounding on the social construction and stigmatization of mental illness.

Perhaps, as a consequence of these strong philosophical and sociological trends of ‘antipsychiatry’, the word ‘normality’ is not expressly mentioned in DSM-5

definition of mental disorders: we read, rather, that “mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities” (American Psychiatric Association, 2013: 20).

Yet, there is no author who, although questioning the definition of ‘mental disorder’ (Bolton, 2008; Stein et al., 2010), does not use the term ‘normal’positing it on the side of mental health, and the term ‘abnormal’ on the side of mental disorders, so that the latter can be explained, as a consequence, since they differ from ‘normal’ mental functions. Allan V. Horowitz (2015: 340), for example, comments the DSM-5 definition of mental disorder stating that it stresses “the difference between a painful but normal emotion and a mental disorder”. In scientific studies, hence, it is generally taken for granted what is the normal functioning of the mind (Regier et al., 2013), whereas it is obvious, on the other hand, that some “abnormal” behaviours or capacities, such as high level of intelligence, or high level of artistic performances are not considered examples of mental disorder.

The question, however, arises as problematic mental conditions such as adolescent antisocial behaviour, intense sadness, intense worry, intense shyness, failure to learn to read, and other types of behaviour are “not merely a form of normal, albeit undesirable and painful, human functioning, but indicative of psychiatric disorder” (Wakefield, 2007: 149). More generally, it is admitted a “normal pain” or “normal grief”, as a standard way in which “normal brains respond to such adverse circumstances with negative feelings”. So, within the mental health science, although that there is little or no consensus about the meaning of “mental disorder” (Graham, 2002; Wakefield, 2007; Bolton and Gillett, 2019), it seems that there is a large consensus on what is a ‘normal’ mental functioning, so that “the normal-disordered boundary” is accepted as an unquestioned ground for diagnosis (Wakefield, 2013: 604-605).

Alternatively, “statistically normal” is generally accepted as an explanation of what is normal, and as a value-free concept (Wilkinson, 2000: 290). There are some reservations about the fact that a science such as statistics may be value-free. The concept of ‘normal distribution’ itself is not the representation of merely raw data, but depends on chosen independent variables such as blood pressure and cholesterol measurement, sex, age, pre-existing morbidity, genetic predisposition, nutrition, and similar variable. Therefore, even if Lennard Davis’ (1995: 30) stigmatization of the eugenic trend of earlier statistics may refer to an obsolete problem, the fact remains that statistics is born as and is still a normative science. Furthermore, on the side of common people’s view on normality, recent studies have also suggested that it involves representations of both statistical norms and prescriptive norms (Bear and Knobe, 2016).

Another way to reduce normality to a scientific concept is to take normality as a biological function (Wakefield, 1999, 2000; Horowitz and Wakefield, 2007), but this approach also meets objections. One of them is that function and dysfunction, being both natural phenomena, should be governed and explained by the same system of natural law. So it is questioned how to mark their difference, if the same biological system can obey to natural rules and can also disobey to them. An answer seems to be that function and dysfunction are two qualitative faces of the same trait that differ in the value associated with this variable (Roux, 2018). Thus, we are back again to value and the question of whether disease and illness are normative concepts or value-free scientific terms (Kendell et al., 1986).

A more general objection to the classic Wakefield’s definition of‘mental disorder’ as ‘harmful dysfunction’ was put forward from the evolutionary conceptual framework, which explains mental disorder as “an inability of some internal mechanism to perform its natural function” (Wakefield, 1992: 373). But Laurence J. Kirmayer and Allan Young (1999: 449) refuted this view as a form of biological reductionism, arguing that “cognitive theories of psychopathology suggest that there are disorders that are due to bad programming, not flawed hardware design or damage”. In this connection, they mention Daniel Dennett, as a champion of evolutionary theory and cognitive neuroscience who, on his turn, claimed that “whereas animals are rigidly controlled by their biology, human behaviour is largely determined by culture, a largely autonomous system of symbols and values, growing from a biological base, but growing indefinitely away from it” (Dennett, 1995: 491).

Besides, it is worth reminding that almost in the same years, Hilary Putnam (1992: 20) noticed: “evolutionists are extremely cautious about saying which capacities and organs, and so on, were specifically selected for (were ‘adaptations’) in the evolutionary history of a species and which ones arose serendipitously. Philosophers, however, are not so cautious”. It might be added that psychiatrists are not too, since despite the notion of normal function is controversial, they still use it.

Today the distinction between normality and abnormality, although its questionability is no more denied (Singh and Sinnott-Armstrong, 2015), seems to be working for the diagnostic purposes of the sciences of mental health, since normal and abnormal are taken as different points of a continuous distribution (Rössler, 2013; Nuevo et al., 2012; Manwell et al., 2015; Clark et al., 2017), underlying symptomatology compatible with both categorical and dimensional classifications (Watson, 2005: 533).

A general conclusion about the question of normality is therefore that psychiatric diagnoses do not constitute mental illness entities, since “categorical classification systems constitute agreed-upon definitions for pragmatically assigning mental illnesses” (Rössler, 2013: 2).

Within this view, the notion of normality plays only a pragmatically necessary role to distinguish patients in need of clinical treatment from sane people, without carrying any moral or social stigma (Clark et al., 2017).

2 Normality and normativity in law

The problem of normality, which can be overlooked in mental health sciences contexts, becomes stringent when we move to consider the perspective of criminal law. Within this context, the scenery changes, since the main topic is the notion of culpability and responsibility and it must be analysed in relation to the normal/ abnormal mental condition of the defendant.

A general point of view, which is the starting point for the alleged not guilty of an agent due to mental disorders, is the notion of‘mental impairment’, according to which a person should not be held criminally responsible if, at the time of the criminal act, the agent lacked the mental capacity to know the nature and quality of her actions or, if she knew the nature and quality of her actions, she did not know, however, that her actions were wrong or she was unable to control her actions.

This is a long-standing rule within the legal tradition and, at the same time, a long-discussed rule: in the legal system, the definition of what constitutes ‘mental impairment’ is a matter of law, though it refers to an underlying pathological infirmity of the mind that can be ascertained only by a clinical diagnosis. It seems important, therefore, to take into account the debate about the legal and scientific definitions of mental disorder trying to understand also the difference between the law and the mental system’s approaches.

Stephen J. Morse (2011: 888) highlighted this difference stating that “the former is primarily concerned with justice and social safety; the latter is primarily concerned with the prevention and treatment of mental disorders”. More specifically, as regards the “insanity defence”, which is a crucial field of law and psychiatry, law aims to find if the defendant is innocent because of his mental impairment. Innocence and guilt, however, are not a matter of psychiatric diagnosis, but of moral and legal judgements.

Therefore, in the field of criminal law and justice, a largely shared view includes that (1) “insanity”, or its recent replacement with the term of “mental impairment”, aiming to avoid the “stigma” related to the word “insanity” (CMIA, 4.13), is a legal concept; (2) law is not bound by extra-legal scientific or professional criteria; (3) psychiatry is not an exact science and its allowed concept of “mental disorder” is broad, vague, and questionable; (4) law also belongs to folk psychology, and (5) it has a wider and stronger social impact than psychiatry.

In principle, therefore, not only the Anglo-American legal system but also many other legal systems (Math et al., 2015; Kooijmans and Meynen, 2017; Baiguera Altieri, 2017) limit the influence of forensic psychiatry to the extent that it can only give suggestions for the court’s decision that, ultimately, determines what mental behaviour can be accepted for the insanity defence, according to normative standards (Allnutt et al., 2007).

On the other hand, the difference between clinical and legal assumptions concerning mental disorders is underlined by forensic psychiatrists who admit that

clinicians entering the forensic arena, however, for the most part, do not immerse themselves in thinking about the current social definition or understanding of mental illness. Because of their training and experience, clinicians most often resort to explaining mental illness through the lens of the most widely accepted classification system.

(Johnson and Elbogen, 2013: 204)

This explains why they think, in turn, that “legal definitions of mental disorders are often quite vague across statutes and can at times be inconsistent with the psychiatric definitions” (Johnson and Elbogen, 2013: 207).

To understand the deep reason of this divergence, it is necessary, however, to address a notion that is often related to that of ‘insanity’, namely ‘the lack of the capacity for rationality’. The latter introduces a broader topic, on which the legal and clinical definition of insanity itself depends, that is the philosophical and common view of rationality. On this issue, it is worth to emphasize two further differences between law and mental health science: (1) law assumes a normative concept of rationality, while mental health sciences refer to an empirically based understanding of rationality, so that, on this point, the law is more suited to both philosophy and common view; (2) not only law but also philosophy (strange as it may seem) is more related to people’s language and understanding than mental health sciences, so scientific objections to the notion of the rationality of psychology of common sense are uninfluential for law and philosophy (Morse, 2011; Sifferd, 2006).

In this connection, it seems interesting to me to take into account the interrelated concepts whose meaning is not univocally understood within the aforementioned perspectives, namely the concepts of evidence and causation.

As regards the evidence, scientists know of course that its relation to data depends on a complex set of interrelated theoretical premises, hypotheses, and observations that do not prevent them from relying, ultimately, on evidence. In the legal system, however, the main question is concerned with the reliability of identifying witnesses, who are often compromised by voluntary or involuntary perception biases. In the US and UK legal systems (Edmond, 2012; Roberts, 2012), it was accepted that the jurors, being alerted by the court about the unreliability of identification evidence, are capable of assessing the credibility and reliability of a witness without expert assistance since “each juror brings to bear on that judgement his experience of life and human atfairs”(Gv HM Advocate ¡20111 HCAJC 40, para 28 see also Roberts, 2012; Nicolson and Auchie, 2017; Kirgis, 2002). Yet, according to a long-standing tradition, expert’s opinion is admissible with some caveats: (1) expert’s competence is to be recognized by the scientific community; (2) the court must be furnished with scientific information which is likely outside its experience; (3) it is required, however, that experts did not trouble juror’s understanding by using scientific jargon or by offering complex and conflicting opinions; finally, (4) it is refuted any pretence to override the role of a jury in the trial (Nicolson and Auchie, 2017).

So again, we can notice that the essential intent of the legal system is to contrast common knowledge and common mind to specialized knowledge and scientific mind. Actually, it has been admitted the necessity to refer to expert testimony, to understand matters related to specialized knowledge such as ballistic analysis, physical matching, and similar topics, as well as genetic science, psychology, and psychiatry (Nicolson and Auchie, 2017). Yet, Gary Edmond (2012: 32) referring to the Law’s Commission report, complained that in England and Wales’jurisdiction,

“expert opinion evidence has been admitted in criminal proceedings too readily and with insufficient scrutiny”. And Andrew Roberts (2012: 105), analysing the Gage’s case, concluded that “the question of the admissibility of expert evidence might boil down to a question of risk allocation”.

On the other hand, legal system, accepting the contribution of expert testimony, on its turn must depend on the general assumptions and constraints governing the method and criteria of the scientific practice. Forensic psychiatry, as any other science, is characterized by intrinsic limits (Stone, 2008), and evidence sometimes is judged “surprisingly equivocal”, for example, when child sexual abuse is considered an evident cause of later violent behaviour (Kennedy, 2005: 4). It is well known that scientific evidence has been debated for decades, from Rudolf Carnap’s (1947: 138-139) requirement of “total evidence”, which in recent times has been criticized for its implicit grounding on “ideally epistemically rational agents” (Santana, 2017: 4), to current theories of scientific evidence (Scheiner, 2004), where evidence is rather formulated as an interrelated set of elements, including empirical observation and its cognitive biases, background information and its selection, and logical relations between hypothesis and expected evidence. Besides, this setting is embedded in a framework where, as Putnam (2002) showed years ago, it is difficult to maintain the dichotomy fact/value. Of course, many epistemologists still claim a real realism (Kitcher, 2001), which is not, however, ingenuously refuting the idea that both scientific and everyday judgements have a broadly normative content.

The same question can be put forward about the related concept of causation. Is it to be treated as the complex concept as it is used by science or as it is understood in everyday life and law system, that is, as a normative concept? Micheál S. Moore (2009), in his influential work on legal causation, aims to explain how it is possible to reconcile normative uses of the concept, which do not involve the technical or special definition, with causal ordinary and scientific uses of the concept. At the same time, we find again that legal system wants to distinguish its field from those scientific and philosophical approaches that interfere with a plain understanding of these central concepts of the decision-making process of juries and courts. Morse has recently pointed out that the most important thing to recognize for lawyers and policymakers is that mental disorders, which play a causal role, do not turn the person into an automaton:

People with mental disorders act for reasons just like people without such disorders. . . . Their criminal acts should not be understood mechanistically, like a fever that spikes as the result of an underlying infection. Causation should be understood in this context in terms of assessing the defendant’s reasons for action.

(Morse, 2018: 259)

One could be tempted to think that mental disorders can be compared to physiological or physical phenomena and, consequently, that they are governed by the same causal mechanism and determinism that are at work in nature. Yet, this sort of reasoning is designated by Morse (2011: 899) as “the fundamental psycho-legal error”, which consists in assuming that, if the behaviour of an agent is caused by mental disorder, is excused. However, physical causation is not to be meant as a legal or moral or excusing condition because, if all behaviour depended only on physical causes, then no behaviour would involve any responsibility, and could ever be appreciated, blamed, or justifiably punished (Berman, 2008). This consequence would be, of course, at odd with the legal point of view, but also with common sense, both sharing the assumption that people can act for and respond to reason, that is the general requirement for law’s concern on “the lack of rational capacity” (Morse, 2011: 934), the only condition diminishing responsibility. Furthermore, science has not yet shown that the folk psychology’s laws fail to explain human behaviour in daily contexts (Dennett, 1987; Dennett, 1998; Lyre, 2018), which are the same that law is concerned with (Morse, 2009, 2011).

These plain reflections would be sufficient to show that the capacity of understanding and using a moral and legal rule for acting has nothing to do with the metaphysical problem of the contrast between causal determinism and free will (Morse, 2007). Yet, also theoretical tenets supported the determinist’s perspective in law (Julian, 1970), and a shared solution to this problem was the so-called com-patibilism, a philosophical view according to which responsibility - the capacity for free decisions and actions - is independent from the causal mechanism which determines the neurological processes of the brain (Morse, 2000; Dworkin, 2011; Vincent, 2015). Besides, it is shown, however, that mental disorders, like other mental states, are not to be considered a deterministic cause of the behaviour. Morse’s example of an agent affected by hypomania is persuasive. According to DSM-5, hypomania is “a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least four consecutive days” that includes some symptoms such as “inflated self-esteem or grandiosity”, “decreased need for sleep”, and “increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation” (American Psychiatric Association, 2013: 124). Morse’s argument is the following:

[IJmagine a “career” armed robber who suffers from clinical hypomania. Suppose our robber never robs except when he is in a hypomanic state because only then does he feel sufficiently confident and energetic to rob. If he is charged with an armed robbery committed while he is hypomanic, his clinical condition played a causal role in explaining his criminal conduct, but no excusing condition necessarily obtains.

(Morse, 2011: 899)

In this case, the agent’s behaviour seems to be intentionally caused and rational, but just for this reason it is not excusable: even if there is a clinical condition explaining his behaviour, it is not sufficient to show that it is lacking of rationality, and consequently involuntary or unintentional.

An antimechanicistic view of causation is widely spread among legal scholars. Indeed, several studies show that people who are alcohol or drugs addicted, or mentally impaired, may be considered responsible for their conditions. For example, although many people are likely advantaged by an alcohol intolerance in avoiding alcohol use, nevertheless alcohol addicts seem responsible of their condition to the extent that “biological variation is not behavioural imperative” (Mitchell, 1986: 277). Therefore, other types of causes, namely non-physical, like having alcoholic parents, living in adverse circumstances, and complying personal desires may be taken into account as resulting in alcohol abuse. Moreover, a “purposive meta-responsibility” is assigned to people mentally impaired, in as much “mental disorder represents strategic and willful behaviour on the part of the patient in an attempt to influence his personal and social situation” (Mitchell, 1999: 599). If this is the case, psychiatric evidence is provided as a mitigatory rather than an excusatory factor. Finally, “where a crime has been a product of a mental disorder, and that disorder has been culpably caused, then the defendant should not be eligible for a full acquittal (whether due to automatism, insanity or otherwise)” (Mitchell, 1999: 614).

Also, recent findings in cognitive neuroscience, aiming to fulfil the gap between mechanistic and neurological explanations of voluntary actions on the one hand, and commonsensical explanations on the other hand, are promising but still uncertain about date interpretation (Schurger et al., 2016; Schultze-Kraft et al., 2016). These results seem to give reason to Morse’s previsions, dating back to some years ago, that he expressed in the following way:

Although I predict that we will see far more numerous attempts to use neuroscience in the future as evidence in criminal cases and to affect criminal justice policy, I have elsewhere argued (Morse, 2008) that for conceptual and scientific reasons, there is no reason at present to believe that we are not agents. . . . What is the nature of the “agent” that is discovering the laws governing how incentives shape behaviour? Could understanding and providing incentives via social norms and legal rules simply be epiphenomenal interpretations of what the brain has already done? How do “we” “decide” which behaviours to reward or punish? What role does “reason” - a property of thoughts and agents, not a property of brains - play in this “decision”?. . . Normativity depends on reason and thus the radical view is normatively inert. Neurons and neural networks do not have reasons. Only people do. If reasons do not matter, then we have no genuine, non-illusory reason to adopt any morals or politics, any legal rule, or to do anything at all.

  • (Morse, 2011: 966)
  • 3 Normativity and moral philosophy

Interestingly, Morse applies to the legal question of responsibility the long-standing normative view of intentionality and rationality in philosophy. Yet, there is a point in his argument from which it is possible to take a cue for developing a view of mental disorders not yet developed enough. It is ‘the lack of rationality’, that is the main law’s concern for insanity or mental impairment. Philosophy’s concern may be different, however, in as much as it may invert the question to be put forward. It will be no more whether mentally impaired people, failing to recognize the normative aspects of the social world, may be excused. The questions will be instead, for example: are psychiatric patients immoral? In breaking the alleged moral rules, do they think to act morally? If this is the case, what can mental disorders teach us about the normative character of moral choices? Can mental disorders shed light on the complex nature of morality? It will be stressed that, putting these questions, the philosophical perspective may propose a new approach to the problem of mental disorders. Unlike mental health sciences and criminal law, whose aim is to certain - clinically or legally - the lack of rationality of people, philosophy can rather address the question of the rationality of patients and their models of morality.

Before proposing this issue, however, it is necessary to try to summarize the main trends of extensive literature on delusional beliefs for two main reasons. The first is because the mainstream philosophical approaches to moral responsibility have been centred on the topic of ‘doxastic responsibility’, which includes both ‘normal’ beliefs and delusional beliefs. The second is because, after reporting the main points of a still ongoing debate, I will focus on this ‘dominance of belief’, as I would call it, to defend an approach on the morality of impaired patients which seems to be more open to new developments.

This topic is characterized by a great division between doxasticism, a view that -unlike the question previously considered about the insanity defence - psychiatrists and other professionals share with common people, and anti-doxasticism, a more sophisticated view introducing some alternatives to the notion of belief. DSM-5’s definition of delusion is grounded on the notion of belief:

A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.

(American Psychiatric Association, 2013: 819)

In line with this definition, defenders of doxasticism (Bayne and Pacherie, 2005; Bortolotti, 2010, 2018; Bortolotti and Miyazono, 2015; McCormick, 2011) maintain that, although in a defective sense, delusions must be regarded as beliefs. Marga Reimer (2010: 317) even argues that they are anomalous or unusual beliefs, whose refutation implies a “fallacy of ignoring anomalies”, since “if something is unusual for an x, even highly unusual for an x, we cannot conclude without further argument that it is not an x”, and parallels them to philosophers’ bizarre nihilist claims.

On the contrary, defenders of anti-doxasticism aim to show that delusions’ failures, or irrationality, or weakness are just what makes them different from beliefs. So, ironically, the same defeating features are the object of contrasting rating by thetwo trends. Let us take some exemplar properties of the standard view of beliefs: they are contentful, evidence responsible, consistent, they have a functional role and are context-sensitive. Both doxasticists and anti-doxasticists find arguments to take the presence or absence of certain features as a support of their account and as a refutation of the opposite account. Although scholars have minutely examined each of the aforementioned features, only some key points of the ascription of contentful beliefs to delusional patients will be discussed, in as much as it includes, in some measure, all the others.

A recent study aims to show that Capgras, Fregoli, or Cotard delusions, from folk psychology, are readily classified as stereotypical beliefs. The authors (Rose et al., 2014: 3) present evidence that “people view these delusions as beliefs because frequent assertion is a powerful cue to belief ascription”, even if the same participants also notice that patients maintain contradictory beliefs. It seems strange, however, that the experimenters may drive a robust conclusion from such evidence, grounding more on the frequency of patients’ assertions rather than on the consistency of their beliefs, which is notoriously a major constraint of common sense psychology (Dennett, 1979, 1987), and a canonical way of beliefs’attribution. On the contrary, arguments supporting the opinion that delusions are contentful but not stereotypical - because they stem from “non-standard perceptual and affective conditions” of patients - have been pointed out (Bayne and Pacherie, 2005: 184) to refute anti-doxasticist objections against delusions’ content, while other objections such as irrationality, absence of evidence (indeed counter-evidence), and lack of commitment of delusions are overcome in that the latter are not exclusive features of delusions.

Another line of reasoning, dating back to K. Jaspers (1963: 59), finds that several mental disorders, despite their diversity, share the relation to content, so that “hypochondriacal contents, whether provided by voices, compulsive ideas, overvalued ideas or delusional ideas, remain identifiable as content”. Still Jaspers, explaining the concept of delusions, states that “their content is impossible” (Jaspers, 1963: 96) and “un-understandable”. It is therefore not surprising to find many scholars referring to Jaspers with the aim of focusing on the opposite view, according to which delusions are not beliefs. Delusions are rather seen as mere “empty speech acts” and “so unlike ‘normal beliefs’ that it must be asked why we persist in calling them beliefs at all” (Berrios, 1991: 7-8). As a consequence, delusions are taken as “non-assertoric” verbal expression. For example, when a patient says: “I am Napoleon”, his words are not to be meant as expressing a literary content (Sass, 1994). Indeed, they may be meaningful if they are understood as metaphors, as in a case of unilateral somatoparaphrenia where the patient said that his foot was like a cow’s foot (Halligan et al., 1995). Yet, such arguments are refuted by Andrew W. Young, who defends, on his turn, the content of delusions: although admitting that generally delusions do not result neither in consequential nor in violent actions, he stresses nevertheless that delusions are not “invariably metaphors, empty speech acts, or solipsistic reflections” (Young: 581), just because Capgras delusion, for example, sometimes caused violent behaviour - as in the famous case of a patient decapitating his father (misidentified by him as a robot), in search of his hardware.

As the last-mentioned case shows, content’s question is far from being unconnected with other features as lack of evidence, of coherence, of control and functional role. Still many studies could be examined that lead, in my opinion, to the same conclusion: any feature of belief is attributed to delusions in a quite idiosyncratic way and, on the other hand, it is admitted that also beliefs reveal many failures. On the contrary, anti-doxasticists, while questioning the content of delusions, do not deny that beliefs are also imputable, in some measure, of the same failing features. Finally, Bortolotti (2010, 2018) offers a general frame of the whole question of belief ascription that seems to me to end in a cul de sac, not promising for future developments of the topic. In particular, Bortolotti challenges the content of delusions by three constraints: procedural rationality, epistemic rationality, and agency rationality. She argues persuasively that all these constraints-having to do with the following subjects’ capacities: (1) to make consistently logical inferences, (2) to form new beliefs or to update existing beliefs supported by available evidence, (3) to form beliefs that are interpretable as reasons guiding action-reveal several and meaningful failures regarding not only delusional, but also “normal” beliefs. She rightly concludes therefore that “there is considerable continuity between delusions and beliefs” (Bortolotti, 2010: 57). Yet, in my opinion this is not a reason “to take seriously the doxastic conception of delusions” because even if it is true that also common beliefs are affected by several limitations to rationality, it is nevertheless true that these limitations are easily understood and managed within the common contexts of communication. However, this does not happen in the context of delusional language where there is no level of shared communication. So, in the case of delusional patient’s verbal behaviour, it does not seem to me that “words speak louder than actions”, as Rose et al. (2014) maintain, while I understand Quine, a master of the criticism of intentional language, when he said: “Actions, behaviour teaches, speak louder than words” Quine (1987: 19).

This is not to say that I will follow Quine thinking that beliefs are just dispositions, since this is just another issue that has been discussed at length by doxasticists. To report the aforementioned opposite opinions is just a way to take a distance from the philosophical debate on the concept of belief which, besides being controversial, is so extensive and dominant as to overshadow other sides of morality that is worth, for me, to address.

4 Kant's view of mental disorder: a different kind of rationality

In particular, in my opinion, Kant’s perspective on morality is particularly interesting, just because it is the most rigorous view of practical rationality. Some philosophical studies, centred on the relation between Kant’s moral philosophy and mental disorders, are still concerned with the question of doxastic and moral responsibility and thereby with the area of interest of law and mental health sciences

(White, 2012; Cohen, 2013; Scolten, 2016; Golob, 2017). Few studies (Frierson, 2009a, 2009b) aim to suggest cues of reflections that go beyond the boundaries of the question of responsibility, addressing the relation between Kant’s principle of ‘the sovereignty of reason’, which is the keystone of his philosophy, and its interest in the broad concept of ‘human nature’ including also its irrational sides flowing into mental illness. This relation is considered important for both its implications for Kant’s philosophy and today’s reflections about the discipline of psychiatry. Interestingly, in these studies, Kant’s concern for rationality is highlighted against the background of‘anthropology’, which Kant himself overtly considers as a secondary and irrelevant disciplinary approach to the question of morality. Yet, despite this notorious Kantian claim, his three major works on the critique of reason were preceded by a minor text like Essay on the Maladies of the Head (1764), and followed by the more important Anthropology from a Pragmatic Point of View (1798), and by other essays and lectures also referring to the problem of mental illness. So, in a recent study (Sisti, 2012), the blindness of Kant’s scholars with regard to the proximity between thought and madness as a constant dimension of Kant’s philosophical reflection has been complained.

My reading of this proximity, as it appears in Kant’s Anthropology, however, aims to emphasize not the importance of Kant’s reflections for current psychiatry, although it is also appreciable for me, but the originality of Kant’s moral findings on mental disorder. Contrary to what one would think, the philosopher of unfailing practical rationality admits a different form of rationality experienced by mentally impaired persons. Describing the ‘inconceivable’ content, made famous by Jaspers, of Vesania, Kant states: “this fourth kind of derangement could be called systematic”. In a marginal note he also writes: “There is a system in lunacy”. So this state of mind of “a deranged reason” is not to be meant, unlike Insania, as a lack of reason or as a cognitive deficit. It rather shows a different type of cognitive capacity that is far from being irrational. In Kant’s words:

For in this last kind of mental derangement there is not merely disorder and deviation from the rule of the use of reason, but also positive unreason; that is, another rule, a totally different standpoint into which the soul is transferred, so to speak, and from which it sees all objects differently. And from the Sensorio communi that is required for the unity of life (of the animal), it finds itself transferred to a faraway placed (hence the word “derangement”) [in marginal note Verriickung - which can also mean “displacement”] - just as a mountainous landscape sketched from a bird’s eye view prompts a completely different judgment about the region than when it is viewed from level ground. ... It is astonishing, however, that the powers of the unhinged mind still arrange themselves in a system, and that nature even strives to bring a principle of unity into unreason, so that the faculty of thought does not remain idle. Although it is not working objectively toward true cognition of things, it is still at work subjectively, for the purpose of animal life.

(Kant, 2007: 321)

This, then, is a subjective state of ‘unreason’ of a subject experiencing the unity and division of his mind, when he “flies over the entire guidance of experience and chases after principles that can be completely exempted from its touchstone” (Kant, 2007: 321). Some contemporary' psychiatrists, criticizing the concept of delusions, find that Kant’s understanding of this mental disorder is more accurate than current understanding in terms of‘delusions’ and, following Jaspers, prefer to turn back to the concept of ‘ Ichstorungen’, namely ‘disorders of the experiencing I’ (Spitzer, 1990).

What is more relevant from my point of view, which is not concerned with replacing diagnostic criteria with philosophical intuitions, is to underline other sides of this radical subjectivism. Kant (2007: 324) insists that “the only universal characteristic of madness is the loss of common sense (sensus communis) and its replacement with logical private sense (sensus privatus)” that is self-deceptive and illusory'. A few pages later, he describes passion as a chronic and severe illness such as dementia (Kant, 2007: 355) and stresses again the rationality' (now focusing on moral rationality') of these states of mind and their implying an act of choice:

Inclination that prevents reason from comparing it with the sum of all inclinations in respect to a certain choice is passion (passio anintt). Since passions can be paired with the calmest reflection, it is easy to see that they' are not thoughtless, like affects, nor stormy and transitory; rather, they take root and can even co-exist with rationalizing. . . . Passion always presupposes a maxim on the part of the subject, to act according to an end prescribed to him by his inclination. Passion is therefore always connected with his reason, and one can no more attribute passion to mere animals than to pure rational beings. The manias for honor, revenge, and so forth, just because they are never completely satisfied, are therefore counted among the passions as illnesses for which there is only' a palliative remedy'.

(Kant, 2007: 367)

Finally, the connection with moral egoism can be highlighted, since it is the crucial point which may' suggest that a radical egoism may be connected to pathological states such as passions. Of course, Kant’s description of this topic shows a steady' will to judge morally wrong egoism and passions. Putting in brackets the longstanding question of Kantian moral rigorism, which is not part of my argument, it is remarkable that Kant described egoism as a mental state which stems from an unlimited sense of “I” and maintained that moral egoism is opposite to pluralism, “the way of thinking in which one is not concerned with oneself as the whole world, but rather regards and conducts oneself as a mere citizen of the world” (Kant, 2007: 240—242). For Kant, of course, this was the accomplishment of his theory of mental illness: to suggest how to overcome a moral evil such as egoism means to open the way to overcome mental damage.

Yet, from Kant’s approach, questions not yet discussed may arise: what suggestions can result from empirical studies about this particular “derangement” of the reason that has been compared by many psychiatrists to schizophrenia? Do we have any confirmation that Kantian equation between morality and health and between moral egoism and mental disorder is well outlined?

A glimpse into recent literature does not allow to give certain and unambiguous answers, for a reason which needs to be underlined to prospect the questions addressed in the right way. The reason can be expressed referring to a couple of terms, such as ‘normative’ and ‘natural’, that is matching to the couple nor-mative/normal opening this study. Philosophical approaches to morality, both rationalistic and empiricist, are normative or, in other words, are governed by the famous Hume’s law. On the contrary, mental health sciences, discovering in recent times the question of morality, of course have treated it from a naturalistic, namely descriptive, perspective (Edwards, 2009). So, when the concept of moral reasoning is analysed, from both rationalistic or intuitionistic perspectives, reasons and intuitions lose their normative role and are reduced to motives. Indeed, if this difference were meant as an insuperable divide, it would imply negative consequences both for philosophers - which in my opinion are always in need of relation to empirical grounds - and for mental scientists, in need of conceptual clarification for drawing good experimental designs.

This difference is clearly visible in the case in question: to find empirical support or counter-evidence to Kant’s approach on the anomaly of moral rationality is a questionable goal, because experimental researches on moral psychology lie outside Kant’s philosophical perspective. Mostly studies are designed to test moral judgement with five psychological systems, that Jonathan Haidt and Jesse Graham (2007) described as the most general concepts on which all the culture, in a different way, ground their forms of life. Later the same authors and others (Glenn et al., 2009) took these five couples of values, harm/care, fairness/reciprocity, ingroup/ loyalty authority/respect, and purity/sanctity, as standards to which relate empirical findings about psychopaths’ moral judgement. The most meaningful result of their study was low ‘Perspective Taking’ and ‘Empathic Concern’ by psychopaths that were interpreted as primarily responsible for moral judgements violating both harm and fairness value. Mostly experimenters shared this assumed lack of concern for others, arriving indeed to unexpected results in studies concerned with utilitarianism and altruism. For example, in a study into economic decision-making (Wischniewski and Briine, 2011), patients with schizophrenia seemed to be less sensitive towards unfairness to their disadvantage but, contrary to experimenters’ prediction, they were punished more than healthy controls, depending on the degree of unfairness shown by the virtual proposer in the Dictator Game. An opposite interpretation of similar results was given by Gabor Csukly et al. (2011), according to whom the higher acceptance rate at unfair proposal and the lower acceptance rate at fair proposal suggested higher ratio of inconsistent decisions, a behaviour that was related to a failing ability to perform altruistic punishment. Again, similar findings are reported by Jonathan McGuire et al. (2014), who underline that fairness and harm are different moral domains and recommends caution as to generalize from economic decision-making to harm-related moral cognition.

Indeed, their results seem to show that people with schizophrenia take a meaningful utilitarian and consequentialist stance as regards moral dilemmas. Moreover, they assume that these subjects are more concerned with outcomes rather than intentions, when making moral judgements and blaming others’ harmful actions. One could object that this utilitarianism is at odd with the impaired abilities as rational maximizers that the authors also noticed, but a further rejoinder could be that we should not expect an overall coherence of moral reasoning from schizophrenics, but only specific-domain moral judgements.

Finally, other studies may significantly be compared with the previous ones in order to propose a different comment which will bring to Kant’ moral philosophy. In my opinion, some studies are very interesting for showing a close relation between moral cognition, firm moral convictions, religious fanaticism, and violent behaviour, to the extent that actions like killings, feuds, crimes of passion, punishments, and honour killings are all associated with specific moral foundation (Glenn et al., 2009; O’Reilly et al., 2019). Intimate partner violence has been also analysed (Vecina et al., 2015) in connection with an autoreferential moral conception, including the utmost certainty of the subject about his moral principles and about what is right, a high moral self-concept, and high level of self-deception whereby he believes to be acting morally while acting selfishly. Curiously, the authors assert that “intimate partner violence is not a disease” (Vecina et al., 2015: 121), presumably to avoid any excusing condition. However, this overvaluation of self, shown by the violent subjects, reminds Kant’s moral egoism and its lack of concern with a shared point of view. The authors, after mentioning several studies ascertaining the presence of antisocial, borderline, and narcissistic characteristics, report their results from two studies conducted on men convicted of domestic violence during their court-mandated psychological treatment, confirming their strong self-concern, and even a sense of moral superiority towards the psychologists who treated them, besides a high level of self-deception.

Another type of moral violence that can be framed into a form of Kantian deontology goes beyond punishment tied to moral egoism. It was analysed to distinguish moral violence, seen as morally justified, obligatory, and even praise, from instrumental violence, experienced as morally objectionable but desirable for instrumental reasons. The authors (Rai et al., 2017) present case studies showing that whereas the latter is supported by a process of dehumanization of the victims nullifying the need of moral desert, the former does need that the victims are perceived by perpetrators as morally deserved, as it happens in police violence act, kingpins’ protecting acts, terrorist bombing, and honour killings.

Going back from these serious cases of righteous violence to the previous studies inspired by the harm/care foundation, by utilitarian and altruist approaches, we can reflect upon the incongruences that we previously detected. The main perplexing problem which received contrasting comments by experimenters is the acceptance of unfairness by patients with schizophrenia, accompanied by a strong wish of punishment. Interpreting this attitude as indifference towards others, the experimenters find support to maintain a low sensitivity of these subject to harm/care foundation but this conclusion is odd with altruistic punishment, which shows, on the contrary, a strong concern for others. Indeed, the pioneering study ofjohnson (1960) on the moral judgement of schizofrenics, grounding on Baruk’s (1947) classification of moral models, reported as ‘deviant’the judgements that justified the punishment in as much as for these patients “social relations are judged in terms of efficiency and orderliness instead of sympathy and compassion. People are viewed and judged as mere object, hardly different from inanimate objects” (Johnson, 1960: 283). The lack of concern for harm/care values, which Johnson called “humanitarian” values, was already determinant in order to consider immoral the punishment. However, it would not be judged immoral from a rigorous Kantian perspective. To support this claim, I will refer to one of the case studies reported by Johnson: a frail and sick woman uses an electrical heater to warm herself violating the restrictions of the use of electricity imposed during a war. She is accused of stealing electricity and imprisoned. While from a humanitarian, hann/care, or empathic perspective, this act is unequivocally immoral; from the rigorous perspective ruled by the Kantian categorical imperative, it should not be. In fact, the rationale of this principle, also known as the Formula of Universal Law, is just that a maxim is permissible because its opposite is logically and practically contradictory, regardless of any other concern that would reduce its applicability. This golden rule seems to be applied in the previous case: if during wartime all people used electricity, the consequence would be a universal damage.

In my opinion, patients with schizophrenia may be considered as unaware Kantian agents, as it is also indirectly revealed from their failures as utilitarian agents in economic decision-making games. Studies designed to investigate this topic could be promising for new findings.


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