The work of two distinguished contributors to the philosophical literature on volitional disorders such as addictions, obsessions and compulsions, Clean Hands? is a clear and thought-provoking discussion of one of the most puzzling corners of psychopathology, the syndrome of Scrupulosity. Those with Scrupulosity are afflicted with a surfeit of virtuous attention to their own ethical and religious responses, in thought and deed. This interferes with their peace of mind, their relationships, and their ability to function. Yet, they are not exactly moral saints and exemplars of moral goodness – so why not, these authors ask?

The answer to this question is complex, and progresses through an illuminating and thorough philosophical discussion which, among other things: locates Scrupulosity in relation to the more familiar Obsessive-Compulsive Disorder it partially resembles; explores theoretical accounts of mental illness or disorder that might assign pathological status to it; and explains the distinctive role played by anxiety in motivating its sufferers. Chapters then move on to assess the degree of responsibility appropriately ascribed to thoughts and actions that are the symptoms of this condition, and end with a review and evaluation of the approaches employed in therapeutic interventions.

The authors begin with a collection of real, clinical cases of Scrupulosity, and allude back to them throughout to anchor, illustrate and support particular claims. The sustained back and forth between cases and interpretation is very helpful to the reader, although as is rightly acknowledged, this material may not be representative of all cases of Scrupulosity, since it is drawn from those who have sought and or received help for their excesses. (I note some potential limitations to this use of cases below.)

With respect to classification, it is persuasively argued that much Scrupulosity is an often ego-syntonic form of OCD, and as such, fits among the anxiety disorders. To account for why Scrupulosity is a distinct psychiatric syndrome, worthy of recognition as a mental illness, are three frequently occurring and mutually-reinforcing traits: perfectionism, chronic doubt, and “thought-action fusion”(explained below). Each of these traits is also found in normal populations, but case material is used to illustrate and support how they are excessively exhibited and cluster with a multiplier effect in Scrupulosity. 

In an exemplary fourth chapter, the authors deal with the question of whether Scrupulosity is rightly regarded as a form of mental illness, rehearsing the many challenges to that concept. It is, they demonstrate, at least if, as we are given reasons to do, we accept the DSM definition (2013) involving a dysfunction in the individual. While being a mental dysfunction, disorder or illness is not incompatible with possessing admirable character traits, we are then promised, it will be shown that scrupulosity is not a moral virtue. 

The fifth and sixth chapters make good this promise, considering whether the person with Scrupulosity might still possess a virtuous character and make genuine moral judgements of the kind we regard as praiseworthy. Even setting aside the evident tension introduced by ego-dystonic elements (typical of OCD), the more harmonious ego-syntonic coherence found in much Scrupulosity is shown to differ from those of more morally exemplary characters. Their fixated inflexibility; their attention to possible rather than likely harms; the target of their perceived personal responsibility (not preventing harm to others but protecting themselves); and finally, the nature of the reasons motivating them, all build towards these distinguishable sorts of motivation and character. Thus, discussion in the sixth chapter points to the scope and focus making up a genuine moral judgement, exposing the narrowness of the seeming moral judgements associated with Scrupulosity, and the part played, in forming them, by the impetus to soothe and/or rationalize feelings of anxiety. Unlike moral saints, those who suffer it are concerned with moral behavior neither for its own sake, nor for the sake of others, but primarily as a means of allaying their own doubts and anxieties, it is concluded. 

Much of the careful analysis from the first six chapters provides groundwork for the question asked in the seventh: are those with Scrupulosity responsible for harms brought about by their condition? This focus is a particularly welcome one, highlighting an area that has often been neglected in philosophical accounts of mental disorder, and is in need of just the kind of patient, knowledgeable, grounded philosophical attention it receives here. Responsibility comes in degrees, we are reminded; moreover, it includes different kinds, such as moral capacity and moral liability responsibility. Once some basic language and distinctions have been established, two candidate theories about responsibility (Deep-self and Reasons-responsiveness approaches) are in turn applied to the case material and its analysis. The same kinds of analysis in light of differing theories of responsibility have been used to test the common intuitions that those suffering OCD and addictions are not fully responsible for their deeds, allowing this chapter to introduce much rich and important philosophical material from recent discussions, including refinements such as Watson’s wantons, and Kennett’s resigned addicts. For example, Deep-self analyses have long determined that the addict was somehow not entirely or authentically himself in seeking his drink. Applying deep-self accounts to deeds stemming from ego-syntonic Scrupulosity, these authors point to obvious disanalogies with addiction: they will not serve to explain the reduced responsibility of Scrupulosity sufferers. By contrast, reasons-responsiveness theories are a better fit, it is shown, explaining and supporting the intuition that these are less than fully responsible agents. 

Being a mental disorder generally implies being apt for therapeutic intervention, and a final chapter on methods of treatment for Scrupulosity provides a review of approaches employed, with their respective degrees of ethical warrant. The rarity of this disorder leaves the authors without data on the effectiveness of these treatments. But regardless, the philosophically interesting question remains: whether any intervention, by anyone, might be objectionable in trying to make Scrupulosity sufferers less moral. The conclusion reached is that some treatments are justified, and those around the sufferer are justified in calling for such interventions, because “as the result of the underlying anxiety that they try to soothe, persons with Scrupulosity are disproportionately and inflexibly concerned with certain areas of morality and religion at the expense of others that they themselves often recognize as important, so their views become internally incoherent” (pp 191-2, emphasis added).

These authors have written a wonderful book, and the three quibbles I note here may be easily-enough overcome. They involve the use of case material, including comments about Jain practices; “thought-action fusion”; and the anxiety that plays such a prominent role in this account.

First, the use of real case material, including Jain practices. This is commendable, and is a strength of the book, as the authors point out in their Epilogue. Each vignette is little more than a paragraph, however, and thus arguably too fragmentary to entirely support the appeal made to them in subsequent analysis, persuasive as it mostly is. The seemingly excessive adherence to their religious beliefs found among Jains raises a related concern over these cases. While somewhat resembling Scrupulosity, Jain practices seem to be dismissed by the authors as short of pathological, and used to support the (undeniably true) view, that because the boundary between normal and abnormal scrupulosity is not always easy to demarcate, focus should be on paradigm examples.(“Clear instances of mental illness aren’t disproven by less clear “twilight”cases”(page 64).) Yet we are left with too little information about Jain practices to be sure where they actually lie on that boundary, and thus how much they challenge the analysis of Scrupulosity offered, which explicitly rejects relativistic accounts of mental disorder (pages 60-68). Although the rest of the cases and the interpretations to which they are subject in subsequent pages are easier for us to think we understand and agree with, the concern is that the same demand for more details might well apply to some of them as well. (I would also question the authors’ claim (page 67) that on pain of absurdity we cannot say the Jains’ behavior changes its status from mentally ill in our society to sane in theirs. Less individualistic accounts of mental illness would find it absurd not to grant just that.)

Next, “thought-action fusion.” This trait bears some resemblance to what would more commonly be understood as a form of magical thinking. It is defined as “difficulty understanding the limitations of one’s thoughts and therefore the boundaries between one’s thoughts and actions” (page 52), whether as the idea that merely by occurring, thoughts can bring some bad outcome, or as treating (bad) thoughts as “close to” the moral equivalent of wrongful actions. The authors acknowledge that thought-action fusion is a broad and not yet well-understood matter, and although it can be illustrated by their case material, it perhaps remains too loose a category to provide much support for their general claims for the distinctiveness of their syndrome. (Among the challenges it raises, the second kind of thought-action fusion cited above evokes the “impure thoughts” judged by some theologies a commonplace and sinful aspect of human experience, calling for confession.) 

And finally to anxiety, the centrality of which, emphasized in the earlier-quoted passage, is evident in key arguments throughout the book (for example, that making the case for Scrupulosity being a mental illness). But the failure to provide us with a more complete examination of it reflects what is to my mind a limitation of these otherwise exemplary discussions. As phenomenological and analytic traditions have made evident, anxiety is a complex emotion, as elusive, and unruly, as it is central to our conscious experience. Its motivating role in the hypothesized reasoning and responses of those with Scrupulosity is nicely identified in many persuasively developed examples. But this reader was left with questions about what “anxiety” was taken to be like as an experience, and how efforts to soothe and dispel it might be understood from the ‘interior’ perspective of the subject. 

The virtues of this book are many, despite these small cavils. Not least, it is meticulously argued yet accessibly written, with none of the ponderous quality of much philosophical writing. (In this respect it would make a valuable teaching tool.) Clean hands does a fine job of defining and explaining the particular disorder of Scrupulosity with all its distinctive ethical puzzles. At the same time it offers a model for how other volitional and behavioral disorders might be approached. Addictions, obsessions and compulsions all exhibit intriguing parallels with the complex forms of irrationality, incoherence and likely anxiety-wrought dysfunction explored here. And the careful teasing apart of Scrupulosity from OCD is as valuable for what it shows about OCD as what it reveals about Scrupulosity. In addition, these insights about motivation, anxiety, irrationality, responsibility and perfectionism can also throw light on our understanding of self-harm syndromes, such as cutting, and perfectionistic eating disorders like restrictive anorexia, and orthorexia. 

In taking very seriously this strange disorder of Scrupulosity, these authors have illustrated the considerable benefit of philosophy for psychiatry, and shown a reasonable and persuasive way forward through the normative thickets surrounding much psychopathology.

Jennifer Radden, professor emerita of University of Massachusetts, Boston, is a leading scholar in philosophy of psychiatry. 

Categories: Philosophical

Keywords: scrupulousness, philosophy, psychology