Aristotle argues in the Nicomachean
Ethics (1985) that we are jointly responsible for our characters and for
the things at which we aim. The idea is that, although our capacities are given
by nature–and even our temperamental abilities to be "naturally"
placid or sociable and so on–we still must make ourselves and each other into
the adults we become. We have help from a variety of social institutions in
this; schools, religious affiliations, families, neighborhoods, and social
services provide moral education (for better or for worse), but we are neither
biologically nor socially determined. So Aristotle argues, the virtues and the
vices are voluntary, and we cannot simply cry, "I can’t help who I am!"
Our characters are, in a complex way, up to us.

As a virtue ethicist, I am
sympathetic with this view: our decisions do seem to add up to dispositions
to act and feel in certain ways. Living the good life involves goods such as
health, friendship, virtues, and material security, and we must actively pursue
these things and face blame when we knowingly and freely make wrong choices.
But as nuanced as Aristotle’s work in moral psychology was for his time, he
could not, in his account of character, moral responsibility, and the good life,
make a place for those actions that are internally compelled yet
apparently voluntary–or any other number of nasty questions about freedom and
responsibility that continue to haunt our daily lives.

Mike Martin’s new monograph on the
relationship between mental health, morality, and therapy, can be read as a
sustained discussion on how these themes can come together in our twenty-first
century Western world. His thesis is that the "mad versus bad"
dichotomy that so ensnares psychiatry, psychology, and the law should be
rejected in favor of what he calls "the moral-therapeutic perspective."
As Martin understands it, the therapeutic project is really an integrative one–integrating
morality and character with healing. The language of "healing"
implies sickness, he argues, but to do so does not require that we eschew
holding people accountable for their actions and choices. Through numerous
examples and in a variety of domains, Martin points out that the
morality-therapy dichotomy prevents us from understanding how one can be both
sick and irresponsible–but still held accountable for one’s actions.

Martin’s book addresses three
themes: the moral-ladenness of health, responsibility for health, and healthy
morality.  He emphasizes that concepts of health and sickness are not only
value-laden, but are infused with moral values in particular. Martin states in
criticism of current diagnoses that "the DSM defines many mental disorders
by reference to moral values and harm caused" (56). This first theme is
not particularly new, as people in the field of philosophy of psychiatry have
been working in this area for at least two decades. (The culmination of these
studies is found in John Sadler’s Values in Psychiatric Diagnosis
(2005). Sadler’s work is a wonderful and dense examination of such values that
includes an ingenious "moral wrongfulness test" whereby we can
determine whether the values of moral badness in diagnosis can be translated
into non-moral terms while preserving the meaning of the diagnosis.)   

For the most part, though, Martin plumps
for the place of moral values in therapy, so his criticisms of the DSM are
slight. In the chapter on how moral and mental health intersect, Martin draws
upon six criteria of positive mental health from Marie Jahoda and suggests that
each has a correlative component in morality. For example, Jahoda claims that
self-esteem is a criterion of mental health, and Martin adds that self-respect
is the moral counterpart. I found most of his parallels to be a reach, though.
The problem with this sort of chapter is that the philosophical literature is
vast and Martin runs through very nuanced and complicated theories, arguments,
and views in such short order that the richer meaning of either self-esteem or
self-respect is lost.

Part II focuses on the relationship
between mental illness and moral responsibility. Martin argues for a Kantian view
of responsibility, where we have duties to ourselves that include not doing
those things that might be self-harming, like drinking too much or developing a
gambling habit. These are binding obligations we have, Martin says, and when we
violate these obligations, we are to blame. Another way in which he
incorporates moral values into his argument is in defending the place of guilt,
love, and forgiveness in our lives. These positive values contribute both to
healing while in therapy and to living a healthy life in general. I agree that
it is important to consider the role that moral values play in psychotherapy, but
I think Martin would do well to include concerns about matters such as the
forgiveness push in therapy (cf. Lamb and Murphy 2002).

Because the idea that people can be
both mentally ill and accountable is such a challenging one, I will focus most
of this review on this argument. Martin is right to note that individual
responsibility for bad habits must be considered in conjunction with the
broader responsibility of citizens to maintain a decent society (11). He takes
pains to insist he is not blaming people for their illnesses. Yet he repeatedly
claims that people can be blamed for making choices that put them in the way of
developing mental illnesses. Martin agrees with Peter Strawson that arguments
about freedom and determinism are more interesting to philosophical theorizing
than to ordinary life practices. Martin writes:

What matters is whether individuals have normal capacities
to participate in moral practices, such as moral reasoning, guilt and shame
when we fail to meet moral standards, gratitude for acts of kindness, mutual
love among adults, resentment toward people who wrong us, indignation toward
people who unjustly harm others, and forgiveness when others repent and make
amends. (59-60)

Yet he disagrees with Strawson’s broader
point: Strawson "assumes that psychopathology undermines normal
capacities," an idea Martin apparently does not hold. Martin asserts that
addicts and others with volitional disorders "are not exempt from
accountability."  He blames people for "acquiring" compulsions,
although the reason is not clear why; it doesn’t seem true for people with
obsessive-compulsive disorder, who truly cannot stop repetitive and
self-defeating actions such as washing their hands every hour. Furthermore, I
have trouble seeing how his claims about responsibility apply to people with
serious mental disorders such as schizophrenia or Alzheimer’s. Martin states
that "[a]lthough mental disorders can seriously impede moral agency, most
do not make it impossible" (67). As someone who is part of a health care
team at Emergency Psychiatric Services, I see patients who tear at our hearts
for their incapacity, confusion, and distress when suffering psychoses or
paranoid delusions. Martin goes so far as to say that platitudes such as "[w]e
reap what we sow; old sins cast long shadows; what goes around comes around"
(81) can be encouraging to people.  When I think of the patients at EPS, I can only think
that such comments come from another world.

Martin is not considering that
population, though. Instead, he is interested in addictions, stealing,
violence, depression, and other problems in living. Take kleptomania, for
example. In his view, people who have irresistible impulses to do immoral
things are to blame for having created a moral handicap in the first place
(18). Presumably, this is why he states that "it is also fair to hold
individuals responsible for alcohol abuse, drug dependency, compulsive
gambling, kleptomania, and myriad other mental disorders listed in the DSM"
(55). Indeed, Martin faults the DSM for being too soft on what constitutes a
volitional disorder. But a crucial point in any move to undermine the
morality-therapy dichotomy requires a clear analysis of how impulse-control
disorders or volitional orders develop, and Martin doesn’t do this, beyond
saying that people who develop impulse-control disorders should not have done
so. Frankly, I just don’t understand the overall argument unless I take an
Aristotelian view where addictions are not understood as addictions but as
vices.

Part III, entitled "Wrongdoing
as Sickness" is a section that addresses specific mental disorders.
Included in this section are alcoholism, pathological gambling, crimes such as
kleptomania and use of illegal drugs, violence as evil, and bigotry as mental
disorder. In the chapter on alcoholism, Martin argues that it is a "disorder
of agency" and a sickness. It is unclear what he means by the former; I
don’t see the distinction between calling alcoholism a "disease" (the
AA view) or a "sickness;" and still he maintains that we are
responsible for the habits we form. In fact, Martin rejects the prevailing view
that the one part of alcoholism one is responsible for is getting treatment
(96.) Since Martin believes that we are to blame for becoming addicted, he
would seem to suggest that we should never try something that "might"
in the future, become an addiction. If Martin genuinely takes virtue theory
seriously, though, he would seem to be advocating that people embrace one vice
in order to avoid another: temperance, which has to do with our experiences of
sensual pleasures and pains, calls for us to find the mean between avoiding
pleasures altogether and wallowing in pleasures at any expense. Aristotle
chastens the person who has the vice of being deficient in pleasures. If it is
right to think that we should not avoid pleasure altogether, it also places us
at risks we may not appreciate for our future relationship to similar
pleasures. I wish Martin had said more about how the virtue of temperance is
supposed to work both in contributing to the good life and to assisting us in
avoiding addictions. On the face of it, it seems messy and difficult to sort
out.

Part III gets repetitive,
especially in light of the absence of genuine argument in each short chapter.
For example, in the conclusion of the chapter on gambling he says, "Finally,
does impaired agency remove responsibility for the harm done by gambling?…It
does not." (106). I take it he thinks the morality-therapy dichotomy has
been sufficiently undermined so he no longer has to argue for it. But I am not
convinced. The chapter on violence and evil focuses on sociopaths but sheds
little light on the mad/bad debate. Martin offers no evidence for the claim
that sociopaths have the capacity to not kill or that cultural reactions of
disapproval play a therapeutic role for sociopaths. But what I most missed was
the omission of Claudia Card’s (2002) rich and complex analysis of evil and
accountability where she painstakingly analyzes evil doers, victims, and people
who fall into both categories simultaneously. Incorporating Card’s
sophisticated philosophical arguments would have prevented this chapter from
its sense of thinness.

Finally, I am unclear who Martin’s
audience is. For a philosophy of psychiatry, many of his points are too breezy.
For example, in discussing models of mental disorder, he goes through five
approaches in just a few pages–surely not enough to make sense of his claims
that someone can be both mad and bad. If readers don’t understand the
complexities of conceptualizing mental disorder, they are not in a position to
evaluate the strength of Martin’s position. For example, he devotes just two
paragraphs to what is arguably the most significant (if controversial)
contribution to discussions of the concept of mental disorder–Jerome Wakefield’s
harmful dysfunction account (1992). Martin’s brief explanation allows him to
dismiss that account as "relativistic" because the "harm"
component of the definition is culturally inflected. But Wakefield’s account,
with its attention to the dysfunction of an internal mechanism from what it was
designed to do, may in fact make it less plausible for Martin to claim that
someone with a mental disorder is still responsible for those actions caused by
one’s disorder. A more sophisticated discussion on matters such as this would
have challenged Martin’s argument more and his ability nevertheless to respond
would then have been more persuasive.

 

Aristotle. 1985. Nicomachean
Ethics. Trans. T. Irwin. Indianapolis: Hackett.

Card, Claudia. 2002. The
Atrocity Paradigm: A Theory of Evil. Oxford: Oxford University Press.

Lamb, Sharon, and Murphy,
Jeffrie, eds. 2002. Before Forgiving: Cautionary Views of Forgiveness in
Psychotherapy. Oxford: Oxford University Press.

Sadler, John. 2005. Values
and Psychiatric Diagnosis. Oxford: Oxford University Press.

Wakefield, Jerome. 1992. "The
concept of mental disorder: On the boundary between biological facts and social
values." In American psychologist 47(3): 373-388.

 

 

©
2006 Nancy Nyquist Potter

 

 

Nancy Nyquist Potter,
Ph.D., Department of Philosophy, University of Louisville, is working on a book on a philosophical analysis of Borderline
Personality Disorder.  She is editor of Trauma, Truth and Reconciliation
(Oxford University Press, 2006), and is author of How Can I Be Trusted? A
Virtue Theory of Trustworthiness (Rowman & Littlefield, 2002).

Categories: Philosophical, Ethics, Psychotherapy