Tuesday 23 May 2017

Delusions and Responsibility for Action

Together with Ema Sullivan-Bissett, Matteo Mameli and Matthew Broome, I have written a chapter on delusions for a new volume on gradualism in psychiatry: Vagueness in Psychiatry, edited by Geert Keil, Laura Keuck and Rico Hauswald for Oxford University Press.

Matteo Mameli

In the paper we argue that it is difficult to distinguish pathological and non-pathological beliefs on the basis of their epistemic features. Then we consider some of the moral and legal implications of our thesis, focusing in particular on the role of beliefs in the attribution of moral responsibility and legal accountability for criminal actions that are motivated by those beliefs.

Ema Sullivan-Bissett
Delusions fail to meet many epistemic standards. It might look like they are not beliefs which are aimed at truth or governed by a norm of truth, that they are not responsive to evidence in the ways which ordinary beliefs typically are. But non-delusional beliefs also share such features. For instance, most people are vulnerable to positive illusions, considering themselves (and sometimes their romantic partners) to be above average, or better than most other people, when asked about positive traits and abilities. Moreover, people tend to exhibit unrealistic optimism about their future underestimating their likelihood of experiencing negative events, and overestimating their likelihood of experiencing positive events.

Matthew Broome

Here is another example: in self-deception beliefs include a motivational element which can involve the misreading or ignoring of evidence in coming to a belief. Consider the person who has the false and motivated belief that his wife is faithful. There may be evidence available to the person that his wife is unfaithful (he sees that she arrives home late, that she is uninterested in him, and so on). But he is highly motivated to believe that his wife is faithful.

The epistemic feature of delusions that is considered most distinctive—resistance to counterevidence—is actually a very common feature of beliefs. Once they adopt a hypothesis, people are very reluctant to abandon it, even when copious and robust evidence against it becomes available. Given that delusions share many epistemic features with non-delusional beliefs, are we justified in considering the presence of delusions as a sufficient reason to determine whether agents are morally responsible and legally accountable for their actions?

On 14th August 2011 Jeremiah Wright killed his seven year old son, Jori, who had cerebral palsy requiring full time care. He beheaded and dismembered the child in the home he shared with the child’s mother. Wright was charged with, and tried for, first-degree murder. Wright was suffering from a delusion at the time of the killing (as well as before and after the act). He believed that Jori was not his son, but a CPR (Cardiopulmonary Resuscitation) dummy, placed in his home as part of a government experiment. Wright was found not guilty on the grounds of insanity.

Now let us suppose that Wright’s beliefs were not delusional, and their content were true. Let us suppose then that Jori, the seven year old boy, was actually a CPR dummy. What ascription of responsibility would we make with respect to the ‘harm’ inflicted on Jori, and what kind of punishment would Wright deserve? If Wright had a CPR dummy in his home, then it would not be obviously morally wrong to ‘decapitate’ and ‘dismember’ that dummy given that it would not be a living being capable of feeling pain and suffering.

Wright’s psychotic symptoms help explain his behaviour. Wright wants to prevent the government from spying on him, and thus wants to destroy the dummy. If the content of his belief were true, it would not be morally problematic to destroy the dummy, and the action could be justified by Wright’s desire to stop the government’s intrusion in his life. Wright’s actions would be permitted given his belief that Jori was a CPR dummy. The presence of Wright’s belief is sufficient to regard the person who committed the crime unaccountable, since what Wright did would not be morally problematic if his belief were true. Wright’s actions were not inescapable as he could have done otherwise given his beliefs, but his delusions seem to offer both some explanation and justification for his actions.

Consider now another case. In July 2011, Anders Breivik killed seventy-seven people in Norway. In August 2012, he was sentenced to twenty-one years in prison. As part of his first psychiatric evaluation, he was diagnosed with paranoid schizophrenia and some of his most implausible beliefs were regarded as persistent, systematised, and bizarre delusions. For instance, one belief he reported was that he was the leader of a Knights Templar organisation which, according to the Norwegian police, does not actually exist.

However, this first assessment leading to the diagnosis of schizophrenia was overruled by a second assessment, according to which Breivik’s strange beliefs were not psychotic symptoms in the context of schizophrenia or of some other psychotic disorder, but could be explained by a personality disorder. Based on the fact that he never manifested hallucinations, the second pair of assessors described Breivik’s behaviour as caused by a narcissistic personality disorder accompanied by pathological lying.

If it had been shown that Breivik experienced psychotic symptoms at the time of his crime, then he would have not been regarded as accountable for his actions and he would have been sentenced to compulsory psychiatric treatment. This is because, in the Norwegian Criminal Procedure Code, when one has psychotic symptoms, one cannot be attributed criminal responsibility for action. As a result of the second assessment and his new diagnosis of personality disorder, Breivik was held accountable for his actions as he was thought not to have been psychotic at the time of his criminal act.

Some questions could be raised about the relation of Breivik’s beliefs to his actions. Breivik could have genuinely believed that multiculturalism was one of the greatest harms of Norwegian society without engaging in the actions that led him to kill seventy-seven people. Breivik’s thoughts could have been channelled into joining a political party in which such views were shared or campaigning against Muslims and multiculturalism. That is, his beliefs go some way towards explaining his action, but do not justify it and do not make it inescapable.

The cases we have looked at highlight that we cannot assume that the presence of delusions implies no or reduced responsibility for action. A more local and nuanced view of responsibility needs to be articulated. More precisely, further argument is needed to support the claim that the presence of delusions and other psychotic symptoms is an appropriate criterion for criminal insanity.

The continuity thesis we defend makes it problematic to rely so heavily on the presence of beliefs that are delusional when assessing responsibility. For claims about responsibility, the significance of the presence of delusional beliefs may derive from the following consideration. If poor reality testing is affecting the beliefs a person is prepared to endorse to the extent that such beliefs are implausible even to members of the person’s same culture or subculture, then maybe such failure of reality testing is also implicated in some of the person’s decision making processes, including those processes that led the person to acting criminally. But this link between the presence of psychotic symptoms and impaired decision-making is just a hypothesis that needs to be tested.

The assumption that people who have psychotic symptoms or have received a diagnosis of schizophrenia lack responsibility or have reduced responsibility for action because their decision-making capacities are impaired is problematic, as the behaviour of two people with psychosis or schizophrenia can differ almost entirely. Some people with schizophrenia are able to function well, cognitively and socially, and to control their delusions to some extent. The presence of psychiatric symptoms and of a diagnosis of schizophrenia should be taken into account in the courtroom, but it should not be regarded as sufficient to determine responsibility.

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