Abstract
The question of moral responsibility, or the degree to which people can be held responsible for their actions, is of great relevance to psychiatry. We make a division in our practice, in law and in our own minds between those who can reasonably be held responsible and those who cannot; however, we do not usually address the question of whether any of us truly have the ability to choose how to behave.
If none of us can make such a choice then expecting our patients to do so would be as illogical as it would be futile. Are we all simply carrying out the actions that our genes and environment have formed us to perform, and if so, how can we be held responsible for them? The first aim of this paper is to examine the important question of whether humans can reasonably be considered morally responsible.
Determinism and responsibility
Determinism, or causal determinism, is a theory that states that every event can be entirely explained by a combination of the state of the universe immediately before it, and a complete description of the physical laws of the universe (usually called the natural laws). This chain of causality stretches unbroken from the beginning of the universe, and into the future until its end (if any). A theory that regards any human action as determined entirely by events that took place long before that person's birth, would appear to conflict with the concepts of free will and choice. If the predetermined chain of events that stretches from the beginning to the end of time includes Sue marrying George, does that not mean that she is not free to marry Fred? Many philosophers have found the un-free will a bitter pill to swallow, and have framed moral theories that have the avowed purpose of finding a way for free will to exist.
Psychological determinism is the theory of determinism applied to human experience. The theory states that all of one's choices are determined by one's beliefs and desires, which are in turn determined by one's inborn temperament and the experiences that one encounters in life.
It is important to distinguish other uses of the term responsibility, such as simple causality, or legal responsibility, from that which forms the subject of this paper – the philosophical concept of moral responsibility. ‘Moral’ in this sense does not imply adherence to a particular set of beliefs about right and wrong. This paper will interpret moral responsibility to mean being answerable or accountable for one's actions, in an ethical rather than a legal sense. It is usually considered that one must possess free will and the ability to choose one's actions to have moral responsibility. Free will may be considered as the personal attribute that permits the application of the interpersonal notion of moral responsibility.
Compatibilism is the belief that free will and determinism can coexist. Incompatibilism is the view that the two are mutually exclusive. Most philosophers have attempted to find ways to support the compatibilist view, as the logic of determinism is difficult to refute outside a supernatural or religious framework, and as free will is an intuitively appealing concept.
It is important to note that in some cultures the question of the free will of the individual person is simply not considered relevant. There is a literature that argues that the concept of a human being as an isolated entity capable of exercising free will is a product of Western culture and is considered invalid in some other cultural contexts [1].
The Ancient Greek philosophers dealt extensively with the issue of free will. Perhaps the most famous early work is that of Aristotle, who put forward a description of the voluntary in his Nicomachean ethics [2]; ‘… what is voluntary seems to be what has its origin in the agent himself when he knows the particulars that the action consists in.’(3–18).
Given that determinism states that nothing ‘has its origin in the agent’, this idea sheds little light upon the conflict between determinism and free will.
Compatibilist theories
The problem with the compatibilist position has tended to be the question ‘If determinism means that I cannot do other than what I actually do, how can I be said to have free will?’ Many philosophers have proposed ways of dealing with this ‘freedom to do otherwise’ question.
Among prominent compatibilists, including the early
Stoics [3], Hume [4], Hobbes [5], Frankfurt [6] and
Dennett [7], the most popular stratagem in the effort to reconcile free will and determinism has been to redefine free will so as to make it fit into a deterministic frame without friction: Free action is defined as doing what we choose to do without being prevented by outside interference. The problem with this approach is that it is still unclear to what extent we do actually choose, when our choice itself is predetermined.
Control and the deterministic universe
Historically, ideas of how we fit into the deterministic universe have been influenced by anthropocentric assumptions. Rachels, in his ‘image of God’ theory, outlines how religious theories have enabled man to consider himself as made in the image of God and therefore special and above all other creatures in a mystical sense [8]. The classic form of free will, requiring
‘freedom to do otherwise’, is based on this idea of ourselves as souls not subject to the physical laws of cause and effect.
The deterministic universe is not, of course, a huge mechanistic system into which we are fed at birth to have our destinies controlled and our many opportunities narrowed to one. The whole block of space–time includes us and all of our desires and purposes. Through our thoughts, desires and actions, we exert effects upon other parts of the universe and vice versa.
In other words, if free will involves having freedom to do otherwise then we do not have free will in the classic sense, as we do not have freedom to choose otherwise than that which is determined by our own desires and beliefs. This would involve the nonsense of choosing against one's choice.
If we can reconcile ourselves to the idea that all of our choices and actions are fully determined, then to regard someone as non-responsible for an action purely because that particular choice was determined by factors such as their upbringing and temperament, would seem irrational. By that logic, no punishment or reward would ever be justified, and none of us would ever be considered to be morally responsible for our actions.
If upbringing and temperament alone are insufficient to excuse someone from moral responsibility, are there people who should be considered non-responsible and, if so, how may we distinguish them?
Many current criteria for responsible action include reference to moral judgement. For example, the
M'Naghten rules stipulate that to be considered sane and therefore responsible, one must have the ability to know the nature of one's act and whether the act was right or wrong. Some psychotic people would pass this test, for example the psychotically depressed person who feels herself to be evil and deliberately commits a crime in order to attract punishment. On the other hand, someone brought up among adults who stole frequently might conclude that stealing is right, and proceed to do so. As society disagrees with this assessment of right and wrong, this person could theoretically be considered non-responsible under the M'Naghten rules.
As moral values vary so much between individuals, between cultures and over time, it would be helpful to use criteria for moral responsibility that examine a person's
process of making choices rather than the nature of that person's moral goals.
The decision-making faculty
In proposing criteria for responsible action, I will address the process of action only as far as the decision about which action to take. I will therefore ignore cases in which one is physically constrained from acting upon one's choice. Note that physical constraint does not include being under psychological duress, for the person under duress still makes a choice [2]. For example, a bank teller who gives the bank's money away to a thief under threat of being shot is still responsible for giving away the money. However, what the teller is responsible for is not ‘choosing to give the bank's money to a thief’, but ‘choosing to give the bank's money to a thief to avoid being shot’, which is an entirely different choice.
Understanding exactly what choice an individual is making is vital to understanding whether they have chosen responsibly.
General conditions for the correct functioning of the decision-making faculty and therefore for responsible action are the ability to:
1 Know the facts about the case needed to make the correct action. This implies that one must have the ability to perceive the relevant facts with the necessary degree of accuracy and not substitute psychotic perceptions for these facts. One also needs the intellectual capacity to learn the facts, and the physical opportunity to seek them out.
2 Make rational causal links between different mental representations concerning the action. For example linking the idea of ‘sunburn’ (rather than that of ‘Satan’) to the memory of a neighbour's reddened skin would prevent one from drawing and acting upon the conclusion that one's neighbour is the devil.
I will not describe borderline personality disorder (BPD) itself at any length, except to say that I have here used the DSM-IV diagnostic criteria to define it (see Table 1) [9].
DSM-IV criteria for borderline personality disorder
The aetiology of BPD is thought to be multifactorial. There is evidence for inherited temperamental factors, especially higher impulsivity and neuroticism [10, 11]. Some studies have found an increased frequency of soft neurological signs and learning deficits in BPD, suggesting an organic component [12–14]. There is a very high rate of childhood abuse, both physical and sexual, as well as other trauma and high levels of neglectful and inconsistent parenting [15, 16]. These adverse experiences are thought to prevent the creation of soothing introjects and to damage the formation of the self. These factors are illustrated in the well-known theories of Kernberg [17], Masterson and Rinsley [18], and Adler [19].
I will examine several prominent features of BPD drawn from both the DSM-IV criteria and the psychodynamic literature, to attempt to determine whether they vitiate responsibility in the person with BPD.
Impulsivity
Impulsivity implies acting with inadequate forethought. The impulsive person does not consider the pros and cons of an action, and may not make rational (or any) causal links between the different mental representations involved (for example ‘shoplifting’ and ‘prison’). Impulsivity may also stop someone from taking the time to enquire into the facts most relevant for making an adaptive decision. Thus, impulsivity could potentially vitiate responsibility, as the person neither has the facts relevant to the decision, nor appears to think rationally about the relevant facts.
Can the person help behaving in this impulsive manner? If what is needed is the unreal type of freedom of ‘freedom to do otherwise’ in the context of psychological determinism, the answer is no. People only do what their formative influences lead them to do, and will change only if other influences appear and teach them to behave differently. This is another example of the futility of applying the principle of abstract ‘freedom to do otherwise’ responsibility to practical questions about social responsibility. Looked at in this way, no one can help doing anything.
From the point of view of whether the decisionmaking faculty is impaired in impulsivity, the situation is less clear. When a person is about to act impulsively there does appear to be some degree of responsiveness to consequences. For example, consider the case of Jessica, a young woman with BPD. She impulsively punched her boss, and was fired. But the impulse to punch her boss was not an insuperable one. Had the immediate consequences of punching him been much more severe, she would most likely merely have shouted at him. The consequences of the action do play some role in the decision of the impulsive person. Also, impulsive people with BPD do slowly learn over the years to be less impulsive, as the unpleasant consequences of impulsive action become apparent.
Moreover, the impulsive action is not a random one. The person aims to fulfil a particular goal, such as communicating anger, avoiding abandonment, or escaping boredom. Thus, there has been some assessment of the desired goal and the movements needed to bring that goal about, however ill-advised the action may prove in the longer term.
There is a tendency to think about impulsive action as occurring so rapidly that no reflection can occur. However, there is time to reconsider before most impulsive acts, such as self-mutilation or a physical attack, can be carried out [20]. The cognitive processes that veto an action take only about 200 ms [21].
Based on the above, I would suggest that impulsivity does not vitiate responsibility.
Acting out
People with BPD may express unconscious material directly as actions, without awareness of their possible underlying motives. This is called acting out. The fundamental question here is, ‘are we responsible for our unconscious processes, as we are for our conscious ones?’
Most of us are aware of at least some of the facts and emotions that contribute to our decisions, however, this occurs in all people to an extremely variable degree. For instance Jane, a woman with no mental disorder at all, may study the Law because of a non-conscious antagonism towards her father, a petty criminal who disappointed her as a child. She is not consciously aware of this motivation, but does that make her any less responsible for the decision to study law?
Even if we were to view the unconscious as some kind of ‘other’, for the contents of which we are not responsible, the person is free to examine the proposed action on its own merits. There is time before the completion of an unconsciously inspired action to veto it consciously, if the person wishes to do so.
Dissociation and psychosis
People with BPD have a tendency to experience dissociated states when distressed, particularly under the threat of abandonment or fragmentation. At times they also report ‘psychotic’ symptoms such as paranoid ideation that may be of delusional intensity.
Dissociation in borderline personality disorder comprises several different clinical phenomena, including memory disturbance, derealization, depersonalization, discontinuity of personal experience and (according to some sources) hallucinatory phenomena [22]. I will not be addressing the very complex issue of dissociative identity disorder.
The Janetian view of dissociation is that conflicting segments of the psyche are separated from each other and operate in entirely separate spheres, sometimes alternating in consciousness [23]. The cutting off of contact with key parts of the conscious mind leads to an altered experience of the self or of the world. Put another way, dissociation is a ‘structured separation of mental processes (e.g. thought, emotions, connotation, memory and identity) that are ordinarily integrated’ [24]. In this view of dissociation, the relevant functions are not lost, merely disconnected from one another.
It is questionable whether this separation of one's intrapsychic faculties from one another would imply a lessening of responsibility. Sartre, in part of his famous challenge to Freudian and Janetian divisions of the self, postulates a unifying element that crosses the boundaries between all the dissociated elements. He gives as evidence for this view the presence of the ‘censor’ which must be aware of the contents of the dissociated part, in order to know that the part needs to be quarantined [25]. In this theory, the existence of a unifying part means that the mind as a whole has some form of access to all of its components, and is therefore responsible for its actions.
Meares presents a different view of dissociation, based on the ‘dissolution’ theory of Hughlings Jackson. This theory states that the most complex and evolutionarily recent brain functions (reflection, semantic memory, and the experience of the continuous self) will be the first to be lost when the mind is damaged. In conditions of cognitive or emotional overload, dissociation can be viewed as the temporary cessation of those vulnerable mental activities in response to a global disruption of a fragile mind's information systems [26].
Thus, dissociation may be the cessation of function of one or more mental components. These vulnerable systems could include memory and the ability to reflect. If one's ability to know (recall) or to draw rational connections between concepts were not functioning, this would impair one's responsibility.
It is difficult to decide to what degree responsibility is vitiated by dissociation, largely because it is difficult to know exactly what processes are occurring in its more severe forms. In the less disintegrated types of dissociation (e.g. depersonalization) both the ability to know information and the ability to make rational mental linkages would seem to be intact. As one enters the philosophical tiger country of severe dissociative states, such as fugue states, if there should prove to be true loss of cognitive functions and information then it would appear that responsibility is indeed diminished.
There is controversy about the nature of psychosis in BPD (whether it is the same kind of phenomenon as the psychosis of schizophrenia, or whether it represents dissociative pathology or regression to primitive thinking). Antipsychotics do help the symptoms, suggesting that the phenomena may be ‘biochemical’, but antipsychotics also produce a sedative or calming effect, which might diminish anxiety and therefore help the distressed mind reintegrate in cases of dissociation.
If we see psychosis in BPD as either severe dissociation or regression, we can conceive of a loss of rational modes of thinking necessary for drawing logical connections between mental representations. In most cases where a person with BPD develops psychotic patterns of thinking, there is still substantial reality testing. The density of the delusion is not as great as that found in, for example, schizophrenia. It is most likely that only in the most severe cases is reality testing sufficiently impaired to vitiate responsibility. For this reason, it would be necessary to take care to ascertain whether the behaviour in question is the result of thinking that is truly impenetrable to reason, especially if there are grounds to suspect that the person may be deliberately trying to disclaim responsibility.
The irresistible impulse
Could those with BPD be experiencing motivating forces that are simply impossible to withstand? The suffering of the person with borderline personality disorder is generally acknowledged to be quite intense. From a psychodynamic perspective, the unmodified intensity of these feelings is a result of inadequate nurturing parental introjects. The BPD sufferer is incapable of offering himor herself comfort in the face of distress. The person with BPD may also be unable to integrate the good and bad aspects of people or events, leading to the experience of intense and unstable affects, such as rage and despair, that have a subjective ‘out of control’ flavour.
In other words, people with BPD are frequently in the grip of what most others in this society encounter only rarely – intense and unalloyed suffering. Their desire for things and people that can protect them from this suffering will be exceptionally strong. To obtain these comforts, they may act inadvisably. Are they responsible for actions taken under the influence of these passionate desires?
Several thinkers have proposed that people acting under the influence of an irresistible impulse (that is, an irresistible desire) may not be responsible for their actions [27–29]. The irresistible desire was incorporated into many legal codes that were thought too strict when they required a person to be impaired in knowledge or understanding to qualify as less responsible under the law. The difficulty lies in knowing whether the desire in question was irresistible or merely unresisted.
Part of the problem is that it is difficult to grasp exactly what desires are. We tend to describe desires in terms of physical forces, things that ‘move’ or ‘drive’ us.
These concepts tie in conveniently with our preexisting ideas of compulsion by physical force as an exculpating factor. When we speak of an irresistible desire, we tend to separate the desire from ourselves, as though we are under the power of something separate from and controlling us [30]. But our desires are really part of ourselves, even if we do not always approve of them. Is it fair, then, to decline responsibility for them?
One approach to the irresistible desire question is to devise a ‘test of irresistibility’ that can be applied to various desires to test their strength. One example is the ‘loaded gun test’. Consider Jim, who, enraged, beats his wife. Could Jim have resisted the urge to assault his wife if someone had pointed a gun to his head at the time, assuring him that he would be shot if he struck her? The answer is probably yes. The desire was not an overpowering force; it was merely one section of Jim's motivational state. There is a capacity to respond to strong reasons for acting otherwise. It would be accurate to say that Jim's desire to beat his wife outweighed some counter-desires (the desire not to hurt his wife, or to avoid possible prosecution), but not others (the desire not to be shot in the head). I would hypothesize that Jim did not have an irresistible desire, merely one that was stronger than any other motivation actually present at the time of his act. As every action we make is merely the result of our strongest motivation at the time, it would seem foolish to regard strong desires as exculpatory factors based on this reasoning.
People with BPD, then, experience powerful emotions and therefore powerful desires. Their actions in response to these desires are the result of rational decisions, for which they are responsible. However, like the bank teller confronted by a gun-wielding thief, their choices are often not the choices faced by the rest of us. Consider Jessica, the young woman who punched her boss. She has another job interview, the prospect of which terrifies her, as she is extraordinarily sensitive to rejection. Jessica is considering avoiding the whole painful process by staying in bed. Her choice is not ‘Shall I go to a moderately frightening interview or stay in bed?’ but ‘Shall I face overwhelming anxiety in the interview and a sense of annihilation if I am rejected (as I'm sure I will be), or stay in a safe place and maintain integration?’ This is not a choice with which the rest of us routinely contend.
People with BPD have a choice between tolerating intense emotional turmoil and acting in a way that they know to be inadvisable in the long term. ‘But is such a compulsion irresistible? In any 100% sense, no. If the patient will pay the price in terms of his anxiety, he can resist…’ [31], p.6].
The person still has responsibility for the decision between acting inadvisably and tolerating the emotional turmoil. However, those who have insight into the inner world of the person with borderline personality disorder will be aware of nature of the decision actually faced by such people when they decide to act inadvisably. They are caught between the Scylla of the unmodified emotional state and the Charybdis of the unfortunate consequences of ill-advised behaviour. It would seem reasonable to make some allowances for the decision that they actually make, rather than the decision that would face the rest of us in the same (external) circumstances.
Akrasia
Perhaps another concept, weakness of will, may account for some kind of decision-making dysfunction in BPD. Weakness of will is known in the philosophical literature as incontinence or akrasia, and is often invoked to explain why maladaptive choices are made [32]. It is thought by many to form grounds for vitiation of responsibility [28, 33]. Aristotle made extensive use of the concept of akrasia to explain why some people fail to act in accordance with their best interests [2]. According to Aristotle, the akratic person (the akrates) knows what it would be best to do, but acts to fulfil less noble appetites and desires instead.
In fact the akrates simply wishes more strongly for immediate satisfaction of a desire than for the long-term benefit that would follow from ‘sensible’ action. Perhaps food, drink, sex or other such pleasures have a more powerful psychological meaning for the akrates than they had for Aristotle. Feeling good is seen as important by the self. These akratic actions are rational actions.
The internal world of the person with BPD will be vastly different from that of someone without the disorder. Pain, death, love, social status and stability – and all the other things that people avoid or strive for, may have very different meanings and relative weights in the minds of people with BPD. Someone else's internally consistent choice aimed at obtaining something that we cannot imagine wanting may outwardly seem irrational and be labelled as evidence of mental disorder.
Every person's likelihood of finding the long-term best decision, the most appealing option, exists on a probability spectrum. People do nevertheless have the capacity to know what the long-term sensible course of action would be. Having stronger short-term motivations to behave inadvisably merely makes the person less likely to find this sensible course the more appealing one. This probability statement is a statement of psychological determinism. It says nothing about the person's decision-making capacity.
Conclusions
The equivocal status of BPD with respect to mental illness leaves the clinician with no real guide as to whether to consider such patients responsible for their actions. In these circumstances it is interesting to examine the automatic assumptions that we make all the time about freedom and responsibility, to try to cast some light on this difficult area of clinical thinking.
By the reasoning in this paper, most BPD features, such as impulsivity, acting out and the milder forms of dissociation do not vitiate responsibility. The more severe forms of dissociation may do so, however. In addition, people with BPD are prone to comorbid conditions, such as depression and substance abuse. The potential of these to disable the decision-making faculty would need to be considered separately.
Footnotes
Acknowledgements
Thanks to Stephanie Winfield and Rob Barrett for their assistance.