Abstract
This article discusses the connection between consciousness and responsibility. Moral responsibility plays a crucial, but often implicit role in psychiatry in that it is often a therapeutic aim as well as an important evaluative concept. This article explains one of the more influential ‘psychological’ theories of moral responsibility, developed by Harry Frankfurt. In the second part of this article, a modified version of this account is applied to a range of psychiatric phenomena.
The link between moral responsibility and consciousness seems obvious in that since Plato we have recognized that an agent cannot be held responsible for doing that which he or she is unconscious of (except where there are conditions involving a duty which one is strictly liable to perform such as to ensure the safety of food one is selling). But the connection needs some spelling out as it applies to those altered states of mind or consciousness that are thought to cause diminished responsibility for one's actions.
Consciousness itself is, on the one hand, as plain as the nose on your face, and, on the other, puzzling. But it is best characterized in a traditional phenomenological way as a flexible awareness of and responsivity to the things and events with which, as human beings, we are engaged. This characterization embeds the idea of intentionality or directed awareness whereby one's mode of apprehending the object or event concerned – as a wolf, for instance, rather than a hunchbacked neighbour – may lead one to act in a way that otherwise one would not [1]. Immediately, it emerges that the way in which one is conscious of or thinks of the events around one is deeply relevant to the reasons one takes oneself as having in acting a certain way. ‘Well wouldn's you throw stones at and wave a lighted branch threateningly in the face of a wolf in your garden?’
Moral responsibility
Moral responsibility is relevant to psychiatry in a number of important ways. Very often the therapeutic aim of psychiatry is to help a person recover control of their life, so on one view, psychiatry often aims at fostering moral responsibility because we are morally responsible for those actions that we control in the right kind of way. It is also important because there are instances where it is necessary for people to be treated against their will in order to restore their self-control. When this is done, it is plausible to demand that such people are genuinely incapacitated by mental illness and are unable to take responsibility for their actions (among other things) [2].
For these reasons, it is important to have a clear idea about what moral responsibility really is. There are paradigm cases that we can all think of: young children or those suffering from concussion, for whom we would have little difficulty in determining that we should not hold this person morally responsible because their understanding of the world at the time of their action is deficient in such a way that they do not (or cannot) act in the light of the kind of conscious appreciation of the facts a normal person would take to be relevant.
But can philosophy help us here? The traditional philosophical discussions of determinism and fatalism depend on a contentious assumption of mechanistic causality as the basis of human action. More recent philosophical discussions of responsibility move away from discussing the metaphysics of a will that is independent of causation [3] to a psychological level of inquiry [4]. Rather than asking whether responsibility is compatible with a determined universe, these discussions focus upon the importance of our thought and psychological development for distinguishing between those who we ordinarily think of as morally responsible and those who have been affected by age, development or mental illness. The effects of these conditions on the mind suggest that we look at the integrity and coherence of the lived experience of the individual and the meaning of the act within that narrative [5].
One particular influential ‘psychological’ theory of moral responsibility is that developed by Frankfurt [6] and an exposition of his account is a good point to begin a detailed discussion.
Frankfurt's hierarchy of desires
Frankfurt regards human actions as distinctive in that they involve the legislation of some desires by other, higher-order desires. We are all familiar with the idea that it is necessary not to act on some of our desires because other important desires and aspects of our life would be adversely affected by the action concerned. This is one feature that sometimes distinguishes our behaviour from that of other animals: one's dog may tend to act upon immediate desires such as needing water, a walk or some attention, but she may not to be very good at prioritizing or controlling her desires.
But Frankfurt's account needs more than the ability to weigh up conflicting desires because human beings evaluate the overall shape of their life rather than just letting their various desires ‘fight it out’. For example, a heroin addict may have a very strong desire for heroin but may not want to prostitute herself in order to satisfy the desire. If it is not possible for her to satisfy both of them then her conflict will provoke a higher-order assessment of her desires and that assessment depends on a framework of evaluation that encompasses both of them. Frankfurt thinks of this in terms of second-order desires that evaluate our simple wants and needs such as the desire for heroin.
Second-order desires create an ordering of desirability of first-order desires and, therefore, give the agents all-things-considered reasons to act in certain ways. Frankfurt offers the example of a man who wants to know what it is like to be a heroin addict. The willing addict becomes addicted to heroin and has first-order desires for the drug, but because he wants to have this desire there is a second-order desire, endorsing the first.
The ability to form second-order desires that are about the kinds of desires we want to have or to be our will, is one important distinguishing feature of human agency. It is linked to a person's conception of the kind of person he or she wants to be and, therefore, is closely related to both moral responsibility and character. A person or animal that is not conscious of and able to exert some control over their own psychological life is, in certain respects, like a child or a person with a mental disorder who is impaired in their ability to act upon reasons based on who they are and how they see the world.
On this account, a person can be held to be a morally responsible or free agent when there exists a hierarchy of desires or an adequately integrated personal story that gives meaning and coherence to that person's life. For example, a heroin addict might have first-order desires for heroin and yet not want to be a person whose actions are controlled by the need for heroin; but they may find it impossible to resist the strength of their desire for heroin so as to produce a liveable life story in which they are free of the compulsions that their addiction causes. Although we can say that this person has reasons for doing what they do, it is less obvious that they are free to act in the way we unequivocally associate with moral evaluation.
This account of lived personhood as a conscious experience that we can own and structure is especially pertinent for thinking about psychiatry, responsibility and consciousness. It is also compatible with the thought, found in the philosophy of Aristotle (and picked up by Davidson [7]), that responsible action is a learned skill that forms part of our nature as reasoning beings.
Acute schizophrenic episode
AFrankfurt style account supplemented by the idea that we learn to translate our reasons into action by acquiring the skills of self-control and self-direction can accommodate some of the more profound effects of mental illness.
Harry is suffering from an acute paranoia during a schizophrenic episode and believes that the psychiatrist trying to help him is in fact collecting information about him for the purposes of a sinister experiment.
Assuming that this is not in fact the case and that Harry's belief is a result of his schizophrenic episode then it is produced by a psyche in which certain skills of reasoning and belief formation are impaired. Suppose that, on the basis of his belief, Harry wants to leave the hospital and does not want to accept any medication offered by the psychiatrist. Knowing that the effect of paranoid psychosis is to disable cognitive skills of belief formation and reasoning (resulting in disordered thought form and content) we can conclude that Harry's beliefs, desires and intentions are not only misinformed, but also seriously out of control and not well integrated within a coherent experience of the world of the type characteristic of a normal human being. Here, it seems likely that Harry's personhood (which underpins the chain of reasoning that is necessary for him to evaluate what he really wants) is disrupted by his schizophrenia so that he lacks the cognitive skills essential to the integrity of his lived conscious narrative.
Clinical depression
Although schizophrenia is often given as the paradigm case of a disorder that disrupts mental function, clinical depression can also influence a person to the extent that they are no longer responsible for their actions.
Jo is a 40-year-old woman who has become depressed after a stressful time juggling work commitments and a complex family life. She no longer thinks that she is able to contribute anything meaningful to her family or workplace and is of little worth as a human being. A psychiatrist assesses her and forms the professional opinion that there is a good chance that she will harm herself and that she is very likely to respond to antidepressants.
Suppose that the psychiatrist's opinion is correct and that Jo's self-image at this point is, in part, the result of her depression. It might be that her evaluation of herself and the desires that she forms on the basis of this attitude – to harm herself, or not to get up in the morning and otherwise neglect herself – are not part of the life she wants to live. If she did not show these debilitating patterns of affect and motivation before becoming depressed and will be released from them if she responds to treatment then these are not, in one important sense, intrinsic to her lived identity in the way that links character and morality and cannot be treated as responsible decisions she is making about herself and her own wellbeing. The life of any human being evinces a harmony of those lively forces that transform our beliefs and understanding of the world into action, and the skills that we exercise in our daily living are an intrinsic part of our conscious being that is severely affected by serious mental disorder so that when that strikes, a person's responsibility for their actions is impaired.
Anorexia nervosa
The compulsory treatment of mental disorders is often contentious, but becomes even more controversial when considering anorexia nervosa.
Jody is 20 years of age and was diagnosed as anorexic six years ago. Her weight has fluctuated significantly over this period of time and she has been hospitalised four times. She says that she attaches great importance to her ability to control her weight loss. This ability is more important to her than succeeding in other ways to the extent that at times it is worth risking her life.
It is important not to over generalize about anorexic psychopathology. However, Jody's preferences are similar to those of other young anorexic women studied by Tan et al. [8], [9]. They studied the performance of young women with anorexia on standard clinical tests of decision-making (the MacCAT-T test). They found that these young women could often perform very well on this test and that their refusal of treatment was explained by the value they put on things like the ability to control their weight or their body. This phenomenology shows exactly the second-order desires found in Frankfurt's theory and, therefore, seems to imply that they are morally responsible for their decisions. Jody's desire to take control of her weight is a second-order desire: it is a higher-order legislating desire about what it is that she wants to want. Rather than failing to act upon reasons she is a paradigm example of someone controlling competing desires for the sake of pursing other ends. The need to understand the whole personality involved in anorexia and the underpinning of this intense desire for control should, therefore, motivate us to look at the integrated and dynamic personality within which the hierarchy of desires is determined [10].
Severe personality disorders
The way that societies should manage those with severe personality disorders is a perennial problem because the decision that a person should not be held morally responsible because of their personality is itself very problematic.
Brian has a lengthy history of violent behaviour including a six-month period in which he was imprisoned. A psychiatric team assessed him after he approached them for help with his outbursts. Initially they thought that his alcohol abuse might be masking schizophrenia but eventually they settled upon a diagnosis of antisocial personality disorder. He had a particularly troubled upbringing that involved a series of abuses and problematic foster homes.
Brian does not face difficulties like those of Harry or Jo, in that mental illness has not straightforwardly changed what it is that he desires, rather his whole life story is one of anger and interpersonal violence. When mental illness causes a person to misunderstand what it is that they want, or systematically misinforms them about the way that the world is, then the impact upon a person's responsibility seems to imply that we should detach the action from the person who was impaired in some way at the time it was performed and who would not want that act to be part of the person who they conceive themselves to be. Having violent dispositions that are difficult to control is less clearly a condition that can be detached from the person's identity or life story in that way. Brian's violent disposition is both a result of his background and also a result of choices he has made in the past. On one count, it seems to be so integrated into his life and character that it meets the psychological criteria for it being his responsibility that he acts as he does. But the picture is complicated by the fact that he is concerned about his behaviour and has contacted a mental health service for help. Thus, he does not want to be the kind of person he manifestly is and we must conclude that his overall conception of the life he would like to be living makes the impulsivity alien in a way importantly captured by the second-order desires for reform and repudiation of violence and their place in the integrated life story to which he aspires. The idea of personal life skills found in Aristotle and Davidson and stressed in cognitive behavioural approaches to psychiatric disorder makes it reasonable to conclude that Brian's responsibility is diminished even though his acknowledgment of and taking responsibility for his violence (and what is required to overcome it) may be an important part of any plan to deal with it.
It, therefore, seems that there is a deep relationship between the conscious lived narrative that makes a person the person who he or she is and the idea of responsibility for one's actions. Those actions for which we are responsible spring out of and are explained by the life one chooses to fashion for oneself even though the skills involved in fashioning and living that life may be deficient in various ways (so that ethical therapy of this or that type is required) [11].
Conclusion
We have suggested that a key feature of moral responsibility is the ability to organize one's life in accordance with regulative or second-order desires. This might be taken to imply that moral responsibility requires a very sophisticated set of skills and is, in fact, quite hard to acquire. Although we are comfortable with this implication it should not be taken to imply that this means that we do not need to respect the right of psychiatric patients to self-determination. Although it might be that many people have problems that mean they are not directing their lives as effectively as they might, this is well short of the degree of irrationality that is required before we should deprive a person of liberty. As we mentioned at the beginning of this article, one of the important objectives of mental health care is the development or restoration of a person's ability to shape and take control of his or her life. As John Stuart Mill pointed out, it is important for us to be at liberty to make mistakes for ourselves. The liberty to experiment with different ways of living is crucial for us to develop a sense of whom we are and what we want to do with our lives.