How does all this theorizing apply to individuals who have psychiatric disorders? And how does a model of "psychiatric naturalism" help us achieve a humane and rational system of justice and rehabilitation?Mr A's case
In this brief space, I can only sketch some answers to these questions. (A much richer and more elegant exposition is provided in Thomas Clark's book, Encountering Naturalism.7)Let's start with a hypothetical patient, Mr A, who has chronic paranoid schizophrenia. In the midst of an acute psychotic decompensation, Mr A is attending to command auditory hallucinations telling him, "Drive your car into the nearest pedestrian."
Mr A is terrified that if he does not comply with the "voice"—which he takes to be that of "Satan"—he will be thrown into a pit of fire. In fact, Mr A sees no viable alternatives to complying with these diabolical voices. As a consequence of this psychopathology (or "brain state"), Mr A appears to be highly agitated according to several witnesses; for example, he is perspiring heavily and hyperventilating as he steps into his car. Tragically, Mr A drives his car into a pedestrian, is subsequently arrested, and is charged with "vehicular homicide."8
An investigation reveals that Mr A had made a decision 2 weeks earlier to discontinue his antipsychotic medication—despite having been warned repeatedly against doing so by his psychiatrist and his wife. Mr A, at that time, was not showing any evidence of acute psychosis. He convinced his physician that he understood the risks of stopping his medication, including the potential for violent acts, but elected to stop the medication anyway because he "did not like the side effects."
Based on the model I have constructed, what can be said about Mr A's actions? First, it seems clear that his act of driving into the pedestrian—terrible as it was—cannot be considered a free act. Assuming we have our facts right (and this is a matter of empirical investigation), Mr A was acting under the internal coercion that the Stoics viewed as inconsistent with a free act. He was also in a state of marked emotional turmoil, judging from the reports of witnesses.
Second, Mr A's act was evidently not intentional, in the strict sense we have defined. Recalling Seddon's requirement that an intentional act entails our rational understanding of "the background of the situation against which we intend to act," it seems clear that Mr A did not have a rational understanding (although he may have believed himself to be rational at the time). Mr A did not, for example, appear to realize that the "satanic voices" were causally related to his having stopped taking antipsychotic medication.
Third, from the posited facts of the case, Mr A felt compelled to act as he did, rather than experiencing his actions as self-motivated expressions of his own wishes. With respect to his hitting the pedestrian, Mr A met none of the 3 threshold criteria for acting freely.
On the other hand, Mr A's earlier decision to stop taking his medication—although no less determined than any other action by any individual—appears to have been undertaken with a greater degree of freedom, as we have defined it. That is, from what we have posited, Mr A elected to stop his medications while in a relatively noncoerced and rationally informed mental state. In ethical terms, therefore, we might plausibly argue that whereas Mr A was not fully responsible for his running down the pedestrian, he was at least largely responsiblefor (unwisely) discontinuing his medication.
I am positing that there is a direct relationship between degrees of freedom and degrees of responsibility. Indeed, I would define "responsibility" as essentially the ethical dimension of freedom. Responsibility, as Clark noted, is also "the dimension which legitimizes social sanctions and rewards as a way to change behavior."6 And although I am not putting forward an explicitly legal claim, I believe that our legal system can draw on such philosophical reasoning, insofar as society applies various "remedies" to acts such as those of Mr A.
In the present legal system, which is based on the Model Penal Code (MPC) that is promulgated by the American Law Institute, it seems likely that Mr A would be found guilty of either manslaughter or negligent homicide. As Daniel W. Shuman informed me (personal communication, April 23, 2007), "Under MPC, a person with a mental disability who is aware of a potential for violence when unmedicated may be liable for reckless or negligent homicide if he fails to remain on medication and then kills [someone]—even if at the time of the crime he would meet the test for not guilty by reason of insanity." Mr A could be found guilty of manslaughter because "he consciously disregarded his physician's warning and subsequently killed someone; or for negligent homicide, because he failed to be aware of the reasonable risk that driv-ing after he discontinued his medica-tion would result in physical injury to others."
All this is more or less consistent with our naturalistic model of freedom. That is, a jury might implicitly understand that while Mr A's mowing down the pedestrian was not in itselfa free act for which he should be held responsible, his refusal to take appropriate medication was a free act, for which he should be held responsible.
However, our current system of justice would most likely diverge from our model of psychiatric naturalism at this point. As Shuman noted, criminal law has "retributive goals"—psychiatric naturalism does not. (For a rebuttal of Michael Moore's contention that retribution is "intrinsically good," see Clark9). Under our present system, Mr A might very well be sentenced to prison in most states.
In contrast, our naturalistic model (and perhaps some judges in specialized "mental health courts") might prompt another course of action; for exam- ple, involuntary inpatient commitment or partial hospitalization, mandatory (court-enforced) depot antipsychotic medication, and immediate suspension of Mr A's driver's license. (This last sanction might remain in force until such time as Mr A's compliance with, and positive response to, medical treatment are unambiguously established.) Mr A might also be ordered to compensate the family of the pedestrian he killed and to perform some type of long-term community service.Conclusion
We can apply this same reasoning to a wide spectrum of psychiatric disorders, ranging from schizophrenia to so-called Internet addiction. Psychiatrists can contribute to legal decision making by providing general empirical evidence regarding specific brain states and disorders and determining the degree to which they may undermine free and responsible action.
Indeed, China has actually developed a diminished criminal responsibility rating scale that has been used to distinguish varying degrees of culpability in patients who have schizophrenia.10
In the end, it must be left to the legal system to determine criminal responsibility and to apply the most useful and humane remedies or sanctions. Psychiatric naturalism does not compel us, logically or morally, to abandon our feelings of outrage or revulsion in the face of, say, terrorism, homicide, or genocide; nor does it require us to jettison our belief that such acts are profoundly wrong. Rather, psychiatric naturalism compels us to reexamine the notion that retribution for retribution's sake is based on sound reasoning or wise public policy.9 Finally, psychiatric naturalism permits us to retain those elements of the criminal justice system that promote such valid objectives as "public safety, deterrence, rehabilitation, community restoration, and victim restitution."11