Psychiatric Naturalism and the Dimensions of Freedom: Implications for Psychiatry and the Law

Ronald W. Pies, MD;

Psychiatric Naturalism and the Dimensions of Freedom: Implications for Psychiatry and the Law

October 1, 2007

Ronald W. Pies, MD

Publication

Article

Psychiatric TimesPsychiatric Times Vol 24 No 12

Volume 24

Issue 12

In part 1 of this essay, I argued that individual freedom is not only compatible with determinism but dependent on it. I also argued that freedom is not an "either/or" condition. Rather, actions may be more or less free, and therefore, more or less "responsible," depending on a number of contingent factors, yielding various degrees of freedom. Psychiatrists, I suggested, can be most helpful in so far as we can describe, study, and categorize these degrees of freedom and the psychopathological conditions that undermine them. In part 2, I elaborate on the "naturalistic" model of freedom and autonomy and suggest how it may be applied to psychiatric disorders and medico-legal determinations of culpability.

By naturalistic, I mean that we need not posit nonmaterial or metaphysical entities-although these might exist-to explain the world or ourselves. As the Center for Naturalism put it: "Nothing about us escapes being included in the physical universe, or escapes being shaped by the various processes-physical, biological, psychological, and social-that science describes. On a scientific understanding of ourselves, there's no evidence for immaterial souls, spirits, mental essences, or disembodied selves which stand apart from the physical world."¹

And yet, in the face of all this, I maintain that we do experience and possess a very real kind of freedom. Of what, then, might this freedom consist? And how might such freedom be vitiated in the presence of certain brain conditions? Finally, how does such a view square with our everyday understanding of moral responsibility and societal punishment for "evil-doing"?

First threshold

I believe that the ancient Stoics had it about right when they construed freedom in essentially negative terms; that is, in terms of what is not presentwhen we say that we act "freely." At the very least, the Stoic formulation may help us toward a first approximation of what is meant by freedom.

In the Discourses, Stoic philosopher Epictetus described a free individual as a person who is free fromcertain inhibiting conditions; specifically, he or she is free from distress,free from fear,free from violent emotions,and free from hindrance.²In the ordinary linguistic use of the term "free," I believe these components are usually understood or intended. That is, we say, Jones acted freely if (among other criteria yet to be specified), Jones acted at a time when, with respect to the act in question, he was not under great duress, was not being coerced, was not experiencing some overwhelming emotional turmoil, and was not hindered from pursuing his wishes.I believe that these negative aspects of freedom bring us to what I would call the first threshold of a free act. These nonconstraint features are generally necessary but not sufficient to constitute what, in ordinary language, we mean by a free act. (I am again appealing to what our ordinary languagetells us about words such as free- dom; and, as the philosopher Ludwig Wittgenstein reminded us, "ordinary language is all right."³)

Second threshold

The second threshold involves the presence of intentionality. The philosopher Keith Seddon defined intentionality as follows: "In order for any action to be intentional, we have to understand the background of the situation against which we intend to act; what we hope to accomplish, and why it is reasonable to suppose that this action will produce that result"² (italics added).

Note that Seddon's concept of intentionality entails more than simply acting consciously or with a purpose in mind-it entails rationality as well. On this admittedly stringent view of intentionality, a person who decided that the KGB had implanted an electrode in his brain and that the only way to correct this situation was to remove the electrode with an ice pick, which could only be accomplished by kidnapping the Russian ambassador, would not be acting intentionally. Nor would that individual be acting freely in the sense I wish to develop. It may also be seen that this unfortunate individual would not meet most ordinary definitions of "sane."

Indeed, Robert Daly has developed the concept of sanity in a way that is readily transferable to the concept of freedomI am developing. Daly wrote: "A person is judged to be 'sane' when the behavioral and experiential foundations of his capacity for action (his personality) are so integrated with his knowledge and capacity to choose that he is... able to secure his prudential interests" (personal communication, March 21, 2007). If we substitute the word "free" for "sane" in the above- noted passage, we will arrive at something similar to what is meant by the second threshold of freedom.

Third threshold

The third threshold for a truly free act is quite straightforward and intuitively obvious: The act must be subjectively experienced as consistent with the individual's wishes. Simply put, we feel free when we think that we are acting in accordance with our own wishes-what Thomas Clark called the authorship criterion of free action. In part 1 of this essay, I described a hypothetical "assault machine" that when strapped to a person's arm and connected to the brain overrides his or her intentions and wishes and causes him to strike the nearest person. Assuming the person does not wish to be assaultive, it is evident that the act of assault cannot be free in this hypothetical scenario.

Note that this third threshold involves an experiential or phenomenological element of freedom: Very simply, we feel freewhile carrying out most of our everyday actions, regardless of how a deterministic science might explain them. (Dr Nassir Ghaemi has pointed to psychiatrist and philosopher Karl Jaspers⁴ as one who understood the importance of this transcendent "world of personal freedom."⁵) Some proponents of determinism argue that this feeling of freedom is nothing more than a "trick" played on humans by our brains-a comforting delusion that belies the causal mechanisms that determine our actions. I strongly disagree: Nothing in the nature of determinism or causality vitiates or renders illusory our conscious experience of being free. That feeling is as real as rocks, trees, or atoms. Indeed, none of the 3 main threshold criteria I have described is vitiated by the operation of physical law, neurochemical processes, causality, or determinism.

According to Clark, a free act is unconstrained, rational, and experienced as self-authored (personal communication, April 12, 2007). These criteria do not require us to posit some contra-causal "autonomous self" rising up, sundered from physical laws, magically choosing a course of action.

Indeed, the "capacity to choose," as was cited in Robert Daly's work, need not be understood as a faculty disconnected from determined, causal events. Rather, the individual's capacity to choosemay be understood as the repertoire of contemplated acts and behaviors that the individual perceives, evaluates and, in principle, is capable of performing, immediately prior to acting. This repertoire is akin to what computer scientist Marvin Minsky referred to as the "resources" available to the human brain at the moment an action is contemplated.⁶ These might include neuronal circuits or brain regions dedicated to aggression, passivity, avoidance, and so on.

In the case of highly creative and abstract actions, such as painting a portrait (as was described in part 1), this repertoire of available acts (resources) might include neuronal pathways representing "impressionist techniques" or "classical style." Note that the individual is capable of performing in principle. There are always sufficient reasons why, at a given moment, the individual does not in fact carry out all potentially available actions. Indeed, that is why determinists argue that for any action performed a person could not have done otherwise at that particular moment. This, however, does not mean that our actions are easily predictable or that we cannot modify our behaviorwhen contemplating similar actions in the future.

On the contrary, the entire foundation of psychotherapy requires the presupposition that we can help many of our patients acquire an ever more flexible, adaptive, and existentially fulfilling repertoire of behaviors.

Thus, psychotherapy is not threatened by determinism; rather, psycho-therapy of any type relies on causality as the underlying basis for favorably modifying thought, emotion, and behavior. It is simply that the causes we ordinarily attend to in psychotherapy are those proximately linked to the patient's behavior: those we ordinarily understand as the patient's enduring wishes, beliefs, impulses, fantasies, and goals.In short, we understand that the proximate cause of the patient's behavior is his personality-essentially what the Stoics called "the ruling principle."

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