Does mental Illness exists ? (3)

Take a look at the following two articles both from the USA. The first is about three mentally ill people who were all involved in serious incidents after stopping their medication. David Tarloff a schizophrenic hacked to death a psychologist, Lee Coleman slashed two while on a rampage and Khiel Coppin a “disturbed” teenager confronted Police and was shot dead, The article suggests tracking mentally ill patients and ensuring their compliance with medication regimes by monitoring Medicaid payments.

The second article suggests using the database to track people with serious mental illness and alerting Health care professionals and Police when psychiatric patients stop their medication but before they fall through the cracks in the system and turn violent. The article also advocates greater communication between the criminal justice and the mental health system to identify potentially dangerous mentally ill people in the first place.

Also mentioned is Kendra’s law, a statute empowering psychiatrists to obtain a court order compelling the most dangerous mentally ill patients to take medication as a condition of their release into the community. It is also advocated equipping the emergency 911 system to notify Police when they are called to the address of someone with a history of serious mental illness.

Setting aside the inflammatory nature of the reporting, (psychiatric patients always hack at their victims usually while on a rampage they are then confronted by cops who end up shooting them) you don’t have to be in complete agreement with Ted [1] [2] to see that these proposals have profound implications for civil liberties and some of the above proposals are to be adopted in this country.

But when are people with mental illness responsible for their behaviour? There are some philosophical positions which maintain that people are never responsible for their behaviour because behaviour is always determined by previous events. Jean Paul Sartre took a diametrically opposed view when he stated that humans have “absolute freedom” the only limits to our freedom being freedom itself. For Sartre to be is to choose oneself and freedom is the essence of what it is to be human. However there remains considerable support for the notion that people with mental illness are not fully responsible for actions which are symptomatic of their illness. To what extent psychiatric patients are responsible for their actions depends on which mental illnesses, if any, provide a valid excuse for an individual’s behaviour.

Schizophrenia for instance causes cognitive as well as emotional distortions on such a scale that most people are comfortable regarding it as a bona fide illness. But it is the distortions in belief and reasoning that provide the clearest justification for excusing the bizarre and sometimes violent behaviour that results from this condition and forms the basis for the insanity defence in law.

Psychopathic personality disorder is a more contentious diagnosis as it often includes symptoms that are destructive and criminal in nature. There is understandably great suspicion of any attempt to excuse the behaviour of psychopaths but it is an open question to what extent psychopaths can comprehend the morality of their actions when their moral understanding is extremely limited. Another way of describing psychopaths is as people with deeply flawed personalities who have no use for morality, to blame such a person for their behaviour would be like blaming a cat for playing with its prey before killing it. How can we blame someone for doing what is in his or her nature?

Alcoholism faces us with a different dilemma. Should alcoholism count as a disease at all? Certainly those thought to be alcoholics can not be detained under the MH Act purely for their alcoholism but a key issue in deciding if alcoholism is a mental illness is in deciding to what degree an alcoholic is responsible for his or her continued drinking. It is only plausible that alcoholism is an illness if alcoholics are in some meaningful way not responsible for their drinking. Evidence to support this view is supplied by the presence of withdrawal symptoms when a chronic alcoholic stops drinking. Brain damage that can occurs through excessive drinking and studies that show alcoholism runs in families is also taken as evidence that alcoholism is an illness and should be treated as such. But this evidence is contestable, withdrawal symptoms merely shows that it is difficult to stop drinking while brain damage is suggestive of a disorder not necessarily an illness. Laziness and cowardice could also turn out to have a genetic component but this would not make them a disease.

The problem for alcoholics is that they are often described in highly pejorative terms, weak, self deceiving, selfish, self-destructive, short-sighted, uncaring and even pathetic. Describing alcoholism in terms of personality traits renders the “alcoholism as illness” argument at best secondary and at worst irrelevant. However it is hard to describe alcoholism as a matter of rational choice, problem drinking often presents as a self perpetuating way of life and while it is difficult to pin point a specific cause for excessive drinking the drinker often has a role in perpetuating his or her problem.

Testimonials from addicts provide evidence for the difficulty of giving up addictive substances and sometimes no amount of willpower or resolution to give up is sufficient to deal with the problem. Heavy drinkers will often fail to cut back or moderate their alcohol consumption despite the knowledge that their actions will have dire and potentially fatal consequences. This argument suggests that the issue of personal responsibility is logically “a priori” to the issue of free will and addiction is therefore a disease because addicts are unable to control their addiction.

Self control in any form of mental illness is a matter of degree and the ability for an individual to exercise free will is central to deciding an individuals competence and if it is justified to deprive them of their liberty on the basis of what they might do to themselves or others. Some people generally have more control over their behaviour than others, some are better at resisting temptation than others and it is rare for anyone to have complete control over their actions and behaviour. It would seem to follow therefore that there must be a limit to which anyone suffering from a mental illness is or is not responsible for their actions. To put it another way the disease status of mental illness is not an all or nothing thing state of affairs. Unfortunately for the purposes of public policy there is little room for a concept of mental illness as a semi disease.