The Rules of Insanity, divided into seven chapters, basically addresses three kinds of mentally ill offender: people who commit crimes as a result of compulsion, as a result of personality disorder, and as a result of psychosis or mania. Although Elliott does discuss some of the legal definitions of insanity, his focus is on ethical issues. He has a crisp writing style, managing to avoid the convoluted sentences of which so many academic writers are guilty. He also uses a good number of fairly detailed case histories to illustrate the issues and explain his views, which helps enormously in bringing the issues to life.
The first chapter runs through legal approaches to the guilt of mentally ill offenders, which is ground well-trodden by previous writers. Elliott keeps his discussion short and to the point. In the second chapter he turns to the general issue of moral responsibility. It is a relief that he does not take the now tired approach of starting out with a comparison of Mill's Utilitarianism with Kant's Deontological theory and show how each theory copes with different kinds of case. Instead, Aristotle's approach provides a good starting point here, since it is still one of the best accounts of how we actually think about morality. Aristotle argues that some of one's actions are involuntary, either because one is forced to do something undesirable by another person or circumstances, or else because one does not realize what one is doing. It is natural to think that one is not morally accountable for actions one did not freely choose. Elliott does a good job in mapping out some of the theoretical terrain of the complexities that arise, without trying to make any original claims.
Kleptomania, voyeurism and sexual compulsion are the examples with which Elliott starts off his detailed discussion of mental illness. He argues that people are not free when they have compulsions. This might seem obvious, but when one realizes that even people with compulsive disorders can on occasion stop themselves, the nature of the lack of freedom involved becomes much murkier. It is even more obscure in the case of addiction, where there is clear evidence that people have some control over their addictive behavior. (It is strange and disappointing that Elliott does not address drug addiction and alcoholism at all in this book, since it would not take much to extend his analysis from compulsion to addiction.) As far as compulsions go, he argues that they can provide a legitimate excuse for what the behavior they cause.
Elliott points out that it is essential for his analysis that the compulsive really be fighting unwanted desires. If she has no qualms or feelings of guilt about what she does, then she is will hardly count as compulsive at all. Even if it is compulsive, the offender can only be excused if she has not persistently avoided available treatment for her condition. Furthermore, Elliott says that not all compulsive behavior can be excused, no matter how involuntary it is. For example, pedophilia is such a terrible action that we may think no excuse can be sufficient. It is not clear how he proposes to draw the line between excusable and inexcusable compulsive behavior, or even what justifies drawing such a line in the first place. All that Elliott provides is an appeal to Aristotle and common intuitions about these things.
In contrast with compulsion, the deeply ingrained behavior patterns of criminals with personality disorders are not excusable, according to Elliott. These people do not fit the criteria for excuse, viz., either acting out of internal duress or being out of touch with reality. In standard descriptions of case histories, the criminal has not struggled with internal demons. Rather, he has shown arrogance and indifference to the rights of others. Although often charming and clever, when one is better acquainted with such a person, it is hard to like or even feel sympathy for him. One explanation for this is that, while a compulsion is in an important sense external to a person and is not an expression of his real self, a personality disorder really forms a person's identity. Rather than having to choose between saying that he is either mad or bad, we could say that his form of madness is that he is bad.
Some might find this distinction between compulsion and personality disorder bewildering. Does a person with personality disorder have any more control over his behavior than a person with compulsive disorder? If anything, the behavior of the former is more inflexible. But the distinction between them which Elliott is making is really to do with the criminal's intent. A compulsive acts against his better judgment, while a person with personality disorder does not.
After making this strong distinction, Elliott goes on immediately to blur it. For he says that psychopaths are out of touch with reality in a sense, in that they have no understanding of morality. These days, 'psychopath' is not a term officially used in American diagnosis of mental disorders. The closest official category is antisocial personality disorder, i.e., a form of personality disorder. While previously Elliott argued that we should hold people with personality disorder accountable, when it comes to what most people think of as one of the most severe form of the disorder, he says that there is an excuse. His reason is that psychopaths are morally blind.
The distinction Elliott is trying to draw here faces problems. What is the difference between being morally blind and being evil? Presumably it is that an evil person knows exactly what she is doing, while moral blindness prevents a person from choosing in full knowledge. Maybe this is a distinction that makes sense, but many including Plato have argued that those who fully know the good will thereby act on it. No wrongdoer fully understands morality on this view. Elliott does not address this large issue. But he does make his position easier by allowing that psychopaths are not completely devoid of moral understanding. Instead, he likens them to adolescents, whom we are still blame when they do something wrong, but we are ready to mitigate the blame because of their lack of maturity.
The main problem I see with this approach is if that there is some excuse for psychopaths, then it would seem to be applicable to the other personality disorders as well. Consider a list of the disorders from DSM-IV: paranoid, schizoid, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive. It seems to me that each of these involves the patient lacking a full appreciation of the moral nature of her behavior, or else acting under some kind of internal duress. Elliott's reasoning about morality may be right, but his assumptions about the actual differences between the personality disorders seem flawed.
Episodes of Personality Change
When someone commits a crime during a manic or psychotic state, we might say that she was not responsible because she did not know what she was doing. But as criminal trials have shown, as in the case of John Dupont, often it is a difficult issue working out the extent to which the person was delusional. Rather than being all-or-nothing, delusion is interwoven with reasonable beliefs in many complex ways. Thinking of cases like the suicides of the Heaven's Gate group, or the refusal of medical treatment by Christian Scientists, it becomes clear that when it comes to religious and spiritual belief there is great uncertainty about counts as a reasonable belief. So it is at least controversial to say that people in manic or psychotic states are not morally responsible for their behavior.
Recognizing this, Elliott suggests a different kind of reason for withholding blame. He says that during these episodes, the patient is not really the same person as the healthy person she was before. Or at least, there is sufficient change that we cannot hold the healthy-self responsible for the actions of the ill-self. Unfortunately, Elliott gives little justification for this excuse. While it is true that people will sometimes say of a past action, "I was not myself when I did that," there is no strong reason to take this literally. Elliott's analysis here is very similar to that in Jennifer Radden's discussion of the difference of identity between a healthy-self and a self-destructive ill-self. So it runs into the same problems as I pointed out for Radden previously. Furthermore, Elliott does not even have the extensive discussion of metaphysics to justify his claims, as Radden had. It is an interesting suggestion, but if it is to gain plausibility, much more work will need to be done on the details.
Failing to be a Moral Agent
Elliott draws a distinction between absolving a person from blame because he has and excuse, and because he doesn't count as a moral agent in the first place. When a wild predator kills a human, we don't say that it did something morally wrong, but this is not because it had an excuse, but rather because we don't think it is the kind of being that can assessed as good or evil in the first place. In the last chapter of the book, Elliott suggests that some people's minds are so disordered that they too don't count as moral agents.
At the same time, he emphasizes the impossibility of ever achieving strict criteria for his distinction. This does not mean decisions about moral agency are hopelessly arbitrary, but there are no simple rules one can use in making the decision. Elliott's claims here are plausible, but it's is hard to know what practical implications to draw. Although he gives a couple of case histories of people who commit crimes while entertaining bizarre beliefs, he doesn't explain how his views about moral agency should affect our deliberations about what to do with those people. He doesn't even relate the ideas of this chapter to the disorders he considered previously in the book. This makes it a somewhat unsatisfying climax to his book.
Both Radden and Elliott deserve praise for even approaching these difficult issues. Radden has a position in the Philosophy Department at University of Massachusetts in Boston, while Elliott is at McGill Centre for Medicine, Ethics, and Law. Generally in academic life, interdisciplinary work is given much lip service but little actual career reward. Engaging in it requires both determination and intellectual sophistication, since it requires an understanding of a wide range of clinical psychology and philosophical theory. I have listed a number of weaknesses in their writing, but I am acutely aware of the difficulties of such work, since it is exactly the kind that I also do. These books are rewarding when considered carefully, and I hope that they will reach a wide readership and spur productive debate. This is an area where philosophers can make a useful contribution to issues of public concern, and they should seize the chance to do so.