Synopsis
The history of psychiatry is littered with examples of clinical and philosophical hubris. Historical views of homosexuality, the utilization of lobotomy, and the nature and breadth of psychiatric institutionalization serve as powerful examples. The philosophical doctrine of free will and its widespread adoption in society and medicine may serve as a contemporary example of an ongoing hubris specific to the practice of forensic psychiatry. Here, the author provides an overview of related topics and ultimately questions whether a dismissal of free will could aid in better serving patient populations including those vulnerable to errors in impulsivity and addiction.
Man can do what he wills but he cannot will what he wills.
― Arthur Schopenhauer, Essays and Aphorisms
The assumption of an absolute determinism is the essential foundation of every scientific enquiry.
― Max Planck, The Dilemmas of an Upright Man: Max Planck and the Fortunes of German Science, with a New Afterword
Life calls the tune, we dance.
― John Galsworthy
The Stanford Encyclopedia of Philosophy defines free will as “a kind of power to control one’s choices and actions”. Given that debates over free will have too often been muddied by unclear descriptions or unshared understandings, Stanford’s definition is a welcomed starting point from which to approach the topic.
Free will, in the conventional sense detailed above is the point from which many interpret human behavior. The belief that we are, ourselves, the prime movers of our actions or inactions is hard wired. From the way we raise our children, to the way we treat patterns of behavior in adulthood, notions of personal responsibility lay the groundwork for how our societies function.
These foundations are consequential. Traditional conceptions of responsibility drive our most complex societal systems. The judicial system, for example, is predicated on free will in theory and practice according to the Supreme Court of the United States. Justice itself, therefore, is conceptualized as a sort of reflection of our choices and the consequences that follow.
Arguments supporting the existence of free will most often rely on the fact that in any given situation a conscious actor could have chosen to do other than they did. The so-called libertarian account of free will is palatable and compelling because it reflects what it feels like to live in the world. In big ways and small ways, we seem to have an abundance of choice in day-to-day life and the idea that we are not ultimately in control seems like an alien concept.
Critics of free will often cite determinism as an argument against the notion. According to the philosophical doctrine of determinism, “every event is necessitated by antecedent events and conditions together with the laws of nature.” Given the obvious link to cause and effect, the doctrine is sometimes referred to as causal determinism.
Determinism comes in various philosophical flavors with the most extreme form, hard determinism, holding that every action in the universe is the result of prior causes that we appreciate to greater or lesser degrees. An inability to map out the specifics of any system, or to be predictive, speaks to our own ignorance and and does not necessitate the suspension of cause and effect according to this view.
In general, a deterministic world view relates closely to a materialistic understanding of the world. Through this lens, human behavior, and indeed all sentient behavior, is ultimately the result of electrical networks and neurotransmission deep within the central nervous system. Importantly, determinism holds that conscious beings, even human beings capable of high-level cognition and deliberation, are still nonetheless bound by cause and effect. Under a hard deterministic view of the world, there is simply no room for traditional free will because its existence would indeed demand a mysterious suspension of cause and effect itself. Do not mistake this reasoning as circular - it isn’t.
Opponents of free will suggest therefore, that human agents, no different than their animal counterparts, do not possess a magic wand with which to wave off causality. We are, in effect, weather systems living in the brain carried out in the world.
Like the mirage of day-to-day choice, this view is compelling and seems to map on to more closely-inspected consciousness. Beyond our genes and the neurochemical pruning that environment leads to (also out of your control), what is left to account for behavior? Do children have the kind of free will that adults do? If not when does the dramatic change happen? What about the bear chasing the camper through the woods? It seems nonsensical to suggest that at some point in development, the will emerges. It seems doubly nonsensical that such a rule would apply only to humans and not other complex animal systems.
Beyond the scientific and philosophical chaos, let us shift back to the day-to-day for a moment. Consider your reaction to what you’ve just read and you might succeed in breaking through. You might realize that the very reaction you’ve summoned was summoned mysteriously. Thoughts and emotions can come with patterns or may be predictable, but we ultimately don’t summon the summoning, we simply watch as if an onlooker. Neuroscientist Sam Harris summarized this idea as coming to terms with the vivid understanding that you are a conscious witness, not a conscious author.
Those in favor of free will reliably critique this as line of thought as reductionist, arguing that to close the door to free will based on our present understanding of the brain would be premature and unscientific. This misunderstanding is more pronounced when faith-based arguments are relied upon when trying to solve the riddle of the will. The push and pull, based on such difficult arguments, has been ongoing for centuries and little philosophical progress has been made on the issue.
Medicine and the Law
The implications of the scientific and philosophical unwinding of free will are, in a word, breathtaking. The intersection between medicine and personal responsibility is one such area fraught with complexity.
Practitioners counsel patients on lifestyle management and in recent years, the useful concept of harm reduction has become a mainstay in medical education and is being increasingly adopted in hospital and community care settings. Functionally, such changes aim to operationalize the biopsychosocial framework we are taught about in medical school in that they meet the patient and their behavioral limitations in a realistic and clinically malleable way.
Despite advances in our scientific understanding of behavior, an over reliance on human agency and personal responsibility nonetheless persists within medicine. Stigma against overweight and obese patients, those with personality and substance use disorders, and those who have committed criminal offences are powerful examples of this stigma in action.
One remarkable characteristic of this stigma is its robust persistence in the face of compelling evidence. For example, patients suffering with paraphilic disorders have become better understood in recent decades. Case reports and more recently, medication studies, have underscored the marked role the material biology of the brain plays in this pathology, and remarkable interventions have and continue to show promise. Nonetheless, patients with such pathology and disease of the brain and the mind are frequently met with disgust reactions and are themselves commonly thought of as evil or deserving of punishment for its own sake.
In Canada, recent Supreme Court rulings related to the behavior and punishment of those with mental disorders have generated outrage and debate with respect to the basis of behavior and notions of personal responsibility and fairness. One recent ruling has found that decision making in a state of substance intoxication would not necessarily preclude a defendant from a viable defense. Another unanimous ruling held that life without parole rulings were unconstitutional. Consequential stuff.
As it pertains to substance use and criminal offence, and their stimulating interaction with notions of free will and responsibility, forensic psychiatry is perhaps the best positioned to contribute to this debate of any medical specialty. Specifically, the mechanisms with which patients are found not criminally responsible serves as a salient case example for how our conventional ideas of free will infect medicine and the law.
In western countries, the diagnostic breakdown of those found not criminally responsible has been remarkably stable over time. In Canada, up to 94% of those found not criminally responsible carry primary mood or psychotic disorder diagnoses; these are illnesses like bipolar mania and schizophrenia. While personality disorders and substance use disorders are often included as co-morbid disorders at startling rates, they are seldom the primary diagnosis in not criminally responsible rulings.
What are we to make of facts of this kind if we agree that the goal of forensic and mental health care systems is to create ethical, fair, and rehabilitative end points for patients with impacting psychopathology? In the case of substance use disorders, this should give our society and specialty much pause. Changes to brain function in substance use disorders have been well-documented. We know that impulse control is significantly impaired in those with substance use disorders and that this scales to the degree of addiction.
Conversely and predictably, during periods of recovery and abstinence, neural networks involved in reward and impulse control begin to repair abnormalities and shift towards prior baseline neurochemistry. But in the disease state, these changes are active and translate directly to behavior including that related to voluntary behavioral control. Despite this phenomenon being well supported by basic and clinical science, western regimes of criminal punishment and forensic psychiatry typically ignore the implications of such scientific understanding.
With respect to how this understanding ought to demand translation in criminal punishment, by way of example, take the case of a criminal offense involving the operation of a motor vehicle under the influence of alcohol.
Suppose that in the first case an offender drinks alcohol, becomes inebriated, and drives home and kills a pedestrian in the process. If we compare this to a second case, identical except for the fact that the offender has a known alcohol use disorder, how does the calculus change if at all?
One might suspect that the inclusion of a substance use disorder ought to shift the culpability calculus in meaningful ways, but our systems of justice simply do not reflect this. Proponents of the system as it is will argue that criminal sentencing takes these factors into account. Perhaps the question that’s worth asking, however, is: how much?
Beyond the science of addiction, the science and psychology of behavior cannot be ignored and many view a relaxation on responsibility as a lateral move that will incentivize bad behavior. While important to consider, this view takes things to the extreme and leaves no room for nuance or a fresh questioning of how we handle crime. And on an issue this important, we need to have that open discussion, and push it into the mainstream where it rightly belongs.
Sapolsky as Nostradamus
If we are to move towards a more equitable and evidence-based theory of punishment, forensic psychiatry will undoubtedly play a major role. Specific to the case examples involving alcohol use disorder discussed above, several implications for clinicians will need to be taken into consideration.
First, consistency in the diagnoses of substance use disorders will need to be maximized. The clinical confirmation of a significant mood spectrum or psychotic disorder diagnosis comes with much more ease than does a substance use disorder. The degree to which a substance use disorder exists in an acute state, remission, and the severity of said state will also need to be more carefully analyzed. Beyond considerations of diagnosis, forensic psychiatry hospitals will need to be logistically supported as they are the institutions who will be primarily responsible for rehabilitation of offenders.
Many fear what a wholesale change in our views about free will might mean for societal functioning generally and in those cases described above. Despite some work suggesting that a rejection in the belief of free will could lead to more unethical behavior, other studies have shown that viewing behavior as resulting from environmental and genetic influences also encourages compassion for psychiatric patients and discourages retribution. This makes some sense, as its hard to account for behavior in any moment using metrics outside your genetics and your upbringing. At some level, that is all there is to talk about. Any rational discussion on the topics must appreciate the power of luck involved in circumstances of brain chemistry. They cannot be casually waved off if we are to be ethical and scientific as a society.
It is encouraging that the act of questioning our traditional frameworks of free will and responsibility is happening out in the open more and more. In 2021, the American Psychiatric Association (APA) closed its plenary sessions with a keynote delivered by famed neuroscientist and staunch determinist Robert Sapolsky. When asked what he hoped psychiatrists would take away from the lecture, Sapolsky said: “How mechanistic we are, how much we are the outcome of random biological luck…”.
Sapolsky’s forthcoming manifesto entitled Determined: A Science of Life without Free Will, will undoubtedly haul more and more of the free will debate into not just medical circles like the APA, but mainstream consciousness as well. That is surely a good thing.
And this impending entry into the mainstream medical and societal consciousness makes the illusion of free will unignorable. As more and more members of our society question the inclination towards belief in free will, more and more will begin to question the structures that rely on the belief. The degree to which substance abuse disorders influence behavior, and how culpable a person under the influence of substances truly is, represents just the first gentle tugs on the fabric of free will in psychiatry and criminal law.
In a 2017 interview, Sapolsky dived into behavior and the notion of free will as it relates to psychiatry and medical history. As he recounts, some of our past understanding of psychiatry and theories of disorder and treatment can only be described as short-sighted and barbaric. The way we viewed homosexuality, the utilization of lobotomy, and the nature and breadth of psychiatric institutionalization are just some of the worst examples of how wrong we can be. In retrospect we view all these approaches as horrific, but the true horror lies in just how sure of ourselves we were in those moments.
When asked what it was that future societies would look back on in horror, Sapolsky poignantly stated the following: “I think it is overwhelming going to be my god, that quaint, medieval, destructive belief they held on to then about human agency and free will. Wow, they punished people who had brains that couldn’t regulate their own behavior. They punished people, who because of toxic exposure, or stress during adolescence, wound up with brains that couldn’t control this or that at particular junctures, and they used words like justice back then. Wow, I can’t believe the stuff they did.”
In this advanced age we find ourselves imbedded within – advanced science, advanced technology, and ongoing philosophy, psychiatry must be agile, quick on its feet, and quick to remember our past errors and the utility found in welcoming new and unsettling but sensible paradigm shifts.
We can always take comfort in the fact that we had no choice.