Page 1 of 18 Moral	Responsibility	&	Mental	Illness: A	Call	for	Nuance Matt	King	&	Joshua	May1 Published	in	Neuroethics	Vol.	11,	No.	1	(2018):	11-22 Abstract:	Does	having	a	mental	disorder,	in	general,	affect	whether	someone	is	morally responsible	for	an	action?	Many	people	seem	to	think	so,	holding	that	mental	disorders nearly	always	mitigate	responsibility.	Against this	Naïve	view,	we	argue	for	a	Nuanced account.	The	problem	is	not just that	different	theories	of	responsibility	yield	different verdicts about	particular cases.	Even	when	all reasonable	theories	agree	about	what's relevant	to	responsibility,	the	ways	mental	illness	can	affect	behavior	are	so	varied	that a	more	nuanced	approach	is	needed. Word	count:	7,897	(excluding	abstract) Keywords:	free	will,	accountability,	blame,	excuse,	psychopathology,	mental	disorders 1.	Introduction In the summer of 2001, in a small town outside of	Houston, Texas, Andrea Yates drowned each of her five young children in a bathtub, one by one. Yates's psychiatrist	had	recently	taken	her	off	of	Haloperidol,	an	anti-psychotic	medication. In	previous	years,	she	had	attempted	to	commit	suicide	and	was	treated for	major depressive	disorder.	During	her	trial,	Yates	pleaded	not	guilty	by	reason	of	insanity, and the jury ultimately agreed. Her lawyer proclaimed the verdict a "watershed event	in	the	treatment	of	mental	illness,"	presumably	because	it	promoted	the	idea that	having	a	mental	disorder	can	compromise	one's	free	will	and	thus	reduce	one's culpability,	even	for	terrible	acts	(Newman	2006). Some	vehemently	resist	such	conclusions,	however.	Just	over	ten	years	later in	Texas,	Eddie	Ray	Routh	was	convicted	of	killing	two	men	at	a	shooting	range,	one of whom was celebrated sniper Chris Kyle. A former marine, Routh had been diagnosed with post-traumatic stress disorder (PTSD) and schizophrenia. His counsel	sought the insanity	defense,	but failed	to	convince	the jury	that	Routh	did not know his actions	were	wrong. The district attorney, Alan Nash, won the jury over, stating, "I am tired of the proposition that if you have a	mental illness, you can't	be	held	responsible	for	what	you	do"	(Dart	2015). 1	The	authors	contributed	equally	to	this	paper.	The	order	of	surnames	is	presented	alphabetically. Page 2 of 18 When and how does mental "illness" or psychopathology sufficiently undermine one's moral responsibility? This question figures heavily in legal discussions regarding	both criminal liability to	punishment	and	civil authority for private	law	decisions.	The	issue	is	also	relevant	to	designing	public	health	policy	and to	our	ordinary	practices	of	assigning	praise	and	blame.	Indeed,	while	philosophers have traditionally focused so intently on	determinism as a threat to free	will and moral	responsibility,	some	have	turned	their	attention	to	psychopathologies.	Walter Glannon,	for	example,	identifies	"brain	dysfunction"	as	the	"real	threat	to	free	will" (2011,	p.	69). Our	guiding	question	is	how	mental	disorders	affect	responsibility	for	action. Our	focus	is	only	on	moral	responsibility,	even	though	it's	intimately	connected	with other forms of responsibility, and even though	we	will sometimes draw on cases from	the	law.	Discussions	of	this	issue,	particularly	in	the	public	sphere	but	also	in academia, often assume that the relevant question is whether having a mental disorder	generally	mitigates	moral	responsibility.	The	usual	approach	is	to	consider people with some category of psychopathology-e.g. schizophrenia, autism, or obsessive-compulsive disorder-and determine whether the individuals are (or could	be)	responsible	agents. Against this approach, we argue that there is no generally supported inference from an individual's having a	mental disorder to any claims about that person's responsibility. Indeed, we think the focus of inquiry should not be on possession	of	disorders	but	on	the	operation	of	symptoms	in	specific	circumstances. Different	disorders	operate	quite	differently, and	even	within	a	given	disorder, its symptoms don't always have a singular effect on capacities relevant to responsibility. Importantly, while "symptom" is often used to refer to only the undesirable	effects	of	an	underlying	disorder,	another	sense	of	the	term	includes	any phenomena	that	are	characteristic,	indicative,	or	symptomatic	of	a	condition,	which includes unproblematic or even desirable effects (more on this later). After all, underlying	dysfunction can remain	while	undesirable symptoms	of a	disorder	are not	manifest. In	Alzheimer's, for	example,	neurodegeneration	typically	begins long before	the	patient	notices	any	symptoms,	such	as	forgetfulness	or	confusion	(Palop et	al.	2006).	As	our	discussion	will	make	clear,	it	is	the	broader	sense	of	"symptom" that	is	relevant	to	assessing	whether	an	underlying	disorder	affects	whether	praise or	blame	is	warranted	in	a	given	case. Another	major	difference	between	our	discussion	and	most	extant	accounts is that ours considers psychopathology generally, and so does not single out any particular	disorder	or	set	of	disorders.	Indeed,	because	the	philosophical	literature already	centers	on	psychopathy	and	addiction	(see	e.g.	Maibom	2008;	Levy	2013), we	deliberately	focus	on	other	cases	that	have	received	less	attention. Throughout the discussion we rely on the latest Diagnostic and Statistical Manual	of	Mental	Disorders (DSM-5) as a guide to the identification of	psychiatric disorders	and	their	symptoms.	Some	researchers	caution	that	the	DSM	is	unlikely	to group patients together in the most informative way for discovering facts about mental	illness	(e.g.	Tabb	2015).	A	further	complication	is	that	many	disorders	have Page 3 of 18 high	comorbidity	with	others,	such	that	in	any	particular	case	there	may	be	multiple disorders	at	work. In response to such worries, the National Institute of Mental Health now employs a set of criteria for assessing research projects that departs from the constructs	of	the	DSM.	The	new	Research	Domain	Criteria	require,	for	example,	that researchers frame their projects as addressing certain psychological phenomena (e.g. anxiety, attention, loss) rather than specific	disorders.	A study	of anxiety, for instance, may include patients exhibiting rather different kinds of disorders identified in the DSM (e.g. obsessive-compulsive disorder, generalized anxiety disorder,	PTSD). If this is right, however, it suggests that the clinical community is already moving toward something more like our account, which denies there are informative	relationships	to	be	drawn	between	mental	disorders	and	responsibility. We council evaluation of responsibility on a case-by-case basis, and the relevant phenomena to focus on are symptoms (e.g. impulsivity, delusions, hallucinations, anxiety, psychological incoherence, melancholy, diminished motivation, memory loss, reasoning deficits, blunted affect, mania, difficulty focusing, loss of consciousness, powerful urges, and so on). We thus appreciate the movement to focus	on	symptoms	in	psychiatric	research	(although	of	course	the	DSM	categories may remain useful in clinical settings). However, employing the DSM constructs would	seemingly	put	standard	treatments	of	the	topic	in	a	more	promising	position, suggesting	an	ontology	to	the	disorders	that	might	support	the	relevant	generalized inference.	Thus,	while	we	do	not commit	ourselves to the	DSM	accurately carving nature at its joints, it is both useful for framing the discussion to come and charitable to	our	opponents.	Ultimately,	our	argument	doesn't turn	on	any	dispute about	categorization	and	diagnostic	criteria. Likewise,	we	take	no	stand	on	how	to	best	understand	mental	illness	or	what properly belongs to it.	We use the terms "mental illness," "mental disorder," and "psychopathology"	interchangeably,	whatever	differences	they	might	suggest.	Given that	we	rely	on	the	heterogeneity	of	mental	disorders	generally, it	should	come	as no surprise that we are skeptical there is much to be gained in greater terminological	precision. We begin by characterizing the standard approach to mental illness and moral	responsibility	and	contrasting it	with	our	preferred	account	(Section	2).	We then examine how one's theory of responsibility will affect whether or not the symptoms of a	mental disorder excuse (Section 3). Next	we discuss how, on any theory,	symptoms	can	affect	moral	responsibility	by	bypassing	or	diminishing	one's agency.	However,	we	show	that	psychopathology	affects	agency	in	such	a	variety	of ways that	we	cannot	draw	an inference	about	one's	moral	responsibility from the fact	that	one	has	a	mental	disorder	(Section	4).	Finally,	we	consider	special	cases	in which symptoms	might actually enhance one's responsibility,	which raises a final complication for the standard approach (Section 5). We conclude with a more nuanced	account	of	the	purported	relationship	between	psychopathology	and	moral responsibility,	and	we	briefly	discuss	some	implications	of	this	approach	(Section	6). Page 4 of 18 2.	The	Naïve	View Merely labeling a mental condition a "disorder" strikes many people as at least typically	mitigating	some	forms	of	responsibility	(Edwards	2009).	Psychiatrists	will often	describe	mental	disorders to their	patients in the same	ways	as	non-mental illnesses,	such	as	diabetes,	precisely	because	it	suggests	the	disorder	is	out	of	one's control	(Arpaly	2005). Philosophers	also	commonly	treat	the	possession	of	a	mental	disorder	as	an excusing	condition.	Galen	Strawson,	for	example,	identifies	as	paradigm	constraints on one's freedom the manifestation of	mental disorders, including "kleptomaniac impulses,	obsessional	neuroses,	desires	that	are	experienced	as	alien,	post-hypnotic commands, threats, instances of force	majeure, and so on" (1994, 222; quoted in Meynen 2010). Similarly, when discussing cases in which individuals are simply exempt from being held accountable for their actions, R. J. Wallace includes as "accepted	exemptions"	cases	of	"insanity	or	mental	illness"	(1994:	165),	along	with childhood, addiction, psychopathy, posthypnotic suggestion, and the like. Daniel Levy (2003) even names more specific disorders-e.g. PTSD, Tourette's, schizophrenia, alien hand, bipolar disorder, and obsessive-compulsive disorder- and	considers	them	all	"maladies"	of	free	will	(cf.	also	the	treatment	of	depression	in Coates	&	Swenson	2013). These	approaches	aren't	patently	absurd	at first	glance.	Decision-making is, after	all,	a	mental	phenomenon	and	mental illness	will	certainly	be	related	to it in some	way-e.g.	by	affecting	one's	preferences,	perceptions,	reasoning,	and	attention span. For instance, even if severe depression doesn't significantly mitigate responsibility, it certainly affects one's desires (e.g. a lack of interest in daily activities). So	mental disorders	may always affect responsibility to a small extent, whether	by	influencing	one's	choices	or	one's	control	over	outcomes.	But	these	sorts of	factors	can	be	relevant	to	some	degree	without	mitigating	blame,	similar	to	one's immediate environment, culture, genes, and mood. For example, while some emotions	may hinder self-control, an adult is	normally still fully blameworthy for attacking a child during a fit of rage. What interests many philosophers and policymakers is:	When	does a factor, like psychopathology, affect one's capacities and abilities to a sufficiently high degree that it mitigates or eliminates responsibility? It	can	certainly	be	tempting	to	think	that	mental	disorders	always	or	nearly always excuse. Responsibility and blame are the provinces of desert and punishment, and on one extreme psychopathology is thought of as a prime candidate	for	removing	someone	from	the	ordinary	social	practices	in	which	these notions operate. The mentally ill are to be treated, not punished (or praised, presumably). Call this approach the Naïve view. On this view, an individual's psychopathology	implies	something	about	their	moral	responsibility;	mental	illness as	such	affects	individual	responsibility. Page 5 of 18 Why	might	someone	adopt	the	Naïve	view?	We	aren't	aware	of	any	rigorous articulation	or	defense,	but	we	can	think	of	several	possibilities. First, one might argue that mental disorders are pathological, almost by definition, and so actions influenced by them inherit the property of being pathological or disordered. The idea here is that being classified as a disorder already	tells	us	something	about the	possibility	of	an	agent's	being	responsible for actions	produced	or	significantly	influenced	by	that	disorder.	However,	just	because an	action	is	in	some	sense	pathological,	it	doesn't	imply	that	one	is	thereby	excused. We'll see that there	are clearly some	cases in	which	one is still responsible for	an action	despite	it	being	the	result	of	a	mental	disorder. A	second	rationale	for	the	Naïve	view	is	the	idea	that	one	isn't	responsible	for actions	resulting	from	psychiatric	disorders	because	one	isn't	ultimately	responsible for	having	the	disorder	itself.	The	thought	is	reminiscent	of	"sourcehood"	principles according to which, roughly, one is responsible for one's action only if one is responsible	for	what	led	to	it	(Strawson	1994).	An	initial	problem	for	this	rationale is that it might overgeneralize to ordinary actions that don't arise from the symptoms of a mental disorder. Ultimately, none of us are responsible for the sources	of	our	actions if	we	trace	the	causal	chain far	enough	back.	So in	order	to make	this	kind	of	rationale	applicable	to	mental	illness	in	particular,	as	opposed	to an uninformative general skepticism, one would have to argue that neurotypical people can	be responsible for the springs	of their actions in	ways that those	with mental	disorders	cannot.	We	doubt	there	is	a	clear	sense	of	sourcehood	such	that	all and	only	mental	disorders	will	undermine	it. One	can	still	appeal	to	sourcehood	as	part	of	a	skeptical	argument	regarding the	very	possibility	of	responsibility.	But	such	a	skeptical	thesis	would	establish	the Naïve view for the wrong reasons. We're exploring whether there is a general relationship	between	moral	responsibility	and	psychopathology	that	is	grounded	in facts internal to both of these concepts, not reliant upon a controversial position held	for	reasons	that	don't	have	to	do	with	the	specifics	of	mental	illness. Third, some might argue that mentally disordered individuals are simply exempt from	our usual practices of holding people responsible. Like children and non-human	animals,	those	with	mental	disorders	are	not	appropriate	targets	of	the "reactive attitudes," such as resentment, that support at least some of our core responsibility	practices.	Some	have	argued	for	this	sort	of	conclusion	for	particular subsets	of	mental	disorder,	such	as	psychopathy	(e.g.	Shoemaker	2015).	At	least	for some	disorders	with	more	pronounced	and	serious	effects, a	kind	of "deep-rooted psychological	abnormality"	(Strawson	1962:	11)	might	warrant	taking	an	"objective attitude"	toward	the	individual,	as	a	thing	to	be	controlled	or	managed,	rather	than held responsible. Or perhaps the idea is that	mental disorders lead to irresistible impulses that preclude proper control	over one's conduct (cf.	Wallace 1994: 169; contrast Pickard 2015). At any rate, whatever the prospects for exempting those with	particular conditions,	we'll see that such	a conclusion is	difficult to	establish with	respect	to	mental	disorders	generally	or	even	an	interesting	subset	of	them. Page 6 of 18 Perhaps	there	are	other	plausible	arguments	for	the	Naïve	view.	We	think	it's already evident that the foregoing have several shortcomings. In fact, we'll argue that	we	shouldn't	expect	that	there	is	any	psychopathology	for	which	possession	of it	implies	anything	definite	about	a	person's	responsibility	for	action.	Ultimately,	we think	any	informative	version	of	the	Naïve	view,	regardless	of	its	rationale,	will	face the same	general	obstacle.	What the	view	requires, and	what	we	deny, is that the class	of	mental	disorders (or some	subset	of them) is	unified	in	a	way that	makes possible a generally supportable inference of the form: if an agent has a mental disorder,	some	conclusion	about	their	moral	responsibility	follows. If the Naïve view is not plausible, we must look more carefully at the distinctions among kinds of disorders, as	well as the features of individuals	most relevant to their responsibility. Indeed, our Nuanced account is decidedly unqualified, for we contend that there is no general relationship between moral responsibility	and	psychopathology;	we	must	evaluate	responsibility	on	a	case-bycase	basis.	Alas,	simplicity	must	give	way	to	complication. Other ethicists may seem to develop nuanced accounts but don't go far enough.	David	Shoemaker	(2015),	for	example,	has	argued	for	an	account	that	may seem	similar	to	ours.	He	denies	that	mental	disorders	necessarily	excuse,	but	thinks this	is	because	the	concept	of	responsibility	itself	is	nuanced.	He	contends	that	there are senses of "responsibility" (such as "attributability" and "accountability"), only some of which apply to those with particular disorders, but which sense can correspond to which disorder varies. For example, he writes that "clinically depressed agents' attributability is (at least) mitigated" (143) and people with "high-functioning autism are (at least) impaired for accountability" (147). So, for particular	kinds	of	responsibility,	Shoemaker	maintains	what	we're	calling	a	version of "the Naïve view." Similarly, Carl Elliott (1996) doesn't contend that all	mental disorders bear the same relationship to responsibility, yet he still argues roughly that psychopaths and those with compulsive disorders categorically aren't responsible,	while	people	with	personality	disorders	are. Other	ethicists	have	held	views	that	look	more	nuanced.	Nomy	Arpaly,	for	example, writes	that,	"while	many	mental	disorders	do	seem	to	provide	exempting,	excusing, or	mitigating	conditions,	some	do	not,	and	with	others	things	are	complicated" (2005:	291;	cf.	also	Feinberg	1970;	Meynen	2010;	Kozuch	&	McKenna	2015). However,	even	this	statement	suggests	that	some	disorders	categorically	excuse.	At any	rate,	we	aim	to	contribute	a	more	detailed	argument	and	framework	on	which to	base	the	Nuanced	view. 3.	How	Theory	Matters An initial complication is that some symptoms of mental disorders might affect responsibility but only on some theories. We'll see that there is some significant amount	of	agreement	about	which	factors	excuse.	However,	examining	some	points of	contention	helps	to	reveal	the	complex	relationship	between	moral	responsibility and	psychopathology. Page 7 of 18 Unsurprisingly, there is an enormous philosophical literature on the necessary	and	sufficient	conditions	for	responsibility.	We	cannot	possibly	canvas	it all here. Instead, we propose to highlight a few features of agency that different theories	of responsibility have emphasized, exploring the	ways in	which different disorders will be more or less threatening to those features. The aim is not to present	a	thoroughgoing	typology	of	theories,	but	rather	to	examine	some	ways	in which	the	answer	to	whether	a	mental	disorder	excuses	may	be	theory-dependent. We	will focus	on three features	of agency that are central to	discussions	of moral	responsibility:	choice,	control,	and	coherence.	These	features	may	overlap,	and there is certainly room for disagreement as to which are necessary for moral responsibility. But, since our aim here is not to adjudicate between competing theories, we will speak fairly broadly and consider elements familiar to a wide variety	of	approaches	to the	questions	of free	will	and	responsibility.	Additionally, we	are	skeptical	that	a	single	theory's	preferred	feature	of	agency	can	be	privileged as	the	common	sense	thinking	on	the	matter	(cf.	May	2014). Some theories emphasize the notion of a free choice between genuine options. On such approaches,	what responsibility requires is that the agent select from a range of available alternatives, electing and enacting one of them, unconstrained	from	external	forces	(Kane	1996).	Accounts	will	vary,	of	course,	as	to the	strength	and	stringency	of	these	requirements.	Nevertheless,	these	views	often stress the agent's ability to consider a range of actions they might perform, and choose	without	constraint	which	one	to	execute.	(While	not	required,	these	accounts tend toward accepting the incompatibility of responsibility and determinism. The thought is that	determinism	would	preclude	alternatives from	which	an individual could	meaningfully	choose.) Other theories focus less on choice among alternatives and more on exercising effective control. On some views, it is appropriately recognizing and responding to the reasons one has (Fischer & Ravizza 1998). Other views favor characterizing	control	as	a	power	to	cause	one's	actions	in	a	particular	way	(Clarke 1993).	Uniting	these	views	is	the	thought	that	the	realm	of	the	intentional	is	unique and uniquely important for responsible agency. Responsibility for what we do depends	on	our	ability to identify	and	assess	reasons,	reasons	upon	which	we	can then act. These views also highlight how lack of control often undercuts one's responsibility. When an agent does something entirely by accident, it looks as though	they	are	(to	some	extent)	excused. In contrast to the	way in	which	an	action	or choice is	brought	about, some views	of	responsibility	emphasize	the	coherence	the	action	(and	its	motivations)	has to the agent's psychology (Frankfurt 1971; Wolf 1987). Actions can reflect or express	aspects	of	an	agent's	psychology	to	varying	degrees	and	mental	states	can be more or less well-integrated into the agent's overall psychology. The guiding thought	here	is	that	an	agent	is	more	responsible	the	more	reflective	of	their	moral selves their action is	or the	better integrated its	motivations.	A	deeply committed racist	is	all	the	more	blameworthy	for	their	racist	remarks	than	one	who	makes	an Page 8 of 18 out-of-character insensitive comment. Responsibility is undercut, therefore, when the	action	fails	to	manifest	the	agent's	real	commitments	and	values. To	see	why	the	answer	to	whether	psychopathology	excuses	may	be	theorydependent, it will help to consider some disorders. Take obsessive-compulsive disorder (OCD), for example, which is characterized by persistent and unwanted thoughts	or	urges	and	repetitive	actions	performed	as	responses	to	the	obsessions. Should	someone	who	suffers	from	OCD	be	excused	when,	say,	he	knowingly	breaks	a promise to attend his daughter's piano recital in order to repeatedly wash his hands? The	answer	seems	to	depend	on	which	view	we	adopt.	On	views	that	stress the	importance	of	choice,	the	fact	that	an	action	is	a	compulsion	seems	prima	facie excusing. It isn't that the agent freely selected among their options. Instead, their options	were	unusually	constrained,	much in	the	way	a	bank	teller	has 'no	choice' but	to	hand	over	the	money	at	gunpoint	(but	see	Pickard	2015).	Similarly,	on	some control-based	views,	one	may	be	excused	if	the	nature	of	the	compulsion	undercuts the	agent's	ability	to	recognize	or	respond	to	the	relevant	reasons.	The	compulsive behavior quiets an intrusive urge, rather than reflects the agent's assessments of what	was	worth	doing. In	contrast,	a	control-based	view	that	only	requires	the	agent	to	control	the action intentionally by exercising special causal powers could still find the compulsive	responsible,	if	the	action	was	brought	about	in	that	way.	Most	strikingly, perhaps, on a coherence view, nothing internal to the view	prohibits agents from endorsing or identifying with the obsessions that motivate their behaviors. For example, rather than seeing one's obsessive behaviors as alienating, one might endorse	the	life	of	trying	to	be	meticulously	clean	or	taking	all	safety	precautions.	It is thus possible for such agents to achieve the sort of integration required to be responsible, even if OCD	will likely excuse	on	most versions of a coherence view. Indeed, OCD often varies in the degree to which patients have insight to their disorder.	Those	with	more	insight	are	presumably	more	aware	of	the	irrationality	of the obsessions, and so may be less likely to identify with those desires (cf. Shoemaker	2015:	ch.	4). Not	all	disorders	will	garner	these	same	results.	Consider	major	depressive disorder,	partially	characterized	by	depressed	moods	for	most	of	the	day,	feelings	of worthlessness, weight loss, and lowered motivation to engage in activities. On coherence views, such agents may be excused, for their motivations to remain indolent or shun interaction are not	well integrated into their overall psychology. Nevertheless, depressed individuals may have no problems controlling their conduct, even when depressed. Their depression need not inhibit their ability to perform	actions for	reasons	of	which	they	are	aware	or to	bring	actions	about	via special	causal	relations.	Whether	or	not	a	person	with	major	depressive	disorder	is excused	depends	on	the	details. More generally, theories premised on coherence must address whether a mental	disorder	expresses	or	masks	one's	true	self.	Yet,	as	Jeanette	Kennett	(2007) Page 9 of 18 points	out,	a	patient's	loved	ones	often	say,	"He's	not	really	like	this"	or	make	similar proclamations.	Many	mental	disorders	(e.g.	schizophrenia	and	dementia)	set	in	well after	one	has	an	established	personality	and	identity.	Other	disorders	may	be	more difficult	to	dissociate	from	one's	real	self,	especially	those	that	tend	to	develop	early in	one's	life,	such	as	autism,	Tourette's	syndrome,	and	various	antisocial	personality disorders. Theories that do not rely on a real self, however, need not grapple so much	with	this	issue.	For	example,	someone	with	kleptomania	may	exhibit	sufficient control	over	stealing	some	jewelry,	whether	or	not	it	issued	from	her	true	self. Just	as	we	cannot	canvas	every	approach	to	moral	responsibility,	we	cannot consider	here	every	disorder.	We	hope	to	have	provided	merely	a	sampling	of the ways	in	which	the	symptoms	of	a	psychiatric	disorder	might	excuse,	depending	on the	particular	approach	to	free	will	or	moral	responsibility	employed.	To	the	extent that	theories	of	responsibility	will	vary	in	the	conditions	or	features	of	agency	they prioritize,	there	will	be	variance	in	the	degree	to	which	the	symptoms	of	particular disorders	will be potential threats to responsibility. This complicated relationship between	mental	disorders	and	responsibility	is	enough	to	raise	initial	doubts	about the	Naïve view.	No standard approach to	moral responsibility supports a general inference	from	mental	disorder	to	any	particular	claim	about	responsibility. 4.	Bypassed	or	Diminished	Agency It's controversial whether moral responsibility requires choice, control, and coherence, but nearly all agree that it requires "agency." Agents believe things, intend things, and desire things. They make and revise plans, reflect on their motivations,	and	judge	ends	to	be	more	or	less	worth	pursuing.	They	seek	to	make their	actions intelligible	and	conform	to	norms	they	accept.	Regardless	of	whether all of these capacities	are	essential to	agency	as such, it seems	only	agents can	be (morally) responsible for their actions. And, importantly, it seems that when individuals	are	responsible for	an	action it is	due	to features	of their	agency	or its exercise. A mental disorder plausibly excuses, then, if its symptoms yield an action that	entirely	bypasses	one's	agency,	such	that	an	outcome	is	the	result	of	no	action	at all	or	an	entirely	unintentional	one.	Consider,	for	instance,	narcolepsy,	characterized by	abnormal	sleepiness	during	the	day	or	lapses	into	sleep,	and	often	accompanied by cataplexy, or sudden muscle weakness that often makes patients collapse. Suppose	a	narcoleptic	is	prone	to	sudden,	unpredictable	cataplexy,	and	during	one such episode, drops the priceless vase he	was carrying. Ordinarily, one	might be blameworthy for dropping a vase. But it seems the mental disorder provides a ready, and full, excuse.	His	narcolepsy	excuses	him in	a	way that	one	who	simply tripped	or	was	distracted	is	not. Now it	might be argued that such excuses are limited. Once one becomes aware that one has a disorder, one has a responsibility to manage its effects. Suppose,	for	example,	that	a	patient	with	schizophrenia	responds	well	to	treatment with an anti-psychotic	medication like loxapine. If she discontinues	use, however, Page 10 of 18 she typically has haunting hallucinations that cause her to violently attack those around her, misperceiving them as imminent threats. In such cases, where symptoms	are	expected	and	their	effects	can	be	mitigated,	one	might	be	responsible for harming others, even if it is due to hallucinations, because the patient knows such situations can be prevented by staying on the	medication. In such cases,	we might	attribute	responsibility	for	an	outcome	that	resulted	from	diminished	agential capacities by transferring the responsibility one has for not allowing those capacities to diminish in the first place (cf. the "transfer principle" in Summers	& Sinnott-Armstrong	2015). However, this oversimplifies the notion of tracing responsibility for acts to some prior opportunity to prevent them. Such scenarios are not common, as symptoms often first present without warning or can't be managed anyhow. Moreover, even when one can knowingly manage symptoms, it remains controversial how best to justify transferring responsibility to outcomes from failures	to	take	suitable	precautions	(cf.	King	2014). So,	if	narcolepsy	can	readily	excuse,	perhaps	most	other	mental	disorders	do as well. However, we must be careful not to generalize too quickly. "Mental disorders"	does	not	denote	a	homogenous	class.	Different	disorders	have	different properties,	they	affect	different	capacities,	and	the	ways	they	affect	those	capacities can vary widely. It would be surprising if, despite these differences, they all amounted to full excuses. Considering Tourette's syndrome is instructive. Many people assume tics are entirely unintentional or involuntary and thus clear candidates for	excusable	actions	not	performed	of the	patient's	own free	will.	But patients with this syndrome often report acting voluntarily; it's just increasingly difficult to overcome the impulse (Schroeder 2005). While those with Tourette's syndrome	may	sometimes	lack	responsibility	for	their	tics,	this	case	illustrates	that matters	are	often	more	complicated	than	they	seem. There is further reason to believe that	we can't generalize from cases like narcolepsy.	The	disorder	seems	to	excuse	dropping	the	vase	so	completely	because the condition is	directly	relevant to the action in a	way that does not hold true of every mental disorder. For example, contrast narcolepsy with someone suffering from	OCD	who	experiences	intrusive	and	unwanted	thoughts	that	cause	anxiety.	In many cases, an episode of such intrusion	will have no bearing on their ability to carry the vase. And so their mental disorder will not significantly affect their responsibility for	dropping	the	vase,	should	they	drop it.	Thus, it	seems	that	one's disorder	must	not	only	compromise	a	capacity	relevant	to	responsibility,	but	it	also must	be	relevant	to	the	act	in	question	(Feinberg	1970:	273). To further illustrate, suppose a man with attention-deficit/hyperactivity disorder (ADHD) assaults an individual at a sporting event after an angry confrontation that escalated from a disrespectful gesture into violence. ADHD involves	difficulties	in	paying	attention,	staying	focused,	and	organizing	one's	life	for success	in,	say,	school	or	work.	Given	the	nature	of	this	disorder,	it	is	unlikely	that	it played a crucial role in generating an aggressive action, especially one that	might Page 11 of 18 typically arise in anyone without ADHD, as it simply involves relatively normal emotional	reactions	to	a	show	of	disrespect. Now,	ADHD	can	involve	increased	impulsivity,	in	which	case	the	symptoms	of the	disorder	may	play	a	crucial	role	in	an	act	of	aggression.	A	similar	analysis	seems appropriate	for	conduct	disorders	affecting	impulsivity,	such	as	kleptomania,	which can	obviously	play	a	key	role	in	an	act	of	stealing.	Even	if	it's	controversial	whether kleptomania should excuse or mitigate responsibility, this is a case where the disorder	quite clearly influences the	act in	question, such that someone in similar circumstances but without kleptomania likely would not steal. In the same vein, however, kleptomania would appear irrelevant to a case of acting out of aggression-indeed,	irrelevant	to	most	of	the	actions	one	performs. Of course, it may seem uncharitable to say the Naïve approach holds that anyone with a psychiatric disorder is thereby excused from all of their actions, including	those	not	influenced	by	the	disorder's	symptoms.	However,	we	think	that even a	more charitable version of the view is problematic, for there are cases in which	actions can	be	affected	by	a	mental	disorder	without	yielding	mitigation	or excuse. Part	of	the	reason	psychopathology	only	sometimes	excuses	lies	in	the	notion of capacity. By definition, mental disorders affect mental capacities, and some of these capacities are integral to freedom and responsibility. However, diminished capacity	does	not	entail	lack	of	capacity	(Glannon	2011,	ch.	3).	Many	disorders,	such as	autism,	involve	a	varied	spectrum.	Some	patients	with	autism	may	appropriately be described as having an inability to pick up on non-verbal social cues or even navigate the social world successfully whatsoever. Others, however, have only minor difficulties in this respect. Indeed, many disorders-from depression to bipolar	disorder	to	psychopathy-are	recognized	to	present	along	a	continuum.	The upshot	is	that,	for	many	disorders,	being	diagnosed	does	not	necessarily	affect	one's responsibility	and	certainly	not in the same	way as	others in the	diagnosed	class. Sometimes the symptoms will be so slight so as to hardly diminish a relevant agential	capacity. Now,	a	proponent	of	the	Naïve	view	might	emphasize	that	mental	disorders can excuse even	when they don't entirely bypass one's agency; they just need to compromise it to a significant degree. Consider, for example, the famous case of Clark	vs.	Arizona (48	U.S. 735 2006). The defense argued that Clark did not kill a certain	police	officer	intentionally	because	he	thought	the	officer	was	a	space	alien, due to his paranoid schizophrenia (discussed in Morse 2011). Now the Supreme Court	thought	Clark	still	knew	this	was	wrong,	but	other	delusions	or	hallucinations might	lead	one	to	do	something	that,	from	one's	own	perspective,	should	be	counted as	morally	permissible	(cf.	Broome	et	al	2010:	183).	However,	even	in	these	cases, one's	agency	in	the	particular	circumstances	is	substantially	compromised. It's certainly true that a	mental disorder's symptoms can excuse	wrongful acts without entirely bypassing one's agency. But normally the symptoms must significantly undercut one's agency. Consider, for example, ADHD	which does not Page 12 of 18 appear	to	disrupt	one's	general	capacity	to	form	intentions	and	act	on	them.	When someone with this disorder acts, their agency is not necessarily diminished substantially. One's ability to focus may be limited, but this may not distinguish ADHD	from	more	ordinary	conditions	like	being	tired	or	upset.	(Various	mild	forms of	anxiety	disorders	may	be	similar	in	this	respect.) Further complexities loom, for there are many ways in which mental disorders	might	(or	might	not)	significantly	affect the	exercise	of	one's agency.	To illustrate,	let's	draw	two	cross-cutting	distinctions	that	can	be	applied	to	categorize how	disorders	might	present	themselves. First, a disorder can be episodic or static. Episodic disorders present themselves in (more or less) discrete instances. Narcolepsy, again, is a good example, as the associated loss of consciousness comes in discreet instances. Though	a	patient	with	narcolepsy is	always	possessed	of their	condition, it is	only episodically activated, as it were. Similarly, while there is currently no cure for Alzheimer's,	patients	can	within	the	same	day	go	from	experiencing	relative	clarity of mind to confusion, despite unchanged neurodegeneration (Palop et al. 2006). Other	examples	might	include	dissociative	identity	disorder,	PTSD,	bipolar	disorder, specific delusions, and various phobias-each of which can manifest in discrete episodes, sometimes in response to specific triggers. In contrast, some psychopathologies	are	more	static, like	autism,	depression,	psychopathy,	dementia, and	generalized	anxiety	disorder.	The	ways	in	which	each	manifests	is	more	likely	to persist	over	time,	with	no	clear	boundaries.	Perhaps	their	effects	can	wax	and	wane, but	we	wouldn't	naturally	carve	them	up	into	discrete	episodes. The	second	distinction	concerns	the	degree	to	which	a	disorder	impinges	on one's	agency.	Narcolepsy,	for	example,	has	quite	global	effects:	loss	of	consciousness undermines the affected agent's abilities across the board. In contrast, certain disorders	may	only	be	relevant	to	a	subset	of	agential	abilities,	yielding	more	local effects.	For	instance,	kleptomania,	as	a	compulsion,	presents	as	strong	urges	to	steal, but	it	leaves	other	elements	of	an	agent's	psychology	relatively	untouched.	Specific or	"simple"	phobias	are	another	kind	of	example,	as	they	are	tied	to	certain	cues,	e.g. spiders, heights, or blood. Similarly, while some delusions can be systematic and elaborated	(as in forms	of	schizophrenia),	others	are	rather	specific	and	relatively circumscribed, as when patients with Capgras take a familiar person to be an imposter	(Bortolotti	2015). These	distinctions cross-cut, so	either	element	of each can	pair	with	either element	of	the	other	(see	Table	1).	Narcolepsy	is	an	episodic,	global	condition,	while severe	schizophrenia	may	be	a	static	condition,	but	still	with	global	affects.	Anxiety disorders may have localized effects, despite being static conditions, while some episodic	conditions,	like	specific	phobias,	will	similarly	only	present	locally. Page 13 of 18 Table	1:	Kinds	of	Effects	on	Agency Episodic Static Local e.g. phobias e.g. anxiety disorders Global e.g. narcolepsy e.g. schizophrenia Drawing these distinctions further motivates the Nuanced Account. Regardless	of	whether	a	disorder	has	only	local	effects	to	agency	or	global	ones,	and irrespective	of	whether it	operates	episodically	or	statically,	psychopathologies	do not support a general effect on responsibility across all contexts. The case in question may not be a relevant episode, or it might not involve the agential capacities the disorder affects. Even global, static disorders,	which	might seem to lend	the	most	support	to	the	Naïve	view,	don't	support	the	general	inference.	Having a	disorder	with	widespread	effects	on	agential	capacities	that	operates	across	time doesn't	guarantee	that	those	effects	were	present	in	the	given	case.	In	short,	as	the Nuanced view holds, establishing that an agent has a particular psychopathology tells	us	nothing	about	their	responsibility. 5.	When	Symptoms	Enhance Let's consider	one last reason to favor the	Nuanced	account.	The	Naïve	view	says that, in	general,	mental illness	excuses relevant	behavior	or significantly	mitigates blame	(and	praise).	This	is	further	suspect	given	that	some	symptoms	are	capable	of enhancing	one's	responsibility. We often associate mental disorders with deficits in various capacities. However,	what	might	normally	disrupt	an	ordinary	person's	life	may	turn	out	to	be beneficial	in	certain	circumstances.	The	early	effects	of	dementia,	for	example,	might free one from haunting memories of abuse (Earp et al. 2014). Similarly, while typically unpleasant, anxiety can alert one to relevant information and reduce uncertainty about potential threats to oneself or others (Kurth in press). Even delusions can serve as defense mechanisms to help patients overcome obstacles, such as psychological trauma or low self-esteem, by making sense of their experiences (Bortolotti 2015), not unlike the rationalizations frequently found among	neurotypical	individuals	(cf.	Summers	2017;	May	forthcoming). So it's	possible that, even if	harmful	overall, a	mental	disorder's symptoms may enhance certain capacities, such that, surprisingly, one becomes, as Stephen Morse (2006) puts it, "hyper-responsible." Here we may find parallels with the enhanced responsibilities of those possessing advanced skills or knowledge (Vincent	2013),	as	when	we	hold	only	physicians	accountable	for	failing	to	provide medical	advice	for	someone	ill	on	an	airplane.	Perhaps	enhanced	capabilities	merely increase the number or kinds of responsibilities, rather than degrees of responsibility itself (Glannon	2011,	p.	120).	Nevertheless, enhanced responsibility can	result from	an increase in	mental	capacity,	whether from	learning, ingesting	a pill,	or	mental	disorder. Page 14 of 18 Conditions that increase attention are natural candidates. Consider, for example, disorders involving episodes of hypomania, such as bipolar	disorder (cf. Arpaly	2005:	290;	Morse	2006;	Vincent	2013).	Unlike	mania,	episodes	of	hypomania don't severely disrupt one's life, but in either case patients often need	much less sleep (e.g. "feels rested after only 3 hours of sleep"), have a "flight of ideas," and increased "goal-directed activity" (DSM-5, 124). Some of these symptoms read as desired	effects	of	cognitive	enhancers, like	amphetamine	or	modafinil,	even if they can be rather disruptive in many contexts or when combined with other typical symptoms (e.g. engaging in risky behavior).	However, it is important to note that patients often don't have knowledge of, or control	over,	when they	will have any purportedly enhanced capacities during hypomania, and thus it may seem inappropriate to hold them more accountable (Turner 2010), at least in many circumstances. Perhaps this is less of a limitation for another candidate for enhancing responsibility: OCD. The obsessive thoughts are often tied to a specific anxiety or source	of	distress,	such	as	uncleanliness	(e.g.	excessively	washing	hands)	or	danger (e.g.	locking	a	door	repeatedly).	Those	with	scrupulosity,	in	particular,	are	especially concerned to behave morally, often concerning others believed to be in need (Summers & Sinnott-Armstrong 2015). Such hyper-awareness and sensitivity to morally relevant considerations	may, in certain circumstances, enhance capacities relevant to freedom	and	responsibility.	For	example,	suppose	Saul	leaves	the	door unlocked and a family of raccoons ransack the house.	We	might hold Saul more responsible given his hyper-awareness of whether the door is locked. Similarly, while	we	might	praise	Sally	for	mindlessly	locking	the	office	door	and	preventing	a robbery,	we'd	likely	praise	Saul	even	more	if	it	resulted	from	his	heightened	concern for safety. But notice that it's not the possession of psychopathology as such that enhances one's responsibility; it's the specifics of a certain symptom and circumstance. 6.	The	Need	for	Nuance The diversity of ways in which the symptoms of mental disorders affect action makes them an extremely heterogeneous class, such that there is no supported general inference from	having a	mental disorder to any claims about	one's	moral responsibility.	Mental	illness	can	sometimes	excuse	actions,	provided	the	symptoms significantly undermine some feature of one's agency that generated the act in question.	While	it	remains	controversial	which	features	of	agency	are	necessary	for responsibility	(e.g.	choice,	control,	or	coherence),	there	is	substantial	overlap	among the	various theories	of responsibility.	Even in this region	of	overlap,	however, it's clear	that	mental	illness	sometimes	excuses	and	sometimes	doesn't.	Many	disorders have local, rather than global, effects on specific agential capacities, sometimes in fairly	discrete	episodes	that leave	the	rest	of	one's life	relatively isolated from	the disorder's	effects.	Moreover,	many	disorders	lie	on	a	spectrum,	and	at	many	points one's agential capacities are diminished to some degree but not sufficiently diminished. Page 15 of 18 We	thus	ought	to	reject	the	Naïve	view	and	adopt	a	Nuanced	account	of	the relationship	between	moral	responsibility	and	psychopathology.	There	is	no	reason to	believe	that	having	a	mental	disorder	generally	makes	one	less	responsible	than those	who	enjoy	better	mental	health. To further illustrate, let's briefly return to the legal cases with which we began. Since these are actual events, they are complex and we certainly lack sufficient evidence to know all of the relevant facts. Nevertheless, we can try to apply some of the lessons developed here. In both cases it is plausible that symptoms	from	the	defendants'	mental	disorders	did	contribute	to	the	criminal	acts in	question.	In	Yates's	case,	her	psychiatrist	warned	about	having	a	fifth	child	when Yates attempted to commit suicide soon after having her fourth. So it seems her major postpartum depression and various delusions plausibly contributed to her intention to end her children's lives just months after the birth of her fifth. In Routh's case,	his	PTSD	plausibly contributed to the	murders, as	his attack	was	on two	military	veterans	at	a	shooting	range.	However,	arguably	these	disorders	do	not typically	yield	actions	that	bypass	one's	agency	entirely.	Thus,	as far	as	morality is concerned,	we	may unfortunately be left	with theory-dependent considerations- e.g.	about	whether	these	defendants	lacked	sufficient	choice,	coherence,	or	control. Arguably,	these	are	precisely	the	sorts	of	considerations	to	which	the	law	should	be sensitive,	even	if	current	practice	has	yet	to	be	suitably	responsive. Indeed,	despite	public	discourse	on	such	high-profile	cases,	the	law	generally operates	with	something	like	our	Nuanced	view,	applied	specifically	to	legal	liability. Lawyers	can't	simply	establish	that	their	clients	have	a	mental	disorder.	They	must show	that	the	relevant	symptoms	of	the	disorder	causally	contributed	to	the	act	in question	and	compromised	some	psychological	capacity	relevant	to	the	elements	of legal	liability,	such	as	negating	the	requisite	mens	rea	or	voluntary	act. A	similar	approach	arises	in	medical	settings.	The	competence	of	patients	to make an informative and autonomous decision is not determined simply by categorizing them as having a mental disorder. Rather, doctors and caregivers evaluate	the	specific	case	at	hand,	quite independently	of	how	the	patient fits into categories	found	in	the	DSM	(see	e.g.	Appelbaum	2007). Our	view	may	appear	harsh	on	the	victims	of	mental	illness,	suggesting	that there are many circumstances in which they are responsible, even for acts substantially influenced by their symptoms. However, the Nuanced account precisely shirks any such general claims about moral responsibility and psychopathology.	Sometimes	one	is	responsible	despite	a	mental	illness,	sometimes not. Indeed,	we resist the idea that those	with psychiatric disorders are	always appropriate	targets	of	praise	and	blame.	Consider,	for	example,	Pamela	Bjorklund's (2004) view that those with personality or character disorders are "rightly 'responsible' for their actions" (190).	Her	position is	partly	a	defense	of therapies that encourage such patients to "take responsibility" for their behavior, including their aim	of achieving	mental health.	More generally,	Hannah	Pickard argues that Page 16 of 18 "psychopathology does not strip people of free will" (137), at least not by eliminating	choice	or	the	ability	to	do	otherwise.	Of	course,	if	read	as	mere	denials	of the	idea	that	having	a	mental	disorder	always	mitigates	one's	blame,	then	we	agree. But	we	caution	against	any	generalizations	of	the	form	that	possession	of	a	mental illness	implies	anything	about	responsibility	for	action. Nevertheless, the more nuanced picture developed here does allow us to treat many who suffer from psychopathologies as autonomous agents whose decisions	about	how	to	live	we	should	respect.	Indeed,	being	responsible	allows	for the	possibility	of	praise	and	discourages	a	passive	attitude	toward	one's	condition that	can	impede	improvement	(Pickard	2015).	Our	approach	also	points	to	ways	in which	those	with	mental	disorders	may	exist	on	a	spectrum	with	the	neurotypical individual, who nonetheless may be exhausted, hungry, or prone to distraction, recalcitrance,	or fear.	Thus, the	Nuanced	account	might	be	viewed	as	supporting	a neurodiversity or integrationist approach to mental illness-where those with psychopathologies and the neurotypical are sometimes more alike than they are different-which	may	help	to	reduce	the	stigma	of	mental	illness. Acknowledgements: For helpful feedback on earlier drafts, we thank: Justin Caouette, Justin	Clarke-Doane,	Neil	Levy,	Kathryn	Tabb,	and	Jesse	Summers.	A	version	of this	paper was presented at a graduate seminar at Columbia University. Many thanks to Kathryn, Justin,	and	their	thoughtful	students	for	a	profitable	discussion	that	greatly	shaped	the	final version	of	the	paper. Page 17 of 18 References American Psychiatric Association (2013). 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