“To See and Listen to the Wicked is Already the Beginning of Wickedness”

I used to work in the lab with a young woman, on her way to medical school, who didn’t “believe in schizophrenia”.  Everyone hears those voices, she explained to us completely in earnest; to succumb to them was simple weakness.  “Schizophrenics”, she would say with air-quotes, were just lazy people gaming the system, exploiting disability and trying to get out of working.

This woman was obviously a malignant idiot (and she is now in medical school, so be very afraid), but I was stunned and fascinated by her.  I have spent my entire adult life working in neuroscience research, where people don’t question the essential validity of psychiatric illness.  We study schizophrenia because we believe it exists, because, and I can’t stress this enough, it does.  It emphatically does: schizophrenics are ill – they are not “lazy”.  I’d never met anyone who’d admit to not believing in mental illness before.

Imputing moral failings to people who suffer from psychiatric disease is retrograde and stupid, and I mention that here because I am about to do it.

There’s been a fair amount of press this week, in the wake of the conviction of Lacey Spears of the second degree murder of her son Garnett, about Munchausen by Proxy.

Munchausen is a factitious disorder, a disorder characterized by the fabrication of symptoms of somatic illness.  People with Munchausen often go to extraordinary lengths to receive medical attention for their fake illnesses: they research their “condition” obsessively, run up huge medical bills, poison or mutilate themselves; they have even been known to undergo surgeries that they do not need.

They do not believe that they have these disorders – Munchausen is not a disorder of delusion or psychosis.  Munchausen patients are deceptive, they are seeking attention and sympathy.

Despite the fact that there is, at this time, no known neurological lesion associated with Munchausen, I won’t dispute that someone who is so desperate for attention that they will drink bleach or undergo unnecessary amputations is mentally ill.  However, Lacey Spears didn’t have Munchausen; she had Munchausen by Proxy.

Munchausen by Proxy is Munchausen Disorder where the medical charades are enacted not on the sufferer but on someone else, usually a dependent, a child or an elderly parent.  Instead of poisoning themselves, people with Munchausen by Proxy poison their dependents, over and over and over again.

I just don’t know that I have what it takes to consider someone with Munchausen by Proxy mentally ill, a victim of their condition in the same way that someone with schizophrenia or bipolar is a victim of their’s.

The argument is that Munchausen by Proxy is a compulsion, that the “need” for attention is like the need that someone with obsessive compulsive disorder might have to wash their hands repeatedly.  That may be, but I doubt it: Munchausen by Proxy deceptions are methodical and controlled, not frantic and compulsive, and well enough in-hand to be perpetrated on other, vulnerable people.

More than that, I’m not sure I care.  This may be my failing – certainly, I believe that it is my responsibility to try to see the world as it is, whether or not it accords with my wants or expectations.  I know I’m not the first person to see a diagnosis as an excuse, and I’m not at all sure that’s company I want to keep.

But I’m not sure it’s right or wise to let every category of human wickedness hide behind pathology.  If you are “compelled” to put feces in your child’s feeding tube because you’re so needy for the attention of others, are you sick or are you so supremely selfish as to be fairly called evil?  Or are you both?  And do your actions really deserve our moral parsing?  Do we owe you the time and energy it takes to figure out why you’ve done this, why you’ve killed your own child for attention?  Do you deserve the protection a diagnosis gives you?

I’ve spent a lot of time thinking about evil people and evil acts – I find them interesting and I want to understand them, maybe more than I should.  I care where the line between illness and evil lies, and I think that, perhaps, I want to draw that line between compulsion to self-harm and compulsion to harm another.  I think it behooves us to treat self-mutilators as sick: they hurt, primarily, themselves.  But we lose moral credibility if, as a society, we decide that anyone who hurts anyone else must be “crazy”, or ill – we should not rob all wrong-doers of volition.

For whatever reason, the coverage of Lacey Spears left me cold and angry.  Even I have my limit, and maybe this is it.  I have a difficult time seeing Munchausen by Proxy as an illness – I see it instead as vileness, as tremendous and terrible selfishness.  And I don’t want to look for moral or psychological complexity in that kind of darkness any more; I just want to look away.

Title quotation by Confucius.

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