Ethics and Neurodiversity

Ethics and Neurodiversity
Copyright © 2013. Cambridge Scholars Publisher. All rights reserved.
Ethics and Neurodiversity, edited by Alexandra Perry, et al., Cambridge Scholars Publisher, 2013. ProQuest Ebook Central,
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Ethics and Neurodiversity
Edited by
C.D. Herrera and Alexandra Perry

Ethics and Neurodiversity,
Edited by C.D. Herrera and Alexandra Perry
This book first published 2013
Cambridge Scholars Publishing
12 Back Chapman Street, Newcastle upon Tyne, NE6 2XX, UK
British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
Copyright © 2013 by C.D. Herrera and Alexandra Perry and contributors
All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the copyright owner.
ISBN (10): 1-4438-4527-2, ISBN (13): 978-1-4438-4527-4

CONTENTS
Acknowledgments .................................................................................... viii
Introduction ................................................................................................. 1
What’s The Difference?
C.D. Herrera
Chapter One............................................................................................... 18
Noise and Metonymic Thinking in the Philosophy of Arthur
Schopenhauer: Some Benefits of Retrospective Psychiatric Diagnosis
Alexandra Perry
Chapter Two .............................................................................................. 39

Equality, Capability, and Neurodiversity
Douglas Paletta
Chapter Three ............................................................................................ 52

Policing Neurodiversity in Higher Education: A Discourse Analysis
of the Talk Surrounding Accommodations for University Students
Jessica Nina Lester, Hannah Dostal, & Rachael Gabriel
Chapter Four.............................................................................................. 67
Mindblindness: A Troubling Metaphor?
Janette Dinishak
Chapter Five .............................................................................................. 86

Antidepressants, Gender, and the Construction of the Moral Self
Kathleen Poorman Dougherty
Chapter Six .............................................................................................. 100

Do No Harm: Neurodiversity, Health Care Advocacy
and the Language and Culture of Informed Consent
Ralph Didlake & Jo Anne Fordham
vi Contents
Chapter Seven.......................................................................................... 111

The Virtue of Psychopathy: How to Appreciate the Neurodiversity
of Psychopaths and Sociopaths Without Becoming a Victim
Audrey L. Anton
Chapter Eight........................................................................................... 131

The Neurodiverse and the Neurotypical: Still Talking Across
an Ethical Divide
Deborah R. Barnbaum
Chapter Nine............................................................................................ 146

Who’s Counting? Cognitive Disability and Rawlsian Contractualism
Christopher Mesaros
Chapter Ten ............................................................................................. 178

How Empirical and Social Explanations of Normal Influence
Decisions to Treat the Neurodiverse
Keisha Ray
Chapter Eleven ........................................................................................ 191

From Neurodiversity to Neurocosmopolitanism: Beyond Mere
Acceptance and Inclusion
Ralph Savarese
Chapter Twelve ....................................................................................... 206

Neurodiversity and Personhood
William Simkulet
Chapter Thirteen...................................................................................... 217

Psychopathy, Moral Reasons, and Responsibility
Erick Ramirez
Chapter Fourteen ..................................................................................... 238

Psychopathy, Autism and Questions of Moral Agency
Mara Bollard
Chapter Fifteen ........................................................................................ 260

Are People with Autism Morally Responsible for Their Harmful
Actions?
Christian Perring and Adam Kohler
Ethics and Neurodiversity vii
Chapter Sixteen ....................................................................................... 276

Odysseus and “The Fools”: Applying Concepts of Neurodiversity
to the Ancient World
Kristina Chew
Notes........................................................................................................ 286
Contributors............................................................................................. 295
Index........................................................................................................ 300
ACKNOWLEDGMENTS
Earlier versions of some of the essays in this volume were presented at

two conferences during the past year. Those conferences, "Define
Normal," and "Social, Political, and Ethical Perspectives on Autism," were
hosted by Bergen Community College, and funded through grants from
the Center for Instructional Research and Development, as well as the
Society for Moral Inquiry. We thank all of those who helped to support,
organize, and contribute to these events. We are also grateful to Carol
Koulikourdi, editor at Cambridge Scholars Publishing, for suggestions on
format and focus. Finally, thanks are also due to our Special Projects
Editor, Jessica Romano. As usual, Jessica's patience was equaled by her
attention to detail, and her ability to work under pressure.
Winter, 2013
C. D. Herrera and Alexandra Perry, Society for Moral Inquiry
INTRODUCTION
WHAT’S THE DIFFERENCE?
C.D. HERRERA
Overview
There are trivial differences between people, just as there are what we
might consider trivial labels and offenses to go along with those differences.
Nevertheless, trivial differences are at least noticeable (as when we
routinely distinguish between those who have a sense of humor and those
who do not). They are noticeable enough to raise important questions
about which differences we are supposed to honor with a label, and what,
if anything, should be said when we do. I would have a hard time
convincing people that you had offended me when you claimed that I had
a bad memory. We typically make light of such things. But what if my bad
memory is due to some disability that I have had since I was a child? In
another setting, what if I say that you make me uncomfortable when you
walk over and begin speaking to me? It would be hard to fault me for that,
though I might not be given this latitude if I announced that it is not you,
but your kind that makes me uncomfortable.
Questions about differences and labels are no easier to avoid than
human interaction is, and it is hard to envision how we could survive
without both. In the settings that I just sketched, the point is to show that
there are things about those differences that we're not supposed to say, and
as some advocates for a more inclusive society might add, things we're not
supposed to think either. Interestingly, the warnings about how careful we
should be to respect differences have a familiar ring to them, as do the
warnings that we should be on the lookout for differences in the first place.
We are used to hearing that labels lead to or are a form of exclusion,
and that this is especially wrong when the differences have to do with
ethnicity or gender, for instance. Most of us probably also have a fairly
good grasp of the reasons for thinking that labels can cause harm. This is
easy to understand where skin color is concerned. Among the things that
2 Introduction
was wrong with the rules for segregated water fountains in the U.S., for
instance, was the fact that they left members of both groups to wonder
what they had done to merit such exclusive treatment. One cannot choose
a skin color, we might explain. Similar explanations would account for the
improvement in attitudes which led to more females being able to enter the
workplace. One can now change gender, but not easily, and this does in
any event only lead to new questions about that difference.
In instances like these, the question is not whether differences exist,
but what society ought to make of them. The good news is that many now
think that differences should be irrelevant for purposes of choosing
employees or allowing people to hydrate. Even the most cynical among us
can find some encouragement in the fact that society is taking more
responsibility for clarifying the issues related to difference, inclusion,
accommodation, and justice. But we are less accustomed to discussing
differences that seem to relate to cognitive abilities or behavioral traits,
and I will try to say a bit about those here.
As an introduction to the essays in this anthology, I want to address the
following problem. We take it on faith that it is better to live in a world
where no person has to feel excluded, and one suspects, where fewer
people need to feel uncomfortable. But the challenge has always been one
of knowing how we can make good on such a lofty promise. I will try to
pose questions rather than supply answers. I am not convinced that the
answers we need exist.
My goal is to take a skeptical view, and suggest ways that we might
rethink the philosophical side of our labeling routines. If I am correct, we
are too casual about the fact that the same person who devotes her life to
eliminating discrimination in society can take real offense at being told

that she should simply flip a coin to decide on a spouse, or that she should
consult tea leaves when deciding whether to share a reading table with two
acquaintances. Our reform efforts must include an examination of the
ways that we might cite these comparatively "new" differences when we
explain who it is that we want to spend time with, who we want to work
next to, and how we want our children to choose their friends.
We need to do this if we want to respond to what are also relatively
new claims of injustice or offense. But allegations about exclusion or
injustice have proven to be challenging topics of conversation, let alone
reform, in part because the linguistic customs that we use even to discuss
these things are themselves prone to misinterpretation and controversy
(Agam Segal, 2009). A common way to offend someone in scholarly
discussion is to allege that a claim of injustice is in fact trivial. So long as
the perceived seriousness of an offense can turn on a disputed interpretation
What’s the Difference? 3
of the language involved, questions about which claims scholars should

address will seem to remain wide open. That is especially so because
many of the qualities or attributes that mark differences are subject to
changing attitudes and interpretations.
The continually evolving understanding of what constitutes a difference
goes hand-in-hand, of course, with changing interpretations of social
justice. This is what give such differences their "newness," and in some
cases, their trendiness. A behavioral trait that one person speaks of as a
"symptom" might to another person be a feature worth describing in much
more positive language. Likewise, behavioral traits that some parents
might trouble over will to other parents be looked more positively, to the
point that a demand might be made for additional resources on the child's
behalf, even while other parents advocated for rules that would keep the
children separated.
Because there are so many ways that injustice claims can arise over
these differences, it should not surprise us that some reformers would, for
a brief period anyway, recommend a relativistic position. They would
have us agree to disagree, but without anyone claiming possession of the
truth. Instead, we would justify our non-judgmental stance on the basis
that truth is a slippery concept, or that no one is really sure how to even
define the differences in contention. Disputes over what should be done
about differences can also lead to a refusal to discuss things any further,
with the participants convinced that nothing is to be gained from those
who, for various reasons, just don't "get it." We understand the differences
well enough, they might argue, and in some cases we can simply ask those
who are being labeled as different what they want most (or we can make
assumptions about what we think they want.)

I'm not sure that we have the luxury of taking up either position. But I
am especially skeptical of the first. It would be a mistake with far-reaching
consequences if we were to reason that in the midst of this uncertainty
about which differences count we should play it safe, treating all claims of
injustice or offense as though they are worthy of our attention. That quasi-
relativistic position would not be nearly as progressive as it first appears,
and it would be a poor way to show how sensitive we are to exclusion,
offense, or other problems related to differences. We cannot learn to
pretend that we do not notice differences; we can only decide what should
be done when we notice.
This might seem to overlook the prospect that, in our conversations
about difference, we could stipulate one or two bedrock values that we
think everyone holds. Values that have to do with rationality are traditional
candidates in that contest, and have been ever since it seemed necessary to
4 Introduction
make one of the most visible distinctions, that between rational beings and
those, such as animals, that we think act only on instinct or genetic
momentum. There is a great deal of wishful thinking in our preoccupation
with using rationality as this dividing line:
If human equality is true, it is not in respect to any host property we can
see or touch; it is, as we have urged, because all rational persons share
uniformly the capacity to be morally good. But that is believable if, first,
all rational humans have a uniform capacity freely to strive to discover and
realize the correct way and, second, if this striving works towards a
person's moral self-perfection (Coons & Brennan, 1999, 121).
Even where we can say that our desire for this kind of taxonomy is
itself made on more rational grounds, it has always been hard to avoid the
political or social bias. The fact is that we very often want to live
alongside others whose behavior can in some respects be understood, if
not predicted. And we know what type of behavior we would like to
follow from this common rationality, and that is not limited to the
behaviors used to solve math problems or find the best price on new
furniture.
The sentiment behind wanting to use rationality as a baseline does
seem to be aimed in the right direction, that of trying to align different
perspectives to a common morality. But there is more than one rationality
to speak of, and there are still many more cognitive or behavioral
differences that, taken in themselves, do not immediately bear on moral
issues or even a vague sense of a social good. There is, for this reason, no
solution to our problems in the systematic treatment of unequals, or those
who we feel are unequal, as though they are equal. A strategy where we
talk of embracing difference without making value judgments about which
ones should take priority would have us acting" as if we were so impressed
by the fact that we could not unscramble scrambled eggs that we denied
that any legitimate distinction could be made between the ingredients"
(Cooper, 1981, 65).
There is also the possibility that in our attempt to avoid privileging one
claim of injustice over another, we would reduce complex moral issues to
the equivalent of slogans ("celebrate difference!"). Slogans, we know from
the history of social reform, tend to be bundled tightly with accusations
and moral obligations, both so vague that society finds it almost
impossible to respond to them in a way that does not leave everyone
involved vulnerable to the next round of slogans. It seems, then, that we
must draw some lines when we weigh claims about injustice, or when we
talk of goals like inclusion. If we don't, we are going to be hard-pressed to
defend the solutions that we do arrive at. It does not make much sense if
we, in an honest attempt to get serious about the full range of offense
claims, work from a model of justice that will in the end leave us able to
respond only to a few of them. This guardedly skeptical outlook follows
from the belief that any account of justice worth having is going to ask that
we make tough choices in light of our increasing stock of knowledge. The
outlook is rationalistic as well, in the sense that reform is needed because
in almost everything we do, we risk misunderstanding the motives, interests,
and abilities of others.
Labeling the Social World

Behind the hypothetical scenarios I will present is the assumption that,
when understood as the results of choices by rational actors, our behavior
and our reactions should lend themselves to critical, and more or less
objective, analysis. There are going to be exceptions, and I am not trying
to reduce all of human experience to some simple, explanatory formula,
any more than I am suggesting that we can take a value-neutral look at our
cultural practices. I mean only that this stress on being able to rationally
confront our customs and conventions where differences are concerned is
as good an approach as we have found so far. And there seems to be much
that we might learn in trying to tweak the details of ordinary interaction so
that we can pose questions about where offense might arise and when we
should respond to that possibility.
It seems undeniable that those of us who try to adopt a scholarly
perspective on differences can pause and reflect on how we want to talk

and write about them. At a common-sense level, we know that we can
speak and write in a way that can make entire groups feel insignificant,
unappreciated, and excluded. We also know that this risk can manifest in
subtle ways, as when a well-intentioned essay or lecture might appear to
gloss over or misunderstand the different priorities that people place on
justice, for example, or the preference that some have for distinguishing
between Us and Them. And it might seem convenient if we could treat
such differences as though they are somehow outside of morality. But
these things are what gives morality its point.
In that regard, one of the most important problems that we must solve
has to do with the fact that not everyone is or can be as concerned to the
same degree about morality or justice. We write on differences in full
knowledge of the fact that there is little or no consensus on how (or why)
one should live a moral life, any more than there is a universally accepted
picture of human happiness.
6 Introduction
Once we recognize that some things are intrinsically valuable independent

of people's desires or conscious states, it seems an open question what the
full range of objective values would involve regarding their nature,
content, or relation to sentient beings. Although presumably there will be
some essential connection between our nature and the boundaries of moral
value, why must it be one of benefit, for either us or others? Why can't the
boundaries of the objectively good extend beyond what is good for
someone, perhaps focusing on our capacity to lead a morally good life, as
well as on our capacity to have a prudentially good life? (Temkin, 1993,
273).
If we are in search of differences to accommodate, the variety of

perspectives on social justice would therefore be one of the first places we
ought to look. But what is to be done about that variety of opinions, and
are we wrong to think that it is a problem to be solved?
To get at this question, we could suppose that you can honestly claim
to not understand or feel the offense that another person feels. Does
society have the right to force you to act like you do? Your reaction, as
well as your reaction to your own feelings, might be significant enough
that we would say that it marks a difference. But it has not been the type of
difference that reformers have wanted to respect, and far too many writers
on social issues presuppose without much evidence, that there is
agreement on things like justice or freedom. This seems to me an instance
where we must ask if the practice of purposely overlooking important
differences, in the interest of practicality, can be sustained.
Of course, no one suggests that achieving a greater level of understanding
of this or other differences is going to be easy. It is as common to find that
what offends you is not, on any conventional view, wrong, as it is to find

those who point out the distinction between something's being wrong and
its being offensive. This is a variation on the idea we looked at earlier. It is
the common-sense idea that:
[N]ot every slight, abuse, injustice, sin, and the like brings with it questions
of toleration. Many are what lawyers call de minimis, beneath notice.
Before questions of toleration arise, the wrong or sin must be sufficient
serious. Some judgments seem to carry seriousness with then, for instance,
those described as wicked, vicious, and cruel; others do not. Even those
judgments that imply serious wrongdoing, sin, or offense are sometimes
used in ways suggesting lesser wrong, since, and offense. Reds may say
that it is a 'sin' or a 'crime' that Blues are lazy, pushy, or excessively loud.
But we mean this only half seriously or in jest, as when someone says that
'there ought to be a law' against wearing leisure suits in public (Oberdiek,
2001, 62).
The point for our purposes is to reiterate that, in spite of good

intentions, there are going to be offensive ways of discussing claims of
offense, and ways that we can carry on that can seem to exclude the very
people who might be able to, through argument or experience, improve
our chances for reform. It might even be true that there is value in talking
about differences without needing to be guided by some visible endpoint.
Perhaps the horizon will continue to shift away from us anyway. That
shift could occur if, as I suspect, the more that we learn about human
differences, the more that we will have to discuss whether (and how) our
policies should promote or embrace them.
By the same token, the more that we sift through what we think are the
lessons from our own history of attempts to get clear on such things, the
more room we will have for second-guessing. When I suggest that we
should pay greater attention to the way that we talk about differences, I
don't mean to say that most people are unaware of, or just don't want to
face, the problems involved. I think that there is widespread agreement
that one of the most pressing issues we confront is that of achieving the
highest possible level of inclusion in society, while remaining realistic
about how, for instance, we should distribute healthcare, educational, and
community resources.
Again, however, the problem is that we are pulled in two directions,
especially when we try to devise general principles will help from one case
to the next. Those of us who study and discuss differences are pulled, from
one side, by the thought that differences shouldn't matter as much as they
seem to, and where they do, it is because we are uninformed, insensitive,
and reluctant to give up our power. From the other side is a pull from the
idea that recognizing differences often means acknowledging that there are
behaviors we prefer, personality traits that we find endearing, and those
that we would rather avoid at all costs. If you are delivering a public
lecture on the need to embrace difference, and I choose that moment to
throw a pie in your face, it is hard to imagine that I would get much
sympathy if I explained that, as it happens, this is just a disposition that I
was born with. It is about time that you learn to be more accommodating, I
might add.
To address the moral issues that scenarios like this one (minus the pie-
throwing) raise, we will have to grant that the potential for offense exists
wherever our conversations rely on the distinctions that we feel we must
make between groups of people, or the attributes that we associate with
individuals in those groups. We might decide that this means that the
Members of the Pie-Throwers United! movement will have to understand
that, in some cases, they must live with the fact that the differences which
8 Introduction
they use to self-identify give others reason to want to find another place to
conduct their lectures. "They have their place, and we have ours," we
might say, if we wanted to put a spin on a very conventional interpretation
of justice or personal liberty.
The trouble this time is that history reminds us that we know better.
We know that in our conversations about difference it can appear that
separate but equal is often too separated and not very equal. There is also
the fact that, some would say, we are learning more about how many of
the differences can be modified, treated, and even eliminated. This is
another point on which it is difficult to make analogies to, say, ethnic
differences, but it is also not something that gives us very much traction
for reform. The prospect that things like differences in emotional reaction
might be altered through various means does not tell us very much about
whether they should be. If anything, that prospect delivers new puzzles
about the boundaries of individual and community. If you notice my
anxiety at parties, can you argue that I need treatment for that, so as not to
upset the other guests? Should Uncle David seek medication that will
block his urge to share smutty thoughts during family gatherings? Why
can't he reply that the rest of the family should not impose their standards,
and their labels, on him?
There are several ways to understand the tension in scenes like these.
But I am interested in the idea that our feelings about cognitive or
behavioral differences are not always reliable guides to what an
appropriate reaction would be. I think that this unreliability is due in part
to the deep-seated ambiguity about what it is that qualifies as a difference
(a word that can itself function as a label), and the way that our reactions
to difference, and our sense that we are different, are in the end expressions
of feelings. It is a truism that one person can never share another person's
feeling the way the two might share a park bench, so to the extent that the
most common way to express and compare those feelings is to rely on
language, we can answer calls for social reform by committing ourselves
to better understanding the labels that we use when we describe differences.
When we try to understand labels, differences, and reactions to both,
we should assume that there is not much that is new or simple in the
puzzles related to our labeling. Questions about how we should describe
and understand differences have been asked, since ancient times, within
the larger conversations about human flourishing and what it can tell us
about how to structure society. There are questions which have to do with
the ontological status of the categories that we attach the labels to. Is there
a real line between the normal and the deviant, or only an imagined,
constructed one? Can a person be in one category while experiencing some
emotions or beliefs, and moved into another category while feeling

something, and accepting beliefs, that are very different (Strawson, 2007)?
Regardless of the origin of those categories, how broadly do we want
the labels that we associate with them to stretch? This last question gets at
one of the most controversial, and political, aspects of our conversations
about difference, so I will say more about it later. Now I will only stress
that new or not, these questions take on practical importance when we
need to explain why, for example, we describe one student as "gifted" and
another as "outgoing."
The questions become more complicated still when we try to explain
whether we think it is a good thing for a person to merit such labels, or for
another person to apply them. As is true with the general attempt to show
which claims of injustice we should take seriously, there do not appear to
be any shortcuts worth taking when we reform our label-use, unless we
want to generate doubts concerning how committed we are to reform in
the first place. If, for example, we are comfortable with the idea that social
categories, like "normal," are only human creations, then that status
transfers to the labels we use when describing them. And if that is the case,
we should have answers ready when someone asks us about the assumptions
that led to our creating and using them.
There is a likely response, on that interpretation, which does not
require any esoteric theory. We create labels when we want to fence one
group of people off from another. With the matter stated that way, it can
seem straightforward that we would cozy-up to the idea that our labels and
categories have some backing in, as we might put it, the natural world. We
could defend our use of them on the basis of some teleological or
naturalistic argument: when we welcome some and reject others we are

only doing what is natural.
This response leaves much to be desired. There is no doubt evidence
that any two people "naturally" have different cognitive skills when it
comes to certain tasks. But that information does not contain within it
instructions on how an employer should structure a workplace around that
difference, or how an employer should conduct hiring interviews. We
should completely dismiss the hints that writers in Critical Theory or
continental philosophy sometimes drop, that when we apply labels we fall
back on the idea that we are only doing what comes natural because this
will keep power where we think it should be. I am skeptical that we can
avoid injustice by going in the other direction, and challenging any use of
labels or by not thinking in terms of categories to begin with. The
drawback to that is that we would still need something to replace those
10 Introduction
labels with. But we should entertain proposals that would have us

scrutinize any claims about how natural it is that are selective.
For the moment, assume that our labels are a necessary part of our
language-use, and that this in turn reflects social necessity. That way, it
would seem that if you ask me to pick up your children from school, I will
need you to also tell me if I can instead transport any other children I see
waiting, on the thinking that they are all pretty much the same, and that
you would feel bad judging any particular child as more deserving of the
ride home. It is easy to see the element of social necessity here, but how
much support do we want to give to the idea that our rules of language-use
do not come complete with guidelines on sensibility? One can understand
the word "unintelligent," for instance, and not have a clue as to whether it
would be wrong to use it when referring to someone.
Later, I will suggest that neither science nor philosophy can pretend to
say, by themselves, why it should matter to us whether or not one can be
labeled intelligent (or anything else). I will set that discussion up,
however, with the following thought experiment. We have probably all
sensed from the time we were young that we can't get very far without
labels and roles. This is so even if at the time our knowledge was not
terribly philosophical or scientific. That is, even if we did not, as children,
try to arrive at consistent and fair ways of talking about these things, it
seems likely that our childhood games like "cops and robbers" required
that we understood the relevant labels, knew which of those went with
certain roles, and which behaviors were suitable for the people we assigned
them to.
This relationship between labels and roles would have had tangible
benefits to us: if nothing else, the relationship would have helped us know
when we were playing the games correctly. The labels might also have
met the metaphysical test of referring to real divisions among groups and
between individuals. Along these lines, it is also easy to think that as
children we brought to our games of Cops and Robbers (or Afternoon Tea
Party) roughly the same types of cultural resources that adults find
necessary in social contexts. Admittedly, there is an important difference
in that, as adults, we place a high value on reflection when we are in a
specific role or when we need to assign someone (or some group) a label.
And as adults we do spend a great deal of time wondering which of our
linguistic references needs to be accurate, and which moral judgments
should apply to the conduct of our games. But it nonetheless seems
plausible to think that we had a vague sense of these things in our childhood
games.
We might put this in stronger language: perhaps those games were

possible, and enjoyable, only because of the assumptions that we held
about how clearly a particular behavior related to a particular role. I also
wonder if as children we did not at least wonder if the benefits which go
along with each role were distributed fairly, what the costs of playing a
role incorrectly should be, and so on. With these assumptions in mind,
how might we, as adults, coach children who were going to play such a
game? We know that these reflections are at the forefront of any social
interaction, and that even a perceived misapplication of a label can raise
questions about the metaphysical or moral basis for the label. But suppose
that we were asked to observe and advise a child's game of cops and
robbers. Couldn't we, without too much hesitation, coach the children on
how to play a good or bad robber, a corrupt or heroic cop, or any of the
other stock of suitable characters in these games?
Could we do this as well for a game in which the children were
supposed to play "autism and neuro-normal," or one that pitted the
"clinically depressed" against the "paranoid"? Although we might at first
be uncertain how to coach the children, could we recommend that in the
same way as before they try to draw on a set of shared cultural ideas about
their dramatic roles? It could hardly be that we would decline the request
for advice on the basis that we were unfamiliar with the roles themselves.
Most of us probably know more people who are autistic than we do people
who are genuine "robbers."1 How much more evaluative license would we
need as spectator-coaches of these games? We know how we could
respond if, say, the child designated with the label of "robber" started to
chase after the "cops." You're supposed to run the other way, we might
explain. In a neuro-normal game, things would seem different, as would

the measures that we could use when assessing the play.
Someone might object that I am omitting too much from the analogy.
When we teach children how to play cops and robbers, part of the
coaching has to do with ensuring that they understand what the roles and
labels actually refer to. We would make sure that they understood, for
example, that while it is fun to pretend to be the robber, they should not
seek to become one in real life. Likewise, while it might seem exciting
about playing the cop, the children should understand that interacting with
real police officers is serious business. In this respect, it might seem that as
soon as we tried to include a similar level of detail into the neuro-normal
game, we would conclude the game before it started, since we would have
to teach the children that it is wrong to make light of the relevant labels.
This objection raises an important point, but it also to make mine. I
don't question whether it would in some settings be inappropriate to role-
12 Introduction
play. On the contrary, it is probably true that games like cops and robbers
have never been terribly sensitive to the realities of police work or the self-
image of robbers. But the thought experiment can test intuitions that we
have about labels like "autistic" or "bipolar," for instance. If we don't think
that children should act out the roles that go along with such labels, it is
worth asking why. It is noteworthy also that parents do ask similar
questions about whether games of cowboys and Indians are insensitive
toward certain groups too. And there the idea is that it is not enough to
draw on what we think we know about our social world and its linguistic
counterpart. The point is to challenge that knowledge. It would be a
valuable lesson in itself if children could grow up thinking that some
labels are ruled out today as holdovers from a time when we did not
understand differences as we do now.
I have no illusions that these would be easy lessons to share with
children either. The difficulty in talking about such things with adults
suggests otherwise. In any event, there seems as much of a risk in thinking
that children don't reflect as much as we might want them to about labels
as there is a risk that we adults will come away from such hypotheticals
thinking that we are better at that reflection than we really are. To that end,
we would want the children to understand that, as vague as our labels can
be, it is rare that we know for sure how they might affect the people we
label. We would want to explain that tossing questions about roles back
and forth is a complicated, serious game in itself because it forces us to
poke around in so many other areas of private and public life.
This dynamic occurs when we focus on things like the different
emotional reactions that people have to environmental stimuli. We
probably think that we have a good idea of what to tell children about how
they should react towards police officers (or cowboys and Indians).
Shouldn't we be able to explain to someone who asks what should be done
when a person in our midst expresses sadness in a way that we don't
expect? We might think that something is amiss if a person laughs during
a funeral ceremony. The trouble is in getting clear on what the wrongness
involves, or how we should deal with the person who finds humor in that
situation. The lines quickly blur when we try to describe the emotional
reactions and judge their social value. If this were not the case, it would be
a simple task to explain why we think that it is right that people be moved
when looking at, say, photos of the victims of a natural disaster, and wrong
that they be moved by looking at photos of their neighbors undressing.
We might imagine how a student could feel an emotional connection
with a particular culture that he has learned about from his teacher. The
student might then try to dress and speak like the people he associates with
that culture. As before, though, there will be questions about how

accurately the student understands this culture, and which details would
we think are important in that regard. When we ask these things, it doesn't
seem beside the point that there are questions about whether there is really
a genuine culture to speak of, populated by those who have been
diagnosed with certain symptoms, or who meet some other useful means
of categorizing. There are deep questions about what must happen to
transform a group of people into a culture, or even a community, and what
demands that group can then make on the rest of us. We must as a society
talk through these considerations if we want to respond to claims of
injustice, since we will need to explain why we think that, for example,
one culture has a stronger claim to certain resources than another.
We Should Talk
These sketches are meant to get at question like the following. What is
and what should be happening when we apply labels and make choices in
light of them? Why is one act of ranking people acceptable and another is
exclusionary or discriminatory? What should we make of a girl who
attempts to model her behavior on the behavior of people she thinks
exhibit symptoms of depression? Or another student who admires what he
takes to be deaf culture, and announces that he will respond to others only
if he can lip-read, for example? Would we judge these students the same
way we might a student who is enamored with what he thinks are aspects
of the culture of the Scottish Highlands, and takes to wearing a "kilt" to
school?
Such questions seem to reveal the two elements at the core of many
labels: a claim that X belongs in a certain group, and a claim that one
ought to feel a certain way about that. The labels let us distinguish: we
carve the social world with our words, and then, standing back, we rate our
efforts. But as useful as these distinctions are, our rules of language use
leave out an account of whether the same moral rules, for instance, which
allow us to tell children not to accept a ride home from someone we would
label a stranger, will let us decide whose children get to sit next to ours on
the bus. When we make social distinctions, we usually do so in a way that
will allow us to discriminate based on the qualities that we think a person
ought to possess in a specific context, and based on the behaviors that we
ourselves value in it.
To return to the skeptical point that I mentioned at the start, it seems
that loaded into these distinctions are cultural values that might or might
not have rational backing. This suggestion, that our use of labels outstrips
14 Introduction
our ability to justify ourselves, will for some require an explanation. There
are some who would argue instead that, as it often happens, their labels
have a self-contained justification, one that somehow immune from
rational reconstruction. I have occasionally heard something to this effect,
and the argument goes like this. Labels are to be fought over like turf, and
the claim to that territory will be established by those who truly understand
the real interests of the who are labeled. Where those who are labeled lack
political or economic clout, it is necessary to establish spokespersons,
institutions, and social movements in support of the reform of language,
and in the name of justice. This could then be seen a positive development,
a way of giving a voice to those who would otherwise have been left out
of our discussions about difference.
In other cases, however, this idea that, once established in their proper
social domain, labels are beyond moral criticism, can be an invitation to
demagoguery and still more discrimination. It is as if the spokespersons
are under the impression that we can speak of inclusion while we build
even more fences. Activists who approach problems related to difference
this way often have a bone to pick with scholars and other researchers who
would recommend that we understand labels as dynamic reflections of the
changing values in society. For those researchers, the way to arrive at
proper balance of difference and discrimination is to update our labeling
routines using scientific or clinical knowledge.
The advocates of this rationalistic method sometimes overstate the
chances of success. As I have tried to explain, whether there is a rational
justification for our labeling routines should not be the question. The better
question is how open to examination our reasoning is, and where we can
look for help when we want to validate it. If one agrees that this is
important, then it would make sense to also examine our methods of
arriving at conclusions about the social world, since that is where the
labels and our routines are. I think that when we look there, we will find
more pluralism and change than we will stability and consensus. Questions
about offense, labels, and justice are controversial because so many of
them turn on more fundamental disputes about how well they should hold
up to scientific and moral scrutiny.
I am not sure that there is a way around the responsibility we have to
continually reinterpret labels. It seems reasonable to assume that we keep
improving our ability to identify one person as belonging to a particular
group (and most people as belonging to several), for instance, just as we
can identify behavior or attributes that we propose as being better or
worse, more advanced, and so on. And if we want to understand how
principles of justice can apply to those people, we must take seriously the
idea that there are empirical characteristics that the sciences might study,
and abstract or conceptual details that philosophy might examine.
What worries some critics is that neither science nor philosophy can
claim priority within the process itself. They warn that since these and
other disciplines have not always been good at self-policing, we should not
trust the scholars to reform our thinking about differences. The trouble is,
when we talk about inclusion, it is unclear where the discussion should
turn if not in the direction of philosophical and scientific territory. The
hope is that science, philosophy, and other speculative disciplines like
fiction can offer checkpoints for our attempts to get clear on what it is that
people are capable of, interested in, and just as important, how we ought to
react to whatever that is. If we assume that the talks that we should be
having will concern what constitutes "normal," for example, any consensus
will require judgments that are themselves informed by scientific accounts
of things like human physiology. In that case too, the only live issue then
is how much philosophy and science we think we need.
In some quarters, drawing those lines is as difficult as it is to know
what should count as a meaningful discussion about justice. Not long ago,
I participated in a panel discussion about, among other things, what should
be done to improve the treatment of cognitively impaired patients. Things
looked promising because the room was packed with scholars and
specialists from across the disciplines, assembled for a day-long conference
on neuro-diversity. But this discussion was off to a bad start when the first
panelist worked a number of jokes into her introduction, announcing at
one point that "when you meet one moral philosopher, you've met them
all." (This was supposed to play on a popular slogan which refers to
persons with autism.) This was followed by suggestions that writers in

philosophy had become, at best, distractions in the public conversations
that we should be having about difference. If there was any consolation to
be had for philosophy that day, it was in the message that science comes
out of all of this looking even worse. The ideas said to come from moral
philosophers, having to do with personhood or moral agency, were
described as flawed if not insulting, mainly because they piggybacked on
developments in medicine.
The accusation was that those of us in philosophy knew just enough
about developments in cognitive science, for example, to be offensive, and
that we knew just enough about logic to be able to convince the wrong
people. Yet who doubts that we all face a significant problem in knowing
how we should translate the feelings that we have about human welfare
and experience into rational arguments, and vice-versa? Once the laughter
had died down in the panel discussion, the speaker began to discuss
16 Introduction
responsibility, respect, social justice, and moral personhood. An audience

that had been told that it would not have to bear one more discussion of
moral philosophy was given, by panelists who had been trained at
universities well-known for their programs in moral philosophy, a
presentation which could not have made sense or been relevant without
specific views about moral agents, for instance, and how we should
account for the differences between them.
Questions about how we ought to treat each other and questions about
how we should understand each other cannot be separated. Meaningful
talk about inclusion and justice has, since Plato and Aristotle, included
observation and speculation which has been directed towards answering
questions of what we should do when people reason differently, when they
manage emotions differently, and when people resist attempts to bring
them into line. It isn't surprising that there are things that we do not like
about this history; it is hard to defend Aristotle's view on the intellectual
abilities of women, for instance. But it is the only history we have, and the
most productive course would be for us to recognize the mistaken ideas
that we have held about differences.
There is nothing to be gained in quarrels about who ought to have the
authority to offer definitive labels like neuro-diverse, or about who can
really "speaks for" those involved. A more productive outlook would hold
that for us to talk about inclusion, and to attempt to resolve some of the
moral, social, legal, and medical problems associated with that ideal, we
need the help of as many specialists and disciplines as we can find. As we
have seen, the distinctions we need when we talk about something like
discrimination or justice will have to be brought alongside our need to
explain what we mean by such terms. When using labels we will have to
come to an understanding, of how far we want to welcome some kinds of
behavior in society and restrict other kinds. And regardless of our
disciplinary backgrounds, we should be secure enough in the knowledge
of our own limitations to bring to these kinds of questions a welcome
skepticism, not just about the possible answers, but to the way that we, as
scholars, choose to break the questions off from the surrounding context.
We can make our skepticism work for us if we continually look for ways
to improve our conversations about what it means to not only live
together, but talk about each other as well.
References
Agam-Segal, R. (2009). Contours and Barriers: What Is It to Draw the
Limits of Moral Language? Philosophy, 84 (4), 549-570.
Coons , J. E. & Brennan, P. M. (1999). By Nature Equal: The Anatomyof a
Western Insight, Princeton: Princeton University Press.
Cooper, N. (1981). The Diversity of Moral Thinking. NY: Oxford
University Press.
Oberdiek, H. (2001). Tolerance: Between Forbearance and Acceptance.
Lanham, MD: Rowman & Littlefield.
Strawson, G. (2007). Episodic Ethics. In Hutto, D. (ed), Narrative and
Understanding Persons, 85-115. NY: Cambridge University Press.
Temkin, L. (1993). Inequality. NY: Oxford University Press.
CHAPTER ONE
NOISE AND METONYMIC THOUGHT

IN THE PHILOSOPHY OF ARTHUR
SCHOPENHAUER:
SOME BENEFITS OF RETROSPECTIVE
PSYCHIATRIC DIAGNOSIS THROUGH WRITING
ALEXANDRA PERRY
Retrospective Diagnosis through Writing

While philosophers have traditionally used introspection to explore
normal conscious experience, an introspective approach may also be
useful in constructing a coherent understanding of atypical conscious
experience such as autistic experience. Of course, the appropriate methods
for retrospective social diagnosis in medicine and psychiatry have been
widely debated, and this type of diagnosis is often done using historical
methods by looking at biographical or autobiographical accounts of
authors and historical figures. Historical methods were used, for example,
to retrospectively diagnose Frédéric Chopin with cystic fibrosis and
bipolar disorder (Majka, 2003; Karenberg 2007).
Shortly after his death, Chopin’s autopsy report was lost, and so
medical historians and geneticists have used the medical records of
members of Chopin’s family to construct a genetic profile for the
musician. Evidence that his father and two of his sisters had died
prematurely from respiratory illnesses led medical historians to believe
that the family might have carried the CTFR gene, which is often linked to
Cystic Fibrosis and Tuberculosis.
Accounts of Chopin’s melancholic periods offered by his pupils and
friends in letters and eulogies have led historians to believe that the
musician also likely suffered from bipolar disorder, and perhaps from
hallucinatory disorder as well (Vasquz, 2011). Relatively conclusive
Noise and Metonymic Thinking in the Philosophy of Arthur Schopenhauer 19
evidence that this diagnosis is accurate is offered by authors such as

Bernard Govaty, a Chopin biographer, who translated a letter that was part
of his own private collection in which Chopin described a hallucinatory
experience. Chopin wrote:
A strange adventure happened to me while I was playing my B flat Sonata
for some English friends. I had played the Allegro and the Scherzo more or
less correctly and I was about to play the March when, suddenly, I saw
emerging from the half-open case of my piano those cursed creatures that
had appeared to me on a lugubrious night at the Carthusian monastery
[Majorca]. I had to leave for a while in order to recover myself, and after
that I continued playing without saying a word (Chopin, 1848 in Gavoty,
1977).
Still, retrospective diagnosis is not a straightforward process. There

are cases where psychiatric episodes are not described in as much detail,
biographically or autobiographically, as Chopin’s were. Oftentimes the
relatively new recognition or identification of a disease or disorder makes
it difficult to use historical information to retrospectively diagnose a
physical ailment with as much accuracy as we might with a modern
biological diagnosis (Mitchell, 2011). The criticism of using historical
methods in retrospective diagnosis has recently been termed the Cunningham
Debate.
Andrew Cunningham questions the legitimacy of the work of
historians of medicine if they do not raise and address the sorts of
philosophical questions about historical methodology and the limits of
history that have been raised by philosophers of science about scientific
methodology. Cunningham claims:

It seems obvious to us, looking through our scientific medicine spectacles,
that of course social interpretations of disease (and what ‘counts as’ a
disease) do and have varied from society to society, but it seems to us that
these just express greater or less success in coping with the underlying
constant disease reality ‘out there’ in Nature. As we assume that our own
success in coping with disease has been the greatest, we naturally take our
models of disease identity as the final, and thereby the only legitimate,
models. So when we come to doing the history, when we come to trying to
identify past outbreaks of plague for instance, we assume that what we
need is the best modern thinking about the disease and its manifestations.
Armed with this supreme form of knowledge we are able, we believe, to
correctly identify outbreaks of plague in the past, even down to pronouncing
on the presence or absence of the bacillus, and we correct the people of the
past in their identifications of plague, telling them when they were right
and when they were wrong, since our form of knowledge is clearly
20 Chapter One
superior to theirs. Yet in fact this is just our society’s way of thinking: true
for us and our world, but not necessarily true for other societies and other
times. (Cunningham, 2002, 14).
Ultimately Cunningham argues that historians of medicine do not have

adequate methods for retrospective diagnosis and that identifying disease
in the past, at least in any reliable way, was philosophically untenable.
The Cunningham debate centers on two points that Cunningham takes to
be true. First, that all disease is experienced both biologically and
socially, and second, that diagnoses and causes of death had no legitimacy
outside of the time and place in which they were recognized, or, as
Cunningham put it:
[Y]ou die of what your doctor says you die of. Your cause-of-death
certificate is not negotiable. While this might seem a reasonable thing to
say about people dying today, I want to argue that it also applies to
everyone in the past. They died from what their doctors said they died of.
Their cause-of-death certificates (as it were, for of course such certificates
are very modern and very western) are equally not negotiable, neither by
the modern medic, whether clinician, pathologist, epidemiologist or
psychiatrist, nor by the modern historian (Cunningham, 2002, 18).
The Cunningham debate has sparked questions in the history of

medicine about the reliability of using historical methods to retrospectively
identify epidemics, disease, and causes of death in the past. Behavioral
scientists, however, have recently started to make the case that the
historical methods used to retrospectively make diagnoses of mental and
cognitive disability can be corroborated using methods from forensic

linguistics, and that retrospective diagnosis may be a useful way to
understand the relationship between language and atypical conscious
experience.
Garrard (2005) conducted a linguistic analysis of the work of Iris
Murdoch, a British author and philosopher who received a diagnosis of
Alzheimer's Disease in 1995. After comparing three works: her first
novel, a novel from the prime of her writing career, and her final work,
Garrard was able to detect linguistic changes in her final book that were
consistent with the linguistic changes expected in patients with Alzheimer’s.
Murdoch’s final work was published over a year before she received a
formal diagnosis. Garrard (2005) reported that her final work showed a
decline in lexical diversity.
Similar work has been done in forensic linguistics to identify cognitive,
developmental, and mental disorders such as schizophrenia, bipolar
disorder, major depressive disorder, and autism.
The unconventional use of rhetorical devices is often reflective of

autistic thought patterns, and text analysis has proven to be a useful
diagnostic method for autism given that at least 39% of all individuals on
the autism spectrum are non-verbal (Jepson, 2007).
In this chapter I argue that an analysis of the use of metonym in the
philosophy of Arthur Schopenhauer, a 19th century German philosopher
shows a striking similarity to the use of metonym found in narrative
accounts of autistic sensory and social experience, and that using historical
methods in looking at Schopenhauer’s philosophy, introspective accounts,
and biographical information corroborates this. Autistic experience differs
somewhat from typical conscious experience. Through the reports of
clinicians and narratives of those on the autism spectrum, we now know
that individuals with autism often have sensory experiences that vary
greatly from those not on the autism spectrum, who are often called
“neurotypical” (Hacking, 2009). These reports and narratives also relate
that individuals with autism spectrum disorders experience differences,
often debilitating differences, in social interaction. I claim that the
retrospective diagnosis of authors like Schopenhauer, who described both
sensory and social experience in great detail in his introspective accounts,
can serve to inform contemporary clinicians about the nature of autistic
experience.
Schopenhauer proposed philosophical theories on topics ranging from
metaphysics to ethics to human relationships. Much of his analysis of the
metaphysical and social worlds was grounded in introspection, and his
accounts often struck critics as being strange or extreme. The linguistic
convention in Schopenhauer’s introspective accounts and metaphysical
theories is similar to what we now recognize as autistic use of language.

Schopenhauer’s introspective accounts of sensory or relational
experience also seem to illustrate autistic experience. In this chapter I
offer an overview of metonymical thinking and compare typical uses of
metonym with atypical or autistic uses of metonym. Finally, I argue that
Schopenhauer’s philosophy and introspective accounts of experience can
offer researchers and clinicians information from which to begin
developing appropriate and ethical interventions and accommodations for
those on the spectrum if the disturbances and differences that
Schopenhauer explores are given a serious look.
Metonymical Thinking
The term “metonymic” refers to a rhetorical device similar to a
metaphor called “metonymy.” Metonymy, as figurative language, is the
22 Chapter One
“transfer of the name of a thing to something else that is closely associated

with it- such as cause and effect, container and contained, possessor and
possessed, and so on; for example, ‘crown’ or ‘throne’ for monarchy”
(Bredin, 1984).
In contrast to metaphor, metonymy relies on contiguity rather than
similarity between related things. It does not indicate shared qualities, but
rather a relationship based on constituency, adjacency, toponymy or
another form of contiguous association. For example the phrase, “Denver
is working hard to address racially-motivated crime” is a metonym, as the
city of Denver is not working hard toward this aim, but rather
representative of those in Denver who are working hard to address such
crimes.
A politician who was concerned about the amount of campaign work
that needed to be done might claim that he needed “all hands on deck”
meaning that everyone’s efforts would be needed during the final
campaign push. “Hands” in this case might be used metaphorically, if
“hands” is taken to refer to “deckhands” or sailors. The term “hands”
might also refer to the body part, as its usage in the term “deckhand” does.
In this case, “hand” is used metonymically for “people” or “campaign
staff” because there is a contiguous relationship: most people, even
campaign staff, have hands.
The use of “deck” in this idiom, however, could be taken as
metaphorical because in using the idiom the speaker is relying on the
transfer of qualities from “deck” to the place where he needs his staff to be
ready and working, the campaign headquarters. This use is not
metonymical because there is no contiguity between a ship’s deck and a
campaign headquarters, which are unlikely to share the same space or be

part of one another. Instead there is a metaphorical relationship between
the deck and the campaign headquarters because they share qualities: they
both exist as a place where people can ready themselves and report to
work hard.
Metonym is also commonly seen as a sort of communicative
shorthand. Capital cities might be used metonymically to represent the
states in which they’re located. Residents of Oregon might claim that
“Salem got it right” if they want to agree with the outcome of statewide
elections while residents of Montana might blame it on “those politicians
in Helena” if they are unhappy with their election night outcomes. The
state capitals are contained within the state and may well be the site of
much political decision-making, and so these terms are used metonymically,
rather than metaphorically. Other ways that metonym might be used as
shorthand are archetypal (“the blue dress” might be used evidence of an
affair); instrumental (the phrase “live by the sword, die by the sword” uses
the word “sword” as metonymical for “violence” because it is a tool or
instrument of violence); or associatively (“locker room behavior” might
refer to the kind of gender-specific joking or bonding that might
commonly take place in a gym locker room).
Normal Use of Metonym in the Work of Nathaniel

Hawthorne
Metonymy often serves a literary purpose as well. The work of
Nathaniel Hawthorne is often cited as being an exercise in metonymic
expression. The gazes offered by Hawthorne’s male characters are said to
metonymically represent larger conflicts over gender and sexuality (Dolis,
1984). Greven (2006) notes, “by rendering male subjects as the objects as
well as the wielders of the gaze, we view men as possible objects of erotic
contemplation, thereby beckoning queer and feminist analysis” (132).
Similarly, Hawthorne’s use of color is claimed to be used metonymically
(Abel, 1969). In The Scarlet Letter one of Hawthorne’s characters, Arthur
Dimmesdale, is offered a black glove. The narrator tells his readers that
the glove “was found this morning on the scaffold where evil-doers are
set up to public shame” (145). Dimmesdale, a minister, is offered the
glove after preaching the best sermon of his life, one that led many who
listened to it to become believers. Dimmesdale has a secret, however. He
has fathered an illegitimate child with Hester Prynne, another character in
The Scarlet Letter. The dark color of the glove is used strategically by
Hawthorne as a metonym for the melancholy shrouding Dimmesdale’s

state of affairs: giving sermons about what he takes to be the truth while
harboring a dark secret from his congregation. Hawthorne’s use of
metonym is typical because it is employed strategically in, the form of acts
or figures that convey larger, related themes.
Schopenhauer’s Use of Metonym

Sandra Shapshay (2008) identifies the type of thinking and reasoning
seen in Schopenhauer’s philosophy as “metonymic thinking” and explains
that it “has not been appreciated in Schopenhauer scholarship to date,” but
“is a primary recurring motif in Schopenhauer’s philosophy, and the
means by which he believes human beings may have indirect access to the
world as it is in itself” (211). Schopenhauer’s use of metonymical thinking,
in contrast to Hawthorne’s, is not exercised as a strategic rhetorical device
but rather resembles a form of introspection in his philosophical work.
24 Chapter One
Schopenhauer’s philosophical method is often noted for its

unconventional style. His pessimism has been described as a method of
dealing with a “life not worth living.” The basis for much of Schopenhauer’s
pessimism, however, in addition to many of his theoretical standpoints, is
a reflective look at the world and his own experiences in it. As Barnes
(1964) notes:
Schopenhauer’s pessimistic description of human existence is based partly
on objective data. He points to physical pain, disease, insanity, and the
debilities of old age, the seemingly inevitable social evils of war, poverty,
slavery, oppression. It was Schopenhauer’s absolute condition that life is
not worth living either on a practical basis, if one should make a utilitarian
calculation of pains and pleasures, or from any higher metaphysical point
of view. In fact, if we are to judge by the criterion of our most lofty human
ideals, our duty is clearly to refuse to play the game and put an end to it all.
(Barnes, 1964, xv-xviii)
The scrutiny and development of theory based on introspection and

empirical observation and conjecture are not unique to Schopenhauer.
Philosophers such as Nietzsche, Heidegger, and Kant each offered
accounts of their own conscious experiences. What is unique to
Schopenhauer is his reliance on these reflections, the degree to which he
generalizes his own experiences, and the extreme pessimism that is bound
to his views. His phenomenological and relational accounts are often
viewed as extreme or atypical and his use of metaphor and analogical
reasoning are frequently questionable. This typicality in Schopenhauer’s
philosophy might be evidence of autistic thinking.
An example of this kind of reasoning in the philosophy of Schopenhauer

is in his view of metaphysics. Schopenhauer claims that the world is an
idea that is held in the mind of a perceiving subject. Because the world is
a subject, it must exist in accordance with the principle of sufficient
reason, which Schopenhauer took to have four distinct forms: The
principle of becoming, the principle of being, the principle of knowing,
and the principle of acting. Each of these forms of the principle of
sufficient reason governs one of four classes of objects: complete
representations, abstract representations, a priori intuitions, and the
subjectivity of the will. Taken together, these classes manifest what
Schopenhauer terms “the will,” which does not belong to any particular
class of objects and therefore is not governed by the principle of sufficient
reason the way each representation of it (all objects belonging to the four
classes) is, and is therefore unknowable. Schopenhauer writes that the will
is a “thing in-itself” (196-7), and so the world exists as both will, which is
objective and unknowable, and idea, because it is a representation that can
be perceived.
In discussing the concept of the self, Schopenhauer proposes a duality
that mirrors his view of the world. He argues that there are two kinds of
knowledge. The first, intuitive knowledge, is not representational, but
rather a view of the body “in-itself.” Intuitive knowledge, then, is an
analog to the will. The second form of knowledge, abstract knowledge, is
representational, and is analogous to the world as idea. So, while the
world exists as will and idea, the self exists as intuition and abstraction or
representation.
While this metaphysical theory is not extreme in its own right,
Schopenhauer’s proposal that this dual-nature of the self be extended to
our understanding of the world is one that is often viewed with some
skepticism (Jacquette, 2008, 73). Schopenhauer “proposes that this dual
knowledge and dual-sidedness of the self be extended to the world as a
whole” and that “insight into one’s own nature as will thereby provide us
with an analogical understanding of the inner nature of the World as Will”
(Shapshay, 2010, 799).
This generalization from self to world, individual to collective, is
typical of the philosophical moves that Schopenhauer makes in using
phenomenological accounts. Jacquette (2008) claims that Schopenhauer’s
analogy falls short because:
“[P]erceptual knowledge of the body is not merely analogous to knowledge
of the world as representation as a whole, and hence not a basis for
analogical inference, but is rather a focus of perceptual knowledge directed
specifically to the individual knowing subject’s body.”
Jacquette’s concern over Schopenhauer’s illustrates the tendency of

Schopenhauer scholars to dismiss the analogies in his work as poor or
representative of dogmatic thinking. Nietzsche, who generally looked to
Schopenhauer as a philosophical role model, claimed that Schopenhauer
often “dressed up an obscure, inconceivable X in brightly colored clothes,
with predicates drawn from a world alien to it” (Appendix I). What
Schopenhauer scholars often take to be poor analogies, however, are quite
often metonymic rather than analogical descriptions or illustrations.
Schopenhauer commonly used metonymy in his philosophical and
introspective work, and quite metonymy was used for no particular reason.
Indeed, Schopenhauer himself seems unaware that he is thinking
metonymically. For example, in Schopenhauer’s analysis of Kant’s
schemata (1781), he faults Kant with relying on a false analogy to build
his concepts of a priori and a posteriori knowledge. Schopenhauer wrote:
26 Chapter One
Thus, since he aimed at finding for every empirical function of the faculty
of knowledge an analogous a priori function, he remarked that, between
our empirical perceiving and our empirical thinking, carried out in abstract
non–perceptible concepts, a connection very frequently, though not always,
takes place, since every now and then we attempt to go back from abstract
thinking to perceiving. We attempt this, however, merely to convince
ourselves that our abstract thinking has not strayed far from the safe
ground of perception, and has possibly become somewhat high–flown or
even a mere idle display of words, much in the same way as, when walking
in the dark, we stretch out our hand every now and then to the wall that
guides us. We then go back to perception only tentatively and for a
moment, by calling up in imagination a perception corresponding to the
concept that occupies us at the moment, a perception which yet can never
be quite adequate to the concept, but is a mere representative of it for the
time being (Schopenhauer, 1818, 449).
Schopenhauer’s response to Kant has been criticized as a poor analogy

(Jacquette, 2008). However, Schopenhauer’s response to Kant, that is, his
theory of the will and representation, is actually built on metonymical
rather than analogical reasoning. Schopenhauer did not hold that the self
was analogous to the world; rather, he claimed that the self was a
representation of the world, the sort of contiguity that underlies this
representational relationship is metonymical rather than analogical.
Shapshay (2008) describes a similar move in Schopenhauer’s
commentary on Kantian aesthetics and moral philosophy as follows:
“Whereas Kant explains that profoundly felt structural analogies can give
one some sensible confirmation of the good will, Schopenhauer employs
the experience of felt contiguities between things that were hitherto

thought to be distinct” (Shapshay, 2008, 211).
Shapshay points out reliance on metonymy in Schopenhauer’s moral
and aesthetic philosophy as well, including the following example from
his account of the experience of listening to music. Schopenhauer writes:
Music does not express this or that particular and definite pleasure, this or
that affliction, pain, sorrow, horror, gaiety, merriment, or peace of mind,
but joy, pain, sorrow, horror, gaiety, merriment, peace of mind themselves,
to a certain extent in the abstract, their essential nature, without
accessories, and so also without the motives for them. (Schopenhauer,
1818, 261)
Shapshay interprets Schopenhauer’s account of music as being

metonymical. She restates his view as follows:
So in music, one does not feel particular instantiations of emotions, in
some subject or another, under certain conditions or another, but rather,
one resonates with and thus gains insight into the essence of these
emotions—regardless of where, when, why, and in whom they occur... It is
not that such symphonic music is felt upon reflection to be like or similar
to the vicissitudes of blind willing, just as Juliet is felt to be like Romeo’s
sun, to play the kind of role in his life that the sun plays for all living
creatures. Rather, music is, according to Schopenhauer, the most direct
expression of the will a human being can experience, seen through the
lightest of veils—in time, but outside of space and distinct from particular
motives, and without the distortions created by the subject’s own willing.
(Shapshay, 2008, 219)
Schopenhauer’s use of metonymical thinking is atypical in both cases

first because he employs metonym where authors might typically employ
analogy or metaphor, and also because of what is being used as
metonymical: music isn’t like will, it doesn’t represent will, it is will.
Autistic Use of Metonym and Writing Convention

The metonymic thinking in the philosophy of Schopenhauer is similar
in nature to the metonymic thinking and linguistic convention that is
commonly seen in individuals on the autism spectrum. Autistic individuals
often think metonymically, organizing ideas through associating concepts
that seem representative or related, regardless of whether those things
would be taken to be representative or related to others (Chew, 2008).
Though metonymic thinking and linguistic usage is found more often in
autistic individuals than those not on the spectrum, it is often atypical
metonymic use. Autistic metonymic use is often atypical in one of two
ways. Atypical metonymic use may take the form of a metonymic

connection that is ambiguous or irregular, or the use of a metonym that is,
itself, non-essential when considered in reference to conventional usage,
or it may take the form of using a metonym inappropriately given the
context of its use.
Examples of autistic usage of metonym might include an autistic
individuals inclination to develop alternative names for individuals known
to them. John Elder Robison (2007) notes, for example, that it is common
for those on the spectrum to have an aversion to using people’s given
names. He explains that he has always adopted functional names for the
people and animals that he interacts with, for example calling his wife,
“Unit Two” and naming his dog, “poodle.” This sort of functional naming
is common among individuals on the autism spectrum. A functional name
is something that relates a person or animal to its role or identity. This sort
28 Chapter One
of naming is metonymical in the sense that a person’s name doesn’t

represent them, it describes them, and so it is consistent and systematic.
More common examples of metonymical thinking in autism include
systems and rituals grounded in seemingly arbitrary (to the outsider)
correlations of concepts. Particular colors may represent particular days;
numbers might be assigned to people or weather patterns; value might be
placed on things that seem value-less in and of themselves (an autistic
child might insist on carrying a particular button in his hand for a number
of years, for example). Often these metonyms are developed in order to
gain some semblance of control or order over an individual’s temporal or
sensory experiences. Autistic children might, for example, eat only things
that are served in even numbers, or that fit a particular color pattern. Some
have intricate systems built around such metonymic connections. An
example of such a system might include the fictional account of the
character Christopher in The Curious Incident of the Dog in the Night-
Time. Christopher develops a system to determine whether or not he is
having a good day, which he describes as follows:
Mr. Jeavons, the psychologist at the school, once asked me why 4 red cars
in a row made it a Good Day, and 3 red cars made it a Quite Good Day,
and 5 red cars in a row made it a Super Good Day, and why 4 yellow cars
in a row made it a Black Day, which is a day when I don’t speak to anyone
and sit on my own reading books and don’t eat my lunch and Take No
Risks. He said that I was clearly a very logical person, so he was surprised
that I should think like this because it wasn’t very logical. I said that I
liked things to be in a nice order. And one way of things being in a nice
order was to be logical. Especially if those things were numbers or an
argument. But there were other ways of putting things in a nice order.
And that was why I had Good Days and Black Days. And I said that some
people who worked in an office came out of their house in the morning and
saw that the sun was shining and it made them feel happy, or they saw that
it was raining and it made them feel sad, but the only difference was the
weather and if they worked in an office the weather didn’t have anything to
do with whether they had a good day or a bad day (Haddon, 2003, 47).
Christopher’s system reflects a metonymical thinking. When Mr.

Jeavons asked Christopher why 4 yellow cars in a row made it a “black
day,” he was anticipating the sort of practical or metaphorical explanation
that we might get if we asked someone why they felt sad on a rainy day.
Instead, Christopher’s reasoning is metonymical: yellow cars don’t share
the properties of bad days; they are a part of them.
If, as Chew (2008) argues, metonymical thinking is a feature of autism,
why is it that research demonstrates that individuals with autism often
show impairments in their ability to understand metonymical or

metaphorical thinking (Wearing, 2010)? Like Schopenhauer’s interpretation
of symphonic music as being metonymical for the will, metonyms in
Autism are often actually felt by the individual. To Schopenhauer, music
wasn’t simply metonymical for the will, that is, the metonym wasn’t used
as part of a larger, grander strategy to persuade his readers toward a
particular view. Music actually was resonant of the essential nature of
will.
Likewise, Christopher did not simply view the act of seeing four
yellow cars as metonymical to having a “black day.” For Christopher, this
relationship was actual, and his change in mood and inability to take risks
very real. This would explain why the ability to recognize and understand
metaphor and metonym in autism is so poor while metonymical thinking is
so common. While autistic individuals employ metonyms, the relationships
that these metonyms describe are not intentionally metonymical, but real.
The development of complex systems and routines is common across the
autism spectrum, and metonymical thinking is suggestive of this. Just as a
routine might organize a day, metonyms organize thoughts systematically
because of the way they function as communicative shorthand.
Schopenhauer’s metonymical response to Kant’s metaphysics and his
introspective account of music, seem to illustrate autistic use of metonyms.
Schopenhauer’s atypical and felt, rather than strategic, use of
metonyms puts him in the company of Ernest Hemingway and Herman
Melville, both of whom have been thought to have been on the autism
spectrum. Hemingway’s writing offers examples of atypical metonymic
usage in stories and novels. While his metonyms are not ambiguous or
vague, they lack the strategic foundation that we see in Hawthorne’s

metonymic use. Hemingway was known to make use of very clear
metonyms, and, as Rabbe (1999) notes, these were often anatomical
metonyms, in other words, the Hemingway often, “metonymically
associates objects in the story with parts and functions of the anatomy.”
Many of Hemingway’s metonyms are rather graphic, but include, for
example the representation of Santiago, the protagonist in his Old Man
and the Sea having a “cramping, claw-like hand” which is “associated
with the teeth of the shark (Rabbe, 1999, 161). These metonyms, while
explicit enough, seem added almost as an afterthought. When they serve a
purpose that purpose seems simply poetic.
Melville is also well known for his atypical usage of metonyms in, for
example, his story of Bartleby the Scrivener, and his texts are also viewed
as illustrating many common features of autistic thinking and writing.1 In
Bartleby, the narrator spends much of the story convincing his readers that
30 Chapter One
Bartleby is not typical, preferring not to write for his employer yet
continuing to show up to his job each day, putting in longer hours than
anyone else in the office.2 The narrator seems to oscillate between
reverence and revulsion for Bartleby, but in either case views Bartleby as
residing outside of the norms. As the story ends, the narrator leaves his
readers with the following commentary on Bartleby:
Conceive a man by nature and misfortune prone to a pallid hopelessness,
can any business seem more fitted to heighten it than that of continually
handling these dead letters, and assorting them for the flames? For by the
cart-load they are annually burned. Sometimes from out the folded paper
the pale clerk takes a ring: --the finger it was meant for, perhaps, moulded
in the grave; a bank-note sent in swiftest charity: --he whom it would
relieve, nor eats nor hungers any more; pardon for those who died
despairing; hope for those who died unhoping; good tidings for those who
died stifled by unrelieved calamities. On errands of life, these letters speed
to death. Ah Bartleby! Ah humanity! (Melville, 1853)
As Aaij (1999) points out, “...the narrator is wholly given over to his
poetic imagination--he does not answer to us exactly how Bartleby stands
for humanity.” It is not clear, however, how Melville or the narrator saw
Bartleby as metonymically related to humanity. Perhaps this last
paragraph might be clarified a bit if the narrator had made a claim that
Bartleby was representative of how society ought to be, but it is not clear
how he represents society as such. Rather, this seems to be an example of
an atypical metonym, one in which the user felt a true connection between
two things but did not take account of how unconventional this metonym
actually was.
Literary critics have also cited some of Melville’s other short stories
and novels, such as The Paradise of Bachelors and the Tartaus of Maids
(Melville, 1855), and Pierre: or, the Ambiguities (Melville, 1852), as
using metonym in atypical ways. In both cases, Melville makes references
to women in ways that illustrate complex metonymical thinking, and his
contrasted is contrasted with the more typical metonymical use of
Hawthorne (Levine, 2008; Dimock, 1997).
The use of metonym in Moby Dick (Melville, 1851) has also been
noted as atypical and open to multiple interpretations (Reed, 2005).
Scholars have cited Melville’s use of “whiteness” in describing the whale,
and also the use of whalebone to replace Captain Ahab’s formerly ivory
prosthetic leg as examples of atypical metonym (Taylor, 2011). Other
indications of autistic experience, such as a strong interest in details
related to a particular and narrow interest have also been observed in Moby
Dick. The level of detail with which Melville describes whales and the
culture surrounding whaling has often been cited as a fascinating feature

of the book. Taylor (2011) writes, “Like a museum, Moby-Dick collects
and gives stories to things strange and quotidian, sampling and displaying
U.S. and oceanic material culture in much the same way that the novel’s
preface, “Extracts,” samples the bibliographic history of whales” (29).
Melville’s detailed descriptions of whales mirror what are called
“encompassing preoccupations” or restrictive, narrow interests often held
by those on the autism spectrum, and led one author to joke:
While reading Moby Dick is a bit like being stoned, it also evokes an
Asperger’s air. Ishamel will tell you everything you wanted to know about
the whale, and much he has made up. (Few books are so filled with
neologisms; it’s as if Melville were frustrated by language itself and strove
to burst out of its confines.) At the same time, Moby-Dick” stands both as
a historical reference for the great age of Yankee whaling and as a work of
imagination in which hales become avatars as much as they are real
animals. Melville would never have finished his book today—he’d be
constantly Googling “whale” (Hoare, 2011).
Short (1992) argues that Melville’s use of metonymy is almost always

reflective of regression, and, knowing a good deal of biographical
information about Melville, often representative of his own experiences.
This atypical usage of metonym, fits, like Schopenhauer’s with common
knowledge about autistic experience. The apparently a-strategic use of
Melville’s metonyms emphasizes an uncommon understanding of
generalization, that is, an unawareness of convention. Shapshay recognized
this uncommon understanding of generalization in Schopenhauer, as well.
She explains his view of generalization as follows:

For Schopenhauer, the ‘fundamental character of the genius’ is ‘[a]lways to
see the universal in the particular . . . whereas the normal man recognizes
in the particular only the particular as such; for only as such does it belong
to reality, which alone has interest for him, has reference to his will . . . In
accordance with this, the real object of genius is only the essential nature
of things in general, the universal in them, the totality’ (WWR II 379)
(Shapshay, 2008, 219).
This view of the metonymic thinking, coupled with Schopenhauer’s

assertion that any man of genius must think the way that Schopenhauer
does, is indicative of autistic experience. Autistic experience is often
accompanied by a deficit with regard to theory of mind, or an inability or
difficulty in assigning mental states to others. Often, if an individual is
without strategies to compensate for such a deficit, for example by
observing the interactions of others or developing social rules to interpret
32 Chapter One
the behaviors of others, then he or she may ascribe his or her own mental
states to others. Schopenhauer, it seems, does this in his relation of
“genius” to his own view of metaphysics. Similarly, Melville illustrates
this kind of ascription in his use of metonym. He assumes, for example,
that his readers will understand the metonymic relationship between
Bartleby and humanity when this relationship is not as straightforward as
he seems to think that it is.
Schopenhauer’s Introspective Work

Forensic linguistic analysis of the work of both Hemingway and
Melville, coupled with historical methods that draw upon biographical
information about each, has led many to speculate that they may both have
fallen on the autism spectrum, had autism existed as a diagnosis at the time
(Murray, 2008). A look at the work of each shows that they shared an
interest in concepts like humanity and struggle, and often took a
pessimistic view of the status quo and human nature. Each documented
their struggle against depression and feelings of melancholy and a desire
for increased solitude and silence. Schopenhauer, though a philosopher
rather than a literary figure, shared each of these characteristics that are
indicative of autistic experience.
Schopenhauer left other clues that lend themselves to the interpretation
that his views might illustrate autistic experience. Schopenhauer wrote
extensively on his own experiences and reflections on every day
occurrences, and these reflections are similar to autistic narratives. This is
particularly true of his accounts of sensory experience and his introspective

accounts of human relationships, which are strikingly similar to autistic
views of empathy and the understanding of metaphysical ideas related to
the relationships between individual bodies. One such account is
Schopenhauer’s account of noise, and his description of the effects that
noise had on his thought processes.
Schopenhauer (1964) wrote: “The super abundant display of vitality,
which takes the form of knocking, hammering, and tumbling things about,
has proved a daily torment to me all my life long” (217). Further, he
fixates on the particular disturbance caused by the cracking of a whip, and
claims:
No one with anything like an idea in his head can avoid a feeling of actual
pain at this sudden, sharp crack, which paralyzes the brain, rends the thread
of reflection, and murders thought. Every time this noise is made it must
disturb a hundred people who are applying their minds to business of some
sort, no matter how trivial it may be; while on the thinker its effect is
woeful and disastrous, cutting his thought asunder, much as the executioner’s
axe severs the head from the body. (218)
Sensory disturbances are a hallmark feature of Autism, and

Schopenhauer’s fixation on one particular disturbance is also indicative of
autistic experience. Grandin (1995) writes of similar sensory experiences:
When I was little loud noises were also a problem, often feeling like a
dentist’s drill hitting a nerve. They actually caused a pain. I was scared to
death of balloons popping because the sound was like an explosion to my
ear. Minor noises that most people can tune out drove me to distraction.
When I was in college, my roommate’s hair dryer sounded like a jet plane
taking off... the kinds of sounds that are disturbing vary from person to
person (Grandin, 1995, 67).
Sensory experiences, like those that Grandin points out, are commonplace
across the spectrum (Klintwall, 2011). Further still, Schopenhauer again
demonstrates the ascription of his own mental states to others, a move that
is associated closely with autism. He writes:
There are people, it is true- nay, a great many people- who smile at such
things, because they are not sensitive to noise, but they are just the very
people who are also not sensitive to argument, or thought, or poetry, or art,
in a word, to any kind of intellectual influence. The reason of it is that the
tissue of their brains is of a very rough and coarse quality. On the other
hand, noise is a torture to intellectual people. In the biographies of almost
all great writers, or wherever else their personal utterances are recorded, I
find complaints about it; in the case of Kant, for instance, Goethe,
Lichtenberg, John Paul; and if it should happen that any writer has omitted
to express himself on the matter, it is only for want of an opportunity (216).
This type of generalization demonstrates metonymic thinking that is

similar to the metonymic thinking found in the works of Hemingway and
Melville. This sort of thinking establishes a contiguous relationship
between two things, in this case genius and intolerance to noise, based on
reasons that make sense only to the individual.
The Practical Application of Retroactive Diagnosis

in Mental Health Contexts
Cunningham’s reluctance to trust methods of retrospective diagnosis is
not entirely unfounded. Historical methods of retrospective diagnosis rely
a great deal on speculation and it is almost impossible to avoid the bias of
the current diagnostic context. In cases of mental or behavioral diagnoses,
34 Chapter One
however, these methods can be corroborated, with the use of forensic

linguistics. The retrospective diagnosis of autism has become commonplace
across various political movements and among interest groups who are
interested in constructing a social history of the disorder, and authors and
thinkers such as Melville, Hemingway, Einstein, Lincoln, and others have
been cited as having autistic tendencies.
While such a social history might be interesting, retrospective
diagnosis may actually serve a practical purpose in understanding mental
illness and disorder. Because the link between autism, creativity, and
language use is very strong, autistic tendencies are often apparent in the
use of language, color, and sound (Fitzgerald, 2005). Establishing a
coherent system of analyzing texts (and eventually maybe art and music)
for features like atypical metonymical use, dyspraxia, and generalization
(not to mention common themes or interests) would allow for the
identification of authors who are likely on the spectrum. Julie Brown
(2010) for example, studied autistic writers and established a list of
features that are found to be common in authors across the spectrum: a
messy writing process, difficulty defining or understanding the audience,
breaking the rules of a genre, incoherent narrative strategies as illustrated
by a lack of connections between concepts, difficulty with character
development, and the inclusion of intricate detail.
If biographical, autobiographical, and introspective accounts of the
author corroborate a retrospective diagnosis, then these accounts might be
analyzed to gain practical insight into autistic experience. Victoria
McGeer (2009) and Ian Hacking (2009) each discuss the role of stories
and narratives in clarifying autistic experience in order to inform
judgments that might be made about those on the spectrum (McGeer,

2009; Hacking, 2009). Each claim that such narratives can serve to shape
autistic experience, and McGeer outlines two views: the informative
interpretation, which maintains that autistic narratives might offer insight
into autistic experience that can be useful for the general public; and the
transformative interpretation, which holds that autistic experience is
actually constructed by the language that is used to talk about it. An
example of this might be found in the way that autism is discussed in a
clinical setting. A clinician might view autism as a developmental
disorder, a neurological disorder, or the result of vaccine damage. This, in
turn, will influence the way autism is treated, whether the clinician uses
medicinal or therapeutic means, or simply directs the patient’s caretaker in
the direction of resources that he or she takes to be valuable. The
narratives of those on the spectrum may serve to shape a clinician’s views
on autism and might also inform the decisions that the patient’s caretakers
make (Perry, 2012).
One problem with views like those of Hacking and McGeer is that,
perhaps because of the ability that autistic stories and narratives have to
transform public understanding of autism, bias-free accounts of autistic
experience are hard to come by. Narratives and stories might support or
be written from the point of view of the recovery movement, which views
autism as a disorder likely caused by vaccine damage or environmental
factors. Narratives might also support the views of the neurodiversity
movement, which views autism as a naturally occurring human difference.
Dramatizations of Autism like the movie Adam, or the television show
Parenthood for example, feature autistic characters who want to be
accepted for their differences, and who try to help others understand
autistic experience. This is also true of a character in the novel The Speed
of Dark. In movies such as Rainman or Mercury Rising and in books
such as The Girl with the Dragon Tattoo, and The Curious Incident of the
Dog in the Night-Time, however, characters with autism are portrayed as
struggling against a disorder that leaves them struggling and, in extreme
cases, unable to engage with their environment. The movie Mozart and
the Whale takes on this polarity and features two characters. One
character is proud of being on the spectrum while the other tries to be
“normal” and keep his diagnosis from his co-workers and employers. The
movie illustrates the tension between the two characters and the positions
that they represent. Autobiographies by those on the spectrum are often
faulted for the same bias and one-sidedness.
Given the current climate surrounding autism, narratives and stories of
autism written today are often biased to the point of being useless.
Though Cunningham’s objections to retrospective diagnosis certainly
make the use of historical methods to diagnose autism risky, one
advantage that the retrospective diagnosis of historical figures might offer
is that they were undiagnosed while they were living. If Schopenhauer
were writing today he might feel the pull to downplay his natural aversion
to noise and to condemn those who had caused the noise in the first place
citing noise-aversion as a valuable human difference. Likewise, if
Schopenhauer had been brought up under the recovery movement
paradigm, he might be compelled to view noise-aversion as pathological,
something that set him apart from the world. As it stands, Schopenhauer
was undiagnosed, and so clinicians and the general public might make use
of his philosophy to understand autistic thought patterns and of his
introspective accounts to understand the degree to which sensory
disturbances might affect autistic functioning or experience.
36 Chapter One
Forensic linguists are able to make accurate diagnoses of autism by

analyzing the linguistic patterns of authors. The similarities between
Schopenhauer, Hemingway, Melville, and other writers on the spectrum
share similar use of metonymic thinking and also illustrate the features of
autistic writing that Brown (2010) found to be consistent across writers on
the spectrum. The biographical and autobiographical accounts of authors
on the spectrum might provide details of the nature of their autistic
experience, and the fictional works of novelists might reflect facets of this
experience as well. Philosophical and introspective accounts, like those of
Schopenhauer, often go a step further and relay the social and sensory
experiences of those on the spectrum, as well as the nature of autistic
thinking and expression. These accounts have not been influenced by the
contemporary debates over autism, and therefore take no position toward
the burning questions: Is it a disorder or a difference? Should autistic
individuals be proud, or should they seek a cure? While Schopenhauer’s
introspective accounts won’t settle these debates, they certainly may
provide some insight from which to begin thinking about them.
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New Monthly Magazine, Vol. 10, 670-678.
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Texts for Investigating Disease in the Past. International Journal of
Paleopathology 1(2), 81-88.
Murray, S. (2008). Representing Autism: Culture, Narrative, Fascination.
Liverpool, UK: Liverpool University Press.
Perry, A. (2012). Autism Beyond Pediatrics: Why Bioethicists Ought to
Rethink Consent in Light of Chronicity and Genetic Identity. Bioethics
26(5), 236-241.
Reed, J. (2005). The Gentleman in the White Waistcoat: Dickens and
Metonymy. Style 39(4), 412-426.
38 Chapter One
Robison, J. (2007). Look me in the Eye: My Life with Aspergers. New

York, NY: Crown Publishers.
Schopenhauer, (1966).The World as Will and Representation, Volume II.
New York: Harper & Row
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Language 25(2) pp. 196-216.
CHAPTER TWO
EQUALITY, CAPABILITY,
AND NEURODIVERSITY
DOUGLAS PALETTA
Philosophical investigations into equality address three distinct

questions: what should be equalized, what is the point of equality and what
is the site or scope of that equality?1 The debate over what should be
equalized roughly divides into two camps: equality of resources and the
capabilities approach. According to the equality of resources position, the
demands of equality have been met once all people have roughly equal
access to the resources necessary to act as citizens. So, for instance, the
United States should require wheelchair ramps to ensure citizens equal
opportunity for employment and equal possibility of serving on a jury.
Focusing less on all-purpose means, the capabilities approach centers
around ensuring everyone meets a threshold level of human functioning or
capability. From the perspective of neurodiversity we can ask: how do
different neurological traits and differing levels of ability affect the

demands of equality in a country that prides itself on having free and equal
citizens?
The traditional paradigm of equality combines a focus on the goals of
democratic institutions with the equality of resources position. The goal of
distributive justice in this picture is to put citizens on equal footing in
mutually accountable relationships by ensuring each has access to the
kinds of things that serve as all-purpose means for pursuing their interests,
like money. This approach, with its overt focus on providing citizens all-
purpose means, however, pays insufficient attention to our neuro-
psychological differences. In many ways, the capabilities approach is
designed to incorporate issues of diversity, including neurodiversity. The
capabilities approach gives issues of diversity a pride of place by starting
from the fact of individual’s variable capability to develop a sense of the
good or use resources. For the capabilities approach, however, the
question of limits looms large. In what sense can we attain equality on a
40 Chapter Two
functioning approach when the fact of neurodiversity highlights a wide

range of neurological difference, both in kind and degree? How many
resources can justly be spent on the project? I suggest the best current
approach to equality brings together elements from the capabilities
framework, which better accounts for what to equalize in light of
neurodiversity, and an institutional framework more readily aligned with
the traditional paradigm, which provides a more principled basis for
establishing limits on the demands of justice.
I will lay out the benefits of this framework in several stages. I begin
by sketching several reasons why the traditional paradigm sidesteps
neurodiversity (§1). Next, I introduce several key facts about neurodiversity
that a conception of equality should incorporate (§2). Then, I argue that
equalizing capabilities rather than resources better maps onto the spectrum
of neurodiversity (§3). With this in hand, I present an argument for a
presumption of inclusion when it comes to who should be included in the
scope of equality (§4). I end by outlining how adopting a political
understanding of the point of equality provides a framework for
establishing limits on expenditures (§5). Again, an institutional approach
focusing on developing capabilities currently provides the best framework
for including traditionally alienated citizens, framing how to address their
needs and satisfying the demands of equality.
The Traditional Paradigm

Traditionally, democratic theory concerns itself with a different kind of
diversity: diversity of beliefs and values. Democracy is often characterized

as the second best solution – each would presumably prefer to live in a
society guided by her substantive moral beliefs. For example, if someone
believes abortion is immoral, a government that bans abortion seems
preferable to one that leaves the legality of the practice an open question.
However, recognizing that others hold different beliefs – beliefs that
should not be simply imposed on the public – points to the need for a
system to adjudicate conflicts. This is what democracy provides,
agreement on a system for settling disputes about issues that themselves
are not amenable to agreement. Within this backdrop, the point of equality
is to ensure the equal standing of citizens by ensuring they stand in
reciprocal political relationships to one another.
When John Rawls, the most significant political philosopher of the
twentieth century, initially introduced this view, he coupled it with an
equality of resources position. Since democracy is largely neutral between
competing moral codes and reasonable people may disagree about
Equality, Capability, and Neurodiversity 41
morality, the government should not prioritize one set of goods or values
over another. Rather, politically we should be concerned with what
everyone values. Rawls called these primary social goods which “are
things it is supposed a rational man wants whatever else he wants”
(Rawls, 1999, 79). These goods are unique in being all-purpose means
and include things like rights, opportunities and money. Regardless of
what someone values, these are the kinds of resources that allow any
citizen to develop and pursue what they think it means to live a good life.
Ensuring citizens have equal access to primary social goods thereby
respects everyone’s standing as agents in a scheme of social cooperation.
While this traditional paradigm works well when idealized, the account
sidesteps issues of neurodiversity in at least two ways: one methodological
and one more substantive. Methodologically, Rawls sets out to determine
“what is the most appropriate conception of justice for specifying the
terms of social cooperation between citizens regarded as free and equal,
and as normal and fully cooperating members of society over a complete
life” (12). He considers this the fundamental question of justice because
failing here means the theory fails in the least ambiguous philosophical
context. The goal is to find a successful theory in the clearer context and
expand the theory to harder philosophical cases. In doing so, he explicitly
sets aside individuals who do not fit neatly into the system as part of his
methodology.
More substantially, this understanding of the point and currency of
equality has implications for who should count as a citizen. Citizens are
characterized as having two moral powers: rationality and reasonableness
(Rawls, 1980, 525).2 Citizens are rational in that each can develop an idea
of what it means to live a good life and devise a plan to pursue it. Being
reasonable, citizens recognize others as legitimate sources of limits on
their pursuits and are motivated to abide by rules that others also accept. In
short, citizens demonstrate a level of motivation, analyticity, sociality and
independence that allows them to contribute to a scheme of social
cooperation. The focus on primary social goods recognizes that these
abilities and skills require certain conditions be in place to develop them,
but traditionally neurological variation among those who have the skills or
capacity to develop those skills is not seen as relevant to the justification
of principles of justice. Rather, from the standpoint of justification Rawls
suggests we should use an ideal “conception of ourselves as moral persons
and of our relation to society as free and equal citizens” (520). Doing so
relegates facts about human variation to secondary considerations.
Neurological variation becomes a fact that needs to be considered when
constructing actual laws rather than something that informs the fundamental
42 Chapter Two
values or principles guiding those laws. As Wong concludes her

discussion of Rawls: “We see that the idea of the person is idealized and
simplified, and makes no attempt to capture the full scope of human
diversity in the population to which the theory of justice will actually
apply” (Wong, 2008, 5).
Normalizing Neurodiversity
The fact of neurodiversity serves as an important corrective at several
levels in political theorizing. The central insight provided by neurodiversity
involves a change in perspective that challenges heretofore assumed
notions of the normal. As sketched in the previous section, philosophers
tend to ignore and more recently idealize away neurodiversity. As
understood in the literature, the neurodiversity movement makes two
central claims (Jaarsma and Welin, 2012, 20-21). First, the difference
between the neuro-typical members of society and those neurologically
different results from natural human variation and does not signal a sharp
break between the normal and abnormal. In part because there is not a
sharp break, a significant amount of the characterization, stigma and
differences in treatment is rooted in the social. Second, we should value –
or at least not stigmatize – our cognitive differences. For present purposes,
we need a framework for understanding this variation to inform both our
account of equality and how it may apply politically. 3
Neurodiversity refers to the neurological constellation of different
neurological types, which can be delineated according to a trait or set of
traits. Understanding diversity in terms of traits is important since several

neurological types, like autism, are “diagnosed solely on the basis of
observed behavior” (Baker, 2006, 19). Other commonly cited examples of
neurological variation range from temporal lobe epilepsy and depression
to hypergraphia (Glannon, 2007, 3). While sometimes referred to as a
spectrum, these examples show that neurodiversity does not distinguish
types using a single criterion. Rather, the variation is set by establishing
different combination of traits. For example, autists have difficulty
communicating and interpreting social cues, hypergraphists feel a
compulsion to write and “temporal lobe epilepsy has … been associated
with a heightened sense of spirituality or mystical visions”(3). While these
traits among others can be used to distinguish different neurological types,
declaring some type of neurological difference a disability makes the
further claim that the difference is an undesirable disorder or deviation
from the norm that requires fixing. Neurodiversity activists claim that
these different sets of neurological traits can, and do, comprise individual’s
identity and potentially provide a basis for culture (Davidson, 2008).
The sharp distinction between the neuro-typical and others breaks
down when considering two factors: the differences already present within
the neuro-typical community and the similarity between those perceived as
low-functioning and those perceived as neuro-typical at different stages in
life. The first shifts from a binary notion of agency focused on rationality
to one that admits of difference and degree. The second demonstrates
overlap between those normally included and those excluded in a way that
further blurs the line of normal.
Rawlsian rational and reasonable citizens gloss over a range of
diversity within the traditional normal range. Many within the range are
autistic, obsessive, compulsive, depressed, and so on. The focus on rational
agency fails to capture the first or second personal agency of these people.
As mentioned earlier, these people are not otherwise neuro-typical with
some affliction, but instead the combination of characteristics or traits
partly makes up who they are. Someone is not a person with autism, but an
autistic person. Put differently, someone’s neurological make up has a
significant impact on how they agentially approach the world. Again
consider the case of an autistic person. This neurological difference will
affect how he perceives the world and thus how he processes decisions. To
take the first, an autist “can focus on the details of parts but not on the
general patterns of wholes” (Glannon, 2007, 2).4 This affects both the
information he has to act on and the way he makes decisions. For example,
one study found that autist’s “susceptibility to the frame manipulation
[including frames invoking emotional context cues] was markedly
reduced” (De Martino, 2008, 10478). This led autists to make more
consistent decisions in risky situations than non-autists. Making more
consistent decisions does not necessarily indicate that autists make better
or worse decisions, the framing or emotional cues may contain important
information or be irrelevant depending on the situation. It does, however,
point to a sharp difference in how autists relate to the world. Importantly,
many people with these neurological traits may well be rational and
reasonable in Rawls’s sense. However, characterizing their agency, and
subsequently disseminating the same bundle of resources, fails to
recognize the difference in agency and thereby equalizes citizens in a way
that is not sensitive to that difference. In fairness, the traditional theory
isn’t supposed to capture these differences, but this is precisely the
problem.
Second, accepting the impact of neurological variation on agency
further makes sense of how to include those in dependency relationships.
44 Chapter Two
Neurological variation occurs across a typical life. In part building on the

work of care theorists, everyone goes through stages of dependency and
limited cognitive ability. Children have not yet developed cognitive
capacities. Disease or injury can lead to temporary or permanent cognitive
impairment, and many elderly live with diminished cognitive capacity.
Moreover, the dependency is widespread with some statistics showing that
“up to 20 percent of adults older than seventy-five suffer from
Alzheimer’s and other forms of dementia” (Carlson and Kittay, 2009,
309). Shifting the paradigm of membership away from rational agency
opens the door recognizing these as stages of life with distinct kinds of
agency perhaps with distinct capabilities, modes of valuing and manners
of political engagement, which allows these normal parts of life to be more
directly incorporated into our political theorizing.
Shifting the perspective of what counts as normal similarly shifts the
significance of neurodiversity for political theories. As Carlson and Kittay
put it, “This realization should compel us to view cognitive disability as a
feature of the human condition that philosophers should take seriously”
(310). Or, to put the point differently, neurodiversity in its various forms
should be part of the paradigm in a political theory, not treated as fringe
cases or secondary considerations. In particular, neurodiversity challenges
the more traditional conception of rationality based agency and therefore
the basis of inclusion implicit in the traditional paradigm. At a minimum,
better incorporating this kind of diversity provides a prima facie reason to
adopt one among competing conceptions of equality.
The Capabilities Approach

Capabilities theorists tend to answer the three questions about equality
differently than Rawls. Most notably, capabilities theorists reject the
equality of resources position. When it comes to the currency of equality
or what should be equalized, these theorists try to contextualize the
resources someone has to see what she can do with them. This focus on
how people function or what they are capable of tends to align with more
substantive, less neutral, ideas about the point of equality. These ideas, in
turn, are compatible with an expanded notion of who to include in the
scope of equality. Sketching the view presented by Martha Nussbaum, one
of the chief proponents of the capabilities approach, demonstrates how the
capabilities approach is better suited to addressing issues in neurodiversity.
Shifting the focus of equality from a more neutral resources position to the
capabilities approach captures the two central elements of neurodiversity
the more traditional view sidesteps. Namely, the capabilities approach
deemphasizes rationality as the core of agency and foregrounds variation

in a way that opens the door for inclusion.
Presenting a moral view similar to a human rights view, Nussbaum,
grounds the capabilities approach in dignity. She states, “the capabilities
are not understood as instrumental to a life with human dignity: they are
understood, instead, as ways of realizing a life with human dignity”
(Nussbaum, 2006, 161). As she later states, “the guiding notion therefore
is not that of dignity itself, as if that could be separated from capabilities to
live a life, but rather, that of a life with, or worthy of, human dignity”
(162). Importantly, this way of grounding the capabilities approach to
equality invokes a single value, the idea of human dignity or a life worth
living, as the single goal of politics. Nussbaum acknowledges that she
does not try to present a comprehensive political or moral doctrine, but her
approach contrasts sharply with positions like Rawls’s democratic
equality, which focuses on enabling the pursuit of different conceptions of
what it means to live a good life. Democratic equality provides the means
to promote a plurality of goods where the capabilities approach ultimately
seeks to promote the chief value of human dignity.
One important corrective to note: living with dignity will involve
pursuing personal projects that may differ radically from person to person
based, in part, on what each values. This sounds like the democratic
equality position. If democratic equality provides the means to pursue
different conceptions of good lives and the capabilities approach seeks to
promote human dignity that involves people pursuing different
conceptions of good lives, the two views seem to come together. The
reason they come together goes back to the moral powers presupposed on
the democratic equality approach. If someone recognizes the legitimate

claims of others and pursues a conception of the good, they most likely are
achieving Nussbaum’s conception of human dignity. That is, the value of
human dignity is largely presupposed and built into the account. Here
again is where neurodiversity gets idealized out of some traditional
approaches to democratic equality. Democratic equality presupposes a
notion of dignity, grounded in rationality, which precludes certain
segments of the neurodiverse. By bringing the notion of dignity to the fore
and presenting a notion of dignity grounded in capabilities and flourishing,
Nussbaum presents an account that scales and adapts to the distinct
neurological make-up of those across the neurodiverse spectrum.
Re-centering the point of equality on human dignity or a human life
worth living straightforwardly leads to capabilities as the currency of
equality. The primary social goods, such as rights or money, only matter to
the extent people are capable of using them. The idea behind primary
46 Chapter Two
social goods is that though some may find them more or less useful this
bundle of goods will have the kind of things that allow people to pursue a
meaningful life. The fact of neurodiversity greatly expands the range of
how useful citizens will find primary social goods. Different neurological
traits leading to different modes of engaging the world may have a
significant impact on the usefulness, and perhaps even recognition, of
certain resources. If the point of primary social goods is to enable citizens
to pursue a good life, in a neurodiverse society resources serve as a poor
proxy for flourishing. In contrast, the capabilities approach cuts directly to
the point. The goal of equality is not to give people the same starting point
but to allow them to function in a way that enables them to meaningfully
engage the world as each sees it. As Nussbaum puts it, the goal is to
ensure citizens live with dignity.
An Argument for Inclusion

So far, I have assumed that individuals falling anywhere on the
neurodiverse spectrum are part of normal human variation and that the
difference is not morally significant. This presupposes answering the first
question posed by neurodiversity – are autistic people abnormal – further
answers the second – a normative question about value. While this
presumption can be compelling in high-functioning cases, whether it
similarly applies to low-functioning, highly dependent persons is less
clear. While not all difference should be thought of as disability, some
people may lack the cognitive capacity to recognize what is happening,
much less have a conception of the good, devise a plan to pursue a

conception of the good, bear the burdens of social cooperation or other
traditionally relevant agential factors.5 Such individuals can give better or
worse lives, but they fall outside of the scope of those who engage
politically. Here the question of scope reemerges – what are the limits on
those who should be included among the equal? Since high-functioning
individuals may already be included and extremely low functioning
individuals seem to fall outside the scope of even potential political
engagement, the philosophical question of scope becomes how to
approach borderline cases. Rather than draw a sharp line, I argue
borderline cases should be considered with a presumption for inclusion.
Excluding people who seem like borderline cases and turn out to be
able to participate at some level politically perpetrates an injustice. Sophia
Wong makes this point in terms of “Enabling Conditions,” though she
remains within a framework where citizenship is based on potentially
developing Rawls’s two moral powers (Wong, 2009, 384). Roughly, at
birth anyone who could potentially develop the capacities for rationality
and reasonableness still need certain conditions to be in place to direct and
ensure their growth. For example, historical conditions that deprived
women of education and locked them into servile roles in misogynistic
cultures inhibited their development of capacities. Wong argues liberal
societies “must provide citizens labeled with cognitive disabilities with the
Enabling Conditions until they become fully cooperating members of
society” (399). Failing to do so marginalizes a group that explicitly
deserves membership in the political community. In addition to ensuring
that borderline cases have the opportunity to become part of the
community, denying rightful members of the community access to the
political sphere directly disenfranchises them. To deny those labeled
cognitively disabled relevant enabling conditions and access to the
political arena errs on the side of injustice.
The opposite seems less true. The potential harm of including in so-
called low-functioning individuals who turn out to lack sufficient capacity
to engage politically, even with enabling conditions in place, attaches to
those in the political community rather than the person who falls short of
being able to become part of it. This potential harm may manifest itself in
various ways. The next section will address a potential worry about the
costs associated with providing enabling conditions, though it should be
noted these concerns with efficiency may not trump concerns about
equality and justice. Perhaps the chief concern is granting equal political
power to an individual who is incapable of wielding it. The lack of
capacity motivating this concern, however, partly mitigated the worry. If
someone who seems like a borderline case turns out not to be able achieve
some minimal level of capacity, he literally will not be able to politically

engage and thereby will not be able to act in a way that significantly
impacts the polis. Selecting between erring on the side of irrelevance
rather than erring on the side of injustice creates a justice-based reason for
inclusion.
Some Notes on Limits

The capabilities approach, with its focus on functioning rather than
rationality, provides the groundwork for a more inclusive membership in
the community of equals precisely because it is more sensitive to the
different kinds of functioning that can be found within the constellation of
neurodiversity. This view, however, seems to have a sharp downfall. If
more people are included, and the presumption should be in favor of
including borderline cases, fostering the development of dignity may
48 Chapter Two
require an extraordinary amount of resources. Looking across the

neurodiverse constellation, it seems like there is always something we
could do to further develop the capabilities of someone within the
spectrum, tailored to each individual’s unique set of traits. However, as
Wong puts it, a successful theory “must provide some principled basis for
limiting our obligations” (Wong, 2008, 1). Restricting the application of
this understanding of equality to institutions provides a basic framework
for a principled basis for limits.6
Perhaps most importantly from the standpoint of limits, the capabilities
approach does not present a maximizing conception. While everyone
should live with dignity, the point of equality is not to achieve some
privileged “full” or “normal” level of functioning. Rather, the goal is to
ensure that within the backdrop of differing neurological make-ups each
has the capability to live a meaningful life. Presenting a view that also
brings together democratic institutions and the capabilities approach,
Elizabeth Anderson puts the idea this way, “once all citizens enjoy a
decent set of freedoms sufficient for functioning as an equal in society,
income inequalities beyond that point do not seem so troubling in
themselves.” (Anderson, 1999, 326). If the main concern with resources is
the amount resources it will take to develop capabilities in lower
functioning cases, this framework provides a theoretical argument against
using every last resource to develop every last capacity.
The nature of institutions further mitigates concerns about
expenditures. While the focus of the content of the policies would be on
individuals, institutions are designed to effectively address a need or
coordinate behavior. Part of what neurodiversity adds is a framework for
recognizing and differentiating kinds of needs that should direct the

structure of new resources put in place. Importantly, the term institutional
here does not refer to anything like an asylum or mental institution. Rather
the focus is on social institutions like schools, the system of taxation and
laws or the courts. In moving away from means or resources, the
capabilities approach focuses more on individual’s abilities, which can
only be assessed by looking at their circumstances. As Nussbaum states,
“no matter how much money we give the person in the wheelchair, he will
still not have adequate access to public space unless public space itself is
redesigned” (Nussbaum, 2006, 127). Using this notion of equality as a
guiding principle structuring our social institutions precisely addresses the
shape of the public space.
As in the case of making sidewalks wheelchair accessible, frequently
creating open access to achieve a universal design requires changing
something once and will address and benefit a range of people. For
example, public transportation systems, which provide mobility that can

greatly expand opportunity, frequently use complex maps that provide a
lot of information in a small amount of space. Finding ways to simplify the
maps, by providing the route of a single bus at each stop or creating
technological systems that bypass the complexity that allows a caregiver to
program a phone alert for when to get off a GPS-enabled bus expands
access to those with different attention or spatial reasoning abilities
(Carmien, 2005). Creating systems like GPS enabled buses further
provides a useful resource for regular commuters. Taking lessons from
universal design in the classroom, government websites can become more
accessible avoiding flashing objects, unnecessary images and graphs;
describing any images and always including consistent headers (Crow,
2008, 53). These kind of changes expand the usefulness of public spaces
without creating new expensive, ongoing budget items. Moreover, where
no special recognition is necessary for developing a capacity, the
institutions will already be in place as they were for the neuro-typical.
Not all institutional changes, however, would be passive.7 Some
institutions, like our educational or public health systems, play an active
role in reaching out to different populations. This is where the capabilities
approach calls for new positive duties to assist those within the
neurodiversity spectrum. Since equality focuses on developing capabilities
rather than distributing resources, there is a positive duty to fund research
on different realistic approaches to how to develop certain capability as
well as to recognize the value and strengths of different abilities. Also,
positively, the government should provide regional outreach tailored to
different kinds of needs. Finally, recognizing that developing and using
certain capabilities may require confederates and caregivers likely calls for
an increase support for care takers, perhaps by changing what counts as a
tax deductible expense, providing access to care and providing well-
researched, current information to caretakers. This is to say, creating a
more open, equal society may well generate new additional costs.
However, many of the changes would be structural rather than ongoing
and many of the prima facie positive duties involve expanding and
targeting services already in place. The capabilities approach provides a
conception of equality tat can serve as a framework for targeting those
services.
50 Chapter Two
Conclusion
From this discussion, there are a few important points to take away.
The fact of neurodiversity should impact our theorizing as much as it does
our practice. Though the issue has largely been set aside, we already have
large segments of theory to address issues of neurodiversity. Most
importantly, we should not let the perfect be the enemy of the good. We
have a pretty good, though still nascent, philosophical framework for
incorporating and addressing neurodiversity. It is a framework that
mitigates some of the concerns over limits and points to several areas, like
creating more neurologically open public spaces, that can be implemented
and lead to a more equal society.
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CHAPTER THREE
POLICING NEURODIVERSITY
IN HIGHER EDUCATION:
A DISCOURSE ANALYSIS OF THE TALK
SURROUNDING ACCOMMODATIONS
FOR UNIVERSITY STUDENTS
JESSICA NINA LESTER, HANNAH DOSTAL

AND RACHAEL GABRIEL
Introduction
Currently, nine percent of students enrolled in US colleges and
universities have disabilities (Institute for Higher Education Policy, 2010).
Historically, university systems have relied upon federal laws to set the
tone and create the policies that facilitate the inclusion and/or exclusion of
students with disabilities. Specifically, the rights of university students
with disabilities are protected under the Americans with Disabilities Act
(ADA, 1990) and Section 504 of the Rehabilitation Act (1973). Yet, even
with legalized norms in place, the meanings ascribed and access granted to
students with disabilities is left, in many regards, to the individual
university to construct. While some universities make claims of pursuing
and welcoming a diverse student body, others express caution in moving
too far beyond their established norms.
Within this chapter, we present findings from a discourse analysis,
informed by poststructural thought (Derrida, 1981; Laclau & Mouffe,
1985) and discursive psychology (Edwards & Potter, 1993), examining
how the top 30 universities and colleges in the United States position the
meaning of disabilities and construct their role in facilitating access for
students with disabilities. Specifically, we analyzed the publically available
web pages of the universities’ offices of disability services, taking note of
Policing Neurodiversity in Higher Education 53
the ways in which they took up (or not) legal discourses when making a
case for why (or why not) accommodations should be provided to students
with disabilities. We attended to how the offices of disability services were
described, with some being positioned as existing because of the law, in
spite of the university’s interests. Others presented their existence as being
about something far more than a law, as they sought to become a space of
inclusion and diversity. We discuss here the function and potential
consequence of discourses that position students’ rights in opposition to
the integrity of institutional programs. In such instances, the university’s
obligation resides not with defending students’ rights, but in protecting the
integrity of institutional objectives. In a previous study (Dostal, Gabriel, &
Lester, in press), we reported on the ways in which the language employed
on many university websites positioned access for students with
disabilities as something that resides outside of the university; housed
instead within federal law. We discussed how orienting to equal access as
being beyond the scope of the university results in students with
disabilities being positioned as too far beyond the norm to be fairly
included. In this chapter, we build upon this earlier work, specifically
illustrating the ways in which neurodiversity is policed and restricted by
the language choices employed on the selected university webpages.
We first present a brief review of the literature surrounding access in
higher education for those who identify and/or are identified as students
with disability labels. Then, we discuss the theoretical commitments that
framed this project and sensitized our data analysis and interpretation.
Next, we conclude by presenting the findings, with discussion embedded
throughout.
Literature Review
The Association of Higher Education and Disability (AHEAD) has
developed and disseminated standards and indicators for disability service
providers on college campuses (Dukes, 2006; Shaw & Dukes, 2006), as
well as a tool for the evaluation of disability services (Dukes, 2011). Such
tools have informed the evaluation and design of a number of offices, as
well as research that examines the relationship between disability service
unit and the larger institution (Harbour, 2009), and the governing
philosophy of a given unit (Guzman & Balcazar, 2010).
The majority of studies in the area of disability services in higher
education focus on program design or service delivery and have relied
upon survey data or other forms of self-reported data (e.g., interview,
questionnaire, etc.). For example, drawing upon a disabilities studies
54 Chapter Three
framework, Guzman and Balcazar (2010) analyzed the philosophies

behind disability services delivery models across universities. They
reported that the majority of programs surveyed in their study were guided
by an “individual” rather than “social” or “universal” approach to service
delivery. That is, most began by first determining an individual’s “deficit”
and then matching the “deficit” with an accommodation (individual
approach), rather than viewing the “deficit” in relation to the social and
cultural environment.
In other cases, surveys, interviews and analysis of existing data have
been used to examine demographics and achievement (Sparks & Lovett,
2009), retention (Mamiseishvili & Koch, 2011; Wessel, Jones, Markle &
Westfall, 2009), and the likelihood of seeking disability services (Collins
& Mowbray, 2008). Relatively little research has examined the ways in
which materials and program features developed by universities function
to construct meanings of disability in higher education settings. In one
example, Ralph and Boxall (2005) examined a sample of recruitment
materials from universities across the United Kingdom and found that the
majority of universities do include photos of students with visible disabilities
and mention disability services in their recruitment materials. This form of
inclusion within recruitment documents was common, but 34% of
universities in the study made no reference (visual or textual) of students
with disabilities or related services. Thus even universities that appear to
include people with disabilities may have widely varying ways of doing so
and degrees of available support. Though there is evidence that researchers
and university administrators are interested in evaluating the efficacy of
the programs they design for students with disability, there have been few
attempts to include the discursive construction of the varied meanings of

disability in campus documents.
Theoretical Perspectives
There were several theoretical perspectives that shaped the way we
made sense of the data. First, we assumed that the very notion of “normal”
and “abnormal” (Kincheloe & Steinberg, 1993) is constructed in and
through discourse. Bodies, minds, and identities materialize in and through
the symbols and images that are part of the everyday, mundane activities
of life. Canguilhem (1989) suggested that “normal” is always compared to
that which is constructed as “pathological,” with the two constructs being
mutually constituted. For instance, one cannot be a disabled college
student, unless there is an abled college student by which to compare her.
Canguilhem further stated that “every conception of pathology must be
based on prior knowledge of the corresponding normal state” (p. 51), for
“this normal or physiological state is no longer simply a disposition which
can be revealed and explained as fact, but a manifestation of an attachment
to some value” (p. 57). Therefore, through a priori standards that are
situated within culturally and historically contingent values and practices,
that which counts as “abnormal,” “disabled,” or “pathological” is always
already constituted and reconstituted.
Positions that invite neurodiversity inevitably confront and conflict
with a deficit and binary-based (you are either “normal” or “abnormal”)
perspective. In contrast to a deficit perspective, a perspective that invites
neurodiversity describes persons through a lens of diversity across
identities (e.g., ethnicity, religion, gender, nationality, ability, sexual
orientation, etc.) (Robertson, 2010). Identity is presumed to be shifting,
dynamic, multiple, and socially embedded. Strengths and weaknesses are
presumed to exist, yet are located within the contexts in which they
emerge. In other words, a college student who identifies as disabled may
only experience “disabling effects” when the environment is structured in
such a way that it makes achievement and access impossible. If, on the
other hand, environmental re-structuring occurred, the student may access
and achieve what they sought to achieve. A socialized orientation to
disability has certainly resulted in a shift from focusing on the “individual”
as the sole “problem” to the ways in which the environment itself can be
shifted to eliminate or (at least) decrease the effects of disabling barriers.
Thus, rather than asking what “deficits” are within the individual that
result in them not being able to access higher education, we can ask: how
can the environment be changed in order to increase the students’ access to
the learning environment?

So, when considering the broader discussion surrounding neurodiversity
(Savarese & Savarese, 2010), it is important to recognize that discourses
about allowable educational accommodations often function to police and
limit the degree to which neurodiversity, at an individual and collective
level, can be “achieved” within university systems, as well as other
contexts. Foucault’s (1995) notion of the “power of the Norm” (p. 184) is
useful when considering how certain identities and ways of being become
privileged, normalized, and positioned within hierarchical systems. He
noted that:
The power of the Norm appears through the disciplines...Let us say rather
that, since the eighteenth century, it has joined other powers—the Law, the
Word (Parole) and the Text, Tradition—imposing new delimitations upon
them...normalization becomes one of the great instruments of power at the
end of the classical age. For the marks that once indicated status, privilege
56 Chapter Three
and affiliation were increasingly replaced—or at least supplemented—by a

whole range of degrees of normality indicating in a homogeneous social
body but also playing a part in classification, hierarchization and the
distribution of rank. (p. 184)
Thus, within our interpretation of the data, we considered the ways in

which the discourse choices themselves functioned to control, police, and
restrict what accommodations were made possible for potential and
current university students with disability labels. Further, we took note of
the ways in which discourse choices functioned to position certain
identities as being “normal”, thereby shutting down possibilities for a
perspective that embraces neurodiversity.
Method
We took a discourse analysis approach (Wood & Kroger, 2000), which
was shaped by the theoretical perspectives discussed above. In taking this
approach, we assumed that discourse is action-oriented; which led us to
focus on what text does within a given context (Potter, 2004). What
identities are produced and made relevant, for instance? We also oriented
to discourse as constructed, resulting in a focus on what various rhetorical
devices do to reify certain versions of reality. Finally, we oriented to
discourse as situated, always being bound up and embedded within given
interactions and institutional practices and norms. Thus, as we pursued the
analysis process, we attended carefully to the language choices and how
such choices constructed certain realities, making some actions and
identities (im)possible. This method informed the type of data we collected

and our analytical approach.
Data Sources and Analysis

Our data sources included publically available websites from the top
30 universities in the US, based on rankings published by U.S. News and
World Report (2011)1. We chose these schools for our purposive sample
because their status in a well-known ranking system positions them as
leaders in the field of higher education. We first identified the top schools
and then collected individual web pages specific to offices or departments
that coordinate disability services. Within this chapter we refer to these as
Offices of Disability Services (a commonly used title) though some
operate under unique names (e.g., student disability office, office of
accessible education, resource office on disability, etc.). This search
resulted in 40 pages of online data, which we copied and pasted into word
documents. These documents were then uploaded to Atlas.tiTM (Muhr,

2004) – a qualitative software program that we used to organize our data.
Through the analysis process, we used the annotating features of
Atlas.tiTM, creating theoretical and analytical memos and eventually
moving to the level of “codes.” More specifically, we engaged in a five-
step discourse analysis process: (1) reading and re-reading of all
webpages, taking note of patterns across the data; (2) individually
developing analytical, theoretical, and reflexive memos, documenting our
thought process and interpretation; (3) joint discussion of the individual
memos and constructing of a “codebook”; (4) individually selecting and
“coding” patterns across the data set; (5) developing explanations and
generating analysis around noted patterns.
Findings
Perspectives that embrace neurodiversity have primarily been outlined
by federal laws in order to protect the rights of students with disabilities.
Offices of Disability Services (ODSs) on college and university campuses
exist, at least in part, to ensure compliance with federal laws related to
equal access and opportunity for individuals with disabilities in education.
Indeed 80% (26/30) of the sites we analyzed made at least one explicit
reference to The Individuals with Disabilities Education Act (IDEA)
(2004), most often within their mission or “about us” statements. Still,
some ODSs described their work as going beyond protecting the university
by simply ensuring compliance with the law and reached towards a more
comprehensive approach to the creating access for students with

disabilities. We noted that universities within our sample fell along a
spectrum from opposing to actualizing the larger mission of the university
(Dostal, Gabriel & Lester, in press). For instance, for some universities,
being responsive and inclusive of students with disabilities stood in
opposition to what they often phrased their “academic integrity.” In
contrast, other universities defined their very identity as embedded within
an approach that invited all students, shifting, when needed, their
environment in order to facilitate access. This spectrum illustrated the
contrasts in approaches and highlighted the many points of tensions for
universities in relation to their institutional (legal) and ethical
responsibilities. We show here how universities were positioned as
policing what counts as a disability, as well as what should be allowed as
an accommodation for students with disabilities. Unlike other offices
designed to provide services or advocacy for students, some ODSs
actually described themselves as working on behalf of the university,
58 Chapter Three
policing who was allowed accommodations, what kinds of accommodations

were to be provided (aka allowable), and the ways in which these
accommodations were incorporated (if at all) within the regular classroom
instruction. In the following section, we include excerpts from the data set
with analysis and discussion that describes our interpretation of the action
orientation of texts from ODS websites.
Presenting a Purpose
We highlight here the ways in which the purpose statements on the
ODS website served to frame the inclusion/exclusion of students with
disabilities in particular ways. We present contrasting excerpts.
Excerpt 1 serves as an example of a university that locates inclusion as
central to its overarching mission, not as an aside.
Excerpt 1.
Welcome to the Office of Accessible Education! Stanford University has a
strong commitment to maintaining a diverse and stimulating academic
community, representing a broad spectrum of talents and experiences.
Students with disabilities, actively participating in the various aspects of
life at Stanford, are an essential part of that diversity.
In this excerpt, the university itself is positioned as the agent that

demands education to be accessible. Rather than placing the onus on the
student to seek services or the law to require them, the university includes
disability services within its own (“strong”) commitment to maintaining a
diverse community. The phrase “broad spectrum of talents and

experiences” is immediately adjacent to “students with disabilities,” thus
including such students within all that counts as “talent” and “experience”,
rather than as separate from the school’s general population. This inclusive
approach is further supported by the opening sentence, one that is
constructed as an enthusiastic (exclamation point) greeting (“welcome”) to
readers who have an interest in the work of this particular ODS. Beyond
being enthusiastically welcoming to those who seek information about
disability services, the site constructs people with disabilities as members
of a desirable population. In the second and third sentences, students with
disabilities are described as “an essential part” rather than a threat to the
kind of community the university seeks to create.
Within this excerpt, as in the neurodiversity movement, disability is
constructed as part of a spectrum of talents and experiences. The lexical
choice of “essential” suggests the absence of tension between accommodations
for students with disabilities and the university’s mission. If disability is
“essential” to the diversity of the university community, the community

could not be what it is without such diversity. This stands in stark contrast
to Excerpt 2, in which providing accommodations for people with
disabilities presents several points of tension between the mission of the
university and the rights protected under federal law.
Excerpt 2.
MIT Student Disabilities Services, as required under the Americans with
Disabilities Act (ADA) of 1990 and Section 504 of the Rehabilitation Act
of 1973, makes every reasonable effort to provide appropriate
accommodations and assistance to students with disabilities. The objective
is to ensure that our students receive equal access to all Institute programs
and services. To that end, we seek to balance the student's right to access
with our obligation to protect the integrity of Institute programs and
services.
One point of tension we identify within Excerpt 2 is between the

“integrity” of the university and students’ rights to equal access. The use
of the word “balance” suggests several things as being in opposition to one
another. First, in this case students’ rights are not part of ensuring the
institution’s mission, as they were positioned in Excerpt 1. Rather, they are
positioned in opposition to the very “integrity” of the institution and are
perceived as a challenge to be managed or policed. Within this second
excerpt, the ODS is positioned as a mediator between competing interests
(“we seek to balance”), rather than a facilitator of mutually held goals of
inclusion. Further, the university “makes…effort” to provide
accommodations because of external requirements, instead of as an
expression of their institutional goals and values. It is within this space

between institutional and legal obligations that ethical questions find
fertile ground. There is a subtle, perhaps implicit question of whether
students with disabilities will ultimately negatively affect the integrity of
the institution, with “integrity” often being a term easily aligned with
ethical commitments and obligations. In many ways, the discourse choices
in Excerpt 2 function to present a moral argument that justifies the
potential exclusion of students with disabilities.
The opposition between the institution’s obligations and students’
rights constructs a version of accommodations that are threatening to an
institution rather than liberating to an individual. Accommodations are
therefore carefully policed, as they stand as a threat to the institution’s
values, even, perhaps, their morally justified obligations. The word
“every”, in line 2 of the excerpt, is an extreme case formulation that works
to draw attention (Edwards, 2000) to the completeness of the effort, yet it
is modified by two descriptors which work to construct a specific version
60 Chapter Three
of accommodations. The use of these modifiers constructs accommodations

as something that can potentially be inappropriate or might require
unreasonable effort. Such a version positions the ODS as needing to
defend the university against some efforts and accommodations. The
words “reasonable” and “appropriate”, as adjectives for the university’s
effort and for kinds of accommodations, also work to limit responsibility
by making the nature of effort and accommodations contingent on an
external definition. What is “reasonable” and “appropriate” is determined
by the university. In determining what counts as “reasonable” and
“appropriate”, ethical dilemmas may arise that are not answered by the text
of IDEA or ADA. For instance, dilemmas about which accommodations are
appropriate and how much effort is reasonable are not at issue in Excerpt 1
because a full, rather than contingent, commitment to equality is
supported, rather than challenged, by the institution’s goals. In Excerpt 2,
on the other hand, an orientation to accommodations and difference is
positioned as something to be policed, in a “morally” justified way, as it is
about protecting the integrity of the university.
Sources of Ethical Tension

The term “reasonable accommodations,” not at all unique to MIT’s
website, is borrowed from the text of the IDEA legislation. Thus, all
universities face the task of putting such contingencies into practice by
defining what counts as reasonable, and different institutions take different
approaches. For instance, on Notre Dame’s website, “An accommodation
is considered reasonable only if it does not significantly alter the essential
components of a course or program.” This type of approach works up a

version of a university course in which there is always an identifiable
essence and a version of an accommodation that has the power to alter the
essence of the course. Similar to Excerpt 2, accommodations are set up as
having the potential to conflict with the mission of the university, and
might even be something to protect against. Additionally, within this
approach the institution and its faculty are the arbiters of what counts as
“reasonable”, as they are the course designers and providers. The power
lies with the supposed “experts”, who in this case are not the students with
disability labels.
In contrast, the ODS at Boston College, “works closely with students,
administrators, and faculty to develop and implement individualized
accommodations tailored to students’ needs”, as further highlighted in
Excerpt 3. The discourse choices here construct a version of accommodations
in which the integrity of the course is not made relevant. Indeed the
contingent term “reasonable” is likewise not present as a modifier for

accommodations. Instead, accommodations are described as being
“tailored to students’ needs.” Thus they are still contingent, but depend on
the student, rather than the course. Decisions about accommodations are co-
constructed by the students, administration, faculty, and ODS, and are
designed to address an individual’s needs.
University websites that construct accommodations for people with
disabilities as a threat or in opposition to their institutional mission create
room for ethical questions to arise, as they construct tensions between
institutional goals and individual rights. Part of this tension lies in who and
what is positioned as the arbiter, particularly in places where the federal
law leaves room for contingent responses. Another part of this tension lies
in the ways in which accommodations are constructed: as helpful or
potentially harmful. In Excerpt 3, the stated mission of the ODS represents
a contrast to Excerpt 2, positioning the ODS within the university
community.
Excerpt 3.
The mission of the Disability Services Office is to assist students with
disabilities at Boston College in achieving their educational, career, and
personal goals through the full range of institutional and community
resources. The office ensures that students with disabilities receive support
services and accommodations that permit equal access to all Boston
College programs and the opportunity to realize their potential and develop
effective self-advocacy skills.
Excerpt 3 uses the word “full” when describing how Boston College
will go about assisting students achieve their goals (“through the full range
of institutional and community resources”). Accommodations, here, are
positioned as that which results in “equal access”, standing in contrast to
the notion that only “reasonable” accommodations remain as the goal (as
was noted in Excerpt 2). If the goal is to assist students, rather than solely
and primarily protect the “integrity” of the university, there is no dilemma
when deciding what accommodations to allow. On the other hand, for
some institutions, as was noted in Excerpt 2, the ODS is positioned as
being required to mediate tensions between what students with disabilities
request and what the university is prepared and willing to give. Excerpt 2
represents a case in which the amount and kind of accommodation is
constructed as an ethical dilemma because of the ways in which
participation at the university level has been conceptualized. In contrast,
within Excerpt 3, a dilemma is not made relevant as “full...resources” and
“equal access” subsumed within the overall mission.
62 Chapter Three
Excerpt 4 illustrates an example in which the prestige of the university

is maintained by the application of disability labels and support of people
with disabilities. The following comes from a section marked “frequently
asked questions” within the disability services page of Dartmouth College.
Excerpt 4.
I don’t know if I have a “disability” per se, but I am having academic
difficulties that don’t make sense to me, and I might want to explore the
possibility. Can SAS help?
We may! Very bright individuals - such as those accepted for selective
schools like Dartmouth College - can have a so-called “cognitive
disability” that goes undetected through high school. “Cognitive disabilities”
refers to various neurologic-based impairments that significantly affect
learning and perhaps other major life activities. Some cognitive disabilities
result from head injuries. Some are lifelong circumstances experienced
from childhood.
In this excerpt, having a “so-called ‘cognitive disability’” is described

as connected with positive characteristics like being “very bright” or
“accepted for selective schools.” The use of the exclamation point after
“we may” marks the possibility that SAS can help someone questioning
whether they have a disability with enthusiasm. This constructs the ability
to diagnose a disability or the diagnosis itself as something that is done
enthusiastically and not considered as being in opposition to the aims of
the university. It would be difficult to imagine a similar expression of
enthusiasm for the possibility of being able to diagnosis something
negative, like a terminal illness. In addition, the extreme case formulation
(Potter, 2000) of “very bright individuals” draws attention to this

population as a special case even as the word “can” asserts the possibility
that cognitive disabilities are a reality among this population. The next
sentence resists the logic that “very bright individuals” are not often
associated with having “cognitive disabilities” by pointing out that they
may go undetected. In excerpt 5, we have a similar example of a
university approaching federal requirements as part of the natural
expression of their own values, rather than as something to balance or
comply with.
Excerpt 5
To ensure the intellectual richness of research and education, the
University of Chicago seeks to provide an environment conducive to
learning, teaching, working, and conducting research that values the
diversity of its community. The University strives to be supportive of the
academic, personal and work related needs of each individual and is
committed to facilitating the full participation of students with a disability
in the life of the University. The University is committed to complying

with Section 504 of the Rehabilitation Act (Section 504) and the
Americans with Disabilities Act (ADA).
In this excerpt, the discourse choices constructs the very notion of

“diversity” as being a part of what brings “intellectual richness”. “Full
participation” is part of the institutional commitment, which is located
prior to making relevant a commitment to “complying” with ADA.
What Counts: Qualifying for Labels and Services

Across the data set, we also found that there were tensions around who
has the authority to name a disability and therefore obtain access to
accommodations. As the website for Dartmouth College described:
Excerpt 6
Service eligibility is based in large part on the quality and comprehensiveness
of a student’s disability documentation and degree of current functional
need. A record of prior accommodation, in and of itself, is usually
insufficient to support academic accommodations in higher education. A
physician’s, psychologist’s or other practitioner’s determination/
recommendation/assertion about appropriate accommodations is valued, but
there are many factors to consider and the ultimate judgment rests with a
college or university.
Though individual disabilities (i.e., learning disability, dyslexia)

represent contested categories, the university here was positioned as the
arbiter, deciding what counts as evidence and who is qualified to declare a

disability label is warranted. On the Dartmouth College’s website, like the
majority of universities, the determination of a disability was made
through formal psycho-educational testing. The place of authority for
naming or qualifying someone as having a disability was often positioned
as negotiable, but rarely was placed with the student him or herself. In that
the university recognizes there is a large financial barrier to such testing
($600-$1200, not generally covered by insurance) they offer funds to
students who are identified through their in-house pre-screening
procedure. At most universities, the burden of proof fell with the student
and was to be determined based on the university’s own criteria or
whatever the university considered allowable evidence. Some universities
required a letter from a licensed professional to demonstrate proof of a
“true” disability, while others referred to independent evaluators with
contracts with the university. There were others who referred students to
in-house evaluators. This constructs a version of disability that requires
64 Chapter Three
policing and regulation by experts, and in which students cannot to be

trusted to describe themselves as disabled. Ultimately, the university
policies were framed as serving to regulate who could be named disabled
and thereby qualify for accommodations and/or access higher education.
Concluding Thoughts
There are potential, perhaps unintended, consequences when particular
discourses position students’ rights in certain ways: some in opposition to
the integrity of institutional programs and others in alignment with the
aims of the institution. First, rights and identities, when constructed, create
certain degrees of possibility. The ways in which an ODS positions itself
in relation to the interests of students, and the ways in which this position
constructs the degree of alignment between students’ rights and university
integrity, can have an impact on the meaning of disability in that setting.
Moreover, through our discourse analysis, we have noted that universities
are often positioned as the authority on both the presence of a disability
and the institutional response to disability. Thus, we argue here that
language choices employed often serve to police what counts as “normal”
or “abnormal”, delineating what qualifies as being an “abled” or
“disabled” way of being and way of learning. Such policing is also
accomplished in texts that construct certain versions of what it means to
make accommodations – with some universities orienting to
accommodations with and for students and some agreeing to only do what
they deem “reasonable” and “appropriate”.
The very idea of neurodiversity within higher education has a direct

ethical implication. Do institutions of higher education, for instance,
intend to include those who have impairments that might result in the
restructuring of the educational environment? For many institutions, this
frequently results in an ethical dilemma that appears to be “talked away”
by citing the ADA and all that it does not require them to do. How, then,
are students who are positioned as “atypical” to be included?
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Shaw, S., & Dukes, L. (2006). Postsecondary disability program standards
and performance indicators: Minimum essentials for the office for
students with disabilities. Journal of Postsecondary Education and
Disability, 19(1), 16.
Sparks, R. (2009). College students with disability diagnoses: Who are

they and how do they perform? Journal of Learning Disabilities ,
46(2), 949.
Wessel, R., Jones, J., Markle, L., & Westfall, C. (2009). Retention and
graduation of students with disabilities: Facilitating student
success. Journal of Postsecondary Education and Disability , 21 (3),
116.
CHAPTER FOUR
MINDBLINDNESS:
A TROUBLING METAPHOR?
JANETTE DINISHAK
Introduction
Currently autism is understood as a pervasive, lifelong,
neurodevelopmental condition that can manifest in diverse ways. It is
diagnosed via a triad of behavioral criteria: difficulties with social
interaction (e.g., little or no eye contact), linguistic challenges (e.g.,
misunderstanding pragmatic uses of language), and repetitive or
stereotyped activities (e.g., spinning objects). There are few uncontested
facts about autism. Although we have some clues about possible
environmental triggers and the biological underpinnings of autism, its
causes are unknown. An intensely debated issue is whether we should
develop ways to eliminate autism, if and when its causes are discovered.
Ongoing debates about autism create “looping effects”— where those

classified interact with their classification, remaking both the classification
and what it is to be a person so classified (Hacking, 2007). One important
mechanism for looping effects is metaphor.
Metaphor is describing and conceptualizing one thing in terms of
another. Generally speaking, many metaphors have the form “A is (like)
B.” To cite a familiar example from Shakespeare, “Juliet is the sun.” A
“[m]etaphor selects, emphasizes, suppresses, and organizes features of the
principle subject [A] by implying statements about it that normally apply
to the subsidiary subject [B]” (Black, 1962, p. 44). Metaphors are
powerful rhetorical devices that can carry affective content that literal
descriptions of the same subject do not. Our choice of metaphors reflects
and reinforces values, and creates and promotes stereotypes, expectations,
and ways of feeling (Sherwin, 2001).
68 Chapter Four
“[T]here is no aspect of our experience not molded in some way by

metaphor’s almost imperceptible touch…Metaphorical thinking…shapes
our view of the world, and is essential to how we communicate, learn,
discover, and invent” (Geary, 2011, p. 3).
In short, metaphors are not just empty tags; they have practical and
ethical significance because they may influence how we think and feel
about the subjects they describe.
Many metaphors, especially in science, prompt a conceptual movement
from the known to the unknown. They invite us to understand the
unknown through the known by making a comparison between the two.
Autism is often depicted as a deeply mysterious condition that resists
understanding. For instance, a widely used and controversial autism
awareness symbol is a puzzle piece. Given all that we do not know about
autism, it is unsurprising that metaphors figure prominently in scientific,
medical, and media representations of it. For instance, autists1 are
portrayed as robotic or alien, as people whose real selves are missing,
hidden, or kidnapped by autism.2 Another metaphor for autism is
“mindblindness.” “Mindblindness” has been used pervasively since Baron-
Cohen (1990) introduced it to characterize autism. The metaphor appears
frequently in the scientific literature on autism (e.g., Baron-Cohen, 2002,
2008, 2009; Carruthers, 1996; Harris, 1999, 2009; Lombardo & Baron-
Cohen, 2011; Myers, Baron-Cohen, & Wheelwright, 2004; Senju,
Southgate, White, & Frith, 2009), practical guides for caregivers and
teachers (O’Toole, 2012; Stanford, 2011; Williams, Wright, & Young,
2004), news pieces (e.g., Gopnik, 2005; Harmon, 2011; Linklater, 2006;
Martin, 2010; Moore, 2001; Ojalvo, 2010; Stevens, 2008;), and even in the
title of a fictional work with an autistic character (Roy, 2010) and a work
in popular psychology that discusses “temporary autism” (Gladwell, 2005).
In this paper I identify three problems with using mindblindness as a
metaphor for autism. First, the comparison between autism and blindness
is misleading in some respects. Second, common uses of “mindblindness”
do not make clear how the difficulties that people with autism have
understanding mental phenomena relate to the difficulties that non-autistic
individuals have understanding mental phenomena. Third, common uses
of “mindblindness” do not do justice to the conceptual distinction between
differences and deficits, a distinction that is important to autism debates
and advocacy movements. Given these limitations, if we continue to use
the metaphor, we should do so in ways that better reflect the complexities
of autists’ social and communication differences and how these
differences overlap with and differ from the social and communication
challenges that non-autistic individuals face in their interactions both with
Mindblindness: A Troubling Metaphor? 69
other non-autistic individuals and with autists. My discussion focuses on

Baron-Cohen’s theory of autism since it is highly influential in scientific
and non-scientific discourse, and revisions to Baron-Cohen’s theory prove
helpful for framing my analysis of common uses of the mindblindness
metaphor.
Mindblindness as a Metaphor for Autism

The mindblindness metaphor is used in the theory of autism known as
the “theory of mind” hypothesis. But what is theory of mind? 3 Premack
and Woodruff introduced the notion in their study of chimpanzees, “Does
the Chimpanzee Have a Theory of Mind?” (1978). They defined theory of
mind as the ability to attribute mental states (e.g., intentions, beliefs,
desires) to oneself and to others, an ability thought to be integral to
explaining and predicting behavior. The philosophers Dennett (1978) and
Pylyshyn (1978) proposed that a test of whether an individual has a theory
of mind is whether that individual can predict what a second individual
will do on the basis of the second individual’s false belief. Development
psychologists quickly began applying this idea to the study of human
social development. An important catalyst for further research was the
model Wimmer and Perner (1983) designed in order to test the ability to
make false-belief attributions and predict actions on the basis of those
attributions. Echoing Premack and Woodruff’s title (1978), Baron-Cohen,
Leslie, and Frith (1985) asked, “Does the autistic child have a ‘theory of
mind’?” and were the first to hypothesize that autistic children have a
specific cognitive deficit in theory of mind since the majority of autistic

individuals they tested did not pass their false-belief test. Baron-Cohen,
Leslie, and Frith concluded that this theory of mind deficit explains
autistic individuals’ social and communicative difficulties.
In subsequent articulations of the theory of mind hypothesis, Baron-
Cohen (1990) emphasized the explanatory utility of the hypothesis. It is
intended to serve as an explanatory bridge between neurobiological
descriptions of autism, which inform research on the biological
underpinnings of autism, and behavioral descriptions, which are the basis
of the psychiatric diagnostic category “autism.” The theory of mind
hypothesis enables researchers to frame testable hypotheses “about the
cognitive mechanisms that generate behaviour, mechanisms which are
located in the brain” (Baron-Cohen, 1990, p. 81). In the same paper
Baron-Cohen compared autism with blindness: “I have coined the term
‘mind-blindness’4 to describe the circumscribed nature of the cognitive
deficit in autism, and to emphasize the gulf that I imagine must exist
70 Chapter Four
between these children and the access people without autism naturally
have to other people’s minds” (1990, p. 88). In this quote Baron-Cohen
provides two rationales for his choice of metaphor. First, the metaphor
stresses that, on this theory, the cognitive deficit that explains autistic
persons’ social-communicative difficulties is specific. Impairments in
“general intelligence” (e.g., mental retardation) are not a sufficient
explanation for social-communicative difficulties associated with autism
(Baron-Cohen, Leslie, & Frith, 1985). Second, the metaphor makes vivid
the gulf between autistic and non-autistic persons. Autists are “blind to the
existence of mental states” (Baron-Cohen, 1990, p. 83), while non-autistic
individuals “naturally have [access] to other people’s minds” (Baron-
Cohen, 1990, p. 88). After 1990, Baron-Cohen began using “mindblindness
theory” to designate his theory of autism.
One shortcoming of the mindblindness theory, acknowledged by
Baron-Cohen himself (2008), is that it does not explain the “nonsocial”
features of autism (e.g., attention to detail, the need for sameness)
(Boucher, 2012). Another is that it does not take into account the aspect of
empathy that involves responding appropriately to the feelings and
thoughts of others (Baron-Cohen, 2008). To address these limitations
Baron-Cohen (2002) developed the empathizing-systemizing theory.
Before I discuss problems with dominant uses of the mindblindness
metaphor, I should note the features of Baron-Cohen’s revised theory that
are relevant to my analysis of those uses in the sections below. On the
revised view, autism is best explained with reference to two psychological
factors, empathizing and systemizing. Delays and deficits in empathizing
explain the social features of autism (i.e., social and communication
difficulties), while “intact or even superior skill in systemising” (Baron-

Cohen, 2008, p. 113) explains the nonsocial features of autism (Baron-
Cohen, 2009). Systemizing is defined as “the drive to analyze objects and
events to understand their structure and to predict their future behavior”
(Baron-Cohen & Belmonte, 2005, p. 110). For example, a person with
Asperger Syndrome might excel at understanding the fine details of an
intricate machine’s parts and mechanisms or be able to detect patterns in
data such as train timetables more rapidly and easily than others.
Empathizing, the second factor in the theory, has two major components:
the cognitive component, which involves attributing mental states to others
and predicting their actions based on those attributions (Baron-Cohen,
2009), and the affective component, which involves having a correct
affective response to the thoughts and feelings of others (Baron-Cohen,
2009). Mindblindness is subsumed under the cognitive component of the
empathizing factor. Despite these revisions to his initial theory, Baron-
Cohen continues to use the mindblindness metaphor in descriptions of

autism (Baron-Cohen 2002, 2008, 2009).
Blindness and Autism: Some Ways the Comparison

is Misleading
Around the same time that Baron-Cohen coined his use of the
mindblindness metaphor, Frith and Frith (1991) chose “mind-reading
blindness” to flag the same deficit in autism. Baron-Cohen (1990) noted,
“[t]he similarity in our independent choices of metaphor suggests to me
that the comparison with blindness may indeed turn out to be a useful one”
(p. 88, endnote 10). Has the comparison between blindness and autism
turned out to be a useful one, as Baron-Cohen predicted?
One obstacle to assessing whether Baron-Cohen’s comparison has
been useful is that he says so little about what he takes the points of
comparison to be. As Gillberg (1995) noted in his review of Baron-
Cohen’s book-length treatment of the mindblindness theory, Mindblindness
(1995), there is “little discussion of blindness and deafness in relation to
the model's explanatory power as it pertains to autism” (p. 1124). Consider
the strangeness of the mindreading-mindblindness binary Baron-Cohen
introduces. According to common usage, the blindness metaphor is a
perceptual metaphor, and by extension so is mindblindness. Insofar as
blindness can be construed as lack of sight, the opposite of blindness
(being unable to see) is sightedness (being able to see). Given this familiar
binary between blindness and sightedness, one might have expected
Baron-Cohen to define mindblindness as the inability to see what others

are intending, doing, feeling, thinking, etc. But Baron-Cohen understands
mindblindness as a cognitive deficit (i.e., a deficit in theory of mind), not
as a perceptual deficit. Moreover, the word “mindblindness” suggests that
those who are not mindblind are able to see minds (i.e., are able to see a
friend’s joy, a stranger’s apprehension, or a child’s fear, for example) and
thus could be said to have mindsight. However, a major supposition of the
theory of mind hypothesis, is that people do not have perceptual access to
the minds of others because mental states are unobservable (Gallagher,
2004). On this conception of the relation between behavior and mental
life, the “inner” (thoughts, feelings, intentions, and so forth) is hidden
behind the “outer” (behavior). To access other minds, humans develop a
“theory” of mind that allows them to infer or “read” unobservable mental
states from overt behavior, which is observable. In other words, on the
theory of mind account of understanding other minds, mindblindness is a
deficit in mindreading, not mindsight. This is conceptually confusing.
72 Chapter Four
Perceptual metaphors such as mindblindness are more apt expressions of

what we might call the perceptual access view of how we understand other
minds.5 On such a view, we do not need to infer what others are intending,
feeling, thinking, etc. Perceptual metaphors such as mindblindness seem
out of place in the theory of mind explanation of autism given familiar
usage of “blindness” and “sight”.
Strange binaries aside, one reason we should be wary of the
comparison between autism and blindness is that we know so little about
the nature of sensory-perceptual differences in autism and even less about
how these differences relate to social and communicative difficulties
associated with autism. As Gerrans (2002) notes, “[p]hilosophers and
cognitive psychologists have paid insufficient attention to the possible link
between autistic sensory disturbances and autistic ‘mindblindness,’ despite
the suggestive label” (p. 316). Also, authors who make use of
“mindblindness” and link it with autism have paid insufficient attention to
recent work (e.g., Pring, 2005) on the relations between the social and
communicative behavior of blind children and autistic children.
Superficial behavioral similarities between these two groups do not
automatically translate into functional and developmental similarities
(Perez-Pereira & Conti-Ramsden, 1999). Referring to social and
communicative difficulties associated with autism as a form of blindness
without detailing particular points of comparison and difference between
this form of blindness and other forms (e.g., physical forms such as
congenital blindness and legal blindness) risks conflating the social and
communicative differences of autistic children with those of blind
children. For instance, Stanford’s book (2011), a well-meaning guidebook
for people with Asperger Syndrome working in business, contains the

following potentially misleading description of mindblindness: “Note that
people with autism are sometimes misdiagnosed narcissistic due to
mindblindness issues. The key differentiating fact is that a person with AS
[Asperger Syndrome] is simply physically blind. A person with
narcissism has ‘mindblindness with a purpose’” (p. 79). In addition, the
existing research on visual capabilities in autistic individuals does not
point to a clear consensus regarding whether sensory perception in autistic
individuals should be understood as inferior to that of typically developing
individuals (Simmons et al., 2009). One recent theory of visual processing
in autism, enhanced perceptual functioning (Mottron & Burack, 2001;
Mottron, Dawson, Soulières, Hubert, & Burack, 2006), proposes just the
opposite—that people with autism have a heightened response to sensory
stimulation and superior visual performance by comparison with typically
developing individuals. On this view, one way of understanding why many
people with autism find it difficult to understand facial expressions is that

they are hypersensitive to relevant visual cues. As a result, they avoid eye
contact because they find it overwhelming, even painful.
Another concern about the autism-blindness comparison is that
“blindness,” the root metaphor in “mindblindness,” has many pejorative
uses (Grigley, 2006). Kleege (1999), who is blind, has reflected on the
longstanding, deeply entrenched negative connotations of “blindness”:
Because the word bears such a burden of negative connotations and
dreaded associations, it can hardly be said to have any neutral, merely
descriptive meaning. Blind means darkness, dependence, destitution,
despair… The word blind has always meant more than merely the inability
to see…Throughout the history of the language and in common usage
today, the word connotes a lack of understanding or discernment, a willful
disregard or obliviousness, a thing meant to conceal or deceive… If you
want to talk about stupidity, prejudice, weakness, or narrow-mindedness,
no other word will do (pp. 19-22).
Embedded as it is in tragedy narratives of autism (Duffy & Dorner,

2011; Smukler, 2005), the mindblindness metaphor inherits negative
connotations of “blindness” and reinforces stereotypes about what it is like
to be blind that disability rights activists have worked hard to correct: that
blindness is a pitiable tragedy, synonymous with epistemic deprivation and
social isolation. Blindness is often portrayed as an all-or-nothing
condition, as if living with blindness is living in a world with complete
darkness. This stereotypical image of “blindness as darkness…is [in many
ways] comforting to sighted people because they do not have to guess
what the blind person can or cannot see” (Omansky, 2011, pp. 4-5). In
fact, the blindness-sightedness binary is misleading when we interpret it in
an either/or or all-or-nothing way; most blind people have some residual,
usable vision. Likewise, we should be wary of simplistic distinctions
between mindreading and mindblindness. We must be careful not to
neglect the diversity underlying the term mindblindness. In later
developments of his theory (2009), Baron-Cohen says that people with
autism are mindblind to varying degrees, but he does not specify whether
and how differences in degrees of mindblindness correspond to different
social and communication behaviors in people with autism. Talk of
different degrees of mindblindness is a step towards acknowledging the
diverse ways autism presents in particular individuals, but we should learn
ways of talking about autism that allow for qualitative differences too. We
would be one step closer to heeding an oft-repeated caution, “If you have
met one person with autism, you have met one person with autism.” These
words are used as a reminder that autism manifests in many different ways
74 Chapter Four
in different individuals but also for a single individual throughout the

course of his or her life. The needs and abilities of autistic individuals can
vary greatly in both kind and degree. One child with autism may be non-
verbal, experience sensory overload unless her teachers whisper, and
prefer quiet time during recess. Another may be highly verbal, prefer loud
speech, and participate in team sports during recess.
Mindreading and Mindblindness: a Tidy Distinction?

There are varying definitions of mindblindness in circulation. Some of
these definitions (Baron-Cohen, 1990, p. 88; Carruthers, 1996; Parritz &
Troy, 2009; Williams et al., 2004) leave open the possibility that autists
are able to understand their own mental states while others explicitly say
or imply that mindblindness applies both to the mental states of others and
to one’s own (Baron-Cohen, 1990, p. 83; Choudhury et al., 2009; Frith,
1989; Lombardo & Baron-Cohen, 2011; Senju et al., 2009). There are
some incompatibilities between the definitions. For instance, the inability
to attribute mental states to others does not logically entail that autists are
unable to conceive of or are blind to the existence of mental states. And
not having “the automatic ability to attribute mental states to the self and
others” (Senju et al., 2009, p. 883) does not render a person unable to
attribute mental states when prompted to do so.
Oftentimes, definitions of mindblindness misleadingly suggest that
people can be neatly divided into two categories: the mindreaders, who
effortlessly, spontaneously, naturally, and automatically employ a theory
of mind and the mindblind, who lack a theory of mind or employ one
unsuccessfully or with great effort and only when explicitly prompted to
do so. The distinction between mindreader and mindblind is murkier than
these broad, unqualified definitions of mindblindness suggest. Mindreading
is not an all-or-nothing trait of a person. Non-autistic individuals can have
considerable difficulty making accurate mental attributions to other non-
autistic individuals and to themselves. As Epley (2008) notes, “Accurate
mind reading is not simply a trait that some people possess and others
don’t, but is rather a more variable state that people can have at some
times more than at others” (p. 1457). Furthermore, recent empirical work
suggests that construing mindreading as an effortless ability to read others’
minds may be misleading. For instance, Lin, Keysar, and Epley (2010)
argue that it takes effortful attention for people to overcome their
“reflexive default” (p. 552): relying on their own mental states to interpret
others’ behavior. In other words, people tend to interpret others’ behavior
egocentrically and are thus “reflexively insensitive or ‘blind’ to another

person’s mind” (pp. 552-553).
Another problem with classifying people as either mindreaders or as
mindblind is that non-autistic individuals can also have considerable
difficulty understanding the mental lives of autistic individuals. Autism
advocates (e.g., Becker, 2011; Smukler, 2005) have called attention to the
ways non-autistic persons can be characterized as mindblind to autistic
points of view. Dominant uses of the mindblindness metaphor deflect
attention away from the senses in which non-autistic individuals are
mindblind to what autists are feeling, thinking, intending, and doing. It is
quite common to explain autists’ social challenges in terms of their
mindblindness only. One autistic blogger pointed out some potential
consequences of non-autistic persons not taking into account their own
mindblindness when interpreting autists’ behavior:
We move, we act…but our movements and acts have no recognizable goal,
and thus people assume we lack intelligence, and lack all but the most
rudimentary stages of consciousness. Our emotional responses are
similarly discarded as meaningless, because we do not react in the same
way most people do to the same things. Things in the environment that
most people might not even notice scare us or irritate us, but because the
stressors don’t make it onto most people’s radar, we are assumed to be
throwing a fit for no reason. So our movements, our behaviors, and even
our emotional responses and attempts to communicate are discarded as
meaningless and we are believed not to be conscious or intelligent to the
same degree that most people are (Lindsay, 2009).
The above quote brings out a danger of failing to acknowledge the

ways non-autistic individuals are blind to autists’ minds. It can leave us
vulnerable to the assumption that certain behaviors are devoid of meaning,
as if behaviors are meaningful only when their meaning is readily
understood by non-autistic individuals.
While Myers, Baron-Cohen, and Wheelwright (2004) concede that,
“[a]utistics may lack a non autistic theory of mind. Just as non autistics
may lack an autistic theory of mind. Each is mindblind to the other” (p.
57, footnote 17), this point was relegated to a footnote and has not been
widely appreciated. If we are going to continue to employ the
mindblindness metaphor, our usage should incorporate the ways non-
autistic individuals may struggle to understand autistics’ mental states and
behavior, to the point of being mindblind themselves. Rethinking the
social challenges of autists in this way could make social interaction with
non-autistic persons less stressful for some autists. For instance, Robison
76 Chapter Four
(2011) shared how realizing that he is not solely responsible for

communication difficulties came as a relief:
It’s ironic—I fail to understand the non-verbal cues of nypicals [non-
autistic individuals], and they fail to read signals from me. It’s as if we are
speaking two different languages. The result: a two-way street of failed
communication. (It’s nice to know the failures aren’t all mine.) (p. 101).
Revising our use of the mindblindness metaphor to signal that

mindblindness can run in both directions between autistic and non-autistic
individuals could also help non-autistic people appreciate their own need
to adjust in social interactions with people with autism. One way non-
autistic persons can compensate for their mindblindness regarding autists
is to familiarize themselves with autistic autobiographies and caregiver
memoirs. First-person accounts and other autism narratives are an
important resource for learning how to talk about autism; in particular,
they help non-autistic persons understand how people with autism
manifest their mental lives in their behavior (Hacking, 2009a, 2009b,
2009c). Although it is questionable how far the insights one gains from a
particular autistic autobiography can be extended to other autists,
familiarizing oneself with such accounts can at least sensitize one to
possible differences in the ways the social experience of autistic persons
differs from that of other persons.
Differences and Deficits: More than Just

a Conceptual Distinction
The distinction between deficit and difference has been important to

autism advocacy movements, especially the neurodiversity movement,
which has raised the question of whether autism is a disability or
difference (Fenton & Krahn, 2004). Neurodiversity is the provocative idea
that some forms of atypical neurological “wiring” in humans, such as
autism, attention deficit hyperactivity disorder, Tourette’s Syndrome, and
schizophrenia, may be positive variations (Blume, 1998). 6 Proponents of
the neurodiversity movement, as it applies to autism, advance the idea that
autism (in at least some of its manifestations) is an ineliminable aspect of
an autistic person’s identity, a way of being that should be respected and
supported, even celebrated, rather than eliminated. The neurodiversity
movement foregrounds a possible practical consequence of viewing autism
as something that should be eliminated: on such a conception a primary
goal of interventions, therapies, and services for autistic individuals is to
lessen their autism. Such a conception of autism seems too narrow to
respect and support autistic individuals that see their autism as an essential
part of their identity. Not all differences are deficits. Some differences are
not harmful to oneself or to others. And some differences are advantageous
to oneself and to others. Can the mindblindness metaphor accommodate
manifestations of autistic social and communicative differences that are
not deficits? Insofar as “mindblindness” is widely used to designate a
deficit, it leaves no conceptual room for understanding some social and
communication behaviors of people with autism as differences that are not
deficits.
Baron-Cohen aptly observed that supporting an “autism is a difference”
point of view and alleviating disabilities are not mutually exclusive:
Nobody would dispute the place for interventions that alleviate areas of
difficulty, while leaving the areas of strength untouched. But to talk about
a 'cure for autism' is a sledge-hammer approach and the fear would be that
in the process of alleviating the areas of difficulty, the qualities that are
special - such as the remarkable attention to detail, and the ability to
concentrate for long periods on a small topic in depth - would be lost.
Autism is both a disability and a difference. We need to find ways of
alleviating the disability while respecting and valuing the difference (qtd.
in Saner, 2007).
Baron-Cohen’s own theory, the empathizing-systemizing theory of

autism, acknowledges areas of strength in autism. He hypothesizes that
autists have superior skills in systemizing by comparison with the non-
autistic population. He even goes so far as to characterize those with hypo-
developed systemizing skills and hyper-developed empathizing skills as
“system-blind” (Baron-Cohen, 2002). Those with system-blindness

“would be people who have difficulty understanding maths or physics or
machines or chemistry as systems, but who are extremely good at tuning
in to others’ feelings and thoughts” (Baron-Cohen, 2002, p. 253). Mottron
(2011), an autism researcher and clinician, likewise argues that some
autistic individuals’ intellectual and personal qualities (e.g., intense focus,
an interest in structures and information) make them well-suited for
academic science. In his view the highly verbal autists in his lab
“contribute to science because of their autism, not in spite of it” (p. 33).
Michelle Dawson, an autistic woman in Mottron’s lab group, helped
Mottron recognize the ways his own research on intelligence relied on
mistaken assumptions. For instance, Dawson asked him: “if autistics excel
in a task that is used to measure intelligence in non-autistics, why is this
not considered a sign of intelligence in autistics?” (p. 34).
Although there appears to be increasing awareness of the ways in
which the superior systemizing skills of autists can be advantageous in
78 Chapter Four
some settings, there is still a conceptual stumbling block when it comes to

the social and communicative differences of people with autism. There
seems to be special difficulty in conceiving of these differences as
anything but disadvantageous. For instance, Baron-Cohen’s empathizing-
systemizing account of autism neatly separates areas of strength from
deficits such that, by definition, areas of strength in autism are classified as
examples of systemizing while deficits in autism are classified as
examples of empathizing. It is worth investigating whether some of the
social and communicative behavioral differences of autistic individuals
may be advantageous in some contexts rather than concluding a priori that
all of these differences are harmful, burdensome, or otherwise bad. H.G.
Wells’ short story The Country of the Blind (1904) is instructive. H.G.
Wells has us imagine a society that is organized around the needs and
abilities of blind people. These people have no sense of a lack of anything.
Blindness is not a limitation in their world. When the only sighted person
in the story claims that his sight is an advantage, the blind people judge
instead that his eyes are a defect and urge him to have his eyes removed
because there are things he is unable to do in their society.7 We should ask
whether, likewise, the social and communicative differences associated
with autism are inherently burdensome, harmful, or otherwise bad.
Perhaps some social and communication differences aren’t impairing for
all autists across all contexts. For example, Robison (2007), an adult with
Asperger syndrome, notes that some aspects of his autism helped him be a
great service person and car mechanic. His directness allowed him to tell
his customers “what they needed to hear about their cars” (p. 214) and his
difficulties reading body language helped him treat people with equality
“in an industry rife with discrimination” (p. 214). In general it would be

best if we did not automatically equate differences with deficits (Akhtar &
Jaswal, in press), and did not interpret harmless behaviors as “symptoms”
to be alleviated, especially when they may serve useful functions. As
Silvers (2003) reminded us, “To characterize an anomaly as a weakness or
loss improperly closes by definition what should be an open empirical
process … for whether a particular physical or cognitive difference is
unfavourable should be an open question” (Silvers, 2003, p. 304).
All in all, we need alternative ways of talking about the social and
communication differences associated with autism—alternative uses of the
mindblindness metaphor as well as new metaphors that can make room for
conceptualizing autists’ as seeing differently in some cases, not just as
blind to what non-autistic individuals see.8 Some people with autism
appear to notice very different things from those noticed by other people.
Most famously perhaps, Grandin (1996), an autistic adult, noticed facts
about cattle that others did not attend to, and this helped her to design
more humane slaughterhouses. She believes that her autism results in
heightened sensory perceptions that allow her to imagine how an animal
will feel moving through a system. Below she describes some of her
observations of cattle behavior and how they informed her slaughterhouse
designs:
The principle behind my designs is to use the animals’ natural behavior
patterns to encourage them to move willingly through the system. If an
animal balks and refuses to walk through an alley, one needs to find out
why it is scared and refuses to move… It is the little things that make them
balk and refuse to move, such as seeing a small piece of chain hanging
down from an alley fence…Cattle will also balk and refuse to walk through
an alley if they can see people up ahead…This is one of the reasons that I
designed curved single-file alleys with solid sides. They help keep cattle
calmer…the cattle are unable to see people up ahead, and each animal
thinks he is going back where he came from (pp. 142-149).
Conclusion
The psychiatric diagnostic category “autism” has undergone a variety
of changes, and scientific and media representations of autism have shifted
over time. Yet the mindblindness metaphor persists, especially in scientific
discourse on autism, where it is used pervasively. I have argued that
common uses of the mindblindness metaphor are troubling in several
respects and have invited the reader to consider some of the potential
pitfalls of such uses. In the light of these concerns, we should consider
revising our use of the mindblindness metaphor to better reflect the

complexities of autists’ social and communicative differences. This brief
examination of a particular metaphor (mindblindness) for a particular
condition (autism) can also serve a more general purpose. Namely, it
confirms and reminds us of familiar truisms that tend to escape our notice
or are neglected, especially when theorizing: metaphors can be useful tools
that facilitate understanding and render abstract scientific concepts more
accessible to non-specialists. But we should take care to remember that
metaphors can also constrain and distort, especially when we fixate on a
single metaphor. Above all, we must not reify them: “[m]etaphors, once
forgotten or ignored, are easily mistaken for objective facts. If that
happens in science, analogies congeal into dogmas, losing the elasticity
that made them useful in the first place” (Geary, 2011, p. 178).9
80 Chapter Four
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CHAPTER FIVE
ANTIDEPRESSANTS, GENDER,
AND THE CONSTRUCTION
OF THE MORAL SELF
KATHLEEN POORMAN DOUGHERTY
Over-medication is a worry in many areas of medicine and mental

health, for we certainly question the over-use of many psychiatric drugs,
including drugs for ADD, anxiety, and a variety of other disorders. Even
so, antidepressant use frequently garners a more passionate response than
other forms of psychopharmacology. Since the introduction of Prozac and
other highly effective antidepressants in the 1980’s, the use and possible
over-use of antidepressant therapy has become a point of consistent
debate. Peter Kramer’s 1993 book Listening to Prozac fueled much of the
discussion, but myriad books, articles, and reports have followed through
the last nearly twenty years.
In most of the literature, it is accepted that antidepressants are life-

saving therapy for those who suffer from profound depression. Elizabeth
Wurtzel, for example, recounts her experience with Prozac as a wonder
drug in the autobiographical Prozac Nation (2000). The cases that provoke
the most commentary and discussion, however, are the “fuzzier” cases
where the need for an antidepressant is less obvious, because the patient
does not meet the traditional criteria for clinical depression. Many of these
patients report, however, that antidepressant therapy, and Prozac
specifically, makes them feel “better than well” (Kramer, 1993). It is use
of antidepressants in these kinds of cases that Peter Kramer famously
called “cosmetic psychopharmacology” (xiii).
In 2000, The Hastings Center Report published a volume devoted
almost entirely to new scholarly articles on antidepressant use. This
grounded the discussion solidly in the medicine and ethics literature
raising serious debate about the role of antidepressants. The President’s
Council on Bioethics continued the discussion in 2003 with its report
Antidepressants, Gender, and the Construction of the Moral Self 87
Beyond Therapy: Biotechnology and the Pursuit of Happiness highlighting

myriad concerns regarding antidepressant use. The President’s Council
indicated that antidepressant use was relatively widespread and would
continue to rise. Though the rate of increase is unclear, National Center for
Health Statistics data indicates that between 2005 and 2008, 15.4% of
American women and 6% of American men were medicated with
antidepressants (Pratt, et. al., 2011). Moreover, 22.8% of women aged 40-
59 were taking an antidepressant, more than any other group determined
by age or sex. 8.4% of men in the same age group used an antidepressant.
For every age group, women were two to three times more likely to use an
antidepressant than men.
By February of 2008, a story in Scientific American Mind that
corresponded with the publication of Charles Barber’s Comfortably Numb
referred to the “Medicated Americans.” In the same month Newsweek ran
a story titled “Happiness: Enough Already.” The debate had made it to the
mainstream media in full force. The over-arching message has been that
much antidepressant use is questionable at best, and that all too often,
antidepressants are being prescribed in response to normal life problems or
undesirable personality traits. The worry seems to be that, in many cases,
we are medicating not for genuine depression, but for character or
personality.
Throughout this paper, I address the philosophical issues regarding
antidepressants by referring to “antidepressants” more generally; however,
in instances in which I have referred to specific patients described by Peter
Kramer, I have referred more specifically to their use of Prozac. The
introduction of Prozac was part of a new era in antidepressant therapy, but
there are now many other similar drugs available. I have tried generally to
avoid claims about particular drugs, except where other authors have done
so.
In this paper, I want to move somewhat beyond the debate regarding
whether antidepressant use as “cosmetic psychopharmacology” is morally
legitimate. My goal is not to argue in favor of or against antidepressant
use; either position would be too simplistic. I want to focus on questions
about the construction of the moral self that are raised by the frequent use
of antidepressants, especially as their use affects women. I argue that
antidepressant use raises philosophical challenges regarding the
development of the moral self, specifically with regard to self-reflection
and the means through which the self should be constructed. Moreover,
the disproportionate rate of antidepressant use in women raises even
greater concerns regarding the kinds of moral selves that may be
encouraged and the ways in which we construct the moral self. This
88 Chapter Five
should prompt us to revisit the problem from a new perspective, one that
takes more seriously women’s moral experiences and opens the door to a
fuller understanding of the feminist implications of antidepressant use.
Antidepressants and Self-Reflection

One concern reflected in the literature is that antidepressant use can
undermine the reflective approach necessary for self-understanding and for
the kinds of change such understanding might bring about. Simply put, the
concern is that we will permit ourselves to take a drug anytime the going
gets tough rather than engaging in further self-reflection about the
potential source of our difficulties. In this section, I argue that the
relationship between self-reflection and antidepressant use cannot be so
simply understood. Rather than undermining self-reflection, for some
patients, antidepressants might become an important part of the reflective
process.
David DeGrazia argues that we should not have qualms about
antidepressant use when the patient has chosen conscientiously and
reflectively the traits that the antidepressant will enhance (DeGrazia,
2000). Moreover, he suggests that the choice to use an antidepressant can
be perfectly consistent with a reflective and authentic approach to the self.
In fact, rather than undermine reflection, antidepressant use might be the
outcome of a fully reflective and engaged process and an authentic effort
at self-creation. We can imagine a patient who clearly identifies the
changes in herself she wishes to bring about. She might wish to become
“more outgoing, confident, and decisive professionally; less prone to

feelings of being socially excluded, slighted, or unworthy of a good
partner; and less obsessional generally” (DeGrazia, 2000, p. 35). As an
informed patient, she could knowingly choose an antidepressant with the
understanding that it can bring about the kind of change she desires. Given
this understanding, her wish to change some of her traits is consistent with
her being reflective and thoughtful about the person she wishes to be.
Antidepressant use need not be thought of as avoiding reflection, it might
be the result of reflection.
However, some of the concern seems to be regarding the reflective
process once antidepressant therapy is already underway. Might the person
who has already been medicated, even if as the result of a fully reflective
process, become less reflective? Peter Kramer’s work indicates that it
might be antidepressant use that enables the patient to be reflective or even
to have a full enough understanding of herself to begin the reflective
process. He suggests that the relationships between reflection, the
construction of the self, and antidepressant use are even more complex,
and perhaps a little mysterious. Two of Kramer’s cases illustrate this point.
Lucy was an over-sensitive, young college student who suffered
childhood trauma (Kramer 1993, pp. 103-107). Her difficulties were
predominantly in handling relationships. She was incredibly sensitive in
her interpretations of other people’s actions: she perceived even the
smallest of slights, intended or not. This sensitivity nearly undermined her
ability to have functional relationships. Very short-term use of Prozac
made a big difference for Lucy: just a brief period on the drug altered her
perceptions of herself (Kramer 1993, pp. 102-103). The drug made her less
vulnerable, even if briefly, so that she could then begin to see the ways in
which her behavior appeared to other people. Even after she was off the
drug, she was able to alter her understanding of her own behavior, which
in turn enabled her to alter her behavior itself. This indicates that in Lucy’s
case the use of Prozac prompted self-reflection, rather than being the result
of it.
Kramer’s case of Allison provides an even more compelling case for
alternative interpretations of the relationship between Prozac and self-
reflection. Allison suffered from such dramatic low self-esteem that she
could hardly see herself except for her faults (Kramer 1993, pp. 204-208).
It was as if she felt foreign to herself: she was detached from her own
successes, could barely connect the image in the mirror with herself, and
experienced consistent impending tearfulness. Treatment with Prozac,
after many years of therapy, enabled her to be sure of her husband’s love,
to feel confident in her work, and to feel like a more loving person. As
Kramer puts it, “when the change occurred, it seemed a matter of changed
self-valuation leading to changed self-understanding, rather than the

reverse: the medication allowed her to locate herself” (1993, p. 208).
Surely both Lucy and Allison experience the changes as significant
improvements in their lives. It is hard to imagine these changes as
anything less than life-altering. Being able to perceive oneself differently,
or moreover to “find” a self that had been nearly invisible can only be a
profound experience. But this possibility should prompt us to rethink a bit
the significance of what these drugs can do and their potential to alter our
selves and our moral experience. As Lucy’s and Allison’s experiences
indicate, reflection and self-construction are symbiotic processes, not with
one preceding the other, but with reflection and self-construction working
together in a give and take.
This understanding of the way that antidepressants might affect
reflection and our understanding of the self is consistent with the kind of
approach advocated in a narrative conception of the self. On a narrative
90 Chapter Five
conception, the self is viewed as a psychological unity created in part by

the stories or narratives we tell ourselves regarding our identity. What
constitutes who I am is partly a matter of how I describe myself, how I
understand, and how my stories about who I am fit together with those
others would tell about me. The idea is not that there is some independent
self that I must come to understand, but rather that my understanding of
who I am will develop over time partly through my own narrative. I give
my experiences a kind of cohesion of interpretation. They are not just
myriad independent experiences; they are experiences tied together by the
narrative I tell about them and with which I identify. Developing a
narrative conception of the self can be in part a matter of building a
narrative after the fact. The self we have developed will influence our
reflection and the narrative story we tell and this in turn may influence the
self we wish to become. This description of a narrative self I take to be the
most minimal version possible of a narrative conception of the self. The
notion of a narrative conception of the self arises in Alasdair MacIntyre’s
After Virtue, but has since been defended in myriad ways (1981). To my
mind, the narrative sense of self I am defending here is relatively skeletal,
so as to be as neutral as possible and does not presuppose any richer notion
of the moral life. I take the narrative sense of self I am using here to be
consistent even with a Humean notion of the self in which the self is
understood as the unifying interpretation we give to our experiences.
If the self is understood in this way, the power of antidepressants can
be quite significant. They not only can help us to become who we want,
but might also influence our understanding of who we want to be. In a
sense, Prozac can significantly influence the narrative in the narrative
conception of the self, so that the patient can reconstruct it in an alternative

way. It enabled both Lucy and Allison to tell themselves a different
narrative, to alter the story about who they were. Not only did it enable
them to tell a different narrative, it radically altered the narrative. It does,
then, constitute a powerful influence on our identity, which ought to at
least give us pause. That said, antidepressant use should not be treated as
an indicator that a person is either reflective or unreflective. Rather, we
can imagine that in reflective persons, antidepressants can play an
important role in the narrative, without undermining self-reflection.
Likewise, an unreflective person may just as easily remain unreflective
with or without an antidepressant.
Antidepressants as Improper Means

The concern regarding antidepressants and self-reflection is intimately
connected with the worry that antidepressants are an “easy way out” in
cases where they are used as enhancement rather than as medical
necessity. Even if a person has been fully reflective about the choice to use
an antidepressant and has even incorporated its use into her self narrative,
there is a nagging sense that something is amiss in the process: it seems
that she has foregone the difficult work of the construction of the self for
the easy solution of a drug. Usually we think of morally significant
personal change as something we bring about through not only a reflective
process, but also through our own doing. Instead of engaging bringing
about the change ourselves, however, the worry is that using an
antidepressant to facilitate the change is equivalent to allowing the drug to
do the work.
A similar worry is raised consistently in the literature on cognitive
enhancement in asking whether the use of cognitive enhancements
constitutes “cheating.” That is, does the use of cognitive enhancements
somehow achieve success by illegitimate means? This discussion parallels
concerns regarding the source of the change in the self in the use of
antidepressants. In the cognitive enhancement literature, this is typically
referred to as the “easy shortcut argument.” The claim is that in using
cognitive enhancements, people take an easy shortcut to success rather
than making use of more traditional means. As Maartje Schermer puts it
the worry is that “there is something wrong with making things too easy
on oneself, with achieving things without effort, or with side-stepping
traditional ways of doing things” (2008, p. 356).

Rob Goodman argues that in addressing this concern one important
consideration involves distinguishing between activities that value
excellence in process and those that value excellence in outcome (2010).
He describes the distinction as follows. There are some goods that we
value simply for their outcome. If we have gone to a surgeon for bypass
surgery, we may not care how our surgery is successfully completed—we
might actually want our surgeon to take a cognitive enhancing drug if it
would improve our chances of a good outcome. We want the surgery to go
successfully more than we care about the process by which the surgery
was completed. In fact, we are probably grateful for all kinds of
technological enhancements that improve our chances of a good outcome.
In contrast, if the good at stake is climbing a mountain, we want more
than just to get to the summit. How we get there matters; engaging in the
process of climbing to get there is an important part of the goal. As
92 Chapter Five
Maartje Schermer points out, the mountain climber who takes a helicopter
to the top has certainly arrived at the top of the mountain, but any sense of
himself as a mountain climber is merely delusional (2008, p. 360). The
Physicians Committee on Bioethics suggests that this same kind of
distinction is relevant in thinking about antidepressants. They suggest that
antidepressants encourage us to treat states of mind as goals and targets
separate from the process of arriving at them (2003, pp. 238-239).
In the case of the construction of the self (and likely also in many other
activities), however, the distinction between a process good and an
outcome good is not so clear-cut. On a narrative conception of the self, the
self is often described in terms that would imply it is a fixed state. This
would make it seem like an outcome good, for example, I might want to
come to have certain traits, and the achievement of them might be viewed
as an outcome good. At the same time, we typically also value a particular
process in coming to a sense of self. Unless we value the self as fixed and
unchanging, it will undergo a continual process of change and alteration. It
undergoes constant revision as new experiences and new insights become
parts of the narrative. These alterations may not always be significant or
meaningful, but on a narrative conception of the self, the self is always
something of a work in progress. Thus, on a narrative conception of the
self, the self may be properly conceived of as both an outcome good and a
process good. We care both about who we are and how we acquired that
identity, and in a narrative conception of the self, who and how are
intimately intertwined.
It is easy, then, to think that antidepressants are problematic insofar as
they unduly influence the narrative; they derail the narrative in progress,
so to speak. However, radical life experiences could also influence the

narrative in profound and significant ways. Many people talk of
transformative life experiences that cause them to see themselves in
different ways, or suddenly allow them a kind of personal insight. In that
sense, antidepressants might be powerfully significant, but not necessarily
more significant than other kinds of experiences. Though it may
consistently contain common elements or themes, our understanding of the
self is also constantly undergoing revision as the narrative unfolds, or is
created or told.
Additionally, part of the concern with antidepressants seems to be that
the source of the new narrative thread is outside ourselves, or is not of our
own creation. But, many of the aspects of ourselves that help to form a
narrative identity arise externally. On the narrative account, I formulate
and make sense of my experiences, but many of those experiences are not
in my control. In fact, much of my narrative may have been influenced by
outside factors. I understand myself in part by how I construct a narrative

in response to both internal factors, such as my temperament, character,
moods, or insights, and also partly in response to external factors that
could be incredibly significant in making me who I am. For example, the
experience of being a woman, which is a significant aspect of my self, is
partly internal. I consistently experience events in my life as a woman.
And part of being a woman is the psychological experience of my self as
such. However, this conception of my self as a woman is also influenced
by the way events in my life play out because I am a woman. On a
narrative conception of the self, there is no self that is fully of my own
creation independent of internal or external factors beyond my control.
Insofar as this is the case, it is unclear why an antidepressant’s influencing
the narrative should be particularly troubling. In fact, we might have more
control over and choice regarding their use than we do over lots of other
significant life experiences that radically influence our narrative identities.
Another way to approach this concern would be to consider what is
lost in using an antidepressant rather than in approaching difficulties by
more traditional means. Schermer suggests that enhancements potentially
make activities less difficult, but also potentially less meaningful (2008, p.
360). If we consider how this approach might to apply to antidepressant
use, we can ask whether antidepressant use results in any loss of meaning
in the construction of the self. In considering Kramer’s patients, Lucy and
Allison, we should ask what they have lost in choosing to medicate. Lucy
and Allison both engaged in years of therapy attempting to achieve the
same results they achieved through Prozac. In their cases, it is unclear that
further therapy or effort using similar traditional means would have been
effective. At some point, encouraging further effort on their parts would

seem cruel. They have resorted to antidepressant therapy only when
traditional means were ineffective. Has something meaningful been lost in
their choice? I doubt it. In fact, I suspect they have found meaning in its
use. Allowing the antidepressant to function as part of their narrative
allows them a kind of freedom and confidence that they might not have
found any other way. Insisting that the result is problematic because it did
not come “from within” or through a proper process seems tantamount to
obligating them to suffer for the sake of proper process. It is making the
process more important than the outcome, when the process and the
outcome should both be construed as morally significant.
94 Chapter Five
Women’s Experience of the Moral Self

Thus far, I have argued that we should not reject the use of
antidepressants simply because they can have significant impacts on the
self. I have suggested that antidepressant use can be perfectly consistent
with a reflective approach to the self, and that it need not undermine the
integrity of the construction of the self. However, I do think there are real
reasons to be concerned about antidepressant use. These reflect, however,
not the impact of antidepressants on particular individuals, but the
disproportionate use of antidepressants by women. This, too, I think is
appropriately considered in terms of the development of the self.
There are myriad possible practical explanations for the fact that
women use antidepressants at a rate nearly 2.5 times that of men across all
age groups (Pratt, et. al., 2011). Among them might be: the differing ways
in which men and women seek medical care, differences with respect to
the ways women are treated in the health care system or by physicians, and
the historically prevalent notion that women are more prone to mental
illness than men. Each one of these potential explanations warrants fuller
investigation, especially for any full feminist analysis of antidepressant
use. For my purposes here, however, I want to maintain the focus on the
notion of the construction of the self and the ways in which our
conceptions of the self may influence the ways in which men and women
experience moral demands and are expected to work toward meeting these
demands.
If we consider the kinds of changes that patients typically achieve
through Prozac or other antidepressants, we might gain some insight into
what makes them more frequently used by women. Most of Peter

Kramer’s patients who find success through Prozac say that it makes them
more outgoing, better able to navigate personal relationships, less anxious,
and less sensitive to rejection (Kramer, 1993). Is there anything in this set
of traits that would be particularly appealing to women? I think that there
is, and that the appeal reflects women’s struggles to navigate the
traditional moral experiences of women and the kinds of moral selves that
women are encouraged to value and develop.
In the last several decades, beginning about the same time Prozac made
its way onto the scene, there has been considerable focus on women’s
moral experience and an effort to legitimate it as different rather than
deficient. This discussion of moral experience has been intimately tied to
understandings of the role of experience and women’s traditional roles in
the development of the self. Carol Gilligan’s In a Different Voice provided
a significant impetus in a shifting discussion of the place of experience in
the development of the moral self. Published in 1982, it preceded Prozac

on the scene by only five years. It was followed shortly thereafter by Nel
Noddings’ Caring in 1984, and Sara Ruddick’s Maternal Thinking in
1989. Gilligan’s book altered the moral landscape by suggesting that
women’s approach to morality differed through greater focus on personal
relationships, the experience of concrete reality, and a caring approach.
This more characteristically feminine moral approach legitimized not only
women’s traditional labor, but also legitimized the recognition of
experience as important in the development of the self and the resulting
approach to morality.
According to Gilligan, women tend to perceive the moral self
differently than men do. For women, the self is frequently thought of more
in relationship to others, rather than autonomously. Similarly, moral
development consists of being able to appropriately navigate complex
moral relationships balancing competing interests and concerns, all the
time approaching the other and the self from a caring perspective. Men, on
the other hand, tend to think of morality in terms of competing interests
and fairness, with the self characterized in terms of autonomy and
independence. Gilligan’s approach was intended merely as a generalization
regarding the ways women and men reason. The claim is not that men and
women cannot approach morality in the same ways, but rather that they
often take on different approaches to the moral realm. It must be noted that
no essentialist claim is being made that suggests that men and women are
inherently different. Rather, the claim is that their roles in the world are
different and that from these differing roles they tend to develop different
approaches to the development of the self and to moral reasoning. This
view is perfectly consistent with other kinds of views that reflect the
importance of culture, experience, tradition, or role. Gilligan, however,
made the powerful claim that in our society, the experiences of men and
women are significantly different enough that they tend to result in a
different kind of approach to morality and the development of the moral
self.
Thus, a care ethic, as Gilligan’s approach has come to be characterized,
grows in some sense out of the traditional realm of women. Women have
historically been responsible for maintaining households, caring for
children, and protecting relationships. Such responsibilities carry with
them the development of certain kinds of moral traits. If the maintenance
of relationships is the focus of my life or at least an important part of my
traditional role, my conception of my moral self will be dependent upon
the degree to which I do this well. The kinds of moral characteristics that I
will expect of myself and that others will expect of me will involve those
96 Chapter Five
traits that are conducive to the successful maintenance of relationships and

the care of children and families. I will also likely experience myself as
inadequate if I do not perform well in this realm.
In Maternal Thinking, Sara Ruddick argues that there are specific
virtues characteristic of mothering. Among these virtues is a trait she calls
“resilient cheerfulness” (Ruddick, 1989, p. 74). This should not be
confused with blind optimism or simple good humor, but it does indicate
an ability to approach the world with a certain air of confidence. Resilient
cheerfulness reflects the mother’s realization that she must continue to
protect her children regardless of all the hindrances that may come in the
way: ordinary cheerfulness involves looking realistically at one’s children
and vowing to protect them knowing all the dangers that may befall them.
Much of Ruddick’s characterization of mothering discusses the moral
struggles that women face and the virtues that grow from these struggles:
attentiveness, compassion, resilient cheerfulness, delight in normally
thriving children (1989, pp. 98-100). Ruddick suggests, however, that
mothers recognize virtues as something to strive for, but do not necessarily
possess them. She thinks of acknowledging maternal virtues as
recognizing a lack; it is part of the constant struggle of mothering. What is
interesting about Ruddick’s characterization of mothering is the focus on
the psychological approach the mother takes to her task. Ruddick
recognizes the experience of the mother as one of striving for a virtue that
may remain just out of reach. This is compelling in the sense that part of
the experience of mothering is in an experience of always falling short, of
knowing that there are desirable traits that one has not been able to fully
manifest.
None of these theories is intended to suggest that such moral

approaches are valuable only for women. In an ideal world, men would
also be well-versed in this kind of moral thinking. It is often thought,
however, that women are more inclined to these sorts of approaches
(Gilligan, 1987). The suggestion is that women have typically valued
connection, relationships, and the emotional life, and these elements of the
moral life that grow out of women’s experience should not be ignored or
thought of as second-class virtues. These theories all acknowledge a
certain development of the self as one that values relationships and
connections. This is hard moral work and it can be exhausting emotional
work. The implication is also that women are more likely to assess their
success by the degree to which they manifest a moral self that reflects the
values of caring.
One might argue that this should not impact women’s lives so greatly
any more in that women are no longer expected to take on such traditional
roles. However, numerous sources indicate that the pressure for women to
take on caring responsibilities has not shifted in any significant way. Arlie
Hochshild’s famous book, The Second Shift, laid out the dilemma that
many women experience (1989). Though now quite a few years old, more
contemporary literature suggests that the balance has not shifted that
much. Anne-Marie Slaughter might have stated the case as compelling as
one could expect in her recent cover story for the Atlantic titled “Why
Women Still Can’t Have It All” (2012). Karine Moe and Dianna Shandy’s
new book, Glass Ceilings and 100-Hour Couples, lays out the challenges
of balancing family and a career for contemporary women (2009). Nancy
Folbre argues in The Invisible Heart that we must, as a society, begin to
consider the economic costs of caring (2002). No one of these books or
articles will easily confirm that women tend to experience their moral
selves differently than men do. However, if our selves are developed
partly in response to our role, this diverse literature does indicate that
women’s role is still not the same as men’s and that they still experience
the pressures of caring as an important part of their role. If this is the case,
and women are experiencing these demands as a significant challenge as
much of the literature indicates, then the fact that they would seek
assistance through the use of a drug that can make personal relationships
less stressful and less demanding should not come as any real surprise.
Antidepressants can make patients less sensitive to rejection, more
confident in relationships, more able to navigate complex psychological
situations, more outgoing, and less obsessive. One of Kramer’s patients
finds herself less over-sensitive to the needs of others and less sensitive to
conflict; she was able to abandon a humiliating relationship and gained
social confidence (Kramer 1993, p. 10). The kinds of traits that

antidepressants make possible are just the kinds of traits that are valued in
a mature manifestation of a caring approach to the moral self.
Notably for Lucy and Allison, Kramer’s patients, part of the appeal of
an antidepressant was the ability to feel more at ease in personal
relationships: Lucy wishes to stop fearing constant rejection, and Allison
finds that Prozac enables her to be more sure of her husband’s love and to
be a more loving person. If we think that effectively navigating relationships
is central to the moral life and that the self is significantly constructed and
finds value through relationships, then it appears that Prozac has radically
altered their ability to lead develop moral selves. And if no other means
would get Lucy and Allison to this point, then the fact that Prozac has
enabled a kind of fuller moral engagement with the world and a more
satisfying sense of self is a significant accomplishment.
98 Chapter Five
Nothing I have said here can draw a straight line between the
expectations of a caring approach to the self and women’s use of
antidepressants. Surely the relationship is not altogether direct. However, I
take the differing moral and psychological expectations for men and
women to be a fruitful line of inquiry, one that deserves further attention.
Perhaps women are more inclined to antidepressant use because it enables
them to live up to moral expectations that are more frequently held of
women than of men. Nothing in this suggestion should undermine the
value of a caring approach to the moral life and the moral self. But, we
must note that expectations for the moral self can also be experienced as
burdens if they seem out of reach.
References
Barber, Charles. (2008a). The medicated Americans. Scientific American
Mind. February/March 2008, 45-51.
—. (2008b). Comfortably Numb: How Psychiatry is Medicating a Nation.
New York: Pantheon Books.
Begley, Sharon. Happiness: enough already. Newsweek, February 11,
2008.
DeGrazia, David. (2000). Prozac, enhancement, and self-creation.
Hastings Center Report, 30, 2, 34-40.
Folbre, Nancy. (2002). The Invisible Heart: Economics and Family
Values. The New Press.
Gilligan, Carol. (1983). In a Different Voice: Psychological Theory and
Women’s Development. Cambridge: Harvard University Press.

—. (1987). Moral orientation and moral development. In Eva Kittay and
Diana Meyers (Eds.) Women and Moral Theory. Rowman &
Littlefield.
Goodman, Rob. (2010). Cognitive enhancement, cheating, and
accomplishment. Kennedy Institute of Ethics Journal, 20, 2, 145-160.
Hochschild, Arlie. (1989). The Second Shift. Viking Penguin.
Kass, Leon. (2003). Beyond Therapy: Biotechnology and the Pursuit of
Happiness. Harper Perennial.
Kramer, Peter. (1993). Listening to Prozac. New York: Penguin Books.
MacIntyre, Alasdair. (1981). After Virtue. Notre Dame: University of
Notre Dame Press.
Moe, Karine and Dianna Shandy. (2009). Glass Ceilings and 100-Hour
Couples: What the Opt-Out Phenomenon Can Teach Us About Work
and Family. University of Georgia Press.
Noddings, Nel. (1984). Caring: A Feminine Approach to Ethics and Moral

Education. University of California Press.
Pratt, Laura A., Debra J. Brody, and Qiuping Gu. (2011). Antidepressant
use in persons aged 12 and over: United States, 2005–2008. National
Center for Health Statistics Data Brief, 76.
Ruddick, Sara. (1989). Maternal Thinking: Toward a Politics of Peace.
Boston: Beacon Press.
Schermer. Maartje. (2008). Enhancements, easy shortcuts, and the richness
of human activities. Bioethics, 22, 7, 355-363.
Sherman, Nancy. (1998). The habituation of character. In Nancy
Sherman (Ed.) Aristotle’s Ethics: Critical Essays. Rowman & Littlefield.
Slaughter, Anne-Marie. Why women still can’t have it all. The Atlantic
Monthly. July/August 2012.
Wurtzel, Elizabeth. (2000). Prozac Nation. Quartet Books.
Zagzebski, Linda Trinkaus. (1996). Virtues of the Mind. Cambridge:
Cambridge University Press.
CHAPTER SIX
DO NO HARM:
NEURODIVERSITY, HEALTH CARE ADVOCACY,
AND THE LANGUAGE AND CULTURE
OF INFORMED CONSENT
RALPH DIDLAKE AND JO ANNE FORDHAM
Perchance he for whom this bell tolls may be so ill as that he knows not it
tolls for him. And perchance I may think myself so much better than I am,
as that they who are about me, and see my state, may have caused it to toll
for me, and I know not that.
—John Donne
Meditation 17, Devotions Upon Emergent Occasions
The fraught ethical context in which physicians exercise their training

is brought into sharp relief by advocacy aimed at securing a systemic
response to new findings on neurodiversity. As human neurological

function is increasingly probed, widespread neurodiversity as a crucial
construct across the human life span, rather than as neurological
compromise contrasted to a neurotypical norm, has been communicated
within the medical, ethics, and neuroethics literature (Kapp 2012, Jaarsma
2012, Brownlow 2009, Fenton 2007, Glannon 2007, Mackenzie 2011).
These extensions to the long history of debate on human capacity have the
potential to exert an influential impact on health care and wider
community connotations of such terms as vulnerability, autonomy,
community, and justice. Most importantly, advocates supporting a widened
understanding of autonomy for the neurodiverse, particularly in the
context of health care decision-making, are challenging any comfortable
interpretation of the relationship of vulnerability to justice within current
social, cultural, and linguistic frameworks.
A physician’s role is to contribute a honed judgment and skill so as to
minimize the impact on function of an incipient, occult, or demonstrable
Do No Harm 101
vulnerability. People do not seek medical care because health exists, but
because illness and injury (often covertly) do. Moreover, caregiver-patient
communications continue, despite impressive institutional efforts to
minimize examination times, because they are crucial to recognizing the
strengths and vulnerabilities likely to affect patient health at the time of the
exam.
These communications are documented. An abbreviated summary,
along with laboratory and imaging findings, potential treatments, and/or
interventional strategies, are entered into each patient’s chart via a
nomenclature rarely unencumbered by health care lore. When read by
other health care professionals, these entries have the potential to evoke
ritualized responses and interchanges (Goffman 1981). Thus in the patient
chart, whether documented in digital or paper format, communities and
standard of care, legal liability, and patient statements summarily converge
in a formalized vocabulary that can enhance or degrade care. Where
physician interview empathy is concisely represented in this record,
respect for the patient – and concomitantly, standard of care –may be
enhanced among other caregivers; where empathy is lacking, respect and
care may well be degraded. The interprofessional exchange occurring
through patient charts is moreover not limited to language, but extends to
perusal of images, quantitative findings compared to a ‘normative’ range,
digitized diagnostic codes, and so forth.
The impact on care posed by this ritualized interprofessional
communication is itself a critical factor within the daily practice of
medicine, as all who present for care do so subject to a power imbalance
delineated by a language that routinely, perhaps of necessity, connotes
frameworks of vulnerability – in medicine, human states are “medicalized.”

Thus challenges brought to the fore by advocates of neurodiversity
represent an important opportunity to examine how these frameworks have
been constructed, their particular impact upon patients who do or may
identify as neurodiverse, and conceptualizations that might better support
the difficult striking of a balance between needed protections for the
vulnerable and the safeguarding of autonomy, crucial to all collaborations.
The construction of an operative framework focusing on vulnerability
emerged in the medical literature across the 20th century through reports
examining the experiences of two World Wars (Jonsen 2000, Rothman,
2003), physician complicity in Third Reich concentration camp practices
(Lifton 2000, Weindling 2005), and egregious ethical breaches in medical
research far removed from the theaters of war (Jones 1981, Revergy 2000).
The commonly employed “benevolent deception” and “nondisclosure,”
prevalent early in that century, gave way to the practice now known as
102 Chapter Six
voluntary informed consent for both research and the selection by a patient
of available therapeutic options in accordance with personal views and
physician explanations. Improvements in standard of care developed
alongside formal frameworks supporting increased transparency in the
provision of health care information, although the burden of documenting
compliance was not trivial. Most importantly, physicians were explicitly
charged with explaining to patients the risks and benefits of competing
treatment options (including the election to forego all therapy) and, where
necessary, to further inform family or other surrogate decision-makers.
With efforts to improve the sharing of medical information, however,
came an increasing identification of gaps in expectations and care.
Discussions on these topics, many of which transpired concurrently with
reductions in times allotted for patient visits by health care institutions,
helped increase cognizance of systemic gaps in access-to-care imposed by
such factors as race and ethnicity, socioeconomic status, employment
status, language group, educational status and literacy level, cultural
assumptions, and belief systems. Debates and investigations of these
factors led to further studies assessing the negative impact they could exert
on health outcomes, as well as strategies for mitigating their impact within
clinical care (Fox 2005, Parker 2012, Delphine-Rittmon 2012) .
Not least in the rise of neurodiversity as a topic within health care
advocacy, improvements in imaging techniques resulted by the end of the
20th century in functional images of brain activity (Belliveau 1991, Kwong
2012). These images introduced a new, albeit still emerging, visual
vocabulary with a concomitant rhetoric. Functional brain images obtained
from animal models, human subjects research, patients and control
participants provided path-breaking information on anatomical structures,

physiological processes, and neurological function (Kilgore 2004, Hamann
2004, Gow 2012). The impact of these images and the wide-ranging
debates they continue to generate, however, are well illustrated by 21st
century exchanges between “locationists,” “constructionists,” and those
who have suggested a “networked” structure for the experience of human
emotion. Author interpretations from a single meta-analysis on that topic
generated 29 published responses from researchers around the world
(Lindquist 2012).
In response to findings in neuroscience and other advances, the
psychiatric and psychological communities proposed and have debated
sweeping changes in diagnostic criteria and categories for the forthcoming
DSM V, the manual delineating factors important to pathological
diagnoses. (American Psychiatric Association 2012). While the urgency
of these debates probe the utility and drawbacks to “pathologizing” human
Do No Harm 103
states and behaviors, they appear to share one assumption: “Unless one’s
brain has the capacity to represent something – percepts, images, thoughts,
emotions, abstract concepts, sense of the position of one’s body in space –
one cannot be aware of it” (Grigsby, 2000). Thus, in clinical care, a
dilemma is posed wherever a discrepancy exists between one’s capacity to
experience and one’s capacity to represent that experience. In the contexts
of informed consent and neurodiversity, this discrepancy can be pivotal to
seeking a surrogate decision-maker.
Clinicians must determine in quick succession whether or not a given
patient has the capacity to provide consent at a specific time for a specific
procedure or intervention. Given the constraints imposed by clinical
exigency, claims raised by advocates of neurodiversity for reconstituting
the understanding of health and illness may appear remote, however
important. To invite clinicians to enter meaningfully into discussions of
neurodiversity, the unstable nature of health and the sheer fact of human
vulnerability must be acknowledged. Deeply troubling experiences at the
limits of health are what clinicians are charged with ameliorating
throughout their professional lives. Better clinical care will not emerge if
their experiences are discounted. Likewise, the medical model will not
proceed apace with scientific advances if the experience of human
neurodiversity, as represented within the neurodiverse community and by
its advocates, is trivialized or ignored.
Despite advances in studies of brain function and newly emerging
visual vocabularies for health and illness, an appropriate clinical lexicon
for acknowledging neurodiversity without tacitly or explicitly representing
neurological difference as a “morbidity” remains lacking. The bell-shaped
curve’s tracing of an attribute’s distribution within a population has long

served as a “norming” description of health. Moreover, the technological
feats that prompted a reassessment of neurological “norming” through
their profound contributions to studies in development, function, and
cognition have yet to produce any reliable metric capable of framing a
better health care lexicon. Thus for physicians and other clinicians to
apply their knowledge on behalf of patients with greater confidence, a
thorough reevaluation of the terms and processes for informed consent in
the context of neurodiversity is needed. Such reevaluation will require
active collaborations between patients, physicians, advocates, bioethicists,
and others with an interest in, but expertise external to the arena of,
clinical practice.
We urgently need to explore together the impact of neurodiversity in
healthcare communications and decision-making with respect to the risks
and benefits of an approach to securing health or treating illness. A pre-
104 Chapter Six
eminent goal should be to mitigate any static concept of neurological;

instead, each patient’s vulnerability-versus-capacity should be determined
as actual circumstances of risk mandate, forthrightly communicated, and
approaches to care accepted, rejected or challenged. In some respect,
questions of informed consent in the context of neurodiversity are second
only to matters of mortality in their ultimate reach: the health and
neurological status of a physician is no more stable across time than that of
any other human being, the neurotypical model is itself suspect, and actual
informed consent, far from static, constitutes a complex clinical variable
across time.
Neurodiversity is not a functional constellation unable itself to
influence attitudes; the literature of the past two decades alone eloquently
documents the rhetorical skillfulness of many authors for whom a well-
established descriptor of neurodiversity has been applied. Strong support
is due for these authors’ challenges to those identifying as neurotypical to
engage broadened concepts of human potentiality and neurodiversity. It
nevertheless remains important to consider whether or not an interlocutor
able deftly to exploit rhetorical structures and the lexicons of justice and
autonomy can adequately represent those who do not wield those skills.
Human empathy may indeed fathom analogous cognitive processes, but
we should approach with caution the idea that apparently analogous
perceptions are analogously produced. True respect for neurodiversity
should consider whether and how to create modalities for representing it.
With medical communications dependent upon charted notes,
diagnostic labels, and such truncations as CPT codes, even an isolated
incident ineptly recorded within a patient’s medical history can precipitate
devastating effects. In fact, negative effects exerted by the awareness of

stigma alone support the clinical usefulness of a lexicon relying less on
models of deficit and pathology to describe the wide-ranging tableaux of
human neurological states (Dovidio 2000). Stigmatizing or coercive
sobriquets, known to produce shame and marginalization, have been
shown ultimately to degrade standard of care (Hebl 2000, Blascovich
2000); they may be especially prevalent in designations of the
neurodiverse and their families. Within the clinic, off-hand comments
demeaning to patients, particularly in response to charted comments,
should become a focus of inquiry to assess their impact on patient care and
outcomes. Clinical terms and the truncated communications recorded in
patient charts should similarly be examined through chart reviews and
structured interviews . Care-giver self-reflection and self-reports can yield
a greater understanding of the perception of shame experienced by a
Do No Harm 105
patient’s tacit knowledge of stigmatization, and so improve understanding

and tact in the clinic as elsewhere (Seidler 2000).
Similarly, contemporary medicine lacks a bioethical lexicon able to
communicate the professional judgment that a patient does not possess, at
a given juncture rather than as a static determinant of being, the requisite
neurological competence to render a health care determination. Well-
developed terms of autonomy and justice, along with improved metrics,
have been used to describe the clinical experiences and health expectations
of many diverse patient communities. However, recent neurological
findings have yet to yield a robust biomedical and bioethical lexicon.
Instead, the interpretation of discrete findings pertaining to human
neurophysiology and function is now a matter of extensive debate, with
discipline-wide reluctance to engage former binary representations of
capacity, competence, health, and pathology common, but its language
still nascent.
Thus, in day-to-day practice, physicians continue to evaluate
neurodiverse patient communications through previously standardized
rubrics to determine capacity for consent. Confidence to treat or forego
treatment relies on signed documents that support action based on five
relatively well defined terms: disclosure, understanding, voluntariness,
competence, and consent. To determine the degree of accord between
these concepts within the health care community and the range of human
factors – competencies and vulnerabilities – that must be brought to an
ethical concordance during medical decision-making, metrics deemed
scientifically sound and ethically acceptable are consulted and recorded.
With these in place, the physician works with the assumption of legal
backing, supported by statutes and case law, and social consensus for a
responsible exercise of professional duties.
Better rubrics for assessing vulnerability, rather than mere difference,
within neurodiversity remain wanting. In their place, a summative clinical
judgment, although reductive, attempts to secure protections from
exploitation or marginalization that may not yet be afforded by an
increased understanding of productive, functional alterities. However
described, no individual can achieve either maximum capacity or ideal
health; all are subject to genetic, anatomical, physiological, and
environmental factors that limit functional and interactive capacities.
While a legal standard can describe health and capacity in static terms, a
clinician – and any useful medical framework – must account each day for
the fact that both terms are poised in a dynamic interaction with
compromise, disease and injury. Thus the language at the fulcrum of each
patient’s personal narrative contributes to standard of care during clinical
106 Chapter Six
decision-making. For this standard of care to be optimized, the physician-

patient relationship and concepts of autonomy, community and justice
must be reimagined and rearticulated to account for the shifting landscapes
of human agency and fragilities throughout the life cycle.
Professional life within psychiatry already treads its course fully aware
of a plethora of inconsistencies that can accompany medical judgments
remanded to Court reviews; however, physicians from all medical
specialties are likely to greet with dismay deliberations on a language
adequate to representing diverse neurological capacities in the context of
informed consent. Despite this likely reluctance, the language, practices
and documents used to obtain and document informed consent should
again be probed. How well do they actually provide for a voluntary,
knowledgeable participation? How do they shape expectations in their
readers? How do the conditions under which they are most often
provided, explained, and signed, if signed, support voluntary engagement
or autonomous dissent? Is capacity a term that denotes understanding,
trust, or risk? And within the context of neurodiversity, what limits argue
for surrogacy in health care decision-making?
The potential for such examinations to improve informed consent
processes, and thereby standard of care, is immense. This acknowledged,
advocates seeking to develop new definitions of competence commensurate
with neurodiversity would again do well to thoroughly consider the
foremost question that a responsible physician faces during the clinical
care of any patient: Is this individual’s consent voluntary and based in
autonomy, rather than coercion, exploitation, or the force of physician
paternalism? Or, if this patient at this moment cannot render a
determination: Who can provide consent or dissent?

However fluid the terms upon which contemporary informed consent is
now based (and examining each term reveals many potential areas for
challenge), an acceptable answer to these questions must be supplied by
the broadest possible community to develop an expanded model of
neurodiversity that both advances the enjoyment of personal autonomy
and protects those for whom vulnerability to coercion and exploitation is a
strong likelihood. Medical interventions are expected to expand
possibilities and reduce the suffering occasioned by human vulnerability to
injury and disease, but no intervention is without risk. Physicians cannot
escape this dilemma; their ethical responsibility is to share their
knowledge of potential benefits and losses with patients, and then to
document patient concurrence or dissent, as well as the patient’s
acknowledgment that actual outcomes within standard-of-care will always
pose uncertainties.
Do No Harm 107
In the introductory paragraph of his nonfiction best seller,

Complications: A Surgeon’s Note on an Imperfect Science, Atul Gawande
provides a snapshot of the profound uncertainty under which a physician
must act, and do so decisively. In it, an emergency surgery on an injured
patient follows a series of systematic evaluations, each contributing
precise information of importance in determining an urgent treatment
strategy. The crucial achievement of the opening, however, lies in
Gawande’s depiction of both the necessity and insufficiency of the rubrics
upon which medical decision-making must rely: the condition which the
rubrics conclusively indicate in fact has not occurred, and the greatest
injury sustained by the patient has been at the hands of his surgeons.
We can set aside the tightly circumscribed time for appraisal, dramatic
indications for intervention, and life-or-death stakes of Gawande’s
example; the necessity and frailty of rubrics in clinical care that it
describes overlap with health care dilemmas faced daily by patients and
their physicians. In neurodiversity, these dilemmas present through a
variety of characteristics, many of which will in no way hamper a patient’s
legal authority to render an autonomous decision on treatment options.
Some, however, will definitively preclude that authority. Each
characteristic must be better described, examined, reconsidered, and
rearticulated to maximize possibilities for autonomy while preserving
justice for the vulnerable.
The deliberations now occurring within the neurodiversity and
neuroethics movement challenge the language of health care, its
inscriptions, and the culture of informed consent. Such challenges strike
at an area little examined within health care: its rhetorical practices.
Health care communications, health care education communications,

physician-patient communications, the role of communication in health
care consultations, healthcare communications outcomes, and caregiver-
caregiver communications in the patient chart and on the floor are topics
of importance in medical education and throughout the daily practice of
medicine. However, the communication techniques modeled continue to
be characterized by specific skill sets through which to respond to
common clinical occurrences, as in “delivering bad news.” Examinations,
such as those earlier described for stigmatizing language, of operative
rhetorical constructs in health care communications continue largely to be
relegated to nonclinical observers.
Medicine is best practiced when physicians gain a thorough
understanding of all facts germane to a particular patient’s care. However,
clinicians must proceed with only a partial communications of information.
Within this tenuous equilibrium between facts germane and facts available, a
108 Chapter Six
clinician faces two key dilemmas. The first dilemma occurs when the
patient presents with a condition that he or she does not deem a pathology,
but for which the clinician possesses knowledge of potentially beneficial
resources and treatments. In this situation, such terms as patient,
pathology, therapy, therapist, and so forth are less important to the
physician than the fact that information about beneficial possibilities
cannot be accessed owing to a strict interpretation of and adherence to
definitions. The second scenario occurs when the communication of
alternatives to care is blocked by a difference in how such information is
processed. In this case, differing beliefs concerning pathology and health
are not at stake, but rather currently unbridgeable differences in
information processing.
Within clinical practice, this latter difference is likely to be constituted
as “difference as comorbidity.” The physician possesses information
concerning a greater “access-to-health” that cannot be communicated
through currently available lexicons to patients who might benefit from it
– and patients possess an experiential reality equally challenging to
represent. Communicating these experiences so as to render the fund of
knowledge of each party accessible remains a key goal for actually
securing informed consent or dissent in the context of neurodiversity.
Until this challenge is surmounted, rather than a charted “yes-no” rubric of
capacity for a given patient deemed applicable at every juncture, a sliding
scale assessment, obtained at specific decision-making junctures, could
demonstrate salient ‘capacity’ features of concern to patients, advocates,
physicians, families, and frontline caregivers. Such a time- and situation-
limited scale could for the moment help safeguard autonomy, protect the
vulnerable from exploitation and manipulation, and counter opportunities

for stigmatization, social marginalization, and concomitant degradation of
care.
Whenever controversies exist with respect to clinical alternatives for
neurodiverse patients, and in the absence of an incontrovertible need for
surrogacy, the inadequacy of our present approach to communications,
professional judgment, and the language of record in patient charts
continues to support a pernicious tendency toward labeling that can
degrade standard of care. As such, the current health care lexicon has a
strong potential to harm. Given this fact, and in light of the Hippocratic
tradition, a physician’s responsibility to neurodiverse patients must now
include engagement of the sociocultural processes by which new terms for
neurodiversity, supportive of higher standards of care, autonomy, and
justice, can emerge and become the language of record. That language
will not provide the last word, but it may yield better health.
Do No Harm 109
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CHAPTER SEVEN
THE VIRTUE OF PSYCHOPATHY:

HOW TO APPRECIATE THE NEURODIVERSITY
OF PSYCHOPATHS AND SOCIOPATHS WITHOUT
BECOMING A VICTIM
AUDREY L. ANTON
Introduction
The scientific community recognizes both Psychopathy and Sociopathy
as disorders. But what constitutes a disorder? Are all disorders bad?
Intuitively, we can say that a condition is a disorder if it is out of order
relative to that of typical human functions. But we must be more precise,
since having an eidetic memory, for example, is certainly an abnormal
function of the mind, but we are reluctant to call that condition a disorder.
In fact, an eidetic memory would seem to be more of a blessing than a
curse. It seems that disorders also constitute disadvantages for the subject.
However, this notion illuminates another problem: it is not clear that
psychopathy and sociopathy are disadvantages for the “afflicted.”
Perhaps our quandary needs a new approach. Perhaps we ought to
question whether psychopathy and sociopathy truly are disorders in the
traditional sense. According to Craig et al. (2009), a psychopathic trait is:
“Not a fault necessarily, and not something that could be classified as a
disease or that is always a disadvantage. At a certain frequency in the
populations, the traits of psychopathy may be highly advantageous to the
individual.” In this paper, I shall argue that psychopathy and sociopathy
can be advantages for both the patient and society when social conditions
are right. Indeed, the psychopath and sociopath have the potential to
develop certain virtues that the rest of us are ill equipped to acquire.
112 Chapter Seven
Who are These People?

There is no universally recognized measure for distinguishing
sociopaths from psychopaths. Nevertheless, recent statistics suggest that
4% of the population is sociopathic (Stout 2005) and 1% is psychopathic
(Hare 1999; Babiak & Hare 2006). Since there is no one standard
distinction, these estimates are not exact. In fact, many people use the
terms synonymously.1 The current version of the Diagnostic and
Statistical Manual of mental disorders (soon to be replaced by DSM V in
May 2013) considers antisocial personality disorder (APD) a genus with
sociopathy and psychopathy as “examples” of APD (though no specific
criteria for differentiating between the examples is given in this entry.
APA, 1994, pp. 649-650). In order to qualify as having APD, the DSM IV
requires that a person exhibit at least three of the following seven traits:
1. Failure to conform to social norms with respect to lawful behaviors

indicated by repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or
conning others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical
fights or assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing
having hurt, mistreated, or stolen from another.
In addition, a person with APD must be at least 18 years of age, have

had evidence of Conduct Disorder prior to the age of 15,2 and the
incidents exhibiting the traits above do not occur exclusively during a
Schizophrenic or Manic episode. This description is often criticized. Given
that only three criteria need to be met, it is entirely possible that two
people could have APD and qualify for entirely different reasons.3
For the clinical setting, Robert D. Hare has developed a standardized
diagnostic test for psychopathy. Though similar to the standards above,
Hare’s criteria take into account behavior as well as personal history and
interview responses to generate a score between 0 and 40. Hare considers
a subject who scores higher than 29 to be psychopathic (Hare, 1993;
Babiak and Hare, 2006). Still, no clear semantic account has been
developed.
The Virtue of Psychopathy 113
David T. Lykken distinguishes between psychopathy and sociopathy

based on the origin of the condition. According to Lykken, psychopaths
are persons “in whom the normal processes of socialization have failed to
produce the mechanisms of conscience and habits of law-abidingness that
normally constrain antisocial impulses” (1995, p. 6) whereas a sociopath is
an individual “whose unsocialized character is due primarily to parental
failures rather than to inherent peculiarities of temperament” (1995, p. 7).
For example, some people have APD despite positive and nurturing
upbringings; these people are psychopathic. On the other hand, some
people survive horrendous abuse and manage to become caring adults,
indicating that abusive environments are not sufficient causes of APD.
Various combinations of nature and nurture yield different degrees and
types of APD. As Lykken puts it, “there is a continuum from sociopath to
psychopath with intermediate cases that could reasonably be assigned to
either or both categories” (1995, p. 31). However, Lykken also states,
“Identifying someone as “having” APD is about as nonspecific and
scientifically unhelpful as diagnosing a sick patient as having a fever, or
an infectious or a neurological disorder” (1995, p. 5). Despite the issue of
vagueness, Lykken advocates assigning either or both categories when
diagnosing a patient with APD.4 The debate continues—no single
description seems adequate for our purposes. Following scholars such as
Babiak, Hare, Stout, and Lykken, I shall paint a portrait of the kind of
APD that best illustrates the condition relevant to our inquiry.
Every account of APD (psychopathy and sociopathy) alludes to some
notion of a lack or deficiency of conscience. Therefore, I shall say that the
essential characteristic of the potentially virtuous sociopath or psychopath
is a lack of conscience. By conscience I mean the common-sense notion of

a “mental check” that urges us to conform to moral and social norms and
plagues us with guilt and remorse when we don’t. Persons with a
conscience experience moral emotions like compassion, gratitude, guilt
and remorse, and these emotions operate more-or-less consistently in
regulating behavior.5 As a result, sociopaths and psychopaths are liberated
from the punitive experiences that compel many of us to stay in line.
Without such mental and emotional consequences, such persons are not
compelled to follow moral and social codes.
Given the diverse ways that one can be sociopathic and psychopathic,
not every sociopath or psychopath can develop virtues. People who are
entirely insensitive to reward and punishment may not be able to develop
virtues and are a liability to society’s safety. Hervey Cleckley claims that
psychopaths are distinguishable from sociopaths in that the psychopath is
“relatively indifferent to the probability of punishment for his actions” (via
114 Chapter Seven
Lykken, 1995 p. 115) whereas the behavior of sociopaths can be affected

by corrective measures (even if their internal attitude cannot). Unlike
Cleckley’s psychopath, the sociopaths and psychopaths discussed in this
paper can be motivated by the consequences of moral, social, and legal
codes. What distinguishes them from everyday people is that they face
different consequences. For example, the sociopath and the psychopath
feel no need to please or to “fit in,” and do not suffer pangs of guilt. It is
common, though not essential, that sociopaths and psychopaths require
more stimulation via risky behavior to achieve a sense of fulfillment. They
either rarely experience fear or experience fear in a significantly muted
way. So, common traits of the potentially virtuous sociopath and
psychopath include: deceitfulness, guiltlessness, reduced fright, emotional
stability, and cold calculation.
Be that as it may, a lack of moral emotions does not preclude the
sociopath or psychopath from adopting the “rules” of morality for the
purpose of game-theoretical reasoning. While such a person might not
appreciate the golden rule, she might be perfectly aware that you do. In
fact, she might be able to comprehend the golden rule in its technical
functions and plan her own behavior in light of such calculations. Just as I
can drive my car adeptly despite my ignorance of its mechanical workings,
the sociopath or psychopath can “drive” the compassion of others to
accomplish her objective even though compassion is an enigma to her.
Both psychopaths and sociopaths have abnormal mental lives. Following
Lykken’s criteria, the psychopath is innately different, neurologically. The
sociopath’s moral neurology, on the other hand, is underdeveloped in an
irreparable way. Nevertheless, their resultant behavior is indistinguishable.
Therefore, for the remainder of this essay, I shall use literature concerning
both sociopaths and psychopaths and I shall heretofore take the liberty of
using the terms loosely and interchangeably.
Neurobiology
In order to consider our psychopath’s potential virtues, we must first
investigate what distinguishes them neurologically and psychologically
from the rest of us. Recent research in the fields of psychiatry and
neurobiology suggests that the structure and processes of the brains of
psychopaths are significantly distinct from those who are neither. For
example, from the mid-1990’s through 2002, R. James Blair studied how
psychopathic inmates were able to distinguish moral rules and transgressions
from conventional ones. Blair’s control participants distinguished well moral
from conventional rules, whereas his psychopathic inmates found difficulty
distinguishing between the two. He also observed how these participants

reacted to images of violence. Blair reported that the psychopathic
participants were noticeably unaffected by the same images that yielded
visible signs of emotional distress in other subjects.
Others have studied similar phenomena with the aid of scientific
technology. Psychologist Robert D. Hare, the creator of the Psychopathy
Checklist, studied participant reactions to morally significant terms in
language. Hare monitored his subjects via EEG and presented neutral
words such as “flower” or “gate” alongside words like “scar,” “rape,” and
“rage.” Control participants showed noticeable brain activity in response
to the morally significant terms, whereas the antisocial subjects showed
little to no change (Hare 1999, chapters 3 & 4; Babiak & Hare 2006, pp.
22-23, 55). More recently, Craig et al.’s (2009) data indicates that there is
noticeable disruption of the interaction between the orbitofrontal cortex
(OFC) and the amygdala in psychopaths, which was absent in the brain
activity of control subjects.6 Craig et al. conclude, “we report associations
between measures of antisocial behavior and anatomical differences in the
UF [unculate fasciculus]” (2009, p. 950).
While little work has been conducted to see whether sociopaths share
similar neurological abnormalities with psychopaths (and some recent
work suggests that they do not (c.f. George et al., 2012)), it is certain that a
sociopath’s mode of cognition is more similar to a psychopath’s than it is
to a typical human being’s. I take it for granted that a difference in thought
indicates a difference in brain activity. Whether a person has a poor
connection between the OFC and the amygdala or an under-exercised one,
the results at the level of human interaction are similar. Neuroscientist
James Fallen, having researched sociopaths for 20 years, interprets such

data in one of two ways: “People with low activity [in the orbital cortex]
are either free-wheeling types or sociopaths" (Haggerty, 2010). Whatever
the neurological cause of psychopathy and sociopathy, one thing is certain:
psychopaths and sociopaths have very different mental lives from those of
typical humans, and this corresponds to something unique about their
brains.
Are Sociopathy and Virtue Compatible?

At first glance, the title of this essay might strike the reader as an
oxymoron. We typically think of sociopaths as vicious, therefore they
must not have any virtues. However, this judgment often rests on the
traditional premises that 1) the virtues are universal and objective and 2)
the virtues are in unity (i.e., an agent has all or none of the virtues).
116 Chapter Seven
Nevertheless, I believe that there are pragmatic reasons to reject these

assumptions. While either of these premises might be true of the abstract
notion of the virtuous agent, neither of these premises can be empirically
verified because neither has a referent in the real world.
The first premise fails to refer to anything in the real world because
there is a difference between virtue in general and a particular person’s
virtues. A particular virtuous person acquired her virtues over time, in the
face of particular choices, and through forming habits conducive to
flourishing in her particular social context. For instance, one brave person
might acquire this virtue through countless military operations in times of
war, while another brave person acquired her courage through regular
peaceful protests of a corrupt government known for its violent retaliation.
If these two brave persons were to swap places for a day, it is unlikely that
their virtues would transfer smoothly, enabling them to act virtuously in
such drastically different contexts. The brave military agent might struggle
to successfully communicate with megalomaniacs oppressing their own
people. This agent is more likely to become frustrated with the tyrants’
threats, reacting in unnecessarily combative ways. On the other hand, the
brave protestor, being accustomed to peace and passivity, might struggle
to cause physical harm to others, even when it is required.
If we insist that a virtuous person could seamlessly move between
contexts, we make two terrible mistakes. First, we would disavow the
sensible explanation for how one acquires virtue through habit. If virtue
can be acquired only through repetition of similar acts, then the virtue
would be constituted in part by the action-types the agent practiced. While
it is likely that having bravery of one sort can facilitate learning bravery of
another sort, expediency is not identity. It is true that once a person learns
Latin, learning another romance language would be much easier. Still, we
would be wrong to say that because our student knows Latin, she also
knows Spanish and Italian. Being equipped to adapt to new situations does
not entail being adapted to new situations. The particular virtues of
individual persons are particular. Therefore, a search for the objectively
virtuous person is sure to fail.
The weakness of the second premise is not as clear. Still, I contend that
this standard is too demanding. The unity of the virtues holds that no one
is virtuous unless that person is fully virtuous. While it is possible, in
theory, that a single person could acquire all of the virtues, it is highly
improbable that such people exist. Again, due to every individual’s limited
context and experience, people experience virtue-learning opportunities of
some types more than others. For instance, contemporary virtue ethicist
Julia Annas (2011) argues that we must continually develop and maintain
our virtues in the face of trying to minimize or render ineffective our vices.
The simultaneous development and completion of all virtues presents
another problem for the unity of the virtues. Given that we learn virtue
through experience and habit and different moral facts are salient in
different situations, it seems highly unlikely that we learn a little bit about
all of the virtues as we become virtuous. Certainly, some virtues do what
Annas calls clustering—they are often found together in complimentary
ways. For instance, the virtues of generosity, kindness, and justice are
often coextensive. One might kindly give to a needy person whose need
justifies them as a beneficiary. Still, it is difficult to see how this relates to
courage. Most importantly, the unity of the virtues is contrary to our
experience. Everyone seems more virtuous in certain ways and less
virtuous in others. If this is the case, we can safely say that one can be
more virtuous in some regards while failing to exhibit all of the virtues.
I acknowledge that some philosophers disagree with the position
advanced here. For example, Martha Nussbaum (2012), a critic of the
relative virtue movement, states:
The rejection of general algorithms and abstract rules in favor of an
account of the good life based on specific modes of virtuous action is
taken, by writers as otherwise diverse as Alasdair Maclntyre, Bernard
Williams, and Philippa Foot, to be connected with the abandonment of the
project of rationally justifying a single norm of flourishing life for and to
all human beings, and with a reliance, instead, on norms that are local both
in origin and in application (p. 756).
Philosophers who believe that all virtues are relative to societies and
social contexts deny that anything grounds similarities between a virtuous
person in one culture and a virtuous person in another. Proponents of this
view point to the fact that no universal list of virtues exists; something
considered a virtue by one culture could be a vice in another. Alasdair
McIntyre (1997) unites distinct views of the virtues across cultures by
connecting them to a few basic, broadly defined, cardinal virtues. For
McIntyre, the virtues of truthfulness, justice, and courage are essential to
all cultures; how they manifest in other ways depends on a culture’s values
as determined by its practices.
Regardless of whether we take up a thoroughly relativistic view of the
virtues or a moderate one like McIntyre’s, it is easy to see how a sociopath
could acquire some virtues. For example, a capitalist’s idea of truthfulness
is thin. There are times when lying is inappropriate (basically, when it is
against the law), but otherwise truthfulness is optional. Similarly, a
capitalist’s idea of justice is whatever the market produces, and courage is
118 Chapter Seven
the will and fortitude necessary to take financial risks. So it is possible for
one to be a virtuous businessperson with characteristics like truthfulness,
justice, and courage while being a sociopath. The sociopath can value
being the best swindler possible while “fairly” acquiring such wealth. This
is compatible with deceiving others routinely so long as such deception is
permissible according to the rules of the practice.
It is perfectly consistent to say that sociopaths are precluded from
becoming virtuous people while maintaining that there are virtues the
sociopath can acquire. This is my stance on the issue. I recognize a
difference between being a good human being and being a good American,
for example. In fact, it seems to me that very few people become virtuous
qua human being, whereas many people have character traits that can be
considered virtues in their given contexts.7 Therefore, if we abandon the
ideas that a virtue is context-independent and necessarily united to all
other virtues, we can see how even a sociopath could have some virtues
(even if she has many vices!). In order to see this possibility, we must
envision the kind of context in which sociopathic characteristics are
valuable and facilitate flourishing.
Individuality in Contemporary Society

Our last point opens the floor for a possible objection. Perhaps, one
might say, it is possible for sociopaths to develop well and flourish in roles
that require skills similar to their natural tendencies. But even when other
virtue ethicists speak of virtues being relative to society, they typically
speak of members in that society as recognizing the universality of the

virtues they value. For instance, while honor might be a central virtue in
some Asian cultures, it is not as if honor is a virtue that only the police
officer, or the lawyer, or the patriarch can develop and exhibit. It might be
found more often in certain subgroups; but this does not mean that it is
inappropriate in others. Such societies expect all members to strive for
honor. But the discussion above (in section 4) suggests something
different. It suggests that deception is valued by society as a virtue of
police officers, legal advocates, soldiers, and businessmen. But these
people make up a small fraction of our population. In fact, we do not value
deception as a virtue for spouses, educators, and clergy, for example. We
expect that these individuals not lie in order to be virtuous. So how can
deception be a virtue for sociopaths if it is not believed to be a virtue
available to all?
This challenge deserves two separate responses. First, we pay too little
attention to the fact that there are special virtues relative to roles just as
there are special obligations relative to roles. Parents have a special

obligation to provide for their children; this obligation is particular to them
because of the role the parent fulfills. A virtuous parent would be a good
provider for her children. It does not follow that every person must be a
parent to develop the virtue of being a good provider and benefactor.
Some religions prohibit members of the clergy from having families so
that they can devote themselves fully to the work and will of their deity.
Are nuns vicious because they won’t have children? While various
characteristics can be virtuous in different contexts, it does not follow that
all good people make sure to develop and exhibit all such characteristics.
The fact that individuality is a virtue in today’s society also answers
this challenge. In the United States of America, independence and
individuality are deemed fundamental goods and a person is considered to
be a better version of herself if she is unique and independent. If the
fundamental value is individuality, then that value expressed in practice
would resemble a chaotic mixture of values. Indeed, when a culture values
individuality, it must also value differences. Different people flourishing
in distinct ways will not appear to have homogenous values or any
hegemonic value. The hegemonic value is individuality. When individuality
is achieved, it creates the appearance of chaos and lack of uniformity.
Sociopathic Contexts: When Deception is a Virtue

(and When it is Not)
Whether or not a given sociopath can flourish and develop virtue will
depend on both the nature of her sociopathy as well as her context. As

mentioned earlier, the primary characteristic that seems to bind all
sociopaths is a lack of conscience. There are, however, infinitely many
ways a conscience can affect its possessor. So let us consider when
conscience can be harmful and which contexts call for a muted or an
absent conscience.
Given that individual virtues are sensitive to culture, context, and
social role, we should ask whether contemporary Western culture fosters
the flourishing of sociopaths. Typically, a person’s conscience hinders
effective lying. While lying is, stereotypically, a vice, we can imagine
situations in which it could come in handy. Careers in military security,
legal advocacy, or criminal justice come to mind—even games such as
poker. Theatre, television, and film demand that actors suppress true
feelings and thoughts when performing.
Many prestigious positions today involve more than simple imagination
and discretion—two skills compatible with honesty. Defense lawyers are
120 Chapter Seven
morally and legally obligated not only to withhold information and

imagine alternative scenarios of a crime, they often must lead a judge or
jury astray. In fact, dissembling is likely the only remaining defense that
an attorney can provide a forthcoming and guilty client. A good legal
defense finds weakness in the prosecution’s case, and sometimes the only
way to do so is to suggest a scenario that the lawyer herself knows to be
contrary to fact. While a defense attorney should not suborn perjury, this
professional obligation does not prohibit the intentional misdirection of a
courtroom. Not only is it allowed, it might also be required. A defense
attorney must provide a vigorous defense.
It is not the case that some bad defense lawyers happen to get positive
outcomes by using deception. Given the way that our legal system is
designed, all good lawyers must be skilled at the art of deception. And it is
not the case that some societal roles are inherently bad. For example, it is
not the case that all defense lawyers are bad simply because their
profession requires them to lie. As Julia Annas (2011) explains, to suggest
such a thing would be to confuse the circumstances of a life with the living
of a life. For Annas, anyone can be virtuous relative to their circumstances.
But virtue in any form is a matter of living well. Unless we are prepared to
suggest that the entire U.S. judicial system is essentially unjust, we must
accept that it is possible to be a good defense lawyer while behaving
justly.
If it is not possible to be a good defense lawyer without ever employing
deception, then being deceptive and being just are compatible. Certainly,
someone can be a good defense lawyer without being a psychopath. But
this concession is consistent with the claim that such persons will struggle
with their conscience. Psychopaths, on the other hand, are naturally able to
avoid such difficulties. As Aristotle tells us, some characteristics are
natural and we may consider them first nature. Other characteristics are
developed voluntarily and over time and we call these second nature. A
good defense lawyer who is not a sociopath but lies well is skilled at
deception as a matter of second nature only. A good defense lawyer who is
a sociopath will be deceptive naturally as well as through practice and
habit. How one develops a characteristic and the difficulty encountered
while developing it have little consequence once the characteristic is
solidified. The sociopath is all but guaranteed to develop virtuous
deception expediently.
Still, we should be careful when considering deception a virtue. To be
a virtue, the sociopath must be motivated to use deception within the
parameters of the law for the benefit society. For instance, if a cunning
sociopath lies when paying taxes, under oath, and about the bodies buried
in her basement, her guile is not a virtue in the sense under consideration.
Her guile might be useful for her, but it only harms society. In this sense,
her guile is merely a personal advantage and not a virtue.
Sociopathic Contexts: The Courage to Kill

As we’ve just seen, deception can be virtuous in certain cases. Can
killing be virtuous? The average conscience tells one not to kill other
human beings. Are there contexts that require killing for the benefit of the
individual and the society? The job of executioner is one controversial
example. Supposing that the state can legitimately sentence someone to
death, the state needs an individual person to carry out that punishment on
its behalf. Therefore, sociopathic traits might be useful in restoring justice
in such scenarios, whereas a person with a conscience would certainly be
conflicted.
A less controversial example of permissible killing is the job of a
soldier in combat. For example, while in combat, a soldier is expected to
take other human lives. In fact, that is the function of the soldier’s position.
Aristotle famously pointed out that the virtue of a thing is relative to its
function. For example, the virtue of a pair of scissors is the excellent
performance of its cutting. If a pair of scissors is sharp and aligned
properly, they cut well and we call them good scissors. What is the virtue
of a soldier, then? Certainly the cardinal virtue of courage comes to mind.
But is that all there is to it? Can one be courageous but incompetent in
battle? A good soldier is not only brave, but also competent at remaining
alive. But part of remaining alive is to kill the enemy before he kills you.
And it is not always the case that good soldiers patiently wait until they
find themselves under attack. It is often the job of a soldier to strike first.
Research suggests that typical soldiers (i.e., those who are not
sociopaths) rarely have what it takes to kill another human being. As Stout
(2005) discusses, one study of the firing rates of American soldiers during
World War II illuminates this trend. While the vast majority of soldiers
would fire their weapons when commanded by a superior officer, when the
commanders were absent, firing rates under similar conditions were as low
as 15-20%. In addition, similar studies suggest that even when soldiers in
such situations do fire a weapon, their woefully poor aim suggests that
they missed their human targets intentionally (pp. 65-67).
Stout uses this data to show the impact of authority on the typical
human being as well as the natural prohibition from killing that most
empathic humans experience. I repeat the results here instead to draw
attention to the dangers such natural human tendencies create. A soldier’s
122 Chapter Seven
job is to kill other human beings to protect oneself, one’s fellow soldiers,
and mission at hand. Having a conscience could make it very difficult to
perform these essential tasks well. The following analogy to drives the
point home: a soldier with a strong conscience is like a pair of scissors
with dull blades. While both might be able to perform their functions, in
neither case will the outcome be excellent. Regardless of whether the
soldier is in a defensive or offensive context, she cannot afford to hesitate
or struggle with her conscience. A good soldier’s conscience does not get
in the way. A good soldier gets the job done.
One’s conscience might get in the way even after the job is done. For
instance, thoroughly training a man with a conscience might eradicate all
hesitation when under fire. However, thorough training is not sufficient for
mitigating guilt after the fact. As Jonathan Shay (1995) argues in his book,
Achilles in Vietnam: Combat Trauma and the Undoing of Character, the
increase of post-traumatic stress disorder among Vietnam Vets is not
simply due to the fact that so many veterans were civilians drafted and
given minimal preparation. On the contrary, argues Shay, the trouble
stems from the lack of time extended to soldiers to grieve. Given the
difficulties that American troops faced in Vietnam, there was no time for
processing trauma, resting, or even enjoying peace of mind between
battles. Military leaders cultivated the anger of remorseful soldiers and
encouraged the expression of rage in future acts of destruction as
substitutes for grieving. Naturally, this strategy created a vicious cycle of
guilt and remorse, and it drove many of our soldiers insane. A sociopathic
soldier, on the other hand, would not have such problems.
Some might object that while sociopathic soldiers wouldn’t suffer from
extreme guilt and remorse, they could still suffer from the stress of
constant fear for their lives. While this objection has some weight, it
highlights another typical (though not necessarily universal) characteristic
of sociopaths. Many sociopaths are high risk-takers with a high threshold
for stimulation. Sociopaths reportedly are comfortable taking safety risks
and some even need to so do regularly to “feel alive” (Hare 1999, pp. 61-
62). This thrill-seeking characteristic might shield sociopaths from post-
traumatic stress related to extreme dangers. In fact, since they seem to
crave such high stimulation, perhaps extreme danger creates an opportunity
for the sociopath to flourish.
Sociopathic Contexts: When it’s not Personal,

it’s Just Business
While current estimates suggest that only 4% of the population is
sociopathic, as many as 8-10% of businesspersons are sociopaths (Paul
Lawrence, July 28, 2010 interview recorded by Max Miller). Experts like
Hare (1993, with Babiak, 2006), who distinguish psychopathy as a more
extreme condition than sociopathy, estimate that while only 1% of the
population qualifies as psychopaths, almost 4% of CEOs are psychopaths.
Babiak and Hare (2006) report:
In our original research working with almost 200 high-potential executives,

we found about 3.5 percent who fit the profile of the psychopath as
measured on the PCL: SV…While this may not seem like a large percentage,
it is considerably higher than that found in the general population (p. 193).
In a similar study, Board and Fritzen (2005) compared a population of

1,085 current and former criminally insane patients to a smaller population
of 39 high-ranking British executives. They concluded that the executives
exhibited more psychopathic traits and to a greater degree than did the
criminally insane. Board and Fritzen suggest that the executives are what
they call “successful psychopaths” since, despite their personality
disorders, they manage to avoid trouble with the law. It seems that many
sociopaths have already found an outlet for their peculiar skill set and
flourish in the business world. Business can be a self-selecting field. While
it is not necessary for one to be a sociopath to be a businessperson,
business is particularly attractive to those who happen to be sociopaths.

The corporate world provides a safe and effective environment for
sociopaths to flourish. Why business?8 Sociopaths want what they want
more than they care about anyone else’s interests. Capitalism in general,
and the American corporate world in particular, are designed for such a
mentality, since both recognize incentives as necessary motivators.
Capitalism is based on the principle that competition breeds excellence;
if one must compete in order to win a client or contract, one will construct
the best possible pitch. In addition, the successful person must also follow
through if she wants similar success in the future, since reputation is
crucial. As Stout (2005) suggests, “Sociopaths, people with no intervening
sense of obligation based in attachments to others, typically devote their
lives to interpersonal games, to “winning,” to domination for the sake of
domination” (p. 96). For many sociopaths, winning is all that matters.
Coincidentally, winning is all that a businessperson must do to be virtuous
qua businessperson. In many instances, “the game” amounts to convincing
124 Chapter Seven
others to purchase your product whether they need it or not. For example,
when someone wants to convey that someone else excels in sales, they say
of the person, “He could sell ice to Eskimos!” The objective is to convince
customers that they do need your product. Such convincing might only be
possible if the seller manipulates the customer. The businessperson must
imagine the potential customer’s desires and finding ways to connect the
desires with the product. Certain positions in business give sociopaths
permission to practice such techniques and earn money while doing it.
Western capitalism is particularly attractive to sociopaths, given the
role that corporations play in the marketplace. In the U.S., corporations are
considered legal persons who have rights to own and sell property, among
other things. A corporation’s only responsibility is to maximize profits for
its shareholders. In fact, the popular documentary film The Corporation
diagnoses this collective person as psychopathic (Achbar et al., 2004). If
the nature of a corporation is psychopathic, corporations are inviting
places to work for psychopaths. Someone must represent the whole by
acting in accordance with its sociopathic principles—who better to do that
than an actual sociopath?
Our culture is also a factor in the prevalence of sociopaths in the
corporate workforce. As Stout (2005) surmises:
It is entirely possible that the environmental influences on sociopathy are
more reliably linked with broad cultural characteristics than with any
particular child-rearing factors…Instead of being the product of childhood
abuse within the family, or of attachment disorder, maybe sociopathy
involves some interaction between the innate neurological wiring of
individuals and the larger society in which they end up spending their lives
(p. 135).
Cook (1998) also observes that the prevalence of sociopathy in a

society varies. Stout (2005) reports that sociopathy is relatively rare in
many East Asian countries such as Japan and China. Recent studies in
both rural and urban areas of Taiwan suggest the prevalence of sociopathy
to be somewhere between 0.03-0.14%—a strikingly small figure compared
to the industrialized West’s 4%. Stout also reports that the percentage in
the U.S. is projected to increase in coming years (p. 136). In efforts to
explain this data, Stout states, “American society seems to allow and even
encourage me-first attitudes devoted to the pursuit of domination” (p.
136). Robert Hare (1993) echoes this sentiment: “our society is moving in
the direction of permitting, reinforcing, and in some instances actually
valuing some of the traits listed in the Psychopathy Checklist—traits such
as impulsivity, irresponsibility, lack of remorse, and so on” (p. 177). These
experts agree that certain cultural norms constitute fertile grounds for
raising sociopaths.
In business, sociopaths have certain advantages over their empathic
counterparts. Having little emotional interest, a sociopath can compete
objectively in the marketplace. She can envision herself as a client or
competitor and easily imagine what their selfish motives might be. When
she purchases and dismantles other corporations, she does so without
remorse. She is, in essence, the impartial judge. She may be a very partial
negotiator, but her ability to see all sides strengthens her hand in
negotiations.
While a business can benefit greatly from a sociopath at the helm, such
sociopaths will need empathic “normal” people as guides in matters of
justice. For example, in the 1970’s, the Ford motor company manufactured
and sold the Pinto, a car they knew to have safety deficiencies that could
result in explosions of gas tanks that could severely injure or kill
passengers. The vehicles could have been altered to prevent such
explosions—a part installation costing approximately $11 per vehicle.
Refraining from the part upgrade was a legal option. Top executives and
analysts did a cost-benefit analysis to determine whether “it was worth it”
to upgrade the cars. They determined that the number of likely deaths
resulting from no upgrade was relatively low. Ford anticipated paying less
in damages for such incidents than it would cost to upgrade the Pintos. The
company opted not to repair the cars and continued production of the Pinto
as planned.
What Ford did not anticipate was public knowledge of this calculation.
When Ford was brought to court to answer for several cases, juries
determined that Ford should be punished severely and they awarded

complainants exponentially more money than Ford had anticipated. The
“normal” empathic jurors relied on a sense of justice that the (possibly)
sociopathic Ford executives did not consider. While corporations behave
sociopathically and the marketplace can be like a Randian state of nature,
companies must remember that their clients are often civilized, ethical
people. Therefore, I do not mean to suggest that all businesspersons ought
to be sociopaths—no more than I would suggest that all businesspersons
be generous saints. Certain social processes work best when the people
involved are diverse. That is why we should appreciate the neurodiversity
of sociopaths and psychopaths. While there are many more in the
corporate world than in the general population, sociopaths remain a
minority compared to non-sociopaths. It is for this reason that their
neurological differences can be advantageous. Like many things in life, it
126 Chapter Seven
is possible to have too much of a good thing. For a society, sociopathy is

most virtuous in small doses.
Preventing Victimization and Putting These Virtues

to Good Use
Everything addressed so far is mostly theoretical. But there is cause for
concern when we consider putting this theory into practice. It is all well
and good to say that we need people without conscience to do the jobs that
conscience makes particularly difficult. But these jobs involve positions of
power, and the sociopath’s lack of conscience makes her particularly
dangerous in positions of power. When she exercises her skills of
deception and callousness to fulfill her role, what is to stop her from
exercising those skills in the wrong setting (or indiscriminately!)? This
concern is great. It is the conscience that sets boundaries for stretching the
limits of acceptable behavior. Since sociopaths do not have internal moral
regulators, it is essential that society set up appropriate external influences.
I have no perfect solution for this problem, though I have a three-step
suggestion for appreciating the virtues of a sociopath without becoming a
victim. First identification is key. While 4% of the American population is
sociopathic, it is difficult to tell who they are. Perhaps we should start
administering sociopathy diagnostic tests as regularly as we do hearing
and seeing exams on our young. Just as it would be a shame for a child to
go without hearing assistance for lack of diagnosis, so too it would be a
travesty if sociopaths made important moral decisions without our
knowledge. Identification is only the first step. Identification can help us

to protect ourselves, and it need not involve ostracization.
When identification is accompanied by careful understanding and
cautious acceptance, we can benefit from interactions with sociopaths
without being victimized. We must familiarize ourselves with these
neurological differences and become accustomed to expect from sociopaths
what they are able to offer. Indeed, no one would expect a person with
Down’s Syndrome to solve the energy crisis. To do so would be both
unfair and irrational. Similarly, it would be irrational for a “normal”
individual to romantically pursue a sociopath as a potential life-partner. A
sociopathic spouse is destined to disappoint a non-sociopathic partner. For
example, Lidija Rangelovska, wife of psychopath Sam Vaknim, experiences
frustration and disappointment in the documentary I Psychopath (2008).
Diagnostic tests determined that Rangelovska scored highly as a caring
empathic person, while Vaknim scored highly as a psychopath. Such
relationships could work if the empathic person were willing to play a
thoroughly altruistic part. However, for the rest of us who expect

reciprocity in our relationships, marrying someone of like mind is
probably wise. The second step, then, involves conditioning ourselves to
avoid likely disappointment and to accept, rather Stoicly, the way that
certain people are. Part of appreciating diversity of any kind (including
neurodiversity) is to accept people as they are—especially when they are
not like us. As a culture, we would need to improve in this area.
Finally, we would have to set up a legal system of rewards and
punishments that is likely to deter sociopathic abuse of non-sociopaths.
Much of our legal system is already set up this way, so what we need to do
is adjusting rather than overhaul our system. The prescription for
appreciating the neurodiversity of sociopaths without becoming a victim is
quite simple. Appreciate the sociopath for what she can do well, do not
expect from her what she cannot do, and adjust policy accordingly.9
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CHAPTER EIGHT
THE NEURODIVERSE
AND THE NEUROTYPICAL:
STILL TALKING ACROSS AN ETHICAL DIVIDE
DEBORAH R. BARNBAUM
Introduction
Persons with autism occasionally refer to themselves as “neurodiverse”
and refer to those without autism as “neurotypical.” Not all persons with
autism think of themselves as aligned with the “neurodiverse,” or the
“neurodiversity moement,” just as not all persons with typically
developing cognitive processes think of themselves as “neurotypical.”
However, for purposes of this paper, I will refer to those with ASD as
“neurodiverse” and those without ASD as “neurotypical.” The neurodiverse
and the neurotypical differ with respect to some cognitive characteristics.
But in addition to cognitive differences, many persons who are

neurodiverse hold a view about autism that many neurotypicals do not:
Many of the neurodiverse argue autism should not be cured.1 Neurotypical
persons are usually less persuaded of this belief. Many neurotypicals
spend enormous time, resources, grant monies and charitable contributions
trying to cure autism, even as the neurodiverse discourse passionately in
books, at conferences such as the annual Autreat, or on websites and
blogs2 that they have no disorder for which they need a cure.
The neurodiverse and the neurotypical can be envisioned as occupying
two camps, each positioned on the edge of an unbridgeable chasm. One
camp believes autism should be cured; the other doesn’t perceive autism
as needing a cure. From the vantage point of those occupying each camp,
their positions are consistent with their theoretical assumptions. It is the
people in the opposing camps who are misguided. However, whether or
not autism should be cured is not just a matter of opinion. Curing autism
would entail fundamentally changing who autistic people are, as well as
132 Chapter Eight
the expenditure of enormous time and resources. A great deal is at stake

in considering if autism should be cured. The chasm between the two
groups represents an ethical divide, a divide that raises two questions.
The first of these questions is: What is it that distinguishes persons in
the neurodiversity camp? Several theorists have attempted to answer this
question, although some analyses are more helpful than others. The
section of this chapter entitled “What is Neurodiversity?” addresses this
question. The second question is: What accounts for the ethical divide in
views with respect to curing autism? In other words, why are each of the
two campus located on opposite sides? Some may answer the second
question this way: One of the parties is just wrong in its moral assessment
of curing autism. Those who take this approach assume there is a single
true moral theory that applies to everyone, neurodiverse and neurotypical.
This shared theory answers applied questions, such as “Should we cure
autism?” The fact that each camp occupies a different side can be
explained because one party has false beliefs, even though both parties
share moral assumptions. An analogy may be helpful here. Imagine a
Kantian who believed that all rational beings were ends in themselves.
Yet, this Kantian was also an unrepentant male chauvinist, who held that
women were not rational beings. Upon being confronted with a Kantian
feminist (let’s call her Professor Barbara Herman), the chauvinist and
Professor Herman would be in disagreement about the status of women.
But Professor Herman would simply assert that the chauvinist had false
beliefs about women. The two parties agree about moral theory; they
disagree about other beliefs. The same lesson may explain the divide
between the neurodiverse and the neurotypical: Perhaps their disagreement
is a disagreement in which one party is just wrong, but both agree about
their background assumptions, such as which is the correct moral theory.
But what if the situation is more complex than the claim that one side
is simply wrong in their beliefs? What if the ethical divide exists in virtue
of a more complex debate? If the debate is in fact more complex, three
accounts emerge that explain the divide beyond the claim that one party
must be wrong. It may be the case that there is a fundamental difference in
the language that is used to communicate about disorders or disabilities,
and that this difference accounts for the divide. It may be that there is a
fundamental difference in moral theories used by the two groups which
accounts for the ethical divide. Finally, there may be a fundamental
difference in the concept of disease, malady, or disability that accounts for
the ethical divide. The remaining sections of this chapter, “Lack of a
Common Language,” “Lack of a Common Moral Theory,” and
“Competing Conceptions of Disease, Malady, or Disability” examine these
The Neurodiverse and the Neurotypical 133
three alternatives. It is concluded that, while some of these explanations

may be better than others, until the problem is resolved, the neurodiverse
and the neurotypical will still be talking across an ethical divide.
What is Neurodiversity?
Philosophers have recently begun to analyze the concept of
neurodiversity. The term ‘neurodiverse’ is used to describe not only
individuals with autism, but also those with schizophrenia, bipolar disorder,
and other conditions. When considering neurodiversity and autism in
particular, it is helpful to begin with the views of Glannon, who observes
that “‘Neurodiversity’ usually appears in discussions of autism spectrum
disorders as the view that individuals with these disorders have at least as
much mental ability as disability” (Glannon, 2007b). Glannon’s claim
about neurodiversity is not as precise as one might hope. In saying that
persons with autism spectrum disorders (ASD) have “at least as much
mental ability as disability” Glannon implies that the abilities of persons
with ASD are limited, as their abilities are somehow only proportionate to
their disabilities. Glannon refines his position, later clarifying that
“…neurodiversity… recognizes that many people have a combination of
neurological and psychological abilities and disabilities” (Glannon 2009a,
quoting Baker, 2006). This is a better formulation, as it makes clear that
the abilities of persons with ASD are not limited by being merely
proportionate to their disabilities. However, this description doesn’t
sufficiently elaborate the concept of neurodiversity. Most people are hard-
pressed to think of anyone they know who doesn’t have a combination of
neurological and psychological abilities and disabilities. Glannon’s

second claim is true for most humans, almost to the point of triviality.
However, while these descriptions aren’t the full story, they do tell us
something interesting and important: The neurodiversity movement holds
that ASD is characterized not merely by impediments, but also by normal
functioning, as well as cognitive strengths. ASD, on this account, may be
best understood as a cognitive difference, not as a shortcoming. This
observation is significant, echoing Francesca Happé’s claim that ASD
characterized by weak central coherence reflects a cognitive approach, not
necessarily a disorder, and thus reflects “skills as well as failures, and as
such can best be characterized not as a deficit account, but in terms of
cognitive style” (Happé, 2000).
According to Fenton and Krahan, neurodiversity is characterized by a
set of prescriptive claims in addition to the above descriptive claims: “The
neurodiverse, as they call themselves, contest the default pathologizing of
134 Chapter Eight
differences in brain circuitry that are revealed in behavioral deviances

from the standard norm” (Fenton and Krahan, 2007). Neurodiversity is,
on this account, not merely reflective of the fact of cognitive pluralism, but
is an endorsement of the value of cognitive pluralism. As such, the
following normative claim emerges from neurodiversity: If it is true that
“default pathologizing” is mistaken, then neurotypicals should be more
accommodating of the neurodiverse. If there is nothing pathological about
neurodiversity, then moral claims made about the neurodiverse should be
similar to moral claims made of the neurotypical. For example, a rights
theorist would hold that both would have an equal right to exist, and the
right not to be forcibly altered without consent. A hedonic utilitarian
would hold that both parties’ happiness matters equally in the hedonic
calculus. Significantly, if “default pathologizing” is mistaken, then the
neurodiverse should not be forcibly cured by neurotypicals. According to
this perspective, ASD is not a disorder that needs to be cured, but instead a
different cognitive approach, per Happé’s claim above.
Yet, this assessment of ASD is not shared by many members of the
neurotypical community. Many members of the neurotypical community
do pathologize ASD, look for its genetic basis, change the diets of people
with ASD, force them to inhale oxytocin, and expose children to countless
hours of floor time or social stories to try to make persons with ASD more
like neurotypicals. Why do the neurodiverse and the neurotypical
communitiees often disagree as to whether ASD is in fact a pathology?
It should be explained that what follows in this chapter is not attempt
to determine whether the arguments for or against curing autism are sound
or not. Barnes and McCabe (2011), for example, consider myriad
arguments for the claims that autism should be cured, or left uncured.
Their arguments consider concerns such as the liberty of the person who
may be forcibly cured, the harms that result from certain disabling
conditions, whether personal identity is compromised, the costs of cure,
and whether certain talents will be lost as a result. Rather than engage in
that level of debate, this discussion goes a step further: Given that there
may be disagreement among the neurodiverse and the neurotypical about
the soundness of Barnes’ and McCabe’s arguments, what accounts for this
disagreement? Is it possible that the disagreement is not a function of the
soundness of the arguments, but of something else?
Lack of a Common Language?

One explanation for the ethical divide is that the neurodiverse and the
neurotypical are speaking different languages. If this is true, it would
stand to reason that one group may be making one set of claims about
ASD, while the other could be claiming something very different. One
version of this hypothesis is that the language of the neurotypicals is
predicated on a common ascription of propositional attitudes typical of
individuals with a fully functioning theory of mind (ToM). If this
hypothesis is true, as it is postulated by psychologists such as Simon
Baron-Cohen (Baron-Cohen, 1995), then theories of meaning familiar to
philosophers that require shared propositional attitude ascription –
Gricean, Davidsonian, Lewisian – would be non-starters for persons with
ASD (Barnbaum, 2008). Grice’s theory requires that the individual who
hears a proposition uttered by a speaker understand not merely what the
hearer thinks the words mean, but also understand what the speaker means
for the hearer to think what the speaker means when language is used.
Such a complex set of iterated mental-state ascriptions, and shared mental-
state ascriptions, would seem problematic for persons with ASD on Baron-
Cohen’s absence of ToM account. Lewisian theories of meaning rely on a
shared common knowledge among users of a language, a common
knowledge which is predicated on shared mental-state ascriptions. Thus,
Lewis’s theory also poses challenges for the autistic language user.
Donald Davidson’s theory of radical interpretation, in which all speakers
attempt to interpret others’ utterances with an eye towards understanding
those utterances to be true, similarly is challenged by individuals who have
compromised ToM. All three of these theories of meaning are thus
unworkable by persons with autism, on Baron-Cohen’s account. As such,
the language used by the neurotypicals, whose meaning requires
functioning and effortless ascription of ToM, may not be the same
language used by the neurodiverse. This could explain why, according to

Alexandra Perry, “autistic individuals may process the information that
they are given in a very different way than neurotypical individuals might”
(Perry, 2011, p. 237). Perry makes her point in the context of evaluating
the validity of certain types of informed consent for medical treatments by
persons with ASD. If these differences in common language persist, then
applied concerns in ethics – informed consent, whether persons with
autism should be cured – will also be in dispute.
Victoria McGeer makes a similar point about a lack of a shared
common experience, although her observation is not dependent on the
ToM thesis advocated by Baron-Cohen. McGeer presents what she calls
the “form of life” hypothesis in which effortless third-person perspective
taking and third-person propositional attitude ascription are “explained as
a species of skilled perception that arises in conjunction with skilled
performance in any norm-governed shared practice, or form of life”
136 Chapter Eight
(McGeer, 2009). According to McGeer, persons with ASD are not skilled
in the shared folk-psychological expertise that characterizes the form of
life of the neurotypical. Thus a divide emerges by which neurotypicals
and neurodiverse do not understand each other. Instead of a “thick”
understanding, the neruodiverse and the neurotypical are both relegated to
a mere “thin” understanding of each other’s psychology (McGeer, 2009).
According to both Baron-Cohen’s ToM thesis and McGeer’s “form of
life” hypothesis, the language of neurotypicals is fraught with terms that
may be foreign to individuals with the social impairments that characterize
ASD. McGeer observes that Ian Hacking’s discussions of autobiographies
of the neurodiverse may reflect precisely this problem:
[T]he language available to display those minds is still our (nonautistic)
communal language, a language geared, for the most part, to typical
psychological experiences. As Hacking points out, autistic individuals will
have their work cut out for them to adapt, manipulate, and perhaps outright
distort the common meanings of our words in order to convey something
of their own subjective experience (McGeer, 2009).
Perhaps the subjective experiences of persons with ASD are not

adequately captured in the language neurotypicals use to describe their
own experiences. The result is an ethical divide: The neurodiverse do not
explain their experiences in ways the neurotypical can understand, and the
neurotypical act on what they believe to be an ethical imperative to “fix”
what they don’t understand. Conversely, the neurotypicals do not explain
to the neurodiverse what they believe to be an ethical imperative in curing
ASD in ways that the neurodiverse understand; thus the neurodiverse
remain unconvinced of the presumed morality of the neurotypicals’ efforts.

A possible objection to this account is that it may prove too much. If
the neurodiverse and neurotypical are using different languages, wouldn’t
it stand to reason that they would disagree about far more than whether or
not ASDs should be cured? It is possible, however, that many will view
this supposed objection as a strength of this position. If the two are using
different languages, this would explain their disagreement on a wide range
of issues. In fact, the neurodiverse and neurotypical do disagree on a wide
range of issues. Questions about whether to cure autism may generate the
most passionate discourse, precisely because so much is at stake. But the
claim that each group is using language uniquely may offer an explanation
more robust than other attempts to account for the ethical divide.
A second objection is that it is unknowable whether this account could
ever be true, unless there was a third language into which both the
neurodiverse and the neurotypicals’ language could be translated. Only
then would we be able to determine that the two parties were in fact using
language to describe different things. But in the absence of a shared meta-
language, which could be used to arbitrate debates among the two object
languages actually being used by the neurodiverse and the neurotypical,
we would never know if this solution is correct. Another explanation that
accounts for the ethical divide is needed.
Lack of a Common Moral Theory?

Perhaps persons with ASD and neurotypicals are speaking the same
language, and yet they draw different moral conclusions about whether
autism should be cured because they are using different moral theories to
draw those conclusions. The claim here is not that persons with ASD lack
moral capacity. Multiple studies have demonstrated that children with
ASD do have moral capacity comparable to their typically developing
peers (Blair, 1996; Grant, Boucher, Riggs and Grayson, 2005).
Rather, the point is that persons with ASD evaluate moral questions
differently than do neurotypicals, because the two are operating from
different moral assumptions. Again, the inability of persons with autism
to fully grasp social cues, either owing to impaired ToM or other
considerations, may be instructive. Barnes, Lombardo, Wheelwright and
Baron-Cohen (2009), for example, examined not merely whether persons
with autism spectrum conditions (ASC) are able to make moral
assessments, but the basis upon which they arrived at their moral
conclusions:
To the extent that both groups (those with autism spectrum conditions and
those who are neurotypical) succeeded in viewing moral dilemmas in terms
of mental content, they do so in different ways, with individuals with ASC
using verbal scaffolding to increase their ability to draw meaning from
social scenes (Barnes, et al, 2009).
In other words, according to Barnes, persons with ASD do perceive

some moral dilemmas as having to do with the intentional attitudes of
others, but they don’t reach this understanding via the neurotypical method
of making mental-state ascriptions. Rather, persons with ASD use other
clues to determine what other people are thinking, clues that allow persons
with ASD to act morally. Persons with autism are able to draw moral
conclusions, but do so in different ways from the neurotypical. But why
might neurodiversity imply diverse moral reasoning?
If the neurodiverse do not effortlessly or spontaneously engage in
third-person perspective taking, then moral theories that do rely on such
138 Chapter Eight
perspective taking would be unworkable. Persons with ASD who do not

easily attribute propositional attitudes to other persons, or who mistakenly
attribute to others the same propositional attitudes that they hold
themselves, find some moral theories difficult to use in practice. The
problematic theories range widely, from a Humean theory of sympathies,
to a Categorical Imperative that says that each person should be treated as
an end in him/herself and not merely as a means, to some forms of
utilitarianism, to a Golden Rule based on treating others in the way that
you wish to be treated, to Rawlsian social contract theory and
contemporary theories of prima facie duties (Barnbaum, 2008). Each of
these theories requires the performer of an action to reflect on the
positional attitudes of others when determining right action. But if third-
person perspective taking is impeded, it compromises the ability of the
neurodiverse to employ the above theories.
It should be observed that saying that the neurodiverse are unlikely to
be using moral theories that require the use of mental-state ascriptions,
whereas the neurotypical are far more likely to do so, does not mean most
neurotypical persons are explicitly Kantians, or Humeans, or Rawlsians.
Very few people explicitly cite philosophical moral theories when making
ethical judgments. But ethical judgments can be found to be compatible
with canonical theories, albeit occasionally in a post-hoc fashion. When
people justify stopping at a stop-sign in the middle of the night on a
deserted road by saying, “Well, it is a good rule to follow, even in the
middle of the night when the consequences don’t matter, which is why I
think everyone should follow the rule all the time,” philosophers wink
knowingly. The reasons and justifications for actions may not explicitly
cite moral philosophy, but familiar themes that characterize moral theories
are a fixture of our moral discourse. The claim that the neurodiverse don’t
employ the same theories as the neurotypical is a claim that the reasons
and justifications offered by the neurodiverse for making moral decisions
are distinct from those offered by neurotypicals.
Persons with ASD are able to employ moral reasons, and be subject to
moral responsibilities, just as typically developing persons are. They
merely do so via a different method from the neurotypicals. What might
this method entail? As Barnes, et al, suggest, this method is a departure
from the neurotypical method of making mental-state ascriptions that
allow neurotypicals to utilize the theories mentioned above. David
Shoemaker articulates this claim when evaluating the moral capacities of
persons with high-functioning autism (HFA):
What is missing for those with HFA, remember, is just the ability to
recognize moral reasons via the standard route, by picking up on the
emotional cues of moral address directly and having an insider’s

understanding of what others are feeling (Shoemaker, 2007) .
A second perspective on the notion that the neurodiverse and the

neurotypical may utilize different moral theories is taken up by Jaarsma,
Gelhaus and Welin (2001). They examine the basis of autistic persons’
frequent inability and/or reluctance to lie, and attempt to frame this
behavior in terms of either a Kantian deontological ethic or an Ethic of
Care. If persons with autism are held to be “systemizers,” rather than
“empathizers” (Baron-Cohen, 2003), this might account for the neurodiverse
predilection towards veracity, as contrasted with a neurotypical
predilection to spare people’s feelings with “white lies.” The upshot is
that Barnes may be right: The neurodiverse utilize a different strategy
when assessing moral questions than do the neurotypical. If this is true,
then it stands to reason that when confronted with a question in applied
ethics – should persons with ASD be cured? – the neurodiverse and the
neurotypicals reach different conclusions. It is not that one group has the
correct theory, and one is operating from a false theory. Rather, each
group conceives of moral questions so differently that their own moral
assumptions are inapplicable, or unrecognizable, to members of the other
group.
Unlike the “lack of a common language” argument, the “lack of a
common moral theory” confronts the ethical divide head-on. As such, it
might be a more promising theory, as it aspires to prove less. The “lack of
a common language” theory would, if true, imply that the neurodiverse
and neurotypical would not agree on anything. But perhaps the two
groups agree more often than not; their most fundamental disagreement
may be about the applied ethical question whether autism should be cured.
The best explanation for an applied ethical divide is that there may be a
divide amongst ethical theories. However, while the neurotypical and the
neurodivese may use different moral theories, or different moral
methodologies, to draw ethical conclusions, that is not to say that they
ultimately draw different moral conclusions. Two moral theories may the
extensionally equivalent, drawing the same conclusions even as they base
their conclusions on different moral considerations. The incessant
perseverating on third-person perspective taking on the part of the
neurotypical, or the lack of effortless and spontaenous third-person
persepctive taking that characterizes the thought of the neurodiverse, does
not necessarily demand that different moral conclusions are drawn. That
is the lesson of Barnes, et al’s, work: The neurodiverse and neurotypical
may draw the same moral conclusions, based on different methodologies.
Thus, while the “lack of a common moral theory” may better reflect what
140 Chapter Eight
we already believe, it does not provide an adequate explanation of the

ethical divide.
Competing Conceptions of Disease, Malady,

or Disability
Perhaps the ethical divide is attributable to different views about the
nature of cognitive impairments. The issue is not whether revised DSM
criteria for autism are correct, or whether Asperger’s is rightly characterized
as a type of autism. Rather, this is a conceptual question about what
having a cognitive impairment actually means. It is important to distinguish
this hypothesis to the “lack of a common language” hypothesis.
According to the lack of a common language hypothesis, the ethical divide
is accounted for by the fact that the neurodiverse and neurotypical do not
share a common understanding of all language. Thus, what it means to
cure, or what ASD itself means, is up for debate. But according to the
“competing conceptions of disease, malady, or disability” hypothesis, the
disagreement is narrowed to a disagreement about a few, salient concepts
– disease, disability, or malady. As Glannon observes, “[neurodiversity]
forces us to ask what counts as a mental disorder, and whether certain
mental traits that deviate from those of the general population should be
characterized as differences rather than disabilities.” (Glannon, 2007a).
There are three prominent views on the subject.3
Irrespective of which is correct, a lack of consensus on the meaning of
these terms yields two possible explanations for the divide among the
neurodiverse and the neurotypical. First, perhaps they are both using the
same conception of disease, disability, or malady, but they disagree as to
whether autism fits that shared conception. Whether or not there is a
moral imperative to cure certain diseases is at best situationally
determined; a fortiori there is no moral imperative to “cure” that which
isn’t a disease. Second, perhaps they are using distinct conceptions which
accounts for their disagreement as to whether autism should be cured. If
the second is true, it is easy to see how the neurodiverse and the
neurotypical would arrive at different conclusions as to whether ASDs
should be cured. But even if the first claim is true – that the neurodiverse
and the neurotypical are operating from the same conceptual views – it is
still the case that they may be in disagreement when assessing the moral
imperative to cure autism.
One set of definitions of disease or impairment posit that these
concepts are best understood as adverse deviations from typical species
functioning. Both Caplan and Cohon offer definitions in keeping with

these claims:
Disease can be defined as any impairment of the functions typical of a

particular biological species – functions required to achieve the natural
goals set, not by politics or culture, but by the twin demands of survival
and reproduction (Caplan, 1996).
Impairment… is [a]ny loss or abnormality of psychological,
physiological, or anatomical structure or function (Cohon, 2004).
Implicit in the above accounts is the pathologizing of any difference

that would impede a species member’s ability to survive or reproduce.
Those who chafe against the “default pathologizing” of autism disagree
that the differences which characterize ASD are diseases or impairments.
There are doubtless many individuals with high functioning autism who
hold that having ASD does not impede survival and/or reproduction.
Perry observes, for example, that some persons with Asperger’s reject the
pending re-categorization of Asperger’s in the revised DSM, “citing that it
is likely to undermine their efforts to construct public opinion of
Asperger’s as a difference, rather than a disability” (Perry, 2012, p. 240).
If the neurotypical find the above views plausible, but the neurodiverse do
not, this could account for different conclusions as to whether autism
should be cured.
A second analysis, this time of malady, focuses not on the failure of
biological functioning, but on harms that result from a particular
condition. Rather than mistakenly equate a malady or disease with a
particular biological condition, it may be best to focus on the harms that
accrue to an individual who has a particular condition. Thus, Gert, Culver

and Clouser (1990) propose an analysis of the term malady which captures
the essential nature of harm intrinsic to any disease condition:
A person has a malady if and only if he has a condition, other than his
rational beliefs and desires, such that he is suffering, or is at a significantly
increased risk of suffering, a nontrivial harm or evil (death, pain, disability,
loss of freedom or loss of pleasure) in the absence of a distinct sustaining
cause (Gert, et al, 1997).
According to this analysis, maladies are those conditions that result in

some sort of harm to the individual who has them. Some members of the
neurotypical community hold that members of the neurodiverse are
suffering a loss of pleasure because autism impedes an individual’s ability
to engage in certain types of social interactions. Autism restricts a
person’s ability to communicate, use language, or engage in eye contact
142 Chapter Eight
for long periods of time – surely these are nontrivial harms, say the
neurotypical. The neurodiverse respond by saying that they aren’t
suffering, or wouldn’t be, if the neurotypical were more inclusive. As
Fenton and Krahn observe, the neurodiverse “contend that autism is, or
perhaps certain forms of autism are, best regarded as different “ways of
being” from what is commonly represented… For these individuals autism
is not something from which they suffer, but is rather who they are…”
(Fenton and Krahn, 2007). It is true that those with ASD are suffering the
harms of lack of social interaction or eye contact, but only because the
neurotypicals set the agenda as to what counts as harming conditions. The
neurotypicals will respond that there is a fact of the matter that these are
harmful, and that they did not make the rules as to what counts as a harm
or not. The ethical divide can be accounted for via alternative notions of
what it is to suffer a malady, or alternative notions as to whether those
with ASD are objectively harmed by having ASD.
Finally, rather than focusing on naturalistic claims or attempting to
make claims about objective harms, a third approach holds that disabling
conditions are socially constructed:
If some portion of the difficulty of disability stems from the biological
limitations, the majority does not and is in fact socially constructed. In
asserting disability is socially constructed, I am making two claims: first,
that even those characteristics we label as “disabling” are at least partly
socially determined; second, that disability’s all-too-frequent consequences
of isolation, deprivation, powerlessness, dependence, and low social status
are far from inevitable and within society’s power to change (Asch 1989).
According to this socially constructed view, there is no fact of the

matter about the harms of disabilities that cannot be altered by social
circumstances. Persons with ASD will hold that it is within the power of
the neurotypical to stop discriminating against and making prohibitive the
form of life of the neurodiverse. The neurotypical form of life is
inhospitable, and downright hostile, to persons with ASD by always
demanding that they make eye contact, for example. Neurotypicals who
don’t recognize the burning discomfort some neurodiverse feel when
having to make eye-contact are contributing to the problem when they
dismiss the inability to make eye contact as insignificant (Gernsbacher, M.
A., & Frymiare, J. L., 2005).
However, it is not merely the activities of daily life that may seem to
be stacked in favor of the neurotypical. The neurodiverse will go further,
claiming that philosophical conceptions are socially constructed in a way
that is unfairly biased against the neurodiverse. For example, respect for
autonomy is an essential component of contemporary bioethics, and a
proper analysis of the concept of autonomy is central to most bioethics

discussions. Persons who live in group homes because they cannot pay
their bills on their own, or cook their own food, are viewed as having
compromised autonomy. But persons who pay an accountant to do their
taxes are not viewed as lacking autonomy. The neurodiverse may ask why
they are perceived as lacking autonomy, whereas the neurotypicals who
cannot fill out a 1040 without help are nonetheless “autonomous.” The
deck is stacked in favor of the neurotypicals, by the neurotypicals. Rather
than capitulating to a cure for ASDs, the neurodiverse will say that the
neurotypicals should change their conception of the neurodiverse to
recognize that they no more require a “cure” than do those who cannot do
their taxes.
Conclusion
A great deal rests on bridging the divide between the neurodiverse and
the neurotypicals who disagree whether or not autism should be cured.
The decision to cure or not has an impact on health care resources,
families’ time and efforts, and the possible infringement of a right of the
neurodiverse to be left alone without being changed without consent.
Barnes and McCabe (2011) were correct to engage the arguments for and
against curing autism head-on. This chapter attempted to go a step further,
and explain why the debate among the neurodiverse and the neurotypical
exists in the first place.
Three explanations may account for an ethical divide among the
neurotypical and the neurodiverse, but many unanswered questions

remain. While the “lack of a common moral theory” is not the strongest
reason for the ethical divide among the neurodiverse and the neurotypical,
it appears that the “lack of a common language” theory is open to even
more serious objections. The “competing conceptions of disease,
impairment, malady, or disability” may best account for the divide;
however, each competing conception offers a different explanation of the
disagreement among the neurodiverse and neurotypical as to whether
autism should be cured. It is unsettled which of these competing
conceptions is correct. Perhaps the disagreement among the neurodiverse
and the neurotypical is genuinely over-determined. Until a common
understanding can be reached, the neurodiverse and the neurotypical will
still be talking across an ethical divide.
144 Chapter Eight
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—. ( 2007b). Special theme: Neurodiversity. Journal of Ethics in Mental
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understanding in children with autism. Autism 9(3),pp. 317-331.
Hacking, I. (2009). How have we been learning to talk about autism: A
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26(25), pp. 236-241.
Shoemaker, D. (2007). Moral address, moral responsibility, and the
boundaries of the moral community. Ethics 118, October, pp. 70-108.
CHAPTER NINE
WHO’S COUNTING?
COGNITIVE DISABILITY
AND RAWLSIAN CONTRACTUALISM
CHRISTOPHER MESAROS
Andrew is, by the standards of most contemporary societies, an adult

citizen. He has relatively modest hopes and dreams, including higher
education and gainful employment. He wishes to be surrounded by those
who love and care for him. Fears, desires, loves and hates are all part of
Andrew’s world, and he is perfectly capable of expressing a need to fit
in—to be treated as normal. Unfortunately for Andrew, he does not fit in.
Andrew has a severe emotional disability and requires intensive
counseling, structure, and medication to help him avoid violent outbursts
that quite frequently harm those he cares most about, and even then he is
unable to engage with society in a fully cooperative manner.
Individuals like Andrew pose a distinctive challenge for theories of

justice. Many of us have the intuition that if someone like Andrew can
hold employment, seek education, pay taxes, vote, and contribute to the
basic structure of society, then that person is a subject of considerations of
justice. Because John Rawls did not specifically address how his theory
might accommodate considerations about these outliers, Rawls has come
under frequent fire from opponents of contractualism who suggest that
care ethics (cf Eva Feder Kittay), capabilities approaches (cf Martha
Nussbaum), or other such theories are better able to account for our
intuition about individuals such as Andrew.
In this paper I will explore what I take to be the pressure points in
Rawls’s own work that open him up to criticism. I will also offer a
Rawlsian revision and explain how it meets certain desiderata that I will
supply for any theory that wishes to be inclusive of the disabled. As a note
of caution, I will use the term “disabled” as shorthand for “severely
cognitively disabled” from hereon, though I recognize that this term can
Who’s Counting? Cognitive Disability and Rawlsian Contractualism 147
range over large and diverse groups of individuals who have the potential
to exercise the two moral powers. I will also generally be referring to the
severely cognitively disabled unless noted otherwise. As far as I can tell,
the only uniform rubric for what we mean when we use the term “severe”
seems to be qualitative, in that it is a placeholder for something “like lack
of sufficient faculties that would make the individual an agent, a person, a
cooperator, etc.” I will begin with problematic features of Rawls’s own
theory and what he says regarding the disabled.
Rawls, the Disabled, and Their Moral Standing

The most pressing question when discussing whether or not Rawls can
be inclusive of the disabled is to ask why this is even a worry. Suffice it to
say, others, notably Martha Nussbaum, have elaborated the concern as
well (See e.g. Frontiers of Justice), so I shall give a brief explication to
motivate the worry. Despite my arguments, it is still open to Rawls to bite
the bullet and reject the disabled as a subject of distributive justice, though
I will show why this would be unadvisable and perhaps unnecessary for a
Rawlsian.
I have already suggested that our intuitions about the disabled will
point towards inclusion of them in theories of justice, and this appeal is
grounded in the contributions made by the disabled in actual societies.
Some will argue that the disabled make contributions to the basic structure
by enhancing relations within the family and providing diversity within the
educational system (for an excellent argument on these fronts, see Christie
Hartley’s “An Inclusive Contractualism”). Care ethicists will highlight the

dependence relation between the disabled and caregivers and capabilities
theorists will insist that we should foster the capacities that the disabled
already possess rather than condemning them for those they lack. For
Rawls to bite the bullet in this case would be to treat the contributions of
the disabled as insufficient for consideration in ideal theory, and it is not
clear he would endorse such a concession.
Even if a skeptic agreed that the contributions of the disabled are
sufficient for meriting political consideration, they may still not see this as
a problem for Rawls per se. After all, Rawls can ask that we consider the
possibility of becoming disabled when forming the principles of justice
and the laws of our society. I see four pressure points in Rawls’s theory,
namely: (1) the two moral powers; (2) the original position device (OP);
(3) the primary goods; and (4) the social bases of self-respect. I will
address them in order to show why inclusion of the disabled within the
scope of the principles of justice is a problem for Rawls.
148 Chapter Nine
The Two Moral Powers

The two moral powers are first, the ability to form, revise and pursue
one’s own conception of the good—i.e. the capacity for ‘rationality’—and
second, the capacity for a sense of right and justice—i.e. the capacity for
‘reasonableness’ (See e.g. Political Liberalism Lecture VIII, §3). Of the
former, Rawls notes:
[A] rational person is thought to have a coherent set of preferences
between the options open to him. He ranks these options according to how
well they further his purposes; he follows the plan which will satisfy more
of his desires rather than less, and which has the greater chance of being
successfully executed (Rawls, 1971, 143).
The cognitively disabled are often regarded as paradigmatically

irrational, though I will challenge this assumption. In the Rawls’s abstract
procedure, reasonableness is modeled by the OP itself and the constraints
therein. Without the capacity to exercise the two moral powers, one is not
a candidate for representation in the OP. This means that it is conceivable
that one would not be considered when the principles of justice are being
chosen and, for Rawls, one does not have a say at the constitutional
convention stage, which is where more concrete laws of the society are
determined via the formation of a constitution. This process will require
brief elaboration.
Rawls envisions a four-stage procedure with the first stage being the
most abstract, and hence with the ‘veil of ignorance’ fully shrouding data
that would bias the parties—this includes knowledge about their socio-
biological features, comprehensive doctrines they endorse (e.g. religious

views), and more general features of the sort of society in which they
reside. In the first stage, the parties select the principles of justice, which
are the foundation for all laws and institutions within their given society.
As the thought experiment proceeds, the veil is gradually lifted, allowing
for more and more concrete information about whom the parties represent
and what sort of a society they live in, as well as other information
pertinent to structuring institutions. Quickly, stage two is where the parties
select their constitution, stage three is where they choose laws, and stage
four is where they agree upon standards for applications of said laws.
Given that the principles of justice set the stage, so to speak, for the
structure of society, it is here where Rawls’s arguments in favor of justice
as fairness and against utilitarianism are most important and most
vulnerable.1
Returning to the discussion at hand, the two moral powers are meant to
provide a conception of agency that most human beings will meet at some
point in their lives. The sorts of individuals lacking in the two moral
powers are young children, elderly persons with diminished cognitive
faculties, those whose unreasonable doctrines (e.g. religious fundamentalists)
or conceptions of the good inhibit or prevent the development or exercise
of their capacity for a sense of justice, and the severely cognitively
disabled. It is significant that of this group of outliers, the disabled are the
only ones that are incapable of having the two moral powers, as all of the
rest have them, had them at one point, or will potentially develop them.
Another outlier group that share permanent lack of the moral powers
would be non-human animals, and while there is much that could be said
here, I will not be concerned to discuss Rawls and animals in this paper.
Returning to Andrew, we can see how the two moral powers may not
necessarily be an all or nothing package. For someone with a behavioral
disability:
The behavioral characteristics of emotional disturbance include an inability
to learn, an inability to build or maintain satisfactory interpersonal
relationships, inappropriate types of behavior or feelings, a general
pervasive mood of unhappiness or depression, and a tendency to develop
physical symptoms or fears (Ysseldyke, 2006, 12).
This means the complications of emotional disorders can prevent the

individual from having a sense of justice that recognizes the rights of
others when those rights would conflict with the goals of said individual.
In addition, “Perhaps more than for any other category of special
education, emotional disturbance has a definition that leaves much room

for subjectivity and confusion (Ysseldyke, 2006, 8).” The labels of
disabilities can give us a loose rubric for understanding who may or may
not have the two moral powers, yet precision in delineating moral faculties
will always be lacking as a result of the variety of mitigating factors that
play a role in development and diagnosis.2 Because the two moral powers
are necessary for personhood on Rawls’s schema, someone like Andrew
will fall outside the scope of justice as fairness as a political conception
due to his unreasonableness, despite the fact that he seems rational in
Rawls’s sense.3 He may be able to form, revise, and pursue a conception
of the good, but this does not entail his respecting the rights of others to do
so.
150 Chapter Nine
The Original Position

The OP is Rawls’s hypothetical social contract where parties
representing citizens select the principles of justice for their society by
identifying principles that are justifiable to all and without endorsing one
specific reasonable conception of the good. The minimum standard for
representation via the OP is possession of the two moral powers
mentioned above. Representatives in the OP are behind the veil of
ignorance, which is meant to abstract away from characteristics that would
unduly bias them towards certain principles of justice. However, the
parties in the OP know that the people whom they represent are not
severely disabled, as they know the citizens they represent have the two
moral powers.
Rawls is aware of the challenge that this segment of the population
presents for theories of justice, as he makes mention of this segment in
both A Theory of Justice and Political Liberalism (Rawls, 1971, 249;
1993, 21). He is also aware that employing a standard that requires even
minimum faculties for expressing rationality and reasonableness means
that certain human beings will not necessarily merit consideration in the
OP on his account, noting, “since we have assumed…that persons are
normal and fully cooperating members of society over a complete life, and
so have the requisite capacities for assuming that role, there is the question
of what is owed to those who fail to meet this condition…I very much
doubt whether [answers are] possible within the scope of justice as
fairness as a political conception” (Rawls, 1993, 21). He makes it explicit
that where agents in the OP recognize that their faculties would be limited
they would choose principles of paternalism to protect their own interests.

This is worth examining in detail:
But once the ideal conception is chosen, they will want to insure
themselves against the possibility that their powers are undeveloped and
they cannot rationally advance their interests…as in the case of those
seriously injured or mentally disturbed…For these cases the parties adopt
principles stipulating when others are authorized to act in their behalf and
to override their present wishes if necessary…Thus the principles of
paternalism are those that the parties would acknowledge in the original
position to protect themselves against the weakness and infirmities of their
reason and will in society (Rawls, 1971, 249).
Rawls goes on to note that the decisions to be made in these cases are
ones that promote the development of the two moral powers. We should
make choices for disabled individuals from the standpoint of the OP and in
a way that we could justify these choices to the individual should they
regain or develop the capacity to be rational and reasonable. This

definition of paternalism takes for granted that the only way for one to be
disqualified from representation in the OP is a lack of the capacity for
rationality, something that does not apply to Andrew. Taking away
rational choices from a rational individual would only frustrate their aims
even further and depreciate the capacities that they do possess. I return to
paternalism in the following section, but we must first lay out the final two
elements of Rawls’s machinery for identifying the principles of justice in
order to see the critique in full.
The Primary Goods

The primary goods for Rawls are the universal means for exercising
the two moral powers. That is, they are the resources and rights that allow
one to develop one’s own conception of the good and to exercise one’s
sense of justice, and they are based on a normative conception of the
citizen as a fully cooperating member of society (Rawls, 2001, 58). The
five primary goods are: rights and liberties; freedom of movement and
freedom of occupation; powers and responsibility; income and wealth; and
the social bases of self-respect (58). The primary goods are meant to be
“things that every rational man is presumed to want (Rawls, 1971 249).”
Given that the primary goods are meant for agents with a capacity for
the rational formation and pursuit of conceptions of the good and who are
capable of engaging in adequate social cooperation, it is not surprising that
the relevance of these goods would come into question with regards to the
disabled. Rawls’s notion of primary goods simply does not consider the
needs or desires of the disabled, and so we should ask why these goods
would be the right ones for someone like Andrew. Certainly, it may turn
out that there is near or perfect overlap with what a disabled individual
would in fact desire as goods, but given that the goods are meant to be
based on and applicable to only and all rational and reasonable agents,
there is no necessary reason why this would be the case. Rawls’s theory
does not pretend to take into consideration whether these goods are the
right ones for outliers, and in the case of the disabled, it is explicitly not
considering these individuals. After all, rational agents are not able to
comprehend the objective interests of those who are banned from the OP;
it is this variance in cognitive functioning that prohibited the disabled from
representation in the first place.
152 Chapter Nine
Self-Respect
Self-respect plays a crucial role in justice as fairness, as Rawls
frequently mentions it as perhaps the most important primary good. He
mentions the two most important aspects of self-respect as a person’s
sense of his own value and confidence in his ability to fulfill intentions.
Not having self-respect means not valuing one’s projects or not believing
them to be attainable. He says:
It is clear then why self-respect is a primary good. Without it nothing may
seem worth doing, or if some things have value for us, we lack the will to
strive for them…Therefore the parties in the original position would wish
to avoid at almost any cost the social conditions that undermine self-
respect (Rawls, 1971, 440).
That Rawls understands the importance of self-respect suggests that he

must surely recognize the importance of self-respect even for some
individuals who do not meet the threshold for being fully cooperating over
a complete life.
This issue relates back to Andrew and individuals like him that I take
to be capable of self-respect in the way I am reading Rawls. We can
suppose that not being a subject of justice at an ideal stage might be
damaging to Andrew’s self-respect, since he may view his lack of
representation as a slight or a suggestion that his political system does not
value his contributions. If one is rational enough to value a political
system that is inclusive and yet is discounted from said political institution
due to natural deficits, then it is plausible that one would devalue oneself,
one’s political system, or both. To be sure, self-respect seems to be a

natural extension of rationality insofar as one cares about one’s ends and
the means to pursue them. If this is correct, then this means that not
including the disabled in our political systems would do damage to the
self-respect of those disabled individuals capable of rationality.
Paternalism
In discussing the four pressure points, I mentioned above that Rawls’s
own proposal for how we might approach the disabled is to employ
paternalism after the four-stage procedure has been completed.
Unfortunately, this account of paternalism is rather underdeveloped and
leads me to some serious concerns. One worry I have is that it is not clear
exactly how we are supposed to act on the behalf of those whose mental
functioning we cannot pretend to comprehend, including what primary
goods would be most valuable to the disabled, particularly on a general

level. As I have said, the primary goods are developed, after all, as a way
to promote the two moral powers for fully cooperating normal citizens.
Likewise, Rawls would have us safeguard against mental infirmity by
imagining what we might desire should we someday be disabled, yet we
exclude the disabled precisely because they do not think like us. This
means being able to appreciate the desires of the disabled would require
taking a standpoint we cannot possibly occupy, making this significantly
different than the abstract citizens representing the interests of agents akin
to themselves in the OP.
Representation is effective in the OP because the representatives
abstract away from biases to discover universal goods. This cannot be
done in the case of the disabled, since fully rational agents cannot abstract
away from the very faculty by which they achieve abstraction—they
cannot imagine themselves with cognitive faculties so low that they would
lack the very faculty to think abstractly. We are never told how we are
supposed to comprehend all of the objective interests of a group that is so
radically cognitively different from us, even though certainly there are
some interests we share in common.
Three Desiderata of an Inclusive Contractualism

Rawls has suggested that his political conception is likely incapable of
addressing the disabled, though this has not prevented others from
attempting to modify his account to make it inclusive. If one sees this as a
genuine worry and wishes to show how contractualism of a Rawlsian

stripe might be inclusive, I propose three desiderata that a theory needs to
satisfy, and these are borne out of the pressure points I elucidated above.
The three desiderata are an inclusive conception of personhood, a method
for determining the objective interests of the disabled, and an applicable
account of primary goods. I will discuss them in order, including the
limitations of attaining such features.
An Inclusive Conception of Personhood

If our theories of justice are meant only to apply to persons, then
having an appropriate conception of what it is to be a person will be
critical the understanding who are the subjects of justice. Some candidate
considerations are IQ, moral standing, species, and ability to contribute.
Saying that some being is a person only if it is a human being seems
improbable if our focus is on contributions to the basic structure of
154 Chapter Nine
society, since this would mean that coma patients or anencephalic infants
count as persons despite their obvious inability to contribute. Given these
limiting cases, we should eliminate that option immediately. The other
considerations require some analysis.
It is possible to adopt a definition of personhood that makes use of IQ,
but I have already supplied an argument against this suggestion. For the
disabled, IQ measurements present a host of complications that could
artificially deflate their performance: disabilities may inhibit focus and
concentration; individuals may test highly in one area while lacking in
many others; and testing requires an ability to communicate effectively in
response to the test, which is simply not possible for some due to certain
cognitive limitations. While IQ measurements may give us precise
boundaries, the cost of the precision is exclusion of individuals who make
important contributions yet who nonetheless test poorly. As they stand, IQ
tests cannot tell us anything important about whether or not an individual
is a subject of justice, and so we should be suspicious of any normative
account that employs this empirical notion, even in part.
Another option open is to employ a certain minimum standard of moral
faculty. For Rawls, this standard is the valuing of one’s own projects and
the recognition of the right of others to value and pursue their own projects
(i.e. a capacity to be ‘rational’ and ‘reasonable’). While we might think
these qualities are valuable in those who determine principles of justice
and set policy, if the principles and policies focus only on individuals with
such moral functioning, then we run head on into my worries elucidated
above. However, I am not rejecting Rawls’s standard wholesale. As a
device for achieving agreement on principles of justice, the two moral
powers are highly apt, and so I think we should not throw the baby out
with the bathwater. Moral faculty has some place in an inclusive
conception, for example when determining principles of justice.
A final candidate consideration is contributions made by the disabled.
These contributions might be labor, taxes, voting, etc., though they need
not be. Rawls says:
Our topic…is that of social justice. For us the primary subject of justice is
the basic structure of society, or more exactly, the way in which the major
social institutions distribute fundamental rights and duties and determine
the division of advantages from social cooperation (Rawls, 1971, 7).
He goes on to list the major institutions as those that protect freedom of

thought and liberty of conscience, competitive markets, private property in
the means of production, and the monogamous family. Thus, an inclusive
conception of personhood should recognize contributions to all of these
elements of the basic structure of society. One need not be employed or

otherwise participate in the political process in order to make contributions
to the family, for example. Contributions will be an essential element of
any inclusive conception of personhood when our concern is justice.
The Objective Interests of the Disabled

An inclusive discussion of what goods are necessary for the flourishing
of persons is one of the most challenging aspects of any theory of justice.
The complications of compiling such a list are compounded by the
boundaries of communication and the variable valuations between
individuals with and without disabilities. The problem here is how to
understand the objective interests of the disabled when we face an
empirical difficulty of bridging cognitive and linguistic gaps. Still, it
would not do to leave this an open question since we cannot expect laws
and constitutions to be formulated without understanding what goods are
of value for the pursuit of reasonable comprehensive doctrines, including
those of the disabled. Hence, this problem is inextricably bound to the
problem of an inclusive account of primary goods.
Goods Primary to All

I have little more to say here than that an inclusive account needs a
way to understand what goods are valuable to the disabled and what goods
we can rightly declare to be primary. If it ends up being the case that we
all value the same primary goods, then we owe an explanation as to why
this is so. If, on the other hand, we determine that something like freedom
of religion is not primary when we consider an inclusive conception of
personhood, then we need to be able to distinguish between goods
valuable to some versus valuable to all. Of course, we are not looking for a
list of goods that are valuable to each and every individual given their
subjective interests, rather we want to know what goods are the subject of
justice and why.
Stepping Back
I have been arguing that Rawls’s theory as it stands faces considerable
worries and that it must be amended in some form in order to accommodate
the disabled. I gave three desiderata that Rawls would need to satisfy, and
I have not yet said whether these can be met via a Rawslian framework.
However, there is still the option for Rawls to bite the bullet and deny that
156 Chapter Nine
we need to address the disabled as subjects of justice. I owe the reader an

explanation as to why I think this would be an unappealing option.
It should be noted that the number of philosophers who view this as a
legitimate problem for theories of justice (as opposed to a problem for
ethical theories) is still relatively small, despite recent growth. While
presenting hard practical cases in response to abstract theories might be
somewhat unfair, it is not entirely surprising that philosophers would
recognize the importance of assuring just treatment for this historically
marginalized population. Humankind as a collective has never suffered
from a surfeit of concern for those whose cognitive impairments prevent
“normal” functioning, and I submit the following as examples of how
justice has failed the disabled.
In Nazi Germany the forced sterilization and eventual euthanizing of
the mentally disabled was the precursor to the extermination of other
groups perceived as genetically impure. The “Law for the Prevention of
Progeny with Hereditary Diseases,” culminated in the following:
On August 18, 1939, the Reich Ministry of the Interior circulated a decree
compelling all physicians, nurses, and midwives to report newborn infants
and children under the age of three who showed signs of severe mental or
physical disability. At first only infants and toddlers were incorporated in
the effort, but eventually juveniles up to 17 years of age were also killed.
Conservative estimates suggest that at least 5,000 physically and mentally
disabled children were murdered through starvation or lethal overdose of
medication (Heberer, 2011).
In China, homosexuality was classified as a mental illness until the

year 2000, and accusing political opponents of being mentally unstable is

still an expedient way to lock up seditionists and keep them out of the
public eye. Women who remained unmarried were also subject to
confinement under the presumption that something must be awry with
their cognitive faculties (Yanhai, 2011). What this says about perceptions
of the mentally ill is that they must somehow exist on the margins of
society, and the solution to this problem is incarceration and isolation.
However, 21st century communist China and 20th century Nazi Germany
are far from being paradigmatic liberal democracies, and hence not
entirely relevant to Rawls’s focus.
The Western world has seen peaks and valleys in its treatment of the
mentally disabled. Asylums were commonplace prior to the 19th century,
and devices like the Utica Crib (a horizontal wooden adult-sized crib with
a hinged top that restricted the movements of patient to the supine position
and little else) were used to literally cage disabled citizens in both France
and the United States. While advances in care and attitudes improved after
this point, the compassionate approach of the 19th century backslid for
several reasons including—importantly—lack of resources such as
facilities, funding, and staff. Both electroconvulsive therapy and sedation
have been and continue to be used in contemporary America, and both
remain sources of controversy. A similar firestorm of controversy rages on
regarding the use of restraint and seclusion, both of which are the subject
of a recent Education Department report that mentions the use of duct tape
to mechanically restrain preschool aged children and one case of a woman
in Kentucky who found her autistic son stuffed in a canvas duffel bag in
his school’s hallway (Hefling, 2012).
Suffice it to say, treatment of the disabled in democracies as a whole
has been generally better than in other political systems and is trending
upward, yet there is no reason to think that each liberal democracy—which
is Rawls’s focus—would necessarily be preferable to, say, a Communist or
Socialist society for someone with mental disabilities. Even where
resources are devoted, care in the United States has the possibility for
regrettable abuses. In this regard, I agree with Eva Kittay that the caregiver
profession is grievously undervalued (Kitay, 2001, 575) and one must
wonder how commonplace these dehumanizing cases would be were
caregivers held in as high esteem as, say, nurses or compensated as well as
other healthcare providers.
The point here is to highlight the reason that justice for the disabled
should be of such concern to political philosophers. Of course, none of this
shows that our concern for the disabled should be a matter of justice rather
than a duty of benevolence, yet it is clear that those goods that are most
often a matter of justice have historically been denied to most disabled
individuals. If we take the principles of justice seriously for a liberal

democracy, then something must be done to rectify the situation, unless of
course the disabled do not merit such considerations. Though, this
dichotomy ignores a third option.
A way that Rawls might bite the bullet, as I have mentioned, is to say
that our treatment of the disabled is a moral concern, and while we have
certain obligations towards them, they are not obligations of justice. This
reply would say something like we have a duty of benevolence whereby
our relation to the disabled (familial, communal, whatever) is what
obligates us to ensure minimum standards of functioning and quality of
life.
While I do not doubt that we have some moral obligation towards the
disabled for the very same reason we have obligations to other human
beings, it is unclear to me exactly how we pull apart justice and morality
in this regard and how the moral distribution of goods (whatever this
158 Chapter Nine
would mean) for the disabled would not fall under the purview of
distributive justice.4 One could compellingly argue that parents have duties
to their disabled children, for example, but this does not explain how we as
a society regard orphaned children with disabilities. If the duty is more
general, such that we are indeed concerned to ensure a minimum standard
of living for all individuals with disabilities, and the goods being
distributed are those that any individual would require for subsistence in
society, then the only difference between one’s being a subject of justice
versus being a subject of morality is the terms involved. Morality would
either be playing the role of justice by distributing goods and structuring
laws, or it would play a less compelling normative role where we say how
we ought to treat the disabled without guaranteeing such treatment. The
former makes morality’s role redundant with that of justice and the latter
raises the question of how we compel just treatment for the disabled if not
through laws and legislatures.
The OP device is the vehicle by which we provide goods and
determine principles of justice for Rawls, and these goods range from
access to employment, to education, to protections under the law. An
alternative or ex post facto moral account would presumably distribute
many of these same resources (though perhaps not an identical set),
otherwise the disabled would be left without vital goods and services. But
if this is the case, then the distribution of goods is not merely political after
all. We might be able to say that the justification of the distribution for the
disabled is now based on moral reasons, but the fact is that we are
distributing goods that are the concern of justice. In addition, justifying the
distribution of goods on moral grounds and not because of the
contributions being made turns the disabled into charity cases and
devalues their participation. As Elizabeth Anderson says, “Self-respecting
citizens would reject a society based on principles that treat them as
inferiors, even if the principles are kept secret” (Anderson, 1999, 306). To
be satisfied with a moral account for the distribution of goods is to ignore
Andrew’s labor, love, and self-respect.
Proposed Modifications and Their Shortcomings

For one sympathetic to Rawls’s account, as I find myself, there are any
number of ways to attempt a modified Rawlsian contractualism that would
be inclusive of the disabled. I will present three such modifications that
achieve varying degrees of success and in each case show what I think the
view gets right and where it goes wrong. Examining these views will
allow us to build an account of certain desiderata that any inclusive

political theory should satisfy.
Stark and the Constitutional Convention Amendment

Nussbaum worries, I believe correctly, that the disabled having no
voice in the OP should be cause for concern, since the foundations of
justice are fully laid out before considerations of the disabled come into
play. Cynthia Stark has attempted to resolve this as follows:
My proposal is to retain the fully cooperating assumption in the original
position but to drop it at the conventional stage of the theory. Ideal
constitutional conventioneers should imagine that they might be disabled in
a way that prevents them from participating in a scheme of cooperation and
should fashion the constitutional provision for the social minimum with
this possibility in mind (Stark, 2007, 138).
The benefit of this account is that it secures a basic minimum for the
disabled as a matter of justice—something Rawls does not explicitly
accomplish. This also alleviates some concerns about the principles of
justice being chosen without considering the disabled, though not entirely.
While Stark’s suggestion may address worries about providing goods
for the disabled, we would still require either justification for Rawls’s
goods or a separate account of goods for the disabled, given that Rawls’s
own primary goods are contingent on a definition of personhood not
attainable by the disabled. It also fails to capture self-respect—something
that Rawls acknowledged as essential for citizens. Namely, it ignores the
self-respect of not only individuals with severe disabilities, but also those
citizens with familial connections to these individuals by still discounting
the value of their loved ones in the political process, since they still lack
representation at the most crucial stage of the procedure. That is, if self-
respect involves valuing one’s political system and the freedom of its
citizens, then seeing one’s family member who could potentially make
contributions to society treated in a less than equal manner due purely to
their natural deficits would plausibly cause one to value the fairness of
their society less, and hence damage their self-respect. In effect, Stark’s
amendment merely pushes the problem down a level without addressing
serious worries about the contributions and status of the disabled.
It is possible that Stark is worried only with those individuals that
would never be able to make contributions to the basic structure,
regardless of advances in medicine or appropriate therapy. If this is the
class of human beings with whom she is concerned, then she and I are
160 Chapter Nine
talking past one another, since I am focusing on individuals who have the
capacity to both contribute and potentially develop the two moral powers
given proper consideration. However, this would mean that she has
nothing to say about individuals like Andrew and the entire spectrum of
disabled individuals between those with the two moral powers and those
who could never develop them. I am reading her description of those who
cannot participate in a scheme of cooperation as referring to those who
may be able to contribute and yet may not be able to cooperate to a
sufficient degree. If her account is targeting individuals who could never
make contributions to a scheme of cooperation, then this makes the
amendment even more restricted in scope, and so I will read her as
focusing on the same sorts of disabled individuals with whom I am
currently concerned.
Rawls stipulates that the representatives are fully rational throughout
the four-stage procedure, and this would hold true for the constitutional
convention stage where despite the fact that the veil of ignorance is lifted
to some extent and the procedure becomes less abstract, the parties are still
imagined as fully rational. The OP, wherein the two principles are chosen,
informs the entirety of the process from thereon. By the time Stark’s
amendment comes into play, representatives would have already made
decisions that would significantly impact the formation of society by
selecting the principles of justice. Thus, it seems that even if we allow for
representation in the conventional stage, we are still doing a disservice to
the self-respect of the disabled, so long as they are not allowed to have a
voice in the OP.
While Stark’s modification does overcome certain concerns, including
a lack of treatment of the disabled within the scope of justice, it does not
satisfy all of the desiderata I have supplied, and hence falls victim to
worries similar to those I raised against Rawls. There is on this
modification at least some attempt to address goods that would be primary
for all by virtue of the fact that parties consider the interests of the disabled
at the convention stage. However, there is no obvious attempt at an
inclusive account of personhood, since this modification does more to
protect the interests of citizens with the two moral powers than it does to
consider seriously the contributions and self-respect of those with
disabilities. Concordantly, lack of representation in the OP means that
fundamental tenets of the political system are being selected without ever
considering the disabled, and by the time the parties reach the
constitutional convention stage, these principles are merely being applied,
regardless of whether they are the correct principles for all.
Wong and the Disability Continuum

To revisit the issue of self-respect, a confounding variable that both
Nussbaum and Sophia Wong (2008) have emphasized is the fact that
disability occurs on a continuum. That there are so many types and
degrees of disability means that there are many who will not qualify for
representation in the OP for Rawls. Nonetheless, these individuals may
possess some capabilities he describes as essential to being liberal
democratic citizens. As I mentioned above, the two moral powers are not a
total package wherein a person is either born with the capacity to develop
both or with no capacities whatsoever. In reality, there are many disabled
persons who arguably fall below Rawls’s threshold for citizenship due to
their irrationality or unreasonableness, yet contribute to the basic structure
of society through employment, voting (depending on local laws), taxes,
family relations and so on. Likewise, there are persons who have the two
moral powers, yet are unable to work, just as there are some who have
only one of the two moral powers.5 If justice is a matter of sheer capacity
for reflective cooperation and rational goal-setting, then many human
beings fall outside the scope of this account besides the archetypical
“severely mentally disabled” or anencephalic infant. There is no reason to
assume that all of these non-citizens are devoid of the capacity for self-
respect, unless that term is inextricably bound to having both of the two
moral powers.
In trying to reconcile their lack of moral powers with our intuitions
about the political rights of the disabled, Wong makes the case (though not
explicitly as I will outline it here) that basing the primary goods on the
development of the two moral powers still holds for the disabled when we
focus on their potential. It is an empirical question, she argues, whether or
not an individual has these faculties but is unable to communicate them
sufficiently (as with her many examples of individuals who are
misdiagnosed or misunderstood), or does not currently have the faculties
but may one day develop them to a degree appreciable by fellow citizens
and thus qualify as rational for Rawls. Individuals with cognitive deficits
may require greater resources for the development of the two moral
powers, yet this is a case for why they should receive a greater distribution
of primary goods, not an argument as to why we should not focus on the
moral powers to begin with or assume that they are discounted from
consideration in the OP, she claims.
Wong laments the prevalence of misunderstandings about the nature of
the disabled and how varied cognitive deficits can be, yet she seems to
ignore the fact that humans can lack rationality, reasonableness (as with
162 Chapter Nine
Andrew), or both. Persons with emotional impairments or mental illness

(e.g. psychopaths) are quite capable of knowing what their conception of
the good is, what means will get them there, are and how to make the
necessary conditions obtain. In fact, they present as paradigms of
normalcy with the exception of their unreasonableness. What is lacking for
these individuals is the ability to cooperate and recognize the rights of
others. An account that says simply providing the means to rationality is
sufficient fails to understand the nature of this deficit and assumes some
fact about human nature generally, namely that humans are intrinsically
reasonable, provided they have the capacity for rationality. It may be
correct that Andrew could potentially develop fully both of the two moral
powers, yet goods such as education and employment will not do the work
of overcoming his unreasonableness.
Wong’s account fares better than did Stark’s when it comes to my
three desiderata, yet her shortsightedness on the range of disabilities
means this amendment also comes up short. We now have a more
inclusive account of personhood where the disabled are viewed as
potentially fully cooperating citizens. However, without recognizing the
full range of possible disabilities we cannot give an adequate account of
primary goods. We still need an account that can make sense of someone
like Andrew and how he will fit into an inclusive account, and with a
greater focus on health care we can move in the right direction.
Daniels, Health Care, and Normalization

Norman Daniels has also defended Rawls’s account, but from a

different vantage point and with a strict endorsement of normalizing as the
right thing to do. He says:
By promoting normal functioning for a population, comprehensive health
care—as well as social institutions and goods aimed at maintaining
population health—make a significant, but limited, contribution to the
protection of fair equality of opportunity (Daniels, 2003, 257).
The argument Daniels presents seems to be that if we normalize the

disabled to the maximum extent, then we increase the scope of justice as
fairness to cover the needs of the disabled without having to fret about
differing accounts of liberties or primary goods. Daniels’s suggestion may
alleviate concerns about the emotionally impaired, in that medication,
therapy, and behavior modification may be the best means to helping these
individuals achieve the closest approximation to being normal and fully
cooperating persons over a complete life.
Daniels concomitantly suggests that maximizing the range of choices

via health care is the superior option. He notes:
Disabilities…require “reasonable accommodation” by society, both in the
workplace and elsewhere, to create an environment in which the
opportunity range of the person with disabilities is reasonably protected
(Daniels, 2003, 258).
This account allows for health care to “prevent and treat disease or
disability and other uses, for example, to enhance otherwise normal traits,”
with the caveat that these disabilities must be publicly recognizable (258-
9). The publicity condition, I take it, is meant to fend off claims of illness
that cannot be diagnosed or are not commonly recognized, e.g. being a
“sex addict.”
Daniels’s account has appeal to me, but just as did Wong’s, I believe it
misses the mark to some degree and undermines Rawls’s own account.
The project of normalization requires much more from citizens than justice
as fairness asks; it places a great deal of economic and social burden on
society in order that the disabled develop traits that may never come to
fruition. An objection to normalization where ideal citizenship is held as
the norm for all agents is that it may violate the strains of commitment for
those shouldering the costs. The economic burden on the “normal” citizens
would be quite large, if contemporary health care and education costs are
any indication: special and regular education programs costs were in
excess of $77 billion for 1999-2000 in the United States alone (“What Are
We Spending on Special Education Services in the United States”). The
disabled often require not only technology but also human assistance to
perform even the most basic functional tasks. One might think that a
society would have to be quite wealthy in order that all citizens assent to
the sort of investments that would be requisite for even the most basic
assistive technology across the board.
Of course, someone like Daniels might insist that the funding be
proportional to the wealth of the society and of course we could not
bankrupt the many for the gains of a few individuals. This also seems to
me a mistaken line of argument without an inclusive conception of
personhood precisely because justice for the disabled is then proportional
to the wealth of society and, unlike for the least advantaged, we could
conceivably have a just liberal democratic society that is economically
able to provide a minimum standard for its cooperating members yet
provides nothing for the disabled. Hence, a society lacking an inclusive
conception of personhood has the potential to be one where the disabled
164 Chapter Nine
are not regarded as a matter of justice at all, which puts us back at the
initial concern of completely discounting the disabled.
There are at least two potential ways for Daniels to avoid the worry
mentioned above. The first is to suggest that society would provide a
minimum amount of goods necessary for survival as a matter of moral
obligation that we have towards the disabled, regardless of the wealth of
such a society. However, this would mean that the modification does not
address concerns about the disabled internal to the system of justice, and
we are back where we started with an unmodified Rawlsian system. The
second way to avoid the worry is to say that society would provide such a
minimum standard as a matter of justice, perhaps by regarding the disabled
as amongst the least advantaged. I think this would be the right way of
responding to the challenge, but it is not clear to me that Daniels has this
sort of a response at his disposal, since the disabled are not regarded as
citizens in the OP and we would need additional machinery for this
account in order that they are counted as such. I will make a case for this
below.
Daniels has come the closest of all the modifications I have examined
to giving us a satisfactory account, but I have argued that simply providing
access to health care will not be sufficient. While it might be the case that
this would meet the standards for goods primary to all and also address
worries about someone like Andrew whose position may be significantly
improved with proper health care, we still lack an inclusive account of
personhood. This means that Daniels cannot yet count the disabled
amongst the least advantaged, and hence does not have the theoretical
framework in place to indemnify them against unbearable conditions.
The problems that I have elucidated for the modifications of Rawls

include violations of the strains of commitment for the cooperating
members, disregard for the complexity of the disabled as a group, and an
inability to reconcile Rawlsian contractualism with our intuitions about
political rights for the disabled in contemporary democracies. These
problems resulted from an overburdening society’s resources in the pursuit
of normalization, a lack of recognition that the disabled can have some
faculties allowing for self-respect and a conception of the good, and a lack
of clarity about why the goods and political rights we grant the disabled
would be the correct ones. Some of these problems may stem from
contractualism itself, but Christie Hartley, sees them as symptoms of
Rawls’s particular variant, insisting the spirit of contractualism allows for
an inclusive theory that abandons the Rawlsian bent (see e.g. “Justice for
the Disabled: A Contractualist Approach.”). I will now turn to Hartley’s
work and propose an inclusive Ralwsian account meant to retain the

appealing features of his work while addressing the concerns of his critics.
Inclusive Contractualism
In the rest of the paper I will present a modification to Rawls’s theory,
drawing heavily on recent work by Christie Hartley, particularly her
suggestion that contribution to any form of the basic structure of society
will suffice for one to be considered a subject of justice, as laid out in “An
Inclusive Contractualism” and elsewhere. As with her account, I will be
addressing those individuals who, though they lack the two moral powers,
may nonetheless be able to develop them through adequate distribution of
goods. I reserve discussion of those individuals wholly incapable of
developing the capacities for rationality and reasonableness for a more
complete account than the one offered here. This modification is meant to
include the majority of disabled individuals and would exclude, for
example, anencephalic infants. My account will be necessarily brief, and I
do not mean to completely address my concerns elucidated above. I intend
for my desiderata for inclusive theories of justice that I have provided to
stand on their own as concerns for any theory, regardless of how
successfully I can amend justice as fairness. That said, I will now offer a
theory for an inclusive Rawlsian contractualism.
While Rawls may be susceptible to worries about the disabled being
excluded, I think that his account has incredible promise for capturing
what an inclusive account should offer. He identifies the importance of the
basic structure, formulates the concept of the primary goods, has a device
for abstracting away from bias, shows the importance of self-respect, and
provides a minimum standard of living for all citizens. What we need is a
way to include the interests and welfare of the disabled in this account, and
I mean the account I provide to function as a plausible amendment to
Rawls’s own work.
Access
In a sense, what should be sought for the disabled is not all that
different from what most persons would want for themselves. Elizabeth
Anderson offers a tripartite conception of individual functioning: as a
human being (the means to one’s biological survival); as an equal
participant (the means to contribute via labor, production, etc.); and as a
citizen. (Anderson, 1999).6 Being a citizen means having access not only
to what we typically view as political rights, such as freedom of speech,
166 Chapter Nine
but also access to civil society. This last point is particularly relevant when
discussing the disabled, so I shall dwell on it for a moment.
Civil society, according to Anderson, includes institutions like public
parks, restaurants, theaters, sports stadiums, airports, schools, hospitals,
and so on. Having the right of being a citizen means not only having
access to these institutions, but also having the right to not feel shame or
exclusion when participating in their use. She says of functioning as a
citizen, “This also entails the social conditions of being accepted by
others, such as the ability to appear in public without shame, and not being
ascribed outcast status” (Anderson, 1999, 318). We can easily imagine
where this might go awry in the public domain: segregated seating;
restrictive access; limited viewing times; inferior facilities; and less
tangible discrimination such as gawking, leers, and derision. Discreet
institutional discrimination (e.g. subtle racist hiring practices), as American
history has shown, can be just as detrimental as overt discrimination.
Access need not guarantee respectful treatment, though this should be a
goal for a liberal democracy. Andrew’s need to feel as though he fits in
should be validated to the extent that he can participate in the same
institutions as others without being the subject of ridicule or being made to
feel like an outcast. This does not suggest that a just society employs
thought police, rather that the system is structured to promote inclusion
and respect in the same way Rawls envisions we promote the development
of the two moral powers, namely through education and socialization.
Access to institutions is important, and it goes a long way towards
addressing my worry about self-respect, but if the access is not extended to
the political domain, then my worry remains. That is to say, so long as the
disabled are denied representation in the political process, including the

structuring of institutions and formulation of laws, their self-respect is
invalidated.
A Modified Veil of Ignorance

An obviously flawed solution to worries about exclusion of the
disabled is to allow for representatives in the OP to be less than rational in
order that the interests of the disabled find representation. For Rawls, this
would be highly problematic since, in order to achieve fairness, we need
principles that all participants can agree upon and that respect various
conceptions of the good. The reason the disabled are excluded in the first
place is that they cannot meet the conditions of rationality and cannot give
assurance against violations of the principles we choose. One potential
solution I will be endorsing is to modify the veil of ignorance such that the
representatives do not know whether they are representing a disabled

citizen or not.7
This modification has several advantages. Because the representatives
would remain purely rational, this would not affect the reasoning of the
parties in the OP in the way that allowing for less than rational parties
could threaten stability. This veil modification would also ease two
concerns: (1) that lack of a voice in their political system would do
damage to the self-respect of at least some disabled individuals, and (2)
that Rawls’s theory offers no consideration of the disabled when
determining the justice of institutions and laws. We satisfy (1) insofar as
having representation in the OP would be analogous to having members of
congress representing one’s interest; knowing that one is represented
means having a voice. The representatives themselves are responsible for
satisfying (2), and this would tie back into (1) since knowing that one is
part of a political system where their conception of the good is taken into
account would contribute to valuing one’s ends and believing them to be
attainable.
This addition is significant because while Rawls’s representatives
behind the unmodified veil know very little about those whom they
represent, they will know that they are not disabled. That is, being a
representative in the OP is contingent on one’s being purely rational and a
representative of citizens with the two moral powers. By modifying the
veil we make it the case that the representatives do not know the moral
standing of the citizens they represent so that it is possible the
representative’s charge could end up being or becoming disabled.
Despite the benefits of such a simple modification, there are several
reasons to reject this modification as the most preferable option available.

One is that it is hard to see why representatives should not also consider
the possibility of the citizen whom they represent having an unreasonable
comprehensive doctrine, in which case this may significantly impact
agreement on principles of justice and determination of the primary goods,
for example. It is possible to say that what separates the two is the
emphasis on potential for contributions, but those with unreasonable
comprehensive doctrines would similarly have such potential. Another
worry is that merely adding the information that one’s representative
would not know the cognitive status of the citizen they represent puts us
back in the position of paternalism. That is, if the fully rational
representatives only know that it is possible that accident or injury might
befall them, they will act in the ways that Rawls proposes we accommodate
the disabled after ideal theory.
168 Chapter Nine
To respond to the first of the objections to this modification, there is a

difference between regarding unreasonable comprehensive doctrine’s as
worthy of consideration in the OP and considering the possibility that one
may need additional goods in order to develop the capacities for the two
moral powers. If we modify the veil in the way that I am proposing, then
we are asking that the representatives consider those individuals whose
cognitive deficits may inhibit their rationality and/or reasonableness. All
that this means is that the representatives would want to allocate additional
goods for individuals of this sort; I am not suggesting that the
representatives endorse irrationality or unreasonableness. Our focus is on
cooperation and contributions. If the primary goods promote the two moral
powers and disabled citizens are capable of developing the two moral
powers, then the veil modification is really just asking that we broaden our
conception of personhood to include those who could potentially develop
the two moral powers. This ends up being a sort of hybrid between Wong
and Daniels’s considerations, with the added emphasis on individuals like
Andrew who require resources beyond the means to exercise rationality.
This modification does not ask representatives to lend equal weight to
unreasonable comprehensive doctrines, though it may be the case that a
consequence of such a modification would be promoting the development
of the capacity for reasonableness in individuals with such unreasonable
doctrines.
The second worry about such a modification was that it does no better
than Rawls’s paternalism where the representatives secure against
irrationality by limiting the choices available to disabled citizens. Tied into
this concern was the idea that from a position of being fully rational, it is
very difficult to appreciate what an individual who lacks the two moral
powers would truly desire. Indeed, one might have trouble appreciating the
value of such a life as even being worth living—fully rational agents may
undervalue a life below Rawls’s threshold where development of even
basic capacities requires great effort and substantial resources. Yet, though
there may be an element of paternalism to even the modified Rawlsian
account, it is not the same as that account employed by Rawls once the
four-stage procedure has been completed. Rawls would have the parties
stipulate when others are authorized to act on their behalf in order to
protect them from themselves. This account would have the parties
consider what goods would help promote the development of their
capacities and respect their ability to contribute to the basic structure.
While both accounts employ a form of paternalism, the veil modification
account does so with the intention of helping the individuals more fully
realize their capacities, and it does so in the OP in order that the disabled
citizens receive representation.
Goods
Rawls’s own account of primary goods is comprehensive and well
thought out to the point that I have been criticizing him by showing how
he fails to guarantee these goods for the disabled. It is of my opinion that
an inclusive account should provide those same primary goods that Rawls
proffers as valuable to rational and reasonable citizens. Again, these goods
include: rights and liberties; freedom of movement and freedom of
occupation; powers and responsibility; income and wealth, and the social
bases of self-respect. However, because the disabled face unique
challenges and because the history of Western democracies has been far
from just in their treatment of the disabled, I will be concerned to highlight
those goods that are of particular value to the disabled.
Even in contemporary democracies, the disabled often lack those basic
human necessities. For example, it is estimated that 20-25% of the
homeless in America have a severe mental illness, as compared with 6%
of the total population, suggesting that the disabled are often the worst off
among us (Mental Illness and Homelessness). Anderson notes that,
“Homelessness—that is having only public dwelling—is a condition of
profound unfreedom” (Anderson, 1999, 318). However, even having
domiciles does not guarantee protections. In 2009 there was a case of
reported abuse where the staff of a school in Corpus Christi, Texas for
adult males with severe disabilities would stage “fight clubs” by goading
the clients into fighting with one another while staff recorded and mocked
the spectacle. Police said twenty such videos were found spanning nearly a
year (Sabo, 2011). Cases like the Kentucky mother and the Texas fight
club point to mistreatment and lack of compassion even where housing
and care are made available. Counting the disabled as citizens would mean
that we would provide at least some bare minimum of support for
nourishment, housing, health care, and so forth, and all of these can easily
fall under the umbrella of Rawls’s goods, so long as the disabled are
accorded the same basic minimum as the least advantaged.
Another set of goods that often escape the disabled are protections by
the state that facilitate biological survival. This would mean not only
protection by law enforcement, but also recognition of the special needs of
the disabled when it comes to policing, e.g. training in psychological
approaches rather than physical. It would also include protection from
abuses in care settings where the disabled are often at their most
170 Chapter Nine
vulnerable, including schools and care facilities. Likewise, other emergency

services, such as medical and fire, would also have training in order to
understand how to approach situations in which the individual might have
a cognitive disability in order that they sufficiently address the needs of
said individual. These protections would go a great distance towards
improving the quality of life of and respect towards the disabled. A
Rawlsian liberal democracy could easily adopt certain policies and
procedures to ensure these liberties for the disabled, so long as they are a
subject of justice when the institutions are formed and laws are chosen.
Employment and education are two goods that are extremely valuable
to many disabled individuals and goods that are often denied or
insufficient. Education seems like an opportunity that we must offer in
order for an individual to have sufficient choices in their life, but what
level of education and what sort of training is difficult to spell out. For
some, post-secondary education will be necessary, but for others
vocational training may suffice. The answer may be as simple as providing
access to all levels should the individual choose to pursue education, even
if some individuals will not have it as a practical option. We need not
adjust those primary goods that would foster the pursuit of one’s
conception of the good merely because it is not valued by an individual or
group of persons. Despite the fact that freedom of movement may not
apply to all citizens’ conception of the good, this not a sufficient reason to
discount it as a primary good. Similarly, though access to positions of
power may be of no use to most severely disabled individuals this does not
speak to its validity as a primary good.
The social bases of self-respect would warrant similar consideration.
Though Andrew may be capable of self-respect, many disabled persons

are not (or at least it is unclear from an empirical perspective). This does
not mean that Rawls’s emphasis on self-respect is wrongheaded simply
because it does not apply to some in an inclusive account. Concordantly, it
may be the case that some individuals have no concern for the right to hold
public office, but this does not mean the right is not foundational to a just
system of government. With the bases for self-respect, it seems clear to me
that they are primary: rejecting them as necessary to a theory would mean
allowing that citizens could live in a society where their goals are always
frustrated and their faith in the just nature of their government is
corrupted. Even if some individuals lack the rational tools for achieving
self-respect, it is a good that is foundational for those that can.
To reiterate, I find that any inclusive account would have to emphasize
a set of primary goods similar or identical to those provided by Rawls.
Leaving any of his set of goods out of discussions of justice runs the risk
of threatening the ability for citizens to pursue their interests (i.e. exercise
their capacity for rationality). For an inclusive Rawlsian account, these
goods are meant to apply to all who contribute to society where
contribution is understood as benefiting the basic structure as a part of the
social community. Though my set of primary goods is identical to those
Rawls provides, this discussion is meant to illustrate that certain basic
goods are often denied to the disabled in contemporary societies which
makes their distribution for the disabled all the more important.
An Additional Argument against a Utilitarian Position

There is an additional argument that an inclusive Rawlsian account can
leverage against the utilitarian when the principles of justice are being
selected by parties in the OP. One of the most potent arguments Rawls has
on hand against the utilitarian is that parties in the OP will recognize that
justice as fairness is the maximin option. That is, when considered from
behind the veil of ignorance where one’s future talents and social standing
cannot be estimated, parties will want to insure against unacceptable
standards of living, and Rawls’s two principles of justice offer the best
worst-case scenario. This will require some more elaboration before we
can see why inclusive contractualism fares even better against utilitarianism
from the standpoint of the OP.
One of the reasons justice as fairness will be the superior option for
parties in the OP is because it offers what Rawls calls the difference
principle. Of Rawls’s two principles of justice, the second one is stated as
follows:
Social and economic inequalities are to satisfy two conditions: first, they
are to be attached to offices and positions open to all under conditions of
fair equality of opportunity; and second, they are to be to the greatest
benefit of the least-advantaged members of society (the difference
principle) (Rawls, 2001, 42-3).
Loosely restated, the difference principle says that any economic

inequalities must be to the greatest benefit of the least advantaged.
Because the parties will not know their socio-economic status in society,
they will prefer principles that provide not only a minimum standard of
living, but ones that also allow for inequalities only when they benefit the
worst off.
I have been arguing that an inclusive Rawlsian account should count
the disabled amongst the least-advantaged members. Though it happens to
be the case that historically this has been true not only as a result of the
172 Chapter Nine
lack of goods accorded to them but also because of their natural

deficiencies and lack of talents, this is not necessarily true of an
unmodified Rawlsian approach. Certainly, it is not the case that all
disabled individuals, regardless of their talents, will be the victims of
economic inequality. However, as their disadvantages are as prevalent, if
not more so than in the general population, it seems at least intuitively
plausible that they should be afforded the same basic minimum as
neurotypical citizens. The reader will remember that it is conceivable that
a moral account of our obligations might distribute goods to the disabled,
but making them a subject of justice will advantage Rawls in a more direct
way.
On the modified veil of ignorance amendment, parties must recognize
that disability is a possibility for those citizens they represent. The way
Rawls addresses this is to say that only after the ideal stage will various
forms of insurance against accident or illness be discussed. This means
that from the standpoint of the OP, there is no accounting for such deficits.
Hence, parties in the OP have nothing to say against a utilitarian argument
when it comes to being disabled; though, they would on a modified
approach.
The worst case scenario for a disabled citizen under some utilitarian
systems of justice is potentially quite horrific. For a classical utilitarian, it
is conceivable that we ought to cull those born with genetic defects, or
even if they are brought to term, their organs would better serve those
without cognitive deficits. We can imagine the old trope about the doctor
with five healthy patients and substitute a disabled individual for the
patient that is in for a routine checkup. This pushes even harder in favor of
a sheer calculation of cost/benefit where the value of one severely disabled

person keeping their organs is heavily outweighed by the value of five
neurotypical individuals receiving badly needed transplants. Of course, a
utilitarian could respond that we have subordinate principles that forbid
those sorts of actions, and these principles so happen to also promote the
greatest happiness. Though, it seems a contingent feature of our society
whether or not we have laws against organ harvesting or eugenics, and
there is no necessary feature of democracies that says these practices
would be outlawed. Besides which, determining via calculation whether or
not happiness would be raised or lowered by a practice limited to a group
that is typically marginalized to begin with is bound to raise more than a
few controversies. Suffice it to say, even in a society where these practices
were not allowed, we can imagine the disabled being shortchanged on all
sorts of goods and rights because it would raise the happiness of the
average citizen, and so the worst case for a disabled citizen would
potentially be even much worse than for cognitively average citizens.
There is still a question of whether or not parties would select
Rawlsian principles when given an option that still provides a basic
minimum for disabled citizens and yet does not maximize the benefit of
the least advantaged.8 For example, consider a utilitarian account that
would not allow for starvation and yet was more cost effective for the
citizens by not allocating resources for the development of the two moral
powers with regards to the disabled. In such a case, we might wonder
whether the parties in the OP would still prefer justice as fairness given the
immense burdens it may require of citizens in contrast with a more
egalitarian utilitarianism that may have a lower standard for the least
advantaged and yet does not ask them to endure an unbearable life with no
basic liberties or rights.
I believe parties in the OP would still prefer the more costly maximin
option in contrast with a utilitarian option that provides a basic minimum.
The representatives would still be behind the veil of ignorance and hence
would not have access to things like probability of having a disability or
becoming disabled. Since the primary goods are meant to apply to citizens
with the two moral powers, representatives would value those goods most
when able to exercise their capacities to a satisfactory level. One might
still have access to goods on a utilitarian scheme that provided a basic
minimum, but without the capacity to utilize such goods, it is hard to see
how they would have value for citizens. Hence, parties would be
concerned to ensure that disabled citizens would be in the best position to
value the goods they were allotted, and this means selecting the modified
veil amendment. In addition, while the economic burden of maximizing

the position of the disabled would be great, parties would be more
concerned with a fair distribution of goods and the ability to value such
goods.
The modified Rawlsian approach allows Rawls to avail himself of the
same reasoning behind the maximin strategy used in the unmodified OP.
From the perspective of parties in the OP, the worst case scenario under a
utilitarian system of justice would be potentially unbearable and certainly
less preferable, and so they would reject these principles in favor of justice
as fairness. This advantage is also unique to this particular modification,
since other modifications fail to consider the disabled or the possibility of
citizens becoming disabled when the principles of justice are being
selected, meaning that this stronger version of the maximin argument are
available to neither these modifications nor the unmodified Rawlsian
contractualism.
174 Chapter Nine
Objections
No Method for Determining Objective Interests
One objection that might be presented with respect to my account is
that I have not satisfied the second of my own three desiderata, namely
that we have a method for determining the objective interests of the
disabled. I will have to offer some defense, though I think there is still a
residual worry.
The first thing to say on my behalf is that, contrary to Rawls’s original
account, we are in a better position on my amended version to determine
the objective interests of the disabled. This is because the representatives
will know certain features of those individuals being represented, namely
that they may be disabled in any of a variety of ways. However, there is
still the cognitive barrier between the representatives and the disabled such
that if we do not have a sufficient means of understanding what goods
would be of value to irrational or unreasonable agents who may still
develop the two moral powers, it can be near impossible to determine what
goods are objectively valued by disabled citizens. We will have to hope
that in making an earnest effort we come close enough. Of course, by
promoting the development of the two moral powers we promote
capacities that would make use of the primary goods being distributed.
The second defense of my account is that we are at least making the
effort to consider what might be primary goods for the disabled. That is to
say, Rawls is open to the worry by virtue of the fact that he fails to even
consider the disabled as citizens, and so we immediately rule out concern
over whether the goods align with their actual interests. My account may
still fall victim to the empirical worry about how we actually know what
goods are the correct ones, but structuring our society in ways that attempt
to appreciate the needs of the disabled will almost necessarily do better at
finding the right goods; this is a response that I believe is open to Hartley
in defense of her own work.
No Way of Making Assurances

One of the virtues of Rawls’s contract is that the rationality of
representatives means they are able to make assurances to each other
against violations. That is to say, they can work together to structure
society such that violations are punished and they do so by employing
their moral powers to create the system of laws. However, representatives
are unable to make assurances for disabled citizens, since they cannot
speak for the future actions of those who are potentially irrational or
unreasonable. Recall Andrew who sincerely wants to fit in, yet cannot stop
himself from doing harm in a fit of rage.
My reply to this objection is to say that while the representatives
cannot give assurances, they can assent to structuring the laws in such a
way that they guarantee respectful and reasonable punishments for
violations by the disabled. I suggested earlier that police should be given
training in order to be sensitive to the special needs of the disabled, and
this would be an example of the function of representatives in the contract
that would give assurances to the other participants that defections will not
be permitted. Representatives in the OP would be able to assent to such
laws because they would uphold the principles of justice, and the disabled
would not be harmed by such laws because they would take into
consideration the limitations of some disabled persons as regards obedience
towards the law.
Conclusion
In this paper I suggested four pressure points of Rawls’s theory that
open him up to criticism by those who insist that the contributions of the
disabled merit consideration within a political conception of justice. I then
gave three desiderata that any inclusive theory would need to address,
which consisted of an inclusive conception of personhood, a method for
determining objective interests, and an accurate list of primary goods. In
the last half of the paper I gave a positive account of an inclusive Rawlsian
contractualism that builds off both Rawls and Hartley, and which
employed some work by Elizabeth Anderson. While I think critics are
right to insist that there is insufficient treatment of this issue in Rawls’s
work, I disagree that this amounts to abandoning justice as fairness as a
viable candidate for an inclusive theory of justice.
What I have offered is a modification of Rawls that is meant to treat
seriously the self-respect of someone like Andrew and the contributions of
all disabled individuals. I have rejected the idea that we face a dichotomy
between an ineffectual contractualism where everyone is allowed
participation and no overlapping consensus is possible, and a contractualism
that rejects the disabled as a subject of justice and ignores their contributions
to the basic structure of society. This modification notices that disabled
individuals are part of the web of society and so intuitively deserve rights,
recognition, and protections that derive not merely from principles of
charity.
176 Chapter Nine
References
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287-337.
Brownlee, Kimberly and Adam Cureton (ed.) Disability and
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Comer, Ronald J. Fundamentals of Abnormal Psychology. 3rd ed. New
York: Worth Publishers, 2001. 10-11.
Daniels, Norman. Democratic Equality: Rawls’s Complex Egalitarianism.
The Cambridge Companion to Rawls. Ed. Samuel Freeman. New
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—. Equity of Access to Health Care: Some Conceptual and Ethical Issues.
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(1982): 51-81.
Hartley, Christie. “Disability and Justice.” Philosophy Compass 6.2
(2011): 120-132.
—. Justice for the Disabled: A Contractualist Approach. Journal of Social
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Hefling, Kimberly. The San Diego Union-Tribune. Activists seek to curtail
restraining students. Web. 24 March 2012.
Kittay, Eva Feder. At the Margins of Moral Personhood. Ethics. 116.1
(2005): 100-131.
—. When Caring Is Just and Justice Is Caring: Justice and Mental
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for the Homeless. Mental Illness and Homelessness. July 2009. Web. 2
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Nussbaum, Martha C. Beyond the Social Contract: Capabilities and Global

Justice. Oxford Development Studies. 32.1 (2004): 3-18.
—. Frontiers of Justice: Disability, Nationality, Species Membership.
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Wong, Sophia. Duties of Justice to Citizens with Cognitive Disabilities.
Metaphilosophy 40.3-4 (2009): 382-399.
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Policy. 26 Jan. 2011. Web. 2 June 2011.
CHAPTER TEN
HOW EMPIRICAL AND SOCIAL EXPLANATIONS

OF NORMAL INFLUENCE DECISIONS
TO TREAT THE NEURODIVERSE
KEISHA RAY
In this chapter I offer a philosophical analysis of the ways that social

and empirical explanations of “normal” are thought to make a difference
in determining what conditions ought to be the concern of medicine as a
matter of justice in health care. Because normative judgments concerning
health care, including the allocation of resources, are unavoidable,
defining and utilizing normal as a baseline for whom medicine ought to or
who medicine is obligated to treat emerges as a common, and perhaps
unavoidable judgment among many others.1 In most instances, utilizing an
explanation of “normality” is unproblematic. Normality as a way to ground
judgments concerning distributive justice in health care is often helpful in
cases when there is a consensus about what role health care ought to play
in individuals’ lives and what conditions are considered diseases. Concerning
the neurodiverse, however, specifically individuals with Asperger’s
syndrome (AS), utilizing normal as a baseline for judgments in health care
can be detrimental to making mental health care available to individuals
whose place within the spectrum of “normality” is unclear, yet can
reasonably be expected to benefit from mental health therapy.
Many explanations of “normal” have been utilized by the sciences for
purposes ranging from theoretically and clinically distinguishing “health”
from “disease” to determine what conditions health insurance ought to
fund. For example Wachbroit (1994) offers three different ways of
understanding normality: 1) as a statistical concept in which what is
normal is the mean of multiple items; 2) as societal norms, in which one’s
culture determines what is normal, typically by distinguishing actions,
behaviors, and viewpoints that are typical or common in that society from
those actions, behaviors, and viewpoints that are unusual or uncommon in
How Empirical and Social Explanations of Normal Influence 179
that society; and 3) as proper functioning, in which an entity is normal if it

functions properly or according to its make or design.2 I focus on the latter
explanations of normal and how they have been used to ground judgments
about what is just in health care.3
Just as I rely on explanations of normal to give an analysis of
judgments in health care and subsequently offer my own judgments about
the role of health care, I also rely on explanations of justice. One
explanation of justice is fairness (Rawls, 2001). An Aristotelian explanation
of fairness is to treat like cases alike. For the purposes of this chapter I
extend this explanation of fairness to justice. Justice as fairness can easily
be misunderstood to also include equality. Justice as fairness does not
necessarily mean treating individuals equally, and in fact there are
occasions when treating individuals fairly requires us to treat individuals
unequally. For example, hospital emergency rooms use a triage system to
manage incoming patients. Triaging patients necessarily treats individuals
differently based on their medical need to ensure that those who are in the
most need are treated first. Triaging patients also represents one form of
just health care. In sum, I rely on justice as fairness in my analysis of
judgments about health care.
I argue that there are instances in health care when explanations of
normal and explanations of justice converge. For instance, using the
example of triaging patients, just health care can be explained as
prioritizing patients who are not functioning biologically or physically
normally before patients who are functioning biologically or physically
normally. In this example both explanations of normal and justice are used
to create standards of health care. I focus on the ways explanations of
normal influence justice health care.

I begin my analysis with a description of AS and the problems that
explanations of “normal” pose for individuals with AS. Next I present
some of the most common arguments for justice in health care that also
relies on an explanation of normality. I then show, how these arguments
can potentially exclude individuals with AS from receiving mental health
therapy. Their exclusion is typically based on the common cognitive and
personality features associated with the cognitive disorder, namely high
levels of intelligence. I contend that individuals with AS show that as a
matter of justice the use of “normality” must be balanced with other values
in health care. Furthermore, the use of “normality” ought not to overshadow
the needs of the neurodiverse community, especially when individuals can
reasonably be expected to have their lives significantly improved with the
help of mental health therapy.
180 Chapter Ten
Asperger’s Syndrome
Asperger’s syndrome is a cognitive disorder with autistic-like
characteristics, but without significant linguistic or cognitive delays.
Although AS is a form of autism, AS is typically contrasted with autism
based on the typically above normal intellectual abilities. This includes a
typical superb sense of their surroundings, but below normal social skills
possessed by some individuals with AS (Landeweerd, 2011). The below
normal social skills typically associated with individuals with AS include
the inability to empathize with others, act in accordance with commonly-
held rules of social interaction, and appear interested in conversation.
Also, individuals with AS often have very rigid, specific interests
(“Asperger’s Syndrome,” n.d.; Ghaziuddin, 2010; Landeweerd, 2011).
Because individuals with AS often have a high level of intelligence
(Horowitz, 2008), they are often thought to have an advantage that most
individuals without AS do not have. Additionally, they are often thought
to not have a disability or a disadvantageous condition that needs to be
treated. Attesting to this, Baron-Cohen (2000) states that describing AS as
a disability may be an inappropriate description of the syndrome, rather
“difference” may better describe the disability. For funding purposes,
however, Baron-Cohen states that we might want to continue to describe
AS a disability. In further support of Asperger syndrome’s questionable
disability status, Landeweerd (2011) gives a testimony from a mother with
AS who explains the disadvantages AS brings to her social life, yet she
also notes the advantages it has brought to her children. Landeweerd
(2011) also gives a testimony from a graphic designer/photographer with
AS who explains how her “disability” allows her to perform her job better
because it made her a visual thinker, a skill important to her career. As
additional testament to the growing belief that AS is not always a
disadvantageous condition, it has been debated whether AS should not be in
the DSM-V, partly because some believe AS to be no different than high
functioning autism (Ghaziuddin, 2010), an uncontested condition, and
arguably, partly because of the believed advantages it brings individuals
with AS demonstrated by the testimony of the designer/photographer.
Based on the characteristics associated with AS, namely high level of
intellectual abilities, individuals with AS are often thought to be normal or
above normal by at least some explanations of normal. Perhaps because of
the potential career and monetary benefits of superior intellectual ability
and societal values of capitalism and financial security, the intellectual
abilities of individuals with AS often overshadow the social impairments
associated with AS, even though social skills, arguably, are also a societal
value. When judged by societal standards of normal some individuals with

AS have below normal social skills. Because a lack of social skills can
prevent individuals with AS from benefiting from their advantageous
intellectual abilities, their lack of social skills can be viewed as a
disadvantage. Nonetheless, the advantages of AS can encourage the belief
that individuals with AS are normal (if not above normal) and should not
be a concern of health care or at least should not be given priority in health
care. Also, the advantages of AS also lend support to the idea that if just
health care requires society or medical insurance to fund some medical
interventions that ameliorate disadvantages conferred to individuals with
AS by way of their by their disorder, social impairments are not some of
those disadvantages.
Health care practices such as behavior management and behavior
therapy, social skills training, and medication for conditions associated
with AS such as depression are advocated mental health therapies for
individuals with AS (“Treatments and Drugs,” 2010). Despite the benefits
of mental health therapy, with the exception of luck egalitarianism, many
judgments concerning just health can be used to justify the claim that
health care personnel ought not to be concerned with individuals with AS.
To show how we should use explanations of normality as the basis for
judgments about just health care with caution, next I explain how the
common uses of “normal” in health care can exclude individuals with AS.
Normal Functioning
Judgments concerning whom health care personnel is and is not

obligated to treat as a part of a system of just health care are often
grounded in an explanation of “normal.” For example, a function of health
care can be viewed as personnel making attempts to maintain individuals’
health and to rid individuals of at least some diseases, conditions, and
ailments. If this is the case then Boorse (1975,1977) gives us one
understanding of justice in health care—treat individuals with a disease, or
individuals that do not meet a predetermined standard of normal. Boorse
utilizes an understanding of “normal” to distinguish “health” from
“disease” in which “health” can be viewed as the body (understood as the
body and any the parts that comprise it) functioning normally, or by
viewing the body as goal-oriented parts, with that goal being to operate
according to their natural or biological function. Health can also be
understood as statistical normality of biological function, whereas
“disease” can be viewed as a deviation from statistical, functional, and/or
biological normality. According to Boorse, theoretically speaking, “health”
182 Chapter Ten
and “normal” can be used interchangeably. If we relied on this brief sketch

of health and disease to determine what is just health care and whom
personnel ought to treat, we can conclude that another explanation of
justice in health care is to maintain individuals’ normal functioning
(Boorse, 1975) or helping individuals reach a level of functioning that is as
close to normal functioning as possible. This particular use of normal can
be seen in other judgments about just health care, such as those made by
Norman Daniels.
Daniels (1985, 2001) offers an empirical, functionalist account of
justice in health care that is meant to maintain individuals’ abilities to
function in ways that are observed to be normal amongst the human
species. Daniels (2001) states that the goal of health care is for health care
personnel to maintain species typical normal functioning. Health care
personnel’s contribution to maintaining normal functioning also protects
individuals’ range of normal opportunities, or the opportunity to live the
kind of lives we want to live. Adapted from Rawls, this is the central idea
behind Daniels’ fair equality of opportunity account of just health care—
that a system of health care should protect our ability to be competitors for
opportunities. Daniels’ account of just health care also represents another
judgment concerning what individuals health care personnel ought to be
concerned with and how individuals should be treated that is grounded in
an explanation of “normal.” In this account, “normal” is used to show
health care’s role in protecting equality of opportunity. I refer to Daniels’
account of just health care—justice in health care including maintaining
species typical functioning to maintain fair equality of opportunity—as
EOP.
Daniels’ (1984, 2001) extensive work on justice in health care includes

the idea of “range of normal opportunity,” or the activities of life that
healthy individuals who are not restricted by unfair societal practices may
choose in a given society. When we rely on EOP then we may be able to
determine how to meet different health care needs by how those needs
affect individuals’ normal range of opportunities.4 Although Daniels notes
how this principle may not be useful in particularly difficult cases of
resource allocation, he still stresses the importance of EOP as a principle
of just health care. Next I offer an explanation of how the features of AS
can be viewed as impacting individuals’ normal range of opportunities.
Additionally, I explain how using “normal” to develop standards for
distributive justice in health care makes the case of allocating mental
health therapy a particularly difficult case.
Normal Functioning and Asperger’s Syndrome

If understanding and abiding by societal norms is the explanation of
normal in which we judged individuals with AS and their level of concern
to a system of health care, then it can be argued that based on their social
impairments, individuals with AS are functioning below normal levels,
and that health care personnel ought to be concerned with individuals with
AS. Boorse’s use of normal and its application to just health care as
presented —the body functioning according to its biological goal—is a
more pervasive use of normal in health care than societal norms, however,
relying on functionalist accounts of normal, we can conclude that
individuals with AS are functioning normally and ought not to be a
concern of health care personnel. Typically individuals with AS are not
persons with mental retardation nor do they have the language or speech
impairments that are associated with autism. If we were to exclude the
likely social impairments that accompany AS, which are often given a
lower priority in health care when compared to the more obvious
biological and physical dysfunction associated with mental retardation, it
would be reasonable to view individuals with AS as physically functioning
normally. The same reason that leads us to believe that individuals with
AS are functioning normally when utilizing Boorse’s account of normal,
also gives us reason to believe that individuals with AS are functioning
normally if we judge individuals with AS using Daniels’ account of
normal as species typical normal functioning.
Both Boorse and Daniels use an explanation of normal that leads us to
believe that individuals with AS are functioning biologically normally (at
least in some sense), and based on this belief we can make the claim that
individuals with AS are not a concern of health care personnel or at least
are not a priority. Even if we conceded that individuals with AS are
functioning normally, the claim that they are not a concern of health care
personnel does not follow. This is especially true if we take into account
the likely biological basis for the below normal social functioning
associated with AS. If biological dysfunction were considered a concern
of health care personnel, then below social functioning would make
individuals with AS a concern of health care. Similarly, if we utilize EOP,
a commitment to the idea that individuals with AS are functioning
normally, does not necessarily lend support to the idea that they are not a
concern of health care personnel.
When applying EOP to individuals with AS the argument seems to
both support and not support the decision to treat and fund mental health
therapy. The high verbal IQ (Ghaziuddin & Mountain-Kimchi, 2004) and
184 Chapter Ten
high cognitive functioning of some individuals with AS may give them

opportunities that most of the population will not have because of our
average level of cognitive function. But because so many factors besides
cognitive functioning and intelligence play a role in reaping the possible
rewards of high cognitive functioning, such as networking and nepotism,
and the normative nature of calculating success, it is difficult to say
whether individuals with AS have equal opportunity for societal goods
without the benefits of health care.
It is possible that individuals with AS could have as much opportunity
to achieve these goods without medical intervention as individuals without
AS. But again the many factors that determine access to societal goods
(e.g. employment, education, etc.) make this almost impossible to determine.
If it could be determined that individuals with AS can be equal
competitors for societal goods like jobs, then Daniels’ account of equal
opportunity may support the decision to not treat and fund treatments for
individuals with AS. However, if it could be determined that without some
kind of medical intervention individuals with AS could not be equal
competitors for societal goods then as a matter of equality of opportunity,
individuals with AS ought to be a concern of health care personnel and
their treatment should be funded. The proven claim that AS confers
disadvantages to individuals with AS, however, is grounds to at least make
some individuals with AS eligible for treatment and funding for treatment
as their chance for equal opportunity is jeopardized by these
disadvantages. In other words, it is more likely that individuals with AS
have disadvantages that make them unequal competitors for societal goods
than it is likely that there are no significant disadvantages conferred by
AS.
I contend that the disadvantages of AS entitle individuals with AS to
medical care; however, relying on some explanations of “normal”
excludes individuals with AS from receiving beneficial medical care.
Counter to this contention is the belief that a lack of social skills is an
impairment that confers minimal disadvantages to individuals with AS.
Because of the mild nature of the impairment, health care personnel are
not obligated to treat individuals with AS. As the argument goes, there are
many factors that determine access to opportunity, and a lack of social
skills, as one of those many factors may not be detrimental to accessing
opportunities, at least no more detrimental than if an individual lacked one
of the other factors that impacts access to opportunities. Social skills may
be just one of the many factors that influences access to opportunity;
however, this does not lead to the conclusion that individuals with AS
should not have access to medical care. This argument bases the claim that
individuals with AS are not necessarily entitled to medical care because of

the mild nature of the disadvantages conferred by AS, yet there are other
minimal disadvantages that result from conditions that are treated by
health care personnel. For example, minimal changes in vision or hearing,
ear aches, mild body aches are all treated by health care personnel with
little question concerning if the individuals with these conditions should be
a concern of health care personnel. Without equating the disadvantages of
AS with the disadvantages of poor vision, I argue that both conditions
have the potential to limit access to opportunities. The point is that when
we rely on explanations of “normal” to determine whether individuals with
AS, or poor vision ought to be a concern of health care personnel we can
potentially exclude individuals whose condition or the effects of their
condition could be disadvantageous to their lives, yet successfully remedied
with medical intervention.
Treatment/Enhancement Distinction
Like philosophers of medicine, political philosophers have also offered
accounts of just health care. For instance luck egalitarianism, a philosophical
position that distinguishes between luck and choice to determine what is a
just distribution of resources, offers an account of just health care. Shlomi
Segall (2010) uses the differences between medical intervention that is
considered treatment and medical intervention that is considered
enhancement to describe one such luck egalitarianism account of just
health care. Treatment can be understood as medical interventions that are
medically necessary and/or medical interventions that are meant to restore

individuals to normal health. Conversely, enhancement can be understood
as medical interventions that are medically unnecessary and/or interventions
that are meant to elevate individuals’ functioning to a level that is beyond
normal. This distinction is commonly referred to as the “treatment/
enhancement distinction” (Colleton, 2008), or T/E as I refer to it.
According to Segall (2010), biomedical intervention should be allowed
and funded by society, regardless of whether intervening would be
considered enhancing normal human functioning. Under this specific
account of luck egalitarian and its application to medical intervention,
medical intervention for enhancement purposes is permissible. I use LE to
represent Segall’s (2010) explanation of the luck egalitarian account of
just health care.
Medical intervention that is considered enhancement is permissible
under LE when health care personnel intervene to ameliorate unwanted
and reasonably unavoidable, disadvantageous conditions that are not
186 Chapter Ten
chosen and are the result of social or natural circumstances. Furthermore,

health care requires the LE stance on enhancement, namely that T/E is
morally irrelevant. Additionally, emphasis should not be placed on
funding medical intervention in the absence of pathology, but on funding
medical intervention for disadvantageous conditions.
LE is also similar to the utilitarian account of T/E, which also places
importance on the benefits of medical intervention and deemphasizes
determining whether medical intervention is to serve therapeutic or
enhancing purposes. The LE account of T/E is a bit more favorable to
individuals in the neurodiverse community whose proximity to normal
levels of functioning is difficult to determine, or whose impairments are
not thought of as disadvantageous by individuals outside the neurodiverse
community. The social disadvantages experienced by individuals with
autism or AS are examples of individuals whose level of normal
functioning may be difficult to determine, yet the LE account of just health
care would obligate health care personnel to medically intervene.
Although the LE account of T/E permits enhancement, like Daniels’
(2001) theory of just health care, T/E has limited bearing on what health
care personnel is morally obligated to provide. There is at least one
instance, however, when using TE to determine health care personnel’s
obligation to individuals is defensible—when medical intervention is
meant to ameliorate a disease, disability, or the symptoms associated with
disease or disabilities. In other words, when medical intervention is for the
sake of returning an individual’s level of functioning to normal Daniels
states that society is obligated to fund the treatment of pathologies,
although our obligations do not hinge on the condition of disease; in fact
we are not obligated to fund all treatments. Treatments that we are not
obligated to fund may include treatments that are unlikely to successfully
remedy an individual’s ailment. Furthermore, in most cases we are not
morally obligated to fund medical intervention in instances when there is
no disease, but we might be morally obligated to do so when funding
medical intervention is done in the name of championing values such as
equality. Daniels (2000) gives the example of funding abortions when
pregnancy is unwanted for non-medical reasons. Daniels (2000,1981)
concludes that health care personnel is only morally obligated to raise
individuals to a level of species normal functioning; however, health care
personnel is not obligated to raise individuals to a level of functioning
beyond normal, but may do so for other reasons.5 Relying on Daniels’ own
example of abortion, we are lead to conclude that in some instances a
system of health care may be obligated to fund some interventions that can
be considered enhancements, such as behavior management for individuals

with AS.
Though often criticized for being too inclusive or too exclusive,
arguments given by Boorse, Daniels, and LE, and TE that all rely on an
explanation of “normal,” represent models of justice in health care that are
still viewed as adequate standards for justice in health care and, are in turn
used as the basis for health insurance policies. Using “normality” as a
baseline for deciding which conditions medicine ought to be concerned
with or which conditions health insurance ought to fund is one method of
making decisions about who ought to take advantage of medical resources.
And indeed relying on “normal” biological, mental, and physical
functioning is very helpful in many instances. This is particularly true
when there is consensus about the presence of disease. This is also true
when medical conditions or the disadvantages bestowed upon individuals
by medical conditions conform to our socially created ideas of what is
normal and what is not normal. Yet when health care personnel, political
philosophers or bioethicists cannot come to a consensus about what
conditions are considered diseases or what is abnormal functioning,
explanations of normal can hinder access to health care for individuals
who may be considered normal but are still in need and can benefit from
health care services.
There are instances when conditions may not be considered diseases,
or may not be considered instances of normal functioning based on
explanations of disease or based on social and empirical explanations of
normal.6 However, since it can be argued that our own values create the
criteria by which conditions are judged to be normal or not normal, it can
also be argued that society creates the environment that makes certain
conditions, such as AS disadvantageous by being unaccommodating to
different styles of communication (Daniels, 2001). Our role in creating
such an environment gives us the option to alter those values, thus
changing the disadvantageous nature of particular conditions. Since it
would be a timely endeavor for a culture to significantly change its values,
we also have the option to promptly help individuals lessen the effects of
their disadvantageous condition.
Treatment/Enhancement Distinction
and Asperger’s Syndrome
A consensus concerning whether AS is a disease would make the
question of whether AS is a concern of health care personnel much easier
to answer within the framework of T/E. Within the framework of T/E, AS
188 Chapter Ten
warrants medical intervention as a therapeutic measure to ameliorate a

disease. Subsequently, health care personnel are obligated to treat
individuals with AS and society is obligated to fund such treatment,
according to Daniels’ (2001) account of T/E. Furthermore, Daniels (2001)
states that the role of health care is to ensure functioning at a normal level.
If judgments such as Daniels’ judgments, which rely on T/E and its use
of normal functioning are used to determine justice in health care, then
medical intervention for individuals with AS can be considered
enhancement because individuals with AS are functioning normally. And
in most cases, society is not obligated to fund interventions that are
considered to be enhancements.7 However, according to the LE application
of T/E to justice in health care, if AS itself or the characteristics associated
with AS create disadvantages for individuals with AS, then whether
medical intervention is considered treatment or enhancement is irrelevant;
health care personnel are obligated to intervene and society is obligated to
fund the intervention. Within the LE framework, individuals with AS are
entitled to treatment, and as a matter of justice, health care personnel is
obligated to fund their treatment because they have an unwanted,
unchosen, and reasonably unavoidable, disadvantageous condition (Segall,
2011). LE is unlike the other judgments that utilize normal for justice in
health care in that it justifies, rather than excludes mental health therapy
for individuals with AS by focusing on the benefits of health care and the
disadvantageous position AS bestows upon some individuals with the
condition.
Conclusion
I have offered common judgments concerning just health care that are
grounded in an explanation of normal. These judgments can be used to
exclude individuals with Asperger’s syndrome from health care by
supporting the viewpoint that these individuals are functioning normally.
To counter this viewpoint I have given ways that individuals with AS can
benefit from health care, and how they may be at a disadvantage because
of AS. Although I used the specific case of individuals with AS, my
argument could easily apply to any member of the neurodiverse
community. Any member of the neurodiverse community whose place
within the wide spectrum of normal and not normal is unclear is subject to
my argument. Any member of the neurodiverse community who does not
neatly and without controversy fit societal, empirical, and/or functional
accounts of what it means to be normal, could potentially be excluded
from the benefits of health care, even though they could benefit from
mental health therapy.
I give the example of individuals living with AS to give light to the
problems that arise when we use standards of normality to make
judgments about individuals who make it particularly difficult to judge
whether they are normal or not normal. Although we must have some
method of distributing health care’s limited resources, and utilizing
explanations of “normal” is one way to do that, we cannot help but
question the value of “normal” in such judgments if utilizing this concept
has the potential to withhold treatment from members of the neurodiverse
community. I do not claim that we should completely terminate using
judgments concerning just health care that utilize explanations of
“normal;” however, utilizing normal must be weighed against values such
as equality. In the name of other societal values, in some instances we are
required to ensure mental health therapy, despite the guidelines that may
be set forth by explanations of “normal” in cases where individuals can
reasonably be expected to benefit from medical intervention.
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Wachbroit, R. (1994). Normality as a biological concept. Philosophy of
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CHAPTER ELEVEN
FROM NEURODIVERSITY
TO NEUROCOSMOPOLITANISM:
BEYOND MERE ACCEPTANCE
AND INCLUSION
RALPH SAVARESE
Neurodiversity has begun to receive its due. More and more attention
is being paid to the idea of neurological differences as both a natural
reflection of human variation and a complex, if not paradoxical, boon—
what one writer, speaking of bipolar disorder, calls “a gift with a shadow
side” (Antonetta, 2010, p. 73). My own co-edited special issue of Disability
Studies Quarterly, “Autism and the Concept of Neurodiversity,” presents
some forty contributors from different academic disciplines and indeed
occupations, each of whom argues in her own way for the need to
eschew a strictly pathologizing view of autism (E. Savarese & R.J.
Savarese, 2010.) Half of these contributors are on the spectrum

themselves--and not just the so-called “high-functioning” end of the
spectrum—and they include such self-advocate luminaries as Amanda
Baggs, Tito Mukhopadhyay, Ari Ne’eman, Dawn Prince, Scott Robertson,
Tracy Thresher, and Melanie Yergeau.
Two contributors, Amanda Baggs and Dawn Prince, lay out the
conventional diversity argument while also gesturing at what I have come
to call neurocosmopolitanism. At the risk of impeding the further
acceptance of the concept of neurodiversity, I want to suggest some of its
limitations and to put forward this more active, mobile, and participatory
notion. If the shibboleth of diversity has made room in the public sphere
for all manner of formerly marginalized peoples, it has also largely
atomized these groups, allowing them to co-exist anxiously and with
relatively little interaction. At my college, for example, where we
interpret our social justice mission as demanding, among other things, a
192 Chapter Eleven
more inclusive faculty, staff, and student body, representatives of these

groups often uphold impermeable enclaves. Take the dining hall: we may
all eat under one roof, but our “we-ness” seems to be a function of said
roof, not of the dynamic interplay of different perspectives underneath it.
Let me be plain: I support the idea of diversity; I just don’t think we
have gone far enough with it. It has become something of a self-
congratulatory platitude: a goal that can be reached, and then celebrated,
by pointing to hiring or admissions statistics. This view of diversity will
not sufficiently aid people with disabilities, particularly neurological ones,
where stigma remains a substantial problem. My son, DJ, will enter
Oberlin College as its first non-speaking student with autism in the fall of
2012; he worries about whether or not he will be warmly welcomed and
engaged, as opposed to simply “included.” In an essay entitled
“Communicate with Me,” he makes this point starkly: “Last year Dr.
Sanjay Gupta of CNN wanted to talk to me so much that he flew me to
New York and got me a room at the fanciest hotel in the city, but
ironically at my school, most kids choose not to talk to me at all. Why is
that” (Savarese, DJ, 2010)?
How can we foster dynamic interaction when neurological difference is
so obviously embodied, which is not to say immune to the forces of social
construction but, rather, conspicuously physiological and, even more,
affecting the organ of consciousness? In the aforementioned essay, my
son instructs readers to ignore his “involuntary gestures” when they meet
him, and yet he makes this plea in linguistically discernible terms. But
what about those autistics who cannot do so or who prefer to
communicate in some other way? What about those, like Dawn Prince,
who “can taste sound and smell colors” (2010a)? Or, like Amanda
Baggs, who organizes the world in elaborate, non-symbolic patterns? Or,
like Tito Mukhopadhyay, who flaps to know that he has arms. That DJ,
Dawn, Amanda, and Tito use language so effectively doesn’t diminish
their difference; rather it attests to the work they have done to learn how
neurotypicals operate. That neurotypicals fail, in turn, to apprentice
themselves to an autistic neurology (including very different sensory
processing) points to the limits of neurodiversity as an emancipatory
concept and to the need for some kind of alternative.
Before discussing the articles I mentioned by Amanda Baggs and
Dawn Prince, I want to establish what postcolonial scholars mean when
they speak of cosmopolitanism. At its most basic, the term signifies a
belief in a single, transnational community, a community whose shared
values can forestall the often negative effects of differences such as
nationality, race, ethnicity, class, language, and culture. The dream of a
From Neurodiversity to Neurocosmopolitanism 193
global citizenship, even a global patriotism, has emerged at a moment

when the planet has never seemed so small and traversable--what with
new possibilities for travel (including space travel) and communication. A
cosmopolite embraces such possibilities, comfortably moving back and
forth from, and in between, local sites of difference. In his book The
Planet, Paul Gilroy advocates a “methodical cultivation of a degree of
estrangement from one’s own culture and history” (2006, p. 67) as an
antidote to what a rigid insistence on difference often produces: namely,
diminishment, sometimes even hatred, of the other. Here the pleasure of
global mobility meets a kind of ethical imperative: purposeful
defamiliarization.
If cosmopolitanism is the idea of a transnational community, the feeling
of being at home everywhere in the world, then neurocosmopolitanism is the
idea of a transneuro community, the feeling of being at home with all
manner of neurologies. But how to “travel” to autism, particularly to its
most challenging forms? How to purposefully defamiliarize one’s own
neurology in order to hospitably greet another? How, in short, to be at
home with autism? Whatever movement is required—and some movement
is most certainly required when people with significant disabilities aren’t
yet fully welcome in the public square—the task involves both an
openness to neurological difference and a willingness to be educated about
that difference by people with autism.
In his memoir of founding the National Theatre for the Deaf, Bernard
Bragg, who needed hearing people to see his plays if his company was to
be financially viable, writes of meeting a young man whose program he
had signed years before and to whom he had communicated the need for
deaf and hearing people to meet “halfway” (1989, p. 146). Bragg didn’t
recognize the young man because he was now fluent in sign language.
Upon learning who he was, he exclaimed joyously, “Halfway!” Bragg’s
notion of “halfway” is akin to what I’m calling, in the context of autism
and other neurological differences, neurocosmopolitanism.
Amanda Baggs became famous for her 2007 YouTube sensation, In
My Language, which presents, initially without explanation, a woman
engaging in what medical professionals would term perseverative
behavior. About halfway through the video, the phrase “A Translation”
appears, and Baggs begins to unpack, with the aid of a text-to-voice
synthesizer, what the viewer has actually just seen. Referring to such
perseverative behavior as her “native language,” she declares, “My
language is not about designing words or even visual symbols for people
to interpret. It is about being in a constant conversation with every aspect
of my environment” (2007). Although she lays bare the presumption of
194 Chapter Eleven
intellectual disability with her keen sense of argument, Baggs wants the
viewer to appreciate her more natural way of experiencing the world. The
viewer can both hear and see her playing with running water in a sink.
“The water doesn’t symbolize anything,” she explains. “I am just
interacting with the water as it interacts with me” (2007). “Far from being
purposeless,” she adds, “the way that I move is an ongoing response to
what is around me” (2007).
At this point in the YouTube, Baggs explicitly politicizes the
denigration of her kind of thinking: “Ironically, the way that I move when
responding to everything around me is described as ‘being in a world of
my own’ whereas if I interact with a much more limited set of responses
and only react to a much more limited part of my surroundings, people
claim I am ‘opening up to true interaction with the world’” (2007).
Rejecting what Erin Manning calls “the primacy of the verbal” (2009, p.
39) and the narrow engagement it affords, Baggs uses her senses in an
utterly dynamic and yet non-symbolic manner. She “call[s] forth a field of
relation rather than a static, interactive self” (2009, p. 40), a self that
masters such sensation with meaning. “To interact in a self-contained
verbal way,” Manning contends, “would involve parsing [the world’s]
taking-form into a simple activity” (2009, p. 40). Might neurotypicals,
then, Baggs implies, fit the definition of autism: people alone in the world,
unable to interact fully and appropriately with their (nonhuman)
surroundings?
Of course, this more holistic response to the environment puts at risk
the personhood of the autist. For one thing, being so attuned to the
relational field can render linguistic distinction a baffling contrivance and
make the autist seem intellectually disabled. Baggs, argues Manning,

“cannot easily subtract from the hyper-relation of her synesthetic and
cross-modal experience to present herself as a unified verbal self” (2009,
p. 40), and yet she is capable of doing it. She simply resents the privilege
that attends to symbolic thinking and the arduous labor necessary for her
to be regarded as competent. “The thinking of people like me is only taken
seriously if we learn your language,” she remarks. “I find it interesting
that a failure to learn your language is seen as a deficit, but a failure to
learn my language is so natural” (2007). Here Baggs reveals the
completely one-sided nature of cross-cultural or cross-sensorial exchange:
act like the majority, or you won’t be recognized. Come the full way, or
you won’t be judged to have value.
In Finding Amanda (2008), the CNN documentary that Baggs’
YouTube inspired, my son, DJ, can be seen communicating with Baggs
via the internet. DJ speaks of organizing a summit for autistic people so
that they might begin to define themselves, as opposed to being defined by

others. When Dr. Sanjay Gupta asks if autism should be treated, DJ types
impishly, “Yes, treated with respect.” In My Language constitutes a
wonderfully instructive example of respectful neurocosmopolitanism. As
much as Baggs vehemently contests neurotypical privilege, she still labors
to educate non-autistics. She still labors to create a space of appreciated
difference, modeling how a fully engaged neurocosmopolite might act.
That she must do all of the work (in a second language), after enduring all
of the prejudice, only attests to her neurocosmopolitan commitment.
Such a commitment becomes even more apparent in her 2010 essay in
“Autism and the Concept of Neurodiversity.” Entitled “Up in the Clouds
and Down in the Valley: My Richness and Yours,” the essay elaborates on
the alternative language conceit of her YouTube video. Citing a remark
by Jim Sinclair—“my unique faculties are thrown back at me as hopeless
inadequacies” (2010)—Baggs wants neurotypicals to understand just how
rich is her way of experiencing the world. “My first memories,” she
writes, “involve sensations of all kinds. Colors. Sounds. Textures. Flavors.
Smells. Shapes. Tones. These are short words, but the meaning of them is
long, involved, and complex” (2010). Sensations fuel what Baggs calls
“patterns of perception” (2010). “These sensory perceptions were repeated
long enough for me to become deeply familiar with them” (2010), she
explains. “This familiarity resolved into patterns that formed the basis for
more patterns, and—to this day—all of this continues to form the basis for
how I understand things” (2010).
But these patterns aren’t categories, Baggs insists. Baggs is careful to
distinguish between how conventional language works, robbing entities of
particularity and sensual immediacy through a process of generalization

and abstraction, and how patterning works. “I mean perceiving
connections without force-fitting a set of thoughts on top of them,” she
says, adding, “my ability to fit words into familiar patterns outstrips my
ability to understand the words themselves” (2010). Baggs, when learning
conventional language, “was able to work out which words go with which
responses long before [she] was able to work out the meaning of the
words” (2010). She appreciated “the way strings of words go together
with other strings” (2010)—appreciated, that is, whatever non-symbolic
relation she had sensuously discerned. Of course, the grammar that makes
conventional language possible is itself a pattern, as is, for example, the
technically meaningless rhythm that accompanies a well-crafted sentence.
Although Baggs seeks to underscore the difference between her language
and that of neurotypicals, the example reveals the way in which the latter,
particularly in poems, can be neurocosmpolitan: trafficking in meaning
196 Chapter Eleven
while bedecked, say, with sound jewelry. In fact, Baggs almost seems to
intuit a Bragg-like meeting ground or “halfway” point in symbolic
language.
Nevertheless, she says that “patterns and connections,” which arise
from “the movements of [her] body” and “the smells in the air,” are “more
[her] language than the words that appear on the screen when [she] let[s
her] fingers use the keyboard” (2010). And she shows how autism can act
like a pattern forging accelerant, as differently expressive and communicative
as typical language:
I have a body language that some others—usually autistic people—can
under-stand. I have the way I interact with things around me at a particular
time,compared to how I usually interact with them. I have ways of
arranging objects and actions that give clues about where my interest is
directed and in what manner. I can tap out rhythms in general or those of
my favorite numbers (I really like the rhythm of seven, for example.). I
can speak Feline about as well as anyone with my limited human senses
(2010).
This last remark reveals a pan-neurocosmopolitan impulse to “speak”

with all manner of beings and objects—to do so without hierarchies or
value judgments.
Of course, Baggs recognizes that patterns and connections don’t
“communicate everything that typical languages communicate, but [she]
do[esn’t] see any reason they should have to” (2010). “They are rich and
varied forms of communication in their own right,” she contends, “not
inadequate substitutes for the more standard forms of communication”
(2010). She calls for a truly capacious understanding of what constitutes

thought, reminding neurotypicals that the “cognitive fanfare” (2010) they
so cherish actually interferes with experiencing the world. Responding to
a man who lamented that she “would never know the richness of the life
that he knows,” she writes,
I wonder if he is capable of looking around and seeing shapes and colors
instead of objects and of mapping the patterns of those shapes and colors. I
wonder if he understands my kind of beauty or only that which comes
from a different sort of perception: more filtered—perhaps in some ways
more efficient—but irretrievably blocking out many things before they hit
consciousness. I wonder if he understands the dance of waiting for “launch
windows” to line up to make actions possible, and all the things that
happen while waiting on the ground for the next “launch window” to open
up (2010).
Troping neurotypical perception as existing “up in the clouds” and

autistic perception as existing “down in the valley,” Baggs exclaims, “This
is about what is, not what is missing…. It is about the fact that those of us
who are viewed purely as having had things taken away—as being
essentially barren wastelands—are not shut out of the richness of life by
being who we are” (2010). Once again, Baggs commits herself to
respectful cross-sensorial exchange, insisting on two kinds of richness,
each coming at a certain cost, while manifesting the neurocosmopolite’s
ease of cognitive movement from one operating system, as it were, to
another.
With Dawn Prince we see something quite similar. She, too, presents a
relational sense of engagement, but she views conventional language as
potentially less alienating than Baggs. Indeed, for her, language, when
sufficiently immediate and sensorial—when sufficiently synesthetic—is
more than up to the task of expressing autistic perception. “I have always
felt everything: the too bright sun, the deafening loudness of whispers. I
can taste sound and smell colors. I was and am permeable,” she writes in
“My Grave and the Last Side Show Tent” (2010a). While conceding that
she is “no doubt…different in some ways from other people,” she believes
that her difference “never lets [her] forget that [she is] part of
everything…” (2010a).
In the essay that appears in “Autism and the Concept of Neurodiversity,”
“The Silence Between: An Autoethnographic Examination of the Language
Prejudice and Its Impact on the Assessment of Autistic and Animal
Intelligence” (2010b), Prince pushes back against the contrived
estrangement of individual words in the dictionary and, like Baggs, hints at
how language can behave differently, as in a poem, by soaking up

whatever resonance the relational context provides:
I remember learning the word “hippopotamus.” “Hippopotamus,” I would
say, going by my grandparents’ bedroom, and the word would become
infused with the security of their sleeping, the cedar of the clothes chest
against the wall, my grandmother’s make up in muted colors. “Hippo-
patamus,” I would say, as I skipped past the bathroom and the word would
partake of the smells there and the joyful sound of running water and the
warm bathing…. To me, it was a completely valid response when
someone asked me, “Do you need to go to the bathroom?” to answer,
“Hippopatamus” (2010b).
From synesthesia comes a radically cross-modal approach to existence:

everything, from ostensibly discrete objects to organisms to words, is
processed through its neighbors. The world itself turns out to be
neurocosmopolitan when relationally experienced. Being at home with
198 Chapter Eleven
oneself means being at home with all manner of organisms and entities,
for identity is always mixed, fluid, and permeable.
It is precisely her feeling of “extreme connection” (Savarese, R.J.,
2010), to borrow Tito Mukhopadhyay’s phrase, the force of her
synesthetic understanding, that allows Prince to communicate with the
non-human world in what she calls “the language of silence”:
When I was young I talked to animals in that language of silence. I knew
what trees and streams were saying because they told me. I knew what
sow bugs were saying because they molded me. I grew together with them
because of the words of living together in a world where everything needed
everything else. Sometimes my grandfather would ask me in the garden,
“What are the worms saying today?” “Fine fine slither dirt push good
rotting green,” I would answer smiling (2010b).
Here again, the alternative language conceit strives to give voice to the
voiceless, if only to undermine the privileged status that neurotypical
humans grant themselves. Unfortunately, this happy, animistic time didn’t
last because Prince was compelled to use language more conventionally--
as a “weapon…that cut up the world [and] also cut groups of people one
from another” (2010b). In this way, “autism” became a term denoting
pathological otherness and deficiency, not relational wholeness.
As Prince relates in Songs of a Gorilla Nation (2010c), she found
herself increasingly alienated from neurotypical society, even becoming
homeless for a while. Only by interacting with gorillas at the zoo, by
mimicking their behavior and language, was she able to reaffirm her
difference and eventually to return to college and even to embark on a
Ph.D. in anthropology. One day, while in graduate school, she flew down
to Decatur, Georgia to meet Kanzi, a Bonobo chimpanzee famous for his
acquisition of human language through keyboard lexigrams and whom
Prince calls a “captive born man” to stress the way that neurotypicals
enforce a rigid and condescending distinction between our species and
other animals. “Naturally, I fell into the gorilla language I knew,” she
reports in “The Silence Between” (2010b). After she had developed a
relationship with Kanzi by “play[ing] chase up and down the fence line,
both of [them] on all fours, smiling in a sea of breath” (2010b), he pointed
to the word “gorilla” on his word board and then made the American Sign
Language sign for “question,” though he himself had only seen a video of
a gorilla using ASL. Because Kanzi hadn’t seen any other gorillas, he
assumed that all gorillas communicated in this fashion. “Are you a
gorilla?” he was asking.
“There were so many miracles of language in that one interaction,”
Prince explains, “that I didn’t know where to start writing about it within
the rules: I couldn’t build on other people’s ideas. I couldn’t cite previous
research, I couldn’t capture what had happened in terse and distant
language. Even the subject itself was taboo as ‘anthropomorphism’”
(2010b). This sort of “halfway” moment seems to mock the categorical
division upon which conventional language is based, to say nothing of the
tradition of disinterested investigation. If a bonobo chimpanzee can call an
autistic woman a gorilla, why can’t an autistic woman call the bathroom a
hippopatamus? Kanzi’s act of species misrecognition—one might even
say of species neurocosmopolitanism--inspires Prince to imagine a larger
community of the unrecognized and disregarded:
All of these creatures the normal world imagines silent. The autistic child,
the ape in the zoo or in the laboratory, the homeless, dogs in cages.
Thinking their silence means they lack language, lack consciousness, is
convenient. We are starting to speak the language of the masses, though,
and the time of silence without meaning is coming to a close…. A
language of the masses larger than us--the world as it warms, the ground as
it’s choked with trash, the animals saying goodbye—is either having the
last word or the first. It depends on our conception of language (2010b).
Call it revolutionary neurocosmopolitanism this frustrated and semi-

apocalyptic vision of the future. Learning the lingua franca of the
oppressor, the neurologically diverse, like some multiform proletariat,
seek to save the world through an insistence on relation. Sadly, the world
has only just begun to listen.
And yet, however frustrated Prince might be, like Baggs, she reaches
out to neurotypicals, using their form of language to make her point. She
clearly practices, in Gilroy’s phrase, “a methodical cultivation of a degree

of estrangement from [her] own culture and history” (2006)—as she and
Baggs make plain, using language symbolically requires eschewing a more
instinctive orientation to experience. The concept of neurodiversity can’t
seem to capture this active striving for dialogue, this neuro-mobility and
mixing. If anything, it seems to preserve essential differences—preserve
them unimaginatively at a distance.
Having now encountered two examples of autistic neurocosmopolitanism,
we might ask, “What would its neurotypical counterpart look like?” I
haven’t sufficient space to lay out a range of possibilities, but let me offer
two examples after briefly elaborating on what I have already intimated:
namely, that certain forms of art—poetry, for example—can behave in a
neurocosmopolitan manner. A poem uses language in both a patterned
and a symbolic way. It deploys words discretely while undermining their
discretion through the creation of a keenly relational or connected
universe. It revels in meaning while insisting that meaning resonate
200 Chapter Eleven
diffusely. It delights in ornament, appealing to the senses directly, while

establishing correspondences between its non-symbolic and symbolic
intentions—to the point that an element like rhythm can seem meaningful
and an element like logic can seem rhythmical.
Such correspondences themselves suggest a neurocosmopolitan mixing
—something analogous to what Jahan Ramazani calls “the alienation of
discourse from one place to another, a movement that involves not only a
one-way shift, but inevitably a bidirectional hybridization” (2001, p. 73).
We’re only just beginning to fathom what an autistic/non-autistic hybrid
might be like. Both autism and neurotypicality must cease to be strictly
themselves in the participatory presence of the other; the anthropologist on
Mars must become, at least in part, a Martian. The point is that we need
not invent from scratch a hybrid space of mutually hospitable cognition,
even as we eagerly await a neurocultural renaissance. This was brought
home to me when I conducted a villanelle-writing workshop with classical
autistics who positively delighted in, and quickly mastered, the form’s
perseverative lyricism.
Significantly, Baggs, Mukhopadhyay, and my son, DJ, report that
hearing poetry read aloud helped to lure them into functional language.
As a form of embodied knowing, poetry quite literally spoke to their
different brains. To put it too simply, a poem’s attention resembled their
attention. And as it lured them into functional language, so it might lure
neurotypicals into a more immediate and relational engagement with the
world. Such an outcome would only be to the good—certainly, nonhuman
species and the environment would be aided by a less instrumental
conception of their value. For my purposes here, poetry constitutes a
linguistic meeting place, one that, however hospitable, requires adjustment

and accommodation on both sides of the neurological divide.
The example that I offer of neurotypical neurocosmopolitanism
ironically takes place in a medical context—specifically, a sensory
integration clinic--and it very much relies on a notion of the poetic.
Indeed, it understands the poetic in as broad a manner as possible. With
the poetic, according to Kenneth Burke, “the appeal of the form lies in its
embodied nature” (as cited n Park, 2010). Of course, to speak of
neurocosmopolitanism in a medical context is to risk re-medicalizing
autism, to risk undoing all of the work that the neurodiversity movement
has attempted to accomplish. I certainly wish to honor my son’s response
to Doctor Gupta’s question, “Should autism be treated?”—“Yes, treated
with respect”—but I do not understand it to constitute a renunciation of
any and all medical interventions; rather, I take it to be emphasizing the
importance of respect as a starting point in the clinician-patient relationship.
And, as we shall see, the treatment must be two-way: whatever healing

occurs must occur mutually. If respect is to flourish, it simply has to find
a foothold in medicine where, as Melissa Park, the scholar whose work I
will now discuss, puts it, “institutionalized forms of misrecognition are as
debilitating as disease processes or diagnostic categories” (2010). Locating
an ethos of neurocosmopolitanism in an explicitly therapeutic arena not
only combats “the biomedical legacy of isolating deficits to components
within particular bodies,” but also “restore[s],” Park says, “the health of
social relatedness” (2010).
In “Beyond Calculus: Apple-Apple-Apple-Ike and Other Embodied
pleasures for a Child Diagnosed with Autism in a Sensory Integration
Based Clinic” (2010), Park, an anthropologist and occupational therapist,
presents an ethnographical study of a child named Timur, a therapist
named Eva, and a mother named Julia as they “confound the isolation-
alienation metaphor of ‘autistic aloneness’ through the creation of
embodied pleasures” (2010). These embodied pleasures, asserts Park, “are
novel associations between multi-modal, affectively laden, bodily sensing
actions and experiences that emerge…in dramatically structured experiences
in ways that afford mutual recognition of the Other” (2010). The phrase
“dramatically structured experiences” is key, for how the clinician stages
the aim of social relatedness has everything to do with her success. For
Park, this staging must be keenly attentive to aesthetics or what I have
been calling the poetic. “A framework of aesthetics,” she argues,
“foregrounds the possible goods of the cultural forms structuring the
sensuousness of bodily-sensing of rhythm, movement, tactility, hues of
light and color, and nuances of sound that organize intersubjective and
joint actions” (2010).

Here Park explicitly alludes to Burke who understood that poetry’s
“organiz[ation],” its form, appeals as much to the listener’s body as to her
mind. Burke believes that rhythm “enjoys a special advantage in that [it]
is more closely allied with ‘bodily’ processes.” “Systole and diastole,” he
explains, “alternation of the feet in walking, inhalation and exhalation, up
and down, in and out, back and forth, such are the types of distinctly motor
experiences ‘tapped’ by rhythm” (as cited in Park, 2010). But whatever the
particular formal aspect, he wants us to see how “such arrangements of
subject matter… produce crescendo, contrast, comparison, balance,
repetition, disclosure, reversal, contraction, expansion, magnification,
series and so on” (as cited in Park, 2010). He wants us to see, that is, how
a poem’s non-symbolic and symbolic correspondences deliver the holistic
experience that is the poem. And, as I have taken pains to point out, it is
202 Chapter Eleven
precisely these non-symbolic patterning elements to which many autistics

are drawn.
By conceiving of occupational therapy as fundamentally poem-like,
Park proposes, in effect, the kind of neurocosmopolitan meeting place, or
halfway point, that I have advocated. For her, “a focus on aesthetics…
reframes the psychosocial, neurological, and sensorimotor terms that
measure the outcome of biomedical interventions toward those more
sensorial and ephemeral outcomes inherent in social relatedness itself”
(2010). A “bodily-sensing game of rhythm” (2010) “prepare[s] Timur’s
bodily-sensing for intentional attunement to Eva; that is, the rhythm and
sequence of their bodily-sensing, improvisatory game mutually attunes
them…to each other’s actions” (2010), which Parks believes is crucial for
learning. The game, interestingly enough, elicits speech from Timur.
“Apple, apple, apple, ike,” he says, but the words are less important than
the relational field, in Manning’s phrase, that the purposefully shaped,
sensory-rich encounter has made possible. “This is a conversation of
mutual recognition of the Other as an equal partner,” writes Park. “It is not
what is said, but the mutuality of unfolding gestures, despite what words
are spoken. Timur’s “apple, apple, apple, ike” no longer evokes a
disability, but a partner in a conversational flow” (2010).
This flow, not unlike what happens at a poetry reading, where the
words wash over the listener as much as they are decoded by him, moves
both the patient and the clinician into a space of embodied possibility—
what Park calls a “mutual healing of regard” (2010). Put another way, “a
gaze of vulnerability and respect transforms a biomedical discourse
enumerating deficits into a rhythm that cannot be calculated” (2010).
Timur takes in more of the human world and Eva takes in more of the
nonhuman one. She does so precisely by recognizing as valuable
everything that the habit of relentless categorization diminishes or
occludes. And, of course, she, too, is given the experience of pleasure.
Lest this poetic process be thought of as just some pretty, pie-in-the-
sky corrective, I should emphasize that it produces effects in patients that
both caregivers and practitioners would call “improvement,” even as these
effects might not be explained by standard evaluative criteria and even as
the issue of “improvement” might never be applied to the neurotypical
actors in this scenario. In her article Park argues for criteria as relationally
aware as the practice she follows, criteria that recognize the “tight
entanglement between intercorporeality and intersubjectivity” (2010)—
between, that is, movement, sensory stimulation, affect, cognition, speech,
and sociality. The knowledge we create, Park implies, must be as
dynamically interconnected as the human body (and larger world) from
which it arises. Who knows what such innovative occupational therapy

might make possible for Timur. Perhaps he will end up being the next
Amanda Baggs or Tito Mukhopadhyay.
By way of conclusion, let me point to a second example of
neurotypical neurocosmopolitanism—this one in a laboratory setting: the
research team of Laurent Mottron at the University of Montreal. Mottron
became identified with the neurodiversity movement by insisting that
autistics were “just of another kind” (Wolman, 2008). Reflecting on his
own development as a scientist in Wired Magazine, Mottron remarks, “I
wanted to go as far as I could to show that their perception—their brains—
are totally different” (Wolman, 2008). “Not damaged,” the Wired writer
clarifies. “Not dysfunctional. Just different.” Superior to neurotypicality
in a range of ways, this difference reveals itself as “a higher prevalence of
perfect pitch, enhanced ability with 3-D drawing and pattern recognition,
more accurate graphic recall, and various superior memory skills”
(Wolman, 2008).
What distinguishes Mottron from other progressive neuroscientists—
what makes his project neurocosmopolitan—is exactly his willingness “to
go as far as [he] could” in advancing the concept of neurodiversity.
Mottron has hired a number of autistics—most prominently Michelle
Dawson—to work alongside him in his lab. Far from superficially
inclusive and patronizing, the gesture not only honors the old disability
rights adage, “Nothing about us without us,” but it also redresses the
intractable problem of unemployment for people with disabilities. And it
continues to be very productive. Dawson recently served as the lead
author for an important study entitled “The Level and Nature of Autistic
Intelligence,” which showed that rates of metal retardation in the autistic

population had been dramatically overstated due to poorly suited testing
vehicles. Dawson had initially sought treatment at Mottron’s clinic but
quickly impressed him with “her gift for scientific analysis—the way she
can sniff through methodologies and statistical manipulation, hunting
down tiny errors and weak links in logic” (Wolman, 2008). Indeed, she
had spotted a problem with one of his studies, something it hadn’t
controlled for.
Once again, a meeting place or halfway point, this one obviously very
different from poetry, has been located and exploited. The result? Better
science, more dynamic neurointeraction or exchange, and a mutual healing
of regard. “Healing,” Park suggests, “entails a type of existential border
crossing, a recognition of and movement towards the Other” (2010). She
speaks of “transforming institutional misrecognition into moments of
recognizing socially occupied beings—the doing something with someone
204 Chapter Eleven
else that matters” (2010). Echoing Nancy Frazer, she calls for a “parity of
participation,” and we certainly see that in Mottron’s lab.
In his essay “Communicate with Me,” my son declares, The time has
come…to get ready for college, so I am here to ask you to help me. What
can you do to help me? The answer is to communicate with me. Boldly
reach out to me, and together we will goldenly share our views of the
world we long to greet (2010).
“The world we long to greet”—let us all think of a thousand ways to

usher in such a neurocosmopolitan world.
References
Antonetta, S. (2010). Dis. Seneca Review, 39-40 (2-1), 68-74.
Baggs, A. (2007). In my language. Retrieved October 8, 2012 from
http://www.youtube.com/watch?v=JnylM1hI2jc
—. (2010). Up in the clouds and down in the valley: my richness and
yours. Disability Studies Quarterly, 30 (1). Retrieved October 8, 2012
from http://dsq-sds.org/issue/view/43
Bragg, B. (1989). Lessons in laughter. Washington, D.C.: Gallaudet
U.P.Finding amanda. (2007). Anderson cooper 360. CNN. Television.
Gilroy, P. (2006). Postcolonial melancholia. New York: Columbia U.P.
Manning, E. (2009). What if it didn’t all begin and end with containment?
Toward a leakysense of self. Body & Society, 15 (3), 33-45.
Park, M. (2010). Beyond calculus: apple-apple-apple-ike and other
embodied pleasures for A child diagnosed with autism in a sensory

integration based clinic. Disability Studies Quarterly, 30 (1). Retrieved
October 8, 2012 from http://dsq-sds.org/issue/view/43
Prince. D. (2010a). My grave and the last sideshow tent. Seneca Review,
39-40 (2-1), 47-63.
—. (1995). Songs of the gorilla nation: my journey through autism. New
York: Three Rivers Press.
—. (2010b). The silence between: an autoethnographic examination of the
language prejudice and its impact on the assessment of autistic and
animal intelligence. Disability Studies Quarterly, 30 (1). Retrieved
Ramazani, J. (2001). The hybrid muse: postcolonial poetry in English.
Chicago: University of Chicago U.P.
Savarese, D.J. (2010). Communicate with me. Disability Studies
Quarterly, 30 (1). Retrieved October 8, 2012 from
http://dsq-sds.org/issue/view/43
Savarese, E. & Savarese, R.J. (2010). Autism and the concept of

neurodiversity, a special issue of Disability Studies Quarterly, 30 (1).
Retrieved October 8, 2012 from http://dsq-sds.org/issue/view/43
Savarese, R.J. (2010). More than a thing to ignore: an interview with Tito
Mukhopadhyay. Disability Studies Quarterly, 30 (1). Retrieved
Wolman, D. (2008). The truth about autism: scientists reconsider what
they think they know. Wired Magazine 16 (3). Retrieved October 8,
2012 from http://www.wired.com/medtech/health/magazine/16-03/ff_
autism?currentPage=all
CHAPTER TWELVE
NEURODIVERSITY AND PERSONHOOD
WILLIAM SIMKULET
A central claim of the neurodiversity movement is that autism ought to

be accepted as a legitimate variation to normal functioning, rather than a
mental disorder to be cured (Solomon, 2008). When taken as a rallying
cry for autistic rights this claim is relatively noncontroversial, but when
taken as a serious policy position it ignores important concerns about the
welfare of the autistic community. Consider the following scenario:
After a medical breakthrough allows for the regrowth of damaged
brain tissues, a leading neurological research institute and pharmaceutical
company begin research designed to back up valuable neurological patterns
and restore these regrown brain tissue to its former state and has met with
some limited success. Drug X is designed to be given to brain damaged
patients and replace or repair neurological damage. However, during the
trial period, doctors soon discovered that when given to individuals from
both the control group and those with traumatic brain injuries, say from
car accidents, the autistic individuals in both groups experienced an
unexpected side-effect; the drug overwrote their atypical neurological
processes and replaced them with those more similar to their neurotypical
peers.
The question this chapter seeks to answer is whether it would ever be
morally acceptable for autistic persons to take, or be given, drug X, and if
so, under what conditions. The morally right thing to do in any given
situation is that which one has the best reasons for. In the following three
sections, I discuss reasons one might have for taking, or giving, drug X,
and in the final section I discuss a reason not to take drug X.
Personhood
Autism is a neurological condition characterized by atypical social
interaction and communication skills, as well as repetitive behavior and
Neurodiversity and Personhood 207
stereotyped interests (DSM-IV, 2000). There are a number of similar

conditions, often referred to as the autism spectrum, that share many of
these characteristics. The American Psychiatric Association characterizes
these conditions as disorders because human beings with these conditions
develop and behave substantively differently than what is considered
normal functioning. The neurodiversity movement challenges this label,
contending that autism and similar conditions should be seen as a morally
legitimate variation to normal functioning, rather than disorders. Although
the behavior associated with autism often causes autistic individuals to
stand out, it typically little to no substantive harm. The neurodiversity
movement contends that autism is a "natural human variant" and that the
neurological condition has value (Jaarsma, 2011). An important part of
the neurodiversity movement can be characterized as an anti-cure
movement, which contends that autism is not a disease, illness, or
handicap, and thus the idea of a cure to autism is wrongheaded (Woodford,
2006). Others in the anti-cure movement contend that an autistic
individual's neurological processes are a substantive part of who they are,
and taking them away is doing substantive harm to that person.
It is outside the scope of this chapter to detail the differences between
the neurological processes of autistic individuals and their neurotypical
peers; however there is at least one distinction relative to neurological
function that is essential to discussing our obligations to autistic
individuals - personhood. Whether or not one is a person plays a
substantial role in determining our moral obligations towards them. As
such, it will be instrumentally valuable to adopt a nonarbitrary, commonsense
definition of personhood.
Personhood is sometimes defined as being biologically human, an

arbitrary biological category and inherently speciesist. In "Why Abortion
is Immoral," Don Marquis (1989) asserts "The term 'person' is typically
defined in terms of psychological characteristics, although there will
certainly be disagreement concerning which characteristics are most
important." Marquis criticizes psychological personhood views for failing
to adequately explain why (arbitrary) psychological characteristics should
matter morally when biological characteristics do not. A satisfactory
theory of personhood, as a moral category, cannot be based on mentalism
any more than it can be based on speciesism. However, although there is
substantive moral disagreement on the matter, it is uncontroversially true
that there are a certain set of psychological characteristics associated with
personhood that are at least prima facie instrumentally valuable; to name a
few - self-awareness, rationality, and the ability to form and abandon
208 Chapter Twelve
beliefs. A human being lacking any of these traits would have a hard time
navigating and flourishing in her world.
Rather than approach the concept of personhood from arbitrary
biological or psychological terms, I think the best way to understand
persons is in moral terms - persons are moral agents. Moral agents can be
said to have the right to life; meaning that all else being equal, it is morally
wrong to kill innocent moral agents. 1 To be a moral agent is to be the sort
of thing that can be truly morally responsible for one's actions. To be truly
morally responsible for one's actions requires that one is the nonarbitrary
source of one's actions; such that it makes sense to trace the goodness or
badness of one's actions back to the agent herself and no farther. Beings
that lack this are not in an enviable position, and to deprive one of such
freedom is amongst the greatest harms that can be done. For the remainder
of this chapter, I use the term "personhood" to pick out all and only the
things that can be appropriately held morally responsible for their actions.
By this, I do not mean to say that only persons have value, or that it is
morally acceptable to ignore the wellbeing of nonpersons.
The control principle, a foundational moral principle, states that one
cannot be morally responsible for something that is outside of one's
control. Assuming the truth of the control principle, personhood requires
free will, or the ability to choose one's actions from a list of possible
alternatives - it is to have the ability to choose either to do the right thing,
or to do the wrong thing. Moral agency, or personhood, of this kind is a
prerequisite for moral praiseworthiness. To be a full moral agent one must
be able to choose one's actions for reasons - to act for good reasons is to be
praiseworthy, to act for bad reasons is to be blameworthy. Beings who
lack the ability to differentiate good reasons from bad reasons cannot be
held fully morally responsible for their actions - for example children, the
ignorant, and human beings with various severe mental disorders often
lack the ability or experience to judge their actions, and are thus not
responsible for their actions in the same way a well informed adult moral
agent would be.
Children generally lack the psychological characteristics and knowledge
to be either responsible moral agents or fully morally responsible for their
actions. It is possible that there are some adult autistic human beings that
might similarly lack complete moral personhood of this kind, either as a
result of unsatisfactory education, or because some neurological processes
associated with autism might act as an impediment towards the informed
exercise of free will.
Moral agency is a necessary, but not sufficient, condition to live a
good, praiseworthy life. To be deprived of full personhood is a substantial
moral harm - arguably one of the worst possible harms that can befall a
human being. If, in some cases, autism prevents full personhood, then
autism in those cases causes a substantial moral harm to the individual. In
such cases, there would be a strong moral reason to provide drug X to the
autistic individual. For these individuals, drug X would, by stipulation,
cure them of the neurological impediments to full moral personhood. It is
worth noting that drug X, also by stipulation, does not discriminate
between good and bad aspects of autism, and may end up taking valuable
neurological processes away to be replaced with their lesser neurotypical
counterparts. If taking drug X is a morally acceptable treatment in this
cases, it is so in the same way amputation is a treatment to stop the spread
of gangrene - by taking the good with the bad.
Quality of Life
In the previous section, I argued that if atypical neurological processes
prevent an autistic individual from developing as a moral agent, it is one of
the greatest moral harms that can befall them because they can never be
truly morally praiseworthy for their good deeds. However, surely the vast
majority of autistic individuals aren't in such a position. What reason do
these persons have for considering drug X?
One of the most notable conditions associated with autism is the
difficulty many autistic persons have communicating with their neurotypical
peers. Compare this with other, neurotypical groups such as the mute and
deaf communities. Although these conditions do not undermine the moral
worth of persons, it does have a noticeable, often negative impact on their

quality of life. There is good reason to think that those who have trouble
communicating with others miss out on a significant number of goods that
come from interacting with other persons.
Set aside for the moment the personal goods that come from relatively
effortless verbal communication; being nonverbal serves as a substantial
impediment in one's professional life. Even in a nonbiased society, there
would be fewer quality professions open to nonverbal autistic persons than
their verbal peers. Many contemporary jobs for nonverbal autistic persons
are low paying jobs, such as reshelving library books, factory assembly
work, janitorial and cleaning jobs, restocking shelves, and data entry
(Grandin, 1999). However, even in these professions, nonverbal autistic
individuals face steep competition from their verbal peers who can
communicate with coworkers with less impediments.
Another concern facing autistic persons across the board are higher
than average medical costs.2 Even assuming no neurological bias and
210 Chapter Twelve
adequate professional specialization, there mere fact that autism is atypical,

and requires more specialization, leads to autistic persons having higher
medical costs over their lifetimes.
Concerns of this kind constitute reasons for autistic persons to consider
taking drug X, although it is ultimately an empirical question whether
autistic persons facing such concerns would be willing to give up the
valuable attributes of autism in exchange for a better chance at finding
adequate employment, lower medical costs, and whatever social goods are
made more easily available to their neurotypical counterparts.
There is good reason to worry about potential abuse here. Historically
many groups have been undervalued and oppressed by majorities unjustly.
Suppose our pharmaceutical company accidentally developed a drug Y,
that turned women into men on a genetic level, or a drug X that changed
any person's genetics into that of the Nazi's ideal German. Just as some
autistic persons might be tempted to take drug X to obtain social mobility,
wealth, and other social goods, so too women might be tempted to take
drug Y, and minorities in Nazi Germany willing to take drug Z. Despite
the practical benefits to taking Y and Z, many would look unfavorably on
those who would take Y and Z except in the most extreme circumstances.
Y and Z would serve as ad hoc solutions to the real social problems of
arbitrary discrimination on the bases of sex and race that peppers out
history as a species. To take these drugs would be to perpetuate
stereotypes and inequity based on arbitrary genetic traits and social roles.
Despite this, it is relatively easy to imagine a person of African descent
during WWII in Germany being given a choice between drug Z and death,
and although we would condemn the circumstances, surely choosing to
take drug Z, under such coercion, would be morally acceptable - even

morally obligatory. So, too, might taking drug X be morally acceptable to
avoid a substantially lesser quality of life brought about by mentalist bias
against autistic individuals. However, even without this mentalist bias,
this section has shown that there is a substantial quality of life gap
between at least some autistic persons and their neurotypical peers, and
this gap constitutes a reason to take drug X.
Many autistic people have been able to narrow, or even close, this gap.
If there were a different drug, X*, which changes nonverbal autistic
persons to be more like their verbal, higher functioning autistic peers,
taking X* might be preferable to X for nonverbal autistic persons,
allowing them to keep many of the valuable aspects of autism while
shedding undesirable aspects. However, in the absence of X*, nonverbal
autistic persons would have good reasons to take drug X as a means to
either escape mentalist bias or achieve substantive moral goods their

neurology stands in the way of.
Another concern about autism is that in many cases it is liberty-
undermining. One's liberty is undermined when one is prevented from
freely choosing something by means outside of one's control. In a sense,
all of our liberties are truncated by laws of nature, events that occurred in
the past, and other circumstances outside of our control, yet we value
having the ability to choose from multiple alternatives because the more
possibilities that are open to us, the greater our chances of satisfying our
desires. Unfortunately, many autistic persons have less freedom than
many of their neurological peers, both in terms of capability and difficulty.3
For many autistic persons, communicating with others is more
challenging than it is to their neurotypical peers; as such autism is
sometimes liberty-sapping because it makes some important things more
difficult than it is for their neurotypical peers. Additionally, many autistic
persons engage in repetitive, sometimes self-destructive, behavior. Such
behavior may be the result of neurological processes outside the control of
the person in question, and in such cases we can say autism is liberty-
sapping because it can rob the person of the ability to control her own
body and reactions. Autism can also be liberty-expanding in some ways -
for example, autistic persons often have better long-term memory than
their neurotypical peers and can utilize this to their advantage.4
For the most part, when agents seek to expand their liberty, through
education, training, practice, or discard their liberty, through drinking,
seclusion, or lack of exercise, we tend to say it is well within their right to
do so. When someone takes up an unhealthy lifestyle, or quits a promising
career to try to take their shot at being a big Hollywood actor, or trades
their reliable car in for a boat, we might agree that they have engaged in
morally bad actions - that they should have done otherwise - but while it
may be acceptable to question their actions, or try to convince them
otherwise, it is prima facie morally wrong to substitute our judgment for
theirs and force them to act as we want.
Because drug X is liberty-expanding (and contracting), apart from
questions whether taking X is morally acceptable, there is good reason to
think one ought to have the right to take it. Whether an autistic person is
willing to trade parts of her current neurological framework for her more
neurotypical counterpart's seems no less within her rights than any of the
decidedly less beneficial options discussed above. It's worth noting that in
such circumstances, it might be inappropriate to call X a "cure" for
anything, but it strikes me the anti-cure part of the neurodiversity
212 Chapter Twelve
movement is not concerned with the semantic issue; it is concerned with

rejecting the notion that autism is an impediment to be removed.
Consent
In the previous sections we've seen that in some cases, some aspects of
autism might constitute serious harms and some less serious harms. In the
second section, I argued that autistic persons ought to have the same right
to self-determination as any person, including the right to expand or limit
their opportunities as they see fit. In this section, I seek to address whether
parents and guardians exert similar rights over those autistic individuals
they are charged with who cannot give their own informed consent. To
that end, it is important to distinguish between two categories of autistic
individuals - first, those judged to be incapable of achieving personhood
without intervention, and second those who are expected to achieve full
personhood at some point in the future without intervention.
In the first section, I argued personhood is a necessary condition to live
a morally praiseworthy life. In light of this, informed legal guardians who
are taking care of autistic individuals of the first kind, those whose autism
stands between them and full moral personhood, have a prima facie strong
moral obligation to consent to treating their charges with drug X if
available. Cases where informed legal guardians fail to do so would seem
to constitute abuse; analogous to parents of coma patient victims refusing
treatment that is expected to awake their charges from their coma.
In cases where both X and X* are available, the anti-cure movement
might advocate choosing X* over X. If X* would liberate an autistic

individual to develop full personhood, assuming no negative side effects
associated with X* and that X would still be available to said person in the
future, there is reason to believe X* is a morally acceptable alternative to
X - at the very least, it is a conservative alternative. When no such
treatment is available, guardians of these autistic individuals have a moral
obligation to seek one out.
Often there are substantial risks involved with medical treatments,
especially treatments of the kind in question. Suppose there was no X or
X* available, but instead there was an experimental drug XX which
medical professionals have shown has a small chance of facilitating full
personhood to autistic non-persons, but that has dangerous, often fatal,
side effects. Would it be morally acceptable for guardians to give XX to
those they take care of? Because moral agency is such an instrumental
and intrinsic good, it seems guardians would not only be allowed to give
this drug, but obligated to do so.5 To not provide such treatment is to deny
the autistic non-person individual a chance at a life worth living. (Note

that whether or not an individual is a person depends upon their
capabilities, not their parent's personal preferences. In situations where
there is some question about the matter, it strikes me one ought to err on
the side of caution.)
What of parents or guardians who have good reason to believe their
charges will develop into full persons on their own? As with all parents
and guardians, they have a moral obligation to do what they believe to be
in the best interest of those they take care of. Above, I argued that some
aspects of autism can deprive autistic individuals of substantial moral
goods. At least in some cases, it's possible that the beneficial aspects of
autism do not offer substantive compensation for this loss. If parents have
good reason to believe this is going to be the case, they have a moral
obligation to provide drug X as soon as possible, so as to prevent the
deprivation of as many good as possible.
There is, I think, good reason to worry that parents or legal guardians
will sometimes make the choice to give drug X not to benefit those they
take care of, but to benefit themselves. Similarly, guardians might
overestimate mentalist bias against autistic persons, and use this as a
rationale for treatment. Drug X would, no doubt, be regulated in much the
same way as many other dangerous prescription drugs are regulated. As
such, in extreme cases, medical professions could step in and stop such
potential abuse - for example, imagine an autistic child whose
communication skills are slightly below average, but whose high
performance in other areas can be reasonably attributed to her autism. If
the parents of such a child were to approach a physician about drug X, a
nonbiased physician might have a moral obligation to recommend not

treating the child and to report the parents for potential child abuse if they
should keep trying to obtain the drug in much the same way a physician
might if parents repeatedly requested dangerous prescription drugs for
conditions their child does not have. In cases like this, an informed
guardian has good reason to think drug X would cause more harm than
good to the child. Unfortunately physicians will not always be in the
position to catch such things, and some parents may consent to give their
child drug X for the wrong reasons, and may ultimately harm the child by
depriving them of some of their future goods. This kind of problem is not
unique to autism cases, though, and it is a byproduct of the leeway parents
are given when they are allowed to raise children.
214 Chapter Twelve
An Anti-Cure Response
In some cases, some aspects of autism may constitute serious harms to
autistic individuals. I have argued that autistic persons have the right to
pursue treatment for autism if so desired, and that they may have good
reason to do so. I have also argued that we have a moral obligation to
confer personhood on autistic nonpersons if possible, as personhood is a
prerequisite for moral praiseworthiness. Finally, I have argued that
guardians of autistic individuals have a moral obligation to pursue the
treatment they believe is in the best interest of those they are charged with
taking care of, and in many, but not all cases, this may constitute treatment
of autism. This has all been built on an assumption - that an autistic
human being is the same person prior to treatment that they would be post
treatment. Jim Sinclair challenges this notion, contending that autism is
inseparable from the individual (Sinclair, 1993). According to Sinclair, to
wish that an autistic person is cured just is to wish that person disappeared
and another, completely different person existed in her place.
There is an ambiguity in Sinclair's claim - the same sort of ambiguity
that faces anyone attempting to articulate a theory of personal identity over
time. The overwhelming commonsense moral intuition is that in the
majority of cases, the person you are now is numerically identical to the
person you were 5 minutes ago, the person you were as a child, and the
person you will be 5 minutes or 5 years from now (if all goes well).
Assuming this, personal identity survives substantial neurological change -
it survives even the change from non-person to person. Our childhood
selves had a radically different neurology and understanding of the world
than we do, yet we believe, in all relevant respects, that we are the same
person we once were. If this is true, personal identity survives such
changes.
There are exceptions to this commonsense notion of personal identity -
one person may become a separate, numerically distinct person by a
number of extreme, atypical, changes to their neurological composition -
for example, it is sometimes said that an amnesiac might be a different
person than they were before they lost their memory. When one's cerebral
hemispheres are separated, arguably one person has become two separate
persons, neither of which is numerically identical to who they were before.
Similarly, the destruction of a large portion of one's mind might constitute
the creation of a new person. There is, at least, a passing similarity
between these kinds of radical, often artificial or atypical, changes to one's
mind and the change drug X is stipulated to have in autistic individuals.
The primary problem with Sinclair's position is that it rests upon the
assumption that we are who we are because of our composite neurology -
rob us of a piece of what makes us tick, and you have a different watch.
But this is a mistake - our commonsense intuition is that we were the same
people we were as kids, even though we have grown up, changed our
priorities and adopted both radically different beliefs and radically
different ways of viewing the world than we had as children. If autism is
to be understood as a set of neurological traits, it seems plausible that
identity persists through the removal and replacement of these traits by
drug X just as it would by the removal or replacement of any number of
other neurological traits that come and go as we develop. This is to say
that there is no reason to think that our personal identity is disproportionately
related to those particular neurological traits than any other neurological
traits. For Sinclair's assertion to be taken seriously would require that
autism not simply be understood as a small set of traits, but a substantial
percentage of an autistic human's neurology - to rob such a human of
autism, then, would be akin to ripping out a hemisphere of their mind.
This, I think, is a mistake - an autistic person is more than just autism with
a little bit of extra neurotypical bits dangling; they are a person with a
certain set of neurological traits. One can take pride in these traits, just as
one might take pride in any number of other traits, abilities, or beliefs one
has, without being defined by them.
Conclusion
The neurodiversity movement is an important one - many human

beings with autism are uncontroversially full moral agents living robust
lives full of goods. To discriminate against such persons solely because
they are not neurotypical is arbitrary and immoral. That said, there are
many traits associated with autism that may make one's life significantly
worse off than if one did not have these traits. These liberty-sapping traits
are like any other liberty-sapping trait - things to be cast aside if the price
is worth paying. I've argued that in cases where autism delays or denies
personhood, it is standing in the way of a good life and should be removed
if possible, and I've argued autistic moral agents have the right to pursue
the removal of their autism, and that in some cases they may have good
reason to do so. Furthermore, I've argued that legal guardians of autistic
persons and non-persons have a moral obligation to do what they believe
is in the best interest of those they are responsible for.
216 Chapter Twelve
References
American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders, 4th, text revision (DSM-IV-TR) ed. 2000. ISBN 0-
89042-025-4, accessed 2-12-2012
http://www.cdc.gov/ncbddd/autism/hcp-dsm.html
Grandin, Temple, 1999, Choosing the Right Job for People with Autism or
Asperger's Syndrome, accessed 2-18-2012,
http://www.autism.com/ind_choosing_job.asp
Jaarsma, Pier; Welin, Stellan, 2011, "Autism as a Natural Human
Variation: Reflections on the Claims of the Neurodiversity Movement,"
Health Care Anal, accessed 2-17-2012
http://www.imh.liu.se/avd_halsa_samhalle/filarkiv1/1.264263/Jaarsma
Welin2011Autismasanaturalvariation.pdf
Marquis, Don, 1989, “Why Abortion is Immoral,” The Journal of
Philosophy, Vol. 86, No. 4 (Apr., 1989), pp. 183-202
Sinclair, Jim (1993). "Don't mourn for us," The Edmonds Institute,
retrieved 2007-11-07,
http://en.wikipedia.org/wiki/Autism_rights_movement, originally:
http://www.edmonds-institute.org/dontmour.html
Solomon, Andrew, 2008-05-25, "The Autism Rights Movement," New
York, accessed 2-12-2012 http://nymag.com/news/features/47225/
Woodford, Gillian, 2006, "'We Don't Need to be Cured' Autistics Say,"
National Review of Medicine, Volume 3. No. 8., accessed 2-17-2012
http://www.nationalreviewofmedicine.com/issue/2006/04_30/3_patient
s_practice05_8.html
CHAPTER THIRTEEN
PSYCHOPATHY, MORAL REASONS,

AND RESPONSIBILITY1
ERICK RAMIREZ
Moral philosophers aim to provide a plausible explanation and

justification of our moral practices. Psychopaths are an undeniable part of
the moral world and so need to be accommodated by moral theory. One
important debate in contemporary ethics centers on psychopathic
responsibility. Responsibility is thought by some to require a capacity to
understand emotions like guilt, shame, and resentment. Psychopaths, we
are learning, have significant difficulty understanding these emotions. This
apparent fact about psychopathy leaves us with several questions: Does the
psychopath's inability to feel or understand moral emotions imply that they
are not morally responsible for their actions? If psychopaths are not
morally responsible for their actions can they still be held accountable in
some way?
In this chapter I argue that psychopaths are open to several forms of

accountability despite the fact that they are not morally responsible for
their actions. I begin with a brief history of the concept of psychopathy. I
also address an unanswered psychological question about the link between
psychopathy and criminal behavior. I then turn my attention to debates
about the moral responsibility of the psychopath. Psychopaths are
competent practical reasoners and yet appear to suffer from important
affective and motivational deficits especially in terms of their ability to
understand moral norms. As a result, psychopathic agency raises problems
for standard theories of responsibility. Reactive attitude theories of
responsibility, theories that make an understanding of moral emotions an
important part of moral responsibility, traditionally hold that psychopaths
are exempt from moral responsibility because of their affective deficits.
Finally, I argue that psychopaths remain open to several forms of
accountability stemming from the kinds of judgments that psychopathic
choices express about the value of other agents.
218 Chapter Thirteen
A Brief History of Psychopathy

In 1739 David Hume, a Sentimentalist moral philosopher, wrote his
Treatise of Human Nature; in it he argued that moral properties were
constituted by innate feelings he called approbation and disapprobation
(Hume 1739/2000, 193-194). Although Hume believed that the capacity to
feel approbation and disapprobation was innate, he considered the
possibility that some people may be born without this capacity. In his later
Enquiry Concerning the Principles of Morals, Hume wrote about agents
who might lack the capacity to feel disapprobation toward the violation of
moral norms. In doing so he made an early philosophical reference to a
type of agent who would now be suspected of being a psychopath. Hume
mentions an especially problematic kind of person, a “sensible knave,”
who
[M]ay think, that an act of iniquity or infidelity will make a considerable
addition to his fortune without causing any considerable breach in the
social union and confederacy. That honesty is the best policy, may be a
good general rule; but is liable to many exceptions: And he, it may,
perhaps, be thought, conducts himself with most wisdom, who observes the
general rule, and takes advantage of all the exceptions” (Hume 1751/1998,
155).
Hume's knave realizes that being moral, while sometimes beneficial,

comes with costs that could be avoided by behaving badly. Although most
of us avoid bad behavior because of the pain of feeling guilt, shame, or
remorse, Hume claimed that sensible knaves would “feel no reluctance to
the thoughts of villainy or baseness” that occur to them (Hume 1751/1998,

156). Sensible knaves believe that their interests are better served by
obeying moral rules only when it is to their advantage. They do not feel
guilt, shame, or remorse when they violate moral norms. If sensible knaves
were incapable of guilt or shame (i.e. if they could not feel disapprobation
toward immoral behavior) then Hume worried that sensible knaves could
be morally incorrigible: they could be insensitive to moral reasons.
Hume's sensible knave has characteristics that correspond to what
would now be seen as diagnostic criteria for psychopathy: selfishness, lack
of empathy or guilt, and antisocial or immoral behavior. Hume's sensible
knave represents an early philosophical treatment of psychopathy. A
clinical description of psychopathy would not appear for another one
hundred and ninety years. 1941 saw the publishing of Hervey Cleckley's
The Mask of Sanity, a work that fundamentally shaped modern conceptions
of psychopathic agency.
Psychopathy, Moral Reasons, and Responsibility 219
The Cleckley Psychopath

Hervey Cleckley was a clinical psychiatrist whose work brought him
into contact with patients who were repeatedly incarcerated or committed
to mental institutions for crimes ranging from check fraud, domestic
violence, theft, and bigamy to assault. Cleckley noticed that some of his
patients shared a cluster of personality traits that made them expert
manipulators, but also left them unable to understand why they had been
incarcerated or hospitalized. Although they claimed to understand right
and wrong, Cleckley argued that this was a show his patients put on to
take advantage of others. Cleckley's patients had symptoms that did not
correspond to a mental illness or disorder recognized by psychiatrists of
his day. In the preface to The Mask of Sanity, Cleckley noted that, at the
time, “[n]o definite or consistent attitude on the part of psychiatric
authorities could be adduced” to explain the behavior of his patients and
that “no useful legal precedent at all could be invoked, and no institutions
found in which help might be sought by the community” to treat them
(Cleckley 1941/1988, xi). Cleckley called his patients “psychopaths” and
tried to define a set of diagnostic traits to help psychiatrists identify and
care for them.
Like Hume's sensible knave, Cleckley's psychopaths participate in their
societies while simultaneously failing to live by moral rules. Cleckley's
psychopaths create a convincing “mask of sanity” that lets them pass as
upstanding members of society even as they violate their community's
most sacred norms. Cleckley describes the mindset of agents like Hume's
sensible knave in great detail. In describing one of his patients, “Frank,”
Cleckley argued that words like

“[b]eauty and ugliness, except in a very superficial sense, goodness, evil,
love, horror, and humor have no actual meaning, no power to move him.
He is, furthermore, lacking in the ability to see that others are moved. It is
as though he were colorblind, despite his sharp intelligence, to this aspect
of human existence. It cannot be explained to him because there is nothing
in his orbit of awareness that can bridge the gap with comparison. He can
repeat the words and say glibly that he understands, and there is no way for
him to realize that he does not understand” (Cleckley 1941/1988, 40).
Cleckley claimed that psychopaths violated moral norms because they

were unable to understand them. Psychologists and psychiatrists still
believe that moral words do not have meaning to psychopaths and that
they learn to parrot them in order to further their own ends.
The alleged moral blindness of the psychopath interests moral
philosophers. It is important to note that although we associate psychopathy
with violent or inexplicable crimes, most of Cleckley's patients were not

murderers. Cleckley's patients led lives defined more by lying, cheating,
occasional violence, and persistent manipulation than recklessness, assault,
or murder. Cleckley argued that psychopaths had specific characterological
traits. He identified sixteen traits ranging from “superficial charm” and
“absence of remorse and shame” to “pathological egocentricity” and
“untruthfulness and insincerity” that most of his patients shared (Cleckley
1941/1988, 338-399). Cleckley's research went on to spark widespread
interest in the study of psychopaths. Robert Hare, who followed in
Cleckley's path, would come to define contemporary conceptions of
psychopathy. His views have produced both controversy and productive
inquiry. The diagnostic tools Hare would develop have been applied to
criminals, (Hare 1999, 31), corporate CEOs, (Babiak, Neumann, and Hare
2010, 174), children, and have even been modified to identify
psychopathic chimpanzees (Lilienfeld, Gershon, Duke, Marino, and de
Waal 1999, 365). Hare's theories have had such a widespread impact that
psychopaths are often referred to as “Hare Psychopaths” (Hervé 2007, 31).
Hare and the PCL-R

In its revised form, Hare's most famous diagnostic tool for
psychopathy is the primary method for diagnosing psychopaths: the
Psychopathy Checklist (PCL-R). Like Cleckley, Hare understands
psychopathy as composed of characterological traits including many from
Cleckley's list: grandiosity, domination, and lack of guilt, remorse, or
empathy (Hare and Neumann 2010, 93-95). Hare also includes behavioral
traits like impulsivity and violations of social and legal norms (Hare and
Neumann 2010, 95). Although developed initially for use with men in
correctional or psychiatric institutions, Hare's PCL-R has been adapted for
use with juveniles (Ridenour and Dean 2001, 227), women (Weizmann-
Henelius, Sailas, Viemerö, and Eronen 2002, 355), and outside of
correctional institutions (DeMateo, Heilburn, and Marczyk 2006, 133).
The PCL-R is a two part diagnostic tool containing both a structured
interview and a historical behavioral assessment. Interviewers ask
questions that aim to identify the degree to which the subject might be said
to possess a psychopathic personality trait. Interviewers rate each question
from 0-2 depending on whether subjects manifest the trait in question
strongly (2), somewhat (1), or not at all (0). A “perfect” score, the score
most indicative of psychopathy, is 40 points. Normal subjects score
between 5 and 6 points; scores are slightly higher for incarcerated subjects
and range between 12-18 points on average (Clotilde-Penteado, Arboleda-

Florez, and Portela Camara 2005, 7).
There is some controversy about where clinicians should mark the
cutoff between non-psychopathic, partially psychopathic, and full-blown
psychopathic scores. Currently, the cutoff score for a diagnosis of
psychopathy ranges from 25-30 depending on the country (Hare, Clark,
Grann, and Thornton 2000, 635). Approximately 15-38% of the male
prison population has a PCL-R score that falls between 25-40 (Hildebrand
& deRuiter 2004, 233).
Although Hare's Psychopathy Checklist is the standard diagnostic tool
for identifying violent offenders, “psychopathy” is not among the 400-plus
mental diseases and disorders in the American Psychiatric Association's
Diagnostic and Statistical Manual (DSM IV-TR) (American Psychiatric
Association 2000). The exclusion of psychopathy from the current version
of the DSM and each of its earlier editions, stems from persistent debates
about the construct validity of psychopathy.
Is Psychopathy A Mental Illness?

In place of psychopathy the DSM-IV uses “Antisocial Personality
Disorder” (ASPD) to cover cases of persistent and harmful norm violators
(American Psychiatric Association 2000). The descriptive paragraphs
preceding the diagnostic traits for ASPD in the DSM make it clear that, in
the minds of the authors of the DSM, ASPD and psychopathy are
equivalent diagnoses. ASPD, they say, “has also been referred to as
psychopathy, sociopathy, or dyssocial personality disorder” (American

Psychiatric Association 2000, 702; Hervé 2007). Along similar lines, some
have questioned whether psychopathy is a mental illness at all (Edens,
Lilienfeld, Marcus, Poythress 2006, 131), whether psychopathy is a
distinct mental illness rather than a form of ASPD, or whether the PCL-R
is the best way of measuring psychopathy. Each of these questions is at the
heart of current debates about psychopathy. In this chapter, I address each
of these questions in turn.
The best available evidence suggests that ASPD and psychopathy,
diagnosed using the PCL-R, are distinct conditions. ASPD and
psychopathy rely on different diagnostic traits. A diagnosis of ASPD is
primarily based on historical behavior, which might be assessed, for
example, by asking whether a patient has a history of repeated
incarceration, fighting, and conning (Gurley 2009, 297). Psychopathy, on
the other hand, refers primarily to agents with a distinctive set of
personality traits. The DSM is a diagnostic manual intended to be used in a
clinical setting to diagnose and treat illness. In the DSM, a diagnosis of

ASPD is based on easily observable criminal acts instead of personality
traits. Hare claims that ASPD rather than psychopathy appears in the DSM
because of a need to guarantee high rates of agreement between clinicians
diagnosing patients in a wide variety of contexts (i.e. private practice,
schools, penal institutions, etc.) (Hare, Hart, and Harpur 1991, 391). It is
easier, Hare argues, for clinicians to agree on a diagnosis when it is based
on facts about a patient's past than it is when clinicians must each infer a
patient's character traits. However, evidence suggesting that ASPD and
psychopathy are distinct mental constructs is mounting. About 80% of
incarcerated prisoners meet the diagnostic criteria for ASPD while only
15%-38% qualify as psychopaths under the PCL-R standard (Hildebrand
and deRuiter 2004; Gurley 2009). Hare Psychopaths are also more likely
to violently re-offend than those with ASPD, and to respond to treatment
differently (Hart and Hare 1997; Barbaree 2005). However, although
psychopathy is distinguishable from ASPD, doubts have been recently
raised about whether the PCL-R accurately measures the construct of
psychopathy.
Psychologists Jennifer Skeem and David Cooke have raised doubts
about the use of the PCL-R as a measure of psychopathy (Skeem and
Cooke 2010a 433; Skeem and Cooke 2010b, 455). Skeem and Cooke
argue that the PCL-R was developed as a tool to predict violent or
incorrigible offenders in forensic contexts; as a result, the PCL-R itself
reifies psychopathy as manifesting in violent, criminal, or antisocial
behavior. They claim that the adoption of the PCL-R as a model of
psychopathy links psychopathy with these behaviors unnecessarily (Skeem
and Cooke 2010, 434). Criminal behavior is diagnostic for (i.e. provides
evidence for a diagnosis of) ASPD and PCL-R but there are important
differences. The PCL-R contains multiple factors, multiple diagnostic
criteria, that make up the construct of psychopathy. Only one of these
factors makes reference to prior criminal behavior; the other factors are
characterological (glibness, selfishness, lack of empathy, etc.). On the
other hand, a person can be diagnosed with ASPD based purely on their
prior criminal behavior. Although there is an important difference between
PCL-R and ASPD in terms of the diagnostic relevance of past criminal
behavior, Skeem and Cooke argue that the PCL-R associates antisocial
personality traits with violent or criminal actions too strongly. They
instead suggest that the antisocial traits characteristic of psychopathy need
not result in or manifest as violent or criminal behavior. They go on to
argue that Hare's focus on antisocial behavior as a marker for antisocial
personality traits strays from the defining features of psychopathy seen in
Cleckley's classic description of psychopathy: that the psychopath is

callous and unemotional. Evidence suggests that Skeem and Cooke's
criticisms are right.
Studies show that antisocial behavior and callous/unemotional traits
are not correlated with one another; this is a significant results because it
implies that antisocial and criminal behavior are distinct from, and not
necessary for, a diagnosis of psychopathy (Vanman, Mejia, Dawson,
Schell, and Raine 2003). Furthermore, a new category of psychopath, the
“successful psychopath,” appears to justify Skeem and Cooke's criticisms
of Hare's PCL-R. Successful psychopaths are persons who meet diagnostic
criteria for psychopathy but who avoid incarceration; some even achieve
great success in corporate or political institutions (Stevens, Deuling, and
Armenakis 2011, 139; Mullins-Sweat, Glover, Derefinko, Miller, and
Widiger 2010, 554). If successful psychopaths exist, then it is possible for
people to manifest the characterological traits of psychopathy but avoid
serious criminal behavior.2 If true, then Skeem and Cooke's claim that
criminal and violent behavior are not diagnostically related to psychopathy
is vindicated.
Psychopathy is a condition that picks out a person who fails to
understand or appreciate the wrongness of immoral behavior. They cannot
feel guilty about behaving badly nor can they empathize with the pain and
suffering their actions (legal or illegal) cause others. Moral philosophers
have taken a keen interest in psychopaths because they demonstrate
aberrant agency and because that agency appears intractable (it does not
appear treatable) (Barbaree 2005, 1120-1125). In the following section I
explore how the growing body of research on psychopathic agency has
played a significant role in debates about moral agency and moral

responsibility. I argue that psychopaths cannot be held responsible
according to one standard theory of moral responsibility, and that, despite
this, psychopathic wrongdoing can merit hate, scorn, and punishment.
Moral Reasons, Moral Responsibility,

and the Psychopath
Hume confessed “that, if a man think, that [the knave's style of]
reasoning much requires an answer, it will be a little difficult to find any,
which will to him appear satisfactory and convincing” (Hume 1751/1998,
155). It is not clear whether Hume believed that the knave could understand
moral reasons but lacked the motivation to act on them or whether the
knave could not understand moral reasons at all. Both interpretations have
been the source of philosophical debates. Psychopathic agency impacts
how we think about the nature of moral reasons and moral motivation.
Some philosophers argue that psychopaths are capable of understanding
moral norms without feeling motivated to act upon them and that this tells
us something important about the nature of moral reasons.3 Furthermore,
because psychopathic agency combines the paradoxical capacities of
pragmatic rationality and moral incompetence it poses a challenge to
theories of moral responsibility. While psychopaths are capable of causing
immense suffering to others and of violating our trust, psychopathic
agency leaves moral reasons outside of what Cleckley called their “orbit of
awareness” (Cleckley 1941/1988, 40). For these reasons, psychopaths are
said to suffer from moral blindness. Philosophers disagree on whether this
moral blindness exempts them from responsibility for their bad behavior.
In this section I map the contours of the traditional debate over moral
responsibility. I pay special attention to views that give pride of place to
moral emotions; I then show why adherents of these theories claim that
psychopaths cannot be held accountable for their actions. I conclude by
offering an alternative to this view. I argue that psychopaths are open to
several forms of normative address despite their lack of moral
responsibility. These forms of address are based on what psychopathic
choices express, the kinds of attitudes psychopathic harms evoke, and
ultimately the forms of punishment psychopathic actions merit.
The Faces of Responsibility and Reactive Attitude

Approaches
There are close connections between our concepts of free will and
moral responsibility. In many cases it appears that an action of ours must
be free in order for us to be responsible for it. Notoriously, philosophers
disagree over how to define free actions. Some argue that free actions
require that physical determinism, the claim that the laws of physics
necessitate every action that has happened and that ever will happen, is
false; freedom, on this understanding, requires the ability to act in ways
that are not necessitated by past events, it requires the existence of genuine
metaphysical alternative possibilities (Pereboom 1995, 23-26; O'Connor
1995, 173). Others argue that a will can be free even if determinism is true
so long as we are open to reasons, are able to deliberate about our options,
and act on the products of our deliberation (Fischer and Ravizza 1998, 62-
91; Frankfurt 1971, 10-14). Others opt for an asymmetric view; they claim
that morally praiseworthy acts can be determined and still be praiseworthy
but that moral blame is appropriate if (and only if) the wrongdoer could
have done otherwise (Wolf 1980, 151; Nelkin 2008, 497). One of the main
reasons philosophers worry about freedom is because our conception of a

free action appears bound up with our conceptions of morally responsible
agency.
Freedom is important for responsibility because free actions and unfree
actions help us understand the psychological capacities that constitute
responsible agency. Free actions function as paradigmatic cases of morally
responsible agency while unfree actions help us better understand the
factors that subvert that agency. Cases of duress are instructive. When a
person is put under duress he or she is threatened with a significant harm if
they fail to comply with an order. The size and immediacy of a duress
threat is often thought to excuse a person, it diminishes a person's
responsibility, because duress threats undermine freedom (Frankfurt 1969,
832-833). Cases like duress, insanity, brainwashing, etc. where a person is
intuitively not responsible for his or her behavior help philosophers model
the capacities required for morally responsible agency. Before I turn my
attention to the factors that result in unfree action and the role psychopathy
plays in improving theories of responsibility, I first elaborate an important
distinction between two judgments about responsibility.
Gary Watson argued that when we hold someone responsible we make
two different judgments each with its own criteria for correctness; these
judgments together form the concept of moral responsibility. Watson
called these two aspects of responsibility its two “faces”: attributability
and accountability (Watson 1996).4 Because attributability and accountability
are distinct, it is possible for a person to satisfy the criteria for one and not
the other and therefore it is important to keep these two judgments distinct.
Attributability refers to instances where we are seen as the proper
source of an action. We are the proper sources of an action if the action

results from our choices and if the action stems from the use of our
deliberative powers. Actions are attributable to us because we are able to
deliberate on and adjust our desires, we can form ends, and we can act on
our deliberations. These actions reflect on us and our agency. When I
maliciously step on your toes you are correct in attributing that action to
me. When an earthquake knocks several books over and they fall on your
toes, the action is not attributable to anyone. If an infant knocks the same
books onto your toes that action is also not attributable to anyone because
infants do not yet have the sort of agency to be bearers of attributability.
Infants cannot deliberate about their ends and modify them in the face of
reason. Attributability, Watson claimed, is concerned with “one’s purposes,
ends, choices, concerns, cares, attachments, and commitments” and infants
and earthquakes lack many (or all) of these capacities (Watson 2004, 287).
Accountability presupposes attributability but concerns itself with our

responses to an agent's action. In the previous paragraph I wronged you by
stepping on your toes maliciously. This action is attributable to me and it
reflects poorly on my character. The accountability face of moral
responsibility poses questions about whether it is fair (or justifiable) for
you (or anyone else, including myself) to do anything to me as a result of
my wrongdoing. Holding a person accountable can range from mild,
“dirty” looks, to severe; the extreme end of the accountability spectrum is
marked by actions like social exclusion or even death (Watson 1996, 266-
267). Watson made clear that questions about attributability and
accountability are settled by different considerations even though our
judgments about moral responsibility appear unitary.5 Your judgment that
I am responsible for stepping on your toes (a judgment about
attributability), may be accompanied by yelling at me (a mild form of
accountability). It is one thing to say that I am the source of an action, a
judgment about attributability, and another to say that you are justified in
doing something to me, praise or blame, because of my action. The latter
is a judgment about accountability. These are Watson's two faces of moral
responsibility.
Competing theories of moral responsibility approach attributability and
accountability from different perspectives. One family of theories appeals
to our moral emotions, “reactive attitudes,” to understand Watson's two
faces of responsibility. Reactive attitude theories of responsibility begin by
noting that reactive attitudes, feelings like resentment, indignation, guilt,
shame, love, etc., are intimately involved with the accountability face of
moral responsibility (Strawson 1962; Wallace 1994). To resent someone is
to hold them accountable. Reactive attitudes are also understood as a

means of social address, they communicate the fact that we are holding
someone accountable. Reactive attitudes also appear to respond to the
quality of their target's will. Resentment, for example, is a reactive attitude
that becomes appropriate only when we resent someone who has
unrepentantly wronged us. The fact that a person is unrepentant, in this
case, is what seems to justify resentment.
The reactive attitude theorist argues that what makes it appropriate for
us to respond reactively (i.e. what makes it appropriate for us to resent
someone) helps to define our understanding of attributability as well. The
reactive attitude theorist blurs the separation Watson created between the
two faces. However, reactive attitude theorists believe that understanding
the role of the reactive attitudes in setting the conditions for attributability
deepens our understanding of the concept. A reactive attitude theory of
attributability (A) and accountability (x) define the terms as follows:
R(A): A person is the proper source of their action if and only if they
are an apt target for reactive emotions in a general sense.
R(x): A person is morally responsible for a specific action, x if and
only if they are an apt target for the reactive attitudes generally and it is
appropriate to respond to the agent reactively in virtue of his or her x-ing.
Jay Wallace holds a reactive attitude theory of accountability. On his

view, what makes it appropriate to hold someone responsible for a specific
action are the conditions that make them an appropriate target of
resentment, indignation, or guilt (when we hold ourselves responsible) in
that case; these conditions will turn out to presume specific notions of
agency and fairness (Wallace 1994, 62-72). Accountability, then, is
understood in terms of the conditions that determine when it is appropriate
to express (as opposed to merely feeling without expressing) reactive
attitudes to an offending agent.
According to reactive attitude theorists,when all goes normally things
work like this: 1) I deliberate about stepping on your toes 2) I step on your
toes 3) you feel pain 4) you judge that I did this on purpose 5) you get
angry 6) you express your anger by yelling at me and 7) you believe that it
was appropriate for you to do this. Item 7 is important. Reactive attitude
theorists do not believe that every reactive attitude is justified. It is also
possible that we might not feel an emotion even when it would be
appropriate for us to do so. This is clearest in cases where things don't go
normally. If you learn that I stepped on your toes to kill a poisonous spider
that was ready to bite you, then it would be inappropriate to resent me
(even if you can't help yourself). Abnormal cases invite us to modify our
reactive attitudes and help define the concept of moral responsibility

(Strawson 1962; Wallace 1994, 118-186).
Abnormal cases show us that behavior can be excused; they also show
us when agents are exempt from reactive attitudes in a more global sense.
Reactive attitude theorists have trouble deciding whether psychopathic
agency excuses psychopathic behavior, globally exempts them from
responsibility or whether psychopaths can still be held responsible. In the
next section I explain the difference between an excuse and an exemption
before I argue that psychopaths should be considered open to forms of
reactive accountability despite their lack of moral responsibility.
Excuses and Exemptions

Reactive attitudes like resentment and guilt focus on the quality of a
person's will. When we resent someone we do so not so much because of
what they have done but because of what their will expresses about their
action. When you rightly resent me for having stepped on your toes
maliciously you do so because of my malicious intent. This is why
resentment is not be appropriate when I step on your toes to save you from
the spider. It is in this sense that reactive attitudes focus on the quality of a
person's will. Call this the quality of will thesis. We can define excuses
and exemptions by their effects on our reactive attitudes. When a person
has a legitimate excuse it is inappropriate for us to continue expressing
negative reactive attitudes toward them. An excuse shows us that we were
mistaken about the quality of a person's will (Wallace 1994, 136-147). If
you knock me over I might resent you until I learn that you pushed me out
of the way of falling debris. If made aware of this, I might instead feel
gratitude but should find it inappropriate to continue resenting you.
Excuses inform us that we were mistaken about what action was done.
Excuses do not cast doubt on a person's ability to be an agent, their
attributability, but instead inform us that we were wrong about what action
we attributed to them. Excuses are singular events. Particular actions are
excused. If you have a global excuse then you are exempt from
responsibility.
Exemptions cause us to question whether a person meets the
attributability requirement. Imagine again that I get knocked over except
now I learn that the person who knocked me over suffers from significant
and persistent psychotic delusions that lead her to believe that she is at
constant risk of alien abduction and that I was an alien. Unlike excuses, a
person whose agency is hampered by delusions as severe as these is not a
proper target for our reactive attitudes at all. Agency as abnormal as this is
exempt from judgments of attributability and accountability. Exempt
agents are not the true source of their actions because exempt agents lack
the ability to regulate their behavior in an intelligibly rational way
(Wallace 1994, 166-180).
The logic of excuses and exemptions implies that responsible agency
requires at minimum the ability to perceive moral reasons and the ability
to understand how these reasons function. Furthermore, many believe that
an agent must have the opportunity to avoid wrongdoing as a result of his
or her agency in order to satisfy the attributability requirement (Shoemaker
2011, 6). Psychopaths, because they seem both rational and morally
incompetent, cut across these traditional distinctions. They possess some
but arguably not all of the necessary qualities for full moral agency.
Moral Blindness and Psychopathic Responsibility

Psychopaths have a poor understanding of moral reasons and moral
norms. This fact prompted Cleckley to compare the psychopath's ability to
understand moral reasons with a kind of blindness (Cleckley 1941/1988,
40). Many philosophers believe that recent research on psychopathic
agency supports this view. Psychopaths are not able to easily distinguish
between violations of moral norms from violations of merely conventional
or social norms (Dolan and Fulam 2010; Turiel 1979; Blair 1995). The
implication is that psychopaths tend to treat all norms as having the same
kind of authority. Whereas most of us note a difference between using the
“wrong” fork during dinner, and stealing a wallet, psychopaths may not.
We characterize moral norms as serious, not dependent on authority, and
generalizable beyond their present context whereas conventional norms
are not (Turiel 1979). This characterization of morality has been
challenged as incomplete and insufficient (Stitch, Haley, Eng, and Fessler
2007, 117; Vargas and Nichols 2008, 157) but it captures a wide range of
important moral norms that psychopaths do not easily understand.
Paul Russell has interpreted these results as showing that that
emotional understanding is necessary for rational agency. Psychopaths
cannot understand the reactive attitudes of others because they cannot feel
or apply them. Because they do not understand the reactive attitudes
directed at them, they fail to understand the kinds of reasons those
attitudes are sensitive to. This failure of understanding impacts the
psychopath's ability to engage in critical self-reflection about moral norms
and undermines their ability to assess the reasons that speak to those
norms. According to Russell, “[t]o appreciate and understand moral

considerations fully is precisely to be able to apply them to oneself and
others and feel the appropriate way when violations occur. Failing this the
agent just 'does not really get it'”(Russell 2004, 11-13). If psychopaths are
unable to understand moral reasons as sensitivities to emotion, as Russell
suggests, then they are not the proper target for our reactive attitudes.
Importantly, if 'ought implies can' then it would be unfair to hold
psychopaths to moral norms they cannot understand(Wallace 1994, 177-
178). Holding the psychopath accountable would be like resenting your
foul-mouthed parrot. The attitudes would be inappropriate.
The data on the psychopath's failure to distinguish between moral
norms and conventional norms appears to validate the intuition that
psychopaths are blind to moral reasons. They think of all norms as purely
conventional. For psychopaths, “harm to others [is] wrong only because
such harms are against the rules” (Levy 2008, 132). Reactive attitude
theories excuse psychopaths from moral responsibility on the grounds that

it would be unfair to hold a person responsible if they cannot understand
moral reasons. If psychopaths cannot understand moral reasons as
distinctly moral (i.e. if they are not receptive to moral reasons) then
psychopathic agency lacks a critical capacity: “guidance control,” or
“reflective self-control,” or “normative competence.” Anyone who lacks
this capacity is exempt from responsibility (Fischer and Ravizza 1998;
Wallace 1994; and Russell 2004 respectively). It would be unfair to hold
someone morally responsible if they cannot understand moral reasons. It is
therefore inappropriate to express reactive attitudes at psychopaths
(Fischer and Ravizza 1998, 78-79).
But how compelling are these arguments? It does seems unfair to hold
someone responsible for failing to do something they cannot do. It is also
true that our reactive attitudes are diminished (or that we think they ought
to be) when we learn that a person's agency is compromised. We seem to
perceive psychopaths under what Peter Strawson called an “objective
stance:” we see psychopaths not as agents with whom we can participate
with as part of a community but instead as “an object of social policy; as a
subject for what, in a wide range of senses, might be called treatment; as
something certainly to be taken account, perhaps precautionary account,
of; to be managed or handled or cured or trained; perhaps simply to be
avoided” (Strawson 1962, 6). In the final section I claim that a wide range
of reactive attitudes are sensitive to the values expressed by psychopathic
agency despite the psychopath's inability to respond to moral reasons.
These attitudes allow us to hold psychopaths accountable for their actions
even if they are not specifically morally responsible.
Hatred, Value, and Psychopathic Accountability

Philosophers generally agree that psychopaths can be justifiably
removed from society if they cause great harm. Because psychopaths are
known for criminal recidivism and poor, sometimes counterproductive,
reception to treatment, incarceration is justifiable for at least some
psychopaths. David Shoemaker's view in this respect is representative:
“[a]s long as [the psychopath] has sufcient cognitive development to
come to an abstract understanding of what the laws are and what the
penalties are for violating them, it seems clear that he could arrive at the
conclusion that [criminal] actions are not worth pursuing for purely
prudential reasons, say. And with this capacity in place, he is eligible for
criminal responsibility” (Shoemaker 2011, 119). The larger debate is over
whether psychopaths are morally responsible for their choices given what
we know about psychopathic agency.
If moral responsibility requires the capacity to understand moral
reasons as distinctly moral and this is grounded on a further capacity to
empathize with others, then psychopaths cannot understand moral reasons.
This lack of understanding is shown by their performance on
distinguishing between moral and conventional norms. For some, this is
enough to exempt psychopaths from responsibility: “[c]ertain psychopaths
...are not capable of recognizing...that there are moral reasons...this sort of
individual is not appropriately receptive to reasons, on our account, and
thus is not a morally responsible agent” (Fischer and Ravizza 1998, 79).
Further, if the reactive attitudes germane to accountability are sensitive to
the quality of an agent's will, then psychopathic agents cannot express
immoral wills because they do not understand morality. This deficiency
affects the degree of control they have over their choices because “[w]hat
makes it appropriate to exempt the psychopath from accountability...is the
fact that psychopathy...disables an agent's capacities for reflective self
control” (Wallace 1994, 178).
A number of philosophers argue that this analysis of psychopaths and
reactive attitudes is incomplete. We are better served, they argue, by
appreciating the full scope of reactive attitudes and how these attitudes
correspond with the kind of will psychopaths can express with their
actions (Greenspan 2003; Talbert 2008; Talbert 2012). This highlights an
important sense in which some reactive attitudes are appropriate to direct
at the psychopath. These attitudes respond to the lack of care psychopaths
express about human worth when they cause us harm. Successful
psychopaths prove that psychopaths, even if not capable of understanding

moral reasons, are capable of conforming their behavior to moral norms.
Insofar as psychopaths have this capacity, they are appropriate targets for a
wide array of non-moral reactive attitudes (and hence accountable).
To see how these views work, we must more carefully describe
psychopathic judgments. Although psychopaths are not capable of moral
judgments, they are capable of making judgments about value and about
the kind of standing their victims have to them. We know that psychopaths
do not suffer from practical irrationality. They are quite good at means-end
reasoning. Successful psychopaths understand what reasons are, how
reasons work, and how to weigh reasons against each another to achieve
their desired ends. When a psychopath judges that it is permissible to
assault me in order to steal my wallet, we can attribute to the psychopath
the judgment that 'there is nothing about my status or standing that
provides a reason against assaulting me or stealing my wallet' and we can

hold psychopaths accountable for these judgments (Talbert 2008, 523).
If attitudes like hatred, disgust or contempt respond to non-moral but
evaluative qualities of an agent's will, then these attitudes are appropriate
to direct at people when their will includes the belief that others do not
matter. The judgment that others do not matter is evaluative, it is a
judgment of relative value, but it need not be construed as a moral
judgment. We can feel justified directing hatred at psychopathic actions
when they express these judgments. This is true even if the psychopath
cannot appreciate that we also have moral reasons for caring about our
status. Insofar as the psychopath can make judgments like these, then, in
the words of Patricia Greenspan, “(h]e is a fair target of resentment for any
harm attributable to his intention to the extent that the reaction is
appropriate to his nature and deeds. He need not be 'ultimately' responsible
in the sense that implies freedom to escape blame” (Greenspan 2003, 427).
Because psychopaths are incapable of understanding moral reasons it is
unfair to hold them morally responsible, but there are forms of
accountability and reactive address, like the ones just mentioned, that are
outside the moral sphere and remain appropriate to direct at psychopathic
agents.
It is fair to hold psychopaths accountable in these non-moral ways
because these forms of reactive accountability are grounded on the
capacities psychopaths have and the quality of will that their judgments
can express. More importantly, although psychopaths do not understand
the distinctiveness and weight of moral reasons, their judgments can still
express condemnable attitudes about those reasons. Greenspan notes that
all of us have “blind spots” about certain narrow classes of reasons and we
stand to those reasons in the same relation that psychopaths stand to moral
reasons; these blind spots do not excuse us from accountability in a
general way and they ought not excuse psychopaths from accountability in
a global way either (Greenspan 2003, 435).
What would non-moral accountability look like in practice? Imagine an
atheist who has a blind spot for divine reasons and values (i.e. reasons and
values stemming only from divine commands). She lives in a community
where divine reasons are routinely appealed to and where they drive some
aspects of her local culture (how members dress, how they greet one
another, whether they work on certain days, etc). Although only able to
understand divine reasons from an external perspective, she understands
that people appeal to divine reasons to justify actions and has some
understanding of how divine reasons work. If the atheist decides to work
on a divinely-mandated rest day, then we can attribute to her the judgment
that she believes that no sufficient reasons speak against working on that
day. Members of her community could hold the atheist accountable for her
decision to flout divine reasons despite her inability to understand or
appreciate them. Although it would be unfair to damn the atheist (i.e. to
religiously condemn her) because she lacks the right kind of access to the
concept of damnation, it may be appropriate for members of her
community to express contempt toward her, a non-religious attitude, given
the kinds of values her judgments express.6
The same holds for the psychopath. Psychopaths satisfy the
attributability requirement in virtue of their practical rationality. They can
deliberate about what to do and modify their desires in the light of reasons.
However, their inability to fully understand moral reasons disqualifies
them from moral accountability. This fact does not imply that psychopaths
are free from all forms of accountability. Psychopathic judgments can
express values that we find contemptible, hateful, spiteful, or disgusting.
In many cases it would be appropriate to express these attitudes at
psychopaths because the attitudes would be appropriate given the values
expressed by their judgments. In doing so we hold them accountable
despite the fact that it would not be appropriate to hold them morally
accountable via attitudes like resentment or indignation. When a
psychopath judges that nothing speaks against repeatedly lying to or
manipulating others we can justifiably direct reactive attitudes at the
psychopath because of the quality of will these actions express. Reactive
attitude theorists are correct that psychopaths cannot fairly be held morally
responsible but moral accountability does not exhaust the forms of reactive
accountability available to us.
Conclusion
Psychopathy is a controversial and complicated phenomenon. Well
before psychopathy became clinically sharpened as a diagnosis in the 20th
and 21st centuries, moral philosophers worried about how best to handle
people who frequently violated moral norms and who were devoid of guilt
and shame. These questions remain relevant today. Although psychopaths
lack an understanding of moral emotions, they seem to be rational agents.
Successful psychopaths are especially good at understanding reasons and
use this understanding to manipulate others. Successful psychopaths have
been identified working in managerial positions in corporations, (Babiak,
Neumann, and Hare 2010) as practicing lawyers, and even psychology
students (Mullins-Sweat, Glover, Derefinko, Miller, and Widiger 2010).
Successful psychopaths make clear that the affective deficits characteristic
of psychopathy do not necessarily have to manifest as criminal or violent

behavior.
Reactive attitude theories of moral responsibility have been too quick
to fully dismiss psychopaths from all forms of accountability. Although
psychopaths appear blind to moral reasons and hence seem exempt from
moral responsibility, their judgments can express values that leave them
open to non-moral reactive attitudes. Because they have unimpaired
rational capacities, successful psychopaths are especially apt targets for
hatred, disgust, and contempt when they judge that they are justified in
harming others. These psychopaths are proper targets for these forms of
accountability in ways that have gone under-appreciated by contemporary
theorists of responsibility.
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CHAPTER FOURTEEN
PSYCHOPATHY, AUTISM, AND QUESTIONS

OF MORAL AGENCY
MARA BOLLARD
Introduction
In recent years, psychopaths have been of special interest to moral
philosophers. Psychopaths are famously amoral, so some theorists have
thought that an examination of their peculiar deficiencies might shed light
on the capacities that are required for moral agency. More specifically,
theorists have looked to empirical findings about psychopaths to help
determine whether moral agency is underwritten by reason, or by affective
sentiments.1 With respect to the latter possibility, empathy is often taken
as the primary focus, something that isn’t all that surprising in light of the
commonsense appeal of the idea that empathy matters a great deal to
morality (Roskies, 2011).2 Given that one of psychopaths’ most glaring
deficits is a lack of empathy, they seem perfectly suited as a test case for
the hypothesis that empathy is necessary for moral agency.
However, psychopaths are not the only group of philosophical interest
when it comes to empathy: people with autism also lack empathy, so it is
reasonable to think that any empirically-informed attempt to answer the
question of whether empathy is necessary for moral agency should give
due attention to findings from autism as well as from psychopathy.
Jeanette Kennett’s thought-provoking paper, ‘Autism, Empathy and Moral
Agency’ (2002), which analyses the respective moral statuses of
psychopaths and autistic people, is the first and arguably the most notable
example of such an attempt. As such, this chapter will take Kennett’s
paper as its focus in an effort to further elucidate the role of empathy in
moral agency.
In brief, Kennett’s argument runs as follows: She begins with the claim
that psychopaths are amoral, and that a common and plausible explanation
as to why this is so is that psychopaths lack empathy. However, autistics,
Psychopathy, Autism and Questions of Moral Agency 239
like psychopaths, lack empathy, yet, unlike psychopaths, they are not
amoral. As such, a lack of empathy cannot explain psychopaths’
amoralism. In order to account for the differing moral statuses of the
groups, Kennett argues that autistic people possess a certain ‘reverence for
reason’ that enables them to become capable moral agents. Psychopaths
lack this rational capacity, and it is this defect, not the empathic one, that
explains why they are amoral. Kennett therefore concludes that empathy is
not necessary for moral agency. Rather, she holds that ‘reverence for
reason’ is sufficient.
In this chapter, I argue that Kennett’s argument is untenable. First, I
review the empirical evidence in order to demonstrate that there is a
component of empathy called affective empathy that is impaired in
psychopaths but largely preserved in autistics. As such, the claim that
psychopaths and autistics share a common lack of empathy is unjustified.
Second, I challenge Kennett’s claim that empathy plays no role in
explaining the moral difference between psychopaths and autistics.
Instead, I contend that the intact affective empathy of autistic people is a
crucial component of their capacity to act out of reverence for reason.
Background
The Traditional Form of the Debate: Hume versus Kant
Kennett’s argument is best understood in the context of the long-
running debate between sentimentalists and rationalists. In this debate,
“the relation between reason, emotion, moral judgment, and behavior is an
old and contested one, with paradigm and opposing positions associated
with Hume on one side and Kant on the other” (McGeer, 2008). According
to Hume (and proponents of sentimentalism in general), “sympathy alone
can be the foundation of morals” (Hume, 1777): that is, that to be a moral
agent is to possess the capacity for sympathy (where sympathy
corresponds to what we currently call ‘empathy’). Conversely, for Kant
(and rationalists in general), to be moral is just the same as being rational.
Kant argued that the requirements of morality are based upon a supreme
rational principle known as the categorical imperative (Kant, 1785). To
qualify as a moral agent is to obey the categorical imperative, which, in its
first formulation, is to “act only in accordance with that maxim through
which you can at the same time will that it become a universal law” (421).
In other words, agents must act for reasons of a type that they would
regard as valid for anyone else in similar circumstances. Agents are
capable of acting in accordance with the categorical imperative only
240 Chapter Fourteen
insofar as they are rational, because the categorical imperative itself is

derived from reason.
Historically, these two approaches have been seen as being mutually
exclusive, even though the nuances of Hume and Kant’s arguments do not
lend themselves to such an extreme division. Each side has fought to
locate the key to morality wholly in either the affective (Humean) or
rational (Kantian) domain, and Kennett is following this all-or-nothing
tradition when she pushes empathy aside so as to point the finger all the
more strongly at “reverence for reason – or duty – [as] the core moral
motive” (Kennett, 2002, 355), eschewing Hume’s story of what is required
for moral agency in favor of Kant’s. In what follows, I argue that this
approach is misconceived, for two reasons. First, such a move inaccurately
reflects the empirical evidence regarding the empathic capacities of
psychopaths and autistics. Second, it unfairly rules out the plausible
possibility that empathy holds an important role within a Kantian account
of moral agency. However, before I spell out these arguments it will be
useful to outline the nature of psychopathy and autism.
The Nature of Psychopathy

First, it must be made clear that neither Kennett nor myself is
concerned with the psychopath as he exists in popular imagination.
Instead, our focus is restricted to the clinically defined psychopath. The
Psychopathy Checklist Revised (PCL-R), developed by Robert Hare, is the
prevailing diagnostic tool used today (Hare, 1991). Factor analysis of the
checklist reveals two different types of symptoms that are fundamental to
psychopathy. The first constellation of symptoms identified by the

checklist is emotional/interpersonal. Psychopaths are glib, superficial, and
egocentric and have a grandiose sense of self-worth. They are manipulative
and fail to show remorse for their misdeeds. Psychopaths also show a
notable lack of emotional depth. Perhaps their most striking feature is that
they display a marked lack of empathy, failing to show any regard for the
rights or feelings of others. As Hare notes,
“Because of their inability to appreciate the feelings of others, some
psychopaths are capable of behavior that normal people find horrific…
They can torture and mutilate their victims with about the same sense of
concern that we feel when we carve a turkey for Thanksgiving dinner”
(Hare, 1999, 45).
The second set of symptoms is related to social deviance. Psychopaths

have poor behavioral controls and tend to commit crimes from a young
age. They are impulsive, irresponsible, and have a constant need for
excitement. They also tend to live parasitic lifestyles and are sexually
promiscuous. Further, they are unable to set or stick to realistic goals for
themselves or to consider the possible consequences of their actions,
which can lead to self-destructive behavior.
The Nature of Autism

In 1943, Leo Kanner, the first clinician to publish accounts of autism,
pinpointed the unique “aloneness” exhibited by autistic children as their
cardinal abnormality (Kanner, 1943). This aloneness is still the most
defining feature of autism; according to the current Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV), autism is characterised
by a primary impairment of social interaction (DSM- IV). Autistic
individuals have great difficulty engaging with others largely because of
their deficient understanding of the mental states (emotions, beliefs,
intentions) of others, a difficulty that is often described in terms of a lack
of empathy. Uta Frith, an authority on autism, writes,
Autistic people are noted for their indifference to other people’s distress,
their inability to offer comfort, even to receive comfort themselves. What
empathy requires is the ability to know what another person thinks or feels
despite the fact that this is different from one’s own mental state at the
time… Empathy presupposes a recognition of different mental states. It
also presupposes that one goes beyond that recognition of difference to
adopt the other person’s frame of mind with all the consequences of
emotional reactions. Even able autistic people seem to have great difficulty
achieving empathy in this sense (Frith, 1989, 154-55).
Autistic people also have trouble expressing emotion, display impaired

language development and have trouble using and understanding
nonverbal gestures. Further, they tend not to engage in make-believe play,
and often display rigid patterns of behavior, which may include repetitive
movements or utterances and obsessive preoccupation with narrow topics
of interest (Frith, 154). The spectrum of autistic disorders ranges widely
from very severe cases, which often feature mental retardation and
language impairment, to mild or “high-functioning” forms (Rumsey, 1992,
45). Kennett limits the scope of her focus to high-functioning autistic
individuals, so in this paper I will do the same.
A Questionable Common Lack of Empathy

Now that we are familiar with the nature of psychopathy and autism,
we are in a better position to understand why Kennett claims that both
groups share a common lack of empathy. From the descriptions given
above, it is clear that a lack of empathy is a defining feature of both
psychopathy and autism. However, it is less clear that we are really talking
about the same thing when we speak of empathy in each case. When Hare
describes psychopaths’ lack of empathy, he is speaking of “an inability to
appreciate the feelings of others” (Hare, 1999, 45). On the other hand,
Frith’s description of the lack of empathy in autism focuses on autistics’
inability to adopt other people’s mental states, which seems to be a
different type of ‘lack’ altogether. Perhaps, then, a closer look at precisely
what is meant by ‘empathy’ in the current literature will help us sort out
this apparent mismatch.
Defining Empathy
It is often claimed that our present understanding of empathy derives
from Hume’s concept of sympathy. Hume thought that sympathy – the
capacity to receive and respond to the sentiments of others – was a
sentiment available to and experienced by all people, albeit in varying
degrees. A generally accepted modern definition says that empathy refers
to the emotional or affective reaction of a given subject in response to the
expressive behavior of others (Davis, 1994). However, empathy is a
notoriously tricky concept, the study of which has often been attended by
definitional disagreement. As Nancy Eisenberg and Janet Strayer write,

“the notion of empathy is, and always has been, a broad, somewhat
slippery concept” (Eisenberg and Strayer, 1987, 3). With this in mind, it’s
not surprising that not all definitions of empathy in the literature are
compatible.
Some researchers emphasise that empathy is a cognitive process,
whereas others take it to be a primarily affective process. Cognitive
empathy may be thought of as the ability to adopt another’s perspective
and to infer or imagine her thoughts, feelings or intentions. It is often
referred to as “mentalizing” or “simulation” (Hoffman, 2000, 29). On the
other hand, affective empathy is the experience of an emotional response
upon perceiving another’s emotion or attending to her situation (30). The
emotional response need not be an exact match with what the target person
is experiencing, but it does need to be congruent with, or appropriate to,
the other person’s emotional state or situation. For example, take the
feeling of compassion I experience when I see my friend, whose pet dog

has just died, crying. Though my emotional response is not identical to my
friend’s feeling of sadness, it is an appropriate reaction to her emotional
situation. In recent years, researchers have distinguished between several
different aspects of the emotional reaction to another person. One such
aspect is emotional contagion, which is the vicarious experiencing of an
emotion in response to a similar emotion in someone else. An example of
emotional contagion is to feel distress (experienced as physiological
arousal) in response to distress in others. Another form affective empathy
can take is sympathy, which is the capacity to experience concern or
compassion in response to another’s emotion or situation.3
One way to reconcile the seemingly incompatible definitions of
empathy is to adopt the increasingly popular view that empathy is a
multidimensional construct that consists of both the cognitive and
affective components. As Baron-Cohen writes, “empathizing involves
attributing mental states to others, and responding with appropriate affect
to the other’s affective state” (Baron-Cohen, 2003, cited in Krahn &
Fenton, 2009, 148). From Kennett’s description of empathy, “construed as
[an] imaginative process of simulation with resulting emotional contagion”
(Kennett, 2002, 345), it is clear that her conception of empathy
incorporates both cognitive and affective elements. It should be noted that,
in her definition, Kennett has explicitly identified emotional contagion as
the affective component of empathy, whereas I have pointed to sympathy
as another facet of affective empathy. While it could be argued that, by
bringing in sympathy, I am creating merely a definitional agreement
between Kennett and myself as to what comprises empathy, I do not think
that this poses any problem to our current project. Even if we disregard
any evidence pertaining to sympathy and focus solely on emotional
contagion, it will be seen in what follows that my criticisms of Kennett’s
definition of empathy still carry significant weight.
Differing Deficits
Thus far, we have seen that Kennett’s conception of empathy lines up
with a view that is broadly agreed upon in the literature insofar as she
thinks that empathy consists in a cognitive and an affective component.
However, in stating that the emotional response stems from simulation,
Kennett is claiming that cognitive empathy is a necessary precursor to
affective empathy. This is contentious. Although cognitive and affective
empathy may sometimes interact, the presence of one need not necessarily
imply the other. As such, it is reasonable to think that different types of
empathy disorders are possible. For instance, an empathy disorder may

arise because of an impairment of the cognitive component while yet
another, distinct type of disorder could result from impaired affective
empathy (Krahn and Fenton, 2009, 149).4
So, Kennett’s definition of empathy fails to capture the possibility that
cognitive and affective empathy are dissociable. After surveying the
literature detailing the deficits involved in psychopathy and autism,
Kennett seeks to find what the two groups may have in common:
“Both psychopaths and autistic people experience outside status, and
deficiencies in social understanding and in social responsiveness… both
sets of literature speak of a tendency to treat other people as tools or
instruments, a lack of strong emotional connectedness to others and
impaired capacity for friendship, and they link these impairments to
failures of empathy” (Kennett, 2002, 348-9).
At this point, Kennett does not go on to explain how the failures of

empathy in psychopaths might differ from the failures of empathy
displayed by autistic people, even though she implicitly acknowledges the
existence of a difference in the groups’ cognitive empathy capabilities
when she says that “those with autism are significantly worse off than
psychopaths…[who] are well able to read the intentions and predict the
behavior of others” (349). Instead, Kennett accepts the unqualified claim
that both groups lack empathy. Indeed, it is important for Kennett’s
argument that psychopaths and autistic people share a common lack of
empathy, because her aim is to pinpoint reverence for reason as the “heart
of the difference” (354) between the two groups. In order for this
argument to pack its intended punch, the respective empathic deficits of

psychopaths and autistic individuals need to cancel each other out so that
the intact rational capacity of autistic people can take center stage as the
explanation for the differing moral statuses of the two groups.
However, as we have already touched on, things aren’t quite so simple
because there is evidence to suggest that the cognitive and affective
components of empathy are dissociable to a certain extent. I review the
evidence below and argue that it contradicts Kennett’s claim that autistic
people and psychopaths share a common lack of empathy.
Impaired Empathy in Autistics

People with autism display difficulty with a wide range of mind
reading and perspective-taking tasks, generally performing significantly
worse than non-autistic control subjects. For example, Isabel Dziobek et
al. assessed the cognitive empathy of autistic individuals by giving them

photographs and asking them to infer the mental states of the individuals
shown in the photographs (Dziobek et. al, 2008). The autistic group
performed significantly worse than the control group on this task.
Further evidence of autistics’ inability to simulate others’ perspectives
comes from Oliver Sacks’ recount of the time he spent with Temple
Grandin, a well-known high-functioning autistic. When Sacks first met
Grandin, he had just completed a long trip. However, Grandin failed to
perceive how tired and thirsty he was, and so did not offer him anything to
drink (Sacks, 1995). Grandin herself says that she often feels like “an
anthropologist on Mars” (248) because she finds the complex emotions of
other people so bewildering.
Consider, too, the case of Jerry, another high-functioning autistic who
disappeared during a family trip to California when he was fourteen. The
family was spending the day at a Mexican border town when Jerry went
missing. His family searched frantically all day, eventually discovering
that Jerry had walked ten miles back to their hotel. Jerry did not realise
that his family would be concerned by his disappearance and so had not
told anyone he was leaving (Bemporad, 1979). Similarly, of Albert,
another autistic individual, Cesaroni and Garber say, “he does not seem to
be capable of, or to see the importance of, placing himself in his
classmate’s position to consider what they may be thinking or feeling”
(Cesaroni & Garber, 1991, 310). These are just some of many examples
that demonstrate that the capacity for cognitive empathy is impaired in
autistic individuals.
As we have seen, according to Kennett’s definition of empathy,
affective empathy is necessarily preceded by cognitive empathy. So, for

Kennett, where cognitive empathy is lacking, affective empathy will also
be lacking. But is this always the case? In some instances, it does appear
that a failure of cognitive empathy precludes autistic people from showing
affective empathy. For example, a study by Sigman et al. assessed
emotional responses to parental distress in autistic children compared to
normal children [34]. While playing with their children, the parents
pretended to hurt themselves with the toy hammer and made facial and
vocal expressions of distress. Autistic children were less likely than the
other children to notice their parents’ distress, which is consistent with a
lack of cognitive empathy. Because of this, they subsequently failed to
react emotionally. However, crucially, when the distress was salient
enough for the autistic children to notice it, they did respond emotionally
(and subsequently went on to display comforting behavior) just as often as
the children in the other groups. The study by Dziobek et al. (discussed
above) also lends support to this point. Though the autistic group struggled
to infer the mental states of the individuals in the photographs, when they
were given feedback about the correct answer – i.e. when the emotional
information about the people in the photos was made salient – they
exhibited emotional reactions in response to the pictures that were on par
with (normal) responses shown by controls [35].
So, it seems that, as long as the emotional expression of others is
obvious enough, autistic people display an appropriate emotional response
to others. This is evidenced by Sacks’ description of a conversation he had
with Grandin during which he told her about a young man with Tourette’s
syndrome who, afflicted by violent tics, gouged out his own eyes.
According to Sacks, Grandin was deeply affected by the story. Sacks
writes that, when it came to “expressions of raw impulse, violence, pain,
she perceived [and] reacted to them straight away” [36]. In a similar vein,
Margaret Dewey says,
“In cases where the pain and suffering of other people is spelled out clearly
– as in the headline, “children are dying from hunger” – the autistic person
can show as much deep concern as any other caring and sensitive person”
[37].
In situations where people’s emotional expressions are obvious (or

brought to autistics’ attention), autistic people are able to perceive them
and go on to display appropriate emotional responses. This suggests that
autistic people, though lacking the sophisticated cognitive empathy of non-
autistic people, possess rudimentary cognitive empathy that is sometimes
enough to help them discern the emotional expressions or situations of
others.
Here it might be objected that, by conceding that affective empathy is
dependent on cognitive empathy, I have failed to show that the two
components are dissociable. However, such a claim is too strong. That
there isn’t a total dissociation does not mean that there is no dissociation at
all. Even though the ability to show intact affective empathy does depend
on cognitive empathy, it does not depend on unimpaired cognitive
empathy. The point is that Kennett does not acknowledge that autistics’
impaired cognitive empathy need not imply a corresponding impairment
of affective empathy.
On the basis of the above evidence, we can conclude that, although
autistics’ cognitive empathy is profoundly impaired, they exhibit
(relatively) intact affective empathy. Admittedly, autistic individuals are
not as adept as normal subjects and do sometimes fail to show affective
empathy because of a failure of cognitive empathy. However, I suggest, in
keeping with (autistic) Jim Sinclair, that it is best to think of autistic

people’s empathic deficit in terms of “not understanding rather than not
caring” [38] – that is, as an epistemic deficit. This idea is supported by
Peter Hobson’s observation that congenitally blind children are
predisposed to autistic behavior, in that they fail to respond affectively to
other people, largely because they lack visually derived information about
other people’s feelings and situations [39]. We will now turn to the
evidence regarding psychopaths’ empathic deficits. It will be seen that the
deficits shown by psychopaths are strikingly different to those displayed
by autistics.
Impaired Empathy in Psychopaths

It is widely agreed that psychopaths show a marked lack of empathy.
But what exactly is meant by ‘a lack of empathy’ in psychopaths? Unlike
autistics, psychopaths are adept at mind-reading and mental state
attribution. For instance, Blair et al. conducted a study in which 25
psychopaths and 25 non-psychopathic control subjects (matched for age
and IQ) were given a task of story comprehension [40]. In order to give a
correct response about the characters’ behavior, subjects had to correctly
infer their mental states. Psychopaths performed just as well as the control
subjects, demonstrating an intact ability to understand and identify others’
mental states. As McGeer writes, psychopaths “have no cognitive deficit
in understanding others’ states of mind, including their beliefs and desires,
motives and intentions, cares and concerns” [41]. Indeed, it is clear from
psychopaths’ manipulative behavior that they not only understand other

people’s mental states but that they exploit this understanding so as to take
advantage of other people. So, psychopaths possess intact cognitive
empathy.
However, when it comes to the capacity for affective empathy,
psychopaths appear to be much worse off. Ted Bundy, a notorious serial
killer and diagnosed psychopath, famously claimed, “I’m the most cold-
hearted son-of-a-bitch you’ll ever meet” [42]. Psychopaths suffer from an
emotional poverty that limits the range and depth of their feelings. For
instance, psychopaths equate love with sexual arousal, sadness with
frustration and anger with irritability [43]. Hervey Cleckley observes that
deeper emotions such as “mature, wholehearted anger, true or consistent
indignation, honest, solid grief, sustaining pride, deep joy and genuine
despair are reactions not likely to be found within [the psychopath’s]
emotional scale” [44]. This idea of the emotional poverty experienced by
psychopaths is captured well by a statement made by a psychopath named

Jack Abbott:
“There are emotions – a whole spectrum of them – that I know only
through words… I can imagine I feel these emotions… but I don’t” [45].
It is plausible that if psychopaths suffer from a broad paucity of affect

– and it appears that they do – then they will be severely impaired when it
comes to affective empathy. This is supported by clinical evidence that
psychopaths show abnormally low physiological responses to facial and
vocal distress cues in others, responding as though the cues were
affectively neutral [46]. Further, when shown pictures depicting moral
violations (e.g. a person attacking another person), psychopaths exhibit
brain activity that differs from the responses of non-psychopathic controls
[47]. When control subjects saw the morally objectionable pictures, areas
of the brain that comprise the limbic system – which is often referred to as
the brain’s “emotional circuit” – lit up. Conversely, when psychopaths saw
the morally objectionable pictures, their brains’ emotional circuits were
not engaged. Both the psychopaths and the controls correctly identified the
pictures as moral violations (they successfully distinguished them from
other types of pictures that were either morally ambiguous or non-moral),
so psychopaths’ aberrant response cannot be attributed to a mistaken
interpretation of the picture’s content. Rather, it suggests that the
psychopaths’ emotional responses (at the neurological level) to pictures of
moral violations (which depicted individuals in distress) are impaired.
Another example of psychopaths’ failure to experience an appropriate
emotional response to another’s situation comes from one of Cleckley’s

case studies in The Mask of Sanity. Pete, a 17-year-old psychopath, had a
mother who was very ill. One day, visibly in pain and physically
indisposed, she asked him to help her by getting some things from the
shops. Pete refused; “his indifference [to her pain] struck her as extreme”
[48]. It seems that Pete failed to experience any emotional response in the
face of his mother’s plight. Consider, too, the words of this psychopath
when asked how he felt when he hurt other people:
“Do I feel bad if I have to hurt someone? Yeah, sometimes. But mostly it’s
like… uh… (laughs) … how did you feel the last time you squashed a
bug?” [49]
Given psychopaths’ intact capacity for cognitive empathy, this

psychopath would have understood the mental states of his victims – i.e.
they would have been very afraid – at the time of his harming them.
However, his callous remarks reveal a shocking lack of an appropriate

emotional reaction in response to their fear.
Taken together, all of this leads to the conclusion that psychopaths
show very different empathic deficits to those shown by autistic people.
Whereas autistics demonstrate impaired cognitive empathy but retain the
capacity for affective empathy, psychopaths exhibit the inverse
combination: a marked impairment of affective empathy coupled with
unimpaired cognitive empathy. Thus, the possibility of dissociable
empathic deficiencies suggested earlier has been definitively borne out.
Moreover, our examination of the respective empathic impairments
displayed by psychopaths and autistics reveals Kennett’s claim that the
groups share a common lack of empathy to be incorrect.
That we have rejected Kennett’s claim about a common lack of
empathy has significant implications for the rest of her argument. As I
stated earlier, Kennett wants to bring forward reverence for reason as the
key to why autistic people are capable of moral agency but psychopaths
are not. Differences in the empathic deficiencies and capacities of each
group complicate this aim, because if such differences exist – and we have
shown that they do – then it is possible that they play a role in explaining
the moral difference between autistic people and psychopaths.
Reverence for Reason

My aim thus far has been to point out that Kennett’s argument, as it
stands, is untenable. I do not deny that reverence for reason is necessary
for moral agency, but I do think we have strong cause to doubt that it is
sufficient, because it is underpinned by a shaky premise: that psychopaths
and autistic people share a common lack of empathy. Significantly, the
weakness of the premise gives us reason to doubt the claims that follow it:
it is far from conclusive that empathy (or one of its elements, affective
empathy) does not play an important role in explaining why autistic
individuals are capable of moral agency but psychopaths are not.
In this section, I examine the evidence that Kennett puts forward in
support of her claim that autistic people are capable of becoming
conscientious moral agents according to a Kantian account of moral
agency because they possess reverence for reason. To succeed in this task,
Kennett must show that the ‘reverence for reason’ she is talking about
maps onto the Kantian conception of reverence. However, I will try to
show that Kennett does not convincingly establish that autistic people
display the sort of reverence for reason that Kant thinks is required for
moral agency. I argue that the evidence Kennett invokes to make her case
that autistics possess reverence for reason is actually better invoked in

support of a different (albeit related) claim: that autistic people, given their
impairment of cognitive empathy, utilize their powers of reason to get the
information they need in order to work out how they should behave in
certain situations.
Which Reverence?
For Kant, ‘reverence for reason’ means respect for the moral law. To
have reverence for reason is to act in accordance with the moral law for
the sake of the moral law; in other words, to act from duty [50]. To say
that an agent acts from duty is to say that he acts because he thinks he is
morally required to act. Only actions that are performed from duty can be
said to be morally worthy. Also, for Kant ‘practical reason’ is the process
by which an agent works out, prospectively, how he ought, morally, to act
[51].
Like Kant, Kennett explicitly equates reverence for reason with duty,
describing “reverence for reason – or duty – [as] the core moral motive”
[52]. More specifically, she says that the preserved moral sensibility of
autistics can be explained by their ability to “develop or discover moral
rules and principles of conduct for themselves by reasoning” [53]. I think
we can plausibly take the latter claim to mean that autistics engage in
practical reasoning in order to work out the rules, or maxims, that they
ought to act on. Rules are of great value to autistics because establishing
and following rules is a means by which they can find their way through a
confusing social landscape [54]. As a result, autistic people are highly

motivated to follow rules and are concerned that others do so too. Given
that moral rules are seen as a fundamental feature of Kantian ethics [55],
either in the form of the categorical imperative or as rules of duty that
result from subjecting one’s specific maxims to the categorical imperative,
it is understandable why Kennett identifies autistics’ concern with rules
and routines as evidence that their moral sensibilities look Kantian rather
than Humean.
Evidence for Reverence

Let us examine the evidence put forward by Kennett in support of the
claim that autistics possess reverence for reason. Kennett begins by
discussing the methodology Grandin utilizes in order to help her understand
other people’s behavior:
“[Grandin] had built up a vast library of experiences over the years… they
were like a library of videotapes which she could play in her mind and
inspect at any time – ‘videos’ of how people behaved in different
circumstances. She would play these over and over again and learn, by
degrees, to correlate what she saw, so that she could then predict how
people in similar circumstances might act” [56].
Kennett describes the methodology Grandin is using as a “cold…

method that chiefly engages [her] intellect and makes no essential use of
[the] capacities for emotion” [57]. It stands in direct contrast to the “hot”
methodology that involves cognitive empathy, the ability to simulate
other’s mental states.
What we have here is a method that Grandin employs in order to get
information about other people’s mental states that non-autistic people are
normally able to acquire via empathy. With her impairment of cognitive
empathy, Grandin “has to compute others’ intentions and states of mind, to
try to make algorithmic, explicit, what for the rest of us is second nature”
[58]. However, I think it is doubtful whether we should see Grandin’s use
of this process as evidence that she is acting from duty. To act from duty is
to act because one feels one ought, morally, to act, yet here I think
Grandin’s diligence is best understood as an attempt to help make the
world a little more intelligible for herself.
On the other hand, it is possible to argue that Grandin is acting from
respect for the moral law because she thinks that it is possible to will as a
universal law the maxim that one ought, morally, to act in order to
maximize one’s understanding of the cares and concerns of others in any
given situation. Interestingly, this point has implications for the role of
affective empathy within Kant’s ethics, and I will explore it further below.
For present purposes, however, the point is that without more information
about Grandin’s primary motive, we can’t say for sure whether her
implementation of this videotape system is an action that evinces moral
worth.
Perhaps, though, Kennett does not intend us to interpret Grandin’s
methodology as an example of morally worthy action. It could be that she
is just trying to demonstrate, by analogy, what the process of practical
reasoning looks like in autistic people: that it is a logical process not
dependent on empathy. Kennett draws from the experience of Jim Sinclair
(an autistic person we have already encountered) to give what she takes to
be an example of autistic practical reasoning:
“I have to develop a separate translation code for every person I meet…
Even if I can tell what the cues mean, I may not know what to do about
them. The first time I ever realized someone needed to be touched was
during an encounter with a grief-stricken, hysterically sobbing person who

was in no position to respond to my questions about what I should do to
help. I could certainly tell he was upset. I could even figure out there was
something I could do that would be better than nothing. But I didn’t know
what that something was” [59].
To Kennett, Sinclair’s realization that he ought to act in a certain way

shows that he saw the other person’s distress as a reason for action. She
thinks that his eventual conclusion about what to do – to touch the person
to provide comfort – is not informed by empathy; rather, it is dependent
“on the application of a more explicit concern to do the right thing,
whatever that might turn out to be” [60]. In other words, Kennett thinks
Sinclair acts from duty.
First, I think we can challenge the claim that Sinclair’s decision as to
how he should act is not informed by empathy. Though Sinclair generally
suffers impaired cognitive empathy, in this situation he is able to tell what
the cue (crying) means (i.e. that the person is upset), which indicates that
his cognitive empathy is not impaired in this case. Further, that he is
emotionally affected by the person’s distress shows intact affective
empathy. (Note that this claim is not undermined by the fact that Sinclair
does not know how to act: to show that someone has intact affective
empathy, it is sufficient to show they experience an emotional response to
another person’s situation.)
That aside, my main point is that it is unclear whether this example
really does provide support for the claim that Sinclair possesses reverence
for reason. Here, Sinclair deliberates about how he ought to act, and
eventually does settle on the right course of action: touching the person.
But just because Sinclair’s action accords with what’s right does not mean
he acted from duty. To draw out this idea, let us consider some possible
motives that could underlie Sinclair’s behavior.
First, we could adopt the explanation that Kennett favors and say that
Sinclair’s motive is to do what’s morally right, whatever that happens to
be. In other words, Sinclair has a de dicto desire to do what’s right. On this
model, Sinclair uses his power of practical reason to work out what the
right thing to do is, and then does it. By these lights, Sinclair is acting from
reverence for reason, so his action is morally admirable. The second
possibility is that Sinclair’s primary motive is to do whatever people
would typically do in that situation, perhaps in order to make social
interaction run smoothly, or to fit in. This is not an implausible suggestion:
many autistic people do have a strong desire to fit in and “pass for normal”
[61]. So, suppose that Sinclair’s motive is to do whatever people would
normally do whenever someone cries. He eventually works out that the
typical action in this sort of situation would be to comfort the crying

person by touching them, so that’s what he does. On this model, Sinclair
does not have reverence for reason: instead, he is acting according to a
heteronomous principle, which means that Kantians would not judge his
action to be morally admirable. We could even posit a third possible
motive. We might say that Sinclair, stirred by his affective response to the
other person’s tears, acts because he has a desire to comfort the person.
Again, he deliberates as to how he ought to act in order to achieve his aim,
works out that he can do so by touching the person, and then does so. On
this model, though Sinclair does the right thing, he has not acted out of
reverence for the moral law. In this case, Kantians would conclude that
Sinclair’s action has no moral worth.
I think that any of these three motives could plausibly explain
Sinclair’s behavior. Without more precise knowledge about Sinclair’s
motive(s), we cannot, contra Kennett, take his action as proof that he
possesses reverence for reason unless we assume that his motive is to act
from duty: in which case we would be begging the question.
So, with all of this in mind, I think that we should treat the examples
Kennett invokes in support of her claim that autistic people possess
reverence for reason with caution. If we take Grandin’s videotape
methodology as evidence of reverence for moral law, we risk conflating
the process by which Grandin becomes aware of the morally salient
features of a situation with the process of recognizing that those features
are morally binding, unless we know for certain that her motive in
utilizing that methodology is the motive of duty. Similarly, we cannot
claim that Sinclair’s behavior evinces reverence for the moral law without
assuming that he is motivated by duty.
The Role of Affective Empathy in Kantian Ethics

In the preceding section, I argued that the evidence cited by Kennett
does not adequately support her claim that autistic people possess the sort
of reverence for reason that is sufficient for Kantian moral agency. In
evaluating the evidence, we came across an interesting idea: that agents
should make themselves aware of the morally relevant facts of a situation
before deliberating about how they should act. Kennett’s aim was to
highlight the rational strategies utilized by autistic people in aid of her
claim that autistic people display morally admirable reverence for reason,
thereby showing that empathy is not necessary for moral agency.
However, I have a different strategy in mind. In light of our earlier
rejection of Kennett’s claim that autistic people and psychopaths share a
common lack of empathy, and the subsequent claim that autistic people
display intact affective empathy, I think that we have found a way by
which we can legitimately incorporate affective empathy into a Kantian
framework. In what follows, I aim to show that it is possible to view
affective empathy as an important source of information that helps agents
to act out of reverence for reason. I also briefly discuss the implications of
this interpretation for our assessments of the moral statuses of psychopaths
and autistic people.
Kant as the Enemy of the Emotions?

Recall that, in the Groundwork, Kant emphasizes that only actions
done from reverence for the moral law have moral worth. This means that
actions performed from inclination – where inclination includes not only
self-interested desires but also other-oriented emotions such as affective
empathy – do not have moral worth, even though they are morally right
insofar as they accord with the moral law.
Kant’s unequivocal assertion that only actions done from duty are
morally worthy has sometimes been construed as meaning that natural
emotions, empathy among them, have no positive role to play whatsoever
in morality (recall our earlier discussion of the assumed schism between
reason and affect in the debate between Kant and Hume). However, this
interpretation is mistaken. It is beyond the scope of this paper to explore
the source(s) of this sort of “Kant is the enemy of the emotions” [62]
reading further, but for present purposes, the point is that Kant’s emphasis
on duty does not mean that affective empathy cannot still retain an
important role within his account of moral agency.
Affective Empathy as a Moral Endowment

For Kant, affective empathy, all by itself, cannot ground morally
worthy action. However, that’s not to say that it is absent from Kantian
ethics altogether. In The Metaphysics of Morals, Kant speaks of “moral
endowments [that] lie at the basis of morality, as subjective conditions of
receptiveness to the concept of duty” [63]. Of course, these endowments
are not objective conditions of morality, but because they help us in
recognizing and, subsequently, acting from duty, we are morally required
to cultivate them. Later in The Metaphysics of Morals, Kant says,
“While it is not itself a duty to share the sufferings (as well as the joys) of
others, it is a duty to sympathize actively in their fate; and to this end it is
therefore an indirect duty to cultivate the compassionate natural feelings in
us, and to make use of them as so many means to sympathy based on moral
principles and the feeling appropriate to them. – It is therefore a duty not to
avoid the places where the poor who lack the most basic necessities are to
be found but rather to seek them out, and not to shun sickrooms or debtors’
prisons and so forth in order to avoid sharing painful feelings one may not
be able to resist. For this is still one of the impulses that nature has
implanted in us to do what the representation of duty alone might not
accomplish” [64].
From this, it can be seen that Kant considers affective empathy – here
described as the emotional response one has to others’ suffering – as one
of the natural endowments that we are morally required to cultivate [65].
In doing so, we increase our receptiveness to the concept of duty, thereby
increasing the number of actions we perform from duty, and making
ourselves into morally better agents.
Affective Empathy as a Source of Moral Understanding

Necessary for Duty
But how precisely does affective empathy enable us to enhance our
receptiveness to duty? We might view affective empathy as a source of
moral understanding, or a way by which we become aware of the morally
relevant features of the situation. Even Kant suggests that, at least
sometimes, affective empathy may help us to become aware of the fact
that we are morally bound to act; something “the representation of duty
alone might not accomplish.”
Barbara Herman argues that the categorical imperative cannot be an
effective practical principle of judgment unless agents have some moral

understanding of their prospective actions before they assess their maxims
according to the categorical imperative procedure. As she points out,
Kant’s analysis of his famous examples in The Groundwork suggests that
the need to assess one’s maxim according to the categorical imperative
“characteristically arises when an agent has what he takes to be a…
compelling reason to act to satisfy some interest…and yet realizes that
what he would do violates a known moral precept” [66]. So, agents engage
in practical reasoning about how they ought to act only once they are
aware that the situation they are in is one that calls for a moral judgment.
For example, Kant’s agent who is tempted to make a false promise in
order to borrow money he needs “has enough conscience” [to ask himself]
“is it not forbidden and contrary to help oneself out of need in such a
way?” [67] He already knows that his proposed deceit is something that is
flagged for moral review, that is, that it is morally relevant.
Though Herman does not state explicitly that affective empathy is a

source of the moral understanding that we need in order to make moral
judgments, she does say that
“There is no doubt that moral principle alone cannot make you sensitive to
need. If you do not see that another is in pain… you will not be an effective
helping agent, however correct your principles of action might be” [68].
As we have already seen, affective empathy is an important way by

which we recognize others’ pain and distress. Helping others, an
obligatory end, often requires the ability to recognize distress. Since in
willing an end an agent must will the necessary means, a Kantian agent is
morally bound to do whatever is in her power to recognize distress, and to
develop her ability to recognize distress [69].
Note that here we have explicit support for the possibility suggested
earlier: that Grandin is morally required to enact the “cold methodology”
that helps her compute other people’s mental states. By using cognitive
strategies to overcome her impaired cognitive empathy, she is more likely
to understand others’ emotional expressions and thus more likely to
display affective empathy in response to those expressions. In this way,
others’ cares and concerns become salient to Grandin. Once she is aware
of these concerns, she is able to draw on practical reason to assess whether
or not they require her, morally, to act in a particular way. This ability
stands her in direct contrast to the psychopath: not only is the psychopath
unmoved by the fact that morality requires him to act in certain ways, he is
precluded from even becoming aware of the morally salient features that
would bring this obligation to his attention because he lacks affective

empathy, an important capacity that provides moral understanding that is
necessary for one to become aware of one’s duty. I think, in keeping with
David Shoemaker, that we should see the psychopath as
“Someone for whom the plight of others makes no emotional dent [who
thus] lacks the capacity to be appropriately sensitive to and motivated by
the moral reasons deriving from their plight” [70].
I propose that his explanation, though still Kantian in essence, is more

convincing than the one Kennett offers because it manages to incorporate
the psychopath’s most striking deficit – his lack of affective empathy –
into the story.
Conclusion
In this chapter, I examined Jeanette Kennett’s compelling paper,
‘Autism, Empathy and Moral Agency’. I argued that Kennett’s argument,
as it stands, is untenable because it rests on a false premise: that autistic
people and psychopaths share a common lack of empathy. This is because
the empathic deficits of the two groups cannot be said to be equivalent:
psychopaths possess intact cognitive empathy but are deficient when it
comes to affective empathy, whereas autistics lack cognitive empathy but
retain intact affective empathy. I went on to attempt to provide a Kantian
argument for why affective empathy is, at least sometimes, necessary for
morally worthy action. It is important to note, however, that from the
Kantian perspective we only have grounds to value affective empathy as a
morally necessary means, not as intrinsically valuable. This means that my
arguments in support of the importance of affective empathy do not imply
that we ought to reject a Kantian moral framework in favor of a Humean
one. But this has never been my intention. Rather, I have tried to show that
Kennett’s removal of empathy from her rationalist framework and her
subsequent insistence that empathy does not play a role in the explanation
of why autistic people are capable of moral agency but psychopaths are
not has given rise to an impoverished account that does not paint a full
enough picture of the respective moral sensibilities of autistic people and
psychopaths.
Ultimately, it is clear that I have reached much the same conclusions as
those reached by Kennett: I agree with her that autistic people are at least
sometimes capable of becoming morally admirable agents, whereas
psychopaths most certainly are not, because (some) autistic people – but
not psychopaths – possess reverence for the moral law. However, though I
agree with Kennett when she insists that an agent is capable of moral
agency insofar as she is capable of the perception of a principle or reason
to which she feels bound, I have criticized her for failing to appreciate that
affective empathy is one way by which the agent can come to have that
perception.
More broadly, in arguing for empathy’s inclusion within a Kantian
framework, I have aimed to show that there is room for a more nuanced
approach to the debate between Kant and Hume than the traditional
“reason versus empathy” view. If we are to gain anywhere near a complete
understanding of the nature of moral agency, we must dispense with any
sort of all-or-nothing approach that forces either reason or empathy out of
the equation.
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CHAPTER FIFTEEN
ARE PEOPLE WITH AUTISM MORALLY

RESPONSIBLE FOR THEIR HARMFUL ACTIONS?
CHRISTIAN PERRING AND ADAM KOHLER
Introduction
Jacob is a sixteen-year-old student at an alternative learning center and
is diagnosed with autism. Although he can feed and bathe himself, and is
even able to perform basic math equations, he is unable to construct full
sentences without being aided by another. Each day he aims to earn going
to the school library to look at Clifford books, and as he reads through
them all he begins to narrow the list down to his favorite. The problem,
however, is that Jacob has a habit of putting items that he desires to make
his own into his book bag when he thinks that no one is looking, and this
particular book has become his new target. After realizing that he would
not succeed in hiding the book in his bag since the classroom teacher
started to check it each day before Jacob would get on the bus, Jacob
devised a plan. One day he went home, took the same Clifford book out of
his own collection, and attempted to make it look exactly like the book in
the school’s library. Using construction paper he made a place for the
library card, taped a red circle to the book’s spine (indicating what section
that book belonged in), and even wrote the name of the librarian on the
back inside-cover. When he came to school the next day he ran into the
library and attempted to switch the two books without anyone noticing
(unfortunately for Jacob, his paraprofessional was with him the entire
time).
While outside at recess one day, Mary, a fifteen-year-old student with
autism, decides that she would like a specific chair that is against the
school building. Like Jacob, Mary is considered to have the same
cognitive ability as a first-grader, and is unable to complete full sentences
without aid. After making this decision, she begins to move the chair a few
inches closer to her classroom window each day until it is close enough for
Are People with Autism Morally Responsible for Their Harmful Actions? 261
her to run to the window and attempt to pull it through from the other side.
This required planning over a long period of time, and indicates that she
knew what she was doing was not acceptable since she seemed to attempt
to move the chair at a rate that would go unnoticed.
Alexander is a fifteen-year-old boy with autism and is generally non-
violent. He tends to repeat the same sentences continually on impulse, and
is considered to be on the same cognitive level as a pre-kindergartener.
What the staff at his school has to watch for, though, is when a particular
female student enters Alexander’s view. If this happens, he begins to
perseverate on her name and violently attacks her, showing no remorse if
he is successful in hurting her.
What these cases share that is most relevant to this chapter is that, due
to the severity of Jacob and Mary’s diagnoses, neither would be held
morally responsible for their actions (at least not nearly to the degree that
an individual without autism would). This chapter will address how to
assess the moral responsibility of people with autism for their actions; this
will include all actions, but our focus will be on those that harm or distress
others, and also on cases where they do not show care or attention to
others where there are normally expectations to do so. The main point is
to understand what difference autism makes to a person's moral
responsibility. We will argue that there are ways that autism does make a
difference, but having autism does not take away moral responsibility
altogether.1
From the start, it is worth emphasizing the tentative and preliminary
nature of this discussion. While there has been a great deal of scientific
study of autism, it is not a well understood condition. The criteria for what
counts as having autism are subject to change, and the autistic spectrum
covers a wide range of conditions. There is room for doubt that the
spectrum is unified by a common feature, and there is evidence that it
instead will require multiple explanations (Volkmar et al, 2009; Happé,
2006). So the ideas about moral responsibility will apply differently
depending where on the spectrum an autistic person is.
A central concern in the project of assessing moral responsibility of
people with mental and neurological disorders is that it may play into
further stigmatizing them and making their lives more difficult. Readers
may wonder what motive authors have for wanting to raise the possibility
of blaming autistic people for their problematic or socially disapproved
behavior. It is a responsibility for us to be mindful of such concerns. We
can make two main points in explaining the project. First, to argue that
people with autism have moral responsibility for their actions is to
emphasize their moral agency and their status as part of our moral
262 Chapter Fifteen
community. To argue that they do not have a capacity for moral

responsibility is potentially to place them outside the moral community,
and is to place them closer to people with severe intellectual disabilities
and even non-human animals (Kennett, 2007). Second, it follows from
this first point that those who deny that people with autism have
diminished moral responsibility for their actions are also at risk for
denying that they can take moral credit for their good actions. It would
take a special sort of argument to plausibly claim that they can take moral
credit but cannot take moral blame. So while the concerns we mentioned
are reasonable, there are also concerns with opposing views.
We should also make very clear that there is a major difference
between a person being blameworthy and being blamed in an act of
condemnation. There are many cases where people are blameworthy for
their actions, yet we cannot express our blame to them because they have
moved away, have died, or are being protected by others. More relevant
for our purposes are cases where a person is blameworthy but we decide to
withhold blame or any form of retributive action because the person is
fragile or it would be counterproductive. We might also decide that while
a person with autism is morally responsible for a harmful action, we will
forgive them rather than actively blame them. People with autism might
have difficult lives, and even though we might judge them blameworthy
for what they have done, we might decide that it would do no good to
follow through on our judgment, or we might just feel that it would be
uncharitable and mean-spirited to make them feel worse when they are
struggling with their lives. So other considerations may trump the
judgment that we could blame the person with autism.
So far we have been discussing blame as a public attitude and a social

practice. We should also remember that blaming can also be more or less
private. There are cases where we blame people we have not met, and will
never meet. So our judgments of blameworthiness do not affect our
behavior towards the person, but nevertheless they may be important for
us. For example, we may be unsure what to think about someone's
behavior, whether what they have done affects our overall assessment of
that person, and even if we never express our judgment to that person or
anyone else, we may consider it important to get clear in our own minds
what we think about the behavior.
Then there is a wide range of possible reactions that lie in the middle
ground between a spoken act of blaming and possible other retributive
behavior, on the one hand, and a purely private judgment of blaming on
the other. A judgment of blameworthiness may affect our inclination to be
warm and friendly to the person, to devote resources to them, to help them
when they are in need, to be generous to them, or to recommend that other

people spend time with them. However, we might have similar behavioral
reactions to the person's wrongdoing even if we judge that they are not
blameworthy. We can judge that the person isn't to blame, but think it is a
better use of our time and energy to give our attention to someone else
who is less inclined to hurt others, or we may simply enjoy more the
company of someone with a kinder and friendlier disposition. So it is
possible that a judgment of moral responsibility would have a distinctive
effect on other people's behavior and emotional reaction to a person with
autism, even in the absence of explicit blame.
Overall Position
We can start off with uncontroversial claims: simply having a mental
disorder does not mean that a person is no longer morally responsible for
their actions. It is of course true that people with mental disorders are
often held legally responsible for their criminal actions. It is also true that
having depression, anxiety, and even non-psychotic mania do not count as
complete excuses for hurting others. Many, and probably most, people are
inclined to hold psychopaths morally responsible for their harmful
behavior, and also they hold sexual abusers, especially those of children,
morally responsible, even if they have a diagnosis of a sexual disorder.
It is possible that some might hold a much more restricted notion of
what counts as a mental disorder, what would not include many conditions
that currently count in the West. In such a case, it would be more feasible
to insist that genuine mental disorders do preclude moral responsibility for

behavior that is symptomatic of that disorder. However, this is to go
against the current trend towards more inclusive approaches to mental
disorders. While there is some debate around whether autism is always a
disorder rather than a difference (especially in regards to Asperger's
syndrome), there is general agreement that autism should count as a
disorder at least for most of the cases currently on the autistic spectrum.
So there is no particular reason here to question the standard approaches to
classification of mental disorders.
Nevertheless, people do also have strong intuitions that having a
mental disorder does make a difference to a person's moral responsibility
for their actions. This is especially true for disorders that make it more
difficult for people to know what they are doing, such as in cases of
delusion. It is also true for disorders where behavior is driven by anxiety,
compulsion, impulsiveness, or powerful emotions. In these cases, while
people may know what they are doing, they have great deal of difficulty
264 Chapter Fifteen
getting their actions to fit with their inner values, because they are less
able to control their behavior. There is plenty of sympathy that
accompanies the idea that in some sense, the person is taken over by the
disorder and is not fully responsible for their actions.
So we need to look at the particular features of autism to see how it
might affect judgments of moral responsibility. Our method here will not
be to try to develop a whole philosophical theory of moral responsibility.
Rather, it will be much more modest, in comparing autism with other
disorders and seeing if this helps shed light on how we consider the moral
responsibility of the autistic person.
Difficulties in Considering Autism

Typically in order to understand a person's moral responsibility for
their actions we need to know how they conceptualize what they do and
what their reasons for their actions are. We often want to know what
emotions they have, too, since their anger or sympathy directed at others
helps shed light on their motives. We need to understand their first-person
perspective to really assess their moral responsibility. It is not necessary
for them to give an explicit account of their reasoning or emotions so long
as we can reconstruct them from the context, their behavior, and other
clues.
However, people with autism tend not to give much clue as to their
inner thought processes or feelings. In severe cases where the individual
is nonverbal, for example, we are left to thinking in terms of symptomatic
responses, such as aggressive behavior due to overstimulation, or the

inability to communicate that they are feeling pain. Even in moderate and
mild cases, people with autism don’t do much explaining of their behavior.
This, of course, may be due to the fact that they experience the world in a
different way than people without autism, and do not recognize the
additional need to explain their reasoning or emotions for others to better
understand them. Nevertheless, the social awkwardness and difference
that often goes with autism makes it hard to reconstruct their reasons for
behavior. The very fact that they are different means that we cannot
typically reconstruct their inner lives from their behavior and context,
because we cannot make the same typical assumptions that we can with
people without autism.
A further factor making it more difficult to assess the moral
responsibility of people with autism is that it may be hard to find cases of
pure autism: many people with autism will also have other disorders that
complicate the assessment. For example, they may have mental
retardation, depression, anxiety, Tourette syndrome, ADHD, and OCD.

So even when we do find people with autism who talk about their own
inner life we cannot be sure that what they are talking about is their autism
in particular, making it difficult to generalize from one person with autism
to another. This problem also occurs with different kinds of autism, in
particular with Asperger's. There are memoirs by people with Asperger's,
most notably by Temple Grandin (Grandin, 1995) and John Elder Robison
(Robison, 2010), but also by many others. Even if we can find some
shared features in these memoirs, it does not follow that people who are
less functional share the same inner life in fundamental ways. For
example, Temple Grandin says that she thinks in pictures and she can
quite easily follow the behavior of cows and other farm animals because of
her distinctive mind. This may be true, but it would be risky to assume
that all people with autism share this distinctive feature. Additionally, the
existence of Individual Education Programs (IEPs) attests to the difficulty
in generalizing from one person with autism to another, as each student
who is classified with a disability is typically given an IEP that stays with
them throughout their entire educational career. The program is
individualized and unique to that student, based on their specific needs,
environment, and capabilities, and is created with the aim of helping the
student reach their educational goals. What is important to note here is that
each individual’s needs are unique to them, despite sharing the same
classification with others.
When faced with this problem, it is helpful to use more third-person
explanations of behavior. We will see later that we can refer to frustration,
overstimulation, and impulsiveness to explain cases of violence by people
with autism. Here we rely on a combination of third-person descriptions

and hypothetical explanations of behavior with some first person accounts
by people with autism. This will be a reasonable approach, but we need to
be aware of the added gap in our knowledge in using such explanations.
Conditions of Responsibility: Knowledge and Control

Standard approaches for a person being metaphysically responsible for
an event put necessary conditions on the agent: he or she should know that
her action would lead to the event, or that the event was a likely or even
possible outcome of the action (depending on how bad the outcome is and
how likely it was to happen), and the person had control over the action.
To be morally responsible it is generally argued that the person knows the
(probable, or even possible) moral status of the event, i.e., that it is bad or
good (Eshleman, 2009; Fischer, 2006).
266 Chapter Fifteen
These conditions are of course debated; there are some philosophers

who deny both free will and moral responsibility ever occurs (Strawson,
1994). The opposite view, that people have responsibility for everything
that happens in their lives, is probably not defended by any philosopher,
except to the extent that some are unsympathetic to excuses and argue that
people should face their circumstances on their own without shirking.
These extreme views need not occupy us because they are not helpful in
distinguishing between normal moral responsibility and other cases.
There is also debate over what it takes to know what one is doing, and
to know whether one is doing right or wrong. This is an issue even in
cases of severe delusion, because unless one is completely disconnected
from the reality around one, one has an idea what physical actions one is
performing and that one's actions are affecting other people. However,
one's delusions may be about who one is, who other people are, or the
deeper meaning of one's actions. However, since people with autism don't
suffer especially from delusions, those worries need not concern us. More
relevant to us is the question of what it means to know that an action is
wrong. Some philosophers have demanding standards for such
knowledge: it is not enough to anticipate that others will condemn or
punish one for performing them. A dog may be able to anticipate that its
owner will be angry that it has done something, but few would argue that
dogs can have any genuine understanding of morality. Psychopaths are
often very calculating and can predict the reactions of other people; they
may even take this into account when deciding how to act. Yet many have
argued that psychopaths lack a conscience and fail to have a genuine
appreciation of why their harmful actions are wrong, and some go so far as
to argue that psychopaths are not morally responsible for their bad actions
(Malatesti & McMillan, 2010). People with autism may share with
psychopaths or people with a variety of personality disorders a difficulty
in empathizing with others, although as we will see later, it seems that the
kinds of difficulty that people with autism have are distinctively different.
Thus it may be difficult for them to understand the effects their actions
have on other people. If they genuinely are not able to fully understand
the feelings of other people, then their moral competence may be severely
limited, and thus it would seem to follow that their moral responsibility
would be at least limited, and possibly negated altogether. We will pursue
this in more depth later.
The claim that in order to be morally responsible for an action the
agent had to be able to do otherwise is controversial although it has a great
deal of plausibility. It rests on the idea that if a person had no choice in
what to do, then it is unfair to blame them. The strongest examples that
lead us to be sympathetic to such ideas are in cases where people are

compelled to do something that would be considered wrong (possibly
when not compelled). A standard example is a case of a bank clerk being
threatened at gunpoint to hand over money to a bank robber. More
sophisticated examples include people doing bad things under the control
of post-hypnotic suggestion, people doing bad things while sleep walking,
or outlandish science fiction scenarios of evil neuroscientists manipulating
people's brains. This leads to debate as to what compulsion or coercion
are: the case of the bank teller certainly involves her making a choice and
she could have decided to refuse to hand over money; she still had a
choice, although it is a deeply unattractive one. It seems, then, that this
line of thought requires clarification about what we mean about people
having a choice available to them.
Examples that push in another direction involve cases where we are
inclined to blame agents even if they have no choice. We are inclined to
blame rapists and child abusers even though their actions are compulsive.
Many people are inclined to blame psychopaths and abusive alcoholics
even if they are not able to control their behavior. Most people will tend
to say that people who were abused as children and brought up to be angry
and violent, and who then subsequently abuse and hurt other people, are to
blame for their behavior, even if they had little or no chance to develop
into good people. Some philosophers say that what is morally significant
is not a particular choice, but rather one's moral character, and that we
should blame people for actions arising from a bad character even if they
could not have done otherwise.
When it comes to autism, it will be difficult to assess how much choice
people with autism have when acting in ways that are difficult or
dangerous. We will look at a few different kinds of behavior and reaction
to stimuli and discuss how the different cases require different kinds of
analysis. One central moral question is whether people with autism are in
some ways selfish, self-centered, uncaring, angry or malicious. When they
do hurt others, what are their moral motives, and can they be related in an
explanatory way with their autism?
Empirical Research
One recent paper reports, "Little is known about risk factors for
violence among individuals with autism spectrum disorder (ASD)"
(Långström, Grann, Ruchkin, Sjöstedt, & Fazel , 2009). Nevertheless, a
paper does report that aggression "is a common and serious problem
268 Chapter Fifteen
among youth with developmental disabilities" (Hellings, Nickel, Weckbaugh,

McCarter, Mosier, & Schroeder, 2005).
The problem of self-injurious behavior is common in some people with
autism, and it can be that carers get hurt in trying to stop self-injurious
behavior. Here the motive is obviously not primarily of anger directed at
others, although we might still wonder about how much people with
autism notice or care that those close to them get hurt by their violent
behavior that is self-directed.
Långström et al. (2009) go on to say that "People on the autistic
spectrum who committed violent crimes were more likely to be older and
male. They also had significantly higher levels of comorbid psychopathology
diagnosed at any time throughout the study period than those without a
history of violent crime. Psychotic disorder, any substance use, and
personality disorder were significantly associated with violent convictions
in individuals with ASD. When diagnoses of autistic disorder and
Asperger syndrome were considered separately, we found that only 3.2%
(n = 10) had been convicted of a violent crime in the autistic disorder
group, compared with 20.0% (n = 21) in the Asperger group." (p. 1366).
This is a rather surprising result, since often the popular image of
people who have Asperger's are high functioning and often more
productive members of society. We should also remember that it is just
one paper, and its findings have not been corroborated through wider
study. At this stage, then, the best we can say is that there is some
indication that some people with autism do have a higher susceptibility to
criminal violence. There are many reports of caregivers being injured
when looking after children or adults with autism, through their violent
reactions.
Philosophical Discussion
Philosophers have been particularly interested in psychopaths and their
moral responsibility because it is an important test case for different
theories (See for example Nichols, 2002). Some of this interest has
extended to autism precisely because, like psychopathy, autism involves a
deficit in the ability to empathize with others, yet at the same time it is
such a different condition that it is far from clear that what would be true
of the moral responsibility of psychopaths would also be true of people
with autism. One prominent discussion is by Kennett. Kennett (2002)
argues that people with Asperger’s are capable of moral understanding
because they are able to understand moral rules, even though they have
less ability to experience empathy with other people. She uses this to
argue for a Kantian over a Humean view of the nature of morality. That is
to say, she believes that the capacity to be a moral agent consists in the
ability to understand and follow moral rules, and thus is a matter of
theoretical and practical rationality. She argues that people with Asperger's
have this form of rationality, even if they have difficulty understanding
moral feelings. The opposing Humean view is that what makes a person a
moral agent is the ability to be moved to action by feelings of sympathy,
compassion, outrage at injustice, resentment at maltreatment, and other
distinctively moral emotions. While people with Asperger's may lack
feelings of empathy for other people, they are good at understanding rules,
and they have the capacity to modify their actions to guide their actions in
accordance with those rules. By way of contrast, she argues that while
psychopaths may achieve some shallow understanding of the rules (in the
sense that they are aware that other people follow those rules), they do not
modify their behavior accordingly, to treat others as they would want to be
treated, for example, and they also have problems with impulse control.
One question that arises for Kennett is whether her analysis rests on a
simplistic or incorrect characterization of Asperger's. This worry is raised
by Krahn and Fenton (2009), who point out that “Adopting an analysis of
empathy that distinguishes cognitive and affective empathy, for example,
has yielded experimental results that suggest a largely spared capacity for
affective, though probably not cognitive, empathy among HFAs [High
Functioning people with Autism]. Unqualified claims about a lack of
empathy among individuals with autism seem suspect in this light" (page
158). Thus, although people with Asperger's may have difficulty
recognizing the emotions of others as registered in their facial expressions
and body language, they still have the capacity for emotions reflecting
those of others. If Krahn and Fenton are right, then even Humeans will be
more inclined to agree that people with Asperger's are capable of moral
responsibility.
Another worry we might have with Kennett's assumptions is in her
supposition that people with Asperger's do not have significant problems
with impulse control and more generally with practical reason, the ability
to act on one's beliefs. The evidence cited earlier that they have a higher
risk of criminal prosecution, and the high rate of ADHD in the population,
suggests that impulse control and reaction to emotional stimuli may be
particularly difficult for them. If so, this would mean that they have more
problems with practical reasoning, and thus on Kennett's own criteria, they
are more similar to psychopaths than she realizes.
More work needs to be done on getting a good way to categorize
different subtypes of autism with respect to people's relevant moral
270 Chapter Fifteen
abilities, and their resulting moral responsibility for their actions. It is

clear that we will not be able to settle the debate between Kantians and
Humeans here, and we will content ourselves with simply setting out what
these two approaches would take to autism. Ultimately the dispute
between these two camps may be of less importance than other issues that
will emerge in the subsequent discussion.
Degrees of Moral Responsibility

Given what we have said so far, we are confident there is good reason
to think that people with Asperger’s are capable of some degree of moral
responsibility, either through their ability to understand rules or their
capacity to experience affective empathy. However, given the difficulty of
a life with Autism and probably also the limitations in understanding and
emotional range, we are likely to feel that people with autism may not be
fully responsible for their harmful behavior. This leaves us with the
question of how can a person be not fully responsible; we need to spend
more time thinking how someone can have partial moral responsibility for
what they do. This does not seem very difficult: we are very used to the
idea that children gradually become morally responsible as they get older,
and our responses to their wrong-doing changes as they become more
mature. In civil tort cases it is possible to find people responsible for a
percentage of damage or problems they have caused. Of course, there are
practical and theoretical problems in working out how responsible a
person is, but this is something that we can do in a wide range of other
cases, and we can tolerate the uncertainty of how much blame to apportion
without deciding that the whole practice of holding people responsible is
vitiated. So we can work out an adequate way to do it in the case of
autism.
This will help us to distinguish different cases of autism. For example,
people with severe autism who are low functioning will have less moral
responsibility for their actions: their cognitive deficits will mean that they
are less able to empathize and will be less able to understand and follow
moral rules. In the most extreme cases, we may be hesitant to say they are
moral agents at all.
Overstimulation and Violence

Let us consider some explanations for why people with autism might
be violent or harm others. Most guides to autism emphasize the worry
about overstimulation and changing routine. People with autism can find
that very difficult, and they can react strongly. Sometimes the reactions
can be violent (Bronsard, Botbol, & Tordjman, 2010). Another frequent
explanation of the difficult behavior of people with ASD is that they have
a low frustration tolerance. They have difficulty making themselves
understood. They may also be perfectionists, and of course perfection is
very difficult to achieve. Because of their frustration, they sometimes
become agitated and violent. These explanations are fairly easy for people
without autism to understand. We all experience frustration and it is easy
to empathize with overstimulation; introverts, for example, do not like to
be among many people, and often people find the experience of going into
a casino very difficult with all the flashing lights, the loud noise level, and
the different kinds of games going on around. We can easily imagine
reacting badly to such circumstances. However, if typical adults become
violent after getting frustrated or overstimulated, we would see this as a
moral failing. This would be true even if they were very frustrated. So
merely experiencing frustration or overstimulation is not by itself a
complete justification for violent or hurtful behavior. However, it does
give us some reason to understand the violent reaction.
People with autism can have temper tantrums, rage, and extreme anger.
These emotions can lead to violent behavior towards others. Again, these
episodes may be caused by frustration and overstimulation. However,
they are still attitudes and actions that we directly condemn in typical
adults; we only think that people are justified in becoming very angry if
they, or people they care for or represent, have been badly treated or
denied rights. When people get angry to a degree out of proportion to the
original problem, we don't regard their tiredness, frustration, or personal
problems as any sort of justification. It might serve as an excuse (the

distinction between justification and excuse for bad behavior is debated.
For one recent discussion, see Baron, 2007). Our reaction towards those
attitudes in typical children is more complicated, because we recognize
they are still developing emotional competency and our main aim is to
teach them to react more appropriately; a “punishment” is meant to be a
lesson and is not generally to blame them. So our reaction to children with
autism will certainly take such considerations into account. Even adults
with autism may be regarded as developmentally delayed. Of course, we
should be very careful about the danger in equating such adults with
children. Nevertheless, there will be some similarities between
developmentally delayed adults and children, by definition (Bronsard et
al., 2010). So our moral reaction to violent developmentally delayed
adults may mirror some, most, or all of our reactions to violent children.
272 Chapter Fifteen
Forgiveness
Given that autism is a real disability and a struggle, we should be very
open to forgive people with autism who are (to an extent) morally
responsible for hurting others. We might even be willing to do this in
cases of terrible action such as murder, and we should be ready to do it in
cases of everyday frustration. Of course, the notion of forgiveness is not
simple, and there are questions it raises. Should we forgive someone who
remains defiant or simply will not ask for forgiveness? Should we forgive
immediately, as a default position, or should we be selective about what
actions to forgive? How do we decide if any actions are unforgiveable?
These are difficult questions that take us in a different direction, and may
be impossible to answer without specifying a more particular moral stance,
such as Christianity.
While there has been considerable philosophical discussion of
forgiveness and the conditions necessary for it to be appropriate, virtually
none of that is about the actions of people with neurodevelopmental
conditions or mental illness. As Hughs (2010) writes, the standard
definition of forgiveness "is the re-establishment or resumption of a
relationship ruptured by wrongdoing." There may be a psychological
necessity for caregivers of people with autism to forgive actions which
they hold their charges or relations morally responsible, if they are to
remain in the position of caring. It is difficult to simultaneously be a good
caregiver and harbor feelings of resentment and anger towards the person
you are helping. If they cannot forgive, then they may need to give up
their position as a caregiver.
What seems pretty clear is that even when people with autism have
done something harmful or hurtful for which they carry at least some
moral responsibility, they still have a strong claim to forgiveness. This
claim derives from the fact that their autism makes life more difficult for
them in many ways, and they have been unlucky in having the condition of
autism. We might also note that should we rethink the status of autism as
a disability, deciding to describe it a difference instead, then we will be
likely to rethink the claim of a person with autism to forgiveness.
Conclusion
As this discussion has exemplified, the discussion of the moral
responsibility of people with autism for their actions is by nature
speculative and tentative, and it will be difficult to achieve any certainty in
conclusions. Nevertheless, we hope that we have shown that it is at least
possible to systematically address the issues and shed some light on what
is at stake. Given the uncertainty involved, and the vulnerable position of
people with autism in our society, we need to be cautious in the expression
of blame towards them for their actions. Anger, resentment and blame can
be caustic emotions, and they can damage the lives of the people they are
directed at.
Nevertheless, there is a case to be made that people with autism have
the ability to experience moral feelings and that they are capable of
understanding moral rules. Their abilities, especially in regards to
understanding and sympathizing with the experiences of other people, may
be impaired, but they still exist in many cases. According to the main
theories of moral agency, it follows that people with autism can be moral
agents, deserving of praise and blame for their actions. There may be
occasions when it is entirely appropriate and reasonable to express moral
disapproval and anger to them for their actions, and to request an apology.
In the cases of people who have strong verbal abilities and who are
high-functioning, this conclusion seems easy to accept. While they are
different from people without the condition, and they have distinct
challenges in their moral understanding, they are still rather obviously
capable of moral credit and blame for their actions, even if they have blind
spots in their understanding where we will be less inclined to hold them
responsible for failings.
So let us finish by considering the cases of Jacob, Mary and Alexander,
who we started with. These three young people had more severe
problems, with developmental delays and major deficits in their language
abilities and their cognitive abilities. Given their environment and their
limited emotional understanding, it would be irresponsible to express any

anger to them. The people serving as their teachers and helpers need to
educate them. Nevertheless, to ignore the moral elements in their behavior
is to ignore their agency. We need to recognize the fact that they are
planning, they have schemes, and they have formulated specific goals
which they are acting on. They have some understanding of the fact that
others disapprove of the particular actions described. To understand this
part of their complex set of goals and their attitude towards other people,
we get a more complete and a less anemic picture of who they are. The
reward systems we implement in alternative learning schools and inclusion
programs, such as earning tokens to be turned in for a certain puzzle the
individual enjoys, or extra computer time, attest to this, since these types
of behavior plans assume a degree of control that the individual has over
his or her actions. Additionally, the use of storytelling tailored specifically
to the individual’s behavior presupposes that the individual is able to learn
274 Chapter Fifteen
social rules and appropriateness (a story about a student getting on the bus
being tailored for an individual who is obstinate when needing to leave for
school in the morning, for example). With the considerations mentioned
in this paper and the effectiveness of these practices in mind, it seems,
then, that the conditions that lead us to assume some degree of agency of
even some of the severe cases of autism are the same conditions that allow
us to think of and treat individuals with autism as moral agents.
References
Baron, M. (2007). Excuses, excuses. Criminal Law and Philosophy, 1(1),
21–39. doi:10.1007/s11572-006-9001-2
Eshleman, A. (2009). Moral Responsibility. Retrieved from The Stanford
Encyclopedia of Philosophy: http://plato.stanford.edu/cgi-bin/ency
clopedia/archinfo.cgi?entry=moral-responsibility
Fischer, J. M. (2006). Free Will and Moral Responsibility. In D. Copp,
The Oxford Handbook of Ethical Theory (pp. 321-356). New York:
Oxford University Press.
Grandin, T. (1995). Thinking in pictures: and other reports from my life
with autism XE "autism" . New York: Doubleday.
Hellings, J., Nickel, E., Weckbaugh, M., McCarter, K., Mosier, M., &
Schroeder, S. (2005). The Overt Aggression Scale for Rating
Aggression in Outpatient Youth With Autistic Disorder: Preliminary
Findings. The Journal of Neuropsychiatry and Clinical Neurosciences ,
17 (1), 29-35.
Kennett XE "Kennett" , J. (2002). Autism, Empathy and Moral Agency.

The Philosophical Quarterly , 52 (208), 340-357.
—. (2007). Mental Disorder, Moral Agency, and the Self. In B. Steinbock,
Oxford Handbook of Bioethics (pp. 90-113). New York: Oxford
University Press.
Krahn, T., & Fenton, A. (2009). Autism, Empathy and Questions of Moral
Agency. Journal for the Theory of Social Behaviour , 39 (2), 145–166.
Långström, N., Grann, M., Ruchkin, V., Sjöstedt, G., & Fazel , S. (2009).
Risk Factors for Violent Offending in Autism Spectrum Disorder: A
National Study of Hospitalized Individuals. Journal of Interpersonal
Violence , 24 (8), 1358-1370.
Malatesti, L., & McMillan , J. (2010). Responsibility and psychopathy XE
"psychopathy" : Interfacing law, psychiatry XE "psychiatry" and
philosophy. Oxford: Oxford University Press.
Nichols, S. (2002). How Psychopaths Threaten Moral Rationalism: Is It

Irrational to Be Amoral? Monist: An International Quarterly Journal
of General Philosophical Inquiry , 82 (2), 285-303.
Robison, J. E. (2010). Look Me in the Eye: My Life with Asperger's. New
York: Ebury.
Strawson XE "Strawson, P.F." , G. (1994). The Impossibility of Moral
Responsibility. Philosophical Studies , 75, 5-24.
Volkmar, Fred R., Matthew State, Ami Klin. (2009) Autism and autism
spectrum disorders: diagnostic issues for the coming decade. Journal of
Child Psychology and Psychiatry. Volume 50, Issue 1-2, pages 108–
115.
CHAPTER SIXTEEN
ODYSSEUS AND “THE FOOLS”:

APPLYING CONCEPTS OF NEURODIVERSITY
TO THE ANCIENT WORLD
KRISTINA CHEW
Applying concepts of neurodiversity and cognitive difference—that,

just as people have diverse ethnic, racial and religious identifies, they can
also have diverse ways of experiencing and being in the world based on
their neurology—to pre-twentieth century texts poses not only interpretative
but also ethical challenges. To consider issues raised by 21st-century
concepts of neurological difference in regard to ancient texts presumes that
neurological diagnoses such as autism have always existed, though under
different names as epilepsy was described as the "sacred disease" by the
4th century medical writer Hippocrates. In this essay, I attempt such an
analysis of Homer's epic poetry using concepts drawn from neurodiversity,
to highlight how intellectual and physical disability are therein represented.
Autism as a 20th- and 21st-century Phenomenon

Ideas from feminism, Marxism, literary theory, multiculturalism have
all made their way into classical scholarship in works such as Before
Sexuality: The Construction of Erotic Experience in the Ancient World,
The Constraints of Desire: The Anthropology of Sex and Gender in
Ancient Greece, and Innovations of Antiquity.1 Investigating the ancient
world and, in particular, Greek and Latin texts, from the perspective of
neurological difference is arguably a more complicated endeavor as
neurodevelopmental and neuropsychiatric diagnoses such as “autism,”
“autism spectrum disorders” and Asperger’s Syndrome are themselves of
very recent detection and identification as specific conditions.2 Only in the
past decade have we begun to view these diagnoses as neurological rather
than as psychological disorders of psychogenic origin categorized within
Odysseus and “The Fools” 277
the framework of mental health. The very notions of neurodiversity and

cognitive and neurological difference are distinctly contemporary and a
phenomenon of the late 20th and early 21st centuries, at a time when
notions of identity politics are well-established and (in the U.S.) where,
after the Civil Rights Movement, diversity and multiculturalism are
broadly familiar concepts and, even more realities. Neurodiversity is
indeed a very late 20th and early 21st-century way of looking at the world.
But alongside this argument for neurodiversity as a contemporary
phenomenon is what could be called one of its central tenets, that those
with neurological difference have always existed but simply not been
recognized as such. Historical developments and cultural and social
changes including the rise of psychology and a greater (though far from
complete) understanding of mental illness from a scientific and medical
perspective (rather than as the result of so-caled moral or character
failings) have all played a part in making it possible to see those with
neurological difference not as "weird, abnormal," etc. but as part of
"natural human variation" (Jaarsma, 2003, 20).
To even attempt to study the ancient world from the perspective of
neurodiversity rests on this latter assumption that conditions such as
autism, while only recently named, have long, and even always, existed
though they have not been comprehended as such. The meaning of autism,
and the criteria for diagnosing it in the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders (DSM), have
themselves changed since Leo Kanner first identified "infantile autism" in
the 1940s and continue to do so. For instance, t diagnostic changes have
been seen by some as a significant reason for the notable rise in the autism
rate in the late 20th and early 21st century. Once considered a rare disorder
occurring at a rate of one in some or even several hundred thousand,
prevalence rates for autism are now as low as one in 88 and even one in 38
(Kim, 2011).3 In Unstrange Minds: Remapping the World of Autism,
anthropologist Roy Richard Grinker writs about the impact cultural and
societal changes (such as for the diagnostic criteria for autism) have had
on autism prevalence and on cultural and societal acceptance of autism. As
Grinker writes, “the cluster of symptoms we now know as autism has
probably been around for a long time, but no one really knows for sure”
(Grinker, 2003, 52). A "perfect storm" of certain historical and cultural
circumstances have contributed to the rising interest and understanding,
and therefore the rising numbers, of autism diagnoses.
While the perspective of understanding and acceptance about
neurological difference is very much a feature of contemporary culture, an
examination of ancient texts suggests that an awareness of what we today
278 Chapter Sixteen
would call neurological difference did exist. The primacy accorded to

ȜȠȖȩȢ, to words and speech and language and talking, in ancient Greek
culture and the influence of ancient Greek literature and thought on
Western culture, make ancient texts of particular interest in attempting a
historical and cultural study of neurodiversity, and all the more as such
texts were created at a time when literacy was far from widespread. The
very emphasis on the word automatically puts into question the experience
of those who do not speak, or who are not so eloquent and verbally gifted,
who are “different” due to being unable to speak well or even to speak at all.
It has become something of a parlor game to post-diagnose famous
individuals (like Leonardo da Vinci) with Asperger's Syndrome and to ask
if "feral children" found in the wild were autistic. I do not attempt any
such retrospective diagnosing of historical figures or reports of individuals
from the ancient world but will explore how neurodiversity might be
studied in the ancient world by focusing on two words in the poems,
ȞȒʌȚȠȢ, “speechless, foolish, child” and ʌȠȜȪĲȡȠʌȠȢ, “much-travelled,
versatile," to explore how ideas of cognitive difference and neurological
diversity are constructed and responded to in Homer’s Iliad and Odyssey.
While ʌȠȜȪĲȡȠʌȠȢ hints at a diversity of thinking and being, ȞȒʌȚȠȢ refers
to being foolish and childlike as a feature of being "unworded." I focus on
the Odyssey, in whose opening lines both of these terms occur and in such
a way as to contrast being ʌȠȜȪĲȡȠʌȠȢ from being ȞȒʌȚȠȢ. The hero
Odysseus' men are referred to as ȞȒʌȚȠȚ, specifically in contrast to the
clever, wily, "versatile" (ʌȠȜȪĲȡȠʌȠȢ) Odysseus.
ȃȒʌȚȠȢ: Fools Who Do Not Speak

At the very beginning of the Odyssey, Odysseus' men are referred to in
line 8 as ȞȒʌȚȠȚ, specifically in contrast to the ʌȠȜȪĲȡȠʌȠȢ Odysseus, the
man (ȐȞįȡĮ) who is, from the first word of the poem, announced as its
subject.
ਙȞįȡĮ ȝȠȚ ਩ȞȞİʌİ, ȝȠ૨ıĮ, ʌȠȜȪĲȡȠʌȠȞ, ੔Ȣ ȝȐȜĮ ʌȠȜȜ੹

ʌȜȐȖȤșȘ, ਥʌİ੿ ȉȡȠȓȘȢ ੂİȡઁȞ ʌĲȠȜȓİșȡȠȞ ਩ʌİȡıİȞ:
ʌȠȜȜ૵Ȟ įૃ ਕȞșȡȫʌȦȞ ੅įİȞ ਙıĲİĮ țĮ੿ ȞȩȠȞ ਩ȖȞȦ,
ʌȠȜȜ੹ įૃ ੖ Ȗૃ ਥȞ ʌȩȞĲ૳ ʌȐșİȞ ਙȜȖİĮ ੔Ȟ țĮĲ੹ șȣȝȩȞ, 5
ਕȡȞȪȝİȞȠȢ ਸ਼Ȟ Ĳİ ȥȣȤ੽Ȟ țĮ੿ ȞȩıĲȠȞ ਦĲĮȓȡȦȞ.
ਕȜȜૃ Ƞ੝įૃ ੬Ȣ ਦĲȐȡȠȣȢ ਥȡȡȪıĮĲȠ, ੂȑȝİȞȩȢ ʌİȡ:
Į੝Ĳ૵Ȟ Ȗ੹ȡ ıĳİĲȑȡૉıȚȞ ਕĲĮıșĮȜȓૉıȚȞ ੕ȜȠȞĲȠ,
ȞȒʌȚȠȚ, Ƞ੄ țĮĲ੹ ȕȠ૨Ȣ ੥ʌİȡȓȠȞȠȢ ਹİȜȓȠȚȠ
ਵıșȚȠȞ: Į੝Ĳ੹ȡ ੒ ĲȠ૙ıȚȞ ਕĳİȓȜİĲȠ ȞȩıĲȚȝȠȞ ਷ȝĮȡ. 10
Ĳ૵Ȟ ਖȝȩșİȞ Ȗİ, șİȐ, șȪȖĮĲİȡ ǻȚȩȢ, İੁʌ੻ țĮ੿ ਲȝ૙Ȟ.
[Sing, goddess, to me of the many-traveled man who

Suffered much when he destroyed the holy city Troy;
Many men's cities he saw and minds he knew,
And many pains he suffered on sea in his very heart.
Striving in his soul and for his crew's return home.
But not could he wrest them away, even as he was sent on:
For by their own wretched acts they were undone,
Fools who ate up the cattle of Hyperion the Sun
But the day of return was taken from them.
Of these things, Zeus' daughter, sing even to me.]4
ȃȒʌȚȠȢ means "infant, child" and also childish" and "not yet speaking";
by extension, it means "silly, without foresight, blind."5 It is made up of
the negating prefix ȞȘ- and the word ਩ʌȠȢ, which means "word," "speech."
ȃȒʌȚȠȢ has connotations of being unable to talk like an infant; of being
unable to communicate and to voice only sounds that have no meaning. To
be ȞȒʌȚȠȢ is to be without speech in a similar formulation as the Latin
word infans, the in- negating what follows (fans means "speaking" and is
from for, fari, fatus sum).
In ȞȒʌȚȠȢ, “not speaking” is associated with not being able to think.
Forms of ȞȒʌȚȠȢ are used 21 times in the Odyssey. Notably, the word
occurs in line 8 of the proem of the Odyssey, with the narrator castigating
Odysseus' men for eating the cattle of the sun, thereby negating their
return home.
ȞȒʌȚȠȚ, Ƞ੄ țĮĲ੹ ȕȠ૨Ȣ ੥ʌİȡȓȠȞȠȢ ਹİȜȓȠȚȠ

ਵıșȚȠȞ: Į੝Ĳ੹ȡ ੒ ĲȠ૙ıȚȞ ਕĳİȓȜİĲȠ ȞȩıĲȚȝȠȞ ਷ȝĮȡ.
[Fools who ate up the cattle of Hyperion the Sun

But the day of return was taken from them.]
The use of ȞȒʌȚȠȚ is particularly resonant here as it is Odysseus' men

who are referred to. While some have names (Elpenor), most do not; they
are not only nameless but, for the most part,voiceless and without words.
They are indeed foolish as they disobey Odysseus’ injunction not to eat the
cattle of the sun, thereby depriving themselves of their return home in
Book 12. Even more, the way they are foolish is that they give in to their
appetites, to their physical needs, even making gluttons of themselves
while Odysseus sits aside and refrains. To be ȞȒʌȚȠȢ is to have insufficient
coordination of body and mind, such that the men's bodily appetites won
over their judgment and the orders of Odysseus.
280 Chapter Sixteen
Odysseus’ men can be said to be “childish” in their thinking and action

and ȞȒʌȚȠȢ is often used in reference to being young and immature. The
word often occurs in such usages in regard to Odysseus' son, Telemachus,
whose growing sense of himself as no longer a child but as an adult who
can stand up to the crowd of suitors of his mother, Penelope, is the subject
of much of th poem's first few books. At 1.297, Athena in the guise of a
traveler, Mentor, tells Telemachus not to practice "childish ways" (ȞȘʌȚȐĮȢ
ȩȤȑİȚȞ) as he is no longer of that age (ȠȪțİĲȚ ĲȘȜȓțȠȢ). Telemachus also
uses ȞȒʌȚȠȢ to describe himself among the suitors (2.313) and in contrast
to his being grown and ȝȑȖĮȢ (“big” or “grown up”). At 11.449, ȞȒʌȚȠȢ
simply means child, baby, in reference to Telemachus' young age when
Odysseus left Ithaca. Telemachos himself uses ȞȒʌȚȠȢ to describe himself
as a child growing up among the suitors in the latter part of the Odyssey
when he meets Odysseus (19.19, 20.310, 20.310).6
Another use of ȞȒʌȚȠȢ at 6.301 shows how the word describes those
with limited cognitive ability and know-how. Nausicaä tells Odysseus that
it is so easy to find the palace of her father, King Alcinous, that a child, a
ȞȒʌȚȠȢ (a reference in part to herself, in a downplaying of her capabilities)
could find it.7 A similar usage occurs at 9.419, Odysseus says the Cyclops
must have thought him ȞȒʌȚȠȞ, "foolish" to think that escape via the great
stone door with the monstrous one-eyed creature guarding it was possible.8
Even more, being ȞȒʌȚȠȢ is to do and even more, say things that are
counter to what is commonly known and considered appropriate. In 4.32-
3, Menelaus says "like a child, you talk foolishly" to a man named
Eteoneus who asks whether or not to observe the rituals of xenia, of guest-
friendship, with Telemachus and Antenor.9 At 6.44, Odysseus uses ȞȒʌȚȠȢ
in a similar sense when he refers to his men as ȞȒʌȚȠȚ when they drink and
eat unwarrantly against his admonitions,10 in a use of the word recalling
that in the opening lies of the Odyssey when such behavior is expressively
identified as the reason Odysseus' men do not return home.
The word ȞȒʌȚȠȢ is often used in proximity to mention of women and
mothers. In 19.530, Penelope, speaking to Odysseus disguised as a beggar,
uses ȞȒʌȚȠȢ along with ȤĮȜȓĳȡȦȞ ("slow of wit, thought") to describe the
young Telemachus who, she says, so long as he was such, would not allow
her to remarry and leave her husband's house.11
In the latter books of the Odyssey, ȞȒʌȚȠȢ is used in reference to the
suitors in another instance of the word being associated with those who are
less than intelligent. The suitor Antinous uses ȞȒʌȚȠȢ to tell off the other
suitors as ȞȒʌȚȠȚ ȐȖȡȠȚȫĲĮȚ (“foolist and boorish”) at 21.86, when they are
all unable to string Odysseus' bow. At 22.32, the narrator calls the
suitors—on the verge of being killed by Odysseus who has just revealed
his true identity—ȞȒʌȚȠȚ, "fools" who did not know (ȑȞȩȘıĮȞ).12 Medon
the herald also uses ȞȒʌȚȠȚ to describe the suitors, and distance himself
from them, at 22.370, in pleading for his life after hiding himself in an ox-
hide. Finally, at 24.469 ȞȒʌȚȠȢ is used (ȞȘʌȚȑȘıȚ) specifically to describe
the words of the old lord Halitherses, who rebukes the actions of the now
slain suitors to their families, who seek vengeance against Odysseus.13
To a modern reader, ȞȒʌȚȠȢ thematizes disability almost too well, as
being associated with being foolish, childlike, unable to think reasonably
for oneself and making errors of judgment. To be ȞȒʌȚȠȢ is to slow of
thought and, in essence, cognitively impaired.
ȆȠȜȪĲȡȠʌȠȢ: Speech, Versatility, Ability

Neurodiversity refers to the diversity, the spectrum of ways of thinking
and perceiving the world. An awareness that people in different places
indeed have different and diverse mentalities appears at the very start of
the Odyssey, in reference to Odysseus’ travels among places and peoples
very different from his home in Ithaca and from himself. The word
ʌȠȜȪĲȡȠʌȠȢ14 literally means “much turning” and, by extension, “much
travel’ed”: ਙȞįȡĮ ȝȠȚ ਩ȞȞİʌİ, ȝȠ૨ıĮ, ʌȠȜȪĲȡȠʌȠȞ, ੔Ȣ ȝȐȜĮ ʌȠȜȜ੹, “tell
me, Muse, of the much-travelled man, who many things” (1.1; also
10.330). ȆȠȜȪĲȡȠʌȠȢ is an epithet of Odysseus; he is from the start
introduced as someone who has "known the cities and minds of many"
(ʌȠȜȜ૵Ȟ įૃ ਕȞșȡȫʌȦȞ ੅įİȞ ਙıĲİĮ țĮ੿ ȞȩȠȞ ਩ȖȞȦ). Odysseus, through his
experiences (ʌȐșİȞ), is knowledgeable (਩ȖȞȦ) of the different ways that
people think and act, an ability that is arguably a reason for his survival.
He saves his men and himself after they are trapped in the Cyclops' cave
by giving himself a false name (ȠȣįİȓȢ, "nobody") and coaxing the
Cyclops to drink wine, calculating that the one-eyed giant will not have
tried such before and will be unable to stop drinking, much manage the
effects of wine.
Odysseus is also ʌȠȜȪĲȡȠʌȠȢ because of his verbal ability, his
signature talent to talk his way out of any and every tight spot. His
heroism lies as much in his verbal ability, his power as a speaker, as in his
military feats and strength. He is not simply clever but able to adapt with
circumstances. His verbal ability is highlighted early in the Iliad in Book 2
in a passage that clearly contrasts him with a figure who could be
considered ȞȒʌȚȠȢ and that has been remarked upon as suggesting ancient
attitudes towards disability. This is Odysseus’ encounter with Thersites
who, a commoner and not a member of the aristocracy, fiercely upbraids
282 Chapter Sixteen
Agamemnon, the commander of the Greeks, for keeping the army at Troy
into a tenth year.
"The Most Hated of the Greeks"

Thersites is physically disabled and described as hunchback. He speaks
rudely to Agamemnon, not showing the proper respect for the authority of
his superiors at Iliad 2.218-220:
ĳȠȜțઁȢ ਩ȘȞ, ȤȦȜઁȢ įૃ ਪĲİȡȠȞ ʌȩįĮ: Ĳઅ įȑ Ƞੂ ੭ȝȦ

țȣȡĲઅ ਥʌ੿ ıĲોșȠȢ ıȣȞȠȤȦțȩĲİ: Į੝Ĳ੹ȡ ੢ʌİȡșİ
ĳȠȟઁȢ ਩ȘȞ țİĳĮȜȒȞ, ȥİįȞ੽ įૃ ਥʌİȞȒȞȠșİ ȜȐȤȞȘ.
[Bowl-legged he was and lame in his other foot: And his shoulders
curved, hunched over his chest and higher up
Was his malformed head, with sparse hairs on it.]
Thersites physical ugliness is associated with an internal "ugliness" of

character, including excessive rudeness towards the "godlike" leaders. At
at 2.212-213, his speech is described as “ugly,” his words in excess (his
speech is “measureless, ਕȝİĲȡȠİʌȒȢ) and “disorderly” (਩ʌİĮ ਙțȠıȝĮ).
In response to his inappropriate (though, arguably, justified) words to
Agamemnon, Odysseus beats Thersites with his staff, a huge welt rises on
his back and the Greek army laughs at his misery (2.265-270). Thersites
can be seen as voicing what everyone is thinking; once he has said this, he
is duly dispatched of by Odysseus, the Greek known for his cunning and
crafty speech. An implicit dislike towards Thersites is apparent in the

response of the other Greeks to his beating. While they might share
Thersites’ sentiments about the long wait at being away at war for so long,
they laugh at Thersites and praise Odysseus for beating him.
Thersites is all the more an unusual figure in that he is one of the very
few commoners, a non-aristocrat, with a speaking role in the Iliad (in
contrast him to the swineherd Eumelos in the Odyssey who, as it turns out,
is of noble birth). Is Thersites' deformity part of a stock characterization of
the common man as lesser, uglier and baser than the nobles heroes of
literature who, being such, are the better to be depicted for the exemplary
models they provide? In reality, due to the physical demands of life in the
ancient world and the state of medical care, people were far more likely to
see someone with disabilities routinely, as Martha L Rose (2003) notes in
The Staff of Oedipus: Transforming Disability in Ancient Greece. That is,
in any Greek army, or community, there have been more individuals of
similar appearance to Thersites.
It would be anachronistic for us to impose contemporary attitudes onto

the character and treatment of Thersites. We are uncomfortable at his
physical abuse at the hands of Odysseus, and at the praise of the Greeks to
Odysseus for beating up Thersites and the description of him as “most
shameful," Į੅ıȤȚıĲȠȢ. The response to Thersites’ speech and to Odysseus
beating him suggest a denigration for physical deformity seen in the
contrast of the Greek words, țĮțȩȢ (“bad,” “ugly,” “cowardly”) and țĮȜȩȢ
(“beautiful, fair, noble”). Odysseus’ punitive response to the very different
figure of Thersites underscores that being knowledgeable about many
peoples and cities does not extend to someone whose difference derives
from their physical condition and the way he uses language. In voicing the
frustration of being ten years at war and away from Greece, and then being
punished for doing so, Thersites functions as a scapegoat for the Greek
army and in ways that recall the ritualistic role of the ĳĮȡȝĮțȩȢ, the
scapegoat in the yearly ritual of a ritual called the Thargelia in classical
Athens.
In the Thargelia ĳĮȡȝĮțȩȢ was selected from the “dregs of society”,
say Jean-Pierre Vernant’s and Pierre Videl-Naquet in Myth and Tragedy in
Ancient Greece:
the țĮțȠȪȡȖȠȚ, gibbet fodder whose crimes, physical ugliness, lowly
condition and base and repugnant occupations marked them out as inferior,
degraded beings, ĳĮȣȜȠȚ [of low rank, common], the refuse of society
(Vernant, 1968).
The word țĮțȠȪȡȖȠȚ means, most literally, “those doing ill,” and, by
extension, “mischievous, villanous, malefactor.” ȀĮțȩȢ is “bad” and
“evil,” while ਩ȡȖȠȞ means “work” or “deed.” The etymology of țĮțȩȢ can
be traced back to the Proto-Indo-European word kakka, “to defecate”:
ȀĮțȩȢ means nothing nice or good. Its additional meanings are “ugly,” in
terms of appearance; “ill-born,” in terms of birth (in contrast, the heroes in
the Trojan War are all of “noble birth” (ȖȞȒıȚȠȢ); “cowardly”; “worthless,
unskilled, sorry” (for instance, of a sailor or doctor who is “bad” at what
he claims to do); “base, evil” in a moral sense; “abusive, foul,” of words.
Used as a noun (and in the neuter gender), țĮțȩȢ has the additional
meaning of “harm” or “ill,” in the sense of “evil coming to a person.”
The various meanings of țĮțȩȢ cohere with the criteria for choosing
the ĳĮȡȝĮțȩȢ, the scapegoat as described by Vernant and Vidal-Naquet.
Notably, those chosen to be ĳĮȡȝĮțȩi (the plural form of ĳĮȡȝĮțȩȢ) were
not only those who had done some evil—a crime—but also those who
were “physically ugly,” which is another meaning of țĮțȩȢ. Physical
ugliness and deformity is, then, associated with baseness of character.
284 Chapter Sixteen
Thersites, in his physical appearance and in his words and actions,

embodies the varied meanings of țĮțȩȢ mentioned above: He is ugly in
his character, speech, and appearance—-though a modern reader is likely
to find Odysseus’ beating of a weaker opponent even more ugly. Thersites
in the Iliad is a literary equivalent of a ĳĮȡȝĮțȩȢ, the scapegoat of the
Thargelia ritual in classical Athens. The beating and expulsion of Thersites
from among the ranks of the Greek army indeed parallels the beating and
ritual expulsion of the ĳĮȡȝĮțȩȢ. And just as (according to Vernant and
Vidal-Naquet) the annual expulsion of the ĳĮȡȝĮțȩȢ was a means of
casting off the community’s collective defilement, so do Thersites’
“insolent” words—expressing what more than a few of the hoi polloi of
the Greek army might be thinking after being camped before Troy and
away from their homes for ten years—and also his beating by Odysseus
provide a sort of “cleansing” or “kathartic” function for the assembled,
restless Greeks, evinced in the laughter in the Greek army on seeing
Thersites limping away in tears.
Thersites is barely mentioned for the rest of the Iliad. His brief
appearance at the beginning of the Iliad has been seen as providing comic
relief in the poem's narrative of war, anger and death, analogous to the
description of the lame god of the forge, Hephaistos, serving nectar on Mt.
Olympus to the gods' amusement—and dissipating Zeus' anger at Hera—at
the end of the first book of the Iliad. Even at a time when there is
increased understanding about disability in the form of laws and policies
framing disability rights as civil rights and civil rights, dislike and
repulsion towards Thersites remain—as one commentator observes,
Thersites has received “an almost universally bad press” (Postlethwaite,
1988, 123)—and are as much a reminder as anything for the need to

analyze ancient texts from the critical perspective of disability studies.
Rather than reiterating stereotypes equating Thersites' physical
appearance with a discriminatory notion of "character defects" or "moral
failings," we can, after centuries, do the right thing and consider how a
man with such physical deformities could still be in the Greek army at all.
Does not the shade of the great Achilles himself say to Odysseus in book
11 of the Odyssey that "I'd rather be toiling under another alive on earth /
for a propertyless man whose livelihood was not much / than be lord to all
the shadowy dead"—that he would rather be as lowly as Thersites than be
dead; that being disabled is not at all a fate worse than death?15
References
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Diseases and Control, last modified March 29, 2012,
http://www.cdc.gov/ncbddd/autism/data.html.
Grinker, R. (2003). Unstrange Minds: Remapping the World of Autism.
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Hexter, R.J. and Selden, D.J. ed., (1992). Innovations of Antiquity
Routledge: New York & London.
Jaarsma, P. and Welin, S. (2012). “Autism as a natural human variation:
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Young, S.K., et al., “Prevalence of autism spectrum disorders in a total
population sample,” American Journal of Psychiatry 168, no. 9 (2011):
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2012.http://www.perseus.tufts.edu/hopper/morph?l=nhpios&la=greek#
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Postlethwaite, N. (1988) “Thersites in the Iliad,” Greece & Rome, Second
Series, 5, no. 2, 123-136.
Rose, M. L., (2003). The Staff of Oedipus: Transforming Disability in
Ancient Greece. Ann Arbor: University of Michigan Press.
Vernant, J. and Videl-Naquet, P. trans. Janet Lloyd, (1968). Myth and
Tragedy in Ancient Greece. Zone Books / MIT Press.

Winkler, J.J. (1990). The Constraints of Desire. The Anthropology of Sex
and Gender in Ancient Greece (Routledge: New York & London,
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NOTES
Introduction
1
Discussing how it is that people might take "the moral point of view," the author
of an otherwise excellent book on the topic writes, "Think of what we are being
asked to imagine, someone with no capacity for sympathy or empathy, someone
with no concern for others, someone with no identification with any human
community, someone with no sense of fairness...What we are asked to imagine is a
truly colossal failure of socialization, someone who has no disposition that can be
satisfied by following moral rules, and who, even after serious reflection, would
still not have one. . . Such a person must be either autistic or a Martian" (Olen,
1988, pp. 51-52_). Olen, J. (1988)..Moral Freedom. Philadelphia: Temple University
Press.
Chapter One
1
Interestingly, some theorists claim that Bartleby himself is a quintessential
example of an autistic adult.
Chapter Two
1
See: Tan, Justice, Institutions, and Luck, 1.
2
For more on how Full Autonomy adds conditions to Rational Autonomy see
pages 528-530.
3
One important aspect of the literature in philosophy should be noted. While
neurodiversity refers to psychological or neurological difference, most
philosophers approach the issue by analyzing disability. While the terminology
triggers othering, here I use the ideas in service of the difference characterized with
neurodiversity.
4
One study looking at the quantification of small numbers further evidences this
point. Rather than seeing “four” when a small number of objects are presented, the
timing of responses is more consistent with a process that counts up to four and is
not subject to framing effects. See: Gagnon et al., “Quantification Judgement in
High Functioning Autism: Superior or Different?”.
5
Kittay and Carson think these individualls present the biggest challenge to
inclusion. See: Carlson and Kittay, “Rethinking Philosophical Presumptions in
Light of Cognitive Disability,” 313.
Ethics and Neurodiversity 287
6
For a nice piece that brings together Rawls’s notion of democracy and the
capabilities approach see: Anderson, “What Is the Point of Equality?”
7
For a nice schema on how to approach different kinds of positive interventions
and goals in resources allocations, see: Wolff, “Cognitive Disability in a Society of
Equals.”
Chapter Three
1
We elected not to anonymize the universities as the school rankings list is
publically available, and the included excerpts are traceable online.
Chapter Four
1
A contentious issue for autism advocates concerns the interplay between
language practices and identity. Is person-first (e.g., “person with autism”) or
autism-first (e.g., “autistic person”) language preferable? Some prefer “person with
autism” because it puts the person before the autism. Others have argued that
person-first language wrongly implies that autism is separable from the person
(Sinclair, 1999). I use both kinds of language in this paper to honor the different
ways individuals may choose to talk about themselves.
2
The existing literature on representations of autism (e.g., Broderick & Ne’eman,
2008; Duffy & Dorner, 2011; Hacking, 2009a, 2009b, 2009c; Sarrett, 2011:
Smukler, 2005) contains valuable analyses of these and other metaphors for
autism. These analyses and others like them are part of an ongoing critique of
tragedy narratives and disability, a central topic in disability studies. For more on
tragedy narratives and disability see Oliver (1990).
3
Hacking (2009c) notes: “Many people hardly waste the time to write out “Theory
of Mind” any more, they just write “ToM.” I do not follow this practice, because
the very fact that we use an abbreviation makes us take it for granted, as some sort
of proven fact” (p. 54). I am sympathetic with Hacking’s concern and do not use
“ToM” in this paper.
4
Actually, there is a slightly earlier occurrence of “mindblindness” in the autism
literature. See Frith (1989).
5
See Wittgenstein, 1953; 1980 and Köhler, 1929 for examples of perceptual access
views of other minds.
6
The views of these autistic advocates do not represent everyone on the spectrum.
Also, there are autistic persons whose functional challenges do not afford them the
opportunity to self-advocate.
7
For a thoughtful philosophical discussion of blindness, including a fascinating
discussion of Wells’ story, see the letter correspondence between the blind
philosopher, Martin Milligan and the sighted philosopher, Bryan Magee: Magee &
Milligan (1995).
288 Notes
8
And yet a metaphor that connotes “seeing differently” would still privilege vision
over the other senses and thus obscure the ways other senses may contribute to
social interaction and communication (Akhtar & Gernsbacher, 2008).
9
I am grateful to Nameera Akhtar, the audience at the Bergen Community College
conference, “Social, Political, and Ethical Perspectives on Autism” April, 2012,
and the editors of this volume for helpful feedback on earlier versions of this
paper.
Chapter Seven
1
For example, experimental philosopher Manuel Vargas claims that sociopathy,
psychopathy, and antisocial personality disorder are synonyms distinguished only
in age and are, therefore, interchangeable (2010, pp. 69-71). Clinical psychologist
Martha Stout, Ph.D. freely switches between the terms in her book The Sociopath
Next Door (2005).
2
Hopefully, this part of the conditions will be revised in the upcoming version of
the DSM, as many professionals acknowledge the existence of acquired
sociopathy, which happens as a result of extreme trauma to the areas of the brain
believed to be responsible for APDs.
3
For example, patient A might satisfy conditions 3, 4, and 5 and patient B might
satisfy conditions 1, 2, and 6. Both would have APD even though that might be all
that they have in common.
4
Lykken (1995) considers character neurosis a third species of APD and distinct
from psychopathy and sociopathy.
5
I want to leave it open that a person could be akratic (susceptible to acting
against her best judgment) and still have a conscience. While an akratic might
rarely do what her conscious demands, her conscious still makes demands of her
and punishes her with guilt and remorse after the fact. Such persons are probably
not clinically distinguishable, though their actions alone might suggest it. By
considering the meaning of the term ‘behavior’ broadly we can include emotional
experiences as well as overt actions.
6
While earlier research suggested similar conclusions, Craig et al. specifically
targeted connections between the OFC and amygdala related to white matter
connections. They found a reduced fractional anisotropy (FA) in the right unculate
fasciculus (UF) in the psychopathic subjects.
7
It should be noted that all instances in this paper that refer to sociopaths as
virtuous are to be interpreted with this caveat in mind. I argue that sociopaths can
have virtues, and that their virtues might even be enhanced and grounded in what
makes them sociopaths. I am not arguing that sociopaths can be virtuous morally
exemplary human beings without (somehow) curing themselves of their
sociopathy.
8
Babiak and Hare (2006) argue that only large businesses such as corporations are
likely to attract psychopaths since psychopaths can remain “under the radar” and
are able to climb the corporate ladder with ease and receive perquisites. Hare and
Babiak doubt that psychopaths would flourish in smaller business where mobility
is limited, mutual monitoring of employees is natural, and a team effort are
expected (pp. 95-7).
9
I am grateful for the comments and suggestions made by Stephen M. Kershner on
earlier versions of this manuscript. Several conversations with participants of The
Capacity-Character Project workshop (held at Delft University of Technology, the
Netherlands, May 21-22, 2012) were formative to the writing of this piece. These
interactions, along with the suggestions of helpful anonymous reviewers, proved
invaluable in the completion of this paper.
Chapter Eight
Acknowledgments: A shortened version of this paper was given as a Bioethics
Grand Rounds presentation at the Cleveland Clinic, Cleveland Ohio, USA, in
September 2010.
1
An accessible overview of the neurotypical movement can be found at the
Wikipedia entry for “Autism Rights Movement”, cross-referenced as “Neurodiversity”
at http://en.wikipedia.org/wiki/Neurodiversity_movement
2
Some of the blogs and websites that espouse a neurodiverse perspective include:
The Autism Women's Network: http://autismwomensnetwork.org/
The Autistic Self Advocacy Network, ASAN: www.autisticadvocacy.org
Autistics.org, with a portal to Second Life: www.Autistics.org
Amanda Bagg’s Blog: http://ballastexistenz.autistics.org/?cat=128
“Neurotypicals Are Weird” Blog: http://thiswayoflife.org/blog/
Asperger Square 8 by Bev http://aspergersquare8.blogspot.com/
Autretreat Main Site: http://www.autreat.com/index.html

3
For yet a fourth analysis see Rachel Cooper, Classifying Madness: A Philosophical
Examination of the Diagnostic and Statistical Manual of Mental Disorders, Springer
(Dordrecht, The Netherlands), 2005. For a rejection of Cooper’s analysis see
Jonathan Y. Tsou, “Review of Classifying Madness” in the British Journal of
Philosophy of Science, vol 61, 2010, pp. 453-457.
Chapter Nine
1
A helpful and concise discussion of the four-stage sequence is given by Leif
Wenar in the Stanford Encyclopedia of Philosophy’s entry “John Rawls.” See,
especially, “4.9 Institutions: The Four-Stage Sequence.” Web. 6 April 2012.
2
An additional confounding factor is scatter, the phenomenon whereby some
individuals may present much higher in certain categories, e.g. verbal tests, while
having diminished capacities elsewhere. Also, because labels are not mutually
exclusive, persons with emotional disabilities or mental retardation may have other
diagnoses that impede on their performance. For example, having ADHD could
290 Notes
mean test taking exceeds the person’s attention span causing skewed results, or
having an emotional disturbance could mean frustrating and challenging questions
would be ignored, or even completing the test itself could be rendered
impracticable. Eva Kittay raises this problem in At the Margins when she says,
“Sesha has no measurable IQ because IQ tests depend on capabilities to express
cognitive capacities and Sesha lacks these expressive capabilities” (127).
3
There are further complications with trying to define who is unreasonable due to
a lack of goods (e.g. mental health facilities or medication) versus someone like
Andrew whose unreasonableness cannot [yet?] be sufficiently mitigated by goods.
4
There is a disanalogy here between duties to animals and humans viz. negative
versus positive obligations. We have obligations to not harm both humans and
animals, but we clearly do not have a positive obligation to provide for the
biological needs of all animals, whereas a strong case could be made that we do
have this obligation for all humans. I owe this objection to Blain Neufeld.
5
For examples of the range of disabilities, consider first someone who is so
paralyzed they cannot even manage communication yet who retains their cognitive
abilities. On the other end of the spectrum, consider a person whose mental
functioning is perhaps at the level of some non-human animals, yet can perform
mechanical tasks (e.g. assembly line work) that allow them to hold employment. In
the middle somewhere we would find persons who have emotional impairments or
mental illnesses such that they can revise and pursue a conception of the good,
maintain employment, yet have no sense of justice and do not recognize the rights
of others. All of these non-citizen humans are capable of contributions in their own
ways, yet none would qualify as persons represented in the OP on Rawls’s
account.
6
In communication, Hartley tells me she has something like Anderson’s goods in
mind for her own account, though this has not yet been developed in her extant
writings).
7
I am indebted to Andrea Westlund for help with this idea.
8
I owe this worry to Julius Sensat.
Chapter Ten
1
In this chapter I use the terms “normal” and “normality” interchangeably.
2
Wachbroit ultimately argues against this understanding of normality.
3
I offer many of the prominent uses on normal in health care but I do not
necessarily argue for the use of any of these explanations of normal.
4
Daniels’ more recent account of justice in health care is given in economic terms.
See “Justice, health, and health care” in Medicine and Social Justice; Essays on the
Distribution of Health Care, edited by R. Rhodes, M.P. Battin, and A. Silvers.
5
Other reasons may include, but are not limited to, as a matter of justice or
equality.
6
For the sake of brevity and a limited, yet focused account of just health care, I do
not present the diverse body of literature on “disease;” however, I acknowledge
this important literature
7
For exceptions, see section “Normal Functioning” and “Normal Functioning and
Asperger’s Syndrome.”
I have benefited greatly from the University of Wisconsin-Milwaukee’s
Philosophy Graduate Student Workshop, an audience at Michigan State University
and from comments by Blain Neufeld, Julius Sensat, Andrea Westlund and Justin
Bernstein
Chapter Twelve
1
There is a simple, analytic argument for why moral agents have a prima facie
non-arbitrary right to life and wellbeing that goes like this: (1) To be a moral agent
is to be the sort of thing that can be morally praiseworthy or blameworthy. (2) To
be morally praiseworthy just is to deserve that good things happen to you. To be
blameworthy is to deserve bad things happen to you. (3) Harms, such as death, are
uncontroversially bad things to happen to individuals in most cases. (4) To say
that something has a right to life just is to say that it would be inappropriate to kill
that thing. (5) Thus, it is prima facie morally wrong to kill morally praiseworthy
moral agents.
2
See: Konrad, Walecia, 2010, Dealing With the Financial Burden of Autism, The
New York Times, accessed 2-18-2012,
http://www.nytimes.com/2010/01/23/health/23patient.html?ref=health; Rudy, Lisa
Jo, 2010, Putting the Costs of Autism in Context, About.com, accessed 2-18-2012,
http://autism.about.com/b/2010/05/18/putting-the-costs-of-autism-in-context.htm;
Ganz, Michael, 2006, “The Costs of Autism,” from Understanding Autism: From
Basic Neuroscience to Treatment, CRC Press.
3
Suppose a person with a broken leg has an interview at the top of a flight of stairs
- under normal circumstances, she would be able to climb the stairs relatively
easily; however her broken leg makes climbing the stairs more difficult. Although
such a person may be able to do all the same things she could before she broke her
leg, it makes sense to say that her broken leg undermines her liberty because
climbing the stairs is more difficult than it otherwise would be. In contrast, a
person in a coma cannot choose to climb the stairs at all, and thus we can say her
liberty is undermined because she is incapable of making such a choice.
4
See Grandin, Temple, 1999
5
Exceptions can reasonably be made if the guardians believe a similar, but safer,
treatment would be available within a reasonable amount of time.
292 Notes
Chapter Thirteen
I thank David Brink, Dana Nelkin, Julie Tannenbaum, Robb Eason, Margarita
Levantovskaya, Joyce Havstad, Adam Streed, Tim Jankowiak, Amy Berg, Per
Milam and two anonymous reviewers for valuable comments on drafts of this
material. I also thank audiences at the 2011 Pacific APA meeting in Seattle and the
2010 Rocky Mountain Ethics Congress in Boulder, CO where drafts of these
arguments were presented.
2
Yalin Yang and Adrian Raine claim that what separates the successful
psychopath from the standard psychopath is that standard psychopaths show
characteristic deficiencies in gray matter volume and that these deficits are
“associated with poor judgment and decision-making, thus rendering unsuccessful
psychopaths potentially more prone to conviction” [Yang and Raine 2008, 134-
135]. Successful psychopaths avoid incarceration but this does not rule out the fact
that they may, in Hare's defense, still behave with persistent criminality. They may
simply be better at getting away with their criminal behavior.
3
Whether moral reasons (or moral judgments) necessarily motivate agents, is a
debate between what philosophers call motivational internalism and externalism
about moral reasons. Internalists claim that moral judgments are connected with
desires to act in accordance with our judgments[Smith 1995; Garrard and
McNaughton 1998]; externalists, on the other hand, deny that moral judgments
imply or necessitate desires to act [Brink 1997; Roskies 2003]. Some alternative
positions resolve the issue by rejecting the belief-desire psychology on which it is
grounded [McDowell 1979]. It is beyond the scope of this chapter to address the
debate about internalism and the role of psychopathic agency in that debate.
4
Although I take inspiration from Watson, these distinctions have been
challenged. Jay Wallace recognizes that attributability and accountability are
separate judgments about an agent and his or her action but denies that the two
judgments are conceptually distinct. In this sense Wallace argues that the two
judgments are conceptually connected [Wallace 1994]. Watson's view of
attributability and accountability as singular concepts has been challenged. John
Fischer and Neil Tognazzini have claimed that there are at least two distinct
notions of attributability and as many as five different senses of accountability
[Fischer and Tognazzini 2011, 381].
5
Some claim that responsibility requires the possession of the kinds of capacities I
have been discussing and the further criterion that an actions flows from the right
kind of historical process. Although evil neurosurgeons may implant malicious
desires in my brain so that I, in the normal way, act on them, that process, even if it
does not undermine attributability, is not something I am fully responsible for on
these views. An action must also be traceable to past historical decisions in an
intelligible way [Fischer and Ravizza 1996, 17-206].
6
Shame is typically understood to be different from guilt because shame is a self-
directed emotion we feel when we judge that we have violated a community's
norms. Guilt, on the other hand, requires the moralized judgment that we have
acted wrongly. Because of this, shame does not appear to require that we accept or
internalize our community's norms in order to feel ashamed of violating them
[Williams 1993/2008; Taylor 1985]. If this analysis of shame is correct then it
might be appropriate for the atheist to feel ashamed of herself for violating her
community's norms even though she believes that it is not wrong to violate them.
Chapter Fourteen
1
See e.g. Shaun Nichols (2004), Sentimental Rules: On the Natural Foundations
of Moral Judgment (New York: Oxford University Press); Heidi Maibom (2005),
‘Moral Unreason: the Case of Psychopathy’, Mind & Language, 20, pp. 237-57.
2
See also Jesse Prinz (2011), ‘Is Empathy Necessary for Moral Agency?’, in Amy
Coplan and Peter Goldie (ed.), Empathy: Philosophical and Psychological
Perspectives (Oxford: Oxford University Press), pp. 211-29.
3
See e.g. Timothy Krahn & Andrew Fenton (2009), 'Autism, Empathy and
Questions of Moral Agency', Journal for the Theory of Social Behavior, 39 (2), pp.
145-66 and Heidi Maibom (2009), 'Feeling for Others: Empathy, Sympathy, and
Morality', Inquiry, 52 (5), pp. 483-99.For a definition of empathy that identifies it
exclusively with sympathy, see Batson et al. (1987), 'Adults' Emotional Reactions
to the Distress of Others', in Nancy Eisenberg & Janet Strayer (ed.), Empathy and
Its Development (Cambridge: Cambridge University Press), pp. 163-84.
4
Shaun Nichols’ discussion of the existence of a double dissociation between what
he calls the Concern Mechanism (equivalent to what we have been calling
affective empathy) and perspective-taking (i.e. cognitive empathy) reinforces this
point. See Nichols (2004), p. 59.
Chapter Fifteen
1
Note that we will vary the ways that we refer to the condition of autism and the
people diagnosed with it, with some preference for "people first" language, but
also recognizing that each form of reference has its own benefits and problems. In
any case, we understand that having autism is not an exhaustive account of a
person’s identity or personhood.
Chapter Sixteen
1
Froma I. Zeitlin, John J. Winkler and David Halperin, ed., Before Sexuality: The
Construction of Erotic Experience in the Ancient World (Princeton: Princeton
University Press, 1991); John J. Winkler, The Constraints of Desire. The
Anthropology of Sex and Gender in Ancient Greece (Routledge: New York &
London, 1990); Ralph J. Hexter and Daniel J. Selden, ed., Innovations of Antiquity
(Routledge: New York & London, 1992).
294 Notes
2
Indeed, in November of 2012, the American Psychiatric Association announced
that Asperger's Syndrome will not be included as a separate condition in the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The
DSM-V, has been widely anticipated as having the potential to alter who qualifies
as on the autism spectrum and who, therefore, can receive educational and other
services.
3
Autism Spectrum Disorders (ASDs), Data & Statistics. Centers for Diseases and
Control, last modified March 29, 2012,
http://www.cdc.gov/ncbddd/autism/data.html.
4
This translation, and all those in this essay, are by the author.
5
ȞȒʌȚȠȢ, Greek Word Study Tool, Perseus, accessed December 12, 2012.
http://www.perseus.tufts.edu/hopper/morph?l=nhpios&la=greek#lexicon.
6
ȞȒʌȚȠȢ, Greek Word Study Tool, Perseus, accessed December 12, 2012,
http://www.perseus.tufts.edu/hopper/text?doc=Perseus:text:1999.01.0135:book=11
:card=440&highlight=.
7
http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext%3A1999.01.0135
%3Abook%3D6%3Acard%3D288.
8
http://www.perseus.tufts.edu/hopper/text?doc=Perseus:text:1999.01.0135:book=9:
card=1&highlight=.
9
card=1&highlight=.
10
card=1&highlight=.
11
:card=499&highlight=?.
12
:card=1&highlight=.
13
http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext%3A1999.01.0135
%3Abook%3D24%3Acard%3D450.
14
ʌȠȜȪĲȡȠʌȠȢ, Greek Word Study Tool, Perseus, accessed December 12, 2012,
http://www.perseus.tufts.edu/hopper/morph?l=neu%3Dron&la=greek&can=neu%3
Dron0&prior=neuromh=trai#lexicontje.
15
Odyssey 11.489-491.
CONTRIBUTORS
Audrey Anton is Assistant Professor of Philosophy at Western

Kentucky University. Her research areas include Moral Psychology,
Ancient Philosophy, and Ethics. Anton earned her Ph.D. from the Ohio
State University in 2011. Audrey's dissertation, "Sources and Reasons:
Moral Responsibility and Desert of Praise and Blame," addresses the
justification of praise and blame for moral attitudes, and the causal
element in theories of moral responsibility.
Deborah Barnbaum is Professor of Philosophy at Kent State

University. She is the author of The Ethics of Autism: Among Them but not
of Them (Indiana University Press, 2008). In addition to her research on
autism, she has done extensive work in research ethics. Deborah has
published her work in IRB: Ethics & Human Research, Politics and the
Life Sciences, and Medicine, Health Care and Philosophy. Currently, she
chairs Kent State's IRB, serves on the Summa Health System IRB, and is a
member of the Data Safety Monitoring Committee (DSMC) for the
Diabetic Retinopathy Clinical Research Network.
Mara Bollard is a graduate student in the Department of Philosophy at

the University of Michigan-Ann Arbor. While an undergraduate at the

University of Sydney, she earned a B.A. in philosophy, psychology, and
Indonesian studies. Mara's primary research interests are in normative
ethics, meta-ethics, and moral psychology. She is particularly interested in
using empirical findings from the cognitive sciences to shed light on
philosophical questions about moral judgments and behavior.
Kristina Chew is an Associate Professor of Classics at Saint Peter's

University in Jersey City. She has published a translation of Virgil's
Georgics (2002) and essays on autism, disability studies, Greek and Latin
poetry and Asian American literature. She also blogs about life with her
teenage son, Charlie, at We Go With Him (autism.typepad.com) and about
education, disability issues, and human rights at Care2.com. Her current
research examines Homeric poetry and scholarship on oral composition
in light of contemporary findings about autism, to study intellectual
disability in the ancient Greek world.
296 Contributors
Ralph Didlake is Professor of Surgery, and is the founding Director of

the Center for Bioethics and Medical Humanities, at the University of
Mississippi Medical Center. He has 23 years of experience in transplant,
vascular, and general surgery, and uses this experience in his investigations
of healthcare ethics, as well as his ethics and humanities training for
clinicians.
Janette Dinishak is Visiting Assistant Professor of Philosophy at the

University of California, Santa Cruz. Her doctoral work examined the
relations between Wittgenstein’s writings on the philosophy of psychology
and Gestalt Psychology. Her current research interests include Wittgenstein,
autism, philosophy and history of psychology, and philosophy of psychiatry.
Janette's publications include “Wittgenstein on the Place of the Concept
‘Noticing and Aspect’” (forthcoming in Philosophical Investigations), and
“A Critical Examination of Mindblindness as a Metaphor for Autism” (co-
authored with Nameera Akhtar, and forthcoming in Child Development
Perspectives).
Hannah Dostal is Assistant Professor of Special Education at

Southern Connecticut State University. Her research interests include
adolescent literacy, bilingual education, and writing instruction of
linguistically diverse students. Her current research examines the impact
of interactive instruction on the writing and language development of deaf
adolescents. Hannah is a member of the International Reading Association,
the Literacy Research Association, and the Association of College Educators
of the Deaf.
Kathleen Dougherty is currently Associate Professor and Chair of the

Department of Philosophy at Notre Dame of Maryland University. Her
areas of scholarship are ethics, especially virtue theory, and the philosophy
of literature. Her work focuses on the development of moral character, the
role of self-knowledge in good character, and the role of personal
relationships both for increasing self-knowledge and for fostering the
development of good character. Her work routinely considers literary texts
and psychological insights hand in hand with traditional philosophical
texts. Her current projects address the relationship between love and
respect, and the nature of self forgiveness.
Jo Anne Fordham is Assessment and Research Coordinator at the

University of Mississippi Medical Center. She has written and edited work
in the humanities, science, engineering, medicine, and health care education
and advocacy communities. Her research interests include literacy, ESL, and
composition. Jo Anne is currently examining the effect that communicative
models can have on hierarchies of naming, inclusion/exclusion, and stigma
in education, healthcare, and research.
Rachael Gabriel is Assistant Professor in Curriculum and Instruction

at the University of Connecticut. She holds a Ph.D. in Education, with a
focus on literacy studies from the University of Tennessee, as well as
graduate certificates in both qualitative and quantitative research methods
in education. Her research interests include teacher education, development
and evaluation; education policy; support for struggling adolescent
readers; and reading interventions. Rachel is a former middle school
reading and English teacher.
C. D. Herrera is associate professor of philosophy at Montclair State

University. His research interests include bioethics, ancient philosophy,
and philosophy of sport. He is the Editor of Theoretical & Applied Ethics,
a quarterly journal.
Adam Kohler teaches philosophy, and ethics in particular, at Suffolk

County Community College and St. Joseph's College. His research
interests include the intersection between metaphysics and the cognitive
sciences, and has recently been working in business ethics and politics.
Jessica Lester is Assistant Professor of Educational Psychology at

Washington State University. She holds a Ph.D. in educational psychology
and research, as well as a graduate certificate in qualitative research

methods in education and autism spectrum disorders. Her research
interests include qualitative methodologies, critical notions of human
learning and development, and the educational experiences of children
with refugee status.
Christopher Mesaros has research interests in ethics and political

philosophy, particularly where the two intersect. In much of his work, he
has tried to examine how, in Rawls’ political liberalism, persons with
cognitive disabilities can be subjects of Justice as Fairness. Christopher's
recent work is on the nature and limits of promise-keeping. He earned a
Master’s in Philosophy from the University of Wisconsin-Milwaukee, and
is currently a lecturer at NVCC Manassas.
298 Contributors
Douglas Paletta earned his Ph.D. in political philosophy from the

University of Pennsylvania in 2010, where he currently serves as
Associate Director of the Critical Writing Program. In his research,
Douglas examines different ways of understanding the social contract as a
political argument which can establish principles of justice. More recently,
his work has explored the ways that we might connect political theory with
the kind of practical problems that are associated with neurodiversity.
Christian Perring is Professor of Philosophy at Dowling College. He

edits Metapsychology Online Reviews, and is on the Executive Council of
the Association for the Advancement of Philosophy and Psychiatry. His
research centers on problems in the philosophy of psychiatry. Christian is
writing a book on mental illness and moral responsibility.
Alexandra Perry is a lecturer in philosophy at Bergen Community

College, and an adjunct assistant professor of philosophy at Drew
University, and William Paterson University. Her research interests include
bioethics, philosophy of history, and cognitive science. She recently
completed a book titled Neuropluralism, which focuses on mental illness
as a challenge to contemporary social and political theories and will be
published in Summer 2013. The book draws on themes from the moral
philosophy of Aristotle, and the political philosophy of John Rawls, and
Nicholas Rescher. She is the managing editor of Theoretical & Applied
Ethics.
Erick Ramirez is currently lecturer of philosophy at Santa Clara

University. His research investigates the ways that empirical data from
psychology and the neurosciences can inform meta-ethical debates about
the moral reasons, emotion, and responsibility. He has written on the
nature of emotion, Sentimentalism, and psychopathic moral psychology.
Keisha Ray is a graduate student in the department of philosophy at

the University of Utah. She has research interests in bioethics and research
ethics. Keisha’s current research focuses on the treatment/enhancement
distinction, and normative judgments about human functioning in
healthcare debates. She also focuses on ethical and political issues
concerning cognitive enhancement practices, such as the prescription of
psychopharmaceuticals to properly functioning individuals.
Ralph Savarese is the author of Reasonable People: A Memoir of

Autism and Adoption, and co-editor of a special issue of Disability Studies
Quarterly, focusing on autism and neurodiversity. He teaches American
literature, creative writing, and disability studies at Grinnell College.
Ralph will spend 2012-2013 at Duke University’s Institute for Brain
Science, as a member of its it neurohumanities research group.
William Simkulet earned his Ph.D. from the University of Kansas. He

research interests include moral responsibility, free will, and bioethics. In
his dissertation, William addressed a libertarian incompatibilist theory of
free will, and its implications for moral responsibility.
INDEX
131, 132, 133, 134, 135, 136,

137, 138, 139, 140, 141, 143,
A 144, 145, 180, 183, 186, 189,
190, 191, 192, 193, 194, 195,
196, 198, 200, 204, 205, 206,
ADD · 86
207, 208, 209, 210, 211, 212,
advocacy · 57, 61, 68, 76, 100, 102,
213, 214, 215, 216, 238, 240,
119, 296
241, 242, 244, 260, 261, 262,
affective deficits · 217, 233
263, 264, 265, 266, 267, 268,
agency · 15, 43, 44, 45, 106, 110,
269, 270, 271, 272, 273, 274,
149, 208, 212, 217, 218, 223,
275, 276, 277, 285, 287, 291,
225, 227, 228, 229, 230, 231,
293, 294, 295, 296, 297, 298
238, 239, 240, 249, 253, 254,
autistic community · 206
257, 261, 273, 292
autistic spectrum · 80, 261, 263, 268
Alzheimer's Disease · 20
American Psychiatric Association ·
102, 109, 207, 216, 221, 234,
277, 294 B
Americans with Disabilities Act ·
52, 59, 63, 65 Baggs, Amanda · 191, 192, 193,
antidepressant · 86, 87, 88, 90, 91, 203
93, 94, 97, 98 Barnbaum, Deborah · 131, 135, 138,
antidepressants · 86, 87, 88, 89, 90, 144, 295

91, 92, 94, 97, 98 Baron-Cohen, Simon · 68, 69, 70,
anxiety · 8, 86, 263, 265 71, 73, 74, 75, 77, 78, 80, 82, 83,
APD · 112, 113, 288 135, 136, 137, 139, 144, 180,
ASD · 131, 133, 134, 135, 136, 137, 189, 243
138, 139, 140, 141, 142, 267, Bartleby the Scrivener · 29, 30, 32,
268, 271 37, 38, 286
Asperger’s Syndrome · 31, 140, Bartleby the Scrivner · 29
141, 178, 180, 183, 187, 188, bipolar disorder · 18, 20, 133, 191
189, 190, 268, 270, 276, 291 Boston College · 60, 61
Association of Higher Education
and Disability · 53
Athena · 280 C
autism · 11, 15, 20, 21, 27, 28, 29,
31, 32, 33, 34, 35, 36, 42, 43, 67,
capabilities approach · 39, 44, 45,
68, 69, 70, 71, 72, 73, 76, 77, 78,
46, 47, 48, 49, 287
79, 80, 81, 82, 83, 84, 85, 109,
capability · 39, 48, 49, 211
Caplan, Art · 141, 144 discourse analysis · 52, 56, 57, 64

Carlson and Kittay · 44, 286 disorder · 19, 34, 35, 36, 42, 76, 80,
Chopin, Frédéric · 18, 19, 37, 38 111, 112, 113, 122, 124, 131,
Cleckley, Hervey · 113, 114, 218, 133, 134, 140, 179, 180, 181,
219, 220, 223, 224, 229, 234, 190, 206, 219, 221, 244, 263,
247, 248 267, 268, 277, 288
Conduct Disorder · 112 DSM · 102, 109, 112, 140, 141,
consent · 100, 102, 103, 104, 105, 180, 190, 207, 216, 221, 235,
106, 107, 108, 134, 135, 143, 241, 277, 288, 294
145, 212, 213 DSM IV · 112, 221
Coons & Brennan · 4 DSM V · 102, 112
Cooper, Neil · 4, 17, 289 duty · 24, 49, 157, 158, 240, 250,
Cunningham, Andrew · 19, 20, 33, 251, 252, 253, 254, 255, 256
35, 36
E
D
education · 47, 52, 53, 54, 55, 56,
da Vinci, Leonardo · 278 57, 58, 62, 63, 64, 65, 66, 107,
Daniels, Norm · 162, 163, 164, 168, 146, 149, 158, 162, 163, 166,
176, 182, 183, 184, 186, 187, 170, 184, 208, 211, 295, 296,
188, 189, 290 297
Dartmouth College · 62, 63 emotions · 9, 16, 26, 103, 113, 114,
Davidson, Donald · 43, 50, 109, 135 217, 224, 226, 227, 233, 241,
democratic · 39, 40, 45, 48, 161, 245, 247, 248, 254, 263, 264,
163 269, 271, 273
deontological · 139 empathy · 32, 70, 101, 104, 218,
determinism · 224 220, 222, 238, 239, 240, 241,
Diagnostic and Statistical Manual · 242, 243, 244, 245, 246, 247,
112, 216, 221, 241, 277, 289, 248, 249, 250, 251, 252, 253,
294 254, 255, 256, 257, 268, 269,
difference · 1, 2, 3, 4, 5, 6, 7, 8, 12, 270, 286, 293
15, 16, 21, 35, 39, 42, 43, 68, 72, Employment · 170
73, 76, 77, 78, 79, 81, 94, 108, equality · 4, 39, 40, 41, 42, 44, 45,
110, 115, 119, 125, 126, 131, 47, 48, 49, 60, 78, 81, 109, 144,
134, 135, 140, 141, 185, 191, 162, 171, 179, 182, 184, 186,
192, 193, 199, 207, 222, 249 189, 290
disability services · 52, 53, 54, 56, Ethic of Care · 139
58, 62, 65
disabled · 47, 54, 55, 64, 66, 146,
147, 148, 149, 150, 151, 152, F
153, 154, 155, 156, 157, 158,
159, 160, 161, 162, 163, 164,
Fenton and Krahn · 142
165, 166, 167, 168, 169, 170,
Frankfurt, Harry · 224, 225, 235
171, 172, 173, 174, 175, 176,
Freedom · 225, 235, 237, 286
194, 282, 284
302 Index
Frith, Uta · 68, 69, 70, 71, 74, 80, Individual Education Programs ·
81, 84, 241, 242, 287 265
informed consent · 104, 106, 135
injustice · 2, 3, 4, 6, 9, 13, 46, 47,
G 269
introspection · 18, 21, 23, 24
Gilligan, Carol · 94, 95, 96, 98
Glannon, Walter · 42, 43, 51, 100,
109, 133, 140, 145 J
Grandin, Temple · 33, 78, 82, 209,
216, 245, 246, 250, 251, 253, justice · 2, 3, 5, 6, 8, 14, 15, 16, 39,
256, 265, 291 41, 47, 66, 68, 100, 104, 105,
Grice, Paul · 135 106, 107, 108, 117, 119, 121,
Grinker, Roy Richard · 277, 285 125, 146, 147, 148, 149, 150,
guilt · 113, 114, 122, 217, 218, 220, 151, 152, 153, 154, 155, 156,
226, 227, 233, 288, 292 157, 158, 159, 160, 161, 162,
163, 164, 165, 167, 170, 171,
172, 173, 175, 178, 179, 181,
H 182, 187, 188, 189, 190, 191,
290, 297
Hacking, Ian · 21, 34, 35, 37, 67,
76, 82, 136, 145, 287
hallucinatory disorder · 18 K
Happé, Francesca · 133, 134, 261
Hare · 112, 113, 115, 122, 123, 124, Kant, Immanuel · 24, 25, 26, 29, 33,
127, 128, 220, 221, 222, 223, 37, 145, 239, 240, 249, 250, 251,
233, 234, 235, 236, 240, 242, 254, 255, 257
288, 292 Kantian · 26, 51, 132, 139, 240,
Hawthorne, Nathaniel · 23 249, 250, 253, 254, 256, 257,

Hemingway, Ernesy · 29, 32, 33, 269
34, 36 Kennett · 238, 239, 240, 241, 242,
Hippocrates · 276 243, 244, 245, 246, 249, 250,
Homer · 276, 278 251, 252, 253, 256, 257, 262,
homosexuality · 156 268, 269
Hume, David · 218, 219, 223, 236,
239, 240, 242, 254, 257
L
I Levy, Neil · 229, 236
Lewis, Michael · 135
Iliad · 278, 281, 282, 284, 285
inclusion · 2, 4, 7, 14, 15, 16, 34,
40, 44, 45, 46, 47, 52, 53, 54, 58,
59, 147, 166, 257, 273, 286, 296
M neurodiverse · 45, 46, 48, 100, 101,

103, 104, 105, 108, 131, 132,
133, 134, 136, 137, 138, 139,
major depressive disorder · 20 140, 141, 142, 143, 178, 179,
Marquis, Don · 207, 216 186, 188, 189, 289
McGeer, Victoria · 34, 35, 37, 135, neurodiversity · 35, 39, 40, 41, 42,
136, 145, 239, 247 44, 45, 46, 47, 48, 49, 50, 52, 53,
Melville, Herman · 29, 30, 31, 32, 55, 56, 57, 58, 64, 76, 81, 100,
33, 34, 36, 37, 38 101, 102, 103, 104, 105, 106,
Menelaus · 280 107, 108, 109, 110, 125, 127,
mental illness · 34, 94, 156, 162, 131, 132, 133, 137, 140, 144,
169, 219, 221, 272, 277, 298 191, 192, 199, 200, 203, 205,
mental states · 31, 33, 69, 70, 71, 206, 207, 211, 215, 276, 277,
74, 75, 241, 242, 243, 245, 246, 278, 285, 286,297, 298
247, 248, 251, 256 Neurodiversity · 39, 42, 50, 51, 66,
Metaphor · 38, 67, 296 76, 80, 82, 100, 104, 109, 111,
metaphysical · 10, 11, 21, 24, 25, 132, 133, 134, 144, 145, 191,
32, 224, See Metaphysic 195, 197, 206, 216, 276, 277,
metonym · 21, 22, 23, 27, 29, 30, 281, 289
31, 32 neurodiversity movement · 42, 76,
Metonym · See metonym 133, 207
metonymic · 21, 23, 25, 27, 28, 29, neuro-normal · 11
31, 33, 36 neurotypical · 21, 100, 104, 131,
Metonymy · 21, 36, 37, 38, See 132, 133, 134, 136, 137, 138,
metonym 139, 140, 141, 142, 143, 172,
mindblindness · 68, 69, 70, 71, 72, 195, 197, 198, 199, 200, 202,
73, 74, 75, 76, 77, 78, 79, 81, 82, 203, 206, 207, 209, 210, 211,
287 215, 289
Mindblindness · 67, 68, 69, 70, 71, Noddings, Nel · 95, 99
74, 80, 82, 144, 296 nonpersons · 208, 214

MIT · 59, 60, 80, 144, 285 Nussbaum, Martha · 44, 45, 46, 48,
moral agency · 223, 228, 238, 240, 51, 117, 129, 146, 147, 159, 161,
249, 253 176, 177
moral judgment · 128, 232, 239, 255
moral responsibility · 145, 217, 223,
224, 225, 226, 227, 230, 231,
234, 261, 263, 264, 266, 268,
O
269, 270, 272, 295, 298
moral theory · 132, 139, 143, 217 Oberdiek · 6
Murdoch, Iris · 20 Odysseus · 276, 278, 279, 280, 281,
282, 283, 284
Odyssey · 278, 279, 280, 281, 282,
N 284, 294
Oedipus · 282, 285
offense · 2, 3, 5, 6, 7, 14
neurocosmopolitanism · 191, 193,
195, 199, 200, 203
304 Index
P 157, 158, 159, 160, 161, 162,

163, 164, 165, 166, 167, 168,
169, 170, 171, 172, 173, 174,
PCL · 123, 220, 221, 222, 223, 234, 175, 176, 179, 182, 190, 287,
235, 240 289, 290, 297, 298
PCL-R · 220, 222 Rawlsian · 43, 138, 146, 147, 153,
Penelope · 280 158, 164, 165, 168, 170, 171,
personality disorder · 268 173, 175, 177
personhood · 15, 16, 149, 153, 154, remorse · 112, 113, 122, 124, 125,
155, 159, 160, 162, 163, 164, 218, 220, 240, 261, 288
168, 175, 194, 207, 208, 212, retrospective diagnosis · 19, 20, 21,
214, 215, 293 33, 34, 35
philosophers · 15, 18, 19, 42, 44, 69, Retrospective Diagnosis · 18, 37
117, 135, 138, 156, 157, 185,
187, 217, 219, 223, 224, 225,
229, 231, 233, 238, 266, 267,
286, 292
S
Prozac · 86, 87, 89, 90, 93, 94, 97,
98, 99 Sacks, Oliver · 245, 246
psychiatry · 18, 106, 114, 296, 298 schizophrenia · 20, 76, 81, 133
psychopath · 111, 113, 114, 115, Schopenhauer, Arthur · 18, 21, 23,
120, 123, 126, 127, 128, 217, 24, 25, 26, 27, 29, 31, 32, 33, 35,
218, 219, 223, 229, 230, 231, 36, 38
232, 233, 235, 240, 247, 248, sensory · 21, 28, 32, 33, 35, 36, 72,
256, 292 74, 79, 81, 192, 195, 200, 202,
psychopathy · 111, 112, 113, 115, 204
123, 127, 128, 129, 217, 218, Sensory disturbances · 33
219, 220, 221, 222, 223, 225, sentiments · 238, 242, 282
231, 233, 234, 235, 237, 238, Shapshay, Sandra · 23, 25, 26, 27,
240, 242, 244, 268, 288 31, 38

Psychopathy · 111, 115, 124, 127, skeptical · See skepticism
128, 129, 217, 218, 220, 221, social contract · 138, 150, 297
223, 233, 234, 235, 236, 237, sociopathy · 111, 112, 113, 115,
238, 240, 293 119, 123, 124, 126, 221, 288
psychopharmacology · 86, 87 Sociopathy · 111, 115, 236
Special Education · 163, 177, 296
Stanford · 58, 68, 72, 84, 289
R stereotyped interests · 207
Strawson, P.F. · 9, 17, 226, 227,
230, 237, 266
rationality · 3, 4, 41, 43, 44, 45, 47, synesthesia · 197
148, 150, 151, 152, 161, 165,
166, 168, 171, 174, 207, 224,
233, 269
Rawls, John · 40, 41, 42, 43, 44, 45,
T
46, 51, 146, 147, 148, 149, 150,
151, 152, 153, 154, 155, 156, Telemachus · 280
Tempkin, Larry · 6 virtue · 96, 116, 117, 118, 119, 120,

The Curious Incident of the Dog in 121, 128, 129, 132, 160, 174,
the Night-Time. · 28 227, 233
The Scarlet Letter · 23, 37 virtues · 96, 111, 113, 114, 115,
treatment · 2, 4, 8, 15, 42, 71, 102, 116, 117, 118, 119, 126, 128,
105, 107, 156, 157, 158, 160, 129, 174, 288
166, 169, 175, 184, 185, 186, vulnerability · 100, 101, 103, 104,
188, 189, 201, 203, 209, 212, 105, 106, 202
213, 214, 218, 222, 230, 283,
291, 298
W
U Wallace, Jay · 226, 227, 228, 229,
230, 231, 237, 292
utilitarian · 24, 134, 171, 172, 173, Williams, Bernard · 68, 74, 85, 117,
186 237, 293
Wong, Sophia · 42, 46, 47, 48, 51,
161, 162, 163, 168, 177
V
Values · 3, 98 Z
veil of ignorance · 148, 150, 160,
166, 171, 172, 173 Zeus · 279, 284
violence · 23, 115, 219, 220, 246,
265, 267, 268

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Ethics and Neurodiversity

Copyright © 2013. Cambridge Scholars Publisher. All rights reserved.

C.D. Herrera and Alexandra Perry

This book first published 2013

Cambridge Scholars Publishing

12 Back Chapman Street, Newcastle upon Tyne, NE6 2XX, UK

British Library Cataloguing in Publication Data

Copyright © 2013 by C.D. Herrera and Alexandra Perry and contributors

ISBN (10): 1-4438-4527-2, ISBN (13): 978-1-4438-4527-4

Acknowledgments .................................................................................... viii

Chapter Two .............................................................................................. 39

Chapter Three ............................................................................................ 52

Chapter Five .............................................................................................. 86

Chapter Six .............................................................................................. 100

Chapter Seven.......................................................................................... 111

Chapter Eight........................................................................................... 131

Chapter Nine............................................................................................ 146

Chapter Ten ............................................................................................. 178

Chapter Eleven ........................................................................................ 191

Chapter Twelve ....................................................................................... 206

Chapter Thirteen...................................................................................... 217

Chapter Fourteen ..................................................................................... 238

Chapter Fifteen ........................................................................................ 260

Chapter Sixteen ....................................................................................... 276

Earlier versions of some of the essays in this volume were presented at

WHAT’S THE DIFFERENCE?

eliminating discrimination in society can take real offense at being told

of the language involved, questions about which claims scholars should

assumptions about what we think they want.)

Labeling the Social World

perspective on differences can pause and reflect on how we want to talk

Once we recognize that some things are intrinsically valuable independent

If we are in search of differences to accommodate, the variety of

what offends you is not, on any conventional view, wrong, as it is to find

The point for our purposes is to reiterate that, in spite of good

emotions or beliefs, and moved into another category while feeling

naturalistic argument: when we welcome some and reject others we are

labels with. But we should entertain proposals that would have us

We might put this in stronger language: perhaps those games were

explain. In a neuro-normal game, things would seem different, as would

that culture. As before, though, there will be questions about how

persons with autism.) This was followed by suggestions that writers in

responsibility, respect, social justice, and moral personhood. An audience

NOISE AND METONYMIC THOUGHT

Retrospective Diagnosis through Writing

evidence that this diagnosis is accurate is offered by authors such as

Still, retrospective diagnosis is not a straightforward process. There

methodology. Cunningham claims:

Ultimately Cunningham argues that historians of medicine do not have

The Cunningham debate has sparked questions in the history of

cognitive disability can be corroborated using methods from forensic

The unconventional use of rhetorical devices is often reflective of

theories is similar to what we now recognize as autistic use of language.

“transfer of the name of a thing to something else that is closely associated

campaign headquarters, which are unlikely to share the same space or be

Normal Use of Metonym in the Work of Nathaniel

Hawthorne as a metonym for the melancholy shrouding Dimmesdale’s

Schopenhauer’s Use of Metonym

Schopenhauer’s philosophical method is often noted for its

The scrutiny and development of theory based on introspection and

An example of this kind of reasoning in the philosophy of Schopenhauer

Jacquette’s concern over Schopenhauer’s illustrates the tendency of

Schopenhauer’s response to Kant has been criticized as a poor analogy

the experience of felt contiguities between things that were hitherto