The document discusses the treatment resistance of psychopathy and argues that it is unlikely to be treatable through recent neuroscientific methods. Psychopathy involves a unified dysfunctional worldview or Weltanschauung, rather than isolated symptoms, making piecemeal treatment unlikely. While some evolutionary accounts view psychopathy as an adaptive strategy, treatment resistance cannot be explained by this alone, as other disorders thought to be adaptations can be treated. The document argues that psychopathy's treatment resistance is best explained by it being a disorder of personality and moral character, requiring moral commitment to treatment that may be difficult to achieve.

1. Theoretical Medicine & Bioethics, 35, 31-42.
To Treat a Psychopath
Heidi L. Maibom
Recent successes in manipulating the activity of the brain more
or less directly—e.g. through transcranial magnetic stimulation
or the administration of drugs that inhibit the production or
reuptake of certain neurotransmitters—promise that one day
soon it may be possible to treat a range of hitherto treatment
resistant disorders [1-4]. Conventional treatment is typically
unsuccessful with psychopaths [5-6]. Some people, however, are
now quite optimistic about the possibility of treating
psychopathy with drugs that directly modulate brain function
[2]. Does the recent evidence support the idea that we will soon
be able to treat psychopathy? I shall argue that it does not.
Psychopathy is a global disorder in an individual’s worldview,
including his social and moral outlook. Because of the unity of
this Weltanschauung, it is unlikely to be treatable in a
piecemeal fashion. But recent neuroscientific methods do not
give us much hope that we can replace, in a wholesale manner,
problematic views of the world with more socially desirable
ones. There are, therefore, principled reasons that psychopathy
is so singularly treatment resistant.
1. The Trouble with Psychopaths
By contrast to depression, which can often be treated by the
administration of mood-enhancing drugs (SSRIs or
SNRIs)[footnoteRef:1] and/or psychotherapy, psychopathy is a
disorder involving a wide variety of symptoms that, on the face
of it, have little in common except for their moral and social
undesirability. Depressive symptoms typically form a unified
picture of a certain type of affective disorder. Psychopathy has

2. been called a moral or an antisocial disorder [7, 8]. Where it
seems relatively obvious, at least in theory, that to treat
depression one must help elevate the subject’s mood and
alleviate her despair, how to treat amoral or antisocial
tendencies is less clear. And since we have experience of
ingesting substances that are mood-elevators, at least in the
short term, such as champagne or chocolate, it is not too far-
fetched to suppose that other substances may produce a longer-
term effect on a person’s mood. But what of amorality or
antisociality? [1: Serotonin reuptake inhibitors and serotonin
and norepinephrine reuptake inhibitors.]
On closer inspection, depression and psychopathy have more in
common than it might seem at first. The two disorders represent
more global divergences of cognitive and emotional functioning
compared to the statistical norm. Depressed individuals tend to
have a rather dark view of themselves and existence in general,
associated with social withdrawal and lack of interest in
activities, even those that were previously of great importance
to them. Georg Northoff has suggested that depressed
individuals may experience difficulties projecting themselves
into the future or, if you like, imagining a future different from
their current reality.[footnoteRef:2] Psychopaths’ divergence
from the statistical norm is also of a more global sort. For the
moral and social issues that psychopaths have are not limited to
a certain domain. They characterize not a weakness or a lacuna
in an otherwise intact socio-moral outlook, but a global socio-
moral deficit or dysfunction. It is no coincidence that
psychopaths are known to be ‘amoral’ or ‘without conscience’.
Let us rehearse, briefly, the main features of the condition.
Psychopaths experience relatively little empathy or sympathy
and they may be unable to truly love others [10]; they
experience little guilt and shame [10], are relatively fearless
[11], and experience mainly unstable and shallow
emotions.[footnoteRef:3] They can experience an emotion very
strongly one minute—great anger for instance—but not at all

3. the next. Their emotional impairments extend to deficits in
recognizing certain emotions.[footnoteRef:4] It is often that it
is the lack of empathic orientation towards others that allows
the psychopath to manipulate, exploit, and parasitize those
around him. However that may be, he seems to lack basic
respect for others. [2: Interview with Lynn Desjardin,
available at: http://www.theroyal.ca/northoff/2011/09/28/800/]
[3: In what follows, I am following PCL-R, except where
noted. That is, I reference emotional and other disorders that are
not part of the diagnostic criteria, but that have nevertheless
been documented by at least some important researchers in the
field.] [4: Some studies have found that psychopaths have
problems recognizing the expression of fear in people’s faces
[14], others that they have special problems identifying disgust,
but not fear [15]. Sadness recognition might also be a problem,
but only in adolescent psychopaths [16]. Vocal affect is another
area that has been studied and it would appear that here, too,
psychopaths are impaired, but again only with respect of certain
emotions. Bagley and colleagues, for instance, only found
evidence for general impaired vocal-semantic sadness
recognition (with some difference between primary and
secondary psychopaths for other emotions) [17].]
Generalizing, we may say that the psychopath tends to regard
others as tools or means to his own ends. Being able to lie
without compunction no doubt makes it easier for him to use
other people. Seeing others as in some sense worthy of respect
in their own right appears to be beyond him [18]. The problem
is not that he has a tenuous regard for humanity, say, but that he
lacks respect even for friends and family. Robert Hare notes
that criminal psychopaths distinguish themselves from other
career criminals by being as likely to cheat, steal from,
mistreat, harm, and generally act irresponsibly towards
members of their own family as they are towards others [19,
20]. Psychopathy is par excellence a problem of living with
others in organized social groups. More universally, they appear

4. to regard the world and everything in it in terms of its use for
their own purposes without being able to see animals, nature,
works of art, etc. as having intrinsic value [18]. Famously, all
traditional methods of treatment have failed to show results,
though some recent treatment programs have shown some
progress for adolescents with psychopathic tendencies [21].
There may be principled, as opposed to more practical, reasons
treatments have failed. First, there are those that argue that
psychopathy is not a disorder at all, but an evolved strategy. It
is, if you like, a human psychological subtype, which either was
adaptive in ancestral environments or is currently adaptive in a
strictly evolutionary sense. If it is an adaptive strategy, it may
be much harder to resolve, if it is resolvable at all, than
illnesses or diseases that can be understood as a dysfunction of
a system relative to a statistical norm [22]. Second, one might
suppose that as a personality disorder, psychopathy is
tremendously resistant to treatment. A version of this argument
is that it is a special type of mental disorder, i.e. a Cluster B
personality disorder, which requires moral commitment for
treatment to work. Ultimately, I shall argue (in section 2) for a
variation of this position, but where it focuses on commitment,
my main concern is the unity of a subject’s moral outlook or, as
I shall argue, her Weltanschauung. But first, let us examine the
two positions, because the ways in which they fall short is
instructive.
There is much evidence of genetic variation within humans. For
instance, lactose tolerance or the sickle cell trait are chronic
genetic conditions, which confer significant advantages on their
bearers, i.e. resistance to parasitization of the red blood cells by
the plasmodium falciparum parasite (one of the more serious
forms of malaria) and the ability to digest lactose throughout
life. In parallel to such genetic variations in physical traits,
Linda Mealey argues that psychopathy should be regarded as its
own special genotype, adaptive if it occurs relatively
infrequently in the group in which it occurs. It is the cheater,
defector, or free rider genotype [23].[footnoteRef:5] In the

5. words of Mealey, psychopaths: [5: I simplify Mealey here a bit.
She thinks primary psychopaths are genetically disposed to
become psychopaths, whereas the expression of secondary
psychopathy is more environmentally determined. ]
are designed for the successful execution of social deception
and […] they are the product of evolutionary pressures which,
through a complex interaction of environmental and genetic
factors, lead some individuals to pursue a life strategy of
manipulative and predatory social interactions.
Lee Dugatkin [24] has suggested something similar, providing a
detailed game theoretic model of the viability of the ‘con
artist’. The idea behind these suggestions is relatively simple.
Being devoid of the emotions that ordinarily curtail immoral
actions of various kinds, psychopaths have an adaptive
advantage over people who come fully equipped with empathy,
guilt, and shame. Psychopaths are able to break their promises,
cheat, lie, steal, and otherwise coerce others into doing their
will without experiencing negative emotions as a result.
Relative fearlessness and impulsivity may add to such
abilities/tendencies. In other words, the psychopath’s presumed
deficits enhance his ability to con, manipulate, and coerce
others. From a certain perspective, what we call deficits are
advantages. Mealey focuses on the emotional deficit, but it is
equally likely that their practical reasoning deficit facilitates
this type of behavior, perhaps by being undeterred by temporary
setbacks in manipulative strategies.
Other defenders of such selectionist accounts of
psychopathy stress psychopaths’ sexual strategy. Grant Harris
and Marnie Rice [5] point out that not only are psychopaths
very promiscuous, but they are also quite willing to use
deception and coercion in order to have sex. Sex offenders who
“preferentially target “reproductively viable” victims (i.e.,
postpubertal females) have significantly higher PCL-R scores
than those who target all other classes of people” [5, pg.
564].[footnoteRef:6] Michael Seto and Vernon Quinsey [6]

6. point out that from a Darwinian perspective at least, to talk of a
condition as pathological (i.e. an illness or a disorder) which
leads to increased reproductive success would be nonsensical.
Whether to call such conditions diseases or dysfunctions or not,
is not relevant to the project at hand. What matters is that there
is a difference between conditions that reflect a genotypic
variation, and thus an abnormality or a deviation from the
statistical norm [cf. 25, 23], and conditions that constitute an
abnormality or deviation from the ordinary functioning of the
individual. In the latter cases, treatment can be aimed at
bringing the subject back to their ‘normal’ state (some state that
is within the statistical norm of functioning for that person).
But in cases where the deviation is due to genetic variation,
treatment aims to change the subject from his or her own norm.
And this may be what the obstacle is to ‘treating’ psychopathy.
[6: But probably this is primarily true for male psychopaths.
Since women traditionally do most of the child rearing and
psychopaths are notoriously irresponsible, female psychopaths
may not fare particularly well fitness wise. The prevalence rate
of psychopathy among women is much smaller than among men,
however [30]. ]
The trouble with this line of thinking is that there are,
indeed, evolutionary accounts of other mental disorders, such as
depression [e.g. 26, 27] and anxiety syndromes [e.g. 28, 29],
and yet there are decent treatment options available for both. So
it cannot simply be in virtue of being an adaptation that a
condition remains untreatable. It must be something more
specific about the condition—whether or not we believe it is
technically a disorder or an adaptation—that makes it resistant
to treatment. One possibility is that psychopathy is really a
disorder of the personality or character of a person rather than
being an episodic condition, which depression typically is. This
is the second position mentioned above. Though psychopathy is
not in the DSM-IV, its closest living cousin in that reference
work is Antisocial Personality Disorder. Personality disorders

7. are life-long conditions, which affects the very character of the
people who suffer from them. Because they affect character as a
whole, some people have been very skeptical about the
possibility of treating such disorders [31]. Even if treatment is
possible, it cannot be aimed at restoring a character that has
been overcome by illness—as in depression, for instance—
because their illness is, in an important sense, part of who these
people are. If one treats the disorder, one changes the
personality or character of the individual. This is, perhaps, most
dramatic in the case of Dissociative Personality Disorder, where
one can argue that by treating the individual, one actually kills
off some of her personalities [32].
Some of these personality disorders are disorders in living with
others. Louis Chartrand [33] calls Cluster B Personality
Disorders—Narcissistic, Histrionic, Borderline, and Antisocial
Personality Disorder—“moral” disorders. These are disorders
where “it is impossible to imagine a successful “treatment” or
“cure” […] that does not involve some sort of conversion or
change in moral character.” [33, pg. 71] In the cases of
Narcissistic and Histrionic Personality Disorders “the
“excessive attention seeking” and “inappropriate sexually
seductive and provocative behavior” […] is flatly inconsistent
with a pattern of empathy and regard for others.” [33, pg. 71]
Any treatment of Antisocial Personality Disorder would have to
address and alter the “pervasive pattern of disregard for and
violation of the rights of others” [33, pg. 71].[footnoteRef:7]
Indeed, such disorders are only treatable if the person shows
moral willingness or moral commitment to therapy and change
[33, pgs. 71-72]. [7: Here Chartrand quotes directly from the
DSM-IV [8, pg. 649].]
If Cluster B Personality Disorders prove difficult to treat
because of the need to ensure the subject’s moral commitment,
we should expect psychopathy to be even more treatment
resistant given that it is, more than any other, a moral disorder.
My point is not that psychopathy is reducible to Antisocial

8. Personality Disorder. Rather, if the latter is a moral disorder,
psychopathy is even more so given that “the formal criteria of
ASP place more emphasis on antisocial and criminal behaviors,
and less emphasis on personality traits, than do traditional
conceptions of psychopathy and the PCL-R” [34, pg.
5].[footnoteRef:8]Chartrand is a bit cagey about why he thinks
that therapy or treatment of Cluster B Personality Disorders
requires moral commitment on the part of the subject, other than
for the obvious reason that therapy in general requires
commitment. What he seems to have in mind is that Cluster B
Personality Disorders are moral, not medical, disorders, and that
they therefore require moral, not medical, treatment. But moral
treatment requires commitment to moral change. At the core of
moral treatment for all Cluster B Personality Disorders is
“[w]illingness and commitment to developing the capacity for
empathy” [34, pg. 71]. Lack of empathy is at the core of
Narcissistic Personality Disorder, Antisocial Personality
Disorder, and Psychopathy. [8: Antisocial Personality Disorder
is a very disputed diagnosis, particularly among psychopathy
researchers. At least half of the prison population meets the
diagnostic criteria, adding credence to critics who regard it as a
thinly veiled “criminality” classification (only a slight advance
on “moral insanity”). And many young people, who would have
received the diagnosis at one point or other, end up as
productive members of society [19]. However, Hare judges that
most psychopaths meet the Antisocial Personality Disorder
diagnosis [34, 92]. Hart et al. 1991 found that 79.2% of
psychopaths had a diagnosis of Antisocial Personality Disorder,
whereas only 30.2% of inmates with this diagnosis also met the
diagnostic criteria for psychopathy (PCL-R). ]
It is often suggested that the psychopath’s more or less
complete disregard for the wellbeing of others is at the core of
their disorder [14, 35]. Many studies report a negative relation
between empathy and aggression [36, 37]. So it would seem that
if we could only increase empathy in violent offenders, we

9. would reduce their violent tendencies.[footnoteRef:9]
Psychopathy researchers have not been too optimistic about the
prospects of increasing empathy in psychopaths. Their
emotional deficits are thought to be too wide-ranging [6]. One
now rather famous psychotherapeutic program aimed to increase
empathy and responsibility lowered violent recidivism in
nonpsychopaths, but increased it in psychopaths [38]. In their
assessment of the treatment options for psychopaths, David
Thornton & Linda Blud argue that: [21, pg. 534] [9: The
matter is more complex than it seems at first. The evidence that
empathy reduces violence is mixed [39, 40, 41]. For instance,
violent sex offenders often have intact empathy [42]. There is
also the additional question of what, exactly, we mean by
‘empathy’. In the psychopathy literature, as many other places,
‘empathy’ may refer to sympathy, empathy, personal distress,
emotional reactivity, or emotional contagion [41]. This gives
rise to considerable confusion, particularly when considering
how to conceptualize the moral impairments of psychopaths
[43].]
Motives based on altruism, empathy, deep emotional needs, or
long-term self-interest are unlikely to be relevant to
psychopathic offenders. Short-term self-interest, excitement,
challenges, status, and a sense of power or control are all much
more relevant.
This makes it very difficult to see how psychopaths could form
a commitment to moral change at all. I take it most moral
philosophers would agree that the project of building morality
of short-term self-interest is pretty hopeless.
2. Medicating Amorality?
The principled difficulties with treating psychopathy suggested
above stems from considerations of traditional treatment
techniques. But what about new ones? If empathy cannot be
therapeutically induced, perhaps it can be done
neuropharmalogically. Molly Crockett and colleagues’ recent

10. success with modulating responses to morally significant
situations by means of the administration of SSRIs is very
promising [1]. The authors build on evidence that: “prosocial
and affiliative behaviors are associated with intact or enhanced
serotonin function, whereas antisocial and aggressive behaviors
are associated with impaired or reduced serotonin function.” [1,
pg. 17433] In their study, they found that increasing a person’s
serotonin increased her acceptance of some unfair offers in the
Ultimatum Game (but not the really unfair
ones).[footnoteRef:10] It also had the effect of increasing
people’s judgment that so-called personal harms are
unacceptable, even when such harms are necessary to save the
many.[footnoteRef:11] This is particularly relevant to
psychopathy as Koenigs et al. [44] found that some
psychopaths—so-called low-anxious psychopaths (also known
as ‘primary psychopaths’)—are more willing than
nonpsychopaths to endorse such harms to the individual when it
is required to save the many.[footnoteRef:12] Psychopaths have
also been found to be more likely to reject moderately unfair
offers in Ultimatum Games [46]. Increasing serotonin, then, is a
very promising lead in the search for a treatment of
psychopathy. [10: In the Ultimatum Game, a certain amount of
money is provisionally allocated two people who may share it
under the following conditions. Person 1 is to make an offer of
how to split the money, e.g. 70/30, and person 2 must either
accept or reject that offer. Only if person 2 accepts person 1’s
offer, does either of them receive any money.] [11: Personal
harms are harms that involve physical contact with the victim,
e.g. one pushes another to his or her death. They contrast with
impersonal harms where, for instance, one dispatches the victim
by pulling a lever or pushing a button. The scenarios are
supposed to involve a moral dilemma between harming the one
and saving the many.] [12: A couple of points bear mentioning
here. First, Cima, Tonnaer, and Hauser [45] found no
statistically significant difference between psychopaths and
nonpsychopaths on moral dilemmas of the type used by Koenigs

11. and colleagues [44] and Crockett and colleagues [1], though
they did use a lower cut-off point for psychopathy (26 vs. 30
points). Koenigs and colleagues also do not find a difference
between the two groups on personal harm dilemmas unless they
divide the psychopaths into high-anxious and low-anxious
groups. Interestingly, even low-anxious psychopaths find
personal harm scenarios unacceptable almost half of the time
(0.58 versus 0.46 for nonpsychopaths). Second, both groups of
psychopaths in the Koenigs et al. study were more likely to
endorse impersonal harms to save the many. Third, though the
studies show a statistically significant difference between
psychopath and nonpsychopath responses, it is hardly as
dramatic as one would expect given the current hype about
psychopaths. ]
Unfortunately, it turns out that the effects described above are
driven by people who are already quite
empathetic.[footnoteRef:13] Increased serotonin has no effect
on low-empathy scorers. Since psychopaths are notoriously low
in empathy, Crockett and colleagues recognize that the therapy
is unlikely to be effective with psychopaths. But why should
serotonin not be effective with psychopaths or with people who
are not very empathetic if, as the authors claimed, it “directly
modifies subjects’ moral judgments and behavior by means of
enhancing aversion to personally harming others” [1, pg.
17433]? And why do we see no increased tendency among
empathetic subjects with increased serotonin levels to accept
quite unfair offers in the Ultimatum Game (18-22% of the
stake)? One assumes that this is because the people judge that
there is a limit to how much unfairness they should accept. But
if this is right, increased serotonin levels do not directly modify
moral behavior in this case. If it does not do it in this instance,
why should we assume that it does so in the other cases? What
is, after all, the difference between the cases that would
motivate (justify) such a difference? In short, the fact that
increased serotonin has no effect on low empathy subjects and

12. no effect on high empathy subjects once offers are sufficiently
unfair together suggest that increased serotonin does not modify
moral judgment or behavior directly at all. More likely, the
effect is mediated by the subject’s other attitudes, beliefs,
propensities, and so on. Increased serotonin levels undergird
psychological phenomena that are only some of the pieces of the
puzzle of human moral judgment. [13: The Interpersonal
Reactivity Index [47], which is used by the authors to establish
the level of empathy of their subjects, is a hodgepodge of
measures, which includes one’s tendency to take others’
perspective, feel sympathy for them, experience emotions in
response to their emotions, distress at their distressing situation,
or one’s tendency to engage with fictional characters. ]
It is notable is that according to Crockett and colleagues,
serotonin therapy boosts pre-existing tendencies or dispositions.
Let us assume, with these authors that high-empathy subjects
are already quite reluctant to harm others and are distressed and
saddened by the prospects of such harm. Increasing their
serotonin level enhances this tendency somewhat (approx. 0.15
on a 0-1 scale). But the concern for the welfare of others is
unlikely to be blocked by, or meet much resistance in, the
person’s other concerns, tendencies, and attitudes. This points
to something that we already surely knew: a subject’s judgment
of what is morally acceptable is not reducible to one factor,
such as preventing harm to individuals simpliciter. Typically, a
moral judgment reflects a wider assessment of the situation,
which is the result of a person’s general moral outlook, the
neurophysiological underpinnings of which are likely to be
considerably complex. We might capture this idea by saying
that a subject’s moral beliefs, judgments, attitudes, and
behavior are a unified whole. They constitute her outlook on the
social world—which, for most of us, simply is the world—and
capture her attitude to life with others. One’s view of the world,
one’s attitude towards it, is hardly an independent variable that
can be modified by direct operation on some of the neurological

13. properties that instantiate it. A Weltanschauung is not merely a
matter of having a handful of interconnected ideas, perhaps of a
rather lofty nature; it is a diffuse network of beliefs,
assumptions, attitudes, and affective dispositions related to a
vision of how to live (including how to live with others).
Removing a handful of those or replacing them with others is
hardly sufficient to change it. For we work at maintaining a
relatively coherent worldview, so that if parts of it come into
conflict, we must resolve it in a way that coheres, more or less,
with our overall view, or with those parts of it that are central
and of greatest importance. Therefore, to change a person’s
Weltanschauung, one must change it wholesale or change a
critical amount, so that the subject can do the rest of the work
himself as part of bringing his belief system into a coherent
equilibrium. But it does not appear that this can be achieved by
means of modulating certain neurotransmitters, as is evidence
by the fact that increased serotonin has no effect on low-
empathy subjects.
I think we ought to conclude that there are rather formidable
difficulties with the project of altering elements of a subject’s
moral outlook—such as their tendency to find harmful actions
acceptable—because harm-considerations are only one part of a
network of closely interrelated beliefs and attitudes. One might
increase the salience of harms and the aversion towards them,
but if the subject does not generally endorse an outlook on
human affairs that places the feelings and wellbeing of others at
the very center of what is important, any such influence will be
swamped by the other beliefs, attitudes, etc. that constitute their
socio-moral outlook. I have suggested that this is due to the
dynamic unity of moral, or socio-moral, outlook. If things fall
into imbalance, if a person who does not place a high premium
on individuals not being harmed compared to the welfare of the
many, inducing aversion to harm or empathy will not have the
desired effect. For these other ideals of what is of greatest
importance will correct the “intruding” thoughts and attitudes.
Nevertheless, it is certainly possible to modify a person’s moral

14. outlook. And if it can be done through other influences, it is not
impossible to imagine that it could be done pharmacologically.
But it is unlikely to be achievable directly. Such a change
would require changes to other parts of a person’s
Weltanschauung. That is, the subject would have to complete
the work that drugs initiate in her. If this is thought to be
problematic in the ordinary individual, the difficulties facing
pharmacological intervention in psychopathic populations are
formidable indeed. For here we are not talking about enhancing
a moral tendency or other; we must implant a tendency that is
more or less absent. Furthermore, we require that our “implant”
replace their own narrowly self-interested Weltanschauung in
its entirety. But everything that we know about the mind, of
moral attitudes, of people’s socio-moral outlook suggests that
this is impossible. We would not merely have to enhance,
reinforce, or even alter their moral outlook, but we would need
to give them one in the first place and, by doing so, alter their
entire personality.
I have focused on just one new neurotechnology for the possible
treatment of psychopathy here, but it illustrates a deeper, more
principled difficulty with any treatment options that are targeted
at globally immoral and antisocial beliefs, attitudes, and
behaviors.[footnoteRef:14] I suggested that this is partly
because of what is involved in moral alteration (given the unity
of a person’s socio-moral outlook), and partly due to the
particular disorder that psychopathy is. If psychopathy is, at
core, the most moral of disorders, then it seems that we must
agree with William Reid and Carl Gacono that psychopathy is a
disorder that is untreatable in all its aspects [20]. [14: Gregor
Hassler and colleagues have recently reported success
modulating behavioral responses with cathecolamine depletion
[3]. By administering alphamethyl-paratyrosine (AMPT), which
inhibits tyrosine hydroxylase, which is essential for the
formation of cathecolamines (e.g. epinephrine, norepineprhine,
and dopamine), the authors produced reduced adaptive
responses in a couple of simple learning tasks. In certain parts

15. of the probabilistic reversal learning and passive avoidance
learning tasks, AMPT drugged subjects performed worse than
controls. This supports the literature that suggests that
dopamine plays an important role in various forms of learning
[48]. Upon finding abnormal responses to negative
reinforcement in passive avoidance learning tasks in youths
with psychopathic tendencies, Elizabeth Finger and colleagues
[2] suggest that treatment with dopamine or cathecolamine
enhancing drugs increases reinforcement learning, and should
therefore be considered as a treatment option for psychopathy or
psychopathic tendencies. The focus of this treatment
intervention is no longer the modulation of emotions that should
increase social and moral concern, but on psychopaths’
deficient learning. Though not often recognized, psychopaths
have significant practical reasoning deficits [49]. Could one fix
them, it should have important and enduring effects on their
behavior. But these deficits are unlikely to exhaust their socio-
moral impairments. And as we have seen, without a more
encompassing change of orientation towards how to lead one’s
life, such interventions will not have the desired effect.]
To return to Chartrand’s idea that treatment of Cluster B
Personality Disorders requires willingness or commitment to
moral change for a moment, I think that the best way to flesh
this intuition out is in terms of the unity of a subject’s socio-
moral outlook. Because of the relative unity or coherence of a
person’s Weltanschauung, one cannot merely fiddle with one
part of it and expect it or everything else to stay intact. Type B
Personality Disorders are conditions where subjects have a
divergent Weltanschauung. In Chartrand’s view these are all
conditions whose disease classification is contingent on
normative assessment. They constitute disorders insofar as they
represent problems that a subject experiences relative to others
or to society more generally. Whether or not we agree with this
position, we can certainly agree that psychopathy is well
conceived as a moral disorder and, for that reason, requires

16. moral commitment on the part of the psychopath to be treatable.
But here is the rub, of course. For psychopaths are supposed to
be without a conscience [19], to be fundamentally amoral. And
since truly making and upholding commitments is plausibly
itself a moral activity, we should not expect psychopaths to be
able to do so. What would be required is either a wholesale
change in moral outlook or, as I have called it, Weltanschauung,
or a commitment to moral change. Any current treatment, even
of the neuropsychological or neuropharmalogical kind, is so far
removed from being able to accomplish anything so
fundamental that I don’t think it is premature to conclude that
the prospect for treating or curing psychopathy are grim.
3. Concluding Remarks
I have argued that we have little reason to think that
psychopathy is treatable, even with new neuro-techniques.
There is a principled reason for this. Unless one can change a
person’s moral outlook entirely, one will have to work with the
outlook a person has. If she already values other’s welfare, one
may increase that valuing either through reasoned discourse or
even pharmacologically. Whether it is ethical to do so or
whether it is desirable to increase a subject’s unwillingness to
be physically involved in harming others under all
circumstances is another issue, which I cannot address here.
However, one must always consider that a person’s moral
outlook is a system where the parts mutually affect another.
People strive to have reasonably coherent views of the world,
and moral considerations must be weighed against each other,
and against other considerations. If we were to introduce a
change in one set of such considerations, it would still be
answerable to all the other beliefs, attitudes, etc. that make up
the person’s moral outlook which, I think, we should understand
as being inextricably linked to their view of how to live more
generally. This is what I have called the subject’s
Weltanschauung. If what is introduced is incompatible with or
sufficiently in tension with other parts of the subject’s outlook,

17. it will be eliminated. A true change in outlook requires either
the subject’s cooperation or extensive, coercive measures of a
kind that we have little knowledge of.
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