Accountability, Illness, and the Human Condition
Should We Hold People Accountable When They Suffer from Legitimate Health Conditions?
One of the most difficult questions society faces is determining how much responsibility a person bears for their actions when those actions are influenced by a medical condition. We often assume that every individual acts with complete free will, fully understanding the consequences of their decisions. In reality, human behavior is far more complicated.
Medical conditions can alter judgment, perception, impulse control, emotions, memory, and decision-making. In addition, the medications prescribed to treat these conditions can sometimes produce significant behavioral and psychological side effects. This creates a genuine dilemma: when a person's actions are influenced by illness or treatment, how accountable should they be?
The Assumption of Personal Responsibility
Modern society is built on the principle that individuals are responsible for their choices. Our legal systems, workplaces, schools, and personal relationships all depend on the belief that people can distinguish right from wrong and control their actions.
For most situations, this assumption is reasonable. Accountability encourages responsible behavior and helps maintain social order. Without accountability, it would be difficult to establish trust, fairness, or justice.
However, the assumption becomes less clear when a person's physical or mental health affects their ability to think, reason, or control their behavior.
The Influence of Medical Conditions
Many medical conditions can significantly impact behavior.
Neurological disorders such as Parkinson's disease, Alzheimer's disease, dementia, traumatic brain injury, epilepsy, and multiple sclerosis can affect cognition, emotional regulation, and executive functioning.
Psychiatric conditions such as severe depression, bipolar disorder, schizophrenia, and psychosis can alter a person's perception of reality and impair judgment.
Even physical illnesses can influence behavior through chronic pain, sleep deprivation, hormonal imbalances, infections, or metabolic disorders.
In some cases, individuals may say or do things that are completely out of character. Family members often describe these situations by saying, "That's not the person I know."
The challenge lies in determining where the illness ends and personal responsibility begins.
The Role of Medications
Complicating matters further are the medications used to treat these conditions.
Many medications have known side effects that can influence behavior. Some Parkinson's medications, for example, have been associated with impulse control disorders such as compulsive gambling, excessive spending, hypersexuality, and other risk-taking behaviors.
Certain antidepressants, steroids, sleep medications, pain medications, and psychiatric drugs can affect mood, judgment, or emotional stability.
Patients frequently take these medications in good faith, following their physicians' recommendations. Yet the treatment itself may contribute to behaviors that the patient would never have engaged in otherwise.
This raises a difficult ethical question: if a medication substantially contributed to a person's actions, should they be judged the same way as someone acting without those influences?
The Legal Perspective
The legal system has long struggled with this issue.
Most legal systems recognize that there are circumstances in which an individual may not be fully responsible for their actions because of mental illness or diminished capacity. This recognition gave rise to concepts such as the insanity defense, competency evaluations, and diminished responsibility.
Contrary to popular belief, a successful insanity defense does not usually result in freedom. In many cases, individuals are committed to secure psychiatric facilities where they receive treatment and supervision. The goal is not to excuse harmful behavior but to recognize that punishment alone may not be appropriate when a person's ability to understand or control their actions was severely impaired.
The legal system attempts to balance two important objectives:
- Protecting society.
- Providing appropriate treatment for individuals whose illnesses contributed to their actions.
This balance is often imperfect, but it reflects an understanding that accountability exists on a spectrum rather than as an absolute.
Compassion Without Excusing Harm
Recognizing the influence of illness does not mean abandoning accountability altogether.
A person suffering from a medical condition can still cause real harm to others. Victims may experience emotional, physical, or financial consequences regardless of the reason behind the behavior.
Compassion and accountability are not mutually exclusive. It is possible to acknowledge that someone acted under the influence of illness while also recognizing the impact of their actions.
In many cases, the most constructive approach focuses on treatment, rehabilitation, and prevention rather than punishment alone.
Living with Uncertainty
Perhaps the hardest part of this discussion is accepting that there are rarely simple answers.
Human behavior is influenced by biology, psychology, environment, life experiences, medications, and countless other factors. We like to believe there is a clear line between choice and illness, but often that line is blurred.
As our understanding of neuroscience, psychology, and medicine continues to evolve, we are learning that many behaviors once viewed purely as moral failings may have underlying biological components. At the same time, society must continue to encourage personal responsibility and protect those who may be harmed by others' actions.
A Personal Reflection
My perspective on this subject has been shaped not only by my own health challenges, but also by my work supporting others who are dealing with Parkinson's disease and other serious medical conditions. One of the questions that frequently arises is whether a patient should be held accountable for a particular behavior, decision, or action. While the question sounds straightforward, I have learned that the answer rarely is.
Oddly enough, I often find myself thinking back to my years working in credit risk management at JPMorgan. Senior managers would frequently ask what seemed like a simple question:
What caused the change?
Perhaps a client's credit exposure increased dramatically from one day to the next. To many people, the answer appeared obvious. Maybe the client traded more. Maybe market conditions changed. Maybe there was a large transaction.
The reality was far more complicated.
In a large global financial institution, there was rarely a single explanation. Exposure calculations were influenced by hundreds of variables and countless interactions between them. We analyzed interest rate curves from multiple markets, spot and forward foreign exchange rates, historical and implied volatilities, correlations between asset classes, collateral arrangements, netting agreements, credit enhancement structures, and sophisticated mathematical models. Each variable influenced the others.
The challenge was not performing the analysis. The challenge was explaining a highly complex answer in a way that could be understood quickly by senior decision-makers.
Medicine often feels very similar to me.
When we ask why a person's behavior changed, we naturally want a simple answer. Yet there may be dozens of contributing factors. A neurological disorder may be affecting judgment. Medications may be influencing impulse control. Sleep deprivation, chronic pain, depression, anxiety, cognitive decline, social isolation, and stress may all be contributing at the same time. Just as in risk management, the variables do not operate independently. They interact with one another in ways that can be difficult to separate and even harder to quantify.
That does not mean accountability disappears. It simply means that understanding human behavior is often more complicated than we would like it to be.
Perhaps that is what I appreciate most about medicine. Physicians, caregivers, patients, and families are all trying to understand a system with countless variables. They gather information, evaluate probabilities, form hypotheses, and attempt to explain what is happening. Sometimes they are right. Sometimes new information emerges and changes the answer.
The longer I live, the less certain I become that there is always a single cause behind any behavior. More often, there is a collection of influences that combine to produce an outcome.
Because of that, I find myself approaching people with greater humility and compassion. When someone causes me perceived harm, I try to understand what may have been happening beneath the surface before rushing to judgment. I still believe in accountability, but I also believe in understanding, empathy, and grace.
Life has taught me that every person is fighting battles we may never fully see. Some of those battles are visible. Many are not.
Life is too damn short not to forgive.
— Aaron D. Cohen