I have been gripped by the trial of Anders Breivik and was intrigued to see the BMJ hosting a Maudsley debate this week about, loosely speaking, Breivik’s “sanity.” The debate ran under the headline question of whether fanaticism is a form of madness which gave a slightly odd spin to the proceedings. As Tom Fahy hints, given that few football fans are incarcerated in secure institutions I am not sure fanaticism in and of itself is necessarily the problem. If political and religious fanaticism are the real problems—mortal threats to the west—then what follows if fanaticism is diagnosed as a mental disorder? What advantage, analytical or practical, could it possibly bring? Can medicine really help frame this debate?

For anyone unfamiliar with the events, on the 22 July 2011 Breivik slaughtered 75 fellow Norwegians. 69 of them, mainly teenagers, were at a summer camp hosted by the youth wing of the ruling Labour party. Breivik was a member of an extreme right wing group and the killings were allegedly a protest against Norway’s liberal immigration policies. It was an act without parallel in a country that is a benchmark for tolerance and political liberalism. During his trial, comment inevitably turned to Breivik’s mental state. In January this year, following 36 hours of interview with Breivik, two court-appointed psychiatrists concluded that he was  indeed “mad”—that he was suffering from a paranoid schizophrenic disorder. A second assessment in April, prompted by solicitors acting for the interests of the victims disagreed, finding no evidence of psychosis.

It is not for me to comment on Breivik’s mental state. This is a matter for expert psychiatric opinion, however much individual psychiatrists might disagree with each other. But the case does remind us of a certain vulnerability of psychiatry both to political hijack and to the courts of public opinion.  If the incredulity that characterizes the immediate aftermath of an atrocity leads to cries of insanity, in time opinions may shift. “The majority of the Norwegian public,” writes psychiatrist Simon Wessely in The Lancet “saw a label of schizophrenia as allowing Breivik to avoid having to answer to his crimes, and worse, that a psychiatric diagnosis raised the spectre that he could be free again.” In essence, an insanity defence argues that the individual does not have the necessary mental conditions for criminal culpability. It puts him outside the community of moral agents, the community of those deemed responsible for their actions. In Breivik’s case, it looks as if public opinion first called upon psychiatry to find him insane and defend the community from trying to make sense of the incomprehensible. As incredulity died away, psychiatry was then called upon to render him sane and return him to the moral community in which he can be tried for his crimes. As Nietzsche puts it in Twilight of the Idols “men were considered free so they might be judged and punished.”

For those of you with longer memories, Breivik’s case calls to mind the trial of Peter Sutcliffe, “the Yorkshire Ripper” for the murder of thirteen women. In that case Mr Justice Boreham set to one side the views of four psychiatrists who diagnosed him as suffering from paranoid schizophrenia and deemed him fit to stand trial. In finding Sutcliffe guilty, the jury sided with the judge against psychiatric opinion. As Michael Ingatieff put it at the time, “the jury could have been forgiven for believing that psychiatry, not Sutcliffe, was in the dock.” Ignatieff also highlights a more philosophical problem. “The crucial difficulty in the insanity defence lay in its circularity…taking the horror of the act itself as proof of the insanity of its perpetrator.”

At least two things seem to emerge from this. The first is a reminder of the need for psychiatry to continue its vigilance against political co-option. As Fahy reminds us, a verdict of insanity was widely used to incarcerate those who disagreed with the ruling political orthodoxy in the Soviet Union. (For a detailed exploration of the human rights impact of institutional abuses of health care see the BMA’s handbook, The Medical Profession and Human Rights.) It is likely that communities will always seek to drive out acts and individuals they find monstrous. It does not follow that psychiatry should lend it spurious scientific legitimacy. Of course this may not be easy. Psychiatry will always have something to do with human meaning and evaluation, with the way people struggle to make sense of their worlds, and whatever the neuroscientists may say, this is unlikely to be reduced to the wiring of our brains. It is worth remembering that what brought Breivik to the attention of psychiatry was a planned and premeditated violation of deep moral norms. Given the nature of its object of attention a value-free psychiatry may remain elusive or even undesirable—better perhaps to acknowledge the deep reach of norms in the evaluation of our mental states.

To label someone mad also means that we do not have to wrestle with his ideas. Whether or not Breivik turns out to have been mentally ill the ideas he voiced and by which he says he is motivated are not his alone. They are the unmistakable ideas of the European far right.  As Daniel Trilling puts it in a recent piece in the New Statesman “…if the beliefs he claims to hold really are delusional, then the frightening thing is that they did not spring forth from a single, deranged mind: they represent a far-right ideology shared by groups across Europe and the US.” Among those ideas are degraded forms of a now largely discredited “racial science” that was near-orthodoxy in the nineteenth century as well as extreme versions of ethnic-based nationalism that owe their provenance to Herder and the European counter-Enlightenment. The way to respond to ideas is with debate—to look at the assumptions on which they are based, the evidence they claim for justification and the logic with which they are applied, as well as the ends to which they are directed. This is not the business of psychiatry but of politics and political theory. And neither discipline is improved by their confusion.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.