Psychopaths Know Right from Wrong but Don't Care

Abstract

Adult psychopaths have deficits in emotional processing and inhibitory control, engage in morally inappropriate behavior, and generally fail to distinguish moral from conventional violations. These observations, together with a dominant tradition in the discipline which sees emotional processes as causally necessary for moral judgment, have led to the conclusion that psychopaths lack an understanding of moral rights and wrongs. We test an alternative explanation: psychopaths have normal understanding of right and wrong, but abnormal regulation of morally appropriate behavior. We presented psychopaths with moral dilemmas, contrasting their judgments with age- and sex-matched (i) healthy subjects and (ii) non-psychopathic, delinquents. Subjects in each group judged cases of personal harms (i.e. requiring physical contact) as less permissible than impersonal harms, even though both types of harms led to utilitarian gains. Importantly, however, psychopaths' pattern of judgments on different dilemmas was the same as those of the other subjects. These results force a rejection of the strong hypothesis that emotional processes are causally necessary for judgments of moral dilemmas, suggesting instead that psychopaths understand the distinction between right and wrong, but do not care about such knowledge, or the consequences that ensue from their morally inappropriate behavior.

Full text

Psychopaths know right from wrong but don’t care
Maaike Cima,
1,2
Franca Tonnaer,
2,3
and Marc D. Hauser
4,5
1
Department of Developmental, Clinical and Crosscultural Psychology, Tilburg University, P.O. Box 90153, 5000 LE Tilburg,
2
Forensic Psychiatric Centre, De Rooyse Wissel, Oostrum,
3
Department of Clinical Psychological Science, Maastricht University,
The Netherlands,
4
Department of Psychology, Harvard University and
5
Department of Human Evolutionary Biology, Harvard University,
Cambridge, MA, 02138, USA
Adult psychopaths have deficits in emotional processing and inhibitory control, engage in morally inappropriate behavior, and
generally fail to distinguish moral from conventional violations. These observations, together with a dominant tradition in the
discipline which sees emotional processes as causally necessary for moral judgment, have led to the conclusion that psychopaths
lack an understanding of moral rights and wrongs. We test an alternative explanation: psychopaths have normal understanding of
right and wrong, but abnormal regulation of morally appropriate behavior. We presented psychopaths with moral dilemmas,
contrasting their judgments with age- and sex-matched (i) healthy subjects and (ii) non-psychopathic, delinquents. Subjects
in each group judged cases of personal harms (i.e. requiring physical contact) as less permissible than impersonal harms,
even though both types of harms led to utilitarian gains. Importantly, however, psychopaths’ pattern of judgments on different
dilemmas was the same as those of the other subjects. These results force a rejection of the strong hypothesis that emotional
processes are causally necessary for judgments of moral dilemmas, suggesting instead that psychopaths understand the
distinction between right and wrong, but do not care about such knowledge, or the consequences that ensue from their morally
inappropriate behavior.
Keywords: psychopaths; moral intuitions; emotions; permissible harms; immoral behavior
INTRODUCTION
The behavior of psychopaths is, without doubt, morally
inappropriate, including murder, sexual molestation, fraud,
and arson. Further, clinical analyses show that they present
abnormal emotional profiles, as well as problems with inhib-
itory control, often leading to both reactive and instrumental
aggression (Blair, 1995, 1997, 2008; Blair and Cipolotti, 2000;
Blair et al., 1995; Glenn and Raine, 2008; Kiehl, 2006;
Kiehl et al., 2001; Raine and Yang, 2006). What is unclear
is the extent to which psychopaths suffer from damage to
morally-specific knowledge that, in healthy individuals,
guides intuitive judgments of right and wrong independently
of their moral actions. On the one hand, studies indicate that
psychopaths, both adults and juveniles, show a diminished
capacity to distinguish between conventional and moral
transgressions (Blair, 1995, 1997, 2008; Smetana, 2005;
Turiel, 1998, 2005). For example, unlike healthy adults,
adult psychopaths will typically judge as equally forbidden
transgressions in which a person wears pyjamas to a restau-
rant (conventional) and a person who gratuitously hits
a waiter in the restaurant (moral). Psychopaths also show
diminished inhibitory control, a deficit that may contribute
to their impulsive behavior, especially in the context of
violence (Blair, 2008; Blair and Cipolotti, 2000; Kiehl,
2006). This research has led to the view that because of
their emotional deficits, psychopaths have corresponding
deficits in moral knowledge which, coupled with poor
inhibitory control, leads to morally inappropriate behavior
(Blair, Mitchell, and Blair, 2005; Nichols, 2002; Prinz, 2008).
Further support for the idea that the deficit in moral
psychology seen among psychopaths is due to the deficit in
emotional processing, comes from the wealth of research
showing a significant relationship between emotional
experience and moral judgment. For example, dozens of
studies now show that you can prime people’s emotional
state, and as a result, change their judgment of particular
moral scenarios. For instance, putting people in a happy
state is associated with a greater tendency to allow someone
to be used as a means to some greater good (Valdesolo and
DeSteno, 2006); associating a neutral word with disgust
under hypnosis is associated with more severe moral con-
demnation (Wheatley and Haidt, 2006); inducing disgust is
associated with more severe moral judgments (Schnall et al.,
2008).
In addition to these behavioral studies, neuroscientific
experiments also support the critical role of emotion
in moral judgment. In particular, several imaging
experiments reveal clear patterns of activation in emotion-
ally-relevant areas when subjects read about moral dilemmas
(Greene, 2003; Greene et al., 2003, 2004; Moll et al., 2002,
Received 31 July 2009; Accepted 19 October 2009
Advance Access publication 6 January 2010
This study was supported by a grant to MC from the Netherlands Organization for Scientific Research
(NWO) grant number: 451-05-020, and to MH from the National Science Foundation-Human Social Dynamics.
We would like to thank the patients of the Rooyse Wissel for participating in this study. For comments on the
data and earlier drafts of the manuscript, we thank James Blair, Joshua Greene, Kent Kiehl, Walter Sinnott-
Armstrong, Liane Young, and two authors of SCAN. The authors declare they have no competing interests.
Correspondence should be addressed to Maaike Cima, Department of Developmental, Clinical and
Crosscultural Psychology, Tilburg University, P.O.Box 90153, 5000 LE Tilburg, The Netherlands.
Email: M.J.Cima@uvt.nl
doi:10.1093/scan/nsp051 SC AN (2 010 ) 5, 59 ^ 67
ßTheAuthor (2010). Publishedby Oxford University Press. For Permissions, please email: journals.permissions@oxfordjournals.org

2005, 2007). And further, recent studies of patients with
severe deficits in emotional processing [i.e. fronto-temporal
dementia (FTD) and individuals with bilateral damage to the
ventral medial prefrontal cortex (VMPC)], show a highly
selective, but significant deficit in moral judgment
(Ciaramelli et al., 2007; Koenigs et al., 2007). For example,
whereas VMPC patients, like controls, judged actions
involving impersonal harms (e.g., flipping the switch on
the trolley to kill one person, but save five) as more permis-
sible than actions involving personal harms (e.g., pushing
the fat man off the footbridge to stop the trolley, killing
the man, but saving the 5), VMPC patients were more
likely to endorse these personal cases, including situations
where aversive acts lead to significant benefits to others.
Thus, for a broad range of moral dilemmas, emotions
appear to play little to no role in guiding judgment; for
dilemmas that pit highly aversive actions against significant
utilitarian gains, these patients favour the outcome, provid-
ing evidence for the causal role of emotion for a specific
class of moral problems.
The neuropsychological data are of particular interest
because they provide a more causal account of the relation-
ship between emotional processes and moral judgment.
Further, and of special interest to the present paper, several
authors have alluded to the similarity in profile between
VMPC patients and psychopaths, especially their flat socio-
emotional responses and their lack of inhibitory control
(Anderson et al., 1999; Barrash et al., 2000). On this view,
psychopaths and VMPC patients should show the same
pattern of moral judgments.
Summarizing, a dominant perspective in the current
literature sees intact emotional processes as essential to our
moral psychology. Here, we consider an alternative frame-
work, one that motivates the present studies of psychopaths.
In particular, though we do not deny that emotions play
some role in our moral psychology, it is possible that our
emotional experiences follow from our moral judgments as
opposed to preceding and guiding them (Huebner et al.,
2008). If this view is correct, then psychopaths may well
show normal patterns of moral judgments relative to control
populations. Where psychopaths deviate is in both not
caring about their judgments (i.e. what they know about
morally forbidden and permissible cases) and in not
engaging with the kinds of motivational systems that inspire
morally appropriate behavior and inhibit morally
inappropriate behavior.
The following study targets three issues at the core of
current work in moral psychology: (i) To what extent is
normal emotional regulation necessary for making normal
moral judgments, especially in the context of moral dilem-
mas where there are no clear, societally-mandated or typical
responses? (ii) To what extent are the systems that guide
moral judgments dissociable from those that guide moral
behavior? More specifically, do psychopaths show deficits
in both moral knowledge and behavior, in knowledge, or
in the link between knowledge and behavior? (iii) Given
the parallels between psychopaths and VMPC patients with
respect to their deficits in socio-emotional processing
and self-control, do they show parallel patterns of moral
judgments?
METHODS
Subjects
Participants (all male adults) provided informed consent in
accord with the policies of the Ethical Commission of the
Faculty of Psychology and Neuroscience, Maastricht
University, The Netherlands. Healthy controls (n¼35;
mean age ¼30.29 years, SD ¼9.99) were recruited from
the south of the Netherlands. The psychopath (n¼14;
mean age ¼36.66 years; SD ¼6.55) and non-psychopath
(n¼23; mean age ¼40.95 years; SD ¼9.77) offenders were
sampled from the Forensic Psychiatric Centre de Rooyse
Wissel (FPCdRW) in Venray, the Netherlands. Of the
37 delinquents, IQ scores were available for a subgroup of
20 (7 psychopaths and 13 non-psychopathic offenders)
participants. Though mean IQ scores for the psychopaths
(M¼81.6, SD ¼8.66) was slightly lower than for the non-
psychopathic offenders (M¼92.5; SD ¼19.37), there was
no group difference [t(18) ¼1.41; P¼0.18; d¼0.66].
Clinical diagnosis
Psychopathy was assessed by a clinician presenting the
Psychopathic Checklist-Revised [PCL-R (Hare, 1991)] test.
The PCL-R is a reliable and valid instrument, designed to
measure psychopathic traits such as antisocial behaviour,
shallowness, impulsivity, callousness, criminal history, and
lack of moral emotions, based on evidence obtained from
medical and juridical records and documents, as well as
extensive interviews with the forensic patients. Based on
a study of Grann et al. (1998), a PCL-R cutoff score of
26 was used to divide the current sample into psychopaths
(PCL-R 26) and non-psychopaths (PCL-R < 26). Total
PCL-R scores were available for all 37 offenders. However,
of the 14 psychopaths, 2 were described in the crime record
as having high PCL-R scores, without mentioning the exact
scores. Therefore, the relationship within the psychopathic
group between PCL-R scores and type of crime (Figures 3
and 4) were only available for 12 psychopaths. Finally,
regarding PCL-R factor scores, Factor 1 and Factor 2
scores were only available for 15 subjects.
The PCL-R has two main factors. The first factor com-
prises interpersonal and affective characteristics of psychop-
athy, including shallow affect, lack of remorse or guilt and
glibness/superficial charm (Cooke and Michie, 2001; Hare,
2003). The second impulsive, antisocial and unstable lifestyle
factor comprises the social deviance characteristics, and
includes impulsivity, early behavioural problems, and
parasitic lifestyle (Cooke and Michie, 2001; Hare, 2003).
All psychopathic offenders had a personality diagnosis
(Table 1). Most of them (57.1%) had a diagnosis of
60 SCAN (2010) M. Cim a et al.

cluster B (narcissistic personality disorder or antisocial per-
sonality disorder), while the minority had a personality dis-
order not otherwise specified. Of the non-psychopathic
offenders, the majority suffered a personality disorder not
otherwise specified, 21.7% had a cluster B personality disor-
der, and 4.3% had a cluster C personality disorder.
To strengthen the link to emotion all subjects in our test
groups also participated in a well-established, physiological
test of stress reactivity involving measures of cortisol
[i.e., Trier Social Stress Test; (Kirschbaum et al., 1993;
Kirschbaum et al., 1995)]. Results showed that psychopathic
offenders, unlike the two comparison groups, showed no
significant increase in cortisol in response to the stressor.
Within both the non-psychopathic group and healthy
controls, cortisol levels significantly increased at T1 (before
administering the stressor) to T3 (after administering the
stressor) as demonstrated by pairwise comparison (all
t’s > 2.81; all P’s < 0.01 and all t’s > 3.07; all P’s < 0.01, respec-
tively). In contrast, within the psychopathic group there
was no significant increase of cortisol levels between T1
and T3 (all t’s < 1.00; all P’s > 0.34); see Cima, Popma,
and Nicolson (in preparation) for a more detailed overview
of these data. Thus, based on both their PCL-R scores
and stress reactivity profiles, this psychopathic population
showed relatively flat emotional responses, consistent with
many other studies.
Participants had no history of psychosis or depression,
and no current alcohol or drug dependence. In the
delinquent sample these criteria were considered by the
psychologist, psychiatrist and file records. In the healthy
control sample, these criteria were inquired. We tested all
offenders on the moral dilemmas after they had been
interviewed with the PCL-R.
Summarizing, both psychopaths and non-psychopathic
delinquents differed from healthy controls in that they had
been convicted of crimes; and as in numerous other studies
(Herpertz et al., 2001; Kirschbaum et al., 1995; Williamson
et al., 1991), psychopaths differed fundamentally from non-
psychopath delinquents in that they showed diminished
emotional reactivity based on both the standard clinical
diagnostic test [i.e. the PCL-R (Hare, 1991)] and physio-
logical measures (Cima et al., in preparation).
Stimuli
We used the moral dilemmas of Greene et al. (2001, 2004),
previously tested with the VMPC patients (Koenigs et al.,
2007). Each dilemma was first translated into Dutch by
FT, back-translated into English by a second bilingual
Dutch-English speaker, and then checked by MH for
accuracy. We presented seven impersonal and 14 personal
moral dilemmas (see Supplementary Information). Subjects
Table 1 Biographical descriptions in percentages and mean (s.d.’s) of the background information of the psychopaths (n¼14),
non-psychopathic delinquents (n¼23), and healthy controls (n¼35)
Healthy controls Non-psychopathic offenders Psychopathic offenders
Diagnosis None Substance abuse:39 Substance abuse:64
Paedophilia: 35 Paedophilia: 0
Personality disorder: 91.3 Personality disorder: 100
Offence None Murder: 35 Murder: 29
Sexual offence: 48 Sexual offence: 36
Bodily harm: 9 Bodily harm: 14
Theft: 8 Theft: 21
Ethnicity White: 91 Asian: 4 Hispanic: 7
Multiracial: 3 White: 88 White: 64
Other: 6 Black: 4 Black: 7
Multiracial:4 Multiracial:14
Other: 7
Religion Buddhist: 3 Buddhist: 4 Buddhist: 14
Catholic: 17 Catholic: 35 Catholic: 21
None: 80 Protestant: 22 Protestant: 21
None: 35 Muslim:14
Other: 4 None: 29
Married 14 4 4
PCL-R scores
a
0.00 (0.00) 13.91 (6.63) 27.08 (8.61)
Age
b
30.29 (9.99) 40.95 (9.77) 36.66 (6.56)
IQ (n¼20)
c
–(n¼13); 92.54 (19.37) (n ¼7); 81.57 (8.66)
Education
d
1.82 (0.76) 1.35 (0.49) 1.07 (0.27)
a
Significant differences between the three groups [F(2,56) ¼95.45; P< 0.000].
b
Significant differences between non-psychopathic delinquents and healthy controls [t(56) ¼4.01, P< 0.000].
c
no significant differences between the groups [t(18) ¼1.41, P> 0.05].
d
The higher the mean, the higher the education: significant differences between psychopaths and healthy controls [t(46) ¼3.60, P< 0.001]; no
significant difference between psychopaths and non-psychopathic delinquents [t(35) ¼1.95, P> 0.05].
Psychopaths know right from wrong SCAN (2010) 61

then answered ‘‘yes’’ or ‘‘no’’ to the question ‘‘Would
you X?’’. A population of native Dutch speakers
(adults, 324 females, 348 males) judged these cases on a
Dutch version of the Moral Sense Test (http://www.serve
.com/harvardpcnl/MST/Dutch/), whereas the three test
groups responded to these dilemmas with paper and
pencil. Though we recognize that studies of moral judgment
and responses to artificial dilemmas in particular, represent
only one of several valid approaches to understanding our
moral psychology, we used this approach to provide the
most direct comparison with VMPC patients, as well as
other recent studies of intuitive moral judgments.
To control the possibility that psychopaths simply lie
about their responses to our moral dilemmas, we also
administered a questionnaire [Socio-Moral Reflection;
SRM-SF (Gibbs et al., 1992)], asking straightforward and
explicitly whether certain familiar transgressions would be
morally permissible. For instance, ‘‘How important is it to
keep a promise to your friend?’’; ‘‘How important is it not to
steal?’’. Answers could be given on a 5-point scale, ranging
from very unimportant to very important. Scores on the
SRM-SF questionnaire result in a total score and a score of
moral standing, indicating the level of moral development.
RESULTS
The Dutch sample responding on the web-based version of
this task replicated the overall pattern obtained in prior
research: subjects provided fewer endorsements of personal
dilemmas (M¼0.37, SD ¼0.28) than of impersonal
dilemmas (M¼0.75; SD ¼0.26; U¼22; z¼2.01; P¼0.04;
r¼0.08).
As in our larger Dutch sample, all three test groups judged
impersonal cases as more permissible than personal cases
(Figure 1): healthy controls (U¼13.0; z¼2.69; P¼0.007;
r¼0.46); non-psychopathic delinquents (U¼18.0;
z¼2.32; P¼0.02; r¼0.48); psychopaths (U¼23.5;
z¼1.92; P¼0.05; r¼0.52). Thus, for all four test popula-
tions, individuals are more likely to perceive up close and
personal harms as less permissible than harms that come
about by impersonal means, such as flipping a switch in
the classic trolley problem.
To examine whether the groups differed on the percentage
of cases in which they endorsed the action –supporting the
utilitarian outcome –and more generally, test the hypo-
thesis that psychopaths (like VMPC patients) are more
utilitarian on personal scenarios, we performed a 3 (test
populations) 2 (impersonal vs personal dilemmas)
ANOVA (see also, Supplementary Information for
Bayesian analyses of the same data set, designed to test the
null hypothesis of no group differences). There was, as
noted above, a highly significant dilemma type effect
[F(1,69) ¼20.02; P¼0.0001; d¼2.03], but no significant
group effect [F(2, 69) ¼0.21; P¼0.81], and a
non-significant interaction [F(2,69) ¼0.22; P¼0.80;
Figure 1]. Bonferroni corrected post-hoc tests revealed no
statistically significant group effect for either impersonal
(P’s > 0.18) or personal moral dilemma (P’s > 0.41).
Evaluation of educational level demonstrated a significant
difference between the groups, with offenders having lower
levels of education than non-offenders, but no difference
between the two groups of offenders (
2
[2] ¼12.90;
P< 0.05). More importantly, an ANCOVA demonstrated
that there was no significant effect of education on
judgments of either personal or impersonal dilemmas (all
P’s > 0.05).
Healthy controls were generally younger than both
delinquent groups. Since there was a significant age differ-
ence [F(2,69) ¼9.29; P< 0.000], due to healthy controls
being younger than non-psychopathic delinquents, we
conducted a correlation analysis to examine whether age
was related to moral responses. For both personal as well
as impersonal dilemmas, there was no effect of age
(r¼0.04 and 0.21 respectively with all P’s > 0.05).
Given that prior work on VMPC and FTD patients
revealed a highly selective deficit within the personal dilem-
mas, with greater endorsements of the utilitarian outcome
for other-serving (i.e. harming one for the benefit of others)
than self-serving (harming one for self-benefit) personal
Fig. 1 The left column presents the results for subjects’ judgments of all 21
dilemmas. There were no differences between healthy controls (white bar,
n¼35), non-psychopathic delinquents (gray bar, n¼23), and psychopaths
(hashed bar, n¼14) for the mean proportion (þs.d.) of Yes judgments. The
right column presents the results for subjects’ judgments on impersonal (top) and
personal dilemmas. Again, there were no differences between groups. However, all
three groups judged impersonal dilemmas as more permissible (i.e. a higher pro-
portion of Yes judgments) than personal dilemmas.
62 SCAN (2010) M. Cima et al.

dilemmas, we explored in greater detail the variance in
responses to personal dilemmas by both delinquent groups
and our controls (Figure 2). An overall 2 (Self vs Other-
serving) 3 (Psychopaths, Delinquents, Controls) ANOVA
revealed a statistically significant main effect for dilemma
type, with subjects judging other serving cases as more
permissible than self-serving [F(1, 36) ¼48.52; P< 0.0001].
There was, however, no main effect for the three test
populations [F(2, 36) ¼0.81; P¼0.45] and nor was there
a statistically significant interaction between dilemma type
and test population [F(2, 36) ¼1.01; P¼0.37]. Thus,
psychopaths were not more likely to endorse the utilitarian
outcome for other-serving, personal dilemmas.
On a scenario level, there were several dilemmas that
elicited virtually complete support of the utilitarian outcome
by subjects in all groups (80–100% Yes judgments) or
virtually complete prohibition of this outcome (0–20% Yes
judgments; Figure 2). For example, each of our test popula-
tions agreed that the actions to be taken in dilemmas 2, 3, 4
and 6 were largely impermissible, whereas those in dilemmas
13 and 14 were largely permissible; furthermore, although
subjects in all three test populations were less clear about the
permissibility of the action for several cases (e.g. 7, 8, and
11 in Figure 2), all clustered around the same proportion of
Yes responses. Lastly, although the mean permissibility rat-
ings for psychopaths were higher than the control popula-
tions for 8 out of 11 other-serving dilemmas, the variance in
all three groups was sufficiently high to make this apparent
difference non-significant. More specifically, for 3 of the
11 other-serving dilemmas, the delinquents provided a
greater proportion of Yes judgments; for four of these dilem-
mas, the psychopaths differed from the other groups by less
than 15%, leaving only four cases where the psychopaths
judged the case more permissible by 20–40%. Thus, even
on a case by case basis, there is no consistent pattern of
judgments that is mediated by the characteristics of our
study populations.
We also explored the difference in judgments within the
class of other-serving cases in which sometimes, harming
one to benefit many others makes the one worse off (e.g.,
the footbridge trolley case where pushing the man off the
bridge kills him but saves five) whereas in others, harm to
the one is inevitable, does not make the individual worse off,
and yet benefits many others (e.g., every person in a war
bunker will be killed by enemy soldiers if anyone makes
noise, so if a baby starts crying, killing the crying baby
doesn’t make her worse off, but saves the others); these
latter cases are often described as Pareto dilemmas, and in
previous work, are typically judged more permissible than
non-Pareto cases where the one is made worse off (Huebner,
Pettit, and Hauser, in review; Moore et al., 2008). Group
contrasts for the Pareto cases failed to reveal a significant
difference (P’s > 0.22).
Of the 37 delinquents, PCL-R factor scores were available
for 15 subjects. There was no statistically significant
correlation between subjects’ moral judgments on personal
dilemmas and their factor 1 (r¼0.02, P¼0.95) or 2 scores
(r¼0.02; P¼0.93; Figure 3A and B).
Though there is a generally agreed upon cut-off on the
PCL-R diagnostic for classifying individuals as psychopaths
(i.e., scores of 26 or higher), there was, as in all previous
work, variation among our subjects in such scores, as well as
in the nature of their criminal conviction. To assess whether
such variation was related to their moral judgments, we
plotted (Figure 4A) each psychopath’s PCL-R score against
the proportion of personal dilemmas that they endorsed, and
further grouped the subjects by their type of crime. Though
the sample size is too small to evaluate statistically, neither
the scatter in the data shows relationship between PCL-R
score and proportion of personal dilemmas endorsed, nor
a clear pattern for type of crime. Similarly, there was no
effect of PCL-R score or type of conviction on the propor-
tion of utilitarian outcomes endorsed for the other-serving
cases (Figure 4B).
Results on the SRM-SF showed that overall there
was no statistically significant difference among the
groups, with psychopaths showing slightly lower SRM-SF
scores (M¼276.14; SD ¼33.43) than healthy controls
(M¼286.03; SD ¼45.15), whereas non-psychopathic offen-
ders had slightly higher SRM-SF scores (M¼290.01;
SD ¼46.59) than healthy controls [F(2,69) ¼0.45;
P¼0.64]. None of the post-hoc tests were statistically
significant (all t0s < 0.98; P> 0.34).
DISCUSSION
Philosophers, legal scholars, and scientists agree that our
moral judgments are influenced by processes of reasoning,
intuition and emotion (Damasio, 1994; Dwyer, 2004;
Fig. 2 Scatterplot of subjects’ judgments (mean proportion of Yes responses) for all
personal moral dilemmas, divided into self-serving (far left, first three cases) and
other-serving (right, 11 cases) vignettes. Healthy controls are indicated by white
circles, non-psychopathic delinquents by gray circles, and psychopaths by hashed
squares.
Psychopaths know right from wrong SCAN (2010) 63

Greene, 2003; Haidt, 2001; Hauser, 2006; Mikhail, 2007,
2009; Posner, 1999), where controversy emerges in deciding
which of these processes alone or in combination provide the
source of our moral judgments. For example, though we
often reflect upon moral problems, weighing the pros and
cons of particular actions and outcomes, using our knowl-
edge of similar cases to deliberate, several recent studies indi-
cate that such rational and reasoned contemplation often
arises after an intuitive system has fired off a judgment of
moral permissibility. Commonly, this intuitive process has
been aligned with the emotions, and more specifically,
the source of our moral judgments lie in our feelings
about particular actions and outcomes (Blair et al., 2005;
Haidt, 2001; Moll et al. 2007; Nichols, 2004; Prinz, 2008).
Support for this position comes from three lines of evidence:
(i) subjects are dumb-founded by their judgments, unable to
provide a coherent explanation for why a particular action is
morally forbidden (Haidt, 1993, 2001); (ii) emotional
priming influences moral judgment (Schnall et al., 2008;
Valdesolo and DeSteno, 2006; Wheatley and Haidt, 2006);
(iii) when healthy subjects process moral scenarios, classic
emotional areas activate (Greene et al., 2001, 2004; Moll
et al., 2002a, b, 2005); in contrast, patients with diminished
emotional processing (i.e., FTD, VMPC, and psychopaths)
show different patterns of moral judgments than healthy
subjects, at least for a particular set of moral problems
(Anderson et al., 1999; Blair, 1995, 1997; Koenigs et al.,
2007; Mendez et al., 2005).
The present work was aimed at both the general thesis that
proper emotional processing is necessary for moral under-
standing, and the more specific thesis that the compromised
emotional processes of psychopaths accounts for their
abnormal moral psychology, including most specifically,
their heinous violence and disregard for others. Our results
license two conclusions. First, like healthy subjects and non-
psychopath delinquents, psychopaths judged impersonal
moral actions as more permissible than personal moral
actions. As previously noted (Greene et al., 2001, 2004),
this distinction is anchored on an emotional gradient, with
impersonal cases considered less emotionally intense than
personal cases. Thus, even though psychopaths show dimin-
ished emotional processing, either a sufficient level or type of
emotion is preserved or non-emotional processes can carry
out the relevant computation required to evaluate these par-
ticular moral scenarios. Second, though psychopaths showed
diminished emotional processing relative to both control
groups, and even though both delinquent groups differed
from healthy subjects in their morally inappropriate behav-
iors (e.g., paedophilia, murder), there were no group
Fig. 3 (A) Scatterplot of psychopathy factor 1 scores for offenders [psychopaths and
non-psychopathic delinquents[ [N¼15*] grouped by the proportion of yes
judgments for all personal moral dilemmas. (B) Scatterplot of psychopathy factor
2 scores for offenders [N¼15*] grouped by the proportion of yes judgments for the
personal moral dilemmas. *: For 20 individuals, crime files documented the
administration of a PCL-R interview. However, these juridical file records only
described PCL-R total score without mentioning both factor scores.
Fig. 4 (A) Scatterplot of psychopathy scores (PCL-R; N¼12*) grouped by type of
crime, against the proportion of yes judgments for all personal moral dilemmas.
(B) Scatterplot of psychopathy scores (PCL-R; N¼12*) grouped by type of crime,
against the proportion of yes judgments for the high conflict, other-serving personal
moral dilemmas. *: For two individuals, crime files documented the administration of
a PCL-R interview. However, these juridical file records only described these subjects
as being a psychopath without mentioning the exact PCL-R score.
64 SCAN (2010) M. Cim a et al.

differences in moral judgments for either impersonal or per-
sonal scenarios. Furthermore, though there was variation
among our psychopathic participants in terms of their
PCL-R scores, as well as the nature of their criminal convic-
tions, there was no relationship between these factors and
their moral judgments.
At one level, these results could be perceived as conflicting
with both previous studies of psychopaths as well as those
with VMPC patients. In particular, adult psychopaths
generally make less distinction between conventional and
moral transgressions, whereas VMPC patients tend to
provide a higher proportion of utilitarian judgments for a
subclass of personal moral dilemmas. These data have been
used to argue among the critical and causal role of emotion
in generating normal moral judgments. However, it is
difficult to provide firm evidence for a causal link between
emotion and moral judgments, since both the theoretical
arguments and empirical evidence to date are unclear
about how specific types of emotion, impact upon moral
judgment with moral concerns. Consider, for example, the
Koenigs et al. (2007) paper, though it is generally agreed
that patients with damage to VMPC have emotional deficits,
and in particular, show difficulty with social emotions such
as empathy, embarrassment, and guilt, it is not clear how
the absence of these emotions, or the reduction in their
manifestation would cause subjects to provide more
utilitarian judgments for the narrow range of other-serving
dilemmas. That is, why would the aversiveness of harming
one person be diminished because one feels less embarrass-
ment, empathy, or guilt? And even if one could provide a
coherent account, including the possibility in the absence
of guilt, one is simply less affected by harming one person,
then why would not the same argument go through for other
cases of harm that were present but that showed no group
differences? Furthermore, even if there is a coherent account
for this aspect of process, it doesn’t necessarily show that
emotions dictate how we decide whether an action is morally
right or wrong. For example, it could be some other set of
processes that makes this decision, but emotions titrate the
severity of judgment. Thus, for example, when the social
emotions are diminished with respect to their impact on
decision making, we see harming one as less bad when
there is a greater good, i.e. both VMPC patients and normals
see harming one for some greater good as bad, but VMPC
patients simply see the harm as less bad. On this view,
emotions are like a gain function, moving our judgments
up and down a scale from very bad or forbidden to obliga-
tory or required (see Huebner et al, 2008, for further devel-
opment of this argument).
There are at least two reasons why the psychopathy data
on the moral-conventional distinction leave many questions
unanswered, especially in terms of the specific role of
emotions: 1) since both adults and juveniles received scenar-
ios that were designed for children, it is unclear how adult
psychopaths would fare on adult versions; 2) the adult and
juvenile psychopaths appear to have opposite judgment
biases, with adults judging most cases to be forbidden
whereas juveniles consider most to be permissible; why
differences in emotion would lead to this developmental
flip-flop is unclear.
Though VMPC patients show some of the same kinds of
emotional deficits as do psychopaths, no one has yet estab-
lished how specific kinds of emotion are causally linked to
specific kinds of moral problems. For example, though
VMPC patients generate normal judgments for most moral
dilemmas tested so far, it is not clear why diminished capac-
ity to experience empathy, embarrassment and loyalty
should lead to a selective deficit for other-serving moral
dilemmas in which a highly aversive action is pitted against
a significant utilitarian outcome. Given these uncertainties,
it is perhaps less surprising, and at odds with the existing
data, psychopaths show normal patterns of moral judgments
for moral dilemmas. More specifically, though psychopaths
show some of the same emotional deficits as patients with
damage to VMPC, other aspects of their emotions may be
relatively preserved, and these may be the most important
with respect to moral understanding. At present, however,
this literature is unclear, with some studies reporting normal
recognition and judgments by psychopaths of basic emotions
such as anger, fear, sadness and disgust, whereas other
studies show differences, including evidence of abnormalities
in brain activation during imaging studies of emotional
processing (Blair et al., 2002; Fullam and Dolan, 2006;
Muller et al., 2003; Pham et al., 2000). Furthermore,
though psychopaths may show deficits in distinguishing
conventional from moral cases, whatever cognitive function
is necessary for this distinction is apparently unnecessary
with respect to judging moral dilemmas, and especially, for
perceiving the difference between personal and impersonal
cases. This conclusion is reinforced by a recent imaging
study of psychopaths in which individuals evaluated the
same set of dilemmas presented here, showed reduced
activation in the amygdala relative to controls (Glenn
et al., 2009), but no difference in judgments (Glenn, Raine,
Schrug, Young, and Hauser, in press). Moreover, Glenn et al.
(in press) show that non-prison convicted psychopaths
(classified based on the PCL-R) evidence significantly lower
amygdala activation relative to controls, and significantly
higher DLPC activation. Amygdala is associated with pro-
cessing predominant negative emotions, and especially fear.
In contrast, the DLPC plays a critical role in conscious rea-
soning and decision making. Despite these neural differences,
population of non-prison convicted psychopaths showed no
differences in moral judgment from a control group.
Lastly, it is possible that the emotional deficits of
psychopaths only show up, or show up most intensely,
under pressure to respond quickly, or feel compelled to do
so, thereby triggering their more impulsive character (Kiehl,
2007). Here, there was no such pressure, perhaps resulting
in normal patterns of judgment.
Psychopaths know right from wrong SCAN (2010) 65

We conclude that psychopaths make the same kind of
moral distinctions as healthy individuals when it comes to
evaluating the permissibility of an action embedded in
a moral dilemma. Consequently, these results support the
hypothesis that normal social emotional processing does
not appear necessary for making these kinds of moral
judgments. Normal emotional processing is likely to be
most important in generating an appreciation of these
distinctions and in guiding actions (Huebner et al., 2008).
Psychopaths know what is right or wrong, but simply don’t
care. Given that legal distinctions often turn on whether
crimes are committed knowingly (e.g., Model Penal Code),
these results could have bearing on court decisions concern-
ing the nature of moral knowledge –i.e. instead of strictly
focusing on criminal actions carried out knowingly,we
should also focus on whether such knowingly immoral and
illegal actions are carried out caringly. Equally important,
these results may shed light on treatment, pushing clinicians
to distinguish between the sources of deficit regarding
morally relevant decisions and actions.
SUPPLEMENTARY DATA
Supplementary data are available at SCAN online.
REFERENCES
Anderson, S.W., Bechara, A., Damasio, H., Tranel, D., Damasio, A.R.
(1999). Impairment of social and moral behavior related to early
damage in human prefrontal cortex. Nature Neuroscience,2, 1032–1037.
Barrash, J., Tranel, D., Anderson, S.W. (2000). Acquired personality
disturbances associated wtih bilateral damage to the ventromedial
prefrontal region. Developmental Neuropsychology,18, 355–381.
Blair, R.J.R. (1995). A cognitive developmental approach to morality:
investigating the psychopath. Cognition,57,1–29.
Blair, R.J.R. (1997). Moral reasoning and the child with psychopathic
tendencies. Personality and Individual Differences,22, 731–739.
Blair, R.J.R. (2008). Fine cuts of empathy and the amygdala: dissociable
deficits in psychopathy and autism. Quarterly Journal of Experimental
Psychology,61, 157–170.
Blair, R.J.R., Cipolotti, L. (2000). Impaired social response reversal. A case
of ‘acquired sociopathy’. Brain,123, 1122–1141.
Blair, R.J.R., Mitchell, D., Blair, K. (2005). Psychopath: Emotion and the
Brain. New York: Wiley-Blackwell.
Blair, R.J.R., Mitchell, D.G.V., Kelly, S., Richell, R.A., Leoonard, A. (2002).
Turning a deaf ear to fear: impaired recognition of vocal affect in
psychopathic individuals. Journal of Abnormal Psychology,111, 682–686.
Blair, R.J.R., Sellars, C., Strickland, I., Clark, F., Williams, A.O., Smith, M.,
et al. (1995). Emotion attributions in the psychopath. Personality and
Individual Differences,19, 431–437.
Ciaramelli, E., Miccioli, M., Ladavas, E., di Pellegrino, G. (2007). Selective
deficit in personal moral judgment following damage to ventromedial
prefrontal cortext. Social Cognitive and Affective Neuroscience,2,84–92.
Cima, M., Nicolson, N., Popma, A. (in preparation). Cortisol reactivity in
different dimensions of psychopathic offenders.
Cooke, D.J., Michie, C. (2001). Refining the construct of psychopathy:
towards a hierarchical model. Psychological Assessment,13, 171–188.
Damasio, A. (1994). Descartes’ Error. Boston, MA: Norton.
Dwyer, S. (2004). How good is the linguistic analogy. Retrieved 25 February,
2004, from www.umbc.edu/philosophy/dwyer
Fullam, R., Dolan, M. (2006). Emotional information processing in
violent patients wtih schizophrenia: assoiciation with psychopathy and
symptomatology. Psychiatry Research,141(1),29–37.
Gibbs, J.C., Basinger, K.S., Fuller, D. (1992). Moral Maturity: measuring the
development of sociomoral reflection. Hillsdale: Lawrence Erlbaum
Associates Publishers.
Glenn, A.L., Raine, A. (2008). The neurobiology of psychopathy. Psychiatric
Clinics of North America,31, 463–376.
Glenn, A.L., Raine, A., Schug, R.A. (2009). The neural correlates
of moral decision-making in psychopathy. Molecular Psychiatry,14,
5–6.
Glenn, A.L., Raine, A., Schrug, R.A., Young, L., Hauser, M.D. (2009).
Increased DLPFC activity during moral decision-making in psychopathy.
Molecular Psychiatry,14, 909–911.
Grann, M., La
˚ngstro
¨m, N., Tengstro
¨m, A., Sta
˚lenheim, E.G. (1998).
Reliability of file-based retrospective ratings of psychopathy with the
PCL-R. Journal of Personality Assessment,70, 416–426.
Greene, J.D. (2003). From neural ‘is’ to moral ‘ought’: what are the moral
implications of neuroscientific moral psychology. Nature Neuroscience
Reviews,4, 847–850.
Greene, J.D., Nystrom, L.E., Engell, A.D., Darley, J.M., Cohen, J.D. (2004).
The neural bases of cognitive conflict and control in moral judgment.
Neuron,44, 389–400.
Greene, J.D., Sommerville, R.B., Nystrom, L.E., Darley, J.M., Cohen, J.D.
(2001). An fMRI investigation of emotional engagement in moral
judgment. Science,293, 2105–2108.
Haidt, J. (1993). Affect, culture, and morality, or is it wrong to eat your dog?
Journal of Personality and Social Psychology,65, 613–628.
Haidt, J. (2001). The emotional dog and its rational tail: a social intuitionist
approach to moral judgment. Psychological Review,108, 814–834.
Hare, R.D. (1991). The Hare psychopathy checklist-revised. Toronto, Ontario:
Multi-Healthy Systems.
Hare, R.D. (2003). Hare Psychopathy Checklist-Revised (PCL-R): Second
edition, technical manual. Toronto: Multi-Health Systems.
Hauser, M.D. (2006). Moral Minds: How Nature Designed Our Sense of Right
and Wrong. New York: Ecco/Harper Collins.
Herpertz, S.C., Werth, U., Lukas, G., Qunaibi, M., Schuerkens, A.,
Kunert, H., et al. (2001). Emotion in criminal offenders with psychopathy
and borderline personality disorder. Archives of General Psychiatry,58,
737–745.
Huebner, B., Dwyer, S., Hauser, M.D. (2009). The role of emotion in moral
psychology. Trends in Cognitive Science,13,1–6.
Huebner, B., Pettit, P., Hauser, M.D. (in review). When are means-based
harms morally permissible? Folk intuitions confirm the philosophical
significance of Pareto considerations. Mind and Language.
Kiehl, K.A. (2006). A cognitive neuroscience perspective on psychopathy:
evidence for paralimbic system dysfunction. Psychiatry Research,142,
107–128.
Kiehl, K.A. (2007). Without morals: the cognitive neuroscience of psycho-
pathy. In: Sinnott-Armstrong , W., editor. Moral Psychology, Volume 3:
The Neuroscience of Morality: Emotion, Brain Disorders, and Development,
New York: Bradford Books.
Kiehl, K.A., Smith, A.M., Hare, R.D., Forster, B.B., Liddle, P.F. (2001).
Limbic abnormalities in affective processing in criminal psychopaths as
revealed by functional magnetic resonance imaging. Biological Psychiatry,
50, 677–684.
Kirschbaum, C., Pirke, K.-M., Hellhammer, D.H. (1993). The ‘Trier Social
Stress Test’ –a tool for investigating psychobiological stress responses in a
laboratory setting. Neuropsychobiology,28,76–81.
Kirschbaum, C., Pru
¨ssner, J., Gaab, J., Schommer, N., Lintz, D., Stone, A.A.,
et al. (1995). Persistent high cortisol responses to repeated psychological
stress in a subpopulation of healthy men. Psychosomatic Medicine,57,
468–474.
Koenigs, M., Young, L., Adolphs, R., Tranel, D., Hauser, M.D.,
Cushman, F., et al. (2007). Damage to the prefrontal cortex increases
utilitarian moral judgments. Nature,446, 908–911.
Mendez, M., Anderson, E., Shapira, J.S. (2005). An investigation of moral
judgment in frontotemporal dementia. Cognitive and Behavioral
Neurology,18, 193–197.
66 SCAN (2010) M. Cim a et al.

Mikhail, J. (2007). Universal moral grammar: theory, evidence, and the
future. Trends in Cognitive Science,11, 143–152.
Mikhail, J. (2009). Rawls’ Linguistic Analogy. New York: Cambridge
University Press.
Moll, J., Oliveira-Souza, R., Eslinger, P.J. (2002a). The neural correlates of
moral sensitivity: a functional MRI investigation of basic and moral
emotions. Journal of Neuroscience,27, 2730–2736.
Moll, J., Oliveira-Souza, R., Moll, F.T., Ignacio, I.E., Caparelli-Daquer, E.M.,
Eslinger, P.J. (2005). The moral affiliations of disgust. Manuscript.
Moll, J., Olivier-Souza, R., Bramati, I.E. (2002b). Functional
networks in moral and non-moral social judgments. NeuroImage,16,
696–703.
Moll, J., Zahn, R., Oliveira-Souza, R. d., Krueger, F., Grafman, J. (2007).
The neural basis of human moral cognition. Nature Reviews Neuroscience,
6, 799–809.
Moore, A., Clark, B., Kane, M. (2008). Who shall not kill? Individual
differences in working memory capacity, executive control, and moral
judgment. Psychological Science,19(6), 549–557.
Muller, J.L., Sommer, M., Wagner, V., Lange, K., Tashcler, H., Roder, C.H.,
et al. (2003). Abnormalities in emotion processing within cortical and
subcortical regions in criminal psychopaths: evidence from a functional
magnetic resonance imaging study using pictures with emotional content.
Biological Psychiatry,54, 152–162.
Nichols, S. (2002). Norms with feeling: toward a psychological account of
moral judgment. Cognition,84, 221–236.
Nichols, S. (2004). Sentimental Rules. New York: Oxford University Press.
Pham, T.H., Philippot, P., Rime, B. (2000). Subjective and autonomic
responses to emotion induction in psychopaths. Encephale,26(1),45–51.
Posner, R.A. (1999). The Problematics of Moral and Legal Theory.
Cambridge: Harvard University Press.
Prinz, J.J. (2008). The Emotional Construction of Morals. New York: Oxford
University Press.
Raine, A., Yang, Y. (2006). Neural foundations to moral reasoning and
antisocial behavior. Social Cognitive and Affective Neuroscience,1,
203–213.
Schnall, S., Haidt, J., Clore, G.L. (2008). Disgust as embodied moral
judgment. Personality and Social Psychology Bulletin,34, 1096–1109.
Smetana, J. (2005). Social-cognitive domain theory: consistencies and
variations in children’s moral and social judgments. In: Killen, M.,
Smetana, J. G., editors. Handbook of Moral Development. Mahwah:
Lawrence Erlbaum Publishers.
Turiel, E. (1998). The development of morality. In: Damon, W., editor.
Handbook of Child Psychology. New York: Wiley Press, pp. 863–932.
Turiel, E. (2005). Thought, emotions, and social interactional processes in
moral development. In: Killen, M., Smetana, J. G., editors. Handbook of
Moral Development. Mahwah: Lawrence Erlbaum Publishers.
Valdesolo, P., DeSteno, D. (2006). Manipulations of emotional context
shape moral judgment. Psychological Science,17, 476–477.
Wheatley, T., Haidt, J. (2006). Hypnotically induced disgust makes moral
judgments more severe. Psychological Science,16, 780–784.
Williamson, S., Harpur, T.J., Hare, H.D. (1991). Abnormal processing of
affective words by psychopaths. Psychophysiology,28, 260–273.
Psychopaths know right from wrong SCAN (2010) 67