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My layman's opinion, looking as the information on psychopaths and other related problems, I suspect that it's a spectrum disorder that affects moral functioning in much the same way that autism is a spectrum disorder that affects social functioning. What I mean is that I think a narcissist is a mild form of a psychopath in much the way that Aspberger's syndrome is a mild form of autism. Here are the puzzle pieces:

Proper moral decision making requires a functional visceral emotional response to moral problems. This visceral emotional response to moral problems is missing or broken in the psychopath so every decision that they make is a coldly rational decision without regard for empathy, compassion, or humanity. This illustrates why (A) utilitarianism always seems to end in brutal atrocities, (B) why rational arguments alone cannot support moral behavior, and (C) why psychopaths can't be fixed.