Szasz On The Myth Of Mental Illness

This semester, in my Landmarks in Philosophy class, I used Thomas Szasz‘s The Myth of Mental Illness as one of the three texts on the reading list (The other two were Mary Wollstonecraft’s Vindication of the Rights of Woman and William James’ Pragmatism.) Szasz’s argument that mental illness does not exist, that psychiatry is a pseudo-science was, as might be expected, fairly controversial; critics accused him of overstating his case and of drawing too sharp a boundary between the physical and the mental. Be that as it may, there are many, many acute insights in Szasz’s work; these continue to make reading his work a useful experience for any philosophy student.

Among these insights, in no particular order, are the following:

1. Reducing the mental to the physical comes at a cost of explanatory power. Especially when such reduction is merely offered in the form of a promissory note; many existing behavioral disorders still lack physical correlates in neurophysiology. The languages of the mental and the ethical often offer us richer and more useful explanations for understanding our fellow human beings than the language of the physical; many phenomena of social and ethical interest ‘vanish’ when subjected to the lens of the physical.

2. The so-called ‘mentally ill’ are engaged in a species of communication with us; it behooves us to try to translate their ‘speech.’ This leads to a consideration of a hierarchy of languages and a study of the metalanguage and object language distinction.

3. The category ‘mentally ill’ functions, all too often, as a catch-all category used to lump in socially undesirable behavior; what counts as desirable and undesirable is clearly a function of existing social prejudices.  The infamous DSM criteria often encapsulate such prejudices; unsurprisingly these need to be revised over time to accommodate such inclinations. (Remember that Dostoyevsky’s ‘Underground Man‘ was a ‘sick man.’)

4. A game-playing and rule-following model of human behavior offers us interesting and useful interpretations of social situations and interactions within them. (Wittgenstein’s notion of language as a kind of social game immediately comes to mind here and allows for a fruitful investigation of this claim.)

5. Medicine functions within a social, economic, political, and ethical context; the rights of patients and healers emerge within this context.  We should expect medicine to be practiced differently–with different medical outcomes–in different contexts. From this, a larger point about the social construction of science, scientific practice, and scientific knowledge can be seen to follow; the boundaries of science are very often informed by social and legal considerations. Consider, for instance, the testing of cosmetic products or new drugs on laboratory animals, experimental procedures which stand and fall depending on whether they have received legal sanction from the surrounding legal regime.

6. The autonomy and personality of the patient is a moral good worthy of respect; the practice of medicine and the relationship between the doctor and patient should be cognizant of this. (The notion of ‘informed consent’ in modern bioethics can be seen to be powerfully informed by such a consideration.)

The Doctor And The Silenced Patient

In Confessions of a Medicine Man: An Essay in Popular Philosophy (MIT Press, Cambridge, MA, 2000, pp. 109-110) Alfred I. Tauber writes:

Health care providers have to listen, respond, and generally account for the subjective experience of a patient’s complaint. So much of our discontent can be traced to the too little time the physician spends with a client, and how poorly a true dialogue develops. Focusing upon the clinical narrative, the patient’s rendition of the disease experience offers crucial insight to the physician, both as scientist and empathetic, that is, ethical, healer. Beyond obtaining information that may be important in tending to the patient’s particular physical needs, a patient’s own description of the illness presents the physician with the problem of suffering, and the profound disruption, uncertainty, and pain that disease imposes. To ignore this aspect of illness is to deny the patient’s fundamental humanity and relegate them to the status of object.

In an older post titled Taylorism and the Doctor’s Office I had complained about the slavish devotion to efficiency and throughput maximization visible in the work of the physician; an important component of the dissatisfaction I felt then, one not fully articulated, was that my physicians, my healers, were simply not listening to me:

The patient, meanwhile, many of his questions unanswered, his possible inputs to the diagnostic process ignored, returns home, disquieted by the experience, disillusioned by the wonders of face-to-face contact with a fellow human being, and supposedly a healer at that.

This is a real frustration with serious consequences. As a patient, I have a great deal to tell my doctor about my personal experience of the illness: this is how it feels on the ‘inside’; this is how it affects the way I move, the way I relate to my body; these are the kinds of things I want to do and cannot do; this is how I now see myself in relation to the world and my body. I see these as important inputs into the healing process; I see them as descriptions of my dis-ease, a tabulation of the ways in which I am no longer whole and long to put back together again. My illness is not just a set of physical markers; it is an impairment of my being in this world, and I am best placed to report on a very particular aspect of that fractured relationship.

Because I consider myself a good observer, and a good reporter, I come to each doctor’s visit with a sense of anticipation: I will place these reports and descriptions at the service of my doctor, and he will combine them with his expert physiological, medical, and scientific knowledge to produce the optimum healing package. Together, doctor and patient, interacting with each other, will move to a new co-anchored state of being: the doctor becomes a better doctor by healing, by having his skills honed on this new ‘challenge’; I will return to good health.

But my doctor has no time for such niceties; he cannot be bothered to listen to his partner; he cannot wait to hear the ‘other side’ of the story; he is only concerned with test parameters, visible observations, and quick slotting into categories (and the submission of an insurance claim for payment.) To listen to a patient will interfere with the most efficient ‘best practice,’ the one recommended by the management consultant group in charge of his clinic or hospital.

The patient’s experience of the illness falls by the wayside; it is the least important part of the modern ‘healing’ process. And with that assessment, the patient becomes just as marginal, ready to be objectified.

No Atheists In Foxholes? Plenty of Atheists In Cancer Wards

In writing about Brittany Maynard, the twenty-nine year old cancer patient who has scheduled herself for a physician-assisted suicide on November 1, Ross Douthat asks:

Why, in a society where individualism seems to be carrying the day, is the right that Maynard intends to exercise still confined to just a handful of states? Why has assisted suicide’s advance been slow, when on other social issues the landscape has shifted dramatically in a libertarian direction?

This question will predictably be answered by some variant of the usual Douthat analysis. To wit:

Because liberals misunderstand the American soul, if not the human condition, which is offered more soothing, palliative balm, more existential comfort, by the religiously infused conservative spirit, the true heart of America, and really, perhaps all of humanity. This Godless, cold, uncaring cosmos of the liberal imagination–where it ultimately fails is in being able to address La Condition Humaine

With that in mind, let us press on.

It does not take us too long to encounter Douthat’s current version of the answer I supplied. Here it is. ‘Liberalism’, in the context of the assisted suicide debate, is:

[A] worldview ill equipped to make sense of suffering that’s bound to lead to death, or that does not have a mountain-climbing, op-ed-writing recovery at the end of it.

Thus, unsurprisingly, in the Maynard case:

[W]hen it comes time to make an affirmative case for what she actually has to live for, they [liberals] often demur. To find that case, you often have to turn to explicitly religious writers — like Kara Tippetts, a mother of four currently dying of her own cancer, who wrote Maynard a passionate open letter urging her to embrace the possibility that their shared trial could actually have a purpose, that “beauty will meet us in that last breath.

But perhaps liberals demur because they don’t think they can articulate a rationale for continuing a life of pain and discomfort, with no possibility of relief, one that saps the soul of those left behind, without descending into dishonest turnings away from the suffering at hand. I’ve read Tippett’s letter. It reminds me of theological solutions to the problem of evil that I often discuss in my philosophy of religion classes: they don’t work; they only do on those already convinced of the theses the suffering find inexplicable.  Tippett has found her solution to her crisis; she should respect Maynard’s.

Douthat continues:

The future of the assisted suicide debate may depend, in part, on whether Tippetts’s case for the worth of what can seem like pointless suffering can be made either without her theological perspective, or by a liberalism more open to metaphysical arguments than the left is today.

I have news for Douthat. Assuming that what he means by ‘liberalism’ is just ‘atheism’ or ‘secularism’, as he so clearly seems to, he should realize it is a metaphysical platform: its ontology is bereft of a Supreme Being, of a non-human scale of value, of a purpose that  somehow transcends human strivings and value-construction.

Let me offer my answer to Douthat’s question: Because political debate in this country, one in which an atheist will never be elected president, is still, all too often, susceptible to, and hijacked by, the religiosity on display in Tippett’s letter, one which infects all too many of our political representatives. Where the ‘landscape has shifted dramatically in a libertarian direction,’ it has done so in those spaces where its progress is not so impeded. The legalization of marijuana is a good example; the abortion debate shows the limits of American ‘individualism’ in a domain where religion and sexism rule the roost. (Gay marriage is a notable exception.) Perhaps too, physician-assisted suicide is a complicated issue in a country where healthcare costs–especially end-of-life ones–are astronomical, where the terminally ill, besides not being mentally competent to make such decisions, might feel the pressure to end their lives to not be a financial burden on those left behind. It is in these issues that the real complexity lies. Here, the theological will have little to contribute, transfixed as it is by a vision of a purpose to human suffering invisible to all too many.

Jonathan Baron’s ‘Against Bioethics’

I’ve been reading and discussing Jonathan Baron‘s Against Bioethics (MIT Press, 2006) this semester – with the Faculty Discussion Group at the Wolfe Institute for the Humanities at Brooklyn College. Roughly, Baron’s thesis is that utility-based decision-theoretic analysis would improve the quality and outcomes of decision making in the medical sphere, which is currently bogged down in a morass of poorly understood and specified deontological principles, biases and heuristics.

My disagreements with Baron are extensive, even as ironically, I agree with him that some kind of utilitarian decision analysis might often be useful in some domains of medical decision making. I often find myself experiencing what Baron would very likely dismiss as the ‘yuck factor’ – a cluster of heuristics and biases that make it so that I find certain courses of actions offensive or problematic, even when there appear to be apparently very good consequentialist or utilitarian arguments for them. I agree that the ‘yuck factor’ is often not a useful guide to action and can lead to problematic beliefs – such as homophobia for instance. Still, I wouldn’t know how else to characterize my opposition to organ sales (a topic on which I have written before, here, on this blog, where I worried about whether these would encourage the poorest to sell their organs at very low prices), or to using subjects in poor countries for drug trials.

Here, the objections are familiar: both practices are forms of exploitation; they capitalize on the weak–economic and otherwise–situation of those exploited under the guise of providing them a better life. The responses to these are familiar too; ultimately, what we get is the following:

From a utilitarian perspective, the behavior of the researchers…is still better than not doing the study at all or doing it in a rich country, but perhaps not as good as possible. [Or in the case of organ sales, we get better outcomes with organ markets than we do in a situation with no organ markets.]

If this argument–that the ostensible exploiters are making a bad situation better, not worse, by their ‘exploitative’ behavior–sounds familiar, it should. Because it is the same one used to excuse the use of sweatshops in places such as Bangladesh, which every once in a while kill hundreds of their workers. It should also be familiar because the dichotomy presented in it is an old one: either the exploitative action is taken, or the status quo of poverty–pernicious in all its forms–persists. Perhaps the disruption of the status quo is deadly, but that price comes out in the wash for we have better outcomes in the final reckoning, provided the correct option is chosen.

While the acceptance of the terms of the dichotomy is interesting what is perhaps even more so is the uncritical acceptance of, in the case of pharmaceutical industry, a very particular corporate axiom: if observing the boundaries noted by a particular ethical injunction is likely to effect profit margins adversely (note: not doing away with them entirely) then so much the worse for the ethical injunction.  The deployment of these arguments in the case of drug testing shows how well-entrenched this principle has become.

Taylorism and the Doctor’s Office

From this vantage, distant point in my life, childhood meetings with doctors, whether at home–they still made house calls–or whether in the doctor’s clinic, appear as encounters with quasi-avuncular figures, benevolent, mostly-solicitous contacts with a wise, ostensibly caring person. I experienced my share of childhood illnesses, suffered from minor ailments, and almost always looked forward to meeting the doctors who treated me. Consultations took place in their office; preliminary wait in a reception, and then entry into the sanctum sanctorum; I sat on a stool next to the doctor’s desk; the doctor was nearby, walked around to his desk to examine me, and sometimes for more extended examination, moved me to an adjoining recliner. While the waits in the office were sometimes onerous, once told the doctor would see you, you got just that – a ‘meeting’ with the doctor. The doctor’s consultation space seemed made for healing.

The times, they’re a changin’.

To visit a doctor now is to experience a cold, unrelenting blast of Taylorist air, a journey through a land dotted with toll-collectors, each aspiring to rapid and efficient quota completion. You make an appointment and wait in the reception like you always did.  Then you are brusquely asked for your insurance forms, and made to fill out–just like at every other doctor’s office that you’ve been to before–a pile of horribly photocopied forms that ask for details on your medical history, whether you’ve understood your privacy rights, and a host of other legally required disclaimers. Then you wait again. When called in, you don’t meet the doctor. Rather, you are ushered into a small consultancy room, cold and bare, while an assistant screens you by conducting a preliminary examination. (You might have to wait a bit before the assistant shows up.) This preliminary examination over, you are left alone again, sometimes clad in a paper gown.

Then, the doctor–whose voice and form can be dimly discerned as he rushes about in the corridors outside–shows up; clearly in a whirl and a tizzy combined, he is brusque, efficient, and keeping an eye on the clock and his production schedule, his throughput. He reads the pre-examination form quickly, asks a few rapid questions–more often than not, not listening too closely to the stream of information a patient can provide on his body, his ailment–dispenses a quick, snap judgment, and leaves. A battery of tests is ordered; pharmaceutical prescriptions written; and you are told that the ‘assistant’ and the ‘receptionist’ will tie up loose ends. You change, head out the door, are reminded by the receptionist that the co-payment is due, and then, it’s all over. You emerge, blinking, into the sunlight, feeling not so much healed, but as if you had been trussed up, placed on an assembly belt, and had several pounds of flesh withdrawn – by the insurance company, by the doctor’s clinic.

The doctors maximize movement through their clinics; the tests ensure expensive bills can be sent in for insurance claims; the prolific prescriptions pad pharmaceutical profit accounts. The patient, meanwhile, many of his questions unanswered, his possible inputs to the diagnostic process ignored, returns home, disquieted by the experience, disillusioned by the wonders of face-to-face contact with a fellow human being, and supposedly a healer at that.