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Pharmacracy

by Thomas Szasz
Praeger, 2001
Review by Gordon Fisher, Ph.D. on Feb 28th 2002

The indefatigable Thomas Szasz is at it again. Dr. Szasz is now about 82 years old, and it is a little more than 40 years since his hit book of the 1960s was published, The Myth of Mental Illness (1961, rev. 1974). He is at present Professor Emeritus of Psychiatry at the State University of New York Upstate Medical University at Syracuse. In this work, Dr. Szasz pursues some of his familiar themes, with updated examples and events.

The first chapter establishes his view that “only the pathologist’s concept of disease is relevant to the scientific view of disease as a departure from normal bodily structure and function. Lest one misinterpret the referent of function, he adds: “ ‘All illnesses,’ writes Stanley L. Robbins, the author of a standard textbook of pathology, ‘are expressions of cellular derangements.’ ” (p. 11, his italics) “In this connection,” Szasz says, “it cannot be overemphasized that while a particular pattern of behavior may be the cause or the consequence of a disease, the behavior, per se cannot, as matter of definition, be a disease.” (p 12)

Thus it appears that paranoia, for example, is not a disease, insofar as no cellular pathology of the sort detected and described by pathologists, using chemical, microscopic and other such techniques peculiar to them, can be associated with paranoia in any direct way. Thus, it seems that according to Szasz’s definition of disease, a patient who exhibits paranoid behavior after, but not before, a brain injury should not be classified as being ill on account of his paranoid behavior, but rather on account of an injury, in case a pathologist certifies that something has changed in the patient’s cellular structure in an adverse way, but otherwise not. If nothing is changed in the cellular structure, then the paranoid behavior should be judged by the legal system, not the medical system, as to whether or not the patient is a danger to a community, and if the patient is so judged, should be taken out of circulation by the legal system, presumably by putting the patient in jail.

Similar judgments can be made about substance abuse, depression, and a host of other diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Szasz says: “Medical bureaucrats confuse not only diagnoses with diseases, but also diagnostic disease entities with peoples’ subjective judgments regarding the need for and value of their treatment. In the case of psychiatric diagnoses – for example, 312.33 Pyromania, 312.31 Pathological Gambling, 313.81 Oppositional Defiant Disorder, 300.7 Body Dysmorphic Disorder, and 307.42 Primary Insomnia – it is plainly false that the diagnostic terms name objectively identifiable diseases. Actually, the DRGs [diagnosis-related groups on which medical disbursements are based] and DSMs are parasitic on one another; the Diagnostic and Statistical Manuals feed the diagnosis-related groups with diagnoses, authenticated as diseases by the medical profession and the government, and the DRGs in turn revalidate the diagnoses in the DSMs as the names of bona fide diseases. The authors of DSM-IV deny this, declaring: ‘DSM-IV is a classification of mental disorders that was developed for use in clinical, educational, and research settings.’ Not true. The diagnoses of most mental diseases are used to justify the psychiatrist’s obligation to commit patients or his need to prescribe drugs and other so-called treatments for them, collecting third-party payments for their treatments for them, and assisting lawyers engaged in civil and criminal litigation making use of psychiatric concepts and interventions.” (p 44)

As the foregoing suggests, Dr. Szasz has political axes to grind (or spin around). He is often described as a libertarian, as believing in the preservation of liberties of individuals in the face of governments who are bent on restricting individual liberties to the extent that the governing individuals can get away with. One could discuss Szasz’s views on this topic at length, but to keep this review from getting too long, I will quote a summary statement of his from his Epilogue:

“Although we have little to fear from the traditional foes of freedom, commentators across the political spectrum lament the creeping loss of our liberties. How can this be? Our foreign policies have not failed: America is more secure than ever from foreign aggression. Our religious policies have not failed: The clergy has no power to deprive anyone of liberty. Our economic policies have not failed: More Americans are working and are economically more secure than ever before. How, then, have we failed to protect our liberties? By entrusting the care of our health to the state …” (p. 161-2)

A major theme of this book is the claim that our health care has become dominated by the state. Szasz says in his Epilogue: “After vanquishing the two great twentieth-century statisms – National Socialism and Communism – we are sacrificing our freedom on the altar of the most catholic and democratic of all modern statisms, the ideology of pharmacracy embodies in the therapeutic state guaranteeing every man, woman, and child a ‘right to health care.’ “ (p. 162)

Szasz is what I will call a binary thinker, a devotee of views that are either/or and not both. Szasz says: “Every American recognizes that when the government controls religion, all religion becomes state religion. But few Americans are willing to accept that when the government controls health, all health becomes public health and all privacy is lost.” (p. 163) And Szasz takes a dim view indeed of public health. For example, he says: “It took centuries of terrible wars before people began to recognize that because the state is, par excellence, an instrument of violence, while the church ought to be, par excellence, an instrument of non-violence, the two should get a divorce or at least a legal separation. Medicine and the state ought also to get a divorce, with primary custody of the citizens (as potential patients) granted to themselves, medicine having visitation rights.” He then speaks of “certain public health measures as legitimate instruments of state coercion.” “However,” he says, “this reasoning does not justify state coercion as a morally legitimate instrument for protecting people from themselves.” He goes on to ask (expecting an affirmative answer): “Should protecting one’s health be the responsibility of the individual, just as it is his responsibility to feed and house himself and provide for his spiritual health?” (p. 131).

The dichotomous, or binary, thinking by Szasz that I spoke of is exhibited early on: “Before there was science,” Szasz says, “there was religion, and before there was scientific medicine, there was magical medicine.” My experience as an historian of science leads me to object that we have had both science and religion simultaneously for a long, long time, and still have them, although to be sure both of these human endeavors have changed over time, and the relations between them have long been uneasy in some respects. And the same for scientific and magical medicine. I find the history of medicine sketched in the first couple of chapters oversimplified to the point of caricature.

It can be said, however, that the binary style of Szasz is stimulating, if only because it arouses one to an examination of some of the problems he discusses, and to see to what extent one may agree with him or not, or with some modification of his views. In a biographical article posted online, “Thomas Szasz, M.D.: Philosopher, Psychiatrist, Libertarian”, the author, Eric V. D. Luft, Curator of Historical Collections, Health Science Library at Szasz’s university says that “Szasz was the most exciting teacher in the psychiatry department from the 1950s to the 1970s, and very popular with residents. About 25 per cent of Upstate’s psychiatric residents at that time came to Syracuse specifically to study under him.”

In conclusion, I note that Luft begins his article with an encomium to Szasz’s The Myth of Mental Illness written in a letter to Szasz from Timothy Leary on July 17, 1961, when Leary was still a member of the Harvard psychology faculty. The quotation from the letter begins: “The Myth of Mental Illness is the most important book in the history of psychology.” Time has shown that this evaluation was, to put it mildly, hyperbolic. My memory is that the charm of Szasz’s book during the 1960s was related to its apparent justification of “dropping out” (as it was called – dropping out of any sort of conventional society) as not being evidence of mental aberration of a certifiable sort, and indeed a kind of exercise of the freedom of individuals to reject morals and ambitions of one’s elders, even if one used some illegal drugs (possible addictive) in the practice of this freedom. For those who may be too young to remember, Leary recommended the use of such drugs, and got into trouble for it.

Gordon Fisher, Professor Emeritus, Mathematics and Computer Science, one-time Senior Lecturer in Mathematics, and History and Philosophy of Science