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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 pathologists 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
Szaszs 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 patients 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 psychiatrists 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 Szaszs 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 ones 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 Szaszs 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 Upstates 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 Szaszs 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 Szaszs 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 ones
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.
© 2002 Gordon Fisher
Gordon Fisher,
Professor Emeritus, Mathematics and Computer Science, one-time Senior Lecturer
in Mathematics, and History and Philosophy of Science
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