Mental Illness: Psychiatry's Phlogiston
We Should Regard All People As Moral Agents
NOVEMBER 01, 2001 by THOMAS S. SZASZ
“The madman is not the man who has lost his reason. The madman is the man who has lost everything except his reason.” —Gilbert K. Chesterton
In physics the same laws are used to explain why airplanes fly and why they crash. In medicine the same principles are used to explain why people live and why they die. In psychiatry, however, one set of rules is used to explain sane behavior and another set of rules is used to explain insane behavior: sane behavior is attributed to reasons (choices), insane behavior to causes (diseases).
God metes out Divine Justice without distinguishing between sane and insane persons. It is hubris to pretend that we know better.
Mental illness is to psychiatry as phlogiston was to chemistry.
Establishing chemistry as the scientific study and explanation of matter depended on the investigators’ willingness to recognize and acknowledge the nonexistence of phlogiston. Similarly, establishing psychiatry as the scientific study and explanation of human behavior depends on psychiatrists’ willingness to recognize and acknowledge the nonexistence of mental illness.
Benjamin Rush (1745–1813) was an American patriot and a signer of the Declaration of Independence who served as physician general of the Continental Army and as professor of physic and dean of the University of Pennsylvania medical school. In 1774 he declared: “Perhaps hereafter it may be as much the business of a physician as it is now of a divine to reclaim mankind from vice.” In that act of medicalization lies the root error of psychiatry.
To distinguish himself from the doctor of divinity, the doctor of medicine could not simply claim that he was protecting people from sin. Badness remained, after all, a moral concept. As medical scientist, the physician had to claim that badness was madness, that his object of study was not the immaterial soul or “will,” but a material object, a diseased body. However, Rush did not discover that certain behaviors are diseases; he decreed that they are: “Lying is a corporeal disease. . . . Suicide is madness. . . .
Chagrin, shame, fear, terror, anger, unfit[ness] for legal acts, are transient madness.” Today some of these and many other unwanted human behaviors are widely accepted as real diseases—“chemical imbalances in the brain”—their existence ostensibly supported by scientific discoveries in neuroscience.
Modern natural science rests on laws uninfluenced by human desire or motivation. We do not have one set of medical theories to explain normal bodily functions and another set to explain abnormal bodily functions. In psychiatry, the situation is exactly the reverse. We have one set of principles to explain the “rational” behavior of the mentally healthy person and another set to explain the “irrational” behavior of the mentally ill person. The former is viewed as an active moral agent; the latter is viewed as a passive body or object—subject to the effects of injurious biological, chemical, or physical forces that create diseases (of the brain), manifested for example by an irresistible impulse to kill.
“The epileptic neurosis,” wrote Sir Henry Maudsley (1835–1918), the founder of modern British psychiatry, “is apt to burst out into a convulsive explosion of violence. . . . To hold an insane person responsible for not controlling an insane impulse . . . is in some cases just as false . . . as it would be to hold a man convulsed by strychnia responsible for not stopping the convulsions.” It is a false analogy. Killing is a coordinated act. Convulsion is an uncoordinated contraction of muscles, an event.
We are proud of our unending quest to abolish prejudiced beliefs about the differences between the human natures of different genders and races. At the same time, we are even prouder that we have created a set of psychiatric beliefs about the differences between the neuroanatomical and neurophysiological natures of the mentally healthy and the mentally ill. Oxidation, a real process, explains combustion better than does phlogiston, a nonexistent, imaginary substance. Attributing all human actions to choice, the basic building block of our social existence, explains human behavior better than attributing certain (disapproved) actions to mental illness, a nonexistent, imaginary disease. Regardless of the condition of an “irrationally” acting person’s brain, he remains a moral agent who has reasons for his actions: like all of us, he chooses or wills what he does. People with brain diseases—amyotrophic lateral sclerosis, multiple sclerosis, Parkinsonism, glioblastoma—are persons whose actions continue to be governed by their desires or motives. The illness limits their freedom of action but not their status as moral agents.
According to psychiatric theory, certain actions by certain people ought to be attributed to material causes, not moral reasons. When and why do we seek a causal explanation for personal conduct? When we consider the actor’s behavior unreasonable and do not want to blame him for it. We then look for an excuse masquerading as an explanation, rather than simply an explanation that neither exonerates nor incriminates. Holding a person responsible for his act is not the same as blaming or praising him for it: it means only that we regard him as a moral agent.
It is a mistake to believe that offering an excuse-explanation for an act is tantamount to showing that the actor has no reasons for his action. Offering an excuse for doing X—“God’s voice commanded me”—is not the same as not having reasons for doing X. To the contrary: what we have shown is not that the actor has no reasons, but that his reasons are wrongheaded—“deluded,” “mad,” “insane.” We conclude that his actions are caused by his being deluded, mad, insane. But we have not proven anything of the sort; we have postulated it.
The “mental patient” who attributes his misdeed to “voices” is not a victim, a robot responding to an irresistible impulse; he is a victimizer, an agent rationalizing his action by attributing it to an irresistible authority. The analogy between a person who “hears voices” and an object, say a computer responding to programmed information, is false. The mental patient responding to the commands of “voices” resembles the person responding to the commands of respected authorities, exemplified by the “suicide-bomber” who martyrs himself for a cause blessed by God. Both persons are moral agents, albeit both portray themselves as slave-like objects, executing the will of an Other, often identified as God or the devil.
Such representations are dramatic metaphors that actor and audience alike may or may not interpret as literal truths. It is not an accident that the “voices” a schizophrenic “hears” never command him to be especially kind to his wife. That is because being kind to one’s wife is not the sort of behavior to which he, or we, want to assign a causal—psychiatric—explanation. There is method in madness.