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Some Comments

Szasz’s concept of freedom is in some ways ambiguous. The first ambiguity is that freedom must be obtained by effort, yet is attainable only in an environment of uncoerced choices. Freedom is needed to learn to be free. The intention is not a “freedom to” which is superimposed on “freedom from” as the “freedom to” can only be learned in an environment which is “freedom to” as well. So apparently the concept “freedom” has two meanings: the process by which making choices in experiencing internal freedom is learned, and an environment around the person that guarantees that such choices can actually be made.

A second ambiguity is that sometimes he considers freedom the hallmark of man, that which makes a person human, and other times he considers it the epitome of man’s duty. In the first case man’s hallmark, and with that his mission, is a given fact, although it immediately raises the question who determined that mission. In the second case there is an essential difference between one imposing this duty upon oneself, or that one believes that this duty applies or should apply to others as well. Szasz states that his portrait of “Moral Man” is based on observation of human behavior in today’s industrial society (for which he refers to, among others, Camus), and that at most he can lay claim upon the identification of the – in fact already existing, albeit in embryonic form – “Moral Man.” But the painting of such a portrait is never a description only. It indicates a development deemed desirable by the painter as well.

A third ambiguity is that freedom on the one hand is expressed as uncoerced choices, yet on the other hand is restricted by Szasz in the sense that he opines about the nature of those choices. The concept of autonomy includes self-development and growth. Achievement and competence are important features of man’s existence (2.1). That creates the paradox that man has freedom of choice, but his choice is free only if it meets certain criteria, for instance, that it is employed for self-development, whereby it is no longer a free choice. Apparently Szasz also sees this ambiguity. He proposes that every citizen declare by way of a psychiatric will whether in the future he wishes to be hospitalized and treated in the event of insanity. I will not go into the logical and moral dilemma whether and to what degree a person can decide like this about the person he may later become, which raises the question whether such a declaration will ever be valid. The ambiguity that man is not free to do as he wishes, but must do as he wishes (or rather: what he once in the past wished) explicitly remains. The proposal above implies – and that is the point here – recognition that, if man is free, he should decide for himself how he wishes to live and what he wishes to choose.

The following example illustrates how these ambiguities can influence the train of thought. Much of Szasz’s writings can be interpreted as an endorsement of freedom and rights for oppressed minorities such as Jews, psychiatric patients, and other scapegoats. Do these minorities want that? The answer can be yes or no – yes, inasmuch as these people wish to live in freedom and responsibility; no inasmuch as they wish to escape responsibility and not be confronted with it anew. It is confusing that extremely diverse groups are discussed as though they are similar. I certainly agree that it is our ethical duty to end racial discrimination as quickly and radically as possible. But in the case of psychiatric patients the situation is quite different, at least if I follow Szasz in his views about these people.

Psychiatrists’ activities figure most prominently in Szasz’s work. Yet it is obvious that people who display the phenomena that can be interpreted as psychiatric disorders, precisely by such a display, are attempting to escape their responsibilities. Thus, according to Szasz, those people are behaving heteronomically. In The Myth of Mental Illness he illustrates this at length regarding hysteria. In other places he does it regarding other psychiatric disorders. When psychiatric patients are treated as free, autonomous adults he expects them to reciprocate. That means that they (have to) give up their psychiatric disorders. Szasz words it thus: “I submit that in much the same way most of what now passes for ‘medical ethics’ is nothing but a set of paternalistic rules whose aim is to diminish the patient while aggrandizing the physician. Genuine improvement in medical, and especially psychiatric, care requires the liberation and full enfranchisement of the patient – a change that can be accomplished only at the cost of full commitment to the ethic of autonomy and reciprocity. This means that all persons – whether sick or wicked, bad or mad – must be treated with dignity and respect – and that they must also be responsible for their conduct.” (The Myth of Mental Illness. Rev. Ed. pp. 176-177, my italics, J.P.) Thereby he puts the patient in a paradoxical situation. He must take responsibility for his behavior. He must be free, whereas freedom (also for the patient) means that he makes his own choices. The paradox is illustrated in the continuation of this last quote, from which it becomes apparent that it is Szasz himself who determines what it means for the patient to take responsibility for his own behavior. “If such a change in medical perspective were instituted, what patients would gain in dignity and control over the medical situation, they would lose in no longer being able to use illness as an excuse.” Szasz not only determines the most important value in life for himself and for others. He also determines which choice this value obligates one to make. When this value itself is precisely the making of uncoerced choices, the paradox is complete.

If I follow Szasz’s habit of speaking in analogues (see Chapter IV, 3,2, 8), I can also clarify the dilemma of this ideology as follows. If I take the analogy of the “Age of Faith” and the “Age of Madness” seriously and apply it to the story of Dostojewski’s Grand Inquisitor, then the psychiatrist represents the grand inquisitor, institutional psychiatry is the Church, the patients are the faithful, and Szasz is … Christ. But there is an essential difference between Christ in Dostojewski’s story and Szasz. Christ remains silent whereas Szasz prescribes a way of living. In other words, a society of people who value individual freedom above all else can exist only by consensus, as was the case in the United States in the past. Such a society can be advocated. It cannot be imposed without throwing the principle of freedom overboard.

Finally I wish to add a comment about freedom as competence or learned skill. The problem that arises when asking who can assess this competence is the same one that arises when judging someone’s competence to stand trial. (See Chapter I, 6.2.) If Szasz assumes that every citizen who is suspected of a crime has the right to be tried equally without consideration of who he is, the question of competence is restricted to the most elementary issues, such as whether the suspect is capable of understanding the accusation levied against him. Considering that a trial is an extremely complicated and ritualized game, the “fine details” of which are understood only by professionals, competence may require relevant and adequate schooling. Even so, if individual autonomy means a personal duty in life and at the same time an existential space to be respected for each person, then it follows that it is also an ethical duty to leave to each his own space. Competency should then be questioned only in the absence of the most basic elements of consciousness, such as in the case of coma, severe mental retardation, or an advanced state of Alzheimer’s disease. However, Szasz sees autonomy as the skill to independently and creatively play the game of giving and taking space in our extremely complicated and pluralistic society. This way only a relatively small group of competent autonomous people remains. Szasz believes – in my opinion correctly – that all citizens have the right to an equal trial. It would be consistent to say that all citizens have the right to be treated with dignity. It would follow that they should not be compelled to accept the conditions of competency and responsibility as formulated for them by Szasz, or whomever, such as abandoning the argument of illness as an excuse for behavior. When Szasz requires that, he does precisely what he wishes to avoid. He creates different kinds of people. Thus he risks the application of contradictory policies in situations that assessment of someone’s autonomy is at stake.

Personally, I believe that Szasz’s sketch – fleeing from responsibility for life’s problems → mystification of these problems into symptoms → being declared a psychiatric patient → not having to take responsibility anymore – has important and worthwhile elements, but that it strongly simplifies reality. The relationship between problems in living, responsibility, and psychiatric disorders seems to me so complicated, that this problem deserves more thorough discussion, that will take place in Chapter V, 3.4.

Speaking for myself, I fully endorse Szasz’s premise that individual freedom is the core value of life, and that experiencing it is what makes one human. I also believe that not many people will dispute this premise by itself. The difficulties begin when the question is asked where the line is between my freedom and other people’s. They increase when the question is asked what people can do for themselves and what they cannot. In the story about the Grand Inquisitor Dostojewski has Ivan express it as follows: “[The faithful] will come to the conclusion that they can never be free because of their weakness, their evil, their worthlessness, and their rebelliousness.” Only those who hold paternalistic views one way or another have used this argument in one form or another, and in doing so justified their paternalism.

This raises the question whether professional help does not always imply weakening the person asking for help and strengthening the helper. I will return to this problem in Chapter VI.

In the history of our culture, according to Szasz, religion is the ruling ideology. It is perceived by him as: the totality of values and meanings in which a person believes that purports to be the only correct way of thinking, all-inclusive, and valid in all places at all times. When, during the Enlightenment religion began losing its power, science’s star started rising. Nowadays, according to Szasz, we live in the “Age of Science,” or rather in the “Age of Madness.” I object to characterizing our era as the age of madness, inasmuch as that this expression implies that psychiatry and insanity are so central to our present-day culture that they are a hallmark of it. Psychiatry fascinates many people because of the sticky dilemmas it poses regarding the best way to live life, and because the way society treats its “madmen” reflects the most important elementary values in society. Nonetheless in my opinion this can be viewed as an example or illustration, rather than as an all-encompassing essence. In 1980 about 4.6% of the population of the Netherlands became involved with some sort of psychiatric institution one way or another. “Insanity” can have been involved only in a small portion of this 4.6%. Aside from this percentage it may be more important whether, and to what extent, the psychiatrist is considered the person who can provide solutions for problems in living. In Dutch society he seems to be one among many, and one who can be accessed only with difficulty. This leads me to conclude that psychiatry is insufficiently manifest in Dutch society to justify speaking of an “Age of Madness.” American publications give the impression that psychiatry in the United States is considered much more important and prominent as a cultural phenomenon than in the Netherlands.

Be that as it may, in the term “Age of Madness” Szasz suggests that medicine and psychiatry have replaced religion, and therefore have themselves become a religion. That is to say, that medicine is no longer an applied science or an art dedicated to maintaining and restoring “clients’” health as well as possible, in order that they can seek purpose, direction, and sense in their lives. Medicine has become a goal in itself, and health, as described by medicine, has become a purpose in life.

We can distinguish two kinds of core values or purposes in life. The first kind consists of those values that describe a principle that determines relationships among people, for example, values as freedom and solidarity with the community. These core values are based on the assumption that the way people treat each other is the most important aspect of human existence. The other group consists of those core values that primarily disregard interpersonal relationships, such as health, happiness, and wealth. To this second group belongs an attached ethic that regulates relationships. It is necessary to determine to what extent, for instance, fraud and oppression as a means of achieving a certain goal, are justified in this ethic.

In other words, even if health becomes an important value in life, that does not determine the consequences this ideology has for human freedom and autonomy. The prime rule of medical ethics has always been, and still is, that medical assistance is extended only at the client’s request, or at least consent. Linked to this is the physician’s freedom to refuse to examine and treat the client. So also when freedom and autonomy are not seen as core values the rule that medical assistance can be freely accepted or rejected applies. Not until this prime rule of medical ethics is abandoned does it become possible to examine or treat people against their will. In somatic medicine this happens only when a very serious danger is posed to the community as in the case of diseases that by law must be reported. This is extremely rare. In psychiatric disorders this is done much more often and occurs regularly. (See Chapter VII, 3.)

Szasz maintains that it is the concept of madness as mental illness that justifies involuntary hospitalization and treatment. Or, put differently, the justification for undesired intervention in someone’s functioning by way of forced treatment is derived from the element of (mental) illness. (Schizophrenia, p. 21)

Szasz’s view on this is in my opinion debatable. There are several arguments in support of a diametrically opposed view. The medical-ethical rule in existence since Hippocrates that medical examination and treatment may occur only upon request and consent of the patient means that medicalizing madness should lead to the elimination of force and involuntary procedures. Since Hippocrates, and even earlier, physicians have been involved in the problem of madness and with madmen, albeit to a different extent and intensity. Nonetheless, during many centuries there was no systematic involuntary institutionalization of the insane anymore than there were other systematic coercions initiated by physicians. And when, in the middle of the seventeenth century, the institutionalization began, it certainly did not involve only mental illnesses, as, among others, Foucault thoroughly described in his History of Madness. The poor, the unemployed, beggars, madmen, and several other categories of citizens who distinguished themselves from others by the fact that they did not engage in productive labor were equally incarcerated. Foucault stresses that the first large institution for incarceration, the Hôpital General in Paris, that served as a prototype for other institutions, “showed no (demonstrable) relationship to any medical thinking, neither by way of functioning nor in aim.”

Szasz of course knows this as well. This is evident when he comments that in spite of the medical model on which psychiatry bases itself, the most characteristic political aspect of medicine, namely the mutual free choice of physician and patient, is absent from involuntary commitment (for example, in Schizophrenia, p. 157). Here is a clear contradiction in Szasz’s work because he simultaneously maintains that the medicalization of madness only occurred in order to justify force and coercion regarding this group of people.

So the involuntary incarceration and manipulation of all sorts of non-criminal deviants were already long applied in society before the intervention of physicians in this social-political practice. And when physicians did become involved, it was initially more so because they were dependable personages and bigwigs than because their qualification was appraised so highly, according to Foucault. Foucault also states that the involvement of physicians was called on to confine the evil to institutions, rather than to examine and treat people. I cannot avoid the impression that Foucault’s representation is somewhat askew. After all, he himself sketches all sorts of treatment activities by physicians outside, and later also inside, the institutions. Nonetheless, this historical development validates the hypothesis that, when clinical psychiatry began to emerge, it did so in a framework of social and political assumptions regarding the necessity of involuntary commitment and other coercions. Only much later did a significant movement from involuntary to voluntary measures gradually take place, albeit with ups and downs.

This does not contradict Szasz’s postulation that institutional psychiatrists, in particular Kraepelin and Bleuler, declared the insane to be ill in order to justify their incarceration. They did that because they simply could not afford to call these people not-ill. Neither the medical, psychiatric, or legal professions, nor the public at large, would have accepted that. However, by doing what everybody expected of them, they validated a justification that did not exist at all.

The above implies that there was a historical development whereby the physician was transformed from uninvolved observer through sympathizer and accomplice to main agent in institutionalization. The physician did bring along medical insights, but also the time-honored social, political, and principally non-medical assumptions in which coerced institutionalization was rooted, and by which it became possible. But this is not all. The physician also submitted his medical knowledge to the service of denying the political nature of these assumptions. This is how he became an extension of that denial. Nowadays he is its main and most eloquent defender.

This view of the historical events may clarify how a link was laid between the world of health and illness on the one hand, and force and coercion on the other. The development was not at all unique. Physicians have colluded with all sorts of social and political developments, including those that sacrificed the prime medical-ethical rule of voluntariness in treatment. Szasz, too, has commented that there has been no dictatorship which was not also served by physicians as accomplices. Mitscherlich et al provide most bewildering examples. Whenever the medical-ethical rule of voluntariness in examination and treatment is abandoned the consequences are disastrous, as physicians have no other ethical framework. They become powerless to resist the demands that those who have political power make of them. In reaction they tend to identify with the powerful, making them even more powerful.

From the above we can conclude that in principle medical and psychiatric territory is confined by the prime medical-ethical rule that has always remained valid in our culture, namely that of consumers’ freedom to allow or refuse examination and treatment. When this rule is abandoned not only has medicine become an ideology, but also an institution that has the power to impose this ideology (by way of involuntary commitment). Further discussion of this to Szasz essential problem, can be found in Chapter VII.
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