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Closing Remarks and Conclusions on
Biomedical or Biopsychosocial?

Two theoretical disadvantages of the biomedical disease concept were discussed. The first is that not only is the biomedical disease concept based on a dualistic view of humanity but it also compels us to maintain this dualistic view, promoting it to (scientific) reality. The second disadvantage is that physicochemical explanations for, for instance, psychiatric disorders, gain undue preference over hermeneutical explanations because only the physicochemical explanation can bestow the disorder with disease status. As hermeneutical explanations are out of bounds in the biomedical disease concept organogenicists can only be proved right. In this disease concept they can never be proved wrong.

Afterwards the validation of psychiatric disorders and how this compares with validation in somatic medicine was examined. It was found that validation of findings is possible in psychiatry. There are clear differences with the validation of organic aberrations. The results of validation in psychiatry reveal that diagnoses are reliable beyond coincidence but less reliable than in somatic medicine. Predictive validity is scant in psychiatry. Although Szasz’s position that validation is purely subjective in psychiatry has been refuted the scant reliability and predictive validity in psychiatry do cast doubt on the sufficiency of diagnostic evaluation as a basis for invasive decisions, in particular when they are made against patients’ wishes.

Then Szasz’s assertion that that which the term psychiatric disorder denotes is none other that problems in living was examined in two ways. First the hallmarks of problems that are encountered in psychiatry were reviewed. It was found that such problems are characterized by relative vagueness, insolubility, and the fact that they manifest themselves in experience and behavior that can be described and recognized as symptoms and syndromes. Then the role of problems in living in psychiatry were investigated. It was concluded that these roles can differ greatly varying from vague to paramount, and secondly, that certain problems in living in certain circumstances within a constellation of conditions to be described, in addition to all sorts of other factors, bear a relevant connection to psychiatric syndromes.

Next the degree of responsibility that a person can be considered to have for his own psychiatric disorder was discussed. A comparison was made between responsibility for somatic disease and responsibility for psychiatric disorder. Szasz here posits a contradiction. Physical illness happens to a person. “Mental illness” is something somebody does. The person is not responsible for the former, but is responsible for the latter. We investigated whether and to what degree a person can or cannot influence events in both cases, whether these events can be described as having causal relationships, and whether they are events that man can influence with his free will and for which he thus bears (partial) responsibility. The question in itself presumes a non-biomedical disease concept. A biomedical disease concept would mean that the question of responsibility for the disease, whether the patient’s or someone else’s, would become irrelevant. In the absence of physicochemical aberration the question could not be asked because there would be no disease. When assuming a biopsychosocial disease concept the questions can be answered as follows:
  • People are not held responsible for their physical illnesses even when their behavior was a clear, albeit indirect, causative factor.
  • People are not held responsible for their psychiatric disorders because it is assumed that they are subjected to those illness involuntarily – at least to the extent that their experience and behavior can be called “disordered” – and are no longer free to experience and act differently from the way they do.
With this restrictions of freedom and autonomy are shown to be the main hallmark of both bodily diseases and psychiatric disorders. In psychiatry patients’ own experiences of unfreedom regarding their symptoms and disordered behavior are a fairly consistent factor. Exceptions are those people who claim to experience themselves as free and totally healthy while their behavior justifies diagnosing a psychiatric disorder. The degree to which unfreedom is experienced can vary greatly. In some psychiatric disorders the loss of freedom and autonomy is spectacular. In others it is much less clear. In some it is dubious. Patients are not considered responsible for their disorders even when there is a more or less clear, though usually indirect, responsibility (however see Chapter VI, 3.2).

So there is obvious commonality between physical disease and psychiatric disorders which is: a. physicians’ basic attitude of exculpation; b. the degree to which co-responsibility, usually indirect, is traceable; and c. the degree to which patients feel responsible.

In bodily disease the measure of unfreedom and loss of autonomy is due to the (objectively demonstrable) physicochemical disorder even though the degree of loss of liberty can usually be only estimated, not accurately assessed. Unfreedom and loss of liberty in psychiatric disorders cannot be objectively measured. On the contrary, the most established psychiatric theories of explanation, due to their deterministic nature, are more likely to play down the significance of restriction of freedom. Nonetheless:
  1. Loss of freedom in the sense of creative hermeneutical adjustment can be determined;
  2. It is not plausible to posit that psychiatric patients are faking their disordered experiences and behavior, particularly when these supposedly faked experiences follow a recognizable pattern that could not have been known to the patients;
  3. Even when following Szasz’s reasoning (see Chapter IV, 3.2) that people’s intentions can be deduced from their behavior, psychiatric disorders also occur in situations where there cannot possibly be any benefit to the disordered person, only loss. At the same time Szasz’s position cannot be refuted as a motive for behavior can always be inferred from its effect. There can be no other conclusion than that Szasz proves that this view about the true meaning of human behavior and experience, when maintained with sufficient consistency, cannot be objectively invalidated. This however can be posited about any established view of motivation and meaning of behavior.
Finally, Szasz asserts that invading people’s lives against their wishes can at the end of the day never be ethically justified. The above argumentation regarding the implications of the conceptualization of disease clearly reveals that his assertion not only remains valid but two arguments were found to support it: Only when there is obvious cooperation between patients and physicians can truly reliable insight be gained into people’s motivations and with that the hermeneutical pattern of their disorders. In those cases that patients do not experience either a psychiatric disorder or restriction of freedom as applying to them, no confirmation of restriction of freedom as a main hallmark of psychiatric disorder can be obtained from them.
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