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Psychiatrists as Social Arbitrators

Until now psychiatrists have been discussed in their role as helping professionals and therapists. However, physicians have multiple social roles. Mechanic lists the roles of scientific practitioner, helper, and bureaucrat, which are usually tied together. I would like to skip the role of scientific practitioner now and focus on the role of bureaucrat, a function that is related to medicine’s function of social control. I will examine more closely two of these bureaucratic roles: A. physicians or psychiatrists who determine whether or not someone is ill; and B. physicians or psychiatrists who determine whether someone is entitled to certain social privileges due to illness.

A. In a biological disease concept only physicians are experts on disease. Patients may feel sick but the presence of disease must be verified – legalized – by a physician. An additional need for expert verification arises from the advantages and privileges associated with the sick role. (See Parsons’ four postulations in Chapter V, 2.1.) These privileges are written into law. Today in the Netherlands recognized patients are in a considerably better position than other people who become unemployed due to circumstances beyond their control. The law entitles them to a pension equal to their previous incomes for the duration of their illness. Employers are prohibited from firing a sick employee. Laws regarding disability benefits guarantee pensions for people who have been sick for at least two years. Employers for their part do not have to worry too much about the fate of their sick employees who after a certain amount of time are pronounced permanently disabled. Their employees are assured of a living from the disability benefits. The disadvantages of this system in view of the enormous inflation of the numbers of people proclaimed to be disabled has become the focus of political debate. In my argumentation the point is that the privileges of the sick role necessitate using experts to guard the entrance gates to the coveted domain of the sick. Both the implications of the biomedical disease concept and the social advantages of being sick entail engaging expert arbitrators. Perhaps this is the reason that this situation draws relatively little criticism. In actuality citizens’ autonomy has been drastically restricted. Officially they cannot pronounce themselves ill. That has to be done by others, physicians. There is a contradiction here. On the one hand being ill is an undesirable, feared condition. Social rules assure sick people access to measures deemed optimal for recovery, and protection in their powerless, helpless state. On the other hand, the sick role is apparently so coveted that measures must be taken to prevent too many people from enjoying its benefits. Obviously certain people in certain circumstances prefer the sick role to their usual social roles. Equally obviously other people in other circumstances prefer their usual social roles to the sick role. The solution for this contradiction was found in engaging social arbitrators who decide whether people’s claims to the sick role are justified. This role of social arbitrator is performed by physicians. Physicians can determine whether a person is sick or well with certainty only when there are reasons for the pronouncement that the person is ill. After all, even in the biomedical disease concept illness can never be definitely excluded. The question of eligibility for certain social privileges on the grounds of illness may be answered by one of the following:
  1. There is an illness on grounds of which said person is eligible (for instance, for benefits);
  2. There is an illness but it is not grounds for eligibility;
  3. No illness is demonstrable nor is there any reason to suppose the existence of illness. Said person is ineligible.
  4. No illness is demonstrable but the expert nonetheless suspects the existence of illness so regards said person eligible.
  5. No illness is demonstrable but as the expert suspects that said person will react to such a pronouncement by managing to procure the benefit anyway the expert considers him ineligible but permits him to receive it;
  6. No illness is demonstrable nor does the expert suspect the existence of illness. The expert suspects said person of malingering and thus he is ineligible.
We now arrive at the question whether the system of physician arbitrators guarding the domain of the sick works well. Within a biomedical disease concept physicians can in certain cases determine the existence of aberrations and pronounce patients sick on that ground. In such cases, however, clarity is more apparent that real. Of how many and which social obligations should the physician exempt his patient? Is the patient still capable of working, and if so, how much and which work can he still do? In spite of extensive research into such matters, decisions remain literally arbitrary except for the most severe and unambiguous cases. Decisions become even more difficult when no physical aberrations are found. In addition to the obvious benefit to patients that any existing aberrations be found, such findings also entail social rehabilitation for those who claim to be ill and entitlement to the privileges of the sick role. This is likely to stimulate over-consumption of medical examination. Huygen states, “Adherence to ‘objective’ standards is in those cases much scantier than for which [the family physician] was trained. These standards as a rule assume that there is always a risk that complaints indicate a life-threatening disease that must be traced or excluded as soon as possible. He was dramatically cautioned how he might fail at this if he does not continue investigating everything. In order to safeguard himself from this risk of overlooking physical aberration the family physician refers many people to specialists every day. His motto is often, ‘One can never be sure.’”

This would mean that physicians cannot be good arbitrators simply because there are way too many uncertainties. Their uncertainty moves them to examining too much, too intensively, too long, which contributes to the duration of the illness. “Health workers consider that the ‘best’ health care is one where everything known to medicine is applied to every individual, by the highest trained medical scientist, in the most specialized institution.”

In addition, the specter of being excluded from employment is not one that “in a cool discussion leads to the conclusion that the social status of being sick has preferable aspects. No, such an invasive event makes many people ill: sleeping problems, headaches, depression, stress symptoms.” It must be said that this last consideration does not fit into the biomedical disease concept but is based on a biopsychosocial disease concept.

In the Netherlands the rights of people who have become ill and can therefore not work are established in law. Grond et al states about that, “Both in and outside of the circle of insurance physicians many physicians worry about the paradoxical situation created by social insurance. Laws intended to compensate sickness and disability as much as possible are found to an important extent to encourage absence from work and disability, and discourage recovery.”

A picture ensues of all sorts of specialists, physicians, employment experts, legislators, and judges, who think of and enforce all sorts of rules for patients’ control and protection, but not participation. Patients meanwhile become increasingly insecure. The many rules often create the very situations they were intended to prevent or remedy. The entire system was called into being in order to slam the brakes on unjustified use of the privileges of the sick role. To that effect physicians were engaged as arbitrators. The result is that all sorts of people are made ill. In compliance with existing laws a life-long sick role is imposed on them even though it is not strictly necessary.

Moreover, Grond et all assert: “Physicians only create conditions for healing. Abandonment of sick behavior and relinquishment of social privileges related to illness must be done by the patient.” This is an interesting assertion because in effect it means that patients themselves must pronounce themselves healthy and that no one else can do it, especially not social arbitrators, who were engaged to do precisely that. If physicians’ pronouncing people ill has so many converse effects and complications for so many people that many more people become ill from this process than would be the case without it, then the following conclusion is inescapable: The only one who can rightfully pronounce a person either sick or healthy is that person himself. All measures of medical control and arbitration have more disadvantages than advantages. All restrictions on individual freedom for the purpose of preventing abuse are ineffective and sometimes destructive. Although it is a problematic and complicated situation, it appears that the situation in which the patient pronounces himself to be sick or well in fact already exists, but lacks official recognition. Grond et al, for instance, distinguish between objective disability to work (that is to say that the physician and the patient agree about the disability to work) and subjective disability to work (the physician and patient disagree. The patient says that he cannot work. The physician finds no symptoms of illness. Note that nonetheless there is a reference here to disability to work, albeit subjective.) The image of the inspecting physician who chased the malingerer out of bed and to work is a thing of the distant past. The resumption of work has become, like so many things, a matter of negotiation between patients and inspecting physicians on the one hand, and patients and treating physicians on the other. When conflicts escalate to the point that disability benefits are forfeited, appeals can always be made to other social laws, for instance, welfare. In other words, not only do the arbitrators lack expertise but they lack power as well, which in turn means that the display of power does not have a leg to stand on. It is more a complicated mystification than a reflection of real functions.

From the above I conclude that the autonomy of people in our society should be reinstated in this respect. They should regain the right, not only de facto, but also officially, to pronounce themselves ill or healthy. The complicated and illness-generating system of controls should be abolished. Instead laws should be formulated that grant the individual this right and protect it. That way their own responsibility, and in some cases, blame, will be returned to citizens/patients. Not being able to work due to illness would be directly comparable to not being able to work for any other reason. There would also no longer be any reason for the difference in the level of benefits for these two classifications. This difference could be abolished.

It is clear, however, that these positions are tenable only when a different disease concept from the biomedical one is chosen as a premise. The secret jargon of the territorial biomedical disease concept is to be exchanged for the much more accessible jargon of the biopsychosocial disease concept. Only then will disease again be a concept that patients themselves can participate in discussing, and on which patients themselves are experts as well.

The above is of course not intended to imply that patients must make such decisions unassisted. Physicians can support them with their expertise – but not from a basic attitude of suspicion, as in “You claim to be ill now, but we will have to prove it first.” Rather, there should be a basic attitude of acceptance from which expert advice and assistance are possible without the unrealizable pretense of arbitration and judgment/condemnation.

Further elaboration on these positions would go beyond argumentation on the consequences of the conceptualization of disease, and exceed my expertise. The point is that the biomedical disease concept imposes on patients the role of powerless consumer of health care. It has rendered patients’ liberation and promotion to physicians’ colleagues impossible. It has turned health care into a fortress of revered expertise. The biopsychosocial disease concept offers a way out of these dilemmas that were in part created by the biomedical disease concept.

Finally, a third description of illness can be added to that of illness as a scientific and theoretical concept and that of illness as a social institution with territorial claims by physicians. Disease is an institution to which belongs a role pattern of illness which features advantageous as well as detrimental aspects for the sick person. The concept of illness has gained two side-definitions in addition to its “main” definition which should constantly be included in argumentation on illness and being ill.

B. As an example of psychiatrists who must judge eligibility for certain services on grounds of illness I propose psychiatrists who participate in so-called abortion councils. In the not too distant past these abortion councils functioned as committees that were burdened with judging whether pregnant women’s requests for abortion were to be granted or denied. The formation of these committees was based on the idea that abortion was permissible when carrying out the pregnancy entailed grave risks for the woman. My participation in such a council revealed to me how extraordinarily difficult it is for physicians to slowly convert a holy “no” into a conditional “yes.” The problem was not only, perhaps not even mainly, the woman’s. It was also very much the physicians’ moral problem. Regardless of how sincerely it was attempted to pass objective judgments there always seemed to be a pitfall. Is the council a scientific forum or a kind of examination committee authorized to mete out an important social privilege? On the one hand there was the issue of responsibility: to what extent could a psychiatric disorder have contributed to the pregnancy? On the other hand there was the issue of the consequences that an abortion or continuation of the pregnancy would have. Such matters could be evaluated only on the basis of intuition as there was scarcely anything known about the nature and size of the risks involved. What was the influence on the decision when a woman made her request calmly and deliberately? Or if she was in a panic? What difference did it make in a situation experienced as hopeless whether or not the woman was neurotic? What sort of principle of “fair share of misery” was applied when abortion was granted to a woman of meager means and denied a moneyed woman, arguing that life for the former was “already so difficult”? Which should be “rewarded,” someone’s continual struggle in circumstances of extreme squalor or retreat into the sick role? In retrospect it is difficult to deny that a complicated process of changing norms was occurring that was moral and political but not medical or psychiatric.

Szasz dubbed this meted distribution of social privileges which are not accorded to everybody “bootlegging” (see Ideology and Insanity, Chapter 7): smuggling human and social values under a smoke screen of medical expertise. Although he condemns it, it seems to me that such a process can be sensible, and even inescapable, in a changing society with changing values, in order to make transitions possible and guide them. Apparently there is a strong inclination in these processes for which wise people are needed to seek (medical) experts, as apparently in our society we have no other way of judging who is wise. When the specific qualifications of psychiatrists in such a council are investigated it becomes evident that they are much less important than the social and political power that the expert takes upon himself or is dealt. The course of such a council would be quite different if the participating psychiatrist thought abortion ethically unjustifiable under all circumstances. Here, the profession is, as Freidson says, “a vehicle for society’s values.” There is only one correct conclusion: women must decide themselves.

Here I will limit myself to these two examples. In Chapter VII a third example will be discussed: psychiatrists’ role in involuntary commitment.

About psychiatrists’ role as social arbitrators remains to be said that they are not trained for that nor experts in it. Generally complicated social problems are involved. Psychiatrists as a rule have insight into only into certain aspects of them. Psychiatric diagnoses and systems are directed at the question, “What is wrong?” in respect of the question, “What can I do about it?” Classifications are designed for certain situations and with certain goals. Situations in which sometimes very specific questions must be answered require a different system of classification and a different kind of diagnostics. However there are no separate classifications to which psychiatrist-arbitrators can resort. When important decisions are involved it is desirable to weigh the facts. Disease is not a fact, it is a concept. Matters of social arbitration seem to be based on the premise that disease must be established as a fact on which a decision must be based. Organic aberrations can at least be presented as facts, although this is dangerous, as the fact of the organic aberration acquires its significance only in the pattern of the disease.

In psychiatry the situation is even more difficult because there usually are no organic aberrations which can objectively confirm the findings. Considering the scant reliability and predictive validity in psychiatry it is already difficult to make diagnoses in a way that leads to meaningful treatment opportunities in the ordinary situation where the psychiatrist is a therapist. (See Chapter V, 3.3.3.) In addition, arbitration almost always is about making a comparison with “normal” people. Such a comparison can actually never be made because psychiatrists have not studied and do not know “normal” people. The matter of normality in psychiatry has only recently become a subject of research. In psychiatry it is extremely difficult to diagnose somebody “normal” because there are no clear criteria for normality.

Psychiatrists’ task should be viewed in regard to their expertise. This expertise is recognizing somatic, psychical, social, and other possible factors that tie in to psychiatric disorders. Psychiatrists are trained to derive information from contacts with people and to translate that information into a number of theoretical frameworks. All of these frameworks are designed and intended to offer therapeutic opportunities. Finally, they are familiar with a number of these therapies and trained to apply some themselves. The problems arising from this expertise are great. Psychiatrists hands are full enough already.

Inasmuch as psychiatrists present themselves as social arbitrators they are extrapolating their skills, theoretical knowledge, and views regarding therapeutic possibilities and expectations on the parties to arbitration. This means that psychiatrists have to go beyond their own expertise and apply their theories outside of the framework for which they were designed and intended. This does not mean that as social arbitrators they can contribute no wisdom. It means that it is impossible to judge the value of their views outside of the context of a relationship which has the goal of advice and treatment. Psychiatrists can only evaluate matters from a therapeutic perspective. This perspective can shed light on one aspect or multiple aspects of a problem, perhaps not even the most important aspect. Psychiatrists can pronounce opinions. Such opinions do have significance but not enough to base a well-considered decision on them. Whoever thinks he has received an expert evaluation is deceived. He has only received an opinion, a guess, or a viewpoint, nothing less and nothing more.
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