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Law, Psychiatric Disorders, and Free Will

There is a second fundamental problem with basing the ethic of coercion on the existence of a psychiatric disorder. The premise that makes social organization possible and is cardinal to every social structure is that every person is responsible for his actions. Without this principle no transaction, no agreement, no obligation would be possible. To what extent this principle can be based on the liberty and responsibility that are intrinsic to human existence in an ontological sense remains arguable. However, it is not necessarily pertinent. Accountability for actions and inactions is a social contract that applies equally to every citizen. Empirically it enables society to function.

There are a number of situations in which a person is alive but does not act. These situations such as coma or sleep exculpate a person for things at which he was present and which he could have influenced or prevented had he been conscious, as it is accepted that in such a state he is unable to act. Should the behavior of a person who is considered psychiatrically disordered be classified with coma or with behavior for which a person is responsible? His behavior apparently has commonality with both. Yet the distinction between willed behavior and behavior that is beyond one’s control is extremely important. The line between these two is fundamental but not clearly identifiable. The position that a person in coma is incapable of action is not an absolute but an empirical certainty.

In a scientific-theoretical sense it can never be certain whether someone fails to perform a certain action of which he is potentially capable because he does not want to or because he cannot. Only an empirical certainty is operative here. Sometimes it is large. More often it is little.

This basic inability, in a scientific-theoretical sense, to distinguish lack of will from lack of power is a troublesome problem in psychiatry as a helping profession. But it is not insurmountable as long as the patient has voluntarily entered into the contact with the psychiatrist. When someone wants to be helped the therapist can generally depend on the patient’s relating his feelings and experiences to the best of his ability. If the patient does not he is mainly harming himself. A much more difficult situation arises when the patient’s contact with the psychiatrist is aimed at seeking certain advantages such as gaining the status of the sick role. Very difficult indeed is the situation that the patient explicitly expresses the desire to have no contact with the psychiatrist and wishes no treatment or other intervention. But even in this last situation a pronouncement may not be impossible as long as the patient’s behavior can be observed, although certainty declines, the risk of error rises, and the pronouncement can be only indirectly substantiated. Finally, most uncertain is an evaluation that has to be made on the basis of information from a third party. Yet even then the pronouncement is not impossible and in the odd case even possible with a certain confidence.

In other words, even when the constriction and stereotypy of a person’s repertoire of behavior makes loss of autonomy highly likely there is never absolute certainty but a varying degree of empirical certainty that it is related to the person’s inability or lack of desire to act differently.

One not infrequent suggestion in psychiatry is that patients refrain from certain behaviors because of anxiety. Although in the practice of daily life this is generally a useful supposition it could be pointed out that human freedom manifests itself precisely in “rowing against the current,” by doing what one does not dare do, rather than by obeying the general rule that people refrain from doing what they do not dare do. When, after involuntary hospitalization, an ex-psychiatric patient proclaims to feel much better and be grateful in retrospect for the intervention this can be considered an indication, but not valid proof, of the patient’s earlier powerlessness. Abductions and concentration camps have shown that even during a brief isolation with and by an aggressor the seized person may develop a strong inclination to identify with that aggressor and adopt the aggressor’s opinions. I do not mean to imply a correlation between the way people are treated in psychiatric hospitals and the way they are treated in concentration camps or when they are taken hostage. I mean that from the moment patients are hospitalized they are surrounded by people who are all convinced of the patients’ being ill and their lack of insight into that illness, and who all consider normal what to patients is incomprehensible and vice versa.

There are patients, a clear example being those who are involuntarily committed with a bipolar disorder, who are treated with lithium, and after release continue to take the prescribed medication loyally. In short, they appear quite pleased with the course of the treatment. In contrast there are patients who were psychotic when involuntarily committed and whose behavior was normalized with psychiatric drugs, yet upon release they stop taking them. Apparently these people prefer being psychotic to being adjusted with medication. These people live unenviable, often quite horrible lives. Yet they behave as though they prefer that to the adjusted existence which is so much more attractive to others. Is that truly a choice or an inability to choose? No ontologically objective answer to that question is possible.

In summary, in psychiatry, it is ontologically impossible to know for sure whether a person does not want to or cannot do something. The notion of restriction of freedom and autonomy in a theoretical-scientific and conceptual way can be included in the definition of psychiatric disorders without objection provided the application of this notion is confined to an area not requiring certainty about whether the observed unfreedom is “chosen” or “compelled.” That area is voluntary therapy. When “patients” experience themselves as not ill and insist that they behave as they do of their own free will, determining a psychiatric disorder is typologically possible though with less certainty. However, the matter of restriction of freedom and autonomy cannot really be determined because when the person does not experience it or claims not to, the possibility of a certain freedom of choice existing in the displayed behavior can never be ruled out. It is precisely in situations that feature this dilemma that coercion and legal measures are pertinent. At this point the question of freedom and unfreedom unavoidably assumes a decisive significance. At the same time it is a question that psychiatry can answer typologically but not in principle.
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