Curing the Therapeutic State: Thomas Szasz interviewed by Jacob Sullum

Thomas Szasz on the medicalization of American life.

Jacob Sullum from the July 2000 issue

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Reason: In the area of drug policy, you've criticized the idea of shifting from a criminal justice approach to a "medical" or "public health" model, which you say would only reinforce the therapeutic state. But if a drug offender who might otherwise go to jail can instead undergo "treatment"--which is now the case in Arizona, for example--isn't he better off, even if the treatment is bogus?

Szasz: He may be better off in the sense in which a Jew in 15th-century Spain may have been better off converting to Christianity than being tortured. But I reject the dilemma. One of these so-called treatment options may be less punitive for the subject. But the side effect is that it reinforces the legitimacy of this kind of medical autocracy.

Reason: Another reform pushed by advocates of a "public health" approach is needle exchange programs. What do you think of them?

Szasz: I am unqualifiedly opposed to this kind of piecemeal reform. I keep falling back on the slavery analogy. You cannot prettify the plantation. You either have slaves as a legal arrangement or you don't. Either you have access to empty syringes just like you have access to guns, or you don't have access.

Reason: A simple way of addressing that issue would be to make the needles available without prescription and to stop penalizing people for possessing them. That's not exactly a fundamental reform in terms of drug policy, but is that the kind of reform you could support?

Szasz: I think that would be fundamental, because the message it would send is that this is a problem only because the government has made it a problem. The American people don't realize that a very large proportion of the AIDS cases in America are government-manufactured, in the sense that the government has prohibited needles. People talk about iatrogenic--doctor-caused--diseases. People never talk about government-caused diseases. There is no Latin word for that.

Reason: Another so-called harm reduction reform is to make methadone more readily available to current opiate users or to make heroin available by prescription. Do either of those suggestions make any sense to you?

Szasz: They make a great deal of sense, in the sense that they strengthen the establishment which is causing the problem. I am bitterly opposed to all of these autocratic medicalizations. All of these glorify the punitive state and the punitive doctor and debase the citizen for exercising his free choice. It's as simple as that.

Reason: You take a similar view when it comes to medical marijuana, that it reinforces the therapeutic state, since the doctor gets to say whether you can have it or not. But from the point of view of somebody who is sick and who finds that marijuana relieves his pain, his nausea, or his muscle spasms, a measure like California's Proposition 215 means that he's less likely to be arrested and prosecuted. Isn't that an improvement?

Szasz: I see this as analogous to leaving Soviet Russia. You could appeal to Stalin and say, "My father is living in America, and he is 80 years old. Won't you let me out?" And then Stalin might say, "OK. I'll let you out, because that really would be a good thing for you, because of your father." The patient is getting a special exception from a general rule, which I find totally unacceptable.

Reason: The general rule or the exception?

Szasz: I find the general rule unacceptable, and the exception is simply doing one particular favor to one particular person or group of persons.

Reason: But the people to whom the exception applies are better off. Is equal enforcement of a bad law better than making exceptions?

Szasz: This is one of those classic problems where if you leave the bad law in place long enough, then maybe it will be repealed, whereas making exceptions prolongs its life expectancy. I am not opposed to being nice to particular groups of people as a humanitarian gesture, obviously. If somebody who is undergoing anti-cancer treatment has nausea and benefits from marijuana, it would be a nice thing for this person to have it. How can I be opposed to that? But that's like smuggling Jews out of Nazi Germany with the help of a Gestapo agent. Wouldn't it be better not to persecute them in the first place?

Reason: The question of whether people may use marijuana to treat various kinds of symptoms seems to be a small part of the drug policy debate. Yet the medical marijuana movement has drawn a very strong response from the federal government. Why do you think people like the drug czar, Barry McCaffrey, get so upset about attempts to legalize the medicinal use of marijuana? Does that reaction suggest that maybe the medical marijuana activists are on to something, that they've found an effective way of undermining prohibition?

Szasz: Probably the reason why the drug warriors are so upset is that they think this will have a kind of a domino effect, that we have to fight the enemy here; otherwise he is going to move somewhere else. I personally think that they are wrong. The drug warriors are the victims of their own ideology. They really believe their own propaganda. I don't think medical marijuana would particularly weaken them, any more than it weakens them that people can smoke cigarettes and relieve their anxiety that way. I think prohibition would be strengthened by making these exceptions. The rationale would be, "See, we leave these relatively harmless ones alone. But by golly, we have to really strike hard at the drug lords if we can find them."

Reason: People who support physician-assisted suicide claim that giving terminally ill patients a legal way to obtain lethal drugs will enhance their autonomy. You disagree.

Szasz: This is the same question as medical marijuana: Anything that people want is being made contingent on getting it from a doctor.

Reason: In Fatal Freedom, you say the debate over physician-assisted suicide ignores the roles of drug prohibition and psychiatric coercion. Why are those factors important?

Szasz: They are fundamental. First of all, if there were no drug laws, then they wouldn't need doctors to give suicidal people drugs to commit suicide with; after all, they don't give patients guns or ropes. Second, people seem oblivious to the fact that doctors--psychiatrists--are given the job both of preventing suicide and of providing suicide. To me these are symptoms of the galloping therapeutic state, where increasingly we are giving away our existential choices and responsibilities to doctors--and therefore to the state, because they're really not talking about doctors as healers; they're talking about doctors as agents of the state.

Reason: You say that the very term physician-assisted suicide is misleading. How so?

Szasz: "Physician-assisted suicide" can be one of two things. The physician can give the patient a drug--let's say a barbiturate--and then the patient takes the drug and dies. But that's simply suicide, a person killing himself. If you buy a rope in a store, you don't talk about "merchant-assisted suicide." On the other hand, what can also happen is that the physician helps a person to die--in effect, speeds his death or kills him. This is how many old people have died in the past and continue to die. They are going to live another few days or weeks; they are in heart failure and can't breathe. The physician gives them a little extra morphine, and they stop breathing. This is how Sigmund Freud died. But this is not suicide. As I emphasize in my book, it's rather significant that the physician-assisted suicide legislation in Oregon specifies that dying in this way is not suicide.

Reason: Looking back at your career, what do you see as your major contributions?

Szasz: It's really two very simple propositions: that there is no mental illness, and that if you are incarcerated in a mental hospital, you are in prison. You are not treated or cured.

Now as far as the greatest impact, there's no question that "the myth of mental illness" and the idea of the therapeutic state are terms and concepts that are widely copied, and often used in ways quite different than I have used them. There's a third idea that hasn't caught on quite as much, though I've seen it used in English publications: "pharmacracy," which I used in Ceremonial Chemistry. It refers to the substitution of medical controls for legal and religious controls. We are pharmacratizing everything, including the control of unruly children. Attention deficit disorder is a perfect example of pharmacratic control of a social problem: how to educate children.

Reason: You seem generally pessimistic. Can you cite any encouraging developments?

Szasz: I should correct that. Intellectually, I am very pessimistic, but temperamentally I am an optimistic person. I am pessimistic because I see the trend as a progressive evasion of personal responsibility.

Reason: But have you seen any encouraging developments since you first started talking about these issues?

Szasz: Yes. The encouraging development is essentially the uprising of the slaves, the increasing protestation by ex-mental patients, many of whom call themselves victims. Through all kinds of groups, they have a voice now which they didn't have before. We should hear from the slaves. Psychiatry has always been described from the point of view of the psychiatrist; now the oppressed, the victim, the patient also has a voice. This I think is a very positive development.

More generally, I see the American political system as infinitely elastic and hopeful. And of course there's the Internet, which is a huge opening of information, giving people access to what the establishment doesn't want them to hear, not only politically but especially medically. I was quite intrigued to learn fairly recently that my Web site was blocked by filtering software at a library in Indiana. Why it was blocked, God only knows. But I was struck by the fact that someone was complaining about it.