By now most of us know who Thomas Szasz is. His various books, articles, and scholarly papers have dealt with a wide range of topics. Most significant to those concerned with liberty have been Szasz's arguments against involuntary mental hospitalization.
What are these arguments? How do they relate to the general case for the value of political liberty?
Szasz has founded his arguments against involuntary mental hospitalization on the idea that mental illness is unlike physical illness and is, in fact, not a "disease" at all as that term is traditionally understood. Because of the controversial and, as I shall indicate, highly vulnerable character of Szasz's position—namely, that mental illness is a myth—we might want to learn whether we can separate his psychiatric from his libertarian arguments. In that case if, as I suspect, the former are untenable, their weakness will not necessarily reflect upon the soundness of Szasz's libertarian arguments.
Let us briefly look at Thomas Szasz's case. This will only be an outline, but the crucial features of the argument will emerge clearly enough.
Szasz opposes the application of the medical model to psychiatry mainly because he sees the logic of the diagnosis of conventional organic disease as being different from the logic of the diagnosis of mental illness. The diagnosis of conventional illness, he notes, is scientific and objective, whereas the diagnosis of mental illness by psychiatrists requires a value judgment on their part, which makes it fundamentally different from conventional medical diagnosis. That is, Szasz argues that the psychiatrist decides that a person is "mentally ill" (as opposed to merely being different, confused, or unhappy), whereas the physician makes no such value judgment or discretionary judgment when an organic disorder is involved.
This argument is not ingenuous if one accepts the traditional concepts of the medical model and organic disease—that there is an objective standard for determining what is organically normal. As Roger J. Williams, discoverer of pantothenic acid and founder of the genetotrophic concept, has shown in his Biochemical Individuality, however, the idea of "normality" is not at all easy to define even when dealing with organic disorders. That is, the medical model, carefully applied, does not allow for complete generality or universality—which is what Szasz means by "objectivity." Thus the judgment that is involved in determining whether an individual is diseased or merely different, the judgment to which Szasz objects, is not unique to psychiatric diagnosis, but permeates the field of medical diagnosis as well.
For example, Williams found that in a study of "normal" (that is, healthy) men in his laboratory, there are great variations among them on just about every physiological measure. By a great variation Williams means, not just 20 percent to 30 percent, which would be clinically significant, but 100 percent to 1,500 percent or more. Thus, according to Williams, even in purely organic or medical illness the physician quite often must make a value judgment as to whether a statistically aberrant physiological measurement is indicative of disease or is merely an expression of biochemical individuality.
So whenever he measures, say, the serum amylase content, the physician must assess whether a numerical value outside of the normal range indicates an "illness" on the part of the patient. This assessment is quite analogous to the judgment that a psychiatrist must make when his patient behaves in a statistically abnormal fashion. In both cases the physician must decide whether these statistical variations are just expressions of biochemical individuality, in the case of Williams, or of psychological individuality, in Szasz's case. There is no fundamental difference in logic or methodology.
MENTAL OR PHYSICAL?
There are, of course, medical diagnoses that are much more clear-cut than the one just described. If by X-rays or inspection the physician can see that the patient has a broken arm or a ruptured blood vessel, there is little judgment involved in the diagnosis. It is the consideration of instances of this type that has led people to accept the notion that the medical model involves neutral and dispassionate analysis based on measurable standards of a nomothetic as opposed to an idiographic nature.
Szasz points out that there also exist cases, traditionally diagnosed as mental illnesses, in which a clear-cut physiological description is evident. He contends, however, that if they can therefore be diagnosed with only a nominal value judgment they are no longer mental illnesses but, rather, physical illnesses. This seems to me to be a curious way of defining away all cases that might be problematical to his point of view. Mental illnesses of this type include general paresis and anatomical disorders of the brain in which lesions of the central nervous system can be observed. These are analogous to their nonbehavioral disease counterparts of broken bones and ruptured blood vessels in that their diagnosis involves no significant discretionary judgment.
It is to Szasz's great credit, however, that he is remarkably shrewd in his clinical guesses. For example, he suggested in The Myth of Mental Illness in 1960 that schizophrenia is probably a physical illness. It was later found that schizophrenic behavior correlated with the serotonin content of the blood, thereby removing it from the ranks of mental illness, according to Szasz.
Szasz has also correctly pointed out that some people are labeled mentally ill (merely) for holding opinions opposed to those held by the labelers. A passage from Harry Overstreet's The Great Enterprise is a good example: "Sometimes, it appears, such persons have constellations of prejudice areas. A man, for example, may be angrily against race equality, public housing, the TVA, financial and technical aid to backward countries, organized labor, and the preaching of social rather than salvational religion. Try as we may, we can scarcely open up a subject that does not tap their permeative, automatic 'againstness.' Such people may appear 'normal' in the sense that they are able to hold a job and otherwise maintain their status as members of society, but they are, we now recognize, well along the road toward mental illness."
For this reason, coercive involuntary mental hospitalization is something that must be avoided for the mentally ill except perhaps, on such emergency occasions as when the individual is incapable of caring for himself, that is, apparently unable to carry out conduct necessary for living. For example, an individual in a catatonic stupor with no one to care for him might benefit from mental hospitalization, even if involuntary.
Szasz argues about this point, not accepting any such emergency cases. He claims that medical ethics prohibits any involuntary psychiatry. In medicine, treatment is permitted because the individual wants it. Szasz argues that involuntary psychiatry is impermissible because the patient does not indicate that he wants treatment. Medical ethics, however, offers many instances of "involuntary" treatment. Unconscious accident victims, without their assent, are "involuntarily" imprisoned in an ambulance and rushed to a hospital. Individuals having their first epileptic seizure have cloths stuffed into their mouths involuntarily and are otherwise treated. People suffering from apparent drug overdoses are involuntarily rushed to have their stomachs pumped.
The question remains, "Does medical ethics in the above cases violate their freedoms by doing something the treated individuals did not desire?" The only way of determining the answer is to ask the people after treatment if they wanted it, as they were incapable of requesting treatment prior to its administration. In nearly every case they say they wanted it. Those who do not still have the opportunity to do away with themselves in another way on another day.
Similarly with mental illness, an autistic, a catatonic, or a severely schizophrenic individual who is obviously unable to care for himself might benefit from treatment and really desire it but just be unable to ask for it or assent to it at the moment. The only way we can know if he really wanted it is to ask him afterward. Again in cases of mental illness, as with physical illness, nearly all individuals who have been involuntarily treated and helped by it say afterward that they really wanted treatment. This is as true of the paranoiac as it is of the epileptic or the accident victim.
Just as there is a discretionary or value judgment in the logic of diagnosis for both conventional medicine and psychiatry, there is such a judgment involved for both in the determination of when to treat involuntarily. Both conventional physicians and psychiatrists prefer a voluntary relationship but recognize the need to treat involuntarily if they see that the patient is going to die or do himself great harm, as in the physical case of the epileptic and the mental case of the catatonic. Involuntary psychiatry, then, is not in conflict with medical ethics but simply involves the same discretion that medical ethics requires.
The answer to Szasz's question, "If diabetes is not treated involuntarily, why should depression be?" is that physical illness is quite often treated involuntarily if the individual appears to be incapable of asking for help. Mental illness should be treated involuntarily on the same basis—which is not to condone the numerous documented abuses of the incapacity criterion.
While one may respect Dr. Szasz's clinical shrewdness as well as his arguments opposing involuntary hospitalization for reasons of social convenience, it is essential to realize that it is not necessary to deny the existence of mental illness to stave off such coercion. Applying the same criterion as with physical illness is enough to ensure that involuntary treatment only occurs in comparably extraordinary cases.
Dr. Szasz fuses the two logically separate problems of the existence of mental illness and what we may do about it because he assumes the overly simplified medical model that has been shown to be inadequate. Indeed, under the medical model of diagnosis, as explained by Williams, the basis of Szasz's argument vanishes, as there exists no difference between the logic of psychiatric diagnosis and the logic of medical diagnosis.
John B. Kizer has four years' experience as a consulting psychologist and has taught at Shawnee State College. He has twice won prizes for essays on the theory of gravitation and has developed a theory of cellular regulation, published in a letter to New Scientist.