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The Ethics Of Psychoanalysis: A Psychiatrist's Guide

A Szaszian Approach To The Right To Refuse Treatment

Donal T. Conley, M.D.

[An invited presentation delivered to the Annual meeting of the
American Bar Association in Washington, D.C., July 1985.  The
occasion was a four-hour Presidential Showcase Panel entitled
The Right to Refuse Treatment.]

     Talking about the "Right to Refuse Treatment" requires the
acceptance of a number of assumptions:

1. There is a medical disease called mental illness.
2. It can be diagnosed, with a great deal of accuracy, by
3. It is treatable, even curable.
4. Individuals, so "diagnosed," should be confined in
   "hospitals" where this "treatment" will be provided.
5. The "treatment" will be effective and not harmful.

     If all, or even one, of these statements is not accepted,
discussion of the subject seems pointless. I am unwilling to
accept any of them and I am joined in this by most of the so-
called "patients" who are the subjects of this concern. These
are metaphorical statements that have been literalized by
psychiatry. The phenomenon of deviance exists but the use of
terms like illness and treatment are inappropriate and add
nothing. The phrase "Right to Treatment," was the result of a
well-intentioned attempt, on the part of the legal profession,
to regulate the abysmal practices of institutional
psychiatrists. It has been corrupted to mean "The Right to
Treat," and has thus necessitated the coeval "Right to Refuse
Treatment." Thomas Szasz, in his 17 books and more than 400
articles, has richly explored the reasons why the concept of
mental illness has no validity; therefore anything I say on the
matter would be redundant. I suspect that many of you are
familiar with his writings although they are not usually a part
of the psychiatric curriculum.

     Now that various convulsive therapies and psychosurgery
have fallen into disrepute, much of psychiatry's claim to being
a medical specialty is found in "psychopharmacology."
Presentations of psychopharmacology made to lay persons or to
medical students, for that matter, are largely misrepresentations, 
for a number of reasons. A major pharmacological breakthrough 
was made in the 1950s, when it was discovered, that certain 
experimental antihistamines produced a tranquilizing effect 
without sedation. These medications proved effective in 
managing patients in mental hospitals and enabled the 
dangerous side effects of general anesthetic agents and
narcotics, usually used for this purpose, to be avoided.

     Unfortunately, psychiatric theorists made a quantum leap in
claiming that these medications were a "treatment," rather than
a control because they enabled "integration of thought" and
"cured psychosis." This claim was made despite the fact that
there was no proof, nor can there be any proof for such a
statement until there is some way to observe thought. At
present, absurd as it must seem, the diagnosis of thought
disorder is based on the Psychiatrist's subjective evaluation of
the patient's conversation. The extravagant claims made for
lithium and the antidepressants are even more bizarre, since not
only are their effects similarly misinterpreted but also the
effects are quantitatively much less striking. The minor
tranquilizers are cross-tolerant with alcohol and really add
nothing new to the barbiturates which have been used for ages,
other than, perhaps, the "ceremonial" aspect of their newness.
This, in fact, wears off rapidly and the new good drugs quickly
become bad "abused" drugs.

     The most serious misrepresentation however, is the implicit
claim of psychopharmacologists that the drugs are complicated,
specific, effective and require a great deal of skill in
selection and administration. In fact the subject of
psychopharmacology is fairly simple, relatively speaking, since
classes of drugs are few, the differences between drugs within a
class are largely irrelevant and the doses are titrated to
effect. Despite its promise, the use of blood level
determinations would seem to have little clinical significance.
Any comparison with drugs, like those used in cardiovascular
disease, reproductive endocrinology, or even dermatology, is
invidious to psychopharmacology in terms of complexity. Most
importantly, however, just as in cases of ECT and lobotomy,
these drugs have been almost universally used, in that they have
been given to "everybody." The result is thousands of patients
with tardive dyskinesia, a fact which has been recently
discovered by the American Psychiatric Association and prompted
a bulletin to all members, warning them of the danger of
litigation. Believe it or not the first cases of tardive
dyskinesia due to these drugs were reported almost 30 years ago.

     The products of almost any artistic or scientific endeavor
should be fair game for criticism. This is, unfortunately, not
true of psychiatry where because of its religious nature, the
psychiatric critic must be declared anathema. Although George
Crile, Jr., confounded his colleagues with his criticisms of
classical breast surgery, he was accorded respectful debate and
eventually many of his ideas were assimilated into the treatment
of breast neoplasms.

     Since my student days, I have been amazed at the outrage
and subsequent catatonia that attends any criticisms of
psychiatric "basics." I am amazed at the unwillingness of my
colleagues to engage in any meaningful debate about the "hot"
issues of psychiatry. When someone says the concept of mental
illness represents the metaphorical use of the term disease, he
or she is immediately accused of not "believing" in mental

     The question is not the existence of the phenomenology of
the behaviors that are called deviant but the validity and
usefulness of these occurrences being classified as medical. The
lack of validity of the concept is obvious since disease and
illness are physical and chemical changes in the body.
Admittedly, certain behavioral problems are regularly found to
be neurological disorders, e.g., central nervous system lues,
psychomotor epilepsy and narcolepsy. When this occurs however,
they are no longer "mental diseases" but neurological diseases.
Although "organic" psychiatrists are constantly claiming that we
are on the verge of a proof that major mental illness is
organic, there is no such proof available and this claim has
been made for more than 100 years. When and if such a finding is
made, these conditions will be neurological diseases not mental

     Discussion of the usefulness of psychiatry is a different
matter. It is quite apparent that nothing is added to the
understanding of the so-called deviant human behaviors by
considering these behaviors to be medical illnesses. Therefore,
in terms of understanding these behaviors, the concept of
"mental illness" is worse than useless because it obscures the
understanding of these phenomena. The concept of "mental
illness" like all base rhetoric is very useful to psychiatrists.
As a consequence of "medicalizing" and "psychiatrizing" human
behavior, a semi-theological system of moral ascription is
legitimized and validated, which might otherwise be rejected out
of hand, as ridiculous, i.e. nicotine addiction, hyperactive
children, compulsive gambling, etc. Does the institution of
psychiatry have any value to its patients? Psychiatric
procedures, like any other activities may be helpful to
consenting adults. They are evil when they are coercive or

     Why is this subject worthy of a Presidential Showcase
Program? There must be a very few people, who, when the benefits
of psychiatric treatment are explained, would refuse or need to
have a "right to refuse." The number of patients who require
involuntary treatment must represent a very small problem.
Nothing could be further from the truth. More than half of all
psychiatric patients, particularly those in the hospitals are
involuntary. If you include the voluntary-involuntary, the
number is much greater. Although there are many chronic patients
roaming the streets, who would like to be in the hospital, they
are refused since they have been de-institutionalized.

     When I was 18 years old, in basic training in the army, I
learned from my first sergeant, rather painfully, that you could
only be in the day room at night, a Deus ex Machina peculiar to
the military. As a first year resident in psychiatry, I
discovered a similar, hidden, ridiculous principle peculiar to
psychiatry. The customer is always wrong! If he wants to go to
the hospital he should not be admitted. If he doesn't want to go
in, call the judge. If he asks for medicine, he shouldn't take
it. If he refuses, he should take it anyway, and so on.

     The most important quality that a human being has is the
ability to make decisions and accept the consequences of those
decisions, in other words, freedom and responsibility or simpler
still autonomy. Any act, on the part of another, which increases
autonomy or moral agency, is good and anything that decreases it
is bad. Most important, for many people don't realize this, the
degree of badness or injury when decisions are made for others
is inversely proportional to the amount of autonomy that the
subject has. Freud recognized this and his greatest contribution
to psychiatry was the creation of a therapy, unheard of before,
that increased the patient's choices. Unfortunately, this
contribution has been largely forgotten in favor of Freud's
concept of "resistance," by means of which the patient's choices
can be ignored or overridden by the psychiatrist.

     "Therapy" in psychiatry encompasses an enormous number of
techniques, some of which are absurd others are criminal.
Everything, from sexual relations with young attractive female
patients, to the use of ECT as a behavioral punishment have
qualified for serious presentation in psychiatric journals or
meetings. That the doctor "do no harm," is one of the caveats,
which has guided medical practice since its inception. Recently,
questions have been raised in this context about artificial and
animal heart transplants. Heart patients appear to be eager
volunteers, whereas, many psychiatric patients, most certainly,
are not.

     In the early 1970s, when I was in my psychiatric residency,
it became apparent that the various state legislatures were
passing laws against psychiatrists. My reaction was somewhat
akin to the consternation I felt when I discovered in 1958, the
year I started my obstetrical practice, that a pill had been
developed which eliminated pregnancy. On the other hand, no one
ever passed any laws against obstetricians. The laws have been
changed minimally since the seventies and they should not
undergo substantive change now.

     In my opinion, the laws do not go far enough. Involuntary
psychiatry and civil commitment should be abolished because they
are wrong in a country that proclaims itself free. There are
other more pragmatic reasons for doing this, however. The
treatment of involuntary patients is, not unsurprisingly
ineffective on any long-term basis and it involves more
psychiatric and mental health time and money than do all those
patients who are requesting help. As a possible consequence,
there is an incredible lack of interest, in a psychiatric
career, on the part of graduating medical seniors. Although I
join with Bruce Ennis and other abolitionists in calling for an
end to civil commitment; I realize that other than in an Edward
Bellamy type of solidarity, socialist utopia or perhaps, in a
Szaszian conservative utopia, this will not be forthcoming very

      Those who argue for involuntary psychiatry and easy
commitment often indulge in a pointless recounting of horror
stories. This man committed suicide, another killed his wife,
and a third struck a nurse while on the psychiatric unit.
Information is read from the medical record and nurses notes to
give the story "clinical accuracy." These cases supposedly are
scientific proof that "mental illness" is responsible for these
crimes and are accompanied by the blatant statement that they
could have been predicted and prevented if the commitment laws
were only less liberal. Sometimes a hypothetical case is posed,
which has changeable facts, which refute any argument that
questions a "non-psychiatric" explanation. These are always hard
cases that do not really represent those problems with which
psychiatry usually deals.

     I have experienced no interference, in the proper treatment
of patients stemming from the laws regulating psychiatry, during
five years on the inpatient service of a county receiving
facility. I have, in fact, found them to provide the basis for
"Patient Advocacy Therapy," in which the psychiatrist allies
himself with the patient in resisting the anti-liberty forces
with which he is contending. It is surprising how much
"compliance" is produced when the patient is convinced that you
are really on his side rather than just looking out for his
"best interests," as you, the psychiatrist, see them. I learned
this lesson of advocacy from a Milwaukee attorney who is half my
age. The problems come from families, law enforcement officers,
the courts, mental health professionals and administrators, and
other political forces, which have a great nostalgia for the
easy commitment of the past. The majority of the laws are
excellent and there should be no problem for psychiatrists in
serving the needs of their patients within their constraints.

     It is time for all of us to cooperate in serving the 
patient's best interests, each faithful to the principles and 
ethics of their individual professions but all observing the 
letter and spirit of the law. In those rare cases where the 
patient cannot be persuaded and is incompetent, consent should 
come from a guardian, acting as the patient would if he were 
competent. It is time for an end to the carping of self-serving 
psychiatrists with their "dying with their rights on" articles 
in journals; replete with horror stories about criminal acts, 
which they assert are absolutely predictable and preventable 
through psychiatry. Rather, they should hone their skills of 
persuasion and subtle influence and spend a little more time 
looking at the real problems and treating them with Iatrologic 
or "healing words" as Szasz recommends.

     It is time for an end to the pressures, from law 
enforcement and the courts, to bypass their own system and dump 
habitual criminals into mental facilities where they are mixed 
with the helpless and the elderly. It is time for an end to the 
"cueing up" of psychiatrists to testify in the trials of every 
infamous murderer. It is time for attorneys to defend their 
clients vigorously against commitment by enthusiastically cross-
examining psychiatrists. It is time for judges to allow a real 
due process hearing rather than the ceremonies that are 
conducted in many jurisdictions. It is time for patients and 
families to realize that they must participate in their own 
problem solving and cannot just throw themselves on the shores 
of the mental health system. Finally, perhaps, it is time to 
implement widespread use of the Psychiatric Will, as proposed by 
Thomas Szasz in 1982. A document with which a person, while 
rational and sane, could consent or forbid treatment should they 
be considered in the future to be irrational or insane.

Donal T. Conley, M. D.
Staff Psychiatrist
Daytona Beach Outpatient Clinic

Dr. Conley lives in St. Augustine, Florida
Email dconley@aug.com

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