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Selected Conley Materials:
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.] REQUIRED ASSUMPTIONS 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 psychiatrists. 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. MISREPRESENTATIONS 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. IMMUNITY FROM CRITICISM 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 illness. CONCEPTUAL VALIDITY 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 illnesses. 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 involuntary. MISCONCEPTIONS 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. AUTONOMY 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. LEGISLATIVE RESTRICTIONS 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 soon. HORROR STORIES 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. PATIENT ADVOCACY 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. PRESCRIPTIONS FOR PROFESSIONALS 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 firstname.lastname@example.org