All Commentary
Thursday, August 1, 2002

Pharmacracy: Medicine and Politics in America

The Therapeutic State Is about Tyranny, Not Therapy

This review was commissioned over a year ago. I was looking forward to writing it. But then the depression began. Stress. A new job. A major move. A new marriage. I felt unfocused, obviously not in a condition to write a review of an important new book.

Many psychiatrists would have no problem diagnosing my malady. Situational depression. And no trouble treating it. Prozac would be one popular choice.

Thomas Szasz is a psychiatrist, professor emeritus at SUNY Upstate Medical University in Syracuse. He, too, would have no trouble diagnosing my malady. Laziness. The cure: more efficient use of my time.

Szasz sees through the rhetoric of the therapeutic state that seeks to cure all our illnesses and salve all our hurts. He insists that there’s a difference between a disease and a problem; between succumbing to illness and succumbing to frustration; between being treated for what ails us and being coerced because others are irked by us.

Pharmacracy distills the reflections of Szasz’s professional lifetime. Arguably, it is his magnum opus, although several of his other books compete for that title. Perhaps someone with Szasz’s prodigious record of publication is allowed more than one magnum opus.

Szasz notes that society’s view of physicians, and what can be accomplished via medical controls, has changed since he went to medical school during World War II. “Pharmacracy” is the word he uses to describe the use of medicine, especially psychiatry, as a method of social control and political rule, just as theocracy was rule by the priesthood. Szasz writes, “In a theocracy, people perceive all manner of human problems as religious in nature, susceptible to religious remedies; similarly, in a pharmacracy people perceive all manner of human problems as medical in nature, susceptible to medical remedies.”

A key question is, what counts as a disease? Is depression a disease like diabetes? Is schizophrenia a disease like smallpox? Is it enough that doctors work to diagnose and cure depression and schizophrenia? Doctors in the nineteenth century worked to cure black slaves of drapetomania, a “disease” that reportedly caused them to escape to freedom.

Szasz insists on the strict definition of disease found in medical books on pathology. He therefore concludes that many contemporary diseases are diseases in name only. That leads to the larger issue of using physicians less for diagnosis and therapeutics, and more as social guardians.

Szasz’s discussion ranges far and wide. I especially enjoyed his excellent insights into today’s labyrinthine maze of governmental regulations on health care. Today, more and more physicians look on their services as vitally important ones that, as it happens, no one is willing to personally pay for. This is a truly schizophrenic view (metaphorically speaking). Szasz summarizes it perfectly: “once the physician ceases to be paid directly by his patient for the services he wants, and is instead paid by others to deliver services the patient ostensibly needs, the physician’s propensity to make certain diagnoses or discover new diseases by creating disease names skyrockets.” Szasz quotes sociologist Edward O. Laumann from the Journal of the American Medical Association (JAMA): “Everyone is at risk of sexual dysfunction, sooner or later.” Laumann is a paid consultant for Pfizer, the company that manufactures Viagra.

Szasz moves on to discuss the widening field of psychiatric diagnoses and the claims by psychiatrists and their defenders that “mental illness is as much a real disease as physical illness.” Szasz quotes Bill Clinton as saying that mental illness is just like physical illness, and then points out the obvious: “there are no illnesses outside of the realm of the mental health field whose disease status requires defense by the White House.”

The book’s final chapter describes intrusions by the state into the free practice of medicine and the provision of medicine as a market product rather than what it has now become, a “right.” Szasz correctly points out that the major medical journals (such as the New England Journal of Medicine and JAMA) have been taken over by academic physicians philosophically committed to the socialist provision of medicine by the state. Alternative viewpoints are dismissed out of hand and never appear in the academic literature. Meanwhile, people have accepted medical care as a right and entitlement, now seen as crucial as life, liberty, and the pursuit of happiness. Politicians promise to rid us of disease, if only we give up more liberty and accept higher taxes for health care.

Szasz’s conclusion is a sad but realistic one: “Formerly, people rushed to embrace totalitarian states. Now they rush to embrace the therapeutic state. When they discover that the therapeutic state is about tyranny, not therapy, it will be too late.”

I guess I do have reason to be depressed.