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Psychiatry: Disease Inflation

Thomas S. Szasz

In his classic, The Economic Consequences of the Peace (1920), John Maynard Keynes observed: “Lenin was certainly right. There is no subtler, no surer means of overturning the existing basis of society than to debauch the currency. The process engages all the hidden forces of economic law on the side of destruction, and does it in a manner which not one man in a million is able to diagnose.”

Debauching disease, the currency of medicine, is an even more insidious and more powerful means of overturning the moral and legal basis of modern society. This is a consequence of the fact that, in modern societies, the definition of disease is a state monopoly, the dispensing of medical care a state responsibility, and the receipt of medical services an “entitlement” of the citizen-patient. Willard Gaylin, co-founder and president of the prestigious bioethics center, the Hastings Institute, and professor of psychiatry at Columbia University College of Physicians and Surgeons, explains: “Hatred is not an entitlement like health care. It is a disease like tuberculosis. It may infect others, but it inevitably destroys the hater, diminishing his humanity.”

Gaylin, one of America’s pre-eminent “medical ethicists,” takes for granted that health care is an entitlement and asserts that hatred is a disease that diminishes the hater’s “humanity.” The assertion is plainly false. Hatred, like love, increases rather than diminishes the subject’s humanity, making him more wicked or more virtuous, as the case may be. It is the absence of these emotions under appropriate circumstances that we regard as inhuman.

Science is synonymous with materialism and with objective standards of measurement. The term objective here means fixed in terms of some fact of nature, not alterable by personal caprice or political power. Familiar examples are the speed of light in natural science, the gold standard in economics, and the pathological standard in medicine. It is axiomatic that there can be no scientific investigation or scientific theory of non material “entities”, “such as hate, racism, and anti-Semitism, now often said to be diseases. Yet, addressing the concept of disease, prominent medical scientists and prestigious publications regularly ignore, overlook, and obscure that we use the concept of disease both as a value-neutral scientific term to describe and explain aspects of the material world, and as a value-laden ethical term to identify, excuse, condemn, and justify (nonmaterial) human aspirations, laws, and customs.

Prior to the nineteenth century, the “scientific” concept of disease was an imbalance among the four “humors,” and blood-letting, emetics, and purgatives were the most important forms of medical treatment. So-called humoral imbalance was a (pseudo)explanatory fiction. It could not be observed, much less measured. The same is true for today’s “chemical imbalance,” said to explain the nature (cause) of mental illnesses.

Only after considerable struggle did the unobservable humoral standard of disease yield to the observable pathological standard. Following the publication in 1858 of Cellular Pathology as Based upon Physiological and Pathological Histology, by Rudolf Virchow (1821-1902), the standard scientific measure, or “gold standard,” of disease became bodily lesion, objectively identifiable by anatomical, histological, or other physico-chemical observation or measurement.

A related watershed event occurred in 1869, when the Russian chemist Dimitri Mendeleyev (1834-1907) published his paper “The Relation between the Properties and Atomic Weights of the Elements,” the first formulation of the Periodic Table of Elements. This scheme provided not only a precise identification of all the then-known elements, but also identified elements not yet known but the existence of which could be predicted by Mendeleyev’s epochal insight.

Gold as a monetary standard, the Periodic Table as a classification of elements, and disease as pathological lesion are examples of ordering an aspect of our world, natural as well as social, by objective criteria, independent of human desire, moral judgment, or political power. The items so ordered are among the most important things in our everyday lives, touching on religion, medicine, drugs, law, economics, and politics. Organizations and persons aspiring to exercise control over our personal lives—church and state, politicians and physicians—have always experienced, and continue to experience, independence from them as an impertinence, an interference with their “sacred duty” to govern, rule, and “do good.”

From the early days of modern scientific medicine in the mid-nineteenth century until World War I, medical theory and practice were independent of the state. During the following two decades, political control of medicine remained relatively minimal, except in the Soviet Union and in Germany after 1933. After World War II the distribution of medical services throughout the developed world was transformed from a capitalist to a socialist system: the source of the physician’s income shifted from the patient to the government or a government-regulated insurance system. Pari passu, medical research, the definition of disease, and the classification and control of drugs became politicized. One result was that more and more “problems in living”—from smoking to obesity to the unruliness of children and unhappiness of adults—became defined as diseases, and more and more drugs were removed from the free market and made available only to persons diagnosed as ill and called “patients.”

People, we must remember, have always used drugs—alcohol, opium, cannabis, cocaine, tobacco—to cope with life. Under the new medical-socialist regime, many of these and other drugs became available to persons only by prescription, and physicians can write prescriptions for them only for persons diagnosed as ill. Not surprisingly, the result is an epidemic of mental illnesses throughout the Western world, especially in the United States.

Medicine and Metaphor

Medical practice is based on science and makes use of scientific technology, but is not a science: it is a type of human service, the content and delivery of which are shaped by economic, ideological, religious, and political interests, and by fashions. Medical science, on the other hand, is a part of the body of science: it is concerned with the empirical investigation of the material world by means of precisely defined methods and measures, rigorously applied. In the delivery of medical care, insistence on precision and rigor is condemned as intolerance, lack of compassion, and rigidity. The irreconcilable conflict between the need for precision and rigor in science and the need for flexibility and compassion in providing medical care is reflected in our current nosology—lumping together uremia and schizophrenia, anemia and addiction, diabetes and depression—as “diseases” belonging in the same “natural” class. This is disease inflation, pure and simple.

A government committed to a gold monetary standard cannot create money by means of printing presses and defining the product as the sole legal currency. Absent the gold (or another commodity) standard—under a fiat paper “legal tender” standard—the government can and does do just that. The same goes for disease. A medical profession and government committed to the “gold” pathological standard of disease cannot create new diseases by attaching disease names (diagnoses) to unwanted behaviors. Absent the pathological standard—under a fiat “medical model” standard—countless metaphorical illnesses have become legally defined and popularly accepted as real diseases. Every one of them entitles, perhaps even obligates, physicians to write prescriptions for them.

In the scope of a few centuries Western societies were transformed from theocracies to democracies and then to pharmacracies, that is, therapeutic states. In such states deprivations of liberty are rationalized as health measures, imposed by medical authorities, and perceived as disease prevention or medical treatment.

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