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The Good Doctor” (Summer 2013)

Medicine and Moral Authority” (Summer 2009)

Medicine Without Limits” (Summer 2006)

 

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Correspondence

The Beginning of Life; An Unbalanced Diagnosis; The Enhancement Wars; Three Cheers for Craftsmanship 

In “The First Fourteen Days of Human Life” [Summer 2006], Robert George and Patrick Lee claim that “in a recent issue of Commonweal, Cathleen Kaveny attacks the position that an individual human life begins at fertilization, as it was articulated years ago by Germain Grisez.” They then go on to quote a passage from the piece, charging that it amounts to “a parade of assertions presented as if they constitute an argument.”

I am surprised — and disappointed — that such distinguished philosophers failed to note that the argument they attribute to me isn’t my argument at all. It’s a capsule summary of the arguments of the eminent Princeton Professor Paul Ramsey (my teacher) against the position of Germain Grisez, whose views I also summarized. The title of the piece (an 800-word column, not an article) is “When Does Life Begin? Two Pro-Life Philosophers Disagree.”

The focus of the column was not the status of the embryo, but the currently overheated debate about the status of the embryo. A conservative Christian think tank, the Center for Bioethics and Culture (CBC), has given an annual Paul Ramsey Award for excellence in bioethics. In my column, I wondered whether the CBC would see fit to give Ramsey himself the award it now issues in his name, given that he had expressed serious doubts about the view that an individuated human life begins at fertilization.

Perhaps George and Lee believed I was endorsing Ramsey’s position. I actually think the status of the early embryo is a tough question — there are good arguments on both sides. I am, however, utterly opposed to the sort of polemics that prevent full and measured consideration of the salient issues. Already a generation old, the civil yet vigorous debate between Ramsey and Grisez still has something to teach us on this score.

M. Cathleen Kaveny
John P. Murphy Foundation Professor of Law
Professor of Theology
University of Notre Dame
South Bend, Ind.

Patrick Lee and Robert P. George respond: We are delighted to learn that Professor Kaveny does not endorse the view that the life of a human being does not begin until twinning is no longer possible. When the great Paul Ramsey very cautiously and tentatively advanced that view many years ago, it was still possible to believe that it might be sound. It is not possible today. The more we learn about human embryogenesis, the clearer it is that the life of a human individual begins when fertilization (or an equivalent process, such as somatic cell nuclear transfer) generates a distinct and complete, albeit developmentally immature, human organism — a new individual member of the species Homo sapiens. From day one on, we now know, this distinct organism directs his or her own integral organic functioning, in a complex and coordinated series of activities, toward the next more mature stage along the gapless continuum of human development. (Some of the most powerful recent evidence is reported by Helen Pearson in “Your Destiny from Day One,” Nature 418, 14-15 [4 July 2002].) That is why it is true to say that the adult human being who is M. Cathleen Kaveny (or Patrick Lee or Robert George) is the same human being who at an earlier stage of her (or his) life was an adolescent, a child, an infant, a fetus, and an embryo. Professor Kaveny was never a sperm cell or an ovum. Those were parts of other human beings — her parents — the union of whose gametes brought into existence the embryonic future professor. But she was — undeniably — once an embryo, just as she was once a fetus, an infant, a child, and an adolescent. The individual she is now is the same individual she was at each of these developmental stages, including the infant, fetal, and embryonic stages.

As for Professor Ramsey’s suitability for the award named in his honor, we would enthusiastically endorse a proposal to the Center for Bioethics and Culture to give him the award posthumously. Professor Ramsey was a bold and forceful defender of the sanctity of human life from the point at which it was reasonable to believe a new life had come into being. We have no doubt about where he would stand in light of the evidence available in our time that was still somewhat sketchy in his. Suggesting that Ramsey would be unsuitable for the Ramsey award is like suggesting that Abraham Lincoln, in view of what we would all today agree was the Great Emancipator’s less than perfect understanding of racial equality, would be unsuitable to receive a Lincoln award for the promotion of racial justice.

An Unbalanced Diagnosis

The article by Jeffrey Oliver, “The Myth of Thomas Szasz” [Summer 2006] is problematic in several ways; let me just point out two of its major problems.

First, the author plays fast and loose with the facts to support his theses. One primary example: to support his contention that Dr. Szasz is remembered “if he is remembered at all, as the great silly...” Oliver states that, “At a 1996 debate, well-known psychiatrist E. Fuller Torrey summed up the sentiment nicely with a joke that began: ‘Let me ask an important question. And this is a question that will be asked by future generations. The question is: Who was Dr. Szasz?’ Few in the audience needed a punch line. The question itself was dénouement enough. ‘If he is unable to acknowledge his big mistake,’ Torrey finished, ‘I think the answer to the question will be: ‘Dr Szasz was the man who wrote The Cat in the Hat, Hop on Pop and Horton Hatches the Egg.’ The audience roared.”

I moderated that debate. I have a tape of it. It was an incongruous cheap shot by Dr. Torrey, who was on-topic, more relevant, and fairer during the rest of the debate. Two or three people laughed at Torrey’s attempt at humor — one loudly. The audience didn’t “roar,” but when Dr. Szasz stood up and said sardonically “This is turning out to be just as nice as I thought it would be,” the audience did roar. Never let the facts inhibit you from making a point.

Second and more substantive, the article suffers from consistent invalidity. Nowhere are Dr. Szasz’s seminal contentions confronted in this extensive article. Nowhere is there any examination of his arguments regarding the need for psychiatrists to accept a consistent definition of illness; the lack of pathological evidence for the great preponderance of “mental illnesses”; the lack of mental health professionals’ engaging distinctions between diseases of the brain and alleged diseases of the mind; and the consequences of the abjuring of individual responsibility for actions allegedly caused by “mental illness.”

It may be true that Dr. Szasz has been more and more ignored by the psychiatric profession as a rhetorical strategy to negate his influence, but that is, of course, not substantive evidence of the incorrectness or the lack of value of his views.

All of these weaknesses notwithstanding, there are periodic lines of analysis that imply that Mr. Oliver is not himself in stark opposition to Dr. Szasz’s views. If so, the article needed another draft for him to develop these positions.

Richard E. Vatz
Professor of Rhetoric and Communication
Towson University
Towson, Md.

Jeffrey Oliver’s article pretends to an objective balance it does not in fact possess. Oliver makes a false equation between “the excesses of both Szasz and his adversaries.”

For the past two hundred years, psychiatry has made the claim that people who do things society does not understand, agree with, or approve of are suffering from a physical illness and should be treated by medical doctors. On the basis of this theory, psychiatrists worldwide have involuntarily committed millions of citizens who have neither been afforded legal rights of due process nor convicted of any crime. Under the name of “treatment,” millions of people have been forcibly subjected to drugs, electroshock, and lobotomy. Untold millions more have been either coerced into psychiatric treatments or defrauded into accepting them as “medically” necessary.

Szasz long ago made the point that involuntary civil commitment violates the fundamental principles of medical ethics (informed consent, confidentiality, and patient autonomy), as well as the 4th, 5th, 6th, 7th, 8th, 13th, 14th, and 15th Amendments of the U.S. Constitution.

I am quite willing to grant psychiatry’s “excesses,” including its fifty-year campaign to dismiss and discredit Szasz.

What are his excesses?

Szasz has not physically harmed anyone, nor has he ever deprived anyone of their civil rights. He has taken up pen and ink and objected to “the myth of mental illness” that serves as the justification for psychiatry’s wholesale violation of human rights.

Would Oliver have equated the “excesses” of William Lloyd Garrison and southern slaveholders, of Martin Luther King, Jr. and violent white segregationists?

Two centuries into this myth, psychiatry has yet to prove that any “mental illness” has a biological cause of any kind; not surprisingly, psychiatry has yet to develop a single physical test to detect any mental illness. The DSM, its diagnostic manual, lacks both scientific reliability and validity.

Thanks to the unholy alliance of psychiatry with the drug and insurance companies, the mental health religion does have more true believers than fifty years ago. Many Americans are committed to mental wards every year, and electroshock and lobotomy are still practiced. Many citizens are under court order to take psychiatric drugs on “outpatient commitment,” and millions more take drugs under the mistaken impression they cure “chemical imbalances,” which no one has ever proven exist and which psychiatrists do not even bother to test for.

Oliver’s pretended balance has often been practiced by psychiatry itself. Psychiatrists and their defenders have often praised Szasz for raising important ethical and legal issues, and for criticizing past and obsolete practices of psychiatry, but then hastened to add that he has gone too far in equating psychiatrists who engage in involuntary commitment with inquisitors, slaveholders, and Nazis.

Szasz has spent a lifetime documenting the massive human rights violations of involuntary psychiatry and comparing them with earlier historical examples. I have no doubt that one day Szasz’s name will be remembered among the pantheon of others who have dedicated their lives to the cause of civil rights, and the names of those who have violated those rights will be long forgotten.

Keith Hoeller
Review of Existential Psychology and Psychiatry
Seattle, Wash.

Jeffrey Oliver responds: Mr. Vatz and Mr. Hoeller are longtime devotees of Dr. Thomas Szasz. They have spent much of their careers defending him. In writing my article, I interviewed both men and benefited from their expertise. I am frankly surprised by the tone of their letters. I was under the impression I had written a fairly favorable piece on Szasz. Apparently it was not favorable enough.

Vatz begins by questioning my take on a 1996 debate between Szasz and E. Fuller Torrey. Vatz moderated the debate. I paid him $25 for a recording of it so that I might report the event accurately. I am satisfied that I did so. That said, I can only agree with Vatz when he argues that Torrey’s banal joke — Dr. Szasz will one day be confused with Dr. Seuss, partly because no one will remember the former, partly because both can be considered silly — was a “cheap shot.” When he calls it “incongruous,” however, I can only assume that he is tone-deaf. The fact that the vast majority of Szasz’s practicing peers now see him as some kind of strange and, yes, silly artifact, seems to me beyond dispute. Steven Sharfstein, former president of the American Psychiatric Association, agrees. When I asked him why he attended the 1996 debate, he laughed and said, “Well, here was Thomas Szasz in the flesh.”

Vatz goes on to say my piece suffers from “consistent invalidity.” As evidence, he provides a laundry list of arguments and plot points that any piece on Szasz must apparently contain before it can be considered valid. I am left to argue that by Vatz’s own standards, my piece is highly valid (though I’m not entirely sure what that means). I am also left to wonder if Vatz actually read the thing.

He writes, for example, that I failed to recognize the “lack of pathological evidence for the great preponderance of ‘mental illnesses.’” Truth is, I make the point more emphatically than he does:

If mental illnesses truly begin in the brain, no psychiatrist on earth can conclusively say when, where, why, or how. Nearly one hundred years after Eugen Bleuler invented the word “schizophrenia”...the only way to diagnose this “disease,” or any other mental illness, remains the observation of behavior.

He says my piece fails to consider the “need for psychiatrists to accept a consistent definition of illness” and ignores the “consequences of the abjuring of individual responsibility for the actions allegedly caused by ‘mental illness.’” Yet a significant portion of the article was devoted to the story of Michael Chomentowski, a man who spent eleven years involuntarily confined to a psychiatric hospital after being diagnosed with “dementia praecox” or schizophrenia. In telling Chomentowski’s story, I took pains to illustrate stunning inconsistencies in the diagnostic criteria used by court-ordered psychiatrists. I showed how at varying times, the psychiatrists offered identical diagnoses for “symptoms that were not only different but precisely opposite.” I quoted extensively from Chomentowski’s psychiatric interviews, drawing a parallel with a fictional/satirical conversation in which two bumbling psychiatrists wonder whether having a delusion of insanity means that one is insane or whether it means that one is sane by definition.

If I failed to make plain that Michael Chomentowski’s involuntary “hospitalization” was an obscene miscarriage of both justice and medicine, it was only because I considered the point so readily apparent that to be explicit was to be redundant. If I failed to say, in so many words, that psychiatric diagnosis is a shot in the dark, one that often does more harm than good, it was for the same reason.

Curiously, Vatz admits that I may be right when I say Dr. Szasz is largely absent from psychiatry’s highly selective mind. He argues, however, that this fact says more about psychiatry than it does about Szasz. It seems to me a very fine thesis. That’s why I wrote an extended essay on the topic and published it in The New Atlantis. In that essay, I argue that when Szasz is remembered at all, he is seen as a “marker of backwardness against which” his peers measure their supposed progress. I then spend the greater part of 6,000 words explaining how psychiatry largely remains where it has always been, which is far removed from the medical bedrock of definable pathology and traceable etiology. Vatz is exactly right. Szasz’s ideas remain relevant.

None of this is to say that I wrote exactly what it is Vatz wishes I had written. I am only trying to clarify exactly what it is Vatz wishes I had written. He gives a hint at the end of his letter. Having found some sympathetic passages in my essay, he comes to the strange conclusion that more time and more writing would have necessarily produced more sympathy. Limited agreement with Szasz must apparently yield to total agreement. This is the story of Vatz’s own career. It isn’t surprising that he considers the process inevitable. Instead of reiterating everything I had already written, however, he should have admitted that his gripe has little to do with what I omitted. What bothers him is what I included — criticism of Thomas Szasz. Like many other devotees I interviewed, it seems Vatz cannot abide the notion that his chosen leader is fallible, that he might have damaged his own cause.

Hoeller, for his part, is more transparent in this respect. He sets Szasz next to Martin Luther King and William Lloyd Garrison. Speaking in terms that ring almost Biblical, he says Szasz will be remembered long after his enemies are vanquished. It is worth noting that many of Szasz’s most ardent foes share this sense of immaculate superiority about psychiatry. This kind of idol worship is foolish and counterproductive, no matter what quarter it comes from. It leads not to honest debate — which is what modern psychiatry so desperately needs — but rather to dogma.

In the end I can only thank Vatz and Hoeller for their letters. Their battle-hardened inability to recognize an essentially friendly effort only serves to buttress one of my central arguments. The war between psychiatry and Szasz has mostly led to unhelpful extremes.

The Enhancement Wars

I have a couple of complaints to register about Daniel Sulmasy’s very critical review of my book The Limits of Medicine [“Medicine Without Limits,” Summer 2006].

I wrote The Limits of Medicine because I wanted to bridge a divide in the debate over how far medicine should advance down the road from curing disease to enhancing human traits. On the one hand are those who believe that medicine should not venture too deeply into the realm of enhancements. They usually make their case by delineating one or another concept of our biological or human nature, and then claiming that medicine should forbear from anything that would dramatically alter that nature. On the other hand are those who, excited by the prospect of quantum leaps in life span, intelligence, physical ability, or psychological well-being, critique the coherence or relevance of biological or objective notions of human nature.

I sympathize with those who believe that medicine should not move too deeply or too quickly into the realm of enhancement. But I also find compelling those who question the pertinence or strength of biological or objective concepts of what it means to be human — not generally, as I make clear in the book (e.g., p. 44), but for the specific purpose of justifying limits to medicine. The aim of the book is to see if limits to medicine could be justified by a different set of arguments.

Dr. Sulmasy obviously believes that biological/objective notions work to sustain limits to medicine. He also doesn’t agree with the particular limits I draw around medicine; he doesn’t like my writing style; he doesn’t like my coinage of new terms; and he doesn’t like what he thinks are my politics. He’s of course well within his rights as a reviewer to hold those views and express them.

But there is one key way in which Dr. Sulmasy crosses a line. He says that I fail to offer even “the slightest shred of justification” for my position that biological notions of normality ultimately cannot be used to define medical conditions; that instead I rely on “mere assertion.” That’s not true. I offer a sustained justification for my position, and since (as I note above) I’m far from the only one who holds it, I cite a number of other people who make various arguments against the biological view. (That’s more or less all that I do from pages 3 to 12 and 31 to 53.)

To take just one of many examples: Dr. Sulmasy says that “physicians think that a hemoglobin of 12 is abnormal in an adult with an X and a Y chromosome (i.e., a man), but not normal in someone with two X chromosomes (i.e., a woman).” Such “a conclusion,” he says, “is simply a reductio ad absurdum refutation of” my belief that medical conditions ultimately cannot and should not be understood as biological categories. In fact, the book mentions Dr. Sulmasy’s “reductio ad absurdum refutation,” using a similar example, and offers an argument against it (e.g., p. 203 and elsewhere).

It may well be that my arguments ultimately fail. But if that’s what Dr. Sulmasy believes, then he should have acknowledged that I made them and offered his refutations; instead, he says that I didn’t make any such arguments in the first place. Perhaps, in his view, my writing is so ponderous that it obscured the fact that I was even making such arguments. If that is his position, though, then he holds extremely precise standards for clear prose, since I quote on numerous occasions the words of others who mount various arguments against the biological approach, and evidently he didn’t catch what they were saying either.

Dr. Sulmasy misrepresents the book in a number of other significant ways, but there’s one correction that is especially necessary for me to place on the record. Dr. Sulmasy says that I view “pregnancy as a disease that can be ‘legitimately cured’ by abortion.” I’d be fascinated to know where he thinks that I say that pregnancy is a disease, especially since (on p. 22) I explain why I won’t be using the term “disease” in the book. Instead, I use a broader category called “medical conditions” — by which I simply mean any phenotypic condition that most of us don’t have at any given time. (A lot rides on what I mean by “phenotype”; I don’t consider race, for example, to be a phenotype and in the book I explain why.)

It seems to me uncontroversial that pregnancy is a medical condition so understood, and while I do say that its being so affords one argument for the legitimacy of abortion (as well as for the legitimacy of delivery and pre-natal care), I conclude by saying that such an argument is far from determinative: that it “doesn’t settle the question of whether abortion is morally justified any more than noting that kidney failure is a medical condition settles the question of whether kidneys should be bought and sold” (p. 46). Elsewhere, I say this: The claim “that pregnancy can legitimately be viewed as an abnormal condition” — by which, again, I mean a condition that most of us don’t have at any given time — “is a necessary but not sufficient prerequisite for the legitimacy of abortion, given the other issues it raises” (p. 209). I’m perplexed as to how Dr. Sulmasy could have so misconstrued those words.

In the end, Dr. Sulmasy’s distortions do little to advance the substantive debate. It would be much better indeed if those who believe that it is important to set limits to medicine were a little more open to others who share that conclusion, but who seek to offer an alternative set of arguments for it.

Andrew Stark
Rotman School of Management
University of Toronto
Toronto, Ontario
Canada

Daniel P. Sulmasy responds: Professor Stark complains that in my review of The Limits of Medicine I was insufficiently “open” to “an alternative set of arguments” for establishing limits on the reach of medicine. In fact, I was (and remain) more than open to this possibility. I had high hopes, based on the title and back cover, that this book might provide such a set of arguments. This may explain why I was so profoundly disappointed in reading it.

Prof. Stark complains that I was incorrect in stating that he provided no justification for his views. I am not certain how to interpret this complaint. Perhaps we have radically different understandings of what justification means. For instance, the example of hemoglobin that he reiterates in his letter is an application of his proposed schema, and a confused one at that. An application of a schema is not a justification of that schema. Perhaps he believes that justification consists in reciting other authors’ arguments against the standard positions regarding a contentious issue, followed by the assertion of an alternative position. Again, this does not count as a justification of that alternative position. Nor does merely demonstrating that “if you follow this elaborate procedure you will find that it gives you the answers I think are correct” constitute a philosophical justification.

Stating, “I think you should go to Toronto and here’s how you get there from New York,” is not a justification for my going to Toronto. I want to know why I should go to Toronto. Best, in a philosophical sense of justification, I want someone to say, “Here are the persuasive reasons that justify using procedure X for deciding where you ought to go. If you follow procedure X, you’ll see that you ought to go to Toronto.” That is what I mean by justification. I could find nothing like this in Prof. Stark’s book, nor does he describe in his letter a place in the book where he does provide such a justification.

Prof. Stark also complains that I say he calls pregnancy a “disease.” He states that he called it a “medical condition” and not a “disease.” In this he is correct. I used “disease” as shorthand, not wanting to explain in an already lengthy review that he uses the term “medical condition” instead of “disease” because he does not believe the word “disease” can be defined. Therefore, pregnancy could not be a disease, and must be, in his view, a medical condition. According to Stark, however, the same must be true of other states that the rest of us naïvely continue to consider diseases, such as appendicitis, tuberculosis, and amyotrophic lateral sclerosis (Lou Gehrig’s disease): they are all medical conditions, not diseases. And like all of these other medical conditions, in his view, one may elect a curative treatment for pregnancy if one is so inclined. The “cure” for the “medical condition” of pregnancy is abortion. Thus, his distinction makes no difference to the overall point I was making in the review.

Finally, Prof. Stark complains that I offer no philosophically justified alternative view of my own. This is true. But I never thought it the task of a reviewer to do so. What I have concluded is that Prof. Stark’s view is not the answer to the question of how we should set limits on medicine. It was my obligation as a reviewer to make that point and explain why. I did not try to tell readers where they should go, but where they should not.

Three Cheers for Craftsmanship

As a publisher and editor of a magazine for tinkerers, I read Matthew B. Crawford’s piece, “Shop Class as Soulcraft” [Summer 2006] with great interest. I want to join Crawford in lamenting the disappearance of shop class (and shop teachers) from schools. More and more, we seem to teach the theoretical at the expense of the practical, perhaps because it’s more efficiently conveyed by textbooks and measured by tests. Maybe schools should reconsider how they think about technology. It could mean a lot more than using computers.

One could make the case that a machine shop could be more beneficial to kids today than a computer lab. Most kids have computers at home and many know more about them than their teachers. What they lack is access to the kinds of machines and tools you might find in a shop class. Learning to use tools and operate machinery is challenging but also deeply satisfying.

Since starting the magazine, I have talked to a lot of people who make things to find out how they became makers. As a group, they have quite varied educational backgrounds and careers. What stands out is how smart they are and how much they enjoy what they do. Most of them were fortunate to find a mentor who encouraged them early on, but they are also largely self-taught, picking up new skills wherever they can. They challenge themselves with new ideas for projects and often share the results via the Internet. Makers are practical, clever, and creative. Most importantly, they have a spark in their eyes.

Last spring, our magazine organized Maker Faire in the Bay Area, which brought together several hundred makers who showcased their amazing projects. It was part science fair, part art show, and part craft fair. Over two days, we had an audience of 20,000 people, most of them families.

There are even some efforts to open community-based machine shops and craft storefronts where kids and adults can go to pick up skills and use resources that may not be available at home. TechShop opened recently in Menlo Park, California. If you have a monthly membership, you can take classes in robotics, moldmaking, or laser-cutting as well as work on your own projects. CraftGym in San Francisco offers a workspace along with classes in knitting, sewing, and silkscreening, all for the price you’d pay to join a fitness club.

All of this, along with the success of MAKE magazine — now in its second year — leads me to think we’re seeing a resurgence of interest in hands-on exploration and experimentation. Much of it seems driven by a creative urge to imagine something and then try to make it with whatever tools, materials, and knowledge one has. I don’t know if it substitutes for shop class, but it should continue to be encouraged as great way to learn.

Dale Dougherty
MAKE magazine
Sebastopol, Cal.

"Correspondence," The New Atlantis, Number 14, Fall 2006, pp. 3-11.