The Szasz Column

#11 "Psychiatry: A Branch of the Law," The Freeman, 56: 18-20 (December), 2006.

#10 The Pretense of Psychology as Science: The Myth of Mental Illness in Statu Nascendi

#9 Keynote Address, "Controversies in End of Life Care: Terri Schiavo's Lessons"

# 8 FEAR AND FOLLY: Bertrand Russell, C. S. Lewis, and the Existential Identity Thief

# 7 "A bogus Benjamin Rush quote: contribution to the history of pharmacracy"

# 6 "Idiots, infants, and the insane": mental illness and legal incompetence.

# 5 Malpractice vs. "Malresult". A new form of insurance for an eternal problem.

# 4 Caveat Emptor (Let the Buyer Beware).

# 3 Self-Ownership or Suicide Prevention?

# 2 Psychiatrist who changed the view of homosexuality as a mental disorder.

# 1 The psychiatric protection order for the "battered mental patient".

Essay by Thomas Szasz on the massacre at Virginia Tech: Dangerousness Is Not a Disease


Did the perpetrator of the Tuscon massacre have a reason?

The Therapeutic State | Thomas Szasz

The Freeman: Posted January 20, 2011

Do people really want to know why, on January 8, 2011, in Tucson, Arizona, a young man named Jared Lee Loughner engaged in mass murder? I submit they do not. Politicians, psychiatrists, pundits, and the press univocally assert that Loughner’s deed is the “senseless” product of mental illness. This belief in a non-existing mental disease causing mass murder is on a par with young children’s belief in Santa Claus. It is false but satisfies the believers. The great French essayist Michel de Montaigne (1533-1592) sagely observed: “Nothing is so firmly believed as what is least known.”

Before his shooting spree Loughner had produced a video he called “My Final Thoughts,” stating: “All humans are in need of sleep. Jared Loughner is a human. Hence, Jared Loughner is in need of sleep.” On the morning of his massacre he posted a message on his MySpace account acknowledging his sense that he was at the end of his rope and his decision to let go: “Goodbye. Dear friends . . . Please don’t be mad at me.”

“War is a continuation of politics by other means,” said Prussian general Carl von Clausewitz (1780-1831). I suggest that, similarly, mass murder in plain sight, such as Loughner committed, is a continuation of suicide by other means. Sometimes it is called “suicide by proxy” or “suicide by cop.”

Loughner, to use his metaphor, has gone to sleep. And so have we if we prefer to believe that his self-destructive and destructive act is the senseless product of his “mental illness” rather than the result of his planned, “sensible” decision. The latter view is unpopular and unacceptable because it acknowledges Loughner’s humanity and free will, precisely the qualities that psychiatrists – aided and abetted by the criminal justice system – are intent on removing from persons they label “mad.” This medicalized view of certain offenses – usually crimes that particularly upset people – has, for reasons I have presented elsewhere, become widely accepted in our society, embraced equally by the right and the left.

Normally, we infer the motive for an action from its consequences. For Loughner, one of the consequences of his action is that his life is over, if not biologically then socially. Loughner was well aware of his failure to transition from childhood to adulthood. After years of fruitless travail, he decided to bring his life to a dramatic end. He committed mass murder and let himself be destroyed by the society that, he felt, obstructed his efforts to succeed.

Loughner’s crime, like any act, was not senseless at all, provided we are willing to put ourselves in his shoes. Of course, it makes no sense if we are unwilling to do that, denying the personhood of the actor, dismissing a priori his possessing free will, attributing his action to mental disease instead of personal decision.

Crime Is Alleged, Craziness Is Asserted

The only thing we know with certainty about the Loughner case is the identity of the shooter. We do not know why he committed this crime. Nevertheless, commentators ritually refer to Loughner as the “alleged” assailant and confidently assert that he is a crazy, deranged, lunatic, mentally ill and schizophrenic. Former Vice President Dick Cheney told NBC News: “We need to be a little careful about assuming that somehow the rest of society or the political class bears the responsibility for what happened here when it was the act of a deranged, crazed individual that committed a crime.”

E. Fuller Torrey, a recognized expert on schizophrenic murderers, agrees. He refers to Loughner as “the alleged shooter” and states that he “is reported to have had symptoms associated with schizophrenia … and almost certainly was seriously mentally ill and untreated…. These tragedies are the inevitable outcome of five decades of failed mental-health policies.”

Torrey’s remedy for the problem of people being at liberty to commit crimes and suffer the consequences is intensifying the traditional legal-psychiatric practice of incarcerating innocent individuals and calling it “hospitalization” and “treatment” and even “suicide and crime prevention”: “The solution to this situation is obvious — make sure individuals with serious mental illnesses are receiving treatment. The mistake was not in emptying the nation’s hospitals but rather in ignoring the treatment needs of the patients being released…. Others are unaware they are sick and should be required by law to receive assisted outpatient treatment, including medication and counseling… If they do not comply with the court-ordered treatment plan, they can and should be involuntarily admitted to a hospital.”

In contrast, Ashley Figueroa, a former girlfriend of Loughner, told ABC News that she remembers Loughner as “a drug user with a grudge against the government…. I think he’s faking everything…. I think that he has been planning this for some time.” A writer for adds: “Figueroa is not a doctor, and these claims conflict with the opinion of top doctors in the field of psychiatry. (Dr. E. Fuller Torrey actually told Salon that Loughner looks like a ‘textbook’ case of paranoid schizophrenia.)”

True, Figueroa is not a “doctor.” Do we need to have a medical degree to diagnose a person we have never laid eyes on as schizophrenic? Does the fact that Figueroa knew Loughner, that they had a real-life human relationship, count for nothing?

It did not take long for authorities, in Arizona as well as nationally, to heed Torrey’s advice to cure would-be “schizophrenic murderers” by constricting the liberties of all Americans. On January 15, exactly one week after Loughner’s rampage, one of his victims, J. Eric Fuller, 63, a military veteran, attended a televised forum on “helping the community to heal” and angrily confronted a fellow participant with the metaphor, “You’re dead.” Fuller’s words were interpreted as a “threat,” and he was involuntarily committed for a 72-hour mental-health evaluation. According to CBS News, “[Pima County sheriff's spokesman Jason] Ogan said the hospital will determine when Fuller will be released.”

The war on words continued in Congress. Before Tucson, the Republicans opposed Obamacare, calling the bill “job killing.” Overnight, that term vanished from the political vocabulary, replaced by “job crushing” and other metaphors. Foolishly, Washington Post columnist Dana Milbank hailed this piece of semantic surgery: “[House Speaker John] Boehner, in a pair of statements on his Web page, dropped the ‘job-killing’ phrase in favor of ‘job-crushing’ and ‘job-destroying.’ House Majority Leader Eric Cantor … did not allow the k-word to escape his lips at Tuesday afternoon’s news conference…. [T]he new GOP majority generally showed a skill that had been lacking in the Republican caucus for the past two years: self-restraint.”

Wedded to the idea that we have two kinds of lawbreakers in America, sane and insane, we are unable to attend to the human problems we call “mental illnesses.” But not to worry, we can always operate on the vocabulary.


The Illegitimacy of the “Psychiatric Bible”

by Thomas Szasz

The Freeman December 2010 • Volume: 60 • Issue: 10

“Mental health experts ask: Will anyone be normal?” So read the title of a July 27 Reuters report. The “experts” warned that the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), scheduled for publication in 2013, “could mean that soon no-one will be classed as normal. . . . [M]any people previously seen as perfectly healthy could in future be told they are ill.”

This is not news. More than 200 hundred years ago Johann Wolfgang von Goethe (1749–1832) warned: “I believe that in the end humanitarianism will triumph, but I fear that, at the same time, the world will become a big hospital, each person acting as the other’s humane nurse.”

Moreover, Goethe foresaw the moral hollowness of the “humanitarian science” on which such therapeutic tyranny would rest: “I could never have known so well how paltry men are, and how little they care for really high aims, if I had not tested them by my scientific researches. Thus I saw that most men only care for science so far as they get a living by it, and that they worship even error when it affords them a subsistence.”

The depths to which such men would happily sink when worshiping error brings them fame and fortune became obvious only in the twentieth century.

Joaquim Maria Machado de Assis (1839–1908), the great Brazilian novelist and playwright, advanced the prescient literary satirization of the dark art of psychiatric diagnosis and the engine that drives it: the phony expert’s insatiable vanity and thirst for controlling his fellow man. His short story “O alienista” (1882, “The psychiatrist”) is a fable of a celebrated doctor retiring to a small town to pursue his scientific investigation of the human mind, gradually finding more and more of the townsfolk insane and needing to be incarcerated in his private asylum. Eventually he alone is left at liberty. As soon as modern psychiatry became a legitimate branch of medicine, Machado de Assis recognized and exposed its quintessentially unscientific-sadistic character.

It remained for the French playwright Jules Romains (1885–1972) to call public attention to the corruption of modern medicine by political power. “It’s a matter of principle with me,” declares his protagonist, “Dr. Knock” (1923), “to regard the entire population as our patients. . . . ‘Health’ is a word we could just as well erase from our vocabularies. . . . If you think it over, you’ll be struck by its relation to the admirable concept of the nation in arms, a concept from which our modern states derive their strength.”

Sigmund Freud (1856–1939), too, has played an important part in persuading people that health is an abnormal state. This old joke is illustrative: “If the patient is early for his appointment, he is anxious; if he is on time, he is obsessive-compulsive; if he is late, he is hostile.”

Particular psychiatric diagnoses have not escaped professional criticism. Wishing to make a name for themselves as psychiatrists, “critics” object to one or another diagnosis (homosexuality)—or to “overdiagnosis” (ADHD)—but continue to respect the American Psychiatric Association (APA) as a scientific organization and regard the various incarnations of the DSM as respectable legitimating documents. This is dishonest. Confronted with the DSM, the challenge we face is to delegitimize the authenticators, the APA and DSM, not distract attention from their fundamental phoniness by ridiculing one or another “diagnosis” and trying to remove it from the magical list.

I have consistently rejected this piecemeal approach. In my essay “The Myth of Mental Illness,” published in 1960, and in my book with the same title that appeared a year later, I stated my view forthrightly. I proposed that we view the phenomena conventionally called “mental diseases” as behaviors that disturb others (or sometimes the self), reject the image of “mental patients” as helpless victims of patho-biological events outside their control, and refuse to participate in coercive psychiatric practices as incompatible with the foundational moral ideals of free societies. In short, I rejected the authority of the APA as a legitimating organization and of the DSM as a legitimating document. I believe nothing less can undo the mischief wrought by the successive editions of the “psychiatric bible.”

Settled by Political Power

But times have changed. Fifty years ago it made sense to assert that mental illnesses are not diseases. It makes no sense to do so today. Professional debate about what counts as mental illness has been replaced by political-judicial decree. The controversy about the nature of so-called mental diseases/disorders has been settled by the holders of political power: They have decreed that “mental illness is a disease like any other.” Political power and professional self-interest have united in turning false beliefs into lying facts: “Mental illness can be accurately diagnosed, successfully treated, just as physical illness” (President William Clinton, 1999). “Just as things go wrong with the heart and kidneys and liver, so things go wrong with the brain” (Surgeon General David Satcher, 1999).

The claim that “mental illnesses are diagnosable disorders of the brain” is not based on scientific research; it is a deception and perhaps self-deception. My claim that mental illnesses are fictitious illnesses is also not based on scientific research; it rests on the pathologist’s materialist-scientific definition of illness as the structural or functional alteration of cells, tissues, and organs. If we accept this definition of disease, then it follows that mental illness is a metaphor, and asserting that view is stating an analytic truth not subject to empirical falsification.

For centuries the theocratic State exercised authority and used force in the name of God. The Founders sought to protect the American people from the religious tyranny of the State. They did not anticipate, and could not have anticipated, that one day medicine would become a religion and that the alliance between medicine and the State would then threaten personal liberty and responsibility exactly as they had been threatened by the alliance between church and State.

The Founders faced the challenge of separating the cure of souls by priests from the control of people by politicians. Today the therapeutic State exercises authority and uses force in the name of health. We face the challenge of separating the consensual treatment of patients by medical doctors from the coercive control of persons by agents of the State pretending to be healers.

When psychiatry was in its infancy the belief that all human “dysfunctions” are manifestations of brain diseases was a naive error. In its maturity the mistake was treated as a valid scientific theory and the justification for a powerful ideology and the powerful institutions based on it. Today, in its senescence, psychiatry is deceit and self-deceit—coercion concealed as objective science (“medical diagnosis”) and benevolent help (“medical treatment”). As a result, paraphrasing Orwell, telling the truth becomes “a revolutionary act.”

Madness, myth and medicine

Ron Roberts on the continuing relevance of
Thomas Szasz, now in his 91st year

vol 23, no 8, August 2010, pp. 694-695

Only after we abandon the pretence that mind is brain and that mental disease is brain disease can we begin the honest study of human behaviour and the means people use to help themselves and others cope with the demands of living (Szasz, 2007a, p.149).

Fifty years ago American Psychologist published a seminal article by the Hungarian-born psychoanalyst and psychiatrist Thomas Szasz, ‘The myth of mental illness’ (Szasz, 1960). The thesis was elaborated at length in a book of the same name a year later (Szasz, 1961).

As the decade got into full swing, Szasz’s critique of psychiatric theory and practice was herded into the same conceptual basket as the musings of Scottish psychiatrist R.D. Laing, and his erstwhile friend and collaborator David Cooper. The quite different ideas of these men came to be bracketed inappropriately under the rubric of ‘anti-psychiatry’ – an expression coined by Cooper though disclaimed by Laing and rejected outright by Szasz.

Since then biological psychiatry has developed a stranglehold on research, teaching and practice in the field of ‘mental health’, and Szasz’s opposition to psychiatry and the basis for it has been mislocated in the art and culture of the day, its relevance for today denied. Szasz’s view has become viewed by many as a supposed child of its time – a component in the social manufacture of the so-called anti-establishment Swinging Sixties. To let such misapprehension pass unchallenged into the history of the behavioural sciences would be a serious error, and Szasz for his part has constantly
endeavoured to set the record straight.

First it must be said that Szasz’s insights into the shortcomings of conventional psychiatry pre-date the 1960s by some considerable margin. In a brief autobiographical sketch Szasz makes clear that the absurdity of psychiatric fictions had dawned on him long before Fellini’s masterpiece was highlighting the shallowness of La Dolce Vita:
‘Everything I had learned and thought about mental illness, psychiatry, and psychoanalysis – from my teenage years, through medical school, and my psychiatric and psychoanalytic training – confirmed my view that mental illness is a fiction; that psychiatry, resting on force and fraud is social control, and that psychoanalysis – properly conceived – has nothing to do with illness or medicine or treatment’ (2004, p.22).

Szasz graduated in medicine in 1944, having migrated to the US from his native Hungary in 1938, a fugitive from the looming menace of Nazism. He undertook a psychiatric residency and trained in psychoanalysis. The appeal of psychoanalysis, besides its intellectual and interpersonal attractions, lay in its ostensibly consensual and contractual nature. Less well known than his other works, his dissection of power in psychoanalytic relationships – published as The Ethics of Psychoanalysis (Szasz, 1965) – is central to his thinking and stands complementary to the assertions that mental illness is a myth. In this Szasz effectively provides a practical guide on how to ensure a level playing field in psychotherapeutic relationships, to the benefit of both parties. He is honest and open enough to explicitly explore the role that money may play in distorting therapeutic means and ends. As such, it not only stands the test of time but stands squarely against the numerous vested interests, both pharmaceutical-financial and professional, which dominate the mental health industry past and present

Anti-psychiatry or pro-consent?

Szasz is not ‘anti’-psychiatry. He advocates the right to agree consensual contractual relations of any kind, including consensual psychiatry if that is what suitably informed people want. He has proposed, for example, the use of advanced psychiatric directives whereby people could agree to accept or refuse specific interventions to be made ‘on their behalf’ in the event of their becoming extremely distressed and ‘irrational’ in future. Such ideas have unfortunately been rejected outright by leading figures in both psychiatry and medical ethics, and accordingly Szasz sees little possibility of any kind of consensual psychiatry until the use of coercion, whether explicit or tacit, is relinquished.

As psychiatry continues to function for the most part as an extension of the criminal justice system, Szasz asserts that psychiatry in its current form must be abolished. This would require a concerted challenge to its support structures, premised as they are on the notions of behaviour as disease, the fear of dangerousness and the necessity for
medical treatment under the guise of protecting the individual from his or herself. The championing of the latter notion in particular owes much to an ignorance of its origins. A careful reading of Szasz’s historical analysis of the origins of the insanity defence in 17th-century England goes some way to clarifying where behavioural scientists got the idea from that people of ‘unsound mind’ were not responsible for their actions and could not be held accountable for them. In Coercion as Cure, he writes

With suicide defined as a species of murder, the persons sitting in judgment of self killers had the duty to punish them. Since punishing suicide required doing injustice to innocent parties…the wives and minor children of the deceased – eventually the task proved to be an intolerable burden. In the seventeenth century, men sitting on coroners’ juries began to recoil against desecrating the
corpse and dispossessing thesuicide’s dependants of their means of support. However, their religiousbeliefs precluded repeal of the laws punishing the crime. Their only recourse was to evade the laws; The doctrine that the self-slayer is non compos mentis and hence not responsible for his act accomplished this task (Szasz, 2007a, p.99)

And so a social practice became reified into an imaginary biological disease process
ravaging through the brains of its unfortunate victims, necessitating psychiatric

The label of ‘anti-psychiatry’ that continues to be attached to Szasz is one which he has been at pains to condemn (Szasz, 2009), used as it is to stultify and nullify any criticism of contemporary psychiatry. While Laing saw himself as ‘essentially on the same side’ as Szasz (Mullan, 1995, p.202), Szasz sees considerable distance between them, for a number of reasons. Perhaps at the forefront of these Laing was known to have forcibly drugged one of his patients (Szasz, 2008) and for all his eloquence and insight into human misery his writings do not in principle condemn the forced treatment or incarceration of people against their will on psychiatric grounds. Finally whilst The Divided Self (Laing, 1960) and Sanity Madness and the Family (Laing & Esterson, 1964) amongst other outpourings proclaimed the intelligibility of going mad within a
human rather than biological framework, Laing did not reject outright the notion of mental illness, which in Szasz’s view remains at best a metaphor.

Szasz has throughout his career stood firmly to his principles and steadfastly
eschewed psychiatric practice in an environment where people have been
deprived of their liberty. He has on occasion appeared in court both to represent individuals deprived of their liberty and to uphold the principle of criminal responsibility in murder cases where those accused have sought to evade it through the insanity defence (see Szasz, 2007b, chapter 13 in particular). Such consistent challenges to institutional psychiatry have been made at some professional cost. Szasz has not simply been the recipient of fierce criticism from the psychiatric fraternity, who feel
betrayed by his actions, but has also endured attempts to limit his academic freedom. In the aftermath of the publication of The Myth of Mental Illness, for example, attempts were made to ban him from teaching at the state hospital medical school – citing his beliefs as ‘proof’ of his ‘incompetence as a psychiatrist’ (Schaler, 2004, p.xix).

Some confusion about Szasz’s work has arisen through the quite different political cultures within which it is interpreted, even by those who oppose institutional psychiatry in its current incarnation. His work has been claimed and repudiated by those on both the ‘left’ and ‘right’ – deemed a liberal in some quarters and a fascist in others – with the claims and counterclaims rooted in the predilections of the critics for different
configurations of state power. European intellectual tradition on the left, for example, clings to a belief and a desire that state power can be harnessed for the good. This means that while Szasz’s attacks on psychiatric authority are applauded, his admonitions against the ‘therapeutic state’ (Szasz, 2001, 2002), with its merging of psychiatric and state power on the one hand and private and public health on the other, are glossed over. In truth, if such a thing can be said, Szasz’s ideas belong to neither the right nor the left. His work challenges and questions all operations of organised
power from the state downwards, as long as they are used to crush and oppress
human freedom. His work implies unanswered questions concerning the
forms of community and social organisation which people can harness for
the individual and common good in order to enable them to deal elegantly with the
insatiable demands of living.


While preparing this article I encountered Philippe Petit’s (2002) wondrous account of his high-wire walk across the twin towers of the World Trade Center in 1974. Immediately after performing his ‘artistic crime of the century’ Petit was arrested and subject to psychiatric examination. Petit was judged to be sane, but the outcome of the psychiatric interview is less revealing than the fact that psychiatrists were willing to play their part in a pseudo-medical intervention provoked by nothing more than social rule breaking of the highest imaginative order. It struck me that Petit – an imaginative, unusual and beguiling figure – exemplifies much that modern psychiatry stands in antipathy to. Petit cares not for the rules and regulations that structure and govern the lives of citizens and lives, in his terms, only to dream ‘projects that ripen in the clouds’ (Petit, 2002, p.6).

There can be little doubt that psychiatry is an enterprise that is engineered to destroy these – that it cannot tolerate idiosyncrasies of thought, whether grandiose or mundane. Petit succeeded in his outlandish and highly improbable quest – but why should one have to achieve outlandish success to be embraced by society and enjoy the right to pop one’s head in the clouds or spend the ‘afternoons in treetops’? Szasz’s efforts over the years can be seen in many lights, but without doubt he has toiled on behalf of the dream of human accountability and responsibility, for the freedom to be different and to take charge of one’s life, free from the machinations of statesponsored psychiatric interference.

Ron Roberts is a Senior Lecturer
in Psychology at Kingston University

The original article in pdf format


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"The Shame of Medicine:
Alan Turing Redux"

by Thomas Szasz
The Freeman, Volume: 60Issue:2 3/10

In my May 2009 column I recounted the tragic story of the medical-legal persecution of the famed British mathematician and World War II code breaker Alan Turing. In June, John Graham-Cumming, a British computer programmer, created a petition on the “No. 10 Downing Street” website asking for a government apology for Turing’s mistreatment. On September 10, Prime Minister Gordon Brown issued a formal apology on behalf of the U.K. government, stating, in part:

Earlier this year, I stood with Presidents Sarkozy and Obama to honour the service and the sacrifice of the heroes who stormed the beaches of Normandy 65 years ago. And just last week, we marked the 70 years which have passed since the British government declared its willingness to take up arms against fascism and declared the outbreak of the Second World War. So I am both pleased and proud that, thanks to a coalition of computer scientists, historians and LGBT [lesbian, gay, bisexual, and transgender] activists, we have this year a chance to mark and celebrate another contribution to Britain’s fight against the darkness of dictatorship: that of code-breaker Alan Turing.

Brown was clueless. Turing had nothing in common with LGBT activists. Comfortable in his identity as a homosexual man, he killed himself because the “treatment” “transgendered” him in ways he did not expect and was not told about. Calling Turing “a quite brilliant mathematician” was another of Brown’s gaucheries. Turing, Brown continued, “was one of those individuals we can point to whose unique contribution helped to turn the tide of war. The debt of gratitude he is owed makes it all the more horrifying, therefore, that he was treated so inhumanely.” Would Turing have been less deserving of belated compassion if he had been just another Englishman caught in the web of his country’s anti-homosexual laws?

“Laws,” warned Solon, the sixth-century B. C. Athenian philosopher, “are the spider’s webs which, if anything small falls into them they ensnare it, but large things break through and escape.” The special irony of the Turing case is that he was not treated as any ordinary violator of the prohibition against gay sex would have been: He was allowed to choose between imprisonment and “medical treatment.” He made the wrong choice. Despite his high intelligence and familiarity with medical crimes in the Third Reich, Turing failed to understand that medical criminals abound in all modern societies, most insidiously in so-called “free societies.”

Brown says that Turing was “treated inhumanely.” That’s not exactly true. He could have gone to prison, where he could have worked, had visitors, and would have been unmolested by psychiatrists, and from which he would have emerged physically and mentally undamaged, as had Gandhi, Nehru, Castro, and many other prominent historical figures. Turing was treated inhumanely because he as well as his doctors failed to heed George Washington’s famous warning: “Government is not reason; it is not eloquence; it is force. Like fire, it is a dangerous servant and a fearful master.”

Physicians who work for the government’s law-enforcement apparatus do not practice therapeutic medicine and are not healers. They practice anti-therapeutic prosecution, governed by the principle Primum nocere (first, do harm): They are professional injurers who define the harm they do as help. Such doctors are medical criminals, the gravity of their crimes depending on the particular laws they help to enforce and the methods they use.
Therapeutic Scapegoating

Turing was blind to the nature of the political system that victimized him. Brown is blind to the nature of the political system over which he presides and the fundamental similarities between it and the system he criticizes. Many more people are now persecuted in the United Kingdom (and in the United States) for “abusing” drugs than were persecuted for “abusing” sex. Neither of these modern (quasi-religious) scapegoat-persecutions could have occurred without the approval and assistance of medical professionals. Yet it does not seem to occur to Brown to mention the role of doctors in the Turing affair, much less blame them or suggest that they, too, owe apologies to Turing and others.

German politicians have apologized for the Holocaust. American politicians have apologized for slavery and post-Pearl Harbor concentration camps. Psychiatrists have not apologized for their institutionalized misdeeds. The American Psychiatric Association (or the Royal College of Psychiatrists) is not about to declare:

We apologize. We erred when we declared homosexuality a disease and the forcible injection of female sex hormones an effective treatment for it. We committed evil when, instead of joining the defenders of liberty and endorsing the abolition of anti-homosexual legislation, we eagerly supported the coercive apparatus of the State and prostituted ourselves in the service of the social control of society’s unwanted.

As an aside, it should be noted that the past medical treatment of homosexuals had included procedures such as surgical sterilization, carbon dioxide inhalation (a kind of suffocation by “gas-boarding”), and electric shock therapy.

Psychiatrists will never apologize for their crimes because they never acknowledge responsibility for harming people. For example, when criticized for depriving people of liberty, they assert that they do not commit mentally ill persons to insane asylums—judges do. “Mental health professionals must understand,” explains Robert Simon in Psychiatry and Law for Clinicians, “that it is not they who make commitment decisions about patients. Commitment is a judicial decision that is made by the court or by a mental health commission.” Psychiatrists call ordinary criminals who deny responsibility for their misdeeds “psychopaths” and say they have no conscience. Doctors, lawyers, politicians, and the press call psychiatrists who deny responsibility for 300 years of psychiatric slavery “conscientious physicians” and honor them as medical healers. Reality, not just history, is written by the victors.

As long as psychiatrists are accepted as medical specialists possessing the privilege to forcibly classify persons as patients and impose tortures on them as treatments, they will not apologize. Acknowledging that the classification of homosexuality as a disease was a mistake would open a Pandora’s box of doubts about the disease status of currently fashionable mental illnesses.

Brown ended by exulting, “This recognition of Alan’s status as one of Britain’s most famous victims of homophobia is another step towards equality, and long overdue. . . . Alan and the many thousands of other gay men who were convicted, as he was convicted, under homophobic laws, were treated terribly.”

Turing was not a victim of homophobia. Many persons are still “homophobic”—and “phobic” as well of Catholics, Jews, Muslims, and atheists, among others—but they have no power to deprive the persons they fear and hate of liberty. Turing was the victim of medical doctors who declared male homosexuals ill and declared torturing them a form of humane “medical treatment.”

The Freeman, Volume: 60Issue:2 3/10

The Shame of Medicine:
The Case of General Edwin Walker

by Thomas Szasz
The Freeman, Volume: 59 • Issue: 8 10/09

In 1962 James Meredith, an African-American student, tried to enroll at the University of Mississippi. His admission was opposed by Ross Barnett, the Democratic governor of the state, former Major General Edwin A. Walker (1909–1993), a decorated hero of World War II and prominent “right-winger,” and a group of segregationist white students. To ensure Meredith’s enrollment and maintain order, President John F. Kennedy sent 400 federal marshals and 3,000 troops to Oxford, Mississippi.

On September 29, 1962, Walker issued a public statement: “This is Edwin A. Walker. I am in Mississippi beside Governor Ross Barnett. I call for a national protest against the conspiracy from within. Rally to the cause of freedom in righteous indignation, violent vocal protest, and bitter silence under the flag of Mississippi at the use of Federal troops. . . .”

The campus demonstration led to a riot in which two people were killed and six federal marshals were injured. Importantly, according to a United Press report, “During a lull in the rioting, General Walker mounted a Confederate statue on the campus and begged the students to cease their violence. . . . His plea was greeted with one massive jeer.”

Unnoticed at the time and forgotten today is the fact that while the federal government used the military to guarantee Meredith’s constitutional right to equal protection of the laws, it used psychiatry to deprive Walker of his constitutional right to trial. This was another example of my long-held view that we are replacing social controls justified by race with social controls justified by psychiatric diagnosis.

Guilt by Diagnosis

Arrested on four federal charges, including “inciting, assisting, and engaging in an insurrection against the authority of the United States,” Walker was taken before a U.S. commissioner and held pending the posting of $100,000 bond. While he was making arrangements to post bail, Attorney General Robert Kennedy ordered Walker flown, on a government aircraft, to Springfield, Missouri, to be incarcerated in the U.S. Medical Center for Prisoners for “psychiatric observation” on suspicion that he was mentally unfit to stand trial.

Walker’s entry in Wikipedia mentions neither this nor the ensuing confrontation between Walker’s legal team and the government’s psychiatric team. The reader is told only that Walker “posted bond and returned home to Dallas, where he was greeted by a crowd of 200 supporters. After a federal grand jury adjourned in January 1963 without indicting him, the charges were dropped.”

How could this happen? Was it legal? It was legal, and in Psychiatric Justice (1965) I presented a detailed, documented account of how it happened. Here I wish to add a few personal details not previously reported.

News of Walker’s psychiatric incarceration had barely hit the newspapers when I received a telephone call from Robert Morris, then president of the University of Dallas, formerly chief counsel to the Senate Judiciary Subcommittee on Internal Security. He identified himself as one of Walker’s attorneys, explained he had been given my name by William F. Buckley, Jr., and asked me to help his team to free Walker from psychiatric imprisonment.

I flew to Dallas and spent a long afternoon and evening with Morris and his team of lawyers. They believed it was obvious that Walker was sane. They wanted me to examine him and say so in court. It was not easy to disabuse them of their conventional beliefs about mental illness as a medical disease and psychiatry as a medical specialty. I summarized the evidence for my view that psychiatry is a threat to civil liberties, especially to the liberties of individuals stigmatized as “right-wingers,” illustrated by the famous case of Ezra Pound, who was locked up for 13 years while the government ostensibly waited for his “doctors” to restore his competence to stand trial. Now the Kennedys and their psychiatrists were in the process of doing the same thing to Walker.

I reminded the attorneys that a courtroom confrontation concerning his “sanity” would not be a search for truth or justice (which they well understood), and noted that they were on the losing side of the civil rights battle (which they well knew). I urged them to avoid unnecessary dramatics and focus on freeing Walker from psychiatric detention as their sole goal. Finally, I persuaded them that in a Mississippi courtroom, I–with a foreign name and a foreign accent–would not be the best possible expert for Walker and talked them out of their plan to have me examine him and engage in a contest of “expert opinions” about the predictably dire diagnoses of the government’s psychiatric experts. Instead, I proposed that they “nominate” a prominent Dallas university psychiatrist as their defense expert–that is, a local, publicly employed physician who could ill afford to declare Walker insane on the basis of his “racist” views. (Before the Civil War, proslavery physicians in the South diagnosed black slaves who tried to escape to the North as mentally ill, “suffering from drapetomania.” In the Walker case, pro-integration psychiatrists in the North diagnosed white segregationists as mentally ill, “suffering from racism.”) Next morning I flew back to Syracuse.

For Whose Own Good?

A competency hearing was scheduled. Dr. Robert L. Stubblefield, chief psychiatrist at the Southwest Medical Center in Dallas, was to examine Walker and testify in his defense. The prosecution’s expert was Dr. Manfred Guttmacher, long-time chief medical officer at Baltimore City’s Supreme Court. Walker’s attorneys had no trouble exposing Guttmacher for the evil quack he was. Guttmacher kept referring to Walker as if Walker were his patient and supported the prosecution’s request that Walker be incarcerated (“hospitalized”) for up to three months, testifying under oath that doing so would be “for Mr. Walker’s own good from a medical point of view.”

In the end, the government’s psychiatric plot failed. Walker was declared mentally fit to stand trial, a federal grand jury refused to indict him, and the charges against him were dropped.

Less than two years later, my view that organized American psychiatry was becoming overtly political, seeking the existential invalidation and psychiatric destruction of individuals who do not share the psychiatric establishment’s left-liberal “progressive” views, received further dramatic support. In 1964, when Senator Barry Goldwater was the Republican candidate for president, 1,189 psychiatrists publicly declared–without benefit of examination–that Goldwater was “psychologically unfit to be President of the United States.” Many offered a diagnosis of “paranoid schizophrenia” as the basis for their judgment.

Psychiatry is despotism in the service of the Therapeutic State, rationalized as “progressive” science and “compassionate” medical care. In the past, racial stigmatization and segregation were indispensable for the political class and the State. Today, psychiatric stigmatization and segregation are indispensable for the political class and the State. This is why no exposure of brutal psychiatric injustices makes a dent in the mental health system’s lofty social status as a benevolent, ethical, scientific medical discipline.

The Freeman, Volume: 59 • Issue: 8 10/09



Psychiatry: The Shame of Medicine

by Thomas Szasz
The Freeman, 59: 12-13 (March), 2009

The practice of medicine rests on cooperation and the ethical-legal premise that treatment is justified by the patient’s consent, not his illness. In contrast, the practice of psychiatry rests on coercion and the ethical-legal premise that treatment is justified by the mental illness attributed to the patient and must be “provided” regardless of whether the patient consents or not. How do physicians, medical ethicists, and the legal system reconcile the routine use of involuntary psychiatric interventions with the basic moral rule of medicine, “Primum non nocere,” a Latin phrase meaning “First do no harm”?

The answer is: by the medicalization of conflict as disease, and coercion as treatment. Carl Wernicke (1848-1905), one of founders of modern neuropathology, observed, “The medical treatment of [mental] patients began with the infringement of their personal freedom.” Today, it is psychiatric heresy to note, much less emphasize, that psychiatry-as-coercion is an arm of the punitive apparatus of the state. Absent the coercive promise and power of mental health laws, psychiatry as we know it would disappear.

Ever since its beginning approximately 300 years ago, psychiatry’s basic function has been the restraint and punishment of troublesome individuals justified as hospitalization and medical care. For two centuries, all psychiatry was involuntary psychiatry. A little more than 100 years ago individuals began to seek psychiatric help for their own problems. As a result, the psychiatrist became a full-fledged double agent and psychiatry a trap. The film “Changeling”--written by J. Michael Straczynski and directed by Clint Eastwood--is a current example.

The story, set in Los Angeles in 1928, is said to be the “true story” of a woman, Christine Collins, whose son, Walter, is kidnapped. The police are corrupt, and little effort is made to find Walter. Months pass. To repair its damaged image, the police decide to stage a reunion between an abandoned youngster pretending to be Walter and his mother, played by Angelina Jolie. Unsurprisingly, she realizes that the fake Walter is not her son. After confronting the police and city authorities, she is vilified as an unfit mother, branded delusional, and incarcerated in a “psychopathic ward,” where she is subjected to the brutalities of sadistic psychiatrists and nurses, and watches fellow victims being punished by electric shock treatment--ten years before its invention. So much for the truth of the story.

Clueless about the true nature of the psychiatric terrorization to which the Jolie character is subjected, film critic Kirk Honeycutt praises Clint Eastwood who “again brilliantly portrays the struggle of the outsider against a fraudulent system. . . . ‘Changeling’ brushes away the romantic notion of a more innocent time to reveal a Los Angeles circa 1928 awash in corruption and steeped in a culture that treats women as hysterical and unreliable beings when they challenge male wisdom.’”

The Jolie character does not simply challenge “male wisdom.” Instead, her actions illustrate the insight of the Hungarian proverb, “It is dangerous to be wrong but fatal to be right.” The psychiatrist as brutal agent of the state enters the story only after the mother proves--by securing the testimony of her son’s teacher and dentist--that “Walter” is an impostor. The psychiatrically incarcerated individual’s greatest crime--for which psychiatrists cannot forgive her--is that she is innocent of lawbreaking and objects to being deprived of liberty.

Medicalized Terrorism
Psychiatric coercion is medicalized terrorism. So-called critics of psychiatry--who often fail or refuse to distinguish coerced from contractual psychiatry--are unable or unwilling to acknowledge this disturbing truth. As a result, the more things change in psychiatry, the more they remain the same, as the following conveniently forgotten example illustrates.

On May 21, 1839, Elizabeth Parsons Ware (1816-1897) married the Reverend Theophilus Packard. The couple and their six children resided in Kankakee County, Illinois. After years of marriage, Mrs. Packard began to question her husband's religious and pro-slavery beliefs and express opinions contrary to his. In 1860 Mr. Packard decided that his wife was insane and proceeded to have her committed. She learned of this decision on June 18, 1860, when the county sheriff arrived at the Packard home to take her into custody. The law at the time stated that married women “may be entered or detained in the hospital [the Jacksonville State Insane Asylum] at the request of the husband of the woman or the guardian . . . without the evidence of insanity required in other cases.”

Mrs. Packard spent the next three years in the Asylum. In 1863, due largely to pressure from her children who wished her released, the doctors declared her incurable and released her. Mrs. Packard stayed close to her children, retained their support, founded the Anti-Insane Asylum Society, and published several books, including Marital Power Exemplified, or Three Years Imprisonment for Religious Belief (1864) and The Prisoners’ Hidden Life, Or Insane Asylums Unveiled (1868).

The Beginning, Not the End
Little did Mrs. Packard realize that she was living at the beginning, not the end, of the Psychiatric Inquisition. Today, “inquiry” into the minds of unwanted others is a pseudoscientific racket supported by the therapeutic state. Millions of school children, old people in nursing homes, and persons detained in prisons are persecuted with psychiatric diagnoses and punished with psychiatric treatments. Nor is that all. Untold numbers of Americans are now psychiatric parolees, sentenced by judges--playing doctors--to submit to psychiatric treatment as so-called outpatients, or face incarceration and forced treatment as inpatients.

The subtext of films such as “Changeling” is always subtle psychiatric propaganda seeking to make people believe they are witnessing past “psychiatric abuses.” The truth is that every new psychiatric policy or practice labeled an “advance” is a step toward making psychiatric deception and brutalization more legal and more difficult for the victim to resist.

As I write this column, I learn from an “antipsychiatry” website that a man named Ray Sandford is being subjected to court-ordered outpatient electroshock treatment.

“Each and every Wednesday, early in the morning, staff shows up at Ray’s sheltered living home called Victory House in Columbia Heights, Minnesota, adjacent to Minneapolis. Staff escorts Ray the 15 miles to Mercy Hospital. There, Ray is given another of his weekly electroconvulsive therapy (ECT) treatments, also known as electroshock. All against his will. On an outpatient basis. And it’s been going on for months.”

As the forced psychiatric treatment of competent adults living in their own homes becomes the “standard of medical practice,” the failure to provide such betrayal and brutality becomes medical malpractice. In a democracy people are said to get the kind of government they deserve. In a pharmacracy they get the kind of psychiatry they deserve.


Questioning One’s Insanity

by Thomas Szasz
Liberty, 23: 27-28 (March), 2009.

"The Changeling," the recent Clint Eastwood movie, “reveals the perversity of a system in which it is virtually impossible to prove one’s sanity,” writes Jo Ann Skousen (Liberty, Jan.-Feb. 2009). This statement completely misses or avoids the point about the problem psychiatric incarceration poses for many libertarians.

To begin, the term “insanity” refers to a judgement, not a phenomenon or illness or fact. In “The Changeling,” the Angelina Jolie character, has no trouble proving to her son’s dentist and teacher that the boy impersonating the child is not her son. She has trouble proving it to the police and the psychiatric system. Why? Because they are corrupt and destructive, each having its own fish to fry. The police’s fish is staging a publicity stunt to enhance its soiled image. Psychiatry’s fish is convincing the world and itself that the lie that insanity is an objectively identifiable illness “like any other” is true.

When psychiatrists categorize (“diagnose”) an unwanted individual as “mentally ill” or “insane,” they do not describe or identify a disease, they delegitimize a person or behavior--formerly homosexuality, now substance abuse. However, our culture and laws authenticate psychiatrists as bona fide medical doctors and define the “conditions” they call “mental illnesses” as diseases on a par with cancer and diabetes. At the same time, psychiatrists continue to incarcerate “mentally sick” persons and possess the power to compel “patients” to submit to unwanted invasions of their bodies with toxic chemicals and electrically induced grand mal seizures.

How do friends of freedom deal with the conflict between elementary libertarian principles and prevailing psychiatric practices? This is the question I addressed and answered in my book "Faith in Freedom: Libertarian Principles and Psychiatric Practices" (2004). The distinguishing feature of the libertarian philosophy of freedom is the belief that self-ownership is a basic right and initiating violence is a fundamental wrong. In contrast, psychiatric practice is based on the belief that self-ownership-- epitomized by suicide--is a medical wrong and that initiating violence against persons called “mental patients” is a medical right.

Are self-medication and self-determined death exercises of rightful self-ownership, or manifestations of mental diseases requiring deprivation of liberty? Does deprivation of liberty under psychiatric auspices constitute odious preventive detention, or is it beneficial, therapeutically justified hospitalization? Should forced psychiatric drugging be interpreted as assault and battery or medical treatment?

These questions point to delicate, embarrassing, uncomfortable human dilemmas that most people prefer to avoid. Although "Faith in Freedom" received glowing prepublication endorsements from several prominent libertarian scholars, neither Liberty nor Reason reviewed it.

Skousen describes the Jolie characte’s psychiatric imprisonment as follows: “When she complains to the police and begs them to continue the search [for her kidnapped son], the police chief has her committed.” Skousen realizes that there is a problem here that stares us in the face and yet we do not want to look at:
It’s a frightening issue, one that hasn’t gone away: many states have the equivalent of Florida’s Baker Act, under which a person can be committed to 30 days in a mental institution without recourse, if a psychologist [sic, not psychiatrist] deems the person dangerous to himself or others. (And when the psychologist is employed by the police department, it’s pretty easy to predict whether the detainee will be so deemed. My own daughter came frighteningly close to being Bakered when she was 17, so I know how quickly it can happen.)

Nevertheless, Skousen avoids a more serious moral engagement with the routine use of psychiatric coercions (and excuses) in the United States. She is not alone.

Deirdre McCloskey--the Tinbergen Distinguished Professor at Erasmus University in Rotterdam--is an internationally recognized economic historian, teacher, and writer. In addition to numerous works on economics, she is the author of "Crossing: A Memoir" (1999), an autobiographical account of her journey from Donald to Deirdre McCloskey. What makes McCloskey’s "Memoir" of particular interest and importance is that she is, to my knowledge, the only prominent libertarian who has been personally violated by psychiatrists: she was “hospitalized”--twice--because she “suffered” from a dread disease called “transsexualism.” If not for her professional and social status, good attorney, and financial ability to fight the Chicago psychiatric machine, McCloskey might still be languishing in some Illinois state mental hospital. And she, too, probably wisely, chose to not engage the psychiatric Leviathan.

In a review of "Crossing" in the New York Times, the poet and writer Maxine Kumin attributes McCloskey’s ordeal in part to mistakes by poor psychiatrists:

His sister and one of her academic colleagues played a sinister role in trying to thwart him. They conspired to have him committed as mentally incompetent--unfit to sign papers for optional surgical procedures. . . . Twice during his determined journey into womanhood, they managed to have him incarcerated--handcuffed, locked away where he could not harm himself, at first in the University of Iowa Hospital's mental ward and later in the University of Chicago Hospital--to await evaluations by psychiatrists whose knowledge of his situation was less than rudimentary. The shrinks he had the misfortune to encounter seemed still to be operating at a pre60's level.

The truth is that the psychiatrists McCloskey encountered were among the leaders of the profession. In Iowa, McCloskey’s psychiatrists were Raymond Crowe, Professor of Psychiatry, an expert on Genetics and Developmental Neurobiology, a “seasoned, well-funded researcher”; and Robert Robinson, Professor and Chairman of the Department of Psychiatry, a recognized researcher in neuropsychiatry, and former Chairman of the Neurosciences Review Committee, National Institute of Mental Health. In Chicago, McCloskey’s psychiatrist was Fred Ovsiew, a Member of the American Psychoanalytic Association, Associate Professor of Clinical Psychiatry at the University of Chicago, and director of its Inpatient Psychiatric Unit. These men cannot be dismissed in the way Kumin dismisses them. The fact that she assumes the doctors who abused McCloskey were bungling psychiatric troglodytes speaks for itself.

Revealing her inability to see past the psychiatric rhetoric to the psychiatric slavery it conceals, Kumin remarks, “Gender crossers are still waiting for the gender identity disorder to be removed from the list of mental illnesses.” After their experiences with the mental health system, I would expect at least some gender crossers to scoff at psychiatric diagnoses and not care what unpopular behaviors psychiatrists classify as diseases. During my own lifetime, psychiatrists have removed masturbation, fellatio, cunnilingus, and homosexuality from the list of mental illnesses, yet managed to triple and quadruple the number of disorders listed in the American Psychiatric Association=s (APA) "Diagnostic and Statistical Manual," adding, for example, caffeinism, nicotinism, dysmorphobia, and pathological gambling.

The legitimacy of psychiatry rests entirely on its being a branch of medicine. It has no legitimacy as a quasi-theological system allied with the state for the forcible resolution of family conflicts and social problems. Sadly, there is, in modern society, no legitimate space for thinking and speaking clearly about psychiatry. Even emphasizing the differences between consensual psychiatric practices helping patients and coercive psychiatric practices harming them is now anathema.

The practices of psychiatric slavery are deeply embedded in our society. Even an account as fine as "Crossing," written by so eminent a witness as Deirdre McCloskey, makes no impact on the unquestioning approval of this peculiar institution by bioethicists, journalists, writers--and many libertarians.


The Therapeutic State ~
Mendacity by Metaphor

by Thomas Szasz
The Freeman, Vol. 58 No. 8  (Oct., 2008)

Once upon a time, law-abiding citizens acknowledged that they wanted lawbreakers punished. They did not say the offenders “needed” punishment. When they used the term “need” metaphorically—as when an outlaw in a bar told his buddies that one of their adversaries “needed” killing—they knew what they were talking about. They did not lie to themselves, nor did they deceive others. This is no longer true. In our society soaked in psychiatry, we systematically use the term “need” metaphorically, to lie to ourselves and to deceive others. Here is an example.

In February 2008 David Tarloff—a career “schizophrenic”—is released from a type of prison we call “hospital.” Ten days later he kills a psychologist who shares offices with a psychiatrist whom Tarloff holds responsible for depriving him of liberty. In June the New York Times reports: “A lawyer for a schizophrenic man accused of killing an Upper East Side psychotherapist tried three times on Tuesday morning to persuade his client to leave his holding cell for a hearing.” The lawyer was unsuccessful. Tarloff was not interested in being cooperative. He was interested in his life situation as he saw (constructed) it. Of course there is nothing new about defendants—especially defendants charged with a capital crime—not cooperating with the judicial system. What is new about it is the way the medical-judicial system now deals with such a person. According to the Times,

    The hearing, held in a small courtroom at Bellevue, was held to decide whether doctors could force Mr. Tarloff to take his medication. . . . Justice John E. H. Stackhouse of State Supreme Court in Manhattan granted the hospital’s request. . . . Ronald L. Kuby, a defense lawyer, said medication was too often used to create a false sense of sanity. “When the jury sees your client sitting there calmly, peacefully, sort of blankly staring, that person then looks sane,” Mr. Kuby said. “But that’s a chemically induced stability designed to make the judicial railroad function.” . . . “When somebody is in need of medication,” Mr. Konoski [Tarloff’s principal attorney] said, “forcing them not to have it, forcing them to deal with their demons instead of being able to suppress them through the medication, that’s almost like torture.” [Emphasis added.]

Voilà: The defendant who refuses to ingest a chemical straitjacket has a medical need for the drug. Acceding to the defendant’s wish to not be chemically restrained is torturing him. Only in the age of psychiatry could people believe such brazen lies.

I was a trained physician and psychoanalyst before the advent of the class of chemicals we call “psychiatric drugs.” I well remember watching—1954 or 1955, when I was serving my required military tour of duty at the National Naval Medical Center in Bethesda, Maryland—what must have been one of the first films promoting chlorpromazine, patented in the United States as Thorazine. The film showed monkeys, rendered irritable and aggressive by starvation and crowding, being injected with the drug and becoming “tranquilized.” The term was new then. This, we were told, was the new cure for schizophrenia. I did not like what I saw and immediately wrote the following: “The widespread acceptance and use of the so-called tranquilizing drugs constitutes one of the most noteworthy events in the recent history of psychiatry. . . . These drugs, in essence, function as chemical straitjackets. . . . When patients had to be restrained by the use of force—for example, by a straitjacket—it was difficult for those in charge of their care to convince themselves that they were acting altogether on behalf of the patient. . . . Restraint by chemical means does not make [the psychiatrist] feel guilty; herein lies the danger to the patient.”

This, then, was the glorious—but unacknowledged and unacknowledgeable—psychopharmacological breakthrough: Restraint could be put in the patient instead of on him and be defined as “drug treatment” (of and for the patient). It was obvious from the start that neuroleptic drugs benefit psychiatrists, not patients. Psychiatrists deal with this predictable result by attributing it to a newly invented mental¬-brain disease they call “anosognosia.”

In 1931 Robert Frost (1874–1963) delivered a lecture at Amherst College with the unexciting title “Education by Poetry.” It is a profound meditation on, and warning about, uses and abuses of metaphor. Long before I “discovered” the vast errors hidden from us by the metaphor of mental illness, Frost wrote:

    Health is another good word. And that is the metaphor Freudianism trades on, mental health. And the first thing we know, it has us all in up to the top knot. . . . What I am pointing out is that unless you are at home in the metaphor, unless you have had your proper poetical education in the metaphor, you are not safe anywhere. Because you are not at ease with figurative values: you don’t know the metaphor in its strength and its weakness. You don’t know how far you may expect to ride it and when it may break down with you. You are not safe with science; you are not safe in history. . . . They don’t know what they may safely like in the libraries and galleries. They don’t know how to judge an editorial when they see one. They don’t know how to judge a political campaign. They don’t know when they are being fooled by a metaphor, an analogy, a parable. And metaphor is, of course, what we are talking about. Education by poetry is education by metaphor.

Paraphrasing that phrase, I suggest that education by psychiatry is education by and with mendacity, a thesis I have maintained for more than half a century.

Recent reports in the press exposed Dr. Joseph Biederman, professor of psychiatry at Harvard Medical School, and his collaborators of failing to report “at least $3.2 million dollars they had received from drug companies between 2000 and 2007,” violating federal and university research rules designed to police potential conflicts of interest.

Biederman is said to be “one of the most influential researchers in child psychiatry, whose work has helped to fuel a controversial 40-fold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder, characterized by severe mood swings, and a rapid rise in the use of antipsychotic medicines in children.”

He is confident that the children whose behavior displeases their mothers suffer from a brain disease that requires pharmacological treatment. But is drugging children allegedly suffering from “pediatric bipolar disease” analogous to vaccinating them against smallpox, as Biederman suggests? Never mind that antipsychotic drugs are promoted as therapeutic agents, not as prophylactics. Never mind that press reports routinely refer to antipsychotic drugs as subduing involuntary subjects. And never mind that the modern psychiatrists’ favorite “patients” are persons who are powerless to resist being cast in that role: children, prisoners, and old people in nursing homes.

If you are ignorant of metaphor, warned Frost, “You are not safe with science; you are not safe in history . . . in the libraries and galleries.” You are certainly not safe if you believe that psychiatrists care for and cure sick people, when in fact they coerce and control persons helpless to resist their violence.


Anti-Coercion Is Not Anti-Psychiatry
by Thomas Szasz

The Freeman, 58: 26-27 (May, 2008)

The term "anti-psychiatry" was created in 1967 by the South African psychiatrist, David Cooper (1931-1986) and the Scottish psychiatrist Ronald David Laing (1927-1989). Instead of defining the term, they identified it as follows: "We have had many pipe-dreams about the ideal psychiatric, or rather anti-psychiatric, community." The "we" were Cooper, Laing, Joseph Berke, and Leon Redler, the latter two American psychiatrists and pupils of Laing.

"A key understanding of 'anti-psychiatry,'" explains British existential therapist Digby Tantam, "is that mental illness is a myth (Szasz 1972)." Alas, this is not true. While many antipsychiatrists pay lip service to rejecting the "medical model" of psychiatry, they continue to conceptualize certain human problems and efforts to resolve them in medical terms and, even more importantly, do not categorically reject "therapeutic" coercion and excuse-making.

Psychiatrists engage in many phony practices but none phonier than the insanity defense. The antipsychiatrists have not addressed this subject in their writings but Laing gave "expert psychiatric testimony" in the famous case of John Thomson Stonehouse (1925-1988). Stonehouse, a British politician and Labour minister, went into business, lost money, and tried to bail himself out by engaging in fraud. When the authorities were about to arrest him, he staged his own suicide. On November 20, 1974, Stonehouse left a pile of clothes on a Miami beach and disappeared. Presumed dead, he was en route to Australia, hoping to set up a new life with his mistress. Discovered by chance in Melbourne, he was deported to the UK and charged with 21 counts of fraud, theft, forgery, conspiracy to defraud, and causing a false police investigation.

Stonehouse pleaded not guilty by reason of insanity, was convicted and sentenced to seven years in prison. To support his insanity defense, he secured the services of five psychiatrists, R. D. Laing among them, to testify in court, under oath, that he was insane when he committed his criminal acts. In his book, My Trial, Stonehouse writes: "Dr. Ronald Laing ...gave evidence on my mental condition. He confirmed ... that in his report he had called it psychotic and the splitting of the personality into or multiple pieces. He went on: 'The conflict is dealt with by this splitting instead of dealing with it openly. ... It was partial reactive psychosis.'"

Laing did not know Stonehouse prior to his trial, hence could have had no knowledge of his "mental condition" during the commission of his crimes. Laing's "diagnosis" was classic psychiatric gobbledygook, precisely the kind of charlatanry he pretended to oppose. Laing and Stonehouse were both liars, plain and simple.

Laing's fame was closely connected with his role as Emperor of Kingsley Hall, a "household" founded by him and by a group of his acolytes. It was promoted as a place to which a person -- whom psychiatrists would diagnose as schizophrenic -- could retreat, secure in the knowledge that he would be neither coerced nor drugged. Day to day life in Kingsley Hall was based on the fiction that all the "residents" are equal, no one is a patients and no one is staff. The American psychiatrist Morton Schatzman, who had chosen to live at Kingsley Hall for a year, emphasized that "No one who lives at Kingsley Hall sees those who perform work upon the external material world as 'staff,' and those who do not as ‘patients.'" This is the lie that characterizes antipsychiatry, much as the lie that deprivation of liberty is care not coercion characterizes psychiatry.

The American writer Clancy Sigal (born 1926) went to London to be Laing's patient. Soon, the "therapy" ended and they became friends and LSD-using buddies. Sigal, one of the co-founders of Kingsley Hall, eventually became disenchanted with the Laingian commune, especially after he discovered that Laing and his cohorts preached nonviolence but practiced violence.

After returning to the United States, Sigal wrote a devastating exposé of Laing and his cult. Zone of the Interior, a roman a clef, was published in the United States in 1976. Using the threat of British libel laws, Laing prevented its publication in the United Kingdom. Only in 2005 did Zone of the Interior appear in a British edition. Sigal writes: "In September 1965, during the Jewish High Holidays, I had a 'schizophrenic breakdown' ... or transformative moment of rebirth. It's all in your point of view. My ´breakdown' did not happen privately but acted out in front of twenty or thirty people on a Friday shabbat night at Kingsley Hall.... The notion behind Kingsley Hall was that psychosis is not an illness but a state of trance to be valued as a healing agent."
In an interview after the publication of Zone of the Interior in the UK, Sigal described his folie a deux with Laing:

We began exchanging roles, he the patient and I the therapist, and took LSD together ... Laing and I had sealed a devil's bargain. Although we set out to 'cure' schizophrenia, we became schizophrenic in our attitudes to ourselves and to the outside world. ... [One] night, after I left Kingsley Hall, several of the doctors, who persuaded themselves that I was suicidal, piled into two cars, sped to my apartment, broke in, and jammed me with needles full of Largactil [Thorazine], a fast-acting sedative used by conventional doctors in mental wards. Led by Laing, they dragged me back to Kingsley Hall.... The last thing I remember saying was, "You bastards don't know what you're doing."

Sigal escaped from Kingsley Hall, returned to the United States, and, in 1975, published Zone Of The Interior. Publication in Britain was stopped by Laing's threat of libel action. The Sigal saga ought to be the last nail in the coffin of the legend of Laing as a psychiatrist opposed to the practice of psychiatric coercion.

Had Sigal's book been published in Britain in 1976, Laing would have been exposed and perhaps punished as a criminal (for assault and battery), Kingsley Hall might have been shut down (as an unlicensed mental hospital), and the legend of Laing the "savior of the schizophrenic" would have been cut short. Shakespeare was right: "The evil that men do lives after them."

The End of the Kingsley Hall Chaos

The chaos at Kingsley Hall endured for less than five years. The inhabitants left the place "derelict and uninhabitable." Unfortunately, the imbecilic term "antipsychiatry" survived, even though, ironically, Cooper and Laing knew full well that it was mischievous and misleading. In an interview toward the end of his life, Laing recalled having said to Cooper: "'David, it is a fucking disaster to put out this term.' But he'd a devilish side that thought it would just serve them all right and confuse them. So let's just fuck them with it."

As a result of the antipsychiatrists's self-seeking sloganeering, psychiatrists can now do what no other members of a medical specialty can do: they can dismiss critics of any aspect of accepted psychiatric practice by labeling them "antipsychiatrists." The obstetrician who eschews abortion on demand is not stigmatized as an "antiobstetrician." The surgeon who eschews transsexual operations is not dismissed as an "antisurgeon." But the psychiatrist who eschews coercion and excuse-making is called an "antipsychiatrist." The upshot is that every physician -- except the psychiatrist -- is free to elect not to perform particular procedures that offend his moral principles or procedures he simply prefers not to perform.

Why is the psychiatrist de facto deprived of this freedom? Because in psychiatry the paradigmatic practice -- coercing patients deemed to be dangerous to themselves or others, called "civil commitment" -- is the medico-legal "standard of care." Deviation from that standard invites malpractice litigation and exposes the "deviant" psychiatrist to forfeiture of his medical license.


Book review by Andrew Scull:
"Untruly Madly Deeply"
in The TLS, January 19, 2007


The madness and marriage of Virginia Woolf.
By Thomas Szasz

Many might be tempted to call Thomas Szasz the enfant terrible of modern psychiatry, save for the fact that he is now eighty-six years of age: obviously, enfant no longer applies. For years, Szasz was a Professor of Psychiatry at the State University of New York Upstate Medical Center at Syracuse. And yet, from 1961 onwards, he consistently proclaimed that mental illness, the presumed object of the psychiatrist's attentions, was a myth -a myth created and nurtured by self-interested professionals acting as agents of social control, either on behalf of families or, more sinisterly, the leviathan State. Disease was a predicate of bodies, and "mental illness", having no demonstrable biological cause, could only be metaphorically and mendaciously classified as a medical matter. So far from being disinterested therapists seeking to assist and cure their patients, psychiatrists were bad-faith con artists in the business of oppressing their patients, stigmatizing them, damaging them with drugs and electric shocks, depriving them of their liberty and their basic human rights. Such false experts, who were no better than concentration-camp guards, served routinely as agents of dehumanization and destruction. .

Mental patients were generally their victims, but the patients themselves might also appear in different guises: as actors consciously or unconsciously playing a role they had created for themselves, exploiting the category of mental illness to obtain absolution from punishment for their crimes and delinquencies; or using their mythical madness as a weapon with which to disrupt and confuse those around them, all the while escaping responsibility for their actions.

In "My Madness Saved Me", Thomas Szasz now takes his ideas in a literary direction. He seeks to recast the accepted view of the life and death of Virginia Woolf. He acknowledges that "Virginia's family, friends, colleagues, and psychiatrists regarded her as having been mad all of her life", and that this was "a view that, for the most part, she shared". Succeeding generations have largely echoed these judgements (though some critics have embraced a variant position, holding that Virginia was a disturbed woman further victimized by her male psychiatrists, her husband, or both). It is a consensus Szasz rejects: "My aim in this study is radically different. I propose to examine how Virginia Woolf, as well as her husband Leonard, used the concept of madness and the profession of psychiatry to manage and manipulate their own and each other's lives". Virginia was, he insists, no victim, but "an active, goal-directed . . . intelligent and self-assertive person, a moral agent who used mental illness, psychiatry, and her husband to fashion for herself a life of her own choosing". It was not a life or a set of choices that Szasz always finds particularly edifying or worthy of praise, but he insists that it was her life, one for which she should be held responsible.

Leonard, too, "used madness and psychiatry like an expert. He used it to deny and cover up the phoniness of his marriage, to control Virginia, and to avoid military service in World War ...". Virginia first became depressed at the age of thirteen, following the death of her mother. Her nephew, Quentin Bell, called this a "(nervous) breakdown".

Szasz denounces such an interpretation as "obtuse", but acknowledges that it was one Virginia "never made a serious attempt to (reject). On the contrary, she embraced the role (of mental patient) and made playing it an integral part of her life strategy -to her profit as well as her peril". Nine years later, her father, Leslie Stephen, the great man of letters, to whom she was deeply attached, died of cancer after a long illness, and once more she was grief-stricken, on one occasion jumping from a window so close to the ground that she sustained no injury -an action her family interpreted as a suicide attempt and as new evidence of her susceptibility to insanity. Szasz insists that it was nothing of the sort.

Virginia was "an uneducated, unhappy, confused adolescent (actually she was by now twenty-two years of age) . . . faced with an empty and useless life, terrified by the challenges of sex and adulthood", and her behaviour was nothing more or less than "a non-verbal dramatization of her dilemma and despair".

But if, in these years, mental illness was a label imposed on young Virginia, then, as she grew to maturity, Szasz alleges, she came to use it as both an excuse and a weapon. "Woolf students assume that Virginia had no part in being identified as mad. This is not true. She played an important part in being identified as a mental patient and she deliberately exploited that role for her own purposes." Indeed, the more accurate way to describe what happened is that she became "a user of madness-and-psychiatry and a victimizer of her husband and those close to her. Hence the legend of Virginia Woolf the mad genius".

Biographers notoriously fall under the spell of their subjects. Not Szasz. It becomes clear in the course of his brief survey that he finds little to like in both Virginia and Leonard Woolf, and much to loathe. About Virginia's fiction, he has little of substance to say; about the lives and attitudes of the couple, he is scathing and unsparing. Leonard is presented as a snob and a social climber, a physically unattractive man consumed with hatred and fury, who sought to marry up into the Stephen family, only settling on Virginia when his first choice, her sister, Vanessa, refused to have him. Autocratic and self-centred, and incapable of understanding another human being, let alone someone as psychologically complex as Virginia, he was a man of neither wealth nor personal distinction. Besides, he was Jewish -a seemingly fatal flaw given that the spouse he sought was an anti-Semite who viewed his Jewishness as "alien, alienating, and abhorrent".

He was -and for the arch-individualist and libertarian Szasz, it is hard to conceive of a worse term of abuse -"at heart a social worker". Like his wife, he was a twentieth- century Mrs Jellyby, "full of love for mankind in the abstract . . . domineering, nasty, and snobbish (in daily behaviour)".

Virginia, despite her attractive appearance, is portrayed as an equally unattractive human being. Desperate to occupy the social role of married woman, she chose a social inferior so she could marry on her own terms. Those terms included a bar to physical intimacy, since intimacy of all sorts, and heterosexual intimacy in particular, repelled her. Her future husband revolted her, and she spent her married life chronically angry with him. Her anger spilled out in vitriolic abuse that was explained away by all sides as another symptom of her madness. Mad she was, Szasz would have it, but mad in the sense of furious -furious with the choices she had made for herself and with the dysfunctional relationship she had entered into. Her subliminal anger was, he judges, the reason that "the theme of Virginia's 'giving pain'" to Leonard recurs throughout her marriage". On Szasz's account, Virginia was a coward, a conformist, self-deceitful, gutless, inauthentic, and lacking in moral seriousness, to say nothing of "disdainful and nasty . . . toward hired help" in a fashion worthy of the way -another revealing Szaszian comparison -"Soviet apparatchiks related to members of the expendable lower orders".

Together, Szasz argues, Virginia and Leonard were "masters at deception and selfdeception". Their marriage was a sham, but each gladly occupied roles that obscured this reality from self and others: "one as madwoman-wife-writer; the other as nurse-husband-manager". And as for Virginia's suicide, stones in pockets, wading into the river to drown, "I surmise that she killed herself, and killed herself as she did, to enhance her fame . . . a lonely, aging woman . . . she feared for her future and escaped it".

"My Madness Saved Me" is a thorough demolition job. The unattractive features Szasz discerns are so many and varied that one can only wonder at the continuing fascination Virginia and Leonard seem to hold for readers and authors alike. Vile creatures both, by now they ought surely to have been cast into oblivion. Except that adherents of the Bloomsbury cult (and admirers of Virginia in particular) seem oblivious to the mismatch between their idealized image of their heroine and her actual behaviour and beliefs -it is enough, for them, that she was intermittently a fine writer; that she can be claimed for the feminist cause; that she came from a privileged background (and exploited that privilege for all it was worth, while criticizing others who did the same); and that she was a martyr, for martyrdom insulates from criticism and creates acolytes, as the life and death of the late Princess of Wales vividly remind us -and except that so much of Szasz's version of the Woolfs' lives depends on one's acceptance of his view of mental illness as myth, and on one's willingness to follow him in relentlessly interpreting the pair's words and actions in the worst possible light.

Nuance is not one of the good doctor's strengths. Nor is subtlety. The contrast between mental and physical illness is, for Szasz, stark and complete. There is black; and there is white. There is real and wholly unambiguous physical illness, which is bereft of any contamination by the social and the cultural; and there is a mere simulacrum invented by a demonic profession and swallowed by the credulous and muddled masses. That neither physical nor mental disease matches his crude representations wholly escapes him.

As his portrait of the Woolfs and their marriage reveals, Szasz is no better at capturing the complexities of individuals and their relationships. The people and intimate relationships with which I am familiar -all of them -are a mix of kindness and cruelty, honesty and illusion, truth and deception, altruism and self-interest, happiness and misery, and that remains the case even when the men and women one is considering are comparatively sane. Individuals, even mad or thoroughly unpleasant ones, cannot plausibly be reduced to one-dimensional caricatures, as Szasz so readily renders the Woolfs here.

When Virginia claims that she is happy with Leonard, except when mentally ill, Szasz insists that her words "ring hollow". On the brink of suicide, she "may have sensed that Leonard . . . was getting tired of her. Perhaps she was getting tired of writing". No evidence is offered for either claim.) She chooses to die by drowning as a means "of dramatizing herself to the end", and as a way of inflicting yet more pain on the odious Leonard. If she acknowledges her madness, she is deceiving herself, her husband and us, or manipulating her audience for nefarious reasons that the omniscient Dr Szasz can reveal to us. He knows better because "in my view" (a phrase that recurs throughout) . . . well, because he simply knows better.


TLS Online, 7 Feb. 2007, Letters: 'My Madness'

Sir, - In his review of "My Madness Saved Me" by Thomas Szasz (January 19), Andrew Scull suggests that Szasz compared psychiatrists to "concentration camp guards". Szasz's favoured analogy has always been with slave owners, who believed their charges to be incapable of independent lives, thus providing the perfect excuse for their "cruel compassion". This telling analogy explains why Szasz, in his ninth decade, remains a radical figure, feted by "survivors" of psychiatric slavery worldwide.However indirectly, Szasz has helped these supposedly "mad" people to find their own voice. Woolf appeared to have little difficulty in making her voice heard. "My Madness Saved Me" offers an intriguing reading of what Virginia might have been "saying" during her periods of "madness". Scull also neglected to acknowledge that a quarter of Szasz's book is devoted to two appendices, which unpack the feminists' adulation of Woolf and also the "myth" of the "mad genius": the book is worth reading for these challenging pages alone. As a historian of the asylum trades, one might have expected Scull to applaud Szasz as the arch "deconstructor" of psychiatric slavery, and its insinuation into literary appreciation. Rather than judging the Woolfs, Szasz respects them as persons; acknowledging their agency, something which psychiatric apologists (and many feminists) have denied, by genuflecting at the altar of the "myth of mental illness".

Trinity College Dublin, D'Olier Street, Dublin.


"Psychiatry: A Branch of the Law,"
The Freeman, 56: 18-20 (December), 2006.

Medicine and law are independent but intimately interacting social institutions. Medicine guards its autonomy jealously and relates to the legal system as an equal partner. Psychiatry, in contrast, submits slavishly to being dominated by the law and obediently meets its demands. Herewith some examples.

On July 3, 2006, Orin Guidry, M.D., president of the American Society of Anesthesiologists, appealed to his colleagues to refuse to assist the states in carrying out a death sentence by means of lethal injections. "Lethal injection," Guidry reminded anesthesiologists, "was not anesthesiology's idea. American society decided to have capital punishment as part of our legal system and to carry it out with lethal injection. The fact that problems are surfacing is not our dilemma. The legal system has painted itself into this corner and it is not our obligation to get it out."

The American Medical Association's code of ethics, Guidry continued, declares: "A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution." Guidry urged the Association's 37,000 members "not to attend executions of death sentences by lethal injection, even if called to do so by a court. The court cannot modify physicians ethical principles to meet its needs".

Evidently, many, perhaps most, American anesthesiologists reject rescuing the criminal justice system from the consequences of its decision to deprive certain persons of life. Depriving persons of liberty is only one rung down the ladder of harms that the state may legally inflict on certain individuals. Nevertheless, most American psychiatrists feel it is their professional privilege to assist the justice system in depriving certain individuals of liberty; indeed, they insist that loss of liberty under psychiatric auspices constitutes a form of medical treatment for the imprisoned individuals. In fact, the assertion of this claim -- as medical "fact" -- was the very first resolution enacted in 1844 by the newly formed American Psychiatric Association (APA; then more descriptively named the Association of Medical Superintendents of American Institutions for the Insane): "Resolved, that it is the unanimous sense of this convention that the attempt to abandon entirely the use of all means of personal restraint is not sanctioned by the true interests of the insane."

Ever since, psychiatrists have clung to their privilege to imprison innocent persons like drowning men cling to life-preservers.

Indeed, psychiatrists never tire of asserting and reasserting their right to deprive people of liberty. In 2005 Steven S. Sharfstein, president of the APA, reiterated his and his profession's commitment to coercion: "We must balance individual rights and freedom with policies aimed at caring coercion." The term "caring coercion" would have fitted perfectly into the Nazi lexicon, along with Arbeit macht frei ( "labor liberates") and Gnadentot ("mercy death").
Because the ideas about psychiatry I have been presenting in these columns differ radically from what people read in the newspapers or see on television, I always present the evidence for my view. The reader is free to judge the information and come to his own conclusion. In support of my contention that psychiatrists have an unappeasable appetite for assisting the legal system in imprisoning individuals who irritate and upset society, I offer the following evidence:
The history of mental health laws and of standard psychiatric practices illustrates that psychiatric confinement has nothing to do with psychiatric treatment. In 1851, the State of Illinois statute specified that "married women ...may be received and detained at the hospital on the request of the husband of the woman ... without the evidence of insanity or distraction required in other cases."

Today, the desire to psychiatrically incarcerate persons who are not committable by the lawyers' and psychiatrists' own criteria looms large in connection with the popular pressure and political need to keep so-called sex offenders confined after they have served their sentences. In 1997 the U. S. Supreme Court declared this practice to be constitutional. In Kansas v. Leroy Hendricks, the Court declared: "States have a right to use psychiatric hospitals to confine certain sex offenders once they have completed their prison terms, even if those offenders do not meet mental illness commitment criteria."

In November 2005, New York Governor George Pataki made the headlines when he initiated "an administrative program to commit sexual predators to public psychiatric hospitals indefinitely." Pataki's order pulls back the curtain. The state's mental health system is like an army. The Governor is the general. The foot soldiers, the psychiatrist -are expected to follow the orders of their superiors. "As citizens, most of us would be comfortable seeing people properly incarcerated if these are considered crimes," said Barry Perlman, M.D., president of the New York State Psychiatric Association (NYSPA). "What we are concerned about is using the mental health system to solve a problem that seems to spill over to it because the criminal justice system cannot adequately handle it."

Perlman acts as if he had just discovered that the mental-health system is an arm of the criminal justice system. But even after discovering it, he does not suggest that psychiatrists, individually or as a group, defy the Governor's orders.

Politicians have no illusions about psychiatry; they know that it is an extension of the state's law enforcement apparatus and use it as such. According to one report, "The governor [Pataki] directed the Office of Mental Health and the Department of Correctional Services to push the envelope of the state's existing involuntary commitment law because he couldn't wait any longer for the Assembly leadership to bring his legislation to the floor for a vote... The state has begun to identify ‘appropriate models for treatment' and to hire staff to treat these patients. ... To date, 16 states and the District of Columbia have enacted laws to allow authorities to confine violent sexual offenders in psychiatric hospitals after their prison terms."

Mental Hospitals as Prisons
It is important to note here that as far back as in 1988 the APA's Council of Psychiatry and Law explicitly approved the use of mental hospitals as prisons. In a document dated November 11-13, 1988, the Council declared: "Psychiatric patients who no longer require active psychiatric treatment or who are untreatable can still be best managed in a psychiatric setting. ... Acquittees who are unable to be discharged to outpatient status should remain under psychiatric care in a hospital environment." Note that the psychiatric prisoner longing for freedom is treated as if he has power over his own discharge but is "unable to be discharged." Not surprisingly, psychiatrists resent being considered jailers. Confronted with the reality that the mental hospital is a prison and that the psychiatrist who works there is a jailer, they deceive themselves, no less than they deceive the public, with a rhetoric of "care."
It is obvious that as long as law, psychiatry, and society define destructive and self-destructive behaviors as mental diseases, assign the duty to control persons who display such behaviors to psychiatrists, who eagerly embrace that responsibility, "seclusion and restraint" -- in plain English, psychiatric coercion -- will remain a characteristic feature of psychiatric practice.

The definition of psychiatry as a medical specialty concerned with the diagnosis and treatment of mental diseases is a monumental falsehood. Psychiatry is a branch of the law, combining features of criminal, civil, and family law: its primary function is to promote and ensure domestic tranquility.

The Pretense of Psychology as Science:
The Myth of Mental Illness in Statu Nascendi

If I was profoundly shocked by the Varieties [of Religious Experience, by WilliamJames], that was not because some of the facts described in it were such as I would rather not hear about. They were, on the whole, amusing. Nor was it because I thought James was doing his work clumsily. I thought he did it very well. It was because the whole thing was a fraud. . . . Psychology. . . regarded as the science of the mind, is not a science. It is what "phrenology" was in the early nineteenth century, and astrology and alchemy in the Middle Ages and the sixteenth century: the fashionable scientific fraud of the age. . . . There were, I held, no merely moral actions, no merely political actions, and no merely economic actions. Every action was moral, political, and economic.

R.G. Collingwood
(1889-1943; 1978: 93, 95, 149)


In the Age of Faith, religion pretended to be a science, offering allegedly empirical observations about God and his works. In the Age of Science, psychology and psychiatry pretend to be sciences, offering allegedly empirical observations about the functions and malfunctions of the human mind. Much modern intellectual and political mischief rests upon this false and pretentious claim. The epistemologically misleading character of the two principal "mental sciences" is inherent in their respective definitions. Wikipedia Encyclopedia identifies psychology as "an academic and applied field involving the study of the human mind, brain, and behavior. Psychology also refers to the application of such knowledge to various spheres of human activity, including problems of individuals' daily lives and the treatment of mental illness." Interestingly, Wikipedia then describes how "Psychology differs from anthropology, economics, political science, and sociology. . . ." and from "biology and neuroscience," but is silent about how psychology differs from psychiatry.

Psychiatry, Wikipedia tells us, "refers to the practice of medicine relating to the mind and behavior. . . . It is a subspecialty of medical practice. . . . While all clinicians encounter patients with mental illnesses and any of them may treat it, psychiatrists specialize in these areas." Missing from these definitions is acknowledgment that the most constant and most characteristic element of so-called mental treatments is and has always been the coercion of the "patient" by the "doctor."

To be sure, many psychologists pursue work unrelated to mental illnesses and mental treatments, and some psychiatrists deal with voluntary mental patients. In this essay, however, I shall use the terms "psychologist" and "psychiatrist" to refer to persons whose professional roles are defined or shaped by mental health laws, that is, coercion. Why do I emphasize the central role of coercion in psychology and psychiatry? Because in my view voluntary mental health relations differ from involuntary mental health interventions the same way as, say, sexual relations between consenting adults differ from the sexual assaults we call "rape." I maintain that it is essential - morally and politically - not merely to distinguish between coerced and consensual"therapeutic" relations, but to contrast them. The terms "psychology" and "psychiatry" ought to be applied to one or the other, but not both.

Mental healing, qua psychology or psychiatry, resembles religion, not medicine or science. Asserting that a respected social institution-such as religion, psychology, or psychiatry-rests on a farrago of fables is disrespectful of received opinion and dangerous. It took us, in the West, a long time before we rejected coercion in the name of religion and punished instead of praised the person who embraced violence in the name of God (Seager, 1933). I believe we ought also to reject coercion in the name of mental health and condemn instead of commend the person who embraces violence in the name of mental healing.


The humoral theory of disease, let us remember, was alive and well a mere 150 years ago. As long as that theory prevailed, there was only one kind of disease, humoral. The idea of two kinds of diseases-one bodily, the other mental-is a product of the scientific revolution; more specifically, of nineteenth century empirical-scientific medicine, based on anatomical and physiological observation and measurement. I coined the term "myth of mental illness" in 1960 to suggest that the distinction between bodily illness and mental illness rests on a misuse of the term "illness." If we restrict the use of the term "illness" (or "disease") to observable biological-anatomical and physiological-phenomena, then, by definition, the term "mental illness" is a misnomer or metaphor. Mind is not matter, hence mental illness is a figure of speech.

The great nineteenth-century neuropsychiatrists regarded this view as a given:

  • Ernst von Feuchstersleben (1806-1848): "The maladies of the spirit (die
    Leiden des Geistes) alone, in abstracto, that is, error and sin, can be called diseases of the mind only per analogiam. They come not within the jurisdiction of the physician, but that of the teacher or clergyman, who again are called physicians of the mind (Seelenärzte) only per analogiam" (Feuchstersleben, 1903/1955: 412).
  • Theodor Meyner (1833-1892): "The reader will find no other definition of 'Psychiatry' in this book but the one given on the title page: Clinical Treatise on Diseases of the Forebrain. The historical term for psychiatry, i.e., 'treatment of the soul,' implies more than we can accomplish, and transcends the bounds of accurate scientific investigation." (Meyner, 1884: v).
  • John Hughlings Jackson (1835-1911): "Our concern as medical men is with the body. If there be such a thing as disease of the mind, we can do nothing for it" (Jackson, 1958, vol. 2: 59).

Emil Kraepelin (1856-1927): "The subject of the following course of lectures will be the Science of Psychiatry, which, as its name [Seelenheilkunde] implies, is that of the treatment of mental disease. It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased [Allerdings kann mann, streng genommen, nicht von Erkrankungen der Seele sprechen]" (Kraepelin, 1901/1968: 1).

In short, the proposition that there is no mental illness is not new. What is new are the practical, political-economic consequences of affirming or denying its existence.
Until the 1970s, the idea that mental illness is a nondisease-a medical name for unwanted personal conduct-was accorded a measure of professional and public recognition. Since then, the debate about the disease-status of mental illness has been brought to a halt. Leaders in politics, jurisprudence, medicine, neuroscience, psychology, and psychiatry allied with business leaders, insurance executives, and journalists, declared that brain and mind, bodily illness and mental illness are identical and must-as a matter of law and justice-be treated as if they were the same.

  • White House Fact Sheet on Myths and Facts about Mental Illness: "Research in the last decade proves that mental illnesses are diagnosable disorders of the brain" (White House Press Office, 1999).
  • Nancy C. Andreasen, professor of psychiatry at the University of Iowa: "What we call 'mind' is the expression of the activity of the brain" (Andreasen, 1997).
  • Donald F. Klein, professor of psychiatry at Columbia University and Paul H. Wender, professor of psychiatry at the University of Utah: "Biological depression is common-in fact, depression and manic-depression are among the most common physical disorders seen in psychiatry" (Klein, D.F. and Wender, P.H., 1993: 4).
  • Daniel C. Dennett, professor of philosophy, Tufts University: "The mind is the brain" (Dennett, 1991: 33).
  • Alan J. Hobson, professor of psychiatry, Harvard University: "[T]he brain and mind are one. They are one entity. . . . I use the hyphenated term 'brain-mind' to denote unity" (Hobson, 1994: 6-7).

In practice, none of this is true. Medicine and law continue to distinguish between neurology and psychiatry, between laws regulating the rights and duties of persons suffering from neurological diseases such as syringomyelia, and the rights and duties of persons suffering from psychiatric diseases such as schizophrenia. What accounts for this disjunction between academic-political declarations about mental illness and the legal-social realities of mental health practices? Answering that question fully requires a reprising of the history of psychiatry. Here I limit myself to showing that the idea of mental illness qua medical disease is a product of modern materialist-reductionist psychology/psychiatry.


The modern history of the mind is a tapestry woven with two different strands, one concerned with "mental healing," another with "mental illness." At the dawn of the age of mental healing, the practice was called "Mesmerism." Freud named it "psychoanalysis." Stefan Zweig aptly dubbed it Heilung durch den Geist, "healing by means of the spirit" (Zweig, 1962). We call it "psychotherapy" or "talk therapy." The subject is important because controversy regarding the nature and scientific status of mental healing antedates and prefigures the controversy regarding the nature and scientific status of mental illness, psychiatry, and psychology.

Noted psychiatric historians, such as Henri Ellenberger and Gregory Zilboorg, trace the origin of modern psychotherapy to the work of Franz Anton Mesmer (1733-1815) (Ellenberger, 1970: 53; Zilboorg, 1941: 347). They do so because he had established-or so Ellenberger and Zilboorg believe-that suggestion ("hypnosis") is a genuine medical method of treating bodily ailments. In my view, Mesmer's so-called therapeutic successes prove the power of human gullibility, resting on man's ultimate helplessness and quasi-religious need for dependence on benevolent (theological or medical) authority. The power and universality of this need is aptly expressed in the adage, "There are no atheists in foxholes." Mutatis mutandis, there are no medical skeptics in operating rooms.

Mesmer's work must be situated in the context of his age. The eighteenth century was a period of revolutions-political and scientific. Although the phenomenon physicists call "magnetism" had been known since antiquity, the fabrication and sale of magnets, mainly to scientific investigators and terrestrial navigators, began only around 1740. The famous Leyden Jar-a simple electrical capacitor that could be used to give a person a sudden, albeit weak, shock and which quickly became a show-business prop and sensation-was invented about 1745, by a Dutch physicist at the University of Leyden. In 1752, Benjamin Franklin (1706-1790), invented the lightning rod, a feat that made him the first modern "scientific celebrity." Finally, in 1780, the Italian scientist Luigi Galvani (1737-1798) discovered the electric current and what he mistakenly thought was "animal electricity." It was in this atmosphere of scientific discovery along with medical quackery and popular showmanship that Mesmer, an Austrian physician, "discovered" what he thought was "animal magnetism," a mysterious "force" and substance (fluidum) to which he attributed vast therapeutic powers (Szasz, 1978/1988: 43-66).


The twentieth century, too, has been a revolutionary period, in politics, science, and medical quackery. In medicine, many important discoveries and new treatments rested on novel uses of electricity and magnetism, such as the x-ray, computerized axial tomography (CT scan), positron emission tomography (PET scan), and magnetic resonance imaging (MRI), not to mention radio, television, computers, and the Internet. It is in this atmosphere that modern-day Mesmers discover near-miraculous cures for mental illnesses making use of electrical-magnetic devices, such as electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and transcranial magnetic stimulation (TMS). Other "therapeutic breakthroughs" make use of pharmacotherapies modeled after antibiotics, called "antipsychotic medications." I am not concerned here with whether these interventions are considered by some to be "effective." I list them only to set the stage for my subsequent remarks about the alleged illnesses they supposedly treat.

Although we live in an age of far greater scientific and technological sophistication than did people in the eighteenth century, human gullibility remains undiminished. Perhaps it is a kind of existential constant, drawing its force from people's seemingly unappeasable need to believe in, and submit to, authority. Today, people are especially credulous concerning matters having to do with the "mind"-its alleged material (anatomical, chemical, electrical) basis, its functions and malfunctions, and, most pressingly, the supposed diseases to which it is subject and the appropriate treatments for them. Social historians are familiar with the roles that the great nineteenth-century psychiatrists and the pioneer psychoanalysts played in exploiting this credulity. Less familiar is the role in this story of William James (1842-1910), whose boundless naïveté about mental matters is hidden by his stature as America's greatest psychologist, one of the founders of the modern science of psychology and of the American Psychological Association.


James's obituary in The New York Times was entitled, "William James Dies; Great Psychologist, Brother of Novelist and Foremost American Philosopher Was 68 Years Old." It summarized his work in these words: "Virtual Founder of Modern American Psychology, and Exponent of Pragmatism and Dabbled in Spooks. Long Harvard Professor" (James, 1910). James's essay on religious belief, tellingly titled "The Will to Believe"; his famous book, Varieties of Religious Experience; and his credulous participation in "spiritualism" all testify to his own deeply-felt need "to believe," if necessary, in the sense of credo quia absurdum est. ("I believe because it is absurd."

Usually attributed to Tertullian, c. 160-220.) Less well-known, but of greater interest to the subject of mental illness and psychiatric treatment, is James's 1892 essay, "A plea for psychology as a natural science" (pp. 146-153). His words are clear and need no extended exegesis. My comments about them will be brief.

James (1892) begins with a puerile statement:

  • I wished, by treating Psychology like a natural science, to help her to become one (emphasis in the original, p. 146).
    The rest of the essay is naive scientism, ending with a lamentable confusion and equation of scientific "control" with social control, the "lawfulness" of natural events with the rule of political despotism:
  • All natural sciences aim at practical prediction and control, and in none of them is this more the case than in psychology today. . . . What every educator, every jail-warden, every doctor, every clergyman, every asylum-superintendent, asks of psychology is practical rules. Such men care little or nothing about the ultimate philosophic grounds of mental phenomena, but they do care intensely about improving the ideas, dispositions, and conduct of the particular individuals in their charge (emphasis added, p. 148).
    Note that James brackets the educator, jail warden, physician, clergyman, and asylum psychiatrist as fulfilling essentially similar social functions-controlling and improving individuals in his charge. The statement brings to mind C.S. Lewis's warning:

    We know that one school of psychology already regards religion as a neurosis. When this particular neurosis becomes inconvenient to the government, what is to hinder the government from proceeding to "cure" It? Such "cure" will, of course, be compulsory; but under the humanitarian theory it will not be called by the shocking name of Persecution. No one will blame us for being Christians, no one will hate us, no one revile us. The new Nero will approach us with the silky manners of a doctor, and though all will be in fact as compulsory as tunica molesta or Smithfield or Tyburn, all will go on within the unemotional therapeutic sphere where words like "right" and "wrong," or "freedom" and "slavery" are never heard. And thus when the command is given, every prominent Christian in the land may vanish overnight into Institutions for the Treatment of the Ideologically Unsound, and it will rest with the expert gaolers to when (if ever) they are to emerge. But it will not be persecution. Even if the treatment is painful, even if it is life-long, even if it is fatal, that will be only a regrettable accident, the intention was purely therapeutic (Lewis, 1953/1970: 293).

Assuming the posture of "doctor knows best," James charges ahead:

  • all the fresh life that has come into psychology of recent years has come from biologists, doctors, and psychical researchers. . . . Cannot philosophers and biologists both become 'psychologists' on this common basis? Cannot both forgo ultimate inquiries, and agree that, provisionally at least, the mental state shall be the ultimate datum so far as "psychology" cares to go? . . . Not that today we have a "science" of the correlation of mental states with brain-states; but that the ascertainment of the laws of such correlation form the program of a science well limited and defined (James, 1892: 149, 151).
    James ends on a note that I interpret as an expression of his effort to believe that his life-long confusions, fears, and "illnesses" were not the meaningful manifestations of his persistently avoided existential-moral problems but the meaningless symptoms of a medical disease susceptible to medical treatment:
  • The kind of psychology which could cure a case of melancholy, or charm a chronic insane delusion away, ought certainly to be preferred to the most seraphic insight into the nature of the soul. And that is the sort of psychology which the men who care little or nothing for ultimate rationality, the biologists, nerve-doctors, or psychical researchers, namely, are surely tending, whether we help them or not, to bring about (emphasis added, p. 153).

By 1892, William James had come out of the spiritualist closet. Here he lists "biologists, nerve-doctors, and [or] psychical researchers" as scientists of the same kind, all engaged in a quest for the material cure of "chronic insane delusions" and not giving a whit about "seraphic insight into the soul."
James was shockingly indifferent to the great controversies in psychology and psychiatry raging around him. It was then even more obvious than it is now that what sets psychiatry apart from medicine is coercion. The incarceration of the insane was, and is, the proverbial 800-pound gorilla in the room. Everyone knows it is there.

Now, it is impolite to notice its presence. Not so in the 1890s. The following is a brief excerpt from an address by Silas Weir Mitchell (1829-1914)-the great American neurologist and founder of the American Neurological Association-presented at the 1894 annual meeting of the American Medico-Psychological Association (now the American Psychiatric Association): "You quietly submit to having hospitals called asylums; you are labeled as medical superintendents . . . I presume that you have, through habit, lost the sense of jail and jailor which troubles me when I walk behind one of you and he unlocks door after door. . . . You have for too long maintained the fiction that there is some mysterious therapeutic influence to be found behind your walls and locked doors. We hold the reverse opinion . . . Your hospitals are not our hospitals; your ways are not our ways" (Mitchell, 1894, pp. 414, 427, emphasis added).

James and the psychologists and psychiatrists who joined his quest for the material cure of "chronic insane delusions" without giving a whit about "seraphic insight into the soul" got what they wished for-and more: a "science of the mind" without soul or ensouled.

Szasz, T., "The Pretense of Psychology as Science: The Myth of Mental Illness in Statu Nascendi," Current Psychology, 25: 42-49 (Spring), 2006.


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  • Myths and Facts about Mental Illness," New York Times, June 7, 1999, Internet edition.
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Keynote Address, "Controversies in End of Life Care:
Terri Schiavo's Lessons"

"I kept my promise" (Schiavo, 2005a).
Theresa Schiavo's grave marker, June 20, 2005.

''I laid a red rose in her hand and said goodbye'' (Schiavo, 2005b).
Michael Schiavo, September 24, 2005.


In 1992, during a deposition in his malpractice suit against the physicians who treated Terri Schiavo for infertility, Michael was asked how he saw his future with his wife.

He replied:
A: I see myself hopefully finishing school and taking care of my wife.
Q: Where do you want to take care of your wife?
A: I want to bring her home.
Q: If you had the resources available to you, if you had the equipment and the people, would you do that?
A: Yes. I would, in a heartbeat.
Q: How do you feel about being married to Terri now?
A: I feel wonderful. She's my life and I wouldn't trade her for the world. I believe in my marriage vows.
Q: You believe in your wedding vows, what do you mean by that?
A: I believe in the vows I took with my wife, through sickness, in health, for richer or poor. I married my wife because I love her and I want to spend the rest of my life with her (Schiavo, 2005c).

Michael Schiavo made those statements, under oath, in 1992. In 2005, he had inscribed on Terri's grave marker "February 25, 1990" as the date she had "Departed this Earth."
Does Michael Schiavo's self-aggrandizing memorial to refer to his promise of marital fidelity? For more than a decade he has lived with another woman, to whom he refers as his fiancee and with whom he has two children.

Does his statement, "I kept my promise," refer to his promise to Terri's parents, Mary and Robert Schindler, that Terri ‘s body would not be cremated and her remains would be buried at a Schindler family plot in Pennsylvania? Two days after she died, Terri was cremated and her ashes were buried at Sylvan Abbey Memorial Park in Clearwater. The Schindlers were notified only after the event.

To what promise-keeping, then, does Michael Schiavo refer on his wife's tombstone? Ghoulishly, he brags about his alleged pledge to kill her, in her own best interest. The removal of Terri's feeding tube was, as Joan Didion points out, "repeatedly described as ‘honoring her directive.' This, again, was inaccurate: there was no directive. Any expressed wish in this matter existed only in the belated telling of her husband and two of his relatives" (Didion, 2005).

The conflict between the Schindlers and Michael Schiavo was clear. The Schindlers preferred a half-dead daughter above ground to a dead daughter in the grave. Michael preferred a dead ex-wife in the grave to a half-dead wife in a hospice. The Schindlers acknowledged that they wanted Terri alive. Michael denied that he wanted his wife dead and instead attributed the death-wish to Terri's desire to have her life terminated if she were as disabled as she was. This is the fiction the courts upheld.
And this is the fiction Michael memorialized -- naively and narcissistically -- with the inscription he chose to have engraved on Terri's grave marker. "I kept my promise": Sartre could hardly have found a more dramatic example of a husband's bad faith following his wife to her grave.

The Schiavo drama was a classic battle of words: he who controlled the vocabulary, controlled the debate and was assured of victory. Apparently, the Schindlers did not recognize this. They failed to emphasize that what Theresa Schiavo allegedly wanted was unconfirmable, based totally on hearsay evidence, and that, in doubtful cases, the long tradition of English and American law and the Christian religion favors the preservation of life and liberty over their forfeiture. (Michael Schiavo and the Schindlers are Catholics.) The moral default position in the case of Terri Schiavo was clear: she was not dead and killing her was an act of medical killing, a type of heterohomicide.

Was it morally justified? In my opinion, it was not: 1) Terri had no living will and there was no credible evidence about what she might have wanted to happen to her half-alive body; 2) Terri's parents wanted to keep her alive, while her husband, living with another woman, wanted her dead; 3) Michael Schiavo's representations lacked credibility and hence the courts erred in appointing him as Terri's guardian; and 4) assuming that Terri Schiavo would have wanted her life ended, she would not have wanted it ended by being alternately starved and fed, by having her feeding tube repeatedly removed and reinserted over a period of months.

Led by medical ethicists, the mainstream media nevertheless defined the case as a battle between "humanists" and "religious zealots," "rationalists" and "irrationalists." Didion observes: "Yet there remained, on the ‘rational' side of the argument, very little acknowledgment that there could be large numbers of people, not all of whom could be categorized as ‘fundamentalists' or ‘evangelicals,' who were genuinely troubled by the ramifications of viewing a life as inadequate and so deciding to end it. There remained little acknowledgment even that the case was being badly handled..." (Didion, 2005).


Medicine and science change and, in our day, change rapidly. Fundamental ethical principles are enduring. Probably the most enduring principle is the injunction against killing human beings, especially when the justification for doing so is morally feeble.
Religion and law decree certain human bonds to be unbreakable, and many people experience them as such. The paradigm of such a bond is that between the pious Jew and his God. Christianity decreed the marriage bond to be similarly unbreakable. This rule, long enshrined in civil law, was repudiated only in recent times.
The principal issue in the Schiavo case -- besides the economics of Terri's care -- was the conflict between two parties both claiming undying love and loyalty to her: her husband who wanted her dead, and her parents who wanted to keep her alive.

In this circumstance, the commandment against killing should alone have been enough to tilt the balance in the parents' favor.
Few moral dilemmas present us with truly novel conundrums. The Schiavo case is not among them. To the contrary, the conflict between the Schindlers and their son-in-law calls to mind the legendary case of the disputed baby in the Old Testament. Two women live together and give birth to babies at about the same time. One baby dies during the night. His mother switches him with the other baby.

The living child's mother discovers the deception and brings the dispute to Solomon for arbitration. The Bible tells what happened this way: Then came there two women... And the one woman said, O my lord, I and this woman dwell in one house; and I was delivered of a child with her in the house. ... And this woman's child died in the night; because she overlaid it. And she arose at midnight, and took my son from beside me .... and laid it in her bosom, and laid her dead child in my bosom .... And the other woman said, Nay; but the living son is my son. ... Thus they spake before the king. ... And the king said, Bring me a sword. ... And the king said, Divide the living child in two, and give half to the one, and half to the other. Then spake the woman whose living child was unto the king ... O my lord, give her the living child, and in no wise slay it. But the other said, Let it be neither mine nor thine, but divide it. ... And then the king answered and said, Give her the living child, and in no wise slay it: she is the mother thereof (1 Kings 3: 16-27; King James Version).

Today's Solomon would order both women to undergo psychiatric examination to determine who would make a better mother and would then rule in accordance with the psychiatric "findings," ratified by committees of bioethicists. Herein lies the difference between the language of love and life, and the language of envy and death; between the philosophy of individualism and libertarianism, and the philosophy of collectivism and statism; and between the ethics of justice and the sanctity of life, and the ethics of bioethics and the justification for medical killing.

Solomon, we might be tempted to glibly observe, had it easy because of the second mother's gratuitous comment. Suppose she had said the same thing the first mother said. How would Solomon have decided? We don't know. It would have been a different case, both contending parties choosing life over death. Ironically, Michael Schiavo's conduct reinforces the analogy with the biblical case. In 1993, when he was ostensibly still trying to keep Terri alive, Michael was asked what he had done with her jewelry. He replied: "Um, I think I took her engagement ring and her... what do they call it... diamond wedding band and made a ring for myself" (Schiavo, 2003).

After Terri died, he defined the date of her death as February 25, 1990, and placed that date on his wife's tombstone. If that is when, in Michael Schiavo's view, his wife died, then, after that date, he considered himself wifeless, a widower who had no morally valid claim to Terri's living body, and no legally valid ground for objecting to the Schindlers' desire to assume caring for their daughter who was, de facto and de jure, still alive. I shall abstain here from considering his financial and other possible reasons for not divorcing Terri and fighting the Schindlers' efforts to be her legal guardians.


The Schiavo case has generated a vast literature, some in print, much of it on the Internet. Most of this literature analyzes the case from the point of view of the supposed "rights" of the main dramatis personae. What would Terri have wanted had she anticipated her half-alive state? Did feeding and hydration constitute "artificial life support"? Who ought to be her legal guardian? Although the Schindlers's efforts to keep Terri alive received much popular and professional support, most of the debate was straitjacketed into medical terminology and dealt with concepts and issues such as the patient's ability to feel pain, recognize persons, respond to stimuli, permanent vegetative state, brain death, prognosis, rehabilitation, and so forth.

All this was shadowboxing. After more than a decade of being half-dead, it required no sophisticated medical knowledge or technology to conclude that, as a person, Terri Schiavo existed no longer, but that, as a human being, she was still alive. That, after all, is why there had been a long battle about the legitimacy of killing her. She had to be put to death before she could be legally declared dead and her corpse buried or cremated.

Most people who are not religious prefer to be completely dead rather than half-dead. They usually assume that their closest relatives, the persons who truly deserve the awkward appellation "loved ones," share this choice. If they assume otherwise, they are likely to execute a living will expressing their desire to be kept alive as long as possible, regardless of circumstances or costs. The Schindlers themselves wished to keep their daughter alive and believed, with good reason -- they were all practicing Catholics -- that that is what Terri would have wanted. I shall now briefly examine the Schiavo affair from what I imagine was the Schindlers' point of view, and do so by reference to a justly celebrated short story by William Faulkner.

"A Rose for Emily" is a Gothic tale set in a small town in the Old South (Faulkner, 1935). Emily Grierson is the only daughter of one of the small town's leading citizens. "The Griersons held themselves a little too high for what they really were. None of the young men were quite good enough for Miss Emily." Mr. Grierson dies, leaving Miss Emily in genteel poverty, living alone in the big house. She becomes a shadowy figure who, however, manages to dominate the town authorities. Afraid to collect the taxes she owes on her home, they are one day confronted with complaints by neighbors about a foul odor emanating from it. "That was two years after her father's death and a short time after her sweetheart -- the one we believed would marry her -- had deserted her. ... 'But what will you have me do about it, madam?'," wailed the mayor. "After a week or two the smell went away."

Having set the stage, Faulkner dispels the mystery. A few years after the death of Miss Emily's father, a construction company comes to town, "with riggers and mules and machinery, and a foreman named Homer Barron, a Yankee -- a big, dark, ready man, with a big voice and eyes lighter than his face. ... Presently we began to see him and Miss Emily on Sunday afternoons driving in the yellow-wheeled buggy and the matched team of bays from the livery stable." The construction company leaves and Homer Barron is seen no more. The townsfolk assume that he left with the company.

In fact, Homer Barron rejected Miss Emily, and she poisoned him with arsenic. The years pass. "Each December we sent her a tax notice, which would be returned by the post office a week later, unclaimed. Now and then we would see her in one of the downstairs windows --she had evidently shut up the top floor of the house ... Thus she passed from generation to generation -- dear, inescapable, impervious, tranquil, and perverse. And so she died."

Distant relatives come to bury her:
Already we knew that there was one room in that region above stairs which no one had seen in forty years, and which would have to be forced. They waited until Miss Emily was decently in the ground before they opened it. The violence of breaking down the door seemed to fill this room with pervading dust. A thin, acrid pall as of the tomb seemed to lie everywhere upon this room decked and furnished as for a bridal: upon the valance curtains of faded rose color, upon the rose-shaded lights, upon the dressing table, upon the delicate array of crystal and the man's toilet things backed with tarnished silver, silver so tarnished that the monogram was obscured.

Among them lay a collar and tie, as if they had just been removed, which, lifted, left upon the surface a pale crescent in the dust. Upon a chair hung the suit, carefully folded; beneath it the two mute shoes and the discarded socks. The man himself lay in the bed. ... The body had apparently once lain in the attitude of an embrace, but now the long sleep that outlasts love, that conquers even the grimace of love, had cuckolded him. What was left of him, rotted beneath what was left of the nightshirt, had become inextricable from the bed in which he lay; and upon him and upon the pillow beside him lay that even coating of the patient and biding dust. Then we noticed that in the second pillow was the indentation of a head. One of us lifted something from it, and leaning forward, that faint and invisible dust dry and acrid in the nostrils, we saw a long strand of iron-gray hair.

Miss Emily preferred the simulacrum of a husband to no husband at all. The Schindlers preferred the simulacrum of a daughter to no daughter at all. I believe their argument was fatally flawed by their failure to acknowledge this and engaging instead in an ill-considered debate about Terri's medical condition and "prognosis." Their claims that Terri was responsive, that she was not in a vegetative state, that her prognosis was not hopeless were counterproductive. Watching the case unfold, my impression was that the Schindlers wanted their daughter to be kept alive regardless of how badly damaged and hopeless her condition was. They preferred a daughter half-dead or four-fifths dead to no daughter at all. But they never said so. Nor did they offer to foot the bill for caring for Terri.


Exploring the economic aspects of the cost of caring indefinitely for persons in Terri's condition would require another essay or, rather, a substantial monograph. Let me say only that I am not aware that the Schindlers ever offered to pay for Terri's care or, for that matter, would have been able to afford doing so. I assume (and I believe it is reasonable to assume) that had the Schindlers been billionaires, they would have mounted a very different kind of legal challenge against their alienated and antagonistic son-in-law. They could have petitioned the courts -- in a type of habeas corpus plea -- for the opportunity to care for Terri, indefinitely and at no cost to the public, supported by appropriate medical, nursing, and other help. In the absence of an advance medical directive by Terri, I believe the courts would have found such a request impossible to reject.

I agree with Nat Hentoff that, since the law lets people execute advance medical directives refusing life support should they become profoundly incapacitated, they have the responsibility to prepare such directives. "Absent that, the law should require the courts in contested cases to give every reasonable benefit of the doubt to sustaining life and not causing death by dehydration."

Importantly, Hentoff adds:
Having reported on the Terri Schiavo case for the past two and a half years -- and having read all of the transcripts of court hearings -- I am certain of one dimension of this case: Terri Schiavo was fatally denied due process because all the appellate courts, state and federal, relied wholly on the rigid misunderstanding of the central facts of the case by one Florida Circuit judge, George Greer. If this had been a case of a prisoner on death row with an execution date, the ACLU and a good many liberals would have demanded habeas review, from the beginning, of all the facts in the case (Hentoff, 2005).

Not only does the problem of so-called "fruitless care" for the terminally ill or severely disabled require serious consideration of its economic implications, it requires also attention to the moral dilemmas attending medical killing, with special reference to the legal-psychiatric prohibition of drugs and suicide. I have written extensively about these subjects and a few observations must suffice here. The Schiavo case touches on many of the difficult economic, moral, legal, and social dilemmas presented by the combination of advances in modern medical technology, the national-socialization of heath care services, and the war on autonomy and personal responsibility and autonomy disguised by a preoccupation with so-called "medical ethics." I use the term "national socialism" here in its precise descriptive sense, to refer to state control of important sectors of the nation's economy, not to the German National Socialist regime.

Medical ethics, as I see it, must be one of two things -- the justification and ratification of prevailing medical principles and political practices or a critique and condemnation of such principles and practices. Since the medical ethics industry is ideologically and economically parasitic on -- is, indeed, a part of -- the same therapeutic state that supports and justifies the medical and pharmaceutical industries, it functions, in effect, as the propaganda arm of the therapeutic state. Hence, it is both unable and unwilling to play the role of moral critic. Supported by co-opted authorities on medical ethics, the Florida courts sidestepped all the complex moral and political problems and chose to pretend that the conflict between husband and parents in the Schiavo case ought to be resolved on the basis of a fictitious autonomy plus a fictitious advance medical directive that they attributed to Terri.

Autonomy is self-government. It can be curtailed only by the self and the state. We limit our own autonomy every time we make a promise or enter into a contract, for example by marrying. The state limits our autonomy every time it prohibits an act, especially the type of act which John Stuart Mill aptly called "self-regarding," such as self-medication. Our autonomy is now strictly limited by a political system I call the therapeutic state (Szasz, 1963 / 1989).

Paradoxically, when I was growing up in a not-very democratic Hungary and the world was on the verge of a totalitarian nightmare, personal autonomy was less limited than it is today in the United States. No one tried to prevent individuals -- not even school children -- from killing themselves. Opiates and sleeping pills were widely available and their possession was not prohibited. Although traditionally a Roman Catholic country, Hungary has long had, and still has, one of the highest suicide rates in the world.

"The free man owns himself. He can damage himself with either eating or drinking; he can ruin himself with gambling. If he does he is certainly a damn fool, and he might possibly be a damned soul; but if he may not, he is not a free man any more than a dog" (Chesterton, 1935). The words are Gilbert K. Chesterton's. He was a devout Catholic and a passionate conservative, not a liberal, much less a libertarian. Today, with the whole "civilized" world waging wars on drugs and suicide, few people agree with this statement.

Physicians, especially psychiatrists, have been waging war on autonomy for more than 200 years. As medical professionals acquired more knowledge about the human body and its diseases, they sought increasing control over it. Physicians attacked autonomy along three fronts, corresponding to three basic human urges -- sex, drugs, and death. Supported by pseudoscience and the state, they declared self-abuse, self-medication, and self-killing diseases and punished them as offenses against the public health and hence the public good. The free man owns himself. The therapeutic state prohibits self-ownership.

Terri Schiavo had no right to kill herself when she was fully alive. "Suicidality," defined as a "symptom of depression," is the main justification for civil commitment -- an act of depriving a person not only of autonomy but of liberty. Nevertheless, so the story goes, Terri Schiavo had a right to have her life terminated when she was only half-alive, because, allegedly, that is what she would have wanted had she been able to express her wants. We often believe X not because X is true, but because believing X helps us to achieve our selfish purposes. We have no right to suicide, yet we insist that respect for "patient autonomy" requires that we have a right to physician-assisted suicide (Szasz, 1999 / 2001).

Reconsider the basic facts of the case. For fifteen years Terri Schiavo's half-alive body lay in bed. Ostensibly, during all this time, both her husband and her parents wanted to "help" her. Initially, they helped her to stay alive. No one then spoke of Terri's wish to be killed. Then came a sudden reversal, when Michael "remembered" Terri's alleged verbal living will. Michael now sought to help Terri by ending her life as soon as possible, while the Schindlers helped her by preserving her life as long as possible.

At the same time -- characteristically for the times we live in -- neither party was willing to assume real obligation to care for her; both parties wanted to use the power and purse of the state to implement their wishes. Michael wanted the state to end Terri's life. The Schindlers wanted the state to keep Terri alive and pay for her care. (Only a small, initial part of Terri's care was paid by the malpractice insurance money awarded to Michael. By the end, the taxpayer was paying the bills.)


The truth is that the Schiavo case had nothing whatever to do with what we fatuously call "patient autonomy." Instead, it had to do with property rights and money -- specifically, with deciding, first, who was the rightful "owner" of Terri's half-alive body, and second, who was to pay for keeping her alive till she was pronounced legally dead.

Regardless of the medical-technical term we choose to describe Terri's state -- coma, permanent vegetative state, severe and irreversible brain damage -- two things are clear: that before her feeding tube was removed, she was not dead; and that she was helpless and dependent on others for survival in much the same way that a newborn baby is: she could breathe and metabolize food, but needed to be fed, and hydrated, and cared for. The difference between Terri and a baby was that Terri was destined to remain totally disabled and dependent until she died.

There is nothing unusual or uncommon about this sort of situation. On the contrary, the problem is pervasive and perennial. But we must be clear about whose problem it is, and what the true nature of the problem is. The problem is not the patient's, just as the problem of abortion is not the fetus's. Terri had no problem. She was the problem. For whom? For her husband, for her parents, and for the agents of society charged with protecting certain classes of dependents. Under the age-old legal principle of parens patriae, incompetent human beings needing and deserving care and protection were, in John Locke's words, "idiots, infants, and the insane." Today, in addition to "idiots, infants, and the insane," the category of such incompetents includes the aged, the unconscious, and persons, like Terri, in a chronic vegetative state.

If relations among family members are harmonious and some are willing to care for a disabled person, they do so, and that is the end of the matter. Many parents care for their severely handicapped children, and many adult children care for their demented parents. If the persons responsible for the dependent are wealthy, they typically delegate the task to others. That is the way Joseph Kennedy, Sr. cared for his daughter Rosemary who, after the lobotomy to which he had subjected her rendered her, too, only half a person. Severely brain-damaged, Rosemary was sent to a Catholic convent home in Wisconsin, lavishly endowed by Kennedy to conceal his embarrassing deed and care for his damaged daughter. Out of sight and out of mind, Rosemary "lived" there for more than 60 years, until her death in 2005, at the age 86.

Family members may also agree on the opposite course, which they often do in the kind of hopeless situation with which Terri's husband and parents were faced. They then instruct medical personnel to desist from heroic measures to prolong the dying process. This is one of the functions of hospice care. It is worth noting in this connection that Terri Schiavo did not qualify for such care.

In the Schiavo controversy, the courts upheld the fiction that Terri's autonomy required that she be medically killed, in her own best interest. In view of the fact that we live in a country whose laws prohibit suicide and often deny patients with terminal illnesses the pain-killers they need, the doctors' and courts' sensitivities to patient autonomy were, in this case, touching to say the least. Michael requested the court to attribute to Terri the de facto right to physician-assisted suicide. That this decision favored Michael's personal and financial interests, and the taxpayers' economic interests, was purely coincidental.

The Schiavo case -- like Shakespeare's Lear or Hamlet -- was and remains great drama. It holds up a mirror, as it were, that reflects our selfishness, our moral uncertainties and vanities, and, above all else, our boundless hypocrisies about drugs, dying, medical care, and money.

Enlisting physicians in the task of killing people, whether patients or enemies of the state, is not a new idea. The fact that the Hippocratic Oath prohibits medical killing suggests that physicians and their superiors must have found it a temptation. The practice seems to have started in Rome under Nero, who would send "doctors to those who hesitated to execute his order to commit suicide, ... instruct[ing] them to 'treat' (curare) the victims, for thus the lethal incision was called" (Hoof, 1990). The guillotine and the gas chamber were developed by medical doctors. The Nazi medical Holocaust was an unabashed euthanasia program planned and carried out by physicians.

In English literature, the earliest reference to death as treatment appears in Sir Thomas More's Utopia. He wrote: "Should life become unbearable for these incurables, the magistrates and priests do not hesitate to prescribe euthanasia. ... When the sick have been persuaded of this, they end their lives willingly either by starvation or drugs" (More, 1516).

The practice of routinely referring to the ostensible beneficiary of physician-assisted suicide (PAS) as a "patient," albeit seemingly harmless, prejudges the act as medical and legitimizes it as beneficial ("therapeutic"). To be sure, a person dying of a terminal illness is, ipso facto, considered a patient. However, dying is not a disease; it may, inter alia, be a consequence of disease (or other causes, such as accident or violence). More importantly, killing (oneself or someone else) is not, and by definition cannot be, a treatment.

Strictly speaking, the phrase "assisted suicide" is an oxymoron. Suicide is killing oneself. We ought to call it autohomicide, to distinguish it from heterohomicide, which is the correct name of the act by which Terri Schiavo's life was terminated. Neither autohomicide nor heterohomicide is a medical matter. Both are legal, moral, economic, and political matters (Szasz, 1999 / 2001).
A person has no need for another to perform a service that he could perform for himself, provided, of course, that he wants to and is allowed to perform the service. If a person knows how to drive but prefers to be driven by someone else, he has no need for a chauffeur, he wants a chauffeur. Such a person is not receiving "chauffeur-assisted driving." The same is true for killing oneself.

Let us not forget that physicians have always been partly agents of the state and are now in the process of becoming de facto government employees. Hence, unless a person kills himself, we cannot be certain that his death is voluntary; under no circumstances should such a death be called "suicide." If a person is physically unable to kill himself and someone else kills him, then we are dealing with a clear case of heterohomicide (euthanasia, mercy killing, or medical murder, as the case may be).

Moreover, if a physician carries out the act, which is what happened in the Schiavo case, then we cannot be sure that the patient did not want to change his mind in the last moment, but could not or was not allowed to do so. We know that many persons who prepare advance directives requesting that physicians abstain from "heroic measures" to prolong their dying change their minds when the time comes to honor their own prior requests.

In short, conjoining the terms "assisted" and "suicide" is cognitively misleading and politically mischievous. The term "physician-assisted suicide" is a euphemism, similar to terms like "pro-choice" (for abortion) and "right to life" (for prohibiting abortion). We ought to reject PAS not only as social policy but also as a conventionally used phrase, especially so long as suicide remains, de facto, illegal, prohibited by mental health law and punished by psychiatric agents of the state.

Words are important. We must be careful about what we call the persons who receive and deliver suicide assistance services. If we call the persons who receive the services "patients" and those who deliver them "physicians," then dying by means of such a service is, ipso facto, a "treatment," and PAS becomes an approved cause of death, like dying from a disease. In short, the legal definition of PAS as a procedure that only a physician can perform expands the medicalization of everyday life, extends medical control over personal conduct, especially at the end of life, and diminishes patient autonomy.


Let us call a spade a spade. Terri Schiavo was killed: to be precise, she was executed, in accordance with a legally valid court order, by starvation and dehydration. Why? Because no one -- not her husband, not her parents, not any philanthropist, not the American taxpayer -- was willing to pay to keep her alive. The elephant in the room no one wanted to see was money. Had Terri's parents been Melinda and Bill Gates, and had they wanted to keep Terri alive, there would have been no "case." If we believe that executing innocent people is wrong, then the Schiavo case presents no ethical problem. It presents economic, political, and social problems.

Millions of persons all over the world -- infants, old people, severely disabled persons -- would die if they were not given food and water by others. Tens of thousands of persons, whose quality of life is not measurably better than Terri Schiavo's was, languish in nursing homes, tied to wheelchairs and drugged with Haldol. Looking after them for seven years, how many of their relatives could "remember" that the "patients" chose to die when they fell into such a state? How many could produce "credible witnesses" from among siblings or close friends to testify that they heard the patients say that? Would this be sufficient legal ground to starve them to death?

The problem is obvious: dependency. Formerly, this was a problem for the family and the church. Now, it is a problem for the state. Why? Because the modern national-socialist state has assumed the social-economic functions of the church, and is assuming more and more of the social-economic functions of the family.

Sir William Osler (1849-1919), perhaps the most celebrated physician in the history of American medicine, foresaw the problem of mass dependency in mass society and boldly offered a notorious recommendation. In 1905, Osler resigned from John Hopkins Medical School, of which he had been a founder, to accept the even more prestigious position of Regius Professor of Medicine at Oxford.

Nearly fifty-six years old, contemplating his own aging, he delivered an address titled The Fixed Period, declaring that "men over the age of sixty were useless," that "the history of the world shows that a very large proportion of the evils may be traced to sexagenarians," and that "peaceful departure by chloroform might lead to incalculable benefits," for them as well as for society (Osler, 1905 / 1943). Subsequently, Osler said, not very persuasively, that his proposal was "whimsical." However, many people took it seriously. His supposed spoof had temporarily enriched the language, generating the verb "Oslerize" (meaning "euthanize"), used both in jest and in earnest.

When Osler delivered his speech, he was a revered figure in American medicine. Nevertheless, the press -- then still vigilant about protecting personal freedom from medical statism -- was alarmed. An editorial in the New York Times castigated his remarks and compared his proposal to the practices of "savage tribes ... whose custom it is to knock their elders on the head whenever the juniors find their elders in their own way" (Johnson, 1996).

Two days after the address was denounced in the papers, a Civil War veteran shot himself to death. A clipping of Osler's address was found on his desk. The story was front-page news in a report entitled "Suicide Had Osler Speech." Undaunted, Osler angrily retorted: "I meant just what I said, but it's disgraceful, this fuss that the newspapers are making about it." In his hagiography of Osler, Harvey Cushing, the famed Harvard neurosurgeon, stated: "Efforts were made in vain to get him to refute his statement; and though there can be no question that he was sorely hurt, he went on his way with a smile" (Cushing, 1925).

His later disclaimers notwithstanding, Osler was serious. This conclusion is supported by his favorable reference to John Donne's now forgotten defense of suicide in Biathanatos (1646 / 1930), and also by the fact that Osler's essay and title were inspired by Anthony Trollope's (1815-1882) novel, also titled The Fixed Period (1882 / 1963). Trollope's tale, cast in the mold of a futuristic utopia/dystopia, takes place on the imaginary island, "Britanulla," where the human life span is fixed at sixty-five years. At the end of their sixty-sixth year, men and women are admitted to a college for a twelve-month period of preparation for euthanasia by chloroform. Trollope was sixty-seven when he wrote the novel. A year later he died, without benefit of chloroform. Despite his stature as the giant of American medicine, Osler never lived down his flirtation with medical killing.


On September 24, 2005, Michael Schiavo traveled to the Twin Cities to speak at a conference on medical ethics at the Hyatt Regency hotel honoring Dr. Ronald Cranford, a Minneapolis neurologist who was one of his medical advisors. "I never, in my entire life, thought I would be thrown into such a national debate," said Michael. "All I wanted to do was carry out my wife's wishes. ... Terri didn't die an awful death. I laid a red rose in her hand and said goodbye." His address was met by a standing ovation from the more than 200 people in attendance (Lerner, 2005).

Writing from Singapore after hurricane Katrina, New York Times columnist Thomas Friedman, an expert on medical ethics and everything else, opines: "There is something troublingly self-indulgent and slothful about America today -- something that Katrina highlighted and that people who live in countries where the laws of gravity still apply really noticed. ... We let the families of the victims of 9/11 redesign our intelligence organizations, and our president and Congress held a midnight session about the health care of one woman, Terri Schiavo, while ignoring the health crisis of 40 million uninsured" (Friedman, 2005).

As befits the true Jacobin, Friedman self-righteously dismisses the rights of the individual in the name of compassion for the masses. More than two hundred years ago, Edmund Burke (1729-1797) -- alluding to Rousseau -- delivered this priceless satirical portrait of the modern "humanist"-collectivist. Wrote Burke:
Benevolence to the whole species, and want of feeling for every individual with whom the professors come in contact, form the character of the new philosophy. ... He melts with tenderness for those only who touch him by the remotest relation, and then, without one natural pang, casts away, as a sort offal and excrement, the spawn of his own disgustful amours, and sends his children to the hospital of foundlings.

The bear loves, licks, and forms her young; but bears are not philosophers. Vanity, however, finds its account in reversing the train of our natural feelings. Thousands admire the sentimental writer; the affectionate father is hardly known in his parish. ... As the relation between parents and children is the first among the elements of vulgar, natural morality, they erect statues to a wild, ferocious, low-minded, hard-hearted father, of fine general feelings -- a lover of his kind, but a hater of his kindred (Burke 1791 / 1961).

Vanity, indeed. In 1993, while ostensibly trying to keep his wife, Terri, alive, Michael Schiavo converts her engagement ring and wedding band into a ring for himself; in June 2005, after Terri is cremated and her ashes are buried, he defines the date of her death as February 25, 1990 and uses her gravestone as a placard for congratulating himself on his self-proclaimed moral fidelity to her; and now, while continuing to loudly disclaim interest in publicity, he lectures on medical ethics.

Michael Schiavo had a choice to relinquish the care of his half-dead wife to her parents, who were begging him to let them assume that role and could have avoided the ensuing publicity which he claims he abhorred. He refused to do so. Cui bono?


- Burke, E. (1791 / 1961). Letter to a Member of the National Assembly. In The Philosophy of Edmund Burke: A Selection from His Speeches and Writings. Edited with an Introduction by Louis I. Bredvold and Ralph G. Ross. Ann Arbor: University of Michigan Press, p. 249.
- Chesterton, G. K. (1935). Broadcast talk, 6-11-35. Quotations of G. K. Chesterton. Http://
- Cushing, H. (1925). The Life of Sir William Osler. London: Oxford University Press, vol. 1, p. 669.
- Didion, J. (2005). The Case of Theresa Schiavo." New York Review of Books, Volume 52, Number 10, June 9.
Donne, J. (1646 / 1930). Biathanatos. New York: Facsimile Text Society.
- Faulkner, W. (1935). A Rose for Emily. Http://
- Friedman, T. (2005). Singapore and Katrina. New York Times, September 14.
- Hentoff, N. (2005). "he legacy of Terri Schiavo for the Nonreligious: The disabled sound the alarm. Free Inquiry. 25: 33-35 (August/September).
- Hooff, A. J., van. (1990). From Autothanasia to Suicide: Self-Killing in Classical Antiquity. London: Routledge, p. 51.
- Johnson, H. A. (1996). Osler recommends chloroform at sixty. The Pharos. 59: 24-26.
- More, T. (1516 / 1984). Utopia and Other Writings. New York: New American Library, p. 18.
- Lerner, M. (2005). Michael Schiavo speaks at local medical ethics conference. Minneapolis Star Tribune. February 24. Http://
- Osler, W. (1905 / 1943). The Fixed Period. In Osler, W., Aequanimitas: With Other Addresses to Medical Students, Nurses and Practitioners of Medicine, 3rd edition. Philadelphia: Blakiston, pp. 375-393.
- Schiavo, M. (2003). Quoted in
- Schiavo, M. (2005a). Quoted in, June 21, 2005 (a).
- Schiavo, M (2005b). Quoted in Lerner, M., Michael Schiavo speaks at local medical ethics conference. Minneapolis Star Tribune, September 24.
- Schiavo, M., (2005c). Quoted in Didion, J.. The Case of Theresa Schiavo. New York Review of Books, Volume 52, Number 10, June 9, 2005.
- Szasz, T. (1963 / 1989). Law, Liberty, and Psychiatry: An Inquiry Into the Social Uses of Mental Health Practices. Syracuse: Syracuse University Press, 1989, pp. 212-222.
- Szasz, T. (1999 / 2001). Fatal Freedom: The Ethics and Politics of Suicide. Syracuse: Syracuse University Press.
- Trollope, A. (1882 / 1993). The Fixed Period. London: Penguin.

"‘A Rose for Emily,' a rose for Terri: The lifeless body as love object and the case of
Theresa Marie Schindler Schiavo," Palliative and Supportive Care, 4: 159-167 (June), 2006.

"A Rose for Emily," a rose for Terri: The lifeless body as love object and the case of
Theresa Marie Schindler Schiavo

Thomas Szasz, M.D., Department of Psychiatry, Upstate Medical University, State University of New York, Syracuse, New York.
Mailing address: 4739 Limberlost Lane, Manlius, NY 13104. Tel. 315-637-8918. E-mail:

Keynote Address, "Controversies in End of Life Care: Terri Schiavo's Lessons,"
Baystate Medical Center, Department of Psychiatry; Smith College School of Social Work; Baystate Health Systems, Office of Continuing Education. Smith College, Northampton, Massachusetts, October 10 and 11, 2005.

Bertrand Russell, C. S. Lewis, and the Existential Identity Thief
Thomas Szasz

Falsehood flies and the truth comes limping after; so that when men come to be undeceived it is too late: the jest is over and the tale has had its effect.
Jonathan Swift (1667-1745)

One of the basic functions of living organisms is avoiding danger. In human beings, the emotion of fear serves that function. Because feeling fear is unpleasant, we try to escape it by seeking protection from danger, typically by looking to a Protector to protect us. Tragically, this longing -- be it for a deity, demagogue, dictator, or doctor -- is, itself, a source of danger. "Necessity," William Pitt (1759-1806) famously remarked, "is the plea for every infringement of human freedom.

It is the argument of tyrants; it is the creed of slaves." (Pitt was British Prime Minister, 1783-1801 and 1804-1806.) Fear of the insane and the psychiatrist's role as society's protector from the risk he allegedly poses is what has made the mere ascription of the label "insane" a justification for depriving the bearer of liberty.

Although the idea of "the dangerous madman" is a bugaboo or a tautology (because we redefine bad as mad, deviant as deranged), it has captivated the contemporary mind -- secular and religious alike -- and has entrapped some of the most admired modern intellectuals.

In A History of Western Philosophy, Bertrand Russell (1872-1970), the great atheist skeptic, tried to refute David Hume's sceptical empiricism and concluded that he was unequal to the task:

It is therefore important to discover whether there is any answer to Hume within the framework of a philosophy that is wholly or mainly empirical. If not, there is no intellectual difference between sanity and insanity. The lunatic who believes that he is a poached egg is to be condemned solely on the ground that he is in a minority, or rather -- since we must not assume democracy -- on the ground that the government does not agree with him. This is a desperate point of view, and it must be hoped that there is some way of escaping from it (Russell, 1945: 673).

Russell's "desperation" was inconsistent with his scepticism, expressed earlier in his Sceptical Essays, where he had stated: "I wish to propose
for the reader's favourable consideration a doctrine ... that it is undesirable to believe a proposition when there is no ground whatever for supposing it true" (Russell, 1928: 1). Russell was sceptical about religion, but not about psychiatry. Positing the existence of a lunatic who believes that he is a poached egg is a perfect example of believing "a proposition when there is no ground whatever for supposing it to be true."

Clive Staples Lewis (1898-1963), the celebrated Christian apologist, believed in religion but disbelieved in psychiatry. Nevertheless, in
his famous "trilemma," he too used the imaginary poached-egg man to support his reason for believing in the divinity of Jesus:

I am trying here to prevent anyone saying the really foolish thing that people often say about Him: "I'm ready to accept Jesus as a great moral
teacher, but I don't accept His claim to be God." That is the one thing we must not say. A man who was merely a man and said the sort of things Jesus said would not be a great moral teacher. He would be either a lunatic -- on a level with the man who says he is a poached egg -- or else he would be the Devil of Hell.

You must make your choice. Either this man was, and is, the Son of God: or else a madman or something worse. You can shut Him up for a fool, you can spit at Him and kill Him as a demon; or you can fall at His feet and call Him Lord and God. But let us not come with any patronising nonsense about His being a great human teacher. He has not left that open to us (Lewis, 1952: 40-41).

The model lunatic as a person who believes himself to be a poached egg evidently was fashionable among twentieth-century English academics, at least at Cambridge. Let us scrutinize this modern psychiatric miracle.

In a debate unrelated to matters psychiatric, Russell, the hard-headed empiricist, would emphasize that we have no way of knowing what a person believes himself to be. We can know only what he tells us about who or what he is and have no grounds for treating his claim as, a priori, true.

In ordinary English as well as in the idiom of psychiatry, we call a person's claim that he is a poached egg a "delusion." I have seen many
persons with so-called delusions and have read about many more, but have never seen or read of a poached-egg-man. In nineteenth-century European asylums, the most popular delusion was being Napoleon. In modern American mental hospitals, it is being Jesus. Whether or not the speaker believes his delusion to be true is irrelevant. The simplest, most parsimonious explanation for his speech act is that he is lying. In his Sceptical Essays, Russell himself suggested this interpretation. He wrote:

A man who has suffered some humiliation invents a theory that he is King of England, and develops all kinds of ingenious explanations of the fact that he is not treated with that respect which his exalted position demands. In this case, his delusion is one with which his neighbors do not sympathize, so they lock him up. But if, instead of asserting only his own greatness, he asserts the greatness of his nation or his class or his creed, he wins hosts of adherents, and becomes a political or religious leader (Russell, 1928: 1).

People often claim or pretend to be someone they are not. When a person does this on the stage, we call his behavior "acting." When he impersonates another for economic gain, defrauding others in the process, we call his behavior "identity theft." We treat him as a criminal, guilty of committing fraud, not as a lunatic harboring false beliefs. When, however, an individual impersonates say, Jesus, we refuse to see the self-evident method in his madness, the desire to gain existential rather economic advantage, and dismiss his conduct as "meaningless delusion."

I submit that we ought to view such behavior as a type of "existential identity theft," a phenomenon that presents no particular challenge to either philosophy or theology. Yet, Russell and Lewis both regarded the existential identity thief as presenting the grandest of philosophical and theological problems. Russell spoke of it "a desperate point of view, and it must be hoped that there is some way of escaping from it." There is, as I just showed. Lewis declared, "Either this man was, and is, the Son of God: or else a madman or something worse." There is an obvious third choice.

The man who says he is a poached egg is a liar, and that ought to be the end of the matter, for theology, philosophy, and psychiatry alike.
If we prefer to cast Lewis's riddle in softer terms, we might say that the man in Nazareth 2000 years ago who said he is the Son of God was a god-obsessed Jew, using a figurative language fashionable at the time, expressing and conveying a meaning to himself and others the exact signification of which we have no way of recapturing.

Much as I admire Lewis the man and his many memorable books, his assertion that -- "You can shut Him up for a fool, you can spit at Him and kill Him as a demon; or you can fall at His feet and call Him Lord and God. But let us not come with any patronising nonsense about His being a great human teacher. He has not left that open to us" -- is simplistic and foolish.

Lewis said that his aim was to show us why we ought to believe in the divinity of Jesus. Accepting his own postulate, he asserted that this hypothetical man-god had forbidden us to say "patronising nonsense" about him and that we must obey his prohibition. In short, Lewis treated his premise as proof of itself.

For the man who says he is Jesus, his identity thievery is an existential coup. For psychiatry, such as man -- Jesus or poached egg -- is an existential and economic gold mine. The fact that modern societies choose to value the products of this "salted mine" more highly than gold, indeed that they revere it as the science and practice of psychiatry, is another issue.

Finally, both Russell and Lewis compounded their mistaken reasoning about the nature of Existential Identity Theft by assuming that individuals or society need to sanction the Thief. Russell declared:
"The lunatic who believes that he is a poached egg is to be condemned solely on the ground that he is in a minority, ... etc."

Lewis agreed:
"You can shut Him [Jesus as liar] up for a fool... " These are non sequiturs. There is no need for individuals or society to condemn and punish the Existential Identity Thief. Severing relations with him suffices for our self-protection.


Thomas Szasz, M.D., Professor of Psychiatry Emeritus, Upstate Medical
University, State University of New York, Syracuse, New York. Home address: 4739 Limberlost Lane, Manlius, NY 13104-1405. Tel.: 315-637-8918.


I thank Professor Robert Spillane, Graduate School of Management, Macquarie University, Sydney, Australia, for calling my attention to this passage.


Lewis, C. S. (1952) Mere Christianity (New York: Macmillan).
Russell, B. (1928) Skeptical Essays (London: Allen & Unwin).
Russell, B. (1945) A History of Western Philosophy: And Its Connection with Political and Social Circumstances from the Earliest Times to the Present Day (New York: Simon and Schuster).

# 7
"A bogus Benjamin Rush quote:
contribution to the history of pharmacracy"

Benjamin Rush (1746–1813), the ‘father' of American psychiatry, is perhaps best known as the inventor of the ‘tranquilizing chair'. In recent decades, political and psychiatric activists have attributed a quotation to him in which he allegedly warned: ‘To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science.' The source of this quotation cannot be found, and Rush's remarks about ‘medical despotism' are inconsistent with the body of his work. Other examples are cited to illustrate the thesis that false attributions, used to support and advance particular ideological causes, are remarkably resistant to efforts at correction.
Keywords: Benjamin Rush; interest groups and their agenda; ‘medical freedom'; truth-falsehood



Benjamin Rush (1746–1813) was a Professor of Physic and Dean of the University of Pennsylvania medical school, physician general of the Continental Army, and a signatory to the Declaration of Independence. In 1812 he published Medical Inquiries and Observations upon the Diseases of the Mind, the first American textbook of psychiatry (Rush, 1812/1962). Appropriately, he is considered the father of American psychiatry: his portrait adorns the official seal of the American Psychiatric Association.

It is the fate of such men that activists and writers with an axe to grind often falsely attribute statements to them in their quest to bolster their own arguments. Such misattributions readily assume a life of their own, in accord with the psychological law discovered by Mark Twain. He wrote (Twain, 1882):
[The …] maxim that ‘Truth is mighty and will prevail' [is] the most majestic compound fracture of fact which any of woman born has yet achieved. For the history of our race, and each individual's experience, are sewn thick with evidences that a truth is not hard to kill, and that a lie well told is immortal. [...] How easy it is to make people believe a lie, and how hard it is to undo that work again!'

Examples abound. One of the most successful fabrications is H. L. Mencken's hilarious hoax about the history of the introduction of the bathtub into the United States. Written during the war-time Prohibition of 1917, the piece ostensibly memorialized the fictitious seventy-fifth anniversary of this momentous event. Fifty years later, Mencken (1917/1967: 592) commented:
The success of this idle hoax, done in time of war, when more serious writing was impossible, vastly astonished me. It was taken gravely by a great many other newspapers, and presently made its way into medical literature and into standard reference books. It had, of course, no truth in it whatsoever, and I more than once confessed publicly that it was only a jocosity [...] Moreover, it was exposed and denounced by various other men, for example, Vilhjalmur Stefansson, the arctic explorer (and great connoisseur of human credulity) [...] But it went on prospering and in fact is still prospering. Scarcely a month goes by that I do not find the substance of it reprinted, not as foolishness but as fact, and not only in newspapers but in official documents and other works of the highest pretensions.

The following bogus quotation attributed to Benjamin Rush is a recent example of foolishness masquerading as fact and mistaken for it. This is, we are told, what Rush said about the relations between medicine and the state:

Unless we put medical freedoms into the Constitution, the time will come when medicine will organize into an undercover dictatorship [...] To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un?American and despotic and have no place in a republic [...] The Constitution of this republic should make special privilege for medical freedom as well as religious freedom. (Grinspoon; 2003: 63; Lord,2 1994)

This bogus quotation – without a scintilla of evidence to support it, and with a plethora of evidence against it – has become a ‘fact.' A search of the World Wide Web (Internet) with the search engine Google reveals dozens of entries to it. But not a single author supplies a verifiable source for it. Hence, I believe this false attribution, depicting Rush as a medical libertarian, needs to be exposed as bogus.

It is important to remember that this is not the first time ‘humanitarian' hagiographers of psychiatry have repainted ugliness as beauty. Famed psychoanalyst and historian of psychiatry Gregory Zilboorg recast Johannes Weyer (1515–88) from medieval demonologist into a proto-psychiatrist who allegedly ‘recognized' that witches were ‘mentally ill.' According to Zilboorg (1941: 216), ‘He [Weyer] leaves no doubt but that one conclusion is warranted: the witches are mentally sick people'. With similar disregard for the truth, psychiatrists have created the legend of Philip Pinel (1745–1826) as a ‘reformer' who ‘struck the chains off the insane.' In fact, what Pinel had done is to medicalize the justification for incarcerating innocent persons in insane asylums (Szasz, 1970/1997: 203–4).


In my book, The Manufacture of Madness, I presented a review of Rush's psychiatric principles and practices and showed that he was a zealous advocate of the medicalization of personal and social problems and their coercive control by means of ‘therapeutic' sanctions. In short, he was a pioneer champion of pharmacracy and the therapeutic state (Szasz, 1970/1997, 2001/2003). Anyone familiar with the history of psychiatry ought to recognize that the quotation in question is a fabrication.
In Rush's day, psychiatry was a newborn infant. Most mad?house keepers were still clergymen, not physicians. Madness, as the term continues to imply, was associated with anger, lack of self?control, murder and suicide (‘self?murder'), in short, with behaviour regarded as sinful (Szasz, 1999/2002: 1–28). In 1774, when Rush was only twenty?eight?years old, he revealingly declared: ‘Perhaps hereafter it may be as much the business of a physician as it is now of a divine to reclaim mankind from vice' (Rush, 1774/1967).

To distinguish himself from the doctor of divinity, the doctor of medicine could not simply claim that he was protecting people from sin or, as Rush put it, from vice.
Badness was still, after all, a moral concept. As medical scientist, the physician had to represent badness as madness, and madness as a bona fide medical malady. He had to demonstrate, by his language and actions, that his object of study was not the immaterial soul, but a material object, a bodily disease. That is precisely what Rush did. In a letter to his friend, John Adams, he wrote: ‘The subjects [mental diseases] have hitherto been enveloped in mystery. I have endeavored to bring them down to the level of all other diseases of the human body, and to show that the mind and the body are moved by the same causes and subject to the same laws' (quoted in Binger, 1966: 281).

Rush did not discover that certain behaviours are diseases, he decreed that they are: ‘Lying is a corporeal disease. / Suicide is madness. / Chagrin, shame, fear, terror, anger, unfit for legal acts, are transient madness' (Rush, 1810/1948: 350). Today, some of these and many other unwanted human behaviours are widely accepted as real diseases, their existence ostensibly supported by the modern science of neurobiology.
In addition to deploying the idea of insanity to rationalize the widespread use of ‘therapeutic' coercion, Rush (1812/1962: 263–70) also championed the insanity defence. He defined crimes as ‘derangements of the will,' explaining: ‘I have selected those two symptoms [murder and theft] of this disease (for they are not vices) from its other morbid effects, in order to rescue persons affected with them from the arm of the law, and render them the subjects of the kind and lenient hand of medicine' (Rush, 1810/1948: 264).

For example, Lester Grinspoon – a Professor of Psychiatry at Harvard and a prominent advocate of so-called ‘medical marijuana' – believes, and would have us believe – that Rush stated: ‘To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science' (Grinspoon, 2003: 63). In fact, Rush is on record stating the exact opposite.

Among the many mental illnesses Rush invented was the disease he named ‘derangement in the principle of faith or the believing faculty'. Instead of defining this ailment, he illustrated it with examples of two types of ‘patients': ‘[P]ersons who deny their belief in the utility of medicine, as practiced by regular bred [trained] physicians, believing implicitly in quacks; [and] persons who refuse to admit human testimony in favor of the truths of the Christian religion' (Rush, 1812/1962: 273–4).

As noted, Rush defined his own ‘medical' methods as ‘kindly.' In fact, his ‘treatments' consisted of inflicting pain on the patient and depriving him of liberty. The following passage illustrates his mind-set: ‘Lying, as a vice, is said to be incurable. The same thing may be said of it as a disease [...] Its only remedy is, bodily pain, inflicted by the rod, or confinement, or abstinence from food' (Rush, 1812/1962: 265–6). For good measure, he added: ‘Terror acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness' (p. 211). Rush went so far as to invent a new ‘therapeutic' device – actually, an instrument of terror and torture – which he presciently called the ‘tranquilizing chair.' It was but a short ideological step from the tranquilizing chair to the tranquilizing drug, each ‘administered' against the will of the patient.

In his persona, Rush displayed all of the manifestations of psychiatric megalomania that characterize modern psychiatric thought and practice (Binger, 1966: 200). Not only did he oppose the kind of ‘medical freedoms' the bogus quote attributes to him, he ‘diagnosed' the ‘excess of the passion for liberty' as a form of mental illness. Lamenting this passion, ‘inflamed by the successful issue of the [Revolutionary] war', he explained: ‘The extensive influence which these opinions had upon the understandings, passions, and morals of many of the citizens of the United States, constituted a form of insanity, which I shall take the liberty of distinguishing by the name of anarchia' (quoted in Boorstin, 1948: 182). Disappointed with his political efforts, he declared: ‘Were we to live our lives over again and engage in the same benevolent enterprise, our means should not be reasoning but bleeding, purging, low diet, and the tranquilizing chair' (Rush, 1951: letter dated xxxx, in Butterfield, 1951: 1092).

To ascertain further the fabricated provenance of the quotation that is the subject of this essay, I sought the help of the Library of Congress. On 17 October 2003, I received the following reply, which requires no further comment.

Subj: Benjamin Rush quotation
Date: 10/17/03 3:40:42 PM Eastern Daylight Time

Dear Dr. Szasz:
This is in reply to your letter of September 24, addressed to the Reference Referral Service, Library of Congress. We have not found the quotation, attributed to Benjamin Rush, which you are seeking. Your suspicion that it is bogus is supported by a look at some of its words in the Oxford English Dictionary. The Dictionary records no use of ‘un?American' until a few years after Rush's death. ‘Under?cover' as an adjective meaning ‘operating in secret' does not appear until 1920.


Rush's stature in the history of American medicine alone justifies calling attention to the bogus nature of the quotation in question. It is further justified by the fact that many of the persons who cite it are academics, politicians and psychiatrists who ought to know better. The following list is merely a sampling of the individuals and organizations who make use of this bogus quote.

The American Association for Health Freedom and the Access To Medical Treatment Act (AMTA)
We strongly support the American Association for Health Freedom (web site in their effort to pass the Access To Medical Treatment Act. This is a Federal bill that has been introduced in the House by Representatives Peter DeFazio, Joe Barton, and Ron Paul [...] As things stand now, those who hold one view of health care expect to be allowed to decide what constitutes legal methods of healing. It is just this kind of despotism that our Founding Fathers intended to prevent. Benjamin Rush, MD, a signer of the Declaration of Independence and personal physician to George Washington said: ‘Unless we put medical freedom into the Constitution, the time will come when medicine will organize into an undercover dictatorship to restrict the art of healing to one class of men and deny equal privileges to others; the Constitution of the Republic should make a special privilege for medical freedoms as well as religious freedom' (American Association for Health Freedom, 2003).
Congressman Ron Paul is trained as a physician. He also supports legislation for ‘medical marijuana' and physician-assisted suicide. The reference to Washington is lamentably shameless. Bloodletting – Rush's panacea – has often, probably rightly, been blamed for Washington's premature death from what may have the flu.
[...] So many massage therapists with so many kinds of training have massaged so many people with so many contraindications so many times for so many years with so many benefits reported in so many publications, but with so few, if any, well?documented cases of harm. [...] Dr. Benjamin Rush, one of the Signers of the Declaration of Independence and Surgeon General of the Continental Army of the United States, believed: ‘The Constitution of the Republic should make special provision for Medical Freedom as well as Religious Freedom. To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un?American and despotic. They are fragments of monarchy and have no place in a republic'. (Schatz and Brewster, 1999)
Demand Healthcare Freedom [...] Read the reports on our links and proposed Health Care Freedom Bill with an open mind. [...] ‘Unless we put medical freedom into the Constitution, the time will come when medicine will organize into an underground dictatorship [...] To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un?American and despotic and have no place in a republic [...] The Constitution of this republic should make special privilege for medical freedom as well as religious freedom.' Dr Benjamin Rush, signer of the Declaration of Independence. (Citizens for Health Care Freedom, 2003)
‘The Constitution of this republic should make special provisions for medical freedom as well as religious freedom. To restrict the art of healing to one class of man and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un?American and despotic.' Benjamin Rush, M.D., Leading Allopath During the Founding of America. (OKHealthfreedom, 2001)
Thomas Jefferson and Dr. Benjamin Rush (who was George Washington's personal physician and a signer of the Declaration of Independence) both foresaw that the federal government might someday attempt to control medicine. Dr. Rush gave this diagnosis: ‘Unless we put medical freedom into the Constitution, the time will come when medicine will organize into an underground dictatorship [...] To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un?American and despotic and have no place in a republic [...] The Constitution of this republic should make special privilege for medical freedom as well as religious freedom'. (Un Sacco di Canapa, n.d.)
Our Mission is the advancement of Hyperbaric Oxygen Therapy used in traditional circumstances as well as the prevention and enhancement aspects of your health. [...] ‘Unless we put medical freedom into the Constitution, the time will come when medicine will organize into an undercover dictatorship […] To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un?American and despotic and have no place in a republic […] The Constitution of this republic should make special privilege for medical freedom as well as religious freedom.' Benjamin Rush, M.D., Signer of Declaration of Independence, Physician to President George Washington (Rapid Recovery Hyperbarics, 2003).
A World Without Cancer
[...] In order to abolish the FDA, or at least to restrict its operation, we will need either legislation or a constitutional amendment. We should pursue both. The possibility of a constitutional revision is not as extreme as it may sound. In fact, Dr. Benjamin Rush of Philadelphia – one of the signers of the Declaration of Independence, a member of the Continental Congress, Surgeon?General of Washington's armies, and probably the foremost American physician of his day – had urged his colleagues to include ‘medical liberty' in the First Amendment at the time it was drafted. He wrote: ‘Unless we put medical freedom into the Constitution, [...]'. As quoted by Dr Dean Burk in The Cancer News Journal, May/June, 1973: 4. (Griffin, 2003)1.
The reference is bogus as well. This author embellishes the quote by claiming that Rush had ‘urged his colleagues to include "medical liberty" in the First Amendment at the time it was drafted' (Griffin, 2003).


The use by various ‘therapeutic' interest groups of the bogus quotation by Rush illustrates that falsehood can serve expediency, but it cannot serve liberty. The advocacy of so-called ‘medical marijuana' – in plain English, marijuana by medical prescription – is a dramatic case in point. It is a bad cause, argued with bad evidence and in bad faith.

For my part, I have long agreed with Gilbert K. Chesterton, the celebrated Christian humanist-humorist-philosopher, who stated: ‘The free man owns himself. He can damage himself with either eating or drinking; he can ruin himself with gambling. If he does he is certainly a damn fool, and he might possibly be a damned soul; but if he may not, he is not a free man any more than a dog' (Chesterton, 1909: 32). Either we have the right to poison and kill ourselves with food, alcohol and drugs, or we do not. For nearly half a century I have opposed drug prohibition, the growing power of the therapeutic state, and mistaken efforts of ‘reformers' to deal with drug prohibition by multiplying instead of repealing regulations that treat drug use as a crime (and mental illness).

In one of his recent essays, Lester Grinspoon reprises the medicinal value, as defined by the consumers, of smoking marijuana, and the objections of the government against permitting physicians to dispense it by prescription. His argument is paternalistic both in content and tone. He laments that we are not moving towards a ‘regulatory system that would allow responsible use of marijuana' (Grinspoon, 2003: 81). No totalitarian authority objects to the ‘responsible use' of the press, sex, alcohol or anything else. In Grinspoon's scheme, who – if not agents of the government – would have the authority to define ‘responsible use'? Grinspoon not only begins his essay with a strategic misattribution to Rush, he also ends it by repeating Rush's non-existing opposition to ‘medical fascism' – precisely the type of pharmacracy Rush supported and Grinspoon (2003: 81) now supports:

If the cynical attitude of the federal government toward patients who use medical marijuana, its attempt to intimidate physicians [the intimidation is a fact, not an attempt] [...] lends credence to Benjamin Rush's concern about medical fascism, then the patients and the people who help them in a variety of ways constitute a resistance movement against medical dictatorship.

This is not a plea for medical liberty. It is the self-congratulation of one medical statist seeking to replace the authority and power of his opponent, defining his coercive regulations ‘to responsibly use this plant' as helpful, and those of his opponent to do the same thing as harmful (Szasz, 2003; also Szasz, 1992/1996).

The facts, let me repeat, contradict the contents of Rush's bogus quote and refute the arguments and claims of those who use them. Rush was, quite literally, a prohibitionist. In a letter to Jeremy Belknap (1744–98), a Congregational minister and amateur American historian in Boston, Rush wrote: ‘In the year 1915, a drunkard I hope will be as infamous in society as a liar or thief, and the use of spirits as uncommon in families as a drink made of a solution of arsenic or a decoction of hemlock' (quoted in Binger, 996: 201).

Sadly, the individuals and organizations who make use of the bogus Rush quote have no interest in separating medicine and the state. If they had such an interest, they could use a genuine quote to support their cause – not by Rush but by Jefferson, who, not by coincidence, considered Rush to be a quack and a medical menace (mainly on account of his enthusiasm for bloodletting). Alluding to the crucial importance of bodily self-ownership as a political issue, Jefferson (1781/1944: 275) mocked would-be statist meddlers into our diets and drugs by reminding his readers that ‘in France the emetic was once forbidden as a medicine, the potato as an article of food. [...] Was the government to prescribe to us our medicine and diet, our bodies would be in such keeping as our souls are now'.

History of Psychiatry (UK), 16: 89-98 (March), 2005.
State University of New York

1. For additional web sites citing the quote, see:;
David Wallace Croft Compilation. Copyright released to the Public Domain by the author, 2003?03?19.
2. Dr Nancy Lord Johnson is both a lawyer and physician. In 1992, she was the vice presidential candidate of the Libertarian Party.
The American Association for Health Freedom (2003) TITLE?? [PO Box 458, Great Falls, VA 22066, USA]. Retrieved from;
Binger, C. (1966) Revolutionary Doctor: Benjamin Rush, 1746–1813 (New York: Norton).
Chesterton, G. K. (1909) Orthodoxy (London: John Lane).
Citizens for Health Care Freedom (2003) Philosophy of Health Freedom [PO Box 62282, Durham, NC, 2771–2282, USA]. Retrieved from;http://www.
Griffin, G. E. (2003) A World without Cancer [, PO Box 2038, Leigh?on?Sea, SS9 2ZB, UK]. Retrieved from
Grinspoon, L. (2003) The medical marijuana problem. Journal of Cognitive Liberties, 4, 63–81.
Jefferson, T. (1781/1944) Notes on the State of Virginia [1781]. In A. Koch and W. Peden (eds) (1944), The Life and Selected Writings of Thomas Jefferson (New York: Modern Library).
Lord, N. (1994). Excerpts from closing argument in the trial of Alternative Health Care Provider Rodger Sless versus The United States Food And Drug Administration, Albuquerque, NM, USA. Retrieved from
Mencken, H. L. (1917/1967) A neglected hoax [1917]. In Mencken, H. L. (ed.) (1967), A Mencken Chrestomathy (New York: Knopf).
OKHealthfreedom (2003). Religious and cultural issues impede attempts to license natural healing arts in Oklahoma. 2001. Retrieved from http://okhealthfreedom.homestead.
Rapid Recovery Hyperbarics (2003) TITLE. Retrieved from
Rush, B. (1774/1967) Letter to Granville Sharp (1774). Quoted by J. A. Woods (1967) The correspondence of Benjamin Rush and Granville Sharp, 1773–1809. Journal of American Studies, 1, 8.
Rush, B. (1810/1948). Lectures on the medical jurisprudence of the mind (1810). In G. W. Corner (ed.) (1948), The Autobiography of Benjamin Rush: His ‘Travels through life' together with his ‘Commonplace book for 1789–1812' (Princeton: Princeton University Press).
Rush, B. (1812/1962) Medical Inquiries and Observations upon the Diseases of the Mind (Reprinted 1962, New York: Macmillan – Hafner Press).
Rush, B. (1951) TITLE. In L. H. Butterfield (ed.), Letters of Benjamin Rush (Princeton: Princeton University Press).
Schatz, A. and Brewster, M. (1999) A declaration of independence for massage therapists. Massage Law Newsletter, 7 (4), PAGES. Electronic version, retrieved from
Szasz, T. (1970/1997) The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement (Syracuse, NY: Syracuse University Press).
Szasz, T. (1992/1996) Our Right to Drugs: The Case for a Free Market (Syracuse, NY: Syracuse University Press).
Szasz, T. (1999/2002) Fatal Freedom: The Ethics and Politics of Suicide (Syracuse, NY: Syracuse University Press).
Szasz, T. (2001/2003) Pharmacracy: Medicine and Politics in America (Syracuse, NY: Syracuse University Press).
Szasz, T. (2003) Marijuana medicalization: bad cause, bad faith. Journal of Cognitive Liberties, 4: 83–5.
Twain, M. (1882) Advice to youth. Retrieved from
Un Sacco di Canapa (date). TITLE. Retrieved from
Zilboorg, G. (1941) A History of Medical Psychology (New York: Norton).

© 2005 Thomas Szasz


# 6
"Idiots, infants, and the insane":
mental illness and legal incompetence

Prior to the second world war, most persons confined in insane asylums were regarded as legally incompetent and had guardians appointed for them. Today, most persons confined in mental hospitals (or treated involuntarily, committed to outpatient treatment) are, in law, competent; nevertheless, in fact, they are treated as if they were incompetent. Should the goal of mental health policy be providing better psychiatric services to more and more people, or the reduction and ultimate elimination of the number of persons in the population treated as mentally ill?

Keywords: conflict between mental patient and psychiatrist; psychiatric reform; involuntary psychiatric intervention; legal incompetence; mental illness.

Contemporary medicine and law define mental illness as an "illness like any other illness".1 The person diagnosed as mentally ill (and dangerous to himself or others) is, however, deprived of liberty, a procedure called "civil commitment" in the US, and "sectioning" in the UK.

Black's Law Dictionary defines incompetence as the "legal status of a person who is unable or unfitted to manage his own affairs...and for whom, therefore, a committee may be appointed".2 It is the function of the court (judge) to appoint a legal guardian for the incompetent person; such a guardian has clearly defined fiduciary duties to protect the best interests of his ward.

In principle, the mental patent is considered competent (until proven incompetent). In practice, he is regularly treated as if he were incompetent and the psychiatrist who asserts that he needs treatment is treated as if he were the patient's guardian.3 This conflation of mental illness and legal incompetence, and the concomitant transformation of the mental hospital patient into ward and the psychiatrist into guardian, is a relatively recent phenomenon.

When I was a medical student in Cincinnati in the early 1940s, there were no voluntary patients in Ohio state mental hospitals. A person could no more gain admission to a state mental hospital voluntarily than he could gain admission to a prison voluntarily. Individuals civilly committed to state mental hospitals were considered legally incompetent. They were released, however, if their next of kin was willing to care for them.

In the UK, too, until recently, the person confined in a mental hospital was assumed to be legally incompetent. Prior to the English Mental Health Act 1983, it was generally assumed that psychiatric detention automatically authorised the psychiatrist to treat the patient without consent. The act explicitly authorised the treatment of detained patients without their consent.

In the aftermath of the second world war, American social attitudes toward mental hospitalisation began to change, partly as a result of the extermination of mental patients in Nazi Germany. Journalists compared state mental hospitals to concentration camps and called them "snake pits". Erving Goffman's book, Asylums,4 and my book, The Myth of Mental Illness,5 challenged the moral and legal legitimacy of psychiatric coercions, exemplified by involuntary confinement in a mental hospital. Presidents of the American Psychiatric Association and editors of psychiatric journals acknowledged the problem of chronic mental patients becoming "institutionalised".

At this critical moment, the psychiatrists' drugs miraculously appeared and saved the profession. At least for a time. Politicians and the public quickly accepted the psychiatrists' claim that mental illnesses were brain diseases ("chemical imbalances"), and that neuroleptic drugs are effective treatments for such diseases. Psychiatrists and politicians used this fiction as a peg on which to hang the complexly motivated programme of emptying the state mental hospitals, misleadingly called "deinstitutionalisation".6 In short, the three events characteristic of modern psychiatry-the development of psychiatric drugs, deinstitutionalisation, and the conflation of mental illness and legal incompetence-occurred in tandem, each facilitating and supporting the others.

Actually, the treatment of mental diseases is no more successful today than it was in the past. Deinstitutionalisation did not liberate mental patients. Some state mental hospitals inmates were transinstitutionalised, rehoused in parapsychiatric facilities, such as group homes and nursing homes. Others were imprisoned for offences they were prone to commit, transforming jails into the nation's largest mental hospitals. Still others became "street persons", living off their social security disability benefits. Most idle, indigent, unwanted persons continue to be incarcerated in mental hospitals-intermittently, committed several times a year, instead of once for decades.

Most importantly, the powers of courts and mental health professionals were vastly expanded: before the second world war, they could control and forcibly "treat" only persons housed in mental hospitals. Armed with "outpatient commitment" laws (in the US), psychiatrists can now control and forcibly "treat" persons living in the community.
Medical practices rest on consent. Psychiatric practices rest on coercion, actual or potential. It is the power and duty to coerce mental patients-to protect them from themselves and to protect society from them-that has always set, and continues to set, psychiatrists apart from other medical practitioners. Nevertheless, the conflation of mental illness and legal incompetence-redescribed as "protection of the patient's best interest"-is widely regarded as an important advance in medical and psychiatric ethics.
In the old days of asylum psychiatry, the connection between mental illness and legal incompetence was unambiguous. If a person was mad enough to merit confinement in a madhouse, then he was manifestly incompetent. Whereas if he was competent, then he was manifestly not a fit subject for incarceration in an insane asylum.

After the second world war, the treatment of "mental illness" by psychoanalysis and psychotherapy achieved sudden popularity. The introduction of neuroleptic drugs into psychiatry created the illusion that mental illnesses, like medical illnesses, were "treatable" with drugs. Doubt about the benefits of long term mental hospitalisation was replaced by confidence in the effectiveness of outpatient chemotherapy for mental illness. A new class of mental patients thus came into being-persons who sought psychiatric help, paid for the services they received, and were regarded as legally competent. In these important ways, they resembled medical patients. This development greatly enlarged the number of persons classified as mentally ill, contributed to the false belief that legal competence is a psychiatric issue, and confused the legal relations between psychiatrist and mental patient.

Two troubling facts continue to bedevil psychiatry and especially the increasingly important field of forensic psychiatry-namely, that we lack objective tests for both mental illness and mental (legal) competence. Competence and incompetence-like innocence and guilt-are attributions, not attributes, judgments, not facts. That is why traditionally they are rendered by lay juries, not professional experts.

In general, the psychiatric patient whose behaviour is socially deviant risks being considered incompetent (as well as mentally ill). If-for example-the patient kills herself or someone else, then, after the fact and simply for this reason, she is considered incompetent and her psychiatrist's treatment of her is judged to be "medically negligent": the psychiatrist, viewed as the patient's guardian, is considered to have failed to fulfil his "duty to protect" his ward. None of this was true as recently as the 1960s.

The conflation of mental illness and legal incompetence entangles both patients and psychiatrists in Alice in Wonderlandish encounters, as the following example illustrates. On December 7, 1981, a man named Darrell Burch was found wandering along a Florida highway, appearing to be disoriented. Taken to Apalachee Mental Health Services (ACMHS) in Tallahassee, his evaluation form stated that: "upon arrival at ACMHS, Burch was hallucinating, confused, and psychotic and believed he was 'in heaven'".7 Burch was asked to sign forms giving consent to admission and treatment and did so. Diagnosed as suffering from paranoid schizophrenia, he was given psychotropic medication.

Subsequently, Burch was transferred to the Florida State Hospital (FSH) in Chattahoochee and again asked to sign, and did sign, forms giving consent to hospitalisation and treatment. At the FSH, a staff physician named Zinermon "wrote a progress note indicating that Burch was refusing to cooperate and would not answer questions" (Zinermon v Burch,7 p 119).

Burch remained at the FSH as a "voluntary" patient for 5 months. After he was released, he sued Zinermon and 10 other staff members of the FSH for having deprived him of liberty without due process of law, because he was mentally incompetent to consent to hospitalisation and treatment. The case was appealed all the way to the United States Supreme Court, which ruled that when Burch was admitted to the FSH, he was incompetent and hence had a constitutionally protected right to a court hearing to determine whether he should be committed and treated as an involuntary patient:
[T]he very nature of mental illness makes it foreseeable that a person needing mental health care will be unable to understand any proffered "explanation and disclosure of the subject matter" of the forms that the person is asked to sign, and will be unable "to make a knowing and willing decision" whether to consent to admission....The characteristics of mental illness thus create special problems regarding informed consent. Even if the State usually might be justified in taking at face value a person's request for admission to a hospital for medical treatment, it may not be justified in doing so, without further inquiry, as to a mentally ill person's request for admission and treatment at a mental hospital (Zinermon v Burch,7 pp 121 and 133, emphasis added).

The court's ruling upset the psychiatric establishment. Bruce J Winick, a professor of law at the University of Miami, complained that "the court's language could have unintended antitherapeutic consequences" (emphasis added).8 This cliché assumes that the purpose of depriving insane persons of liberty is therapy, which, given the dangerousness clause in commitment laws, is patently false.

In order to conduct relations with individuals we do not know, we must make certain presumptions about them. The automobile dealer must presume that his customer is legally competent and responsible for his purchase. The physician whose patient complains of blood in his stool must presume that the patient has a disease. The Anglo-American legal system must presume that a person accused of a crime is innocent until proven guilty, and competent until proven incompetent.

We are proud of our criminal justice system because it protects the accused from the power of the state, a power we distrust because its avowed aim is to harm the individual. Similarly, we are also proud of our mental health system, because it protects the mentally ill person from the dangers he poses to himself and others, a power we trust because its avowed aim is to help the individual.

Difficulties arise, however, once the power of the state to "help" goes beyond offering services (or money) and, instead, the state makes use of coercion. The justification for psychiatric coercion is further weakened by resting the requirement for commitment on "mental illness" and "dangerousness". There are no objective criteria for either mental illness or dangerousness. Thus psychiatric determinations and declarations of their presence or absence are essentially oracular and rhetorical. Nevertheless, they fulfil a very important function: they instruct the listener to assume a desired attitude toward the "patient".9 The distinction between descriptive and dispositive terms is crucial for understanding this conundrum.

Characterising a door as brown or white is descriptive. Characterising it as needing to be opened or closed is dispositive. Descriptive characterisations can be proved or disproved. Dispositive characterisations cannot, they can only be obeyed or disobeyed. The difference between the situation of the person accused of a crime and the situation of the person accused of mental illness is illuminating. The defendant has a right to deny his crime and disagree with his accusers. His insistence on his innocence is not interpreted as evidence of his guilt. The person diagnosed as mentally ill loses this right. His disagreement with the psychiatrist is interpreted as "lack of insight into his illness" or "denial of his illness". His insistence on his sanity is interpreted as evidence of his insanity.

Psychiatrists use the term "competent" as if they were identifying a "mental condition" in the designated person. That is why courts request the psychiatrist to examine defendants for competence, as if they were looking for and detecting (or not detecting) certain facts. Psychiatric "findings," however, especially in a forensic setting, are not facts but recommendations for a course of action toward the defendant.

Ironically, it is precisely because the American system of criminal justice is so intensely concerned with protecting innocent persons from punishment that it is especially vulnerable to corruption by excuses couched in terms of psychiatric disabilities and coercions justified as psychiatric treatments. The root of the problem lies largely in the concepts of mental illness and dangerousness, and partly in the doctrine of mens rea, sound mind.

Because both "mental illness" and "dangerousness" lack objectively verifiable criteria, they are easily abused.9 The legal doctrine of mens rea, sound mind, which holds that unlawful behaviour constitutes a crime only if it is committed by an actor who possesses a "guilty mind"-that is, whose "mind" can be held responsible (because it knows right from wrong), also works to strip the person incriminated as mentally ill of his rights. Since the Middle Ages and before, insane persons-perceived as similar to "wild beasts"-have been regarded as lacking mens rea. This is why "infants, idiots, and the insane"-in John Locke's famous phrase, repeated unchanged ever since-are not prosecuted or punished by the criminal law, but instead are restrained, as minors and as mad, by family courts and mental health laws.

Treating mentally ill persons as if they were like children fails to take into account the many obvious differences between them. Minority is an objectively defined (chronological) condition and a legal status. Mental illness is neither. Children are, by definition, under tutelage. Few mental patients are under tutelage and those that are, are in that status not because they are mentally ill but because they are declared to be legally incompetent.

Persons called "mental patients" are not children and are not like children. They are adults, entitled to liberty and responsible for their crimes. I maintain that "mental illness" is not something the patient has, it is something he is. The modern psychiatrist is likely to view Lady Macbeth as insane, the victim of manic depressive psychosis, an illness that renders her not responsible for her crimes. Shakespeare viewed her as "Not so troubled with thick coming fancies", for which she needs "the divine [minister, rather] than the physician".10

The very survival of psychiatry as a medical specialty depends on postulating and perceiving "mental illness" as a disease, an entity "outside" and separate from the patient as a moral agent, in the sense that, say, malaria, in a European tourist returning from Africa, is "outside" and separate from his persona.11

In an interesting recent paper, Sadler and Fulford struggle with this issue and propose that, in formulating criteria for psychiatric diagnoses (but not for medical diagnoses), psychiatrists include the opinions of mental patients and their relatives. They write: "Why should psychiatry involve patients in diagnosis? A key part of psychiatric treatment, rehabilitation, and recovery is helping the patient to distinguish between the features of illness and the features of the self-to move patients from battling themselves to battling their disorders" (emphasis added).12

A hundred years ago, psychiatric nosology was the province of the neuropathologists: by definition, mental diseases were brain diseases, identified at autopsy and demonstrated by histological evidence. The purpose of a diagnosis-medical and psychiatric alike-was to convey scientific information. Since then, without anyone quite realising it, neuropathological diagnostic criteria were transformed into psychopathological diagnostic criteria, and the reasons for making psychiatric diagnoses have expanded and now serve a vast number of complex economic, political, social, and other non-scientific ends.

Regarding Sadler and Fulford's therapeutic aim of "moving patients from battling themselves to battling their disorders", it is necessary to note that everyone harbours contradictory desires and thus everyone may be said to be battling himself.

Psychiatrists accentuate the metaphor of "inner battle", while they avert their gaze from the bitter reality of the "outer battle", the battle between the involuntary mental patient and "his" psychiatrist. I dare say that that embarrassing spectacle is our profession's "elephant in the room". The need to pretend that it is not there is the most important unwritten rule of psychiatric etiquette.13

In legal theory, mental illness and mental incapacity are separate issues. In psychiatric practice, they are the same issue. In Re C (1994), the English High Court held that detained patients were entitled to the presumption of competence: a hospitalised patient with schizophrenia was considered competent to refuse amputation of his gangrenous foot. Had the patient sought to refuse drug treatment for schizophrenia, his decision could have been overruled and he could have been medicated against his will.13

In a 1999 review article in the BMJ, Barbara Hewson, a London barrister, concluded that: A person may remain competent even if detained under the Mental Health Act 1983....Adults are presumed competent to refuse treatment, even in an emergency; but it is not easy to judge in practice what factors are capable of rebutting the presumption. Every case turns on its own facts. The detention of incompetent patients for controversial, and likely to generate litigation under the Human Rights Act 1998.... the law in this area is complex.14

I believe the law in this area is not just complex, it is not true law at all: absent objective criteria for the key concepts, decisions about competence and the right to reject psychiatric treatment, remain in the hands of psychiatrists. This gives psychiatrists both too much power and too much responsibility.15

In a reply to Hewson's article, a Canadian psychiatrist complained: "After reading Hewson's article I was more confused than ever. No matter what is decided, to treat or not treat, a doctor has the pleasure of looking forward to an assault charge or wilful negligence. This entire debate is ludicrous. The law should be changed so that a self harm is viewed as a declaration of incompetence".16 This respondent can think of no better solution than to revert to the "good old days of psychiatry": restore absolute medical power over mental patients to psychiatrists, complemented by legal immunity for the consequences of their decision.

In a 2002 editorial in The Psychiatric Bulletin, Vanessa Raymont, an English psychiatrist, reminds us:
Although the notion of informed consent was recognised in medical practice as early as the 1700s, it was not until the advent of the voluntary boarder status in the Lunacy Act 1890 and the voluntary patient in the Mental Treatment Act 1930 that the issue of capacity and consent for psychiatric treatments was first raised in non-detained patients....The Mental Health Act 1983 allows treatment without consent in psychiatric illness, but not physical illness.17,18

Decisions by the European Court of Human Rights (ECHR) regarding complaints of psychiatric deprivations of human rights further illustrate the discrepancy between legal theory and psychiatric practice. A woman in the Netherlands voluntarily entered a psychiatric hospital. A month later, a judge, without notifying the patient, confined her to the hospital for 6 months without holding a hearing. The ECHR ruled that the defendant/patient's "right to a speedy trial or hearing applies to both criminal arrests and psychiatric detentions and hence the patient's rights were violated".19

It is inevitable that many persons in society-infants and young children, severely retarded individuals, demented and unconscious patients-must be treated as legally incompetent. This is not true for mental patients.

The ostensible motive behind recent so called mental health reforms has been the desire to free the mental patient from anachronistic, authoritarian psychiatric controls. Certain crass psychiatric coercions-such as indefinite involuntary mental hospitalisation, beatings, and cold showers-have become unfashionable. Yet, changes in mental health policy have failed to increase the mental patient's responsibility to care for himself, to be accountable for his everyday behaviour, and to be legally answerable for his criminal conduct. On the contrary, today more people than ever are defined as mental patients and are "treated" without their consent, as if they were incompetent. More worryingly, the coercive practice of commitment, formerly confined to the mental hospital, has metastasised: outpatient commitment has turned all of society into a kind of mental hospital.

We cannot make progress in mental health care policy until we clarify and agree on what we mean by progress. Psychiatrists and politicians mean by it making more and better mental health services available to more and more people. I consider that to be not progress, but a plan to turn more people into "consumers of mental heath services". There can be only one humane goal for mental health care policy, namely, reducing and ultimately eliminating the number of persons in the population treated as mentally ill. We cannot attain this goal - indeed, we cannot even begin to pursue it-as long as we cling to the notion that "mental illness" is a disease that the patient "has".

Mental illness may look like an illness and may be called an illness, but it is not a true illness. Similarly, mental health law may look like law and may be called law, but it is not true law. Anglo/American criminal law is a shield to protect the person accused of crime from the power of the state. Anglo/American mental health law is a weapon to protect the state from the person denominated as "mental patient" (as well as the "patient" from himself).

Nearly 300 years ago, Montesquieu (1689-1755) warned: "There is no more cruel tyranny than that which is perpetrated under the shield of law and in the name of justice".20 This is perhaps even truer today, when tyranny is perpetrated not in the name of justice, but in the name of therapy.21

I thank Professor Phil Fennell for his helpful suggestions.

-Sharma VP. Mental illness is like any other sickness <> (accessed 22 Jul 2004).
- Black HC. Black's law dictionary. St Paul, MN: West, 1968:906.
- NY keeps forced mental health treatment. New York Times 17 Feb 2004.
- Goffman E. Asylums: essays on the social situation of mental patients and other inmates. Garden City, NY: Doubleday Anchor, 1961.
- Szasz T. The myth of mental illness: foundations of a theory of personal conduct. New York: Hoeber-Harper, 1961.
- Szasz T. Cruel compassion: the psychiatric control of society's unwanted. New York: Wiley, 1994.
- Zinermon v Burch, 494 US 113, 1990:118.
- Winick BJ. Voluntary hospitalization after Zinermon v Burch. Psychiatr Ann 1991;21:584-9 at 584.
- Szasz T. Psychiatry and the control of dangerousness: on the apotropaic function of the term "mental illness". J Med Ethics 2003;29:227-30.
- Macbeth act 5, Scene 3, lines 38-39 and scene 1, line 69. In: Harbage A, ed. The tragedy of Macbeth. Baltimore, MD: Penguin, 1956.
- Szasz T. Insanity: the idea and its consequences. New York: Wiley, 1987.
- Sadler JC, Fulford B. Should patients and their families contribute to the DSM-V process? Psychiatr Serv 2004;55:133-8.
- Iglehart JK. The mental health maze and the call for transformation. N Engl J Med 2004;350:507-14.
- Hewson B. The law on managing patients who deliberately harm themselves and refuse treatment. BMJ 1999;319:905-7.
- Szasz T. Liberation by oppression: a comparative study of slavery and psychiatry. New Brunswick, NJ: Transaction, 2002.
- Osmun T. Damned if you do, damned if you don't. Rapid responses to Hewson B 1 Oct 1999 <> (accessed 22 Jul 2004).
- Raymont V. "Not in perfect mind": the complexity of clinical capacity assessment. Psychiatr Bull R Coll Psychiatr 2002;26:201-4 <> (accessed 22 Jul 2004).
- Fennell PWH. Treatment without consent: law, psychiatry, and the treatment of mentally disordered people since 1845. London: Routledge, 1996.
- Van der Leer v The Netherlands. (series A, no 170: application no 11509/85). European Court of Human Rights (1990) 12 EHRR 567, 7 BMLR 105.
- Montesquieu C.The spirit of the laws [trans Nugent T]. New York: Hafner Press, 1949; <> (accessed 22 Jul 2004).
- Szasz T. Pharmacracy: medicine and politics in America. Westport, CT: Praeger, 2001.

© 2005 Thomas Szasz

# 5
Malpractice vs. "Malresult"
A new form of insurance for an eternal problem

Doctors and patients both take risks when they do business together. The physician (for the most part), only puts his wealth is at risk: He protects himself by means of malpractice insurance. But for the patient, both wealth and physical health are at risk. At present, the patient can protect himself only against the risk of incurring a ruinous financial cost for the diagnosis and treatment of his illness: He protects himself by means of health insurance. How do we create an insurance regime that provides a form of protection neither of these policies can provide?

I propose a new form of medical insurance for the patient: protection against the risks of diagnostic and therapeutic procedures that may or may not be due to bona fide medical negligence—that is, "malresult insurance."

When a patient suffers an undesirable outcome as a result of medical care, the harm may or may not be the physician's fault. More often than not, the "malresult" is an "act of God." Nevertheless, malresults are now often attributed to and treated as cases of medical malpractice (negligence). Making medical malresult insurance available and expecting patients to use it would be a step toward more fully recognizing the commercial aspects and risks of the medical situation.

People who choose to buy a house purchase home owner's insurance. People who choose to drive purchase (are compelled by law to purchase) automobile insurance. Similarly, people who choose to undergo diagnostic and therapeutic procedures ought to be able, and be expected, to purchase medical malresult insurance.

In ordinary commercial relations, premiums for insurance depend on the demonstrated behavior of the insured. Drivers with a good record pay a lower premium than drivers with a record of traffic violations. In medical malpractice insurance, this fundamental principle is largely inoperative.

Obstetricians and neurosurgeons pay a much higher premium for malpractice insurance than do ophthalmologists and pediatricians. Why? Not because they are more prone to practicing medicine negligently than physicians in other specialties, but because the procedures they perform are more hazardous than those performed by ophthalmologists and pediatricians. Accordingly, patients who submit to high-risk procedures especially need insurance to protect themselves from malresult, just as physicians who perform such procedures especially need insurance to protect themselves from malpractice.

Virtually all medical encounters are risky. The chance of dying during or after general anesthesia is one in 10,000. The risk of perforation of the colon during diagnostic colonoscopy is 0.2 to 0.4 percent; it increases to between 0.3 and 1.0 percent if it is combined with polypectomy; the overall death rate from the procedure is about one in 12,500. The chance of a pregnant woman dying as a result of her pregnancy is approximately 1 in 12,000 (in the U.S.).

The woman who chooses to become pregnant incurs risks similar, in principle, to the risks an entrepreneur incurs who chooses to engage in an activity that may be dangerous to others or himself, say, transporting gasoline. The pregnant woman exposes herself to the risk of having an abnormal baby or becoming the victim of a medical complication (for example, a stroke). It is reasonable that she bear the cost of insuring herself against these contingencies.

If an obstetrician delivers an abnormal infant, regardless of whether he is innocent or guilty of malpractice, juries are likely to find him liable for large damages. If the expectation for the purchase of insurance for malresult were as firmly established as is the expectation for the purchase of insurance for malpractice, pregnant women would be expected to protect themselves by purchasing such insurance. Obstetricians could then restrict their practices to women who have such insurance (the cost of which would be negligible compared with the cost of raising a child). As a consequence, their exposure to malpractice litigation would shrink to a fraction of its present size.

The diagnosis and treatment of disease is dangerous for the patient economically as well as medically. At present, the patient protects himself from the economic harm of the medical situation by health insurance, and expects to be protected from the medical harm by the physician's malpractice insurance. This arrangement fails to distinguish between injury the patient suffers as a result of the nature of his illness and treatment, and injury the physician inflicts on him as a result of improper care.

To the victim of a medical catastrophe, it makes little difference why such a calamity befalls her or him. Delivering an infant with spina bifida or becoming quadriplegic as a result of a hazardous spinal cord operation irrevocably changes the life of the mother and neurosurgical patient. Perhaps largely for that reason, tort law does not adequately recognize the difference between medical "malresult" that happens through no fault of anyone, and medical malpractice, that is, bona fide medical negligence. The result is that, in a suit for malpractice brought by a poor, disabled patient against a rich insurance company (and healthy physician), the jury is more likely to base its judgment on compassion for the sufferer than on the merits of the case (that is, on the question of the physician's culpability or lack of it for the patient's injury). Awarding a large sum to the plaintiff-victim "feels" like the "right thing to do" and makes members of the jury feel better.

Tort litigation cannot restore health irrevocably lost, much less bring back the dead. All it can do is take money from the insurance company (and/or the physician) and give it to the victim or his family (and his lawyers). Adding a market in patient insurance for malresult to the market in physician insurance for malpractice would accomplish two important goals. It would guarantee compensation for the injured patient, more expeditiously and securely than malpractice insurance does, and it would protect the physician innocent of malpractice from having to settle claims against him. (Insurance companies could establish a schedule of specified diagnostic and therapeutic malresults similar to the schedule of bodily injuries specified in policies for accidental bodily injury and death.)

According to the American Medical Association, 20 states now face a full-blown medical liability crisis. Data from the National Association of Insurance Commissioners shows a 750 percent increase nationally in malpractice insurance premiums since 1975. For some specialists, such as obstetricians, the annual insurance premium exceeds $200,000.

High malpractice premiums cause physicians to restrict their practices or retire early, and lead medical students to avoid going into lawsuit-magnet specialties like obstetrics and neurosurgery. While the risk of malpractice litigation affects all physicians, those most affected are specialists whose patients are most likely to suffer devastating injuries. Similarly, while all patients need malresult insurance, those who need it most are obstetrical and neurosurgical patients.

People do not go skiing to break a leg. If they do so, they are, as a rule, responsible for paying the cost of their treatment or for having insurance to pay it. People do not consult physicians to become disabled or die. If they do, they ought to be responsible for the financial consequences or have insurance to compensate them for their loss, unless the physician commits demonstrable malpractice.

Sooner or later, we shall have to confront our inconsistent expectations from modern medical technology. We demand, as a "right," the accurate diagnosis and effective treatment of disease; but when, in the process, we suffer, we feel medically and legally wronged and take to the courts. Rights and responsibilities cannot be disjoined forever. It is a delusion to believe that we can continue to assume medical risks without assuming responsibility for the harms we suffer as a consequence. The availability of insurance for malresult would radically change the medical tort litigation scene: it would place some of the responsibility for risks inherent in medical diagnoses and treatments on patients, where it rightfully belongs

Contributing Editor Thomas Szasz, a professor of psychiatry emeritus at the SUNY Upstate Medical University in Syracuse, is the author, most recently, of Faith in Freedom: Libertarian Principles and Psychiatric Practices (Transaction).

January 10, 2005 © Thomas Szasz,
emeritus professor of psychiatry
Department of Psychiatry, Upstate Medical University, State University of New York, Syracuse, NY 13210, USA Correspondence to: 4739 Limberlost Lane, Manlius, New York, NY 13104, US

# 4
Caveat Emptor
(Let the Buyer Beware)

Why do some people seek psychiatric help and find psychiatric harm? Whose fault is it? Although I consider psychiatry's responsibility for misinforming people and mangling their lives self-evident, I also hold the victims partly responsible for their fate. Why? Because I believe it is every person's responsibility to inform himself, to the best of his ability, about the world he lives in. "A popular government without popular information, or the means of acquiring it," warned James Madison, fourth President of the United States (1809-1817), "is but a prologue to a farce, or a tragedy, or perhaps both. Knowledge will forever govern ignorance; and people who mean to be their own governors, must arm themselves with the power which knowledge gives."

Madison's remarks about political self-government apply with even greater force to personal self-government, especially in a modern society in which the manipulation of information is of paramount importance. The less a person knows about the social institutions of his government, the more he must trust those who wield power over them. The more he trusts those who wield such power, the more vulnerable he makes himself to becoming their victim. In the case of "voluntary" commitment, both the psychiatric victimizer and his victim must share the blame - though not necessarily in equal proportion - for the injury the former inevitably inflicts on the latter. Unlike the typical victim of psychiatric despotism who comes to love his oppressor and believe in his goodness, a minority of people escape from psychiatric slavery, and shed their illusions about the benevolence of jailers and poisoners who masquerade as doctors.

The institution of psychiatry - epitomized by the practice of incarcerating persons innocent of crimes in buildings deceptively called "hospitals" - has always been dangerous to the welfare of its inmates. It had never been the purpose of psychiatry to help the inmates rendered powerless by psychiatric imprisonment. Psychiatry's aim has always been, and still is, to help a relatively powerful person - primarily the denominated patient's parent, spouse, or other relative - by disqualifying the less powerful kin whose behavior troubles him as "troubled", which is to say mad, and by incarcerating the victim defined as a patient in a madhouse. While this has always been true, people today are more misinformed and more gullible about the true nature of psychiatry than ever. Accordingly, it is imperative that men, women, and children learn to protect themselves from the dangers of psychiatry. As adolescents must learn not to climb mountains during a thunderstorm, lest they be struck by lightening, they must also learn, when their lives are stormy, to avoid psychiatrists and stay away from mental hospitals.

People who have power are ipso facto dangerous to others. Because of the obvious connections between power and evil, only the corrupt seek power. Psychiatrists have a great deal of power. Because they are utterly corrupted by the pretense of helping the so-called patients while in fact acting as agents of social control on behalf of the patients' familial and social antagonists, it is imperative that potential consumers of psychiatric services be familiar not with what mental health professionals say, but with what they do.

I do not doubt that the desire to help is often genuine. The problem is that if the Other's affliction lies in his soul rather than in his body, then the urge to help him cannot be satisfied without establishing a bond of intimacy with him. Inevitably, the very attempt turns into a disaster, into an opportunity for existential cannibalism. I use this term to denote encounters officially defined as therapeutic that, in fact, consist of the malefactor de-meaning his maleficiary - by destroying the meaning that he, the nominal beneficiary, has given his own existence. There are many ways of practicing existential cannibalism. In our society, the most popular form is to give one's "beneficiary" a psychiatric diagnosis and impose on him a psychiatric treatment, neither of which he wants. This enables the "benefactor" to claim that he is helping and strengthening his beneficiary, while in fact he is harming him and rendering him more powerless.

We can and must oppose the mental health industry's massive campaign of disinformation, essential for maintaining the practice of cannibalism. For every patient psychiatrists claim to have helped, there are others who assert to have been harmed. Against every glamour story about the therapeutic powers of neuroleptic drugs, electroshock, and incarceration in insane asylums told by psychiatrists, psychiatric survivors can pit a horror story about the noxious powers of psychiatrists exercised by means of their deceptive vocabulary and pseudo-medical interventions.

Federal law now requires that cigarettes carry a warning label, cautioning the buyer about the risks he assumes if he uses the product. It is not a new idea. Dante depicted the entrance to Hell as emblazoned with the warning, "All hope abandon, ye who enter here." Not until the same warning is prominently displayed over the office door of every mental health professional who has not forsworn therapeutic coercion, and over the entrance to every mental hospital, will persons who seek psychiatric help be in a position to give informed consent to their social stigmatization and spiritual self-destruction.

This essay has been condensed and adapted with permission by the author from the Foreword to Madness, Heresy, and the Rumor of Angels, The Revolt Against the Mental Health System, by Seth Farber, Open Court, Chicago, 1993. The adaptation is by Mira de Vries, Chairman of MeTZelf. MeTZelf thanks Dr. Szasz for his kind permission to use his work.

© Thomas Szasz

# 3
Self-Ownership or
Suicide Prevention?

The core libertarian principle of self-ownership implies that we have a right to commit suicide: the state has no right to forcibly prevent us from killing ourselves.

The core psychiatric practice of suicide prevention implies that we have no right to commit suicide: the state -- through its mental health laws and psychiatric agents -- has the "duty" to forcibly prevent us from killing ourselves.

That is not all. "Suicide prevention" -- a euphemism for incarceration in a mental hospital -- is preventive detention, par excellence. From a civil rights viewpoint, depriving a person of liberty because he might commit an act in the future is anathema. Doing so because he might commit an act that is not a crime is an outrageous injustice. Mental health laws authorize and obligate the psychiatrist to incarcerate his patient if he deems him to be "mentally ill and dangerous to himself or others." Marcia Goin, president of the American Psychiatric Association for 2003, states: "We can make contracts with builders, insurers, and car dealers, but not with patients." (Marcia Goin, "From the President," Psychiatric News, 38: 3 & 27 [July 18], 2003.

Goin offered her unqualified rejection of contracting with mental patients in the context of the so-called "no suicide contract." That absurd term refers to the psychiatrist's promising the "suicidal" patient that he will forego committing him, provided the patient promises that, as long as he is under the psychiatrist's care, he will not kill himself.
Whether such a "contract" is or is not effective in preventing suicide does not concern me here. What concerns me, instead, is the psychiatric premise that the patient has no right to kill himself; the psychiatrist's professional duty to prevent the patient from killing himself; and the incompatibility between this psychiatric practice and the libertarian principle of self-ownership.

Both de facto and de jure, once a person enters into a professional relationship with a psychiatrist, he forfeits his right of self-ownership, and the psychiatrist acquires the fiduciary duty of protecting the person -- henceforth "mental patient" -- from himself (and of protecting others from the patient). Should the psychiatrist, in his judgment,
deem the patient to be a danger to himself (or others), he is professionally obligated to initiate violence against him, called "civil commitment" and "suicide prevention." If the psychiatrist fails to do so and the patient injures or kills himself (or others), the psychiatrist can expect to be the defendant in a tort action for medical negligence ("failure to prevent harm to self or others").
There is no evidence that suicide prevention prevents suicide. The rate of suicide among psychiatrists is at least two or three times that among the general public. Psychiatrists and psychiatric hospitals are regularly found liable for patient suicides (and for harm to others).

Given these circumstances, why do psychiatrists assume -- indeed, demand to shoulder -- such a risk? As I show in my book, Fatal Freedom, therein lies the answer to why psychiatry cannot be reformed and must be abolished. Suffice it to say here that, from its earliest beginnings in the late seventeenth century, psychiatry (formerly "mad-doctoring") was synonymous with the control of the patient by the psychiatrist. It still is.

Psychiatry and the Abolition of Contract

Famed English jurist Sir Henry Sumner Maine (1822-1888) aptly observed: "The movement of the progressive societies has hitherto been a movement from Status to Contract." In other words, in liberal (free) societies, the law treats persons as contracting individuals, not as members of status groups (men / women, sane / I insane).
Modern psychiatric ethics has declared war on this principle, as Marcia Goin's reaffirmation of the psychiatrist's unyielding commitment to coercion illustrates. She asserts that psychiatrists cannot makes contracts with the persons they call "patients." Builders, insurers, and car dealers make contracts with such persons. Why can't psychiatrists make contracts with them? Because contracting implies two (or more) legally equal parties, each putting his cards on the table. It implies mutual obligations, each party having legal power to compel his partner to fulfill the contract or compensate him for failure to do so.

Such mutuality is contrary to psychiatric ethics. Specifically, psychiatrists reject the ethics of commerce in favor of the "loftier" ethics of care. The seller of plumbing services is obligated to deliver only that which his customer has requested and he has promised to provide. The seller of psychiatric services is obligated to deliver something more: he must protect the customer from himself, even at the cost of depriving him of liberty.
In contrast to such control-command relationship between psychiatrist and patient, modern psychotherapy, exemplified by psychoanalysis, was characterized by a cooperative-contractual relationship between therapist and client. Yet, psychoanalysts never emphasized this essential element of the enterprise. Worse, the integrity of the analytic contract was, almost from the start, eagerly compromised by Freud and his followers. In one breath, Freud declared, "With the neurotics, then, we make our pact: complete candor on one side and strict discretion on the other." In the next breath, he took it all back: "I make use of his [the patient's] communication without asking his consent, since I cannot allow that psychoanalytic technique has any right to claim the protection of medical discretion."

A contract is an agreement equally binding on both parties. Psychiatrists reject contracting with patients. They refuse to be bound by agreement. Instead, they claim, and the law grants them, the power to impose unwanted (suicide prevention) "services" on patients, whenever they, the psychiatrists, decide that depriving the patient of liberty serves "his best interests."

Of all the complex issues of social policy that we face, probably the most vexing -- and undoubtedly the most neglected -- is the conflict between libertarian principles and psychiatric practices.

First published in:
The Freeman, 54: 23-24 (March), 2004.

# 2
Psychiatrist who changed the view of homosexuality as a mental disorder.

Although the Latin proverb, "De mortuis nil nisi bonum," enjoins us that "Of the dead, we should speak kindly or not at all," giving Marmor credit for the idea that homosexuality is not an illness is undeserved. In fact, he deserves blame for knowingly borrowing this idea from Thomas Szasz, and claiming it as his own.

In the first edition of the book on homosexuality that he edited, Sexual Inversion: The Multiple Roots of Homosexuality, (New York: Basic Books, 1965), Marmor included a chapter by Szasz. In that chapter, published 5 years after his paper titled "The myth of mental illness" (later the title of his book), Szasz set forth his case against viewing homosexuality as a mental illness. Revealingly, Marmor, in his Introduction to the volume, wrote: "Is homosexuality an 'illness,' or is it merely a different ‘way of life'? Most of the psychoanalysts in this volume (except Szasz) are of the opinion that homosexuality is definitely an illness to be treated and corrected" (p. 15).

Marmor's parenthetical phrase, "except Szasz," clearly indicates that Marmor, also a psychoanalyst, did not then share this view. (He never ceased his bitter opposition to Szasz's views.) In that book, Marmor never asserted that homosexuals are not mentally ill and regularly referred to them as "patients."

Ronald Bayer, in his definitive Homosexuality and American Psychiatry: The Politics of Diagnosis (New York: Basic Books, 1981), wrote: "It was Thomas Szasz who attempted to shift the terms of discussion to a conceptual level, focusing his attack on both the underlying ideological assumptions of psychiatry and the power of the profession in contemporary society. ... For Szasz the fundamental self-serving error of psychiatry was its effort to claim that deviations from behavioral norms were illnesses..." (Pp. 54-55).

Moreover, Szasz did not simply assert that homosexuality is not an illness, he asserted, and showed why, none of the (mis)behaviors psychiatrists classify as mental illnesses are illnesses. This, as Bayer recognized, was too much for psychiatry to stomach: Szasz's "far-reaching critique could not serve as the basis for the transformation of psychiatric thinking on homosexuality. To follow Szasz would have required a radical rupture with the deepest commitments of contemporary psychiatry" (p. 60).

Bayer noted that Marmor's 1965 views on homosexuality were "seen by contemporary homosexual critics as supportive of the dominant pathological view [of mental illness]" (p. 61). Unlike Szasz, Marmor was a loyal psychiatrist, always ready to defend the profession from its critics.

In short, Marmor rescued psychiatry from its commitment to labeling and persecuting homosexuals as sick, while at the same time he carefully preserved the profession's privilege to label and persecute as mentally ill other deviants, such as drug abusers and transsexuals. For this, organized psychiatry was duly grateful to him.

Szasz, T. The myth of mental illness.
American Psychologist 1960 Feb; 15: 113-118
Szasz, T. The myth of mental illness: foundations of a theory of personal conduct. New York: Paul B. Hoeber, 1961.
Szasz, T. Legal and moral aspects of homosexuality. In, Judd Marmor, ed., Sexual inversion: the multiple roots of homosexuality. New York: Basic Books, pp. 124-139, 1965.
Bayer R. Homosexuality and American psychiatry: the politics of diagnosis. New York: Basic Books, Inc., 1981.

Competing interests: None declared

Re-published with the permission of the Author:
Jeffrey A. Schaler, Ph.D.,
Assistant Professor, Department of Justice, Law and Society, School of Public Affairs, American University, 4400 Massachusetts Avenue, N.W., Washington, D.C. 20016-8043 U.S.A.
First published in Britisch Medical Journal
2004;328:466 (21 February).

# 1
The psychiatric protection order
for the "battered mental patient"

Psychiatric patients are routinely treated against their will. Legally enforceable psychiatric protection orders would protect patients from coercive psychiatric interventions.

The avowed desires of patients and doctors conflict more often in psychiatry than in any other branch of medicine. People known as "mental patients" are routinely subjected to "diagnostic" and "therapeutic" interventions against their will. Many such people see being committed (sectioned) and treated against their will as a personal violation—a "psychiatric abuse"—and want to protect themselves from future involuntary psychiatric hospitalisation and treatment. At present, former psychiatric patients, even when legally competent, have no means to defend themselves from such a contingency. Mental health laws—reflecting the point of view of psychiatrists and society—protect (or are said to protect) mentally ill patients from the dangers they pose, because of their illness, to themselves and others. Many mental patients view—and have always viewed—psychiatrists as posing a danger to them. Respect for the self defined interests of such patients requires that the law protect them from further unwanted psychiatric interventions.

The psychiatric protection order
Courts recognise the validity of "psychiatric wills" (psychiatric advance directives) only when they prospectively authorise treatment; courts do not recognise them when the "psychiatric testator" rejects psychiatric "help."1 To remedy this defect, especially when patients are released into the community after a period of involuntary treatment for mental illness, I propose a new legal safeguard: the psychiatric protection order. Such an order, similar to the protection order used in domestic conflicts, would make it a criminal offence to impose involuntary psychiatric interventions on people protected by the order. In free societies only psychiatric patients are routinely treated against their will. (Public health laws explicitly serve the interests of the public, not the therapeutic needs of particular persons.)

Competent patients with uraemia are not treated against their will and can use a "medical will" to protect themselves from undergoing dialysis. If psychiatry were like any other medical specialty competent patients with schizophrenia would not be treated against their will and could protect themselves with a psychiatric will from being treated.2 But they cannot: neither psychiatrists nor the courts recognise the validity of the psychiatric will. Mental health laws trump psychiatric advance directives. Not by coincidence the history of psychiatric interventions forcibly imposed on patients is long and depressing.

In a letter he wrote to me in 1988 Karl Menninger summarised the history of psychiatry with these sad words: "Added to the beatings and chainings and baths and massages came treatments that were even more ferocious: gouging out parts of the brain, producing convulsions with electric shocks, starving, surgical removal of teeth, tonsils, uteri, etc."3 To this list Menninger might have added the use of straitjackets, tranquillising chairs, confining chairs, cold baths, emetics, purgatives, Metrazol shock, inhalations of carbon dioxide, and neuroleptic drugs.

Freedom from enforced psychiatry
From the beginnings of the specialty, psychiatric patients have had no opportunity to free themselves from their protective-oppressive relationship with psychiatrists. In this brief paper I focus on a single issue: the desire of some psychiatric patients to free themselves, once and for all, from what they regard as an abusive relationship with the psychiatric profession. The Anglo-American legal system has always denied this option to these patients. This denial resembles the denial of slaves' opportunity, in a slave society, to leave their master; of the wife's opportunity, in traditional marriage, to leave her husband; and of citizens' opportunity, in the modern totalitarian state, to leave their country and its rulers. These people may enjoy all manner of benefits and privileges, but they cannot, without the permission of the repressive authority, leave the system for good.

The English and American legal systems maintain the fiction that the relationship between a family member responsible for committing a "loved one" and the incarcerated individual—as well as that between psychiatrists and involuntarily detained patients—is always one of "care" and "treatment." It can be otherwise only in "unfree," "totalitarian" countries; such was the case in the Soviet Union and is now the case in China. That self serving rationalisation is at the core of the problem facing us. Anglo-American law assumes, as a matter of fact, that the relationship between a person and a legal agent of the state is adversarial. Justice Potter Stewart of the US Supreme Court famously remarked: "To force a lawyer on a defendant can only lead him to believe that the law contrives against him."4

The law student is taught the duties and roles of both prosecuting attorney and defence attorney. Both jobs are legitimate and proper. In contrast Anglo-American psychiatry assumes, as a matter of law and psychiatry, that the relationship between a person and a psychiatric agent of the state is therapeutic. Forcing psychiatrists on mental patients is routine practice, and the patient who protests is likely to be given a diagnosis of paranoia. The medical student is taught only the duties and roles of the psychiatrist making diagnoses and providing treatment. The psychiatrist has no other legitimate duties or roles; only the job of the coercive psychiatrist is legitimate and proper. The psychiatrist who tries to help the coerced "patient" to reject the patient role is ostracised, or worse.

The gatekeepers: the family
We are hypocrites if we ignore who the parties are that support the enactment of mental health laws and deny patients the option of rejecting psychiatric services. Everywhere the supporters of mental health laws are psychiatrists and the relatives of so called mental patients. In the United States the relatives are now also in control of a powerful lobby, the National Alliance of the Mentally Ill, that legitimises the abuse of family members (mainly adult children) as the care of "loved ones." Organisations of former psychiatric patients—who call themselves "victims of psychiatric abuse"—are not among the parties clamouring for more psychiatric coercions or "services." People subjected to involuntary psychiatric hospitalisation and treatment often feel victimised in much the same way as do wives (less often husbands) who are abused by their spouses. Until recent times women had no effective protection from their abusers, whom the law defined as their protectors. In many parts of the world women are still in that situation. Similarly, in the days of Dickens children were not protected from abuse by their parents.

Specific treatments may have changed since this 1818 drawing, but psychiatric patients are still forced to undergo unwanted interventions

We in the West now recognise that the family is not just the primary locus of affection, care, and security for its members: it is all too often also the source of the most insidious danger to their physical and spiritual wellbeing. We acknowledge this unhappy fact and accordingly speak of "battered" children, spouses, parents, and grandparents. In the conflicts that often arise between adults living together as married couples or lovers, legal separation, divorce, and the so called protection order exemplify the legal system's acknowledgment of the problem and the need for legally sanctioned and enforceable mechanisms to remedy it.

A protection order mandates physical separation between the parties and makes it a criminal offence for the denominated threatener to impose their mere presence on the threatened person. I suggest that we similarly acknowledge the unhappy fact of "battered mental patients" and the need to protect them from their batterers. In the absence of a protection order the power relations between psychiatrist and involuntary patient will continue to generate "psychiatric abuse," rationalised as protection and treatment. Indeed, it is precisely because psychiatrists reject advance psychiatric directives authorising abstinence from further treatment (a request that non-psychiatric doctors accept) that makes a legal mechanism such as the psychiatric protection order necessary.

Legalise "divorce" between psychiatrists and patients
Psychiatrists object to efforts to treat patients as responsible moral agents and cite the prevention of harm as a basic social mandate of psychiatry. Typically, they argue that people who would have committed suicide but for their involuntary detention would thereby have been deprived of the option of changing their minds once they had recovered from depression. A similar argument could be made against last wills or, indeed, any decision that profoundly affects one's future, such as marriage or having children. The standard psychiatric justification for "therapeutic" coercion either ignores the familiar conflict between liberty and security or, more often, equates (involuntary) psychiatric treatment with ("true") freedom.5

Elsewhere I have examined and discussed this and related problems in great detail and proposed reconciling psychiatry with liberty.6 7 Human memory is notoriously short and selective. We have forgotten that until recently—even in the United Kingdom and the United States—people could not divorce. In some countries women still cannot divorce their husbands. For a long time the law, supported by religion, ranked the sanctity of marriage more highly than the need to protect the wife from her abusive husband and so prohibited divorce. To make matters worse, the law deprived her of her voice. The history of the "marriage" between mad people and their doctors shows a similar pattern. Since the beginning of mad doctoring in the 18th century, the law, supported by medicine (psychiatry), has ranked the "health" of mad people more highly than the need to protect them from the abusive psychiatrist and prohibited them from divorcing their psychiatrist. This is still the case. (The psychiatrist is free to leave the patient, typically by forcibly "marrying" the patient to another psychiatrist.) And again the law deprived, and still deprives, the victim of his or her voice. Only writers were, and are, willing to face the realities of psychiatry, illustrated for example by James Thurber's miniature masterpiece, The Unicorn in the Garden.8

Summary points
Many psychiatric patients are denied the right to refuse treatment they don't want.

"Psychiatric wills" are recognised by courts only when patients use them to authorise treatment, not when they use them to reject the possibility of treatment.

Like protection orders that protect wives from abusive husbands, "psychiatric protection orders" would protect patients from coercive psychiatric interventions

Doctors, politicians, and journalists assert that mental illnesses are real diseases and that psychiatrists are regular doctors. If that were true there would be no need for psychiatric protective orders.

Competing interests: None declared.

Szasz T. Liberation by oppression: a comparative study of slavery and psychiatry. New Brunswick, NJ: Transaction, 2002.

Szasz T. The psychiatric will: a new mechanism for protecting persons against "psychosis" and psychiatry. Amer Psychol 1982;37: 762-70.[ISI]

Menninger, K. Reading notes. Bull Menninger Clin 1989;53: 350-1.

Stewart, P Faretta v California, 422 US 806 ( 1975), p 834.

Satel S. For addicts, force is the best medicine. Wall Street Journal, 1998 January 7: 6.

Szasz T. Insanity: the idea and its consequences. New York: Wiley, 1987.
Szasz T. Pharmacracy: medicine and politics in America. Westport, CT: Praeger/Greenwood, 2001.

Thurber J. The unicorn in the garden [1940]. In: Fables for our time. New York: Harper & Row, 1968.

First published in:
British Medical Journal 2003;327:1449-1451 (20 December), doi:10.1136/bmj.327.7429.1449

© Thomas Szasz,
emeritus professor of psychiatry
Department of Psychiatry, Upstate Medical University, State University of New York, Syracuse, NY 13210, USA Correspondence to: 4739 Limberlost Lane, Manlius, New York, NY 13104, USA

Dr. Szasz´s newest book "Szasz Under Fire" is soon to be released and can be pre-ordered here.

Thomas Szasz ( was professor of psychiatry emeritus at SUNY Upstate Medical University in Syracuse. His latest books, both from Syracuse University Press, are The Medicalization of Everyday Life: Selected Essays and Psychiatry: The Science of Lies.

The 50th anniversary edition of the epochal book by Thomas Szasz "The Myth of Mental Illness" is launched in February 2010. Read the new foreword by Thomas Szasz here.

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IAAPA thanks Thomas Szasz for the permission to republish his text in "The Szasz column"! We will regulary update it with a newer text.