THE ROLE OF ETHICS IN PSYCHIATRY
Anything that people do — in contrast to things that happen to them (Peters, 1958) — takes place in a context of value. In this broad sense, no human activity is devoid of ethical implications. When the values underlying certain activities are widely shared, those who participate in their pursuit may lose sight of them altogether. The discipline of medicine, both as a pure science (for example, research) and as a technology (for example, therapy), contains many ethical considerations and judgments. Unfortunately, these are often denied, minimized, or merely kept out of focus; for the ideal of the medical profession as well as of the people whom it serves seems to be having a system of medicine (allegedly) free of ethical value. This sentimental notion is expressed by such things as the doctor’s willingness to treat and help patients irrespective of their religious or political beliefs, whether they are rich or poor, etc. While there may be some grounds for this belief — albeit it is a view that is not impressively true even in these regards — the fact remains that ethical considerations encompass a vast range of human affairs. By making the practice of medicine neutral in regard to some specific issues of value need not, and cannot, mean that it can be kept free from all such values. The practice of medicine is intimately tied to ethics; and the first thing that we must do, it seems to me, is to try to make this clear and explicit. I shall [p. 116] let this matter rest here, for it does not concern us specifically in this essay, Lest there be any vagueness, however, about how or where ethics and medicine meet, let me remind the reader of such issues as birth control, abortion, suicide, and euthanasia as only a few of the major areas of current ethicomedical controversy.
Psychiatry, I submit, is very much more intimately tied to problems of ethics than is medicine. I use the word “psychiatry” here to refer to that contemporary discipline which is concerned with problems in living (and not with diseases of the brain, which are problems for neurology). Problems in human relations can be analyzed, interpreted, and given meaning only within given social and ethical contexts. Accordingly, it does make a difference — arguments to the contrary notwithstanding — what the psychiatrist’s socioethical orientations happen to be; for these will influence his ideas on what is wrong with the patient, what deserves comment or interpretation, in what possible directions change might be desirable, and so forth. Even in medicine proper, these factors play a role, as for instance, in the divergent orientations which physicians, depending on their religious affiliations, have toward such things as birth control and therapeutic abortion. Can anyone really believe that a psychotherapist’s ideas concerning religious belief, slavery, or other similar issues play no role in his practical work? If they do make a difference, what are we to infer from it? Does it not seem reasonable that we ought to have different psychiatric therapies — each, expressly recognized for the ethical positions which they embody — for, say, Catholics and Jews, religious persons and agnostics, democrats and communists, white supremacists and Negroes, and so on? Indeed, if we look at how psychiatry is actually practiced today (especially in the United States), we find that people do seek psychiatric help in accordance with their social status and ethical beliefs (Hollingshead & Redlich, 1958). This should really not surprise us more than being told that practicing Catholics rarely frequent birth control clinics.
The foregoing position which holds that con- temporary psychotherapists deal with problems in living, rather than with mental illnesses and their cures, stands in opposition to a currently prevalent claim, according to which mental illness is just as “real” and “objective” as bodily illness. This is a confusing claim since it is never known exactly what is meant by such words as “real” and “objective.” I suspect, however, that what is intended by the proponents of this view is to create the idea in the popular mind that mental illness is some sort of disease entity, like an infection or a malignancy. If this were true, one could catch or get a “mental illness,” one might have or harbor it, one might transmit it to others, and finally one could get rid of it. In my opinion, there is not a shred of evidence to support this idea. To the contrary, all the evidence is the other way and supports the view that what people now call mental illnesses are for the most part communications expressing unacceptable ideas, often framed, moreover, in an unusual idiom. The scope of this essay allows me to do no more than mention this alternative theoretical approach to this problem (Szasz, 1957c).
This is not the place to consider in detail the similarities and differences between bodily and mental illnesses. It shall suffice for us here to emphasize only one important difference between them: namely, that whereas bodily disease refers to public, physicochemical occurrences, the notion of mental illness is used to codify relatively more private, sociopsychological happenings of which the observer (diagnostician) forms a part. In other words, the psychiatrist does not stand apart from what he observes, but is, in Harry Stack Sullivan’s apt words, a “participant observer.” This means that he is committed to some picture of what he considers reality — and to what he thinks society considers reality — and he observes and judges the patient’s behavior in the light of these considerations. This touches on our earlier observation that the notion of mental symptom itself implies a comparison between observer and observed, psychiatrist and patient. This is so obvious that I may be charged with belaboring trivialities. Let me therefore say once more that my aim in presenting this argument was expressly to criticize and counter a prevailing contemporary tendency to deny the moral aspects of psychiatry (and psychotherapy) and to substitute for them allegedly value-free medical considerations. Psychotherapy, for example, is being widely practiced as though it entailed nothing other than restoring the patient from a state of mental sickness to one of mental health. While it is generally accepted that mental illness has something to do with man’s social (or interpersonal) relations, it is paradoxically maintained that problems of values (that is, of ethics) do not [p. 117] arise in this process. Yet, in one sense, much of psychotherapy may revolve around nothing other than the elucidation and weighing of goals and values — many of which may be mutually contradictory — and the means whereby they might best be harmonized, realized, or relinquished.
The diversity of human values and the methods by means of which they may be realized is so vast, and many of them remain so unacknowledged, that they cannot fail but lead to conflicts in human relations. Indeed, to say that human relations at all levels — from mother to child, through husband and wife, to nation and nation — are fraught with stress, strain, and disharmony is, once again, making the obvious explicit. Yet, what may be obvious may be also poorly understood. This I think is the case here. For it seems to me that — at least in our scientific theories of behavior — we have failed to accept the simple fact that human relations are inherently fraught with difficulties and that to make them even relatively harmonious requires much patience and hard work. I submit that the idea of mental illness is now being put to work to obscure certain difficulties which at present may be inherent — not that they need be unmodifiable — in the social intercourse of persons. If this is true, the concept functions as a disguise; for instead of calling attention to conflicting human needs, aspirations, and values, the notion of mental illness provides an amoral and impersonal “thing” (an “illness”) as an explanation for problems in living (Szasz, 1959). We may recall in this connection that not so long ago it was devils and witches who were held responsible for men’s problems in social living. The belief in mental illness, as something other than man’s trouble in getting along with his fellow man, is the proper heir to the belief in demonology and witchcraft. Mental illness exists or is “real” in exactly the same sense in which witches existed or were “real.”
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PETERS, R. S. The concept of motivation. London: Routledge & Kegan Paul, 1958.
SZASZ, T. S. Malingering: “Diagnosis” or social condemnation? AMA Arch Neurol. Psychiat., 1956, 76, 432-443.
SZASZ, T. S. Pain and pleasure: A study of bodily-feelings. New York: Basic Books, 1957. (a)
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SZASZ, T. S. Moral conflict and psychiatry, Yale Rev., 1959, in press.
 Freud went so far as to say that: “I consider ethics to be taken for granted. Actually I have never done a mean thing” (Jones, 1957, p. 247). This surely is a strange thing to say for someone who has studied man as a social being as closely as did Freud. I mention it here to show how the notion of “illness” (in the case of psychoanalysis, “psychopathology,” or “mental illness”) was used by Freud — and by most of his followers — as a means for classifying certain forms of human behavior as falling within the scope of medicine, and hence· (by fiat) outside that of ethics!
[*] Classics Editor’s note: In the original American Psychologist text the word “not” appears at this point. Dr. Szasz has informed me, however, that it “was a typo, which [he] corrected when [he] reprinted the piece, e.g., in Ideology and Insanity” (personal communication, 2002).