J Med Ethics 2003;29:227–230 227 ....................... PSYCHIATRIC ETHICS J Med Ethics: first published as 10.1136/jme.29.4.237 on 20 August 2003. Downloaded from Debate Psychiatry and the control of dangerousness: on the apotropaic function of the term “mental illness” T Szasz he term “mental illness” implies that persons atric detention, also known as involuntary mental with such illnesses are more likely to be dan- hospitalisation or civil commitment. And the pro- Tgerous to themselves and/or others than are cedure is a patent violation of due process and the persons without such illnesses. This is the source presumption of innocence. of the psychiatrist’s traditional social obligation to We call all manner of human problems “(men- control “harm to self and/or others,” that is, tal) diseases”, and convince ourselves that drugs suicide and crime. The ethical dilemmas of and conversation (therapy) solve such problems. psychiatry cannot be resolved as long as the con- Solutions exist, however, only for mathematical tradictory functions of healing persons and problems and some medical problems. For human protecting society are united in a single discipline. problems, there are no solutions. Conflict, dis- Life is full of dangers. Our highly developed agreement, unhappiness, the proverbial slings consciousness makes us, of all living forms in the and arrows of outrageous fortune are challenges universe, the most keenly aware of, and the most that we must cope with, not solve. Only after we adept at protecting ourselves from, dangers. admit that our solutions are illusions can we Magic and religion are mankind’s earliest warn- begin to develop more rational and more humane ing systems. Science arrived on the scene only methods for dealing with “mental illness” and about 400 years ago, and scientific medicine only the “dangerous mental patient”. 200 years ago. Some time ago I suggested that We are proud that we do not punish acts or “formerly, when religion was strong and science beliefs that upset others, but do not injure them weak, men mistook magic for medicine; now, and hence do not constitute crimes. Yet, we pun- when science is strong and religion weak, men ish people—albeit we call it “treatment”—for mistake medicine for magic”.1 annoying family members (and others) with We flatter and deceive ourselves if we believe behaviours they deem “dangerous” and also for that we have outgrown the apotropaic use of “being suicidal”. To be sure, persons who exhibit language (from the Greek apostropaios, meaning “to such behaviours—labelled “schizophrenics”, turn away”). “persons with dangerous severe personality disor- http://jme.bmj.com/ Many people derive comfort from magical ders,” and “suicidal patients”—frighten others, objects (amulets), and virtually everyone finds especially those who must associate with them. Unable to control non-criminal “offences” by reassurance in magical words (incantations). The means of criminal law sanctions, how can the classic example of an apotropaic is the word offended persons and society protect themselves “abracadabra,” which The American Heritage Dic- from their unwanted fellow men and women? tionary of the English Language defines as “a magi- One way is by “divorcing” them. However, this cal charm or incantation having the power to method of separating oneself from an unwanted on September 29, 2021 by guest. Protected copyright. ward off disease or disaster”. In the ancient world, companion—especially when it involves relations abracadabra was a magic word, the letters of between disturbing and disturbed spouses or which were arranged in an inverted pyramid and between disturbing adult children and their dis- worn as an amulet around the neck to protect the turbed parents—strikes most people as an unac- wearer against disease or trouble. One fewer letter ceptable rejection of family obligation. Psychia- appeared in each line of the pyramid, until only trists offer to relieve the disturbed person of the the letter “a” remained to form the vertex of the burden of coping with his disturbed relative by triangle. As the letters disappeared, so supposedly incarcerating the latter and calling it “care” and did the disease or trouble. “treatment”. I submit that we use phrases like “dangerous- How do psychiatrists do this? By allying them- ness to self and others” and “psychiatric treat- selves with the coercive apparatus of the state and ment” as apotropaics to ward off dangers we fear, declaring the offending individual mentally ill and much as ancient magicians warded off the dangerous to him or herself or others. This magic man- dangers people feared by means of incantations, tra allows us to incarcerate him in a prison we call a exemplified by “abracadabra”. Growing reliance “mental hospital”. Ostensibly, the term “mental on compulsory mental health interventions for illness” (or “psychopathology”) names a pathologi- protection against crime and suicide illustrate the cal condition or disease, similar say to diabetes; actu- phenomenon. Physicians, criminologists, politi- ally, it names a social tactic or justification, permit- T Szasz, 4739 Limberlost cians, and the public use advances in medicine ting family members, courts, and society as a body, Lane, Manlius, NY, and neuroscience to convince themselves that to separate themselves from individuals who 13104–1405, USA; such interventions are “scientific” and do not vio- exhibit, or are claimed to exhibit, certain behav- [email protected] late the moral and legal foundations of English iours identified as “dangerous mental illnesses”. Accepted for publication and American law. This is a serious error. There is This tactic is dramatically illustrated by the follow- ............... 13 September 2002 no scientific basis whatever for preventive psychi- ing “advice” appearing on the web site of the www.jmedethics.com 228 Debate ....................... National Alliance for the Mentally Ill (NAMI), a In his classic treatise on schizophrenia, Eugen J Med Ethics: first published as 10.1136/jme.29.4.237 on 20 August 2003. Downloaded from mental health advocacy organisation that identi- Bleuler complained: “People are being forced to fies itself as representing “more than 200 000 continue to live a life that has become unbearable Debate families, consumers, and providers across the for them for valid reasons. ... Even if a few more country”. As will be evident, NAMI represents the [patients] killed themselves, does this reason jus- interests of mental patients the same way that the tify the fact that we torture hundreds of patients Ku Klux Klan represented the interests of black and aggravate their disease?” (emphasis added).7 Americans. Why are psychiatrists expected to prevent suicide by depriving the “suspect” of liberty? The Sometime, during the course of your loved idea of suicide makes us nervous. We cannot one’s illness, you may need the police. By decide whether killing oneself is a “right” or a preparing now, before you need help, you wrong, an element of our inalienable personal can make the day you need help go much more smoothly. ... It is often difficult to get liberty or an offence of some sort that ought to be 911 to respond to your calls if you need prohibited and perhaps punished. We are too someone to come & take your MI [mentally uptight about suicide to recognise that killing ill] relation to a hospital emergency room oneself is sometimes a reasonable and right thing (ER). They may not believe that you really to do, sometimes an unreasonable and wrong need help. And if they do send the police, thing to do, but that, in either case, it ought to be treated as an act that falls outside the scope of the police are often reluctant to take 8 someone for involuntary commitment. That is interference by the state. because cops are concerned about liability. The right to kill oneself is the supreme symbol ... When calling 911, the best way to get of personal autonomy. Formerly, the church allied quick action is to say, “Violent EDP”, or with the state prohibited and punished the act. “Suicidal EDP”. EDP stands for Emotionally Now, psychiatry, as an arm of the state, prohibits Disturbed Person. This shows the operator the act and “treats” it as if it were a symptom of that you know what you’re talking about. an underlying disease (typically, depression or Describe the danger very specifically. “He’s schizophrenia). The deprivation of liberty intrin- a danger to himself” is not as good as “This sic to such an intervention is viewed not as a morning my son said he was going to jump human rights violation but as a human rights off the roof.” ... Also, give past history of protection. The modern reader may be surprised, violence. This is especially important if the perhaps even shocked, at seeing the words person is not acting up. ... When the police “prohibition” and “suicide” bracketed. Lack of come, they need compelling evidence that familiarity with the long history of the religious the person is a danger to self or others prohibition against self murder, together with before they can involuntarily take him or her unquestioning acceptance of coercive psychiatric to the ER for evaluation. ... While AMI/ suicide prevention as “therapy,” make such a FAMI [Alliance for the Mentally Ill/Florida reaction a virtual certainty. This is unfortunate. Alliance for the Mentally Ill] is not Formerly, religious doctrine defined the permis- suggesting you do this, the fact is that some sible uses of the body. Its impermissible uses—self families have learned to “turn over the abuse (masturbation), sex abuse (homosexuality http://jme.bmj.com/ furniture” before calling the police.2 and other “perversions”), substance abuse (drunk- Giving false information to the police is a enness and gluttony), and self murder (suicide)— crime, unless it is in the cause of “mental health”. were sins, crimes, or both, punished by informal or In the United Kingdom, unlike in the United formal sanctions.