In a nice segue to the last post, and with a thanks to Retriever (since the current New Yorker hasn't quite arrived at the house yet), it was a pleasure to read Louis Menand's take on psychiatry's discontents. It is probably the best single overview of the profession's vexing ambiguities that I have seen; it's all there--the diagnostic quibbles, the ideological clashes, the greedy pharmaceutical companies.
Talk about fact and metaphor...on the way in this morning, I was thinking about how wisdom in psychiatry is a microcosm of wisdom in life, that is, learning to distinguish facts from metaphors, or things we can't change from things we can. Medicine is metaphorical to begin with, but psychiatry is meta-metaphorical; it engages metaphors to understand how our minds make metaphors.
It's good every now and then to revisit the obvious: nothing in medicine or psychiatry comes pre-stamped with a "DISEASE" label. The marvelously complex human body (including the brain), developed through natural selection, behaves in mulitfariously patterned ways with variable implications for life-span and subjective distress. All that science can do is to identify and trace these patterns in all their hideousness or glory; everything else--how to describe these patterns and what if anything to do about them--is the stuff of politics in the broadest sense of social wrangling and consensus (or the lack thereof).
Doctors are trained and appointed to diagnose and treat, most literally, but more widely, they act as society's representatives and arbiters when it comes to managing (juggling?) facts and metaphors as they pertain to the body (again, including the mind) and its existential frailty. Whether or not to compel treatment, or whether or not to recommend disability, or even to grant the "sick role" are not fundamentally scientific, but rather bespeak the negotiated attitudes of the culture at large. As Menand suggests, perhaps our error is to expect medicine and psychiatry to be primarily scientific in the first place. What happens in the lab or the clinical trial is (one hopes) science; what happens in the consulting room is quite different. The mistake is to assume a congruence between science and moral authority. In either direction, it is quite possible to have one without the other.
There is much more to be said, but this is a lunch hour post.