Doctor Death

"Will you tell us when to live, will you tell us when to die?"

Cat Stevens

The execution of Albert G. Brown, Jr. in California has been delayed not only because of legal concerns, but also due to dwindling supplies of sodium thiopental. In my eight years of doing ECT we often had to switch back and forth between methohexital and thiopental (both barbiturates) because for whatever reason national supplies recurrently ran short. Why I wonder?

I remember that the morning of Timothy McVeigh's execution some years ago was an ECT day, and incredibly, the anesthesiologist involved (not one I usually worked with fortunately) commented before the patient was asleep that pre-ECT drugs and lethal injection drugs are similar (big differences: ECT involves supplemental oxygen and therapeutic effect; execution, not so much). When it comes to surgical types, the stereotypes are generally true.

The article mentions, to morbid and comic effect, the assurances of the spokesperson of California's Department of Corrections that adequate thiopental was available "to stop Mr. Brown's heart." Absurdly, the drug's maker then objected that its product was not "indicated for capital punishment."

Capital punishment is ultimate faith in the power of the state, which makes the conservative case for it puzzling. Execution is misguided for the same reason that suicide is misguided--in both cases death's finality overlooks the perennial possibility of human errors of judgment, whether of culpability or of the value of one's own life.

In any case, making execution into a quasi-medical procedure is a mockery. If we will celebrate death and its deterrent effect, let us haul out the gallows and the guillotine.

Becoming Who You Are

Sean Wilentz's Bob Dylan in America (excerpt here from The Daily Beast) is a worthy review of that force of nature, offering not a comprehensive examination (which will some day run to many volumes), but a series of deep core samples, as it were, taken from representative phases of Dylan's tortuous and protean career.

Dylan's story is a half-century version of Seinfeld's "show about nothing," that is, he is the trickster irrationalist, the artiste supreme, resisting every categorization. He is about nothing but sheer exuberant creativity, following his own quiddity, throwing off songs as a fire throws off sparks. For him there is only history, human nature, and the music driving the flower through the green fuse. He speaks endlessly but does not answer questions (as such, he is a kind of ultimate counter-example to psychiatry, or perhaps rather a competitor, the great blank screen and arch-therapist).

In parallel, D. G. Myers at A Commonplace Blog neatly identifies the dilemmas of religious toleration vs. tolerance. A deeply religious man to judge from his writing, he points out that all theological justification is logically circular, and there is no arguing first principles; in a process that apparently remains mysterious, one finds oneself either inside or outside of a belief system. So religious toleration is the recognition that one has nothing to fear from other faiths outside of coercion and violence.

What do Dylan and religion have in common? For me, it is the realization that there is finally nothing outside of nature, attachment, and seduction. I mean the latter not in any manipulative sense, but in the sense that not only art, but also persuasion and reason, are attempts to beckon others hither, to say, "Look at this wondrous state of being, if only it could be realized."

Why This Psychiatrist Isn't Practicing Psychotherapy

In expectation of their forthcoming book, the Shrink Rap folks did a post soliciting inquiries about psychiatry. Predictably, among them was: why aren't more psychiatrists doing psychotherapy? There are a number of ways to answer this, the simplest and least sophisticated being: shrinks are increasingly co-opted by Big Pharma and choose big bucks over introspection and integrity. That happens, of course, but it isn't the whole story.

Another way of looking at it is just the division of labor. People tend to get better at what they spend a lot of time doing. In recent decades huge numbers of psychologists and social workers entered the therapy arena, and not only do they often do therapy as well as a psychiatrist could--often they do it better. Why don't internists offer physical therapy, or detailed nutritional counseling? Because there are specialists who offer those services. Yes, they do offer them somewhat cheaper than an internist could or would offer them, but the more important point is that those specialists get really good at what they do.

To assume that psychiatry without formal psychotherapy (of the explicitly defined, 50-minute variety) is nothing more than pill-pushing is a warped and shrunken view of the medical role. The medical dimension of psychiatric practice has its own healing frame and ritual, the management of which calls for nuanced understanding of human nature and diagnosis; that is, psychiatry should offer a unique professionalism. Psychiatry without psychotherapy should not be confined to the peddling of antidepressants any more than internal medicine without physical therapy or nutritional counseling should be defined by the peddling of muscle relaxants or oral hypoglycemics.

As Freud himself believed, an M.D. after one's name does not endow one with unique therapy skills. As a psychologist reminded me years ago, people tend to do what they are trained to do. And as a commenter responded to a previous post on this topic (I can't seem to find it, so I paraphrase), people tend to practice what they believe. That is somewhat limiting (there are a lot of things I believe in more than in psychiatry, but it is necessary to pay the bills), but more or less true. I practiced ECT for years, but I don't "believe in" ECT more than in therapy. There is also, crucially, the matter of personal fit.

There are a lot of good therapists out there, and there are a lot of primary care physicians able to offer an SSRI (for better or worse) for transient or mild conditions. But people seem to have a hard time finding intelligent psychiatrists to offer, if nothing else, prognosis and understanding if typical treatments don't seem to work. One can have and apply a knowledge of the history, sociology, and philosophy of mental disorder without feeling the need to provide formal psychotherapy. I have done the latter in the past, and perhaps I will do it again, but for the time being it is more interesting in the abstract than in actuality.

The Solitary

"In a soulmate we find not company but completed solitude."

Robert Brault

Briefly, The Atlantic features a story on Donald Triplett, the now 77-year-old who was the original child diagnosed with autism by Leo Kanner. After him, I suppose, le deluge.

One can only marvel at the complexities of this diagnosis, which rival those of schizophrenia. In both cases, is this a diagnosis unique to modern times? In contrast to mood disorders, which have demonstrably always been with us, it is difficult to find clear traces of schizophrenics and autistics in the historical record. Did they merely elude the spotlight of history, ekeing out obscure lives in remote farms or urban hovels? Or is some relatively recent pathogen, toxin, or environmental poison at work?

Does autism represent merely aberrant wiring, the vulnerability of a vastly complex process to contingent errors? On the face of it, autism (like schizophrenia) would seem likely to have caused a major fitness disadvantage to our ancestors (Donald in the article lacks not only offspring, but any history of girlfriends). Or does autism merely represent the severe form of gene associations that in milder forms may have generated unusual social respect in evolutionary times past? And as with ADHD, autism has no place to hide in hyper-social, hyper-competitive societies. Anxious suburban settings strive to emulate the more relaxed small-town acceptance and support enjoyed by Donald Triplett. One could also ask, inasmuch as he does not appear to be unhappy, whether he is "disordered" at all.

America's Most Wanted (Doctors)

The dogs may bark, but the caravan moves on. Just when I had carried my graduate school application to the mailbox (do they still accept paper?)--I heard the market for Wallace Stevens studies is strong--I see that, according to an update in Psychiatric Times, I may not want to give up my day job quite yet.

It is striking that as many critics deride the profession and its tools, its real-world prospects grow apace. Indeed, the treatment of children, now most controversial, is precisely where the best jobs are. Why I wonder? Pharmaceutical behemoths stoking demand? Post-imperial, recessionary American malaise? Perhaps it is also related to the increasing pressure on primary care doctors, who just can't handle the huddled masses of the unhappy.

Murray Bail's The Pages

In Murray Bail's The Pages (NYT review here), two women, one a philosopher and the other a psychoanalyst, drive into the Australian hinterland so that the former may appraise the unknown work of a reclusive self-styled philosopher who has died, leaving his work in disarray in the austere corrugated steel shed where he labored for years.

So far the story itself sounds austere, but Bail's short novel is told briefly and impressionistically. Within the framework of the mystery of Wesley Antill, of his life and his life's work, philosophy and psychology as competing ways of being and knowing are set in relief.

That Bail, previously unknown to me but clearly an assured and sophisticated writer, trots out certain well-worn stereotypes makes me wonder if he didn't do so knowingly, as if defying the stigma of stereotyping or implying that there is more truth in such than we would care to admit. For we meet the flaky psychoanalyst, who has affairs with married men (and at least once in the past, with a client) and who manages to come across as both curious and self-absorbed. Her ambivalent friend is the detached, vaguely awkward, Aspergers-ish philosopher. Both of these are juxtaposed with the tough, taciturn ways of the sheep farmers (Antill's brother and sister) whom they meet on their errand.

Of course, philosophy and psychology do not exist in simple contrast or parallel. Philosophy is seen to have crucial emotional and biographical functions, whereas psychology makes truth claims, all too often unexamined. But Bail is obviously not interested here in academic arguments, but in philosophy and psychology as differing ways of being in the world, which Bail strikingly links to the physical environment:

Hot barren countries--alive with natural hazards--discourage the formation of long sentences, and encourage instead the laconic manner. The heat and the distances between objects seem to drain the will to add words to what is already there. What exactly can be added? "Seeds falling on barren ground"--where do you think that well-polished saying came from?

It is the green smaller countries in the northern parts of the world, cold, dark complex places, local places, with settled populations, where thoughts and sentences (where the printing press was invented!) hae the hidden urge to continue, to make an addition, a correction, to take an active part in the layering. And not only producing a fertile ground for philosophical thought; it was of course an hysterical landlocked country, of just that description, where psychoanalysis itself was born and spread.

It would appear that a cold climate assists in the process. The cold sharp air and the path alongside the rushing river.

In Bail's telling, here and elsewhere, philosophy (even if it is thoroughly naturalistic) has an otherworldly aspect; that is, it can only deal with deeply human problems, yet it seeks to distance itself from its human roots, becoming suspicious of language itself and attempting to break into some situation of truth above or beyond. It thrives in barren (mental and physical) landscapes, whether everything extraneous is put aside. It is unclear whether the enterprise is heroic or pathological. Elsewhere he writes:

"Too much light is fatal for philosophical thought." But some light is necessary.

That is, philosophy is about clarity, but total illumination lays bare the questionable motives of philosophy itself. Philosophy can only seek its own justification as a cat chases its tail. Yet one comes away from the book with the impression that psychoanalysis, while stemming from an honorable impulse to know oneself, is forever losing its way in acts of self-indulgent navel-gazing in cluttered, verbose interactions. Like I said, stereotypes--there it is, that idea again.

This is an intriguing fly-by view of philosophy--see its towering peaks and desert expanses--and psychology--see the buildings crowded into the hillsides, with people busily moving to and fro. Overarching it all is a book like this, the work of the imagination.

Is Science Interesting?

(The above purports to be a Chinese periodic table; if the characters instead express sentiments hilarious or profane, the more fool me).

Over at 13.7 Ursula Goodenough eloquently makes the case for scientific understanding as a civic and spiritual duty--it is not enough that we admire or respect nature, as individuals we must know how she ticks, at least in basic terms. She recognizes that such knowledge not only doesn't always come naturally or easily--often it is actively resisted. And yet she is not primarily interested in science as a means to technology.

It seems to me that curiosity is to science what speech is to the written word. Curiosity is spontaneous and natural, whereas science is part of culture and must be taught to successive generations. And while humans are inherently inquisitive about the physical world, we tend to be most curious about those environmental aspects that affect us most directly, and even so, our interest in social matters of love, violence, power, and gossip is often stronger still.

Is science necessary, any more than the invention of writing was necessary, or are both these merely contingent? Verbally and scientifically literate cultures are not superior to oral and pre-scientific ones, or if we consider them so, it is only because that is the water that we swim in. The most straightforward importance of science is its enabling us to manipulate the physical environment; when we wring our hands about the state of math and science education in this country, this is no high-minded spiritual concern, but rather worry that other nations may develop competitive technologies ahead of us.

I think that beyond the salience of science as means to other ends, it offers two other enticements, one spiritual and the other, for lack of a better term, I would call the human pleasure of puzzle-solving. These sometimes contrasting satisfactions shed light on different cognitive styles.

Science performs certain spiritual functions in relation to the physical world, functions pertaining to origins, essences, regularity, and plenitude. Science teaches us, in a manner dependent on logic and replicated experiment and not dogma, that there is far more to reality than what our immediate senses may perceive, from the microscopic to the cosmic and to the extent and variety of the living world. Science reassures insofar as it shows that reality obeys laws rather than whimsy, endowing the universe with a sublimity beyond that achieved by art or religion. However, beyond a certain point, details do not matter so much; I can appreciate the grand implications of evolution without a thorough acquaintance with the development of snails over two billion years.

The spiritual offerings of science go only so far. Over the years I have often had an intense interest in science, but I never felt a temptation to become a scientist. I majored in chemical engineering and then chemistry before realizing that I was not enough of a puzzle-solver to do science. I found scientific research to be soul-crushingly dull.

Many people (fortunately) take delight in how things work, either mechanically or verbally. They get a kick out of Rubik's cubes, crossword puzzles, or detective stories. My mind never really worked that way--I am naturally drawn to semantic, verbal, emotional and narrative insights. Neither mindset is superior, and I'm sure it's no evolutionary accident that human nature encompasses these two ends of a spectrum.

To be sure, I "got" science well enough to get into and through medical school without a problem, and it is wondrous that a biological system generates the insights I'm interested in, but the existential condition of suffering is what engaged me in the first place; the mere details of neuroscience are not, finally, compelling. That is, neuroscience does provide self-knowledge, but it is not the primary or even the best source, and it says nothing about how one should live.

And yet one might object: isn't psychiatry or psychotherapy like puzzle-solving? Not really. Yes, it is about pattern recognition, but it is not about arriving at a final aha! moment at which all the ambiguities drop away and nature stands revealed. Psychological treatment is an amalgam of personal history, emotional hermeneutics, and biotechnology in the service of existential goals and values.

Goodenough makes excellent points in her piece, but I think she protests too much. As a scientist and a puzzle-solver, she is baffled that many are not similarly wired. She ascribes it to some degree to fears of reductionism, but I think this applies only to a few scientific issues, such as evolution or neuroscience inasmuch as many see them as opposed to God or the soul.

Otherwise science is a specialized and contingent preoccupation. I am glad that I understand that plants grow not because spirits in the ground are telling them to, but because they convert solar energy into carbohydrates via photosynthesis in their leaves. However, the precise chemical equations involved, unless or until they are practically imperative for me to know, I am content to leave to the scientists.

The Dragon's Hoard

"Man is hungry for beauty. There is a void."

Oscar Wilde (via review by Arthur Krystal)

I always thought of dragons, the greatest and darkest creatures of Faerie, chiefly as collectors and connoisseurs, not primarily as plunderers or marauders. Their treasures would be rich, strange, and obscure, gained as much by study and ingenuity as by brute force or fire. The trove under the mountain promised a hidden plenitude.

As I think more about Paul Bloom's How Pleasure Works, and his theory of the "life force" embodied in art works and artifacts, it occurs to me that this life force really consists of attachment, to a transcendent Other that is an artist or other cathected individual. The memento is a repository of attachment. If money is about power and freedom, collected items are about connection and the gravity of history.

In Plato's "Symposium" Socrates presents a theory of erotic love as a deficit state, as the craving of an inherently incomplete entity. Aristotle wrote that the solitary man is either a beast or a god (and I don't think he saw men as gods). No matter how we attempt to defend against it, need is the default state of humanity. This need is best satisfied by relationships, but even those with abundant relationships maintain a system of stored attachments in the form of memorabilia, whether in the form of photographs, letters, books, or other valued items.

Having a romantic connotation of the dragon's hoard from childhood, I found it jarring for a while to hear of hoarding as a hallmark of pathology. How indeed does one shape and prune one's network of keepsakes? This is a deeply personal art. Just as, per Samuel Johnson, one should keep one's friendships in constant repair, so should one maintain one's personal record of attachments.

This art is distinguished by discrimination. Just as we are dismayed by those who would cast away every book, photograph, and card, we are appalled by those who cast away nothing. Just as he who loves everyone arguably loves no one (in particular), so he who keeps everything has become blind to relative value. In the case of hoarding the "life force" has become clotted and stagnant; a natural need has defeated its own purpose. If Thoreau was right that one is wealthy in proportion to what one can do without, it is also the case that human beings are those animals in need of apparent superfluity.

Entitlements High and Low

James Ledbetter at Slate describes the explosion of Social Security Disability Insurance coverage in recent decades, to the current rate of 4% of the potentially working population, as high as 6% in some states. The two most common kind of conditions covered? Mental disorders and musculoskeletal injuries (think lower back pain), both of which are notoriously elastic. Both are often quite real and severe, but surely these soaring disability rates are driven by non-clinical factors as well.

I work at one clinic at which virtually all the patients (or "consumers" as they are designated in the community mental health setting) either have disability status or are assiduously seeking it. They openly compare notes on how best to get a "crazy check" and to retain it long-term (patients often resist reduction or removal of medications in the belief that it may make them appear less disabled). Before they learn the system they are surprised to learn that I am not directly involved in the process--Social Security has its own protocol for determining disability. The bar is set apparently high--people are often turned down multiple times over a period of years, but repeated appeals especially with legal support usually seem to succeed, and once attained, disability is rarely lost, at least in the population I see.

Obviously many warrant disability support whatever the circumstances. But even among the questionable ones it is no simple matter of conscious malingering. Between $500 and $1000 per month isn't much, but it compares well with full-time minimum-wage work, which is the best that many disability candidates could hope for. And as Ledbetter mentions in his piece, disability rates may reflect long-term weakness in the job market that could be worse than feared. If someone with any mental symptoms whatsoever is chronically unable to find a job, his/her natural inference may come to be that s/he is disabled by those symptoms. Certainly I have seen this deduction at work (so to speak) in many young, quite able-bodied men in rural areas who have lost once abundant construction jobs. I was pleased to see that Ledbetter also produced the argument (as I did in a post last week) that increasingly technical jobs may be out of reach of a greater fraction of the labor pool.

Meanwhile, at the other end of the socioeconomic spectrum, NPR's health blog, citing a JAMA study, looks at reasons why doctors accept pharmaceutical company perks despite well-known concerns about conflicts of interest. The most common reason appears to be that they believe that they deserve them. This sounds familiar from my years of trying educate residents and medical students about the ethical issues involved. The latter just could not compete in general with their conviction that as they were working hard and--at that point in their careers anyway--not mind-bogglingly well-compensated, they were in fact entitled to a free lunch. One man's entitlement is another man's just deserts (or just desserts as the case may be).

The suppression of freeloading is the ultimate evolutionary game of whack-a-mole.

Little Thoughts

I am steering clear of Big Thoughts today; sometimes one just has to write something, anything.

1. Whenever I despair of psychiatry's approximations, I am consoled by economics. Am I the only person who wearies of the endless liberal/conservative tug-of-war on taxes? Really, wouldn't one think that in 2010 it should be possible to empirically determine the optimal tax rate in terms of effect on economic stability and growth? No? And people are surprised we haven't figured out depression?

2. It is official, according to Thomas Friedman and David Brooks: the United States is in a national funk, 300 million slackers with respect to the values that made this country great. Is this surprising? Having achieved the greatest prosperity in the history of the world, and lacking a coherent antagonist (Islamic terrorism is more akin to organized crime than to an Evil Empire), complacency sets in. It is human nature. Is it necessary that not only the 20th, but also the 21st, be American centuries? When can we mutate into a more temperate version of Canada?

3. Paul Bloom's How Pleasure Works (Bob's review here) is an entertaining if unchallenging stroll through his pet theory of "essentialism," the human tendency to believe in and attach to unique and individual identities as opposed to interchangeable sets of properties. I particularly enjoy his discussions of objects such as artworks or even random possessions of celebrities that retain the transferrable "life force" of their originators. The collector (and bibiophile) in me loves this: one accumulates loved objects as a reservoir of life force, a tide that in the case of hoarders gets out of hand.

4. Check out Douglas Coupland's amusing "Dictionary of the Near Future"--I particularly like his "pseudoalienation" (technology as an intensification of the human, alas) and two varieties of melancholy.

Conundrums and Credulity

A couple of recent links usefully examine the empirical and moral implications of religious belief. Tim Crane considers the ambiguous relation of faith and evidence, pointing out that while a demanding need for evidence for God is seen to reflect a fragile faith, it is nonetheless the case that religion collapses without a crucial intersection between the supernatural and the historical record.

John Cottingham, reviewing books by Mark Johnston and Andre Comte-Sponville (unread by me), suggests the paradoxical moral effects of specific belief. His review reminds us that belief in a personal God, with its implied promises of salvation and heavenly reward, cannot escape entirely the taint of idolatry and self-interest. The highest, most heroic spirituality would be that which conducts itself as if God existed while relinquishing any actual belief that this is the case. That is, the truest Christian, even if it could somehow (impossibly) be conclusively demonstrated that Jesus Christ was merely a man, would go on just as before.

However, Cottingham argues, in a way that is probably familiar to readers of this blog, that without the existential anchor of actual theistic belief, religion loses all specific content and disintegrates into well-meaning but empty notions of the life force. And worse, he claims that the project of a fully secular ethics is ultimately doomed, that without the foundation of communal faith underlying Western civilization, the elaborate complexities of Locke, Kant, etc. have no binding force.

This introduces a paradox of morality: so long as it is buttressed by a personal God (who by implication may dole out rewards and punishments), it is primitive and tribal in nature, but if God is jettisoned, morality becomes metaphysically optional. Cottingham clearly prefers the former as the lesser of two evils. Of those who, like myself, are non-believers yet do not routinely indulge our worst impulses, he would presumably say that we are either merely timid or are ungratefully coasting on a sense of decorum stemming ultimately from the Western faith we profess to be unmoved by.

I guess I see secular morality as a historically novel trend, as unprecedented in our ancient evolutionary history as, say, scrupulous regard for the welfare of animals or acceptance of antipodal human beings as something other than targets for conquest. I think that the emotional roots of religion are biologically deep, but that they can find other soil than historical theism. After all, the historical specificity of faith accentuates the paradox of religious tolerance: if a Christian truly believed that a Muslim's tradition were as valid as his own, he would have no compelling reason to remain a Christian. Instead, he consents to respect the Muslim point of view, but for reasons of social concord that lie outside of faith itself; for monotheistic gods are inherently jealous.

But to return to Crane's point about history and faith, it is important to recall that belief cannot avoid being mediated through and through, as the crucial roles of Scripture and the Koran reveal. When I say that I do not believe in Allah or the Christian God, I am really saying that I do not believe that the assembled writings of various Middle Easterners of 1300 or 1800 years ago reveal anything more than compendia of hearsay. It is not God that I disbelieve in; it is a specific historical product of deeply fallible humanity that I disbelieve in. Similarly, those who profess to believe actually subscribe to a particular and all-too-human historical tradition, in the absence of which religion sublimates into a vapor of vague feeling.

It could also be said that I (presumptively perhaps) await the one and true religion, which will come after all of these false starts. I propose a return to the Egyptians, those worshippers of cats and of the sun.

The Analogy with Education

Briefly and speculatively this morning, at a friend's behest I've been reading Robert Whitaker's Anatomy of an Epidemic, another entry in the thriving anti-psychiatry industry. I am still early in the book, but so far it is, for its genre, a sober attempt to answer the question of why, after decades of intensive research, the problem of mental illness and its attendant disability appear to be, if anything, worse than ever. A hypothetical answer came to me when I read Robert J. Samuelson's suggestion about educational reform in Newsweek.

Samuelson observes that the United States has been in educational "crisis" for decades now, yet despite the application of massive resources and large numbers of teachers (and immeasurable pedagogical ingenuity), average academic performance has not significantly budged. He makes the not very politically correct claim that the problem is no longer the educational system, it is the students, or at least the kinds of students that the culture at large now produces. He adduces two factors: the increasingly anti-intellectual and autonomous culture of adolescence, and the huge increase in educational access in an increasingly technological and sophisticated society. In a nutshell, the educational system increasingly aspires to wring blood from a stone.

Human beings naturally vary in cognitive skills, concentration, etc. and for most of human history only a minority of the population endured extended formal schooling. The past generation or so has been the first experiment in population-wide education, and it could be that the system is coming up against natural human variability. In the past those who, whether due to lack of opportunity or aptitude, could not obtain extensive education were able to find niches in agricultural or other basic functions that are now increasingly occupied by machines. In an economy increasingly requiring advanced and specialized skills, niches are more competitive and harder to come by. Thus the uneducated are, relatively speaking, more disabled than in times past.

It could be that mental disorders, except perhaps for the most severe forms (the exact boundaries of which are still not determined), are not so much discrete entities as they are one end of the bell curve in terms of parameters such as mood, anxiety, attention, and reality testing. They may be analogous to learning disabilities inasmuch as deficits in stress tolerance, mood stability, and sustained attention increasingly place persons at greater disadvantage. Contemporary society is not so much provoking these problems as it is making them more apparent, that is, revealing natural human variability in the same way that, say, a basketball camp highlights differences in jumping ability. Because these capacities are complex and developmental, they are not easily modified.

Just as in centuries past, the academically challenged found niches, so those with anxiety and mood disorders may have been able to gravitate to settings that accomodated their symptoms. They found rural occupations permitting distance from people; they found solace in church; they were able to obtain support from family. But in our more mobile and dispersed society, the only jobs available are often intensely stressful, requiring constant contact with people even if only on a telemarketer's line. Individuals who used to rely on family increasingly have to resort to official disability status. It is not the case that psychological disability is new or unprecedented--it is just that there is nowhere for it to hide.

ADHD is obviously the place at which educational and psychiatric challenges intersect, and to my mind it is the perfect example of a hypercompetitive, ambitious post-industrial society illuminating natural and evolutionary variation in a human cognitive capacity, in this case attention and impulse control. The fact that distractibility, like the ability to metabolize (then scarce) calories parsimoniously, was adaptive for much of human evolution, does not unfortunately mean that it is adaptive now. The effort to suppress obesity, like much of psychiatry, may be an instance of cultural evolution, one that appears to have a lot of bumps in the road.

The Perfect Game

For the holiday, just a nod to David B. Hart's passionate paean to baseball, which he, tongue only obliquely in cheek, proposes as the most uniquely American contribution to culture, one that differs in kind and essence from those more cramped sports lumped together as "the oblong game:"

All of this, it seems to me, points beyond the game's physical dimensions and toward its immense spiritual horizons. When I consider baseball sub specie aeternatis, I find it impossible not to conclude that its metaphysical structure is thoroughly idealist. After all, the game is so utterly saturated by infinity. All its configurations and movements aspire to the timeless and the boundless. The oblong game is pitilessly finite: Wholly concerned as it is with conquest and shifting lines of force, it is exactly and inviolably demarcated, both spatially and temporally; having no inner unfolding narrative of its own, it does not end, but is merely curtailed, externally, by a clock (even overtime is composed only of strictly apportioned, discrete units of time).

__________________

No other game, moreover, is so mercilessly difficult to play well or affords such a scope for inevitable failure. We all know that a hitter who succeeds in only one-third of his at-bats is considered remarkable, and one who succeeds only fractionally more often is considered a prodigy of nature. Now here, certainly, is a portrait of the hapless human spirit in all its melancholy grandeur, and of the human will in all its hopeless but incessant aspiration: fleeting glory as the rarely ripening fruit of overwhelming and chronic defeat. It is this pervasive sadness that makes baseball's moments of bliss so piercing; this encircling gloom that sheds such iridescent beauty on those impossible triumphs over devastating odds so amazing when accomplished by one of the game's gods (Mays running down that ridiculously long fly at the Polo Grounds in the 1954 World Series, Ted Williams going deep in his very last appearance at the plate); and so hearbreakingly poignant when accomplished by a journeyman whose entire playing career will be marked by only onen such instant of transcendence (Ron Swoboda's diving catch off Brooks Robinson's bat in the 1969 series).

___________________

I am not nearly as certain, however, that baseball can be said to have any discernible religious meaning. Or, rather, I am not sure whether it reflects exclusively one kind of creed (it is certainly religious, through and through). Its metaphysics is equally compatible and equally incompatible with the sensibilities of any number of faiths, and of any number of schools within individual faiths; but, if it has anything resembling a theology, it is of the mystical, rather than the dogmatic, kind, and so its doctrinal content is nebulous. At its lowest, most cultic level, baseball is hospitable to such a variety of little superstitions and local pieties that it almost qualifies as a kind of primitive animism or paganism. At its highest, more speculative level, it tends toward the monist, as a consistent idealism must.

Science Run Amok

Every art and every inquiry, and similarly every action and pursuit, is thought to aim at some good; and for this reason the good has rightly been declared to be that at which all things aim.

Aristotle (trans. W. D. Ross)

Over at Edge, Sam Harris writes on science as it may apply to morality. He raises many compelling issues, but his piece exemplifies the grievous attempt to extend the relentless rigor of science beyond its rightful purview. If nothing else, the article is worth reading for its sheer effrontery (leave aside the moral debates of three thousand years, it's really rather simple!).

Harris argues that the force of science may be brought to bear on the problem of morality in three respects, not only anthropologically (documentation of actual ethical practices), but also as regards the ends of morality (which he stipulates as the well-being of conscious creatures), and surprisingly the art of persuasion, that is, bringing the benighted into the orbit of the empirically right-thinking.

His method is to claim that since the methods of science (i.e. evidence, consistency, parsimony) depend on consensus, and morality depends on consensus, then they are parallel endeavors; that is, normative moral phenomena--the ways one should live--are objectively true or false in the fashion that physical states of affairs are true or false. In other words, one may dissent from scientific methods (appealing, presumably, to revelation or intuition) just as one may opt out of moral claims, but to do so, Harris implies, is to place oneself beyond the pale. He also draws an analogy with economics, suggesting that just as goods and services may (theoretically) be generated and distributed in an objectively optimal manner, so is there a neutral calculus of human well-being.

The problem is that one may recognize many modes of human well-being without falling into the mire of moral relativism. To be sure, we are not entirely adrift in ambiguity. It is uncontroversial, for instance, to suggest that the citizens of Switzerland are better off in absolute terms than those of North Korea, just as it is safe to say that Bach is superior to Kate Perry. However, these are extremes, and most moral distinctions are more subtle. Are Americans better or worse off on average than Germans? Is Bach superior to Schubert?

The real problem for Harris appears to be what to do with the outliers, that is, those unreconstructed folks who fall in with creationism, or those societies that do things like execute adulterers. But the problem is that those with whom we disagree do not generally object to human well-being; they merely assess it differently. Those who oppose abortion or even stem-cell research believe that a society in which post-conception Homo sapiens are not disposed of is, on the whole, a desirable one. Muslim societies that discriminate against women or execute adulterers believe that they do so for the average benefit of all. Even Hitler believed that he was adding to the sum total of moral goodness (of the human beings who mattered to him). Can the methods of science, as opposed to moral consensus, really prove otherwise?

If so, there would presumably be some foolproof method, as yet undiscovered, of ascertaining comparative well-being. Are Californians better off than New Yorkers? How about men and women? Doctors and lawyers? The very notion is absurd.

Unsurprisingly, given the ambit of this blog, the matter may be best approached through the lens of psychopathology. In the various realms of fact, of morality, and of aesthetics, there are those with whom we merely disagree and those who are indeed beyond the pale. For instance, the evidence supporting the human contributions to global warming is strong, such that those to disbelieve are suspect and perhaps perverse, but nothing more. However, those who hold that the moon landing was faked or that Barack Obama was born in Kenya are, properly speaking, delusional in the sense of the cultural fringe.

Similarly, Auschwitz and North Korea are examples of psychopathy and megalomania, respectively, both of which may be held to be forms of moral delusion. In contrast, those who object to abortion or secularism are those with alternative moral views. Except in jest, there is no such thing as aesthetic delusion, although it seems to be ubiquitous.

The problem with applying the authority of science to moral and aesthetic realms is twofold. First, the external world exists independently of us, and is has certain characteristics and laws that we come to understand more or less accurately. Science is supreme here--no other technique for fathoming external reality comes close. However, ethics and art are not external to us--they are generated by us, and are found after the fact to be more or less admired or salutary. In science consensus as to method is the means to an end, but in matters of morality and art it is consensus through and through.

The second problem is that science leads inexorably to technology; understanding here implies the power to control and manipulate. And unfortunately the history of trying to engineer consensus in morality and art where it does not naturally exist is not propitious. For when we apply technological methods not to external reality but to human reality (ourselves), strange things start to happen. Yes, human beings and societies have a material reality that is subject to science, but that reality also supersedes and frames the very undertaking of science. Ethics and art are not technical problems to be solved but perennially unfolding realities to be experienced. The moralist and the artist are gardeners, not machinists.

On Antidepressants

Macbeth: Cure her of that.

Canst thou not minister to a mind diseased,

Pluck from the memory a rooted sorrow,

Raze out the written troubles of the brain,

And with some sweet oblivious antidote

Cleanse the stuff'd bosom of that perilous stuff

Which weighs upon the heart?

Doctor: Therein the patient

Must minister to himself.

Macbeth: Throw physic to the dogs, I'll have none of it.

The other day I was reading an account of Mozart's final hours, in which he lay wracked by fever and pain, still idiopathic to this day. When the doctor arrived, he prescribed cold compresses. If that good medical man had any notion of what he was dealing with, what might it have been like to attend to one of the greatest composers in the history of the world and to be able to do nothing better than cold compresses? (Of course, it is thought that his life may have been iatrogenically shortened by previous blood-letting as well).

I've been reading Thomas Hines's Architecture of the Sun, a history of modernism in southern California, in which various people moved to that region upon medical recommendations of a more salubrious climate. Those were the days, when a prescription for sunlight, dry air, and palm trees was respectfully viewed as deep medical wisdom! A doctor's word could relocate people across continents.

The history of medicine is a weird amalgam of ignorance and authority, incapacity and power. Even through the millenia in which the practical (positive) effects of medicine were minimal, doctors nonetheless occupied a crucial social locus of judgment and prestige.

Physicians now fight for space in a more crowded arena, but some of their outsized influence remains. For better or worse, a diagnosis from a psychiatrist often carries more weight than one from a therapist. When patients need temporary time off from work or apply for disability, the paperwork seeks the opinion of the physician, not the therapist, nurse practitioner, or physician's assistant. The physician still wields the gavel of the sick role most vigorously.

But if, as the commenter to the previous post suggested, the primary function of the doctor must be the relief of suffering, what happens when the doctor's tools are in fact too weak to accomplish this, or what is more complicated, what happens when the effect of those tools is owing to their wielders' social power rather than to any inherent properties (i.e. the placebo effect)?

Much has been heard of late about the dubious effects of antidepressant drugs, an issue that can only give any psychiatrist serious pause. This issue has been raised many places, and this post is not intended as a literature review, but Sharon Begley's Newsweek article may be as good a summary as any. If antidepressants are truly no better than placebo, then a scientific fraud on an unprecedented scale would have been perpetrated over the past half-century, and there would be something seriously rotten in the state of psychiatry.

I believe, of course, that antidepressants have real effects, otherwise I could not do my job in good faith. This belief could be deemed meaningless inasmuch as I have self-interested reasons of both professional standing and financial stability for holding it, and the human capacity for self-deception is unfortunately vast. But there are of course scientific reasons to doubt ambiguous drug trials, chief of which is the fact that many patients (or "patients") enrolled in drug studies are not representative of real clinical settings. Their disorders tend to be milder and more pure (i.e. uncomplicated by other diagnoses), and the very fact of their willingness to participate in a drug trial may heighten their response to placebo.

So, what do I believe about antidepressants based on 15 years of prescribing them to many hundreds if not a few thousand individuals in various settings? I believe that they are imperfect drugs that too often fail to work--my ECT experience alone would tell me that. I believe that antidepressants treat symptoms of still mysterious illnesses; they do not target the illnesses themselves. They are non-specific, affecting a broad spectrum of emotional response and anxiety level; in that sense they are more like what David Healy, in The Antidepressant Era, referred to as tonics than like magic bullets (think aspirin, not penicillin).

I believe that antidepressant effects are stronger, relative to placebo, the more severe and sustained depression or anxiety is. For mild and transient conditions they are often useless (thus the irony of the moral panic over Prozac-based emotional enhancement). I believe that people (prodded by drug advertising and cultural momentum) rely on them too much on average. Social and psychological interventions should be tried first.

But I refuse to believe, broadly and scientifically, that antidepressants are indistinguishable from placebos. For one thing, within the pharmacopeia there are a few drugs that I think of as internal placebos (buspirone or hydroxyzine, anyone?) having little effect beyond a hope and a prayer. But the mainstream antidepressants aren't like that, and while I know that the placebo effect is powerful and still not well understood, I have seen too many unimpressionable people with dramatic and sustained responses, and too many impressionable types who fail to improve, to believe that there is no physiological effect.

On what may seem like a trivial note, I haven't researched the literature, but many pet owners and veterinarians attest to the effects of Prozac, etc. on neurotic cats and dogs; can that merely be a mass phenomenon of placebo effect by proxy?