Remember psychiatric patient's civil rights
Thursday, April 3, 2003
By THOMAS SZASZ
"The madman is not the man who has lost his reason. The madman is the man who has lost everything except his reason." -- Gilbert K. Chesterton
The Washington Legislature is considering two bills that ostensibly deal with psychiatric advance directives. I say "ostensibly" because these bills, and all others like them, are reaffirmations of the mental patient's status as de jure medical patient and de facto psychiatric slave.
Barely a century and a half ago, a black man in America was treated as a slave or as not a slave. Today, every American is potentially in such a position: He is treated as a mental patient deprived of civil rights or as not a mental patient possessing civil rights. Once placed in the role of mental patient, he is, for all practical purposes, a slave of the mental health system.
What is the purpose of a psychiatric advance directive? There are only two options: A PAD can enhance the powers of relatives and psychiatrists who want to "treat" people whom they regard as mentally ill or it can enhance the powers of people designated as mentally ill who want to reject the role of mental patient and rely on the legal system to support their right to divorce their would-be benefactors. There is no third possibility.
The supporters of House Bill 1041 and Senate Bill 5223 claim that mental illnesses are brain diseases. If true, there would be no need for PADs.
No neurological patient -- suffering from multiple sclerosis or Parkinson's -- can be treated against his will. We have no neurological health laws but we do have mental health laws.
It is bad faith and hypocrisy to ignore the identity of the parties that support the enactment of mental health laws and PADs.
They are the relatives of so-called mental patients, their powerful lobby, the National Alliance of the Mentally Ill, and most important, the American Psychiatric Association. Organizations of former mental patients, who correctly call themselves victims and survivors of "psychiatric abuse," are conspicuous by their absence.
The aims of the supporters of PADS and of the politicians who endorse their efforts are thinly disguised: They wish to expand the state's power to "treat" people for mental illness and obstruct the individual's power to reject coercion by psychiatric agents of the state, provided their use of force is called care or treatment.
Here are three statements from HB1041 that illustrate its aim to tighten the shackles already fastened on America's psychiatric slaves: Only an "individual with capacity has the ability to control decisions relating to his or her own mental health care." The proposed PAD does not "supersede a determination of medical necessity." The proposed PAD may not "be used as the authority for inpatient admission for more than 14 days in a 21-day period."
In other words, in vain would a person execute a PAD for the purpose of rejecting involuntary psychiatric interventions of all kinds: He could still be committed and treated against his will. The avowed desires of patients and doctors conflict far more often in psychiatry -- in which "therapeutic" interventions are routinely imposed on patients against their will -- than in any other branch of medical practice.
Thus, advance directives are particularly important and useful for potential psychiatric patients, not to permit treatment but to refuse it. Any PAD that does not offer this option, valid even if contested by psychiatric expert opinion, serves the interest not of the denominated patient but the interest of his "benevolent" adversaries.
It may be well for us to remember some remarks on involuntary servitude that, unhappily, apply equally to our country's practice of involuntary psychiatry.
James Madison said: "We have seen the mere distinction of color made in the most enlightened period of time, a ground of the most oppressive dominion ever exercised by man over man" while Jefferson Davis said: "[Slavery is] a moral, social, and political blessing . . . [It is] the most humane relations of labor to capital which can permanently subsist between them."
The problem we now face is just as clear and just as tragically intractable. Anglo-American law assumes, as a matter of fact, that the relationship between a person and a legal agent of the state is adversarial. The student of law is taught the duties and roles of both prosecuting attorney and defense attorney. Both jobs are legitimate and proper.
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. The student of psychiatry is taught only the duties and roles of psychiatrist administering 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 reject the patient role is likely to be cast out of the profession as a renegade and rejected by the court as an expert.
All the so-called ethical problems of psychiatry flow from this source. Washington state's proposed psychiatric advance directive pretends to extend the mental patient's civil rights but does the opposite: It asks the unsuspecting patient to sign away his right to be free of psychiatric meddling.
Thomas Szasz, M.D., is professor of psychiatry emeritus at SUNY Health Science Center in Syracuse, N.Y. His most recent book is "Liberation By Oppression; A Comparative Study of Slavery and Psychiatry" (Transaction Publishers 2002).
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