xxAACP Newsletter, Volume 11, Number 4, Autumn 1997
Editor's Column: Politicizing Psychiatry
Physician assisted suicide has been a nearly ubiquitous topic in recent months and has been discussed in many publications and considered by organizations such as the American Medical Association and the American Psychiatric Association. Apart from the larger question of whether a person has a right to take their own life with the assistance of a doctor is the corollary question of how we could insure that this decision would not be the product of a mental disorder. We must consider whether or not a person whose mental health is intact can choose to end their life. If not, can there be any rational for assisting someone who is essentially incompentet to pursue this course? When does suffering of a kind justify suicide? Are we capable of eliminating suffering so that this solution is not necessary? Should psychiatry be the arbiter of these complex questions?
Our society's treatment of sexual offenders has likewise drawn a great deal of attention in recently. In considering policy toward sexual offenders, considerable confusion exists around the distinction between psychiatric illness and criminal behavior. Is it reasonable to violate the privacy of people who suffer from deviant sexual compulsions for the protection of our communities and children? Who will define deviant sexual behaviors and determine who is subjected to such violations? In some cases, states have made the decision to incarcerate offenders beyond the completion of their sentences on the basis of the likelihood that they will repeat their crimes. Does this type of extended incarceration differ from civil commitment? How shall these determinations be made and what role should psychiartry play? A similar dilemma exists with the treatment of persons with addictions. The debate over the staus of addiction as a disease as opposed to criminal behavior has been an endless one. How can psychiatrists and other professionals avoid collusion with the criminal formulation? Can there be separation between social policy and clinical treatment?
In a third example, recent legislation has limited the definition of disabilities which make people eligible for public support in an attempt to reduce disability payments. Many people with additctive disorders and children with behavior problems will no longer be considered disabled. While legislators and bureaucrats make decisions regarding who can receive benefits and who cannot, psychiatrists are often asked to participate in the implementation of these mandates as they sign disability applications. Is this a proper role for psychiatrists and what impact does this have on our ability to provide clinical assistance?
In a final example, what position should the psychiatrist take with regard to recently "discovered" memories? The resurgence of this Freudian formulation of repression and catharsis and the purported validity of these memories have taken on legal ramifications that have the potential for destroying the lives of those they touch. Is there a proper role for psychiatry in making determinations regarding the veracity of these recovered memories when they have implications for litigation or even criminal prosecution?
On the surface, it may seem that there is more disparity than similarity between these issues, and the answers to these questions are not necessarily or immediately clear. What they do have in common though, is a blurring of the boundary between mantal health, and legal and/or moral behavior. While psychiatrists, as private citizens, may have political or ethical positions on these questions, when it is appropriate for us to inject these views into our professional lives in the service of poliltical ends? Is it possible to divorce these roles from one another? Our charge is to provide care to those in need and assistance to the communities we serve. What should be our guide in our efforts to fulfill this responsiblity?
Of course, it should not be surprising that psychiatrists are caught in debates which have more to do with social order and control than they do with the diagnosis and treatment of mental health disorders. Almost by definition, behaviors associated with mental illness will fall outside the norms of social order, and may therefore, come into conflict with the laws that maintain it. Some would argue that all criminal behavior falls to some extent within the realm of mental illness, others would argue that most political dissent is a product of mental illness. In one case we may err in excusing deviant behaviors from social sanction, in the other we may err in defining mental illness to serve political ends. Few actually advocate these extreme positions, but they illustrate where certain logical constructions may lead us.
We cannot avoid addressing these questions that have no answers, since they are inextricably bound to many of the activities in which we are engaged. We can only confront the absurdity of attempting to legislate responses to behaviors that fit no molds and the injustice that often results from these attempts to understand our world in black and white. We are left to attempt to formulate situational responses to individual needs based on the dictates of our conscience. We can only be guided by virtues which have drawn us to our work: compassion and respect for those we serve. We will not always be able to separate our work from politics, but if we can follow the dictates of these virtures, we may be able to limit the injustice done by those who would attempt to further a self serving political objective and play some small role in preserving the qualities that make our communities whole.
Wesley Sowers, MD
Editor
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