Noble Lies?

A New Scientist book review:

In the face of life’s inconvenient facts – alcoholism, drug addiction, depression and craziness, to name a few – pseudoscientific medical concepts allow us to cast difficult moral problems as simple factual questions, readily soluble in the lab and in the hospital. Gary Greenberg’s The Noble Lie is an impressive and fascinating round-up of such pseudoscientific notions and the ways in which they have come to count as genuine illnesses.

For instance, Greenberg explains how alcoholism’s transition from vice to disease was a welcome one, especially following Prohibition. It was long viewed as an allergy, though the specific allergen persistently failed to appear. Even today, neither its disease-nature nor any possible cures have manifested themselves. Regardless, people are happy to accept the idea that addiction is a medical illness, perhaps, Greenberg suggests, because of our ambivalence towards the role of pleasure and our uncertainties about free will and self-determination. "With the disease model we have an answer," he writes, "one that has the imprimatur of science; addiction isn’t wrong, it’s sick."


In the absence of scientific proof that addiction is a disease, is it wrong for medical professionals to perpetuate the idea? Not necessarily, Greenberg says – there are times when what is scientifically wrong, or at least uncertain, is morally right. "There can be no doubt that the disease model has helped millions of people. If a made-up disease can be of such immense value, then we must consider the possibility that the truth is not what it’s cracked up to be. Perhaps, in the republic of medicine, the fiction that addiction is a disease is a noble lie."

Sometimes the noble lie works the other way round. In a chapter on homosexuality, Greenberg shows how humane concerns first led people to prefer a medical to a criminal definition, but conflict followed concerning the disrespect a medical definition implied toward what should perhaps be viewed as a free life choice.  In 1973, following the Stonewall riots and the start of the gay rights movement, the American Psychiatric Association deleted homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), a move decided not by scientific facts but by political and moral attitudes. "It may be the first time in history that a disease was eliminated by the stroke of a pen," Greenberg writes. …

In a fascinating correspondence with the clear-headed and callous murderer known as the Unabomber, Greenberg tells Ted Kaczynski that he should never have been forced to accept the defence of schizophrenia at his trial, both because he believes Kaczynski was in fact "evil and not sick", and because "his very character seemed to bear the imprint of large social and historical forces" which could not be investigated once he was classed as too mad to be taken seriously.

People quite reasonably have different categories in their minds for disabling conditions; they distinguish diseasese, deliberate choices, weaknesses etc.  While there may be ambiguities at the boundaries, these seem reasonable categories to use.  You might not approve of how people choose to treat people in these different categories, I have little much pateince with lying to folks about what behavior falls in what category just to trick folks into treating folks the way you would prefer.

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  • http://www.ciphergoth.org/ Paul Crowley

    I absolutely reject the distinction you’re arguing for here. It’s not just that there are a few tricky edge cases, but that the entire distinction is unfounded.

    I’m guessing you wouldn’t consider Phineas Gage culpable for the many flaws he exhibited following his accident, since you can see a clear cause. If you see another man with the same flaws, you have no way of knowing if a similar accident befell them – perhaps it happened to them so young that no-one knew that it was the cause of a change in temperament. Equally, rather than being caused in such a dramatic way, perhaps it’s just a subtle combination of genetics and upbringing; either way it is caused. Or perhaps it is in some sense wholly uncaused; a freak outcome of the brain that just happens with some probability, but that isn’t predicted by some straightforward cause we can identify. As soon as you’ve rejected the idea of a soul, you have no “ultimate” place for a person’s culpability to rest; either their behaviour is caused, or it is uncaused, and neither of these give ultimate culpability.

    The whole idea that we can distinguish between what someone “can’t help” and what they can help but won’t just can’t survive our current understanding of genetics and the brain. We need to give up on that distinction, and replace it with distinctions we can ground in fact, such as what sort of behaviour can be altered with reward and punishment, and what other factors come into play.

    This is especially important when considering large groups of people, such as all alcoholics. You can make progress with an individual alcoholic even if you are muddled with this outdated concept, but it will completely bar your ability to understand an entire population.

  • prase

    An interesting post which deals with quite important question. I always understood that the boundaries of the category of mental diseases is very arbitrary. On the other hand, you write that the category is reasonable. Can you give some reasonable definition of what is disease?

  • Yvain

    I completely agree with Paul Crowley. Determinists can’t and shouldn’t make those distinctions, except maybe as a higher-level heuristic that helps predict things like ease of treatment and thorniness of surrounding ethical issues.

    I treat “disease” and “vice” less as ontological categories and more as social categories. Calling something a disease is a way of telling people to pity and support a certain group of people. Calling something a vice is a way of telling people to blame and feel contempt for a certain group of people. Oh, we’ve decided to feel pity for alcoholics instead of contempt? Let’s call it a disease instead of a vice.

  • http://www.cawtech.freeserve.co.uk Alan Crowe

    The issue is a rhetorical trick that I call “up and back down again”.

    You take something specific, such as alcoholism, go up to the general category, illness, then back down to the prototype of the general category, for illness it would be stroke, cancer or heart disease. The purpose of the rhetoric is to persuade the listener to treat the specific in the same way he would treat the prototype of the general category. So an alcoholic gets treated as blameless, just as we consider a cancer patient blameless.

    The error lies in doing “up and back down again” which is a mistake because it throws away relevant information. Perhaps we know quite a lot about alcoholism. To throw this knowledge away and treat an alcoholic in the same way as some-one with cancer *because* cancer is the prototype of the category “illness” to which alcoholism belongs is absurd.

    Can “up and back down again” be rescued from absurdity? Notice what it is being used for. It is being used to impose uniformity of blame-worthiness across the broad category of “illness”. Suppose that our understanding of “illness” was as a contour in the landscape of blame-worthiness. Then it would be reasonable to swap one illness for another in our discussions of blame, but it would also affect the way we defined the boundaries of the category “illness”. We would police the boundaries of the category with comparisons of blame-worthiness. Is alcoholism an illness? We would debate whether alcoholics and cancer patients were equally blame worthy. The conclusion of our debate would guide us as to whether alcoholism was an illness. We could not hope to deduce the blame-worthiness of alcoholics from the categorisation of alcoholism as an illness; that would beg the question.

  • alexa-blue

    I don’t see any theoretical reason whey we should treat disabling conditions differently based on which category they fall into, just pragmatic and historical ones. Medicine today, insofar as it’s good at anything at all, is better at treating disease than poor choices or weaknesses. But the best argument against “medicalizing” alcohol and drug abuse, sadness, sexuality, etc. is that we don’t have very effective treatments for those things. I suspect, though, that I’m using “treat” in a different sense than you are.

  • Lara Foster

    As a medical student who has just suffered through three lectures on the topic of ‘substance abuse disorders,’ I will expound what I see the current medical opinion to be.

    1) Substance use is only considered a psychiatric disorder if it negatively affects a person’s life. (health, job, relationships, etc, and there’s a whole list of criteria used to determine this.) Thus the happily married stoner/kindergarten teacher might be judged by society as having a disorder, but not by medicine.
    2) Most people who abuse substances claim that they could stop if they really wanted, but don’t want to. ‘If you were garunteed a million dollars if you were clean for a year, could you do it?’ ‘Of course! But then I’d use my million to buy more crack.’
    3) Psychiatric treatment of substance abuse MUST address the underlying reasons patients don’t want to stop using a substance. ie- not having anything better in life (depression), fear of what society would expect of them if they stopped (anxiety), etc.
    4) Thus it’s not that substance abuse is *itself* an illness, but it can both trigger and feed into real psychiatric problems… unless of course you’re going to argue that depression, anxiety, and the like don’t have any medical aspects…
    5) Data shows that people with substance abuse disorders will frequently relapse if they are not kept in psychiatric treatment/counseling. Therefore there is predictive value in making this diagnosis, because it indicates whether or not a patient should remain in treatment/counseling.

    Comparing ‘alcoholism’ to cancer makes as much sense as comparing the whole field of psychiatry to oncology. Sure, they both use medication to treat undesirable conditions… but that’s about it. I have sympathy for the publics interpretation of substance abuse as an ‘illness,’ because the total explanation is more complex than they care to explain or hear, and illness is closer to the truth than ‘evil,’ or so I believe for the majority of people with self-destructive tendencies.

  • http://occludedsun.wordpress.com Caledonian

    This is true of virtually every ‘mental illness’. The few counterexamples were removed from the scope of psychiatry once we understood them.

    Which is the point: when we find how condition X is an actual medical condition, we move it to an actual medical field — usually neurology.

    Try explaining to people that we do not know what mental disorders are, or that the commonly-promulgated understanding of what they are is known to be wrong. They don’t respond to the arguments you make, they’ll immediately begin arguing against a strawman they substitute for your arguments.

    There are active psychological defenses preventing people from even thinking about the possibility that the various mental disorders might not be based in physiological problems.

  • Lara Foster

    Caledonian-
    -Incomplete knowledge of the etiology of a disorder does not indicate that there is NO evidence for a physiological role. There are many known biological and/or genetic contributors to the big three in psychiatry: depression, anxiety, and schizophrenia.

    -Existence of disorders in the DSM for which there are no biological evidence does not negate the existence of disorders for which there are.

    -Knowing the etiology of a disorder does not necessarily make it a neurological as opposed to a psychiatric problem. A person with two copies of the truncated 5-HT gene, who develops depression and subsequently responds to SSRIs is not going to be sent to a neurologist if they relapse, but to a psychiatrist.

    -Even if no common biological roles or treatments exists, if counseling is effective at treating a mental ‘illness’, it is reasonable to use- whether you want to call this medicine for illness as opposed to life-coaching for confusion doesn’t seem to make much difference to me, though many people seem to split hairs over the exact terms. I tend to feel sorry for the suffering regardless of what we label it, but that’s just me.

  • http://silasx.blogspot.com Silas

    Don’t forget the other noble lie about alcohol, specifically, that there is something enjoyable or special about it, which excuses you for getting high. The lie that there are special subtleties in the taste, that the taste is very good, that it’s okay because it’s a tradition … nope. You just want to take drugs without the social stigma. See my expose of this phenomenon on my blog and the discussion, joined by people gaining the courage to notice the emporer’s nakedness.

  • http://entitledtoanopinion.wordpress.com TGGP

    I had a pretty big argument about whether mental illnesses are really illnesses in the medical sense at my blog with mtraven and Caledonian. It was a while back, but anyone can feel free to add as I don’t mind resurrecting dead threads.

  • http://occludedsun.wordpress.com Caledonian

    -Incomplete knowledge of the etiology of a disorder does not indicate that there is NO evidence for a physiological role.

    1) Strawman. That was not an argument I made; your response is a non sequitur.
    2) It’s idiotic. Humans exist, and thus are material, and thus are physiological. Necessarily physiology plays a role — that does not require that physiology can be considered a cause, or that any problems are physiological in nature.

    There are many known biological and/or genetic contributors to the big three in psychiatry: depression, anxiety, and schizophrenia.

    No duh. That’s true of every human property. The point is obvious to the point of complete triviality — for you to offer it as an argument indicates that you haven’t actually thought through the position you’re supporting.

    Existence of disorders in the DSM for which there are no biological evidence does not negate the existence of disorders for which there are.

    Biological evidence of what, Foster? The issue is whether the evidence supports the common contentions — which it does not. It in fact rules out the most common contentions regarding mental disorders. They are not merely unsupported, they are actively contradicted by what we know.

    Knowing the etiology of a disorder does not necessarily make it a neurological as opposed to a psychiatric problem.

    It does, if the etiology is neurological in nature. That the disorders are such is what is asserted. That they are nevertheless NOT included in neurology indicates that the assertions are false, and recognized to be false on some level.

    A person with two copies of the truncated 5-HT gene, who develops depression and subsequently responds to SSRIs is not going to be sent to a neurologist if they relapse, but to a psychiatrist.

    Exactly!

    Why do you cite what is done as a means of justifying those practices? More importantly, why don’t you recognize that by doing so, you are providing powerful evidence for my assertions?

    Even if no common biological roles or treatments exists, if counseling is effective at treating a mental ‘illness’, it is reasonable to use

    I’m going to have to write up the story of B12 and PMS sometime, because it’s a perfect counter to the hidden assumptions you’ve just made.

    whether mental illnesses are really illnesses in the medical sense

    Just to clarify, TGGP, the issue is not whether they’re illnesses in the medical sense, but whether we know that they are, and whether the explanations that are commonly given to people regarding what we know are accurate. In short: we don’t, and they aren’t.

  • Lara Foster

    Caledonian-
    You are arguing, but it is entirely unclear what you are arguing in favor of. That mental disorders are NOT illnesses in the medical sense whether or not there is a biological component that can respond to chemical intervention? Ok… that’s a seemingly irrelevant labeling issue. Maybe you want category A: Bodily illnesses and B: Mental disorders and C: Mixed origin. Has that solved your problem? I guess that’s what Hanson’s whole post was about- people getting offended by certain labeling issues that give them the right to react certain ways to labeled groups. Mentally ill- uh- fucked up people have *real* problems, regardless of how you label them, that can be just as unpleasant, disabling, and difficult for them to control as a physical ailment. Which should we blame the individual more for: diabetes or depression?

    Maybe you are just complaining that many doctors claim to ‘KNOW’ what the cause is, when the data is ambiguous? This is true for many, many, disorders, not only mental ones, and is indeed a problem of overconfidence in medical training in general. Yet, would you suggest calling a moratorium on treatment until you have an exact detailed explanation of how exactly each disorder occurs in each affected individual, and how to treat them? There seems to be ample evidence that psychiatric medications are effective at relieving symptoms (if not fully curing the disorder in question), hence the field of psychiatry exists instead of only psychology, life coaches, etc.

    Maybe you don’t like the idea of altering behavior with chemicals, period, want to chalk all behavior up to ‘the will,’ and leave mentally messed-up people alone to solve their (very difficult) problems by themselves. You would not be the first. You would need to present some very compelling evidence that psychiatric medicine causes more harm than good for me to buy that argument.

  • http://occludedsun.wordpress.com Caledonian

    You are arguing, but it is entirely unclear what you are arguing in favor of.

    It is clear to me that you believe this; it is equally clear to me that you do not comprehend either the subject or the argument we’ve been having about it.

    That argument is over now.

  • Jor

    I’ll just second Lara’s comments. They key is functional impairment (i.e. person can’t work, etc.)

    I would also say that I have little much pateince with lying to folks about what behavior falls in what category just to trick folks into treating folks the way you would prefer. is sort of foolish — as there is ambiguity in the case of addiction itself — not just at the boundary.

    Also there is a gigantic contradiction here in terms of interests — if you want to spend $10K on every patient with depression to get an fMRI — so you can measure the depression with your eyes — we could probably go ahead and do that. Or we could stick to some questions that are reasonably accurate enough. You decide — either we waste a lot of money on unneccessary testing so we have a “real disease” or we stick to the status quo.

  • EH

    To Caledon:
    I’m trying to understand you’re argument. You seem to make a couple of claims. Forgive me if I am misconstruing you. If you like, I can show where I’m getting this information from.

    1) Psychiatry is a pseudo-medical field, as opposed to neurology, which is a real medical field. If something is understood at any sort of scientific level, it is moved from psychology to neurology.
    2) A scientific, mechanistic understanding of a disease is necessary for it to be considered an actual disease.
    3) The fact that we haven’t yet found a unified physiologic mechanism for many mental illnesses is sufficient evidence to discount the possibility of there being one.

    These claims conflict with my experience as a medical student. You account for this by making a distinction between medically defined illnesses versus real illnesses. Now, as best as I can tell, a medically defined illness refers to a cluster of statistically associated symptoms (as judged by clinical evidence) which may or may not respond in a statistically predictable way to treatment (as determined by clinical evidence), be it counseling or statins or appendectomy. A mechanistic understanding of the disease and/or treatment process is irrelevant. We don’t precisely understand why lupus patients develop the cluster of symptoms that they do. Nor do we understand clearly why bipolar patients develop their symptom clusters. We do know that various treatments (such as rituximab and lithium) will result in an improvement in their symptoms. Perhaps the only differentiating factor between a medical illness as I’ve defined it and a “real” illness would be patient/societal attitudes as to whether a given symptom constellation is a good thing (i.e. whether it should be treated). This applies to physical as well as psychiatric illness (consider deafness among deaf people).

    As for my own experience is neurology versus psychiatry. Neurology generally deals with localizable neurological defects; psychiatry generally deals with behavioral defects, which in the materialistic theory of medicine translates to generally non-localizable defects. If it is discovered tomorrow that chronic depression, in most people, is caused by a slightly different shape in serotonin transporter X, neurologists won’t start seeing them. Arguing that psychiatrists shouldn’t treat neurological disorders just because neurologists look at neurons is equivalent, in my mind, to arguing that rheumatologists shouldn’t treat lupus because it’s ultimately an immunological disease and not, at its heart, a disease of the joints.

  • http://www.ciphergoth.org/ Paul Crowley

    Caledonian: just as a data point, I can’t work out what you’re on about either.

  • Douglas Knight

    Lara Foster,
    Re: your first comment, which is based on your experience as a medical student. Medical school lectures may not have much relation to actually existing diagnosis. Predictive claims about diagnosis in the wild are great, but that could be just, say, severity, that is the real meaning of the diagnosis. (I make no claim about whether C said anything, let alone anything relevant to this.)

    I might say similar things to EH, but neurology seems like a field in which people could be doing what they are saying (though I doubt it), while it seems extremely implausible that psychiatrist and psychologists are not making use of tacit knowledge, of which they may or may not think they can articulate.