By Szasz, Thomas
Freeman , Vol. 57, No. 10
In my October column I discussed the concept of medicalization and its role in modern societies. In this column I propose to answer the question: How are we to understand the contemporary confusion about -what counts as a disease?
Medical classification-the linguistic-conceptual ordering of phenomena we call "diseases" and of the interventions we call "treatments"-is a human activity, governed by human interests. In the United States today, the forces of medicalization rule virtually unopposed, indeed unrecognized for the economic, moral, and political interests they represent. Our drug policies are illustrative. For millennia, the regulation of drug use was a matter of self-control, custom, religion, and law. In part, this is still the case. More importantly, however, drug use is regulated by laws and ostensibly scientific "facts," exemplified by a broadly based drug prohibition consisting of prescription laws and criminalization of the trade in many drugs, such as opiates, cocaine, and marijuana. This is drug medicalization from above. Drug medicalization from below is pursued no less zealously by individuals who, while ostensibly opposed to our drug laws, promote so-called medical-marijuana initiatives, physician-assisted suicide, and similar schemes. The result is loss of self-ownership and the right to self-medication-the classical liberal/libertarian perspective on drug use.
Because the mind is not an object like the body, it is a mistake to apply the predicate disease to it. Hence, as I asserted half a century ago, the "diseased mind" is a metaphor, a mistake, a myth.
Actually, this idea is not as novel as it might seem. Emil Kraepelin (1856-1926), the creator of the first modern psychiatric nosology, acknowledged the fundamental analytic truth that there are no mental illnesses. In his classic, Lectures on Clinical Psychiatry (1901), he stated: "The subject of the following course of lectures will be the Science of Psychiatry, which, as its name [Seelenheilkunde] implies, is that of the treatment of mental disease. It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased." Half a century earlier, the Viennese psychiatrist Ernst von Feuchtersieben (1806-1849) explicitly emphasized the analogicalmetaphorical character of mental illnesses: "The maladies of the spirit alone, in abstracto, that is, error and sin, can be called diseases of the mind only per analogiam. They come not within the jurisdiction of the physician, but that of the teacher or clergyman, who again are called physicians of the mind/soul only per analogiam."
The transformation of religious explanations and controls of behavior into medical explanations and controls of behavior is one of the momentous consequences of the Enlightenment. The waning power of religion and the Church and the waxing power of science and the State are manifested, among other things, by the political control of medical practice and the drug laws that deny access to the layperson to drugs (except those classified as over-the-counter).To legally obtain or possess a "prescription drug," the layperson must establish a professional relationship with a licensed physician and receive a diagnosis for an illness; that is, he must be a patient who suffers from a proven or putative illness. For example, to receive a sleeping pill, the person must "suffer from insomnia." This charade contributes mightily to the medicalization rampant in our society. In turn, medicalization is mindlessly equated, especially by the cognoscenti, with scientific, moral, and social progress, and contributes further to its popularity.
Although medicalization encompasses more than psychiatry, we must be clear about one thing: Psychiatry is medicalization through and through. Whatever aspect of psychiatry psychiatrists claim is not medicalization, is not medicalization only if it deals with proven disease, in which case it belongs to neurology, neuroanatomy, neurophysiology, neurochemistry, neuropharmacology, or neurosurgery, not psychiatry. …