Bryan needs to explain why someone with schizophrenia who is in the midst of a psychotic episode is fundamentally different than someone in the midst of an epileptic seizure shaking on the floor, in the sense than in both cases the person's brain is in a highly abnormal state which causes various behaviors we wouldn't normally expect. Does the epileptic have a preference for flailing around on the ground? Obviously not.
One central problem (as I see it) is Bryan's belief in free will, which totally clouds his entire analysis. Many of the conditions we are talking about systematically warp and distort peoples' decision-making and judgment. Viewing the mentally ill as just making different choices based on different preferences is the kind of things I would expect to hear from someone who has never actually met a severely mentally ill person in their lives, which I suspect may actually be the case for Bryan (but that's just my suspicion from the way he talks about this stuff).
Martin, I think you missed the word "most." Let's ignore the possibility that schizophrenia might be brought on by environment. And let's ignore that maybe the hypothesis addresses something somewhat less than 50% of mental illness. And while we are at it we might as well ignore that some people are probably more susceptible to some or many mental illnesses. Given that, what percent of mental illness is more like epilepsy and what percent is more like depression? Personally, I'd focus this discussion on ones more like depression.
quote "Bryan needs to explain why someone with schizophrenia who is in the midst of a psychotic episode is fundamentally different than someone in the midst of an epileptic seizure shaking on the floor, in the sense than in both cases the person's brain is in a highly abnormal state which causes various behaviors we wouldn't normally expect. Does the epileptic have a preference for flailing around on the ground? Obviously not."
Both scenarios you describe are of people with physical illnesses. Therefore the epileptic and the schizophrenic you describe are not fundamentally different in any way. If someone has a disease of the brain, i.e., an atypical or "abnormal" brain, then they have a physical illness, not a mental illness.
Whether you think people with physical illnesses should have treatment forced upon them or not is a separate question. I suspect B.Caplan and T.Szasz would not force people to treat their physical illnesses. But that is not the topic at hand.
The topic at hand is about "mental illness" and whether it is or is not based on physical abnormalities of the body like the name implies. We do not use physical abnormalities of the brain to diagnose schizophrenia, depression, or ADHD. If we did, these would be brain illnesses. Instead, we diagnose "mental illnesses" based on people's behaviour. In other words, the decisions people make based on their preferences.
If people's behaviour is socially disapproved of or atypical, these people are "diagnosed" with "mental illnesses". The word illness is there to add medical effect where it does not exist. And this medical effect carries with it the authority to subjugate people to treatment which they do not want.
We force schizophrenics to undergo treatment without their consent. We do not force epileptics to do the same. People with physical diseases, like epilepsy, cancer, or broken bones, can choose whether to accept or decline medical treatment. Often, people with mental illnesses cannot.
A diagnosis is the identification of the nature and cause of a certain phenomenon, often in the context of medical or psychological conditions. Specifically, the term is often used to determine which disease or condition explains a person's symptoms and signs.
A psychological diagnosis of mental illness is nothing more than a moral judgement which states that someone else's behaviour is immoral. And because behaviour is made up of the decisions one makes based on their preferences, mental illnesses falsely portray people's preferences as disease. Diseases for which they must seek treatment against their will. Hence, mental illness is a tool of social control.
I think this links up with Lott’s comment below. What you’re essentially saying is that for certain “choices” (socially disapproved preferences) the person should not be allowed to do so because it is not in their best interest regardless of what they will, because what they will is objectively wrong.
It’s paternalistic and anti-libertarian, but maybe it’s justice in some cases.
Saying “the outside judge could get it wrong” is true but that’s an argument for caution, not for letting the mentally I’ll run wild because your afraid of being judgemental.
Every dispute about this stuff will boil down to a question of "the good," and the people in this conversation (you, Kling, Caplan, SA) have no common ground to discuss that and reach anything like a persuasive conclusion.
Good post. Caplan's framing of these issues is way too reductive in my opinion. I think the big issue here is executive function. Many people with those "preferences" Caplan describes wish they had different preferences. Their conscious mind wants one thing but they find themselves behaving in a way that thwarts those conscious goals or desires. A gun to the head can certainly help someone like that override compulsions, but wouldn't it also be nice if they could do that for themselves, without extreme duress?
A person who wants to change her self-defeating desires may enter treatment voluntarily. A key issue in Arnold's post is forced treatment.
Separately, a case might be made for subsidies for voluntary treatment — if such subsidies might be cost-effective and/or humane.
If the person engages in behaviors that harm others (crime, public nuisance), and credibly makes a case that she wishes otherwise but finds herself backsliding, then law officers may offer her a choice between treatment and confinement.
An additional note that I think adds to this framework: generally, treatment can make sense when someone’s immediate preferences differ from *their own* long-term preferences.
So someone on fentanyl/etc might have a strong preference for murder in the moment, but if you surveyed the person at many different points in their life, the person over time, as a whole, would probably choose treatment such that they would never be on fentanyl or have that momentary preference to murder to begin with.
When we consider victimless preferences like trans, the question (perhaps not easy to answer) should also be to ask what their long-term self wants.
1) Re: "the philosophically fraught issue of the extent to which others are entitled to force such treatment on such an individual."
Your 3 examples — Brinton, the unruly child in school, & Neely — are instances of wrongdoers (indeed, chronic wrongdoers). Coercion would be justified on several grounds:
* Retribution (to restore a balance).
• Incapacitation (to prevent the wrongdoer from harming innocent persons again).
• Individual deterrence (to convince the wrongdoer that it would be imprudent to offend again).
• General deterrence (to caution observers that it would be imprudent to engage in such wrongdoing).
• Rehabilitation (to change the wrongdoer's preferences for the better, from a social point of view).
• Social communication (to express to the wrongdoer and to observers, 'This is how wrong what you did is.')
Compare "treatment" and these standard justifications of coercion (listed above):
Treatment might be an instance of Incapacitation, if, say, a drug blocks the unlawful behavior.
Or treatment might be an instance of individual deterrence, if the treatment — say, electroshock therapy or a very unpleasant drug — induces aversion (operant conditioning) in the offender, causing her to refrain from the unlawful behavior that she now deeply fears will trigger new treatment.
Or treatment might be an instance of rehabilitation, if, say, talk therapy changes the offender's beliefs and preferences away from harming others.
Or treatment might mainly be social communication, perhaps cloaked in one or another of the other rationales.
The point is that, in Arnold's 3 examples, the putatively mentally ill person has engaged in wrongdoing — theft, public nuisance, aggression — that harms others. Harms to others are what justify coercion.
If a person, who is putatively mentally ill, hasn't engaged in wrongdoing — particularly, chronic wrongdoing — that harms others, then coercion (incarceration and/or forced treatment) isn't justified. What is philosophically fraught here?
2) Re: "In the case of ADHD, I do not believe that anyone other than the child’s parents should actually force the child to go on medication. But I think you have to allow a school to tell parents that the child cannot continue to attend without obtaining treatment."
Given the astonishingly high prevalence of "ADHD" diagnosis among male schoolchildren, the better part of wisdom would be allow much more flexible education; education that reasonably lets boys be boys. A more fundamental diagnosis of "institutional illness" applies to the school system!
I think (2) is an absolute NO for libertarians because it violates the sovereignty of a person -- even a child or "crazy" person -- to refuse any technological intrusion into his mind.
But I would not have any problem with locking up either the luggage thief or Jordan Neely and offering each of them early release *if* he accepts treatment *and* the doctors come to believe it has worked.
Caplan also believes that parents have little influence on their children (beyond the genetic contribution). As if parents have no role in providing the care, structure, education, and moral values of their children....and as if parents and family life have no influence on the incidence of mental illness and behavioral problems in children. Libertarianism has little to say about family life, and therefore IMO has little to say about how we should live.
I'm much more skeptical than you of how effective "treatment" is. Robyn Dawes' "House of Cards" discussed how his colleagues in psychology/psychiatry ignored their own research and persisted in believing that their experience gave them insight when it did not, and that students were just as effective as experienced professionals in treating people. Psychology has more recently been the epicenter of the replication crisis (Scott Alexander on 5-HTTLPR* is worth reading). Physical medicine itself was pseudoscientific crankery until basically the 20th century and is still not nearly scientific enough, but psychology had pseudoscientists like Freud & Jung as its leaders much more recently and is particularly prone to political distortion. Greg Cochran would say that it's a discipline full of people who WANT to get the wrong answer, lacking in anyone interested & capable of "carving reality at the joints" (as Eliezer Yudkowsky would put it).
If someone sprains their ankle, they walk with a limp to take pressure off the injury. I suspect if I offered them a billion dollars to walk without a limp, most people would find a way. Yet there is actual tissue damage so the limp is not merely a preference.
I think if we had an MRI-like machine that could detect the “tissue damage” in the brain that leads to mental illnesses (or the lack thereof), it would be obvious Bryan is wrong in many cases (but also that he’s right in some). But we don’t. So we’re left to speculate whether there is actual damage or if it’s only imagined.
These examples are great and lead to Lenin's important question "What is to be done?"
Bryan totally fails to answer this question, instead "the game Caplan is playing with definitions" is an attempt to avoid the question, or distract away from it.
Innocent people need to be protected from criminals, those whose behavior has been legally defined as against the law. Whether a thief steals because he's mentally ill or merely wants the thrills is less important than socially asserting that such bad behavior is unacceptable - that some social coercion is acceptable and just (or at least not unjust). Similarly with a crazy guy who sometimes punches innocents on a subway but more often is threatening to do, whose (mentally ill???) "free will" chooses to avoid treatment or confinement.
The well-behaved kids shouldn't have to put up with badly behaving kids, but that's also a huge social mistreatment -- setting up a school system for good female behavior and punishing males for being lousy females. Tho even in an "ideal" school, what to do about bad behaving students remains an issue, whether it's due to an illness or merely preference.
Incentives should be attempted first, then treatment, then protection of the innocent thru confinement.
Funnily enough we did an episode of our show on “what if marvel was real?” Talking about the implications of forced treatment with respect to super powered heroes and villains from the 1960s. We touched on this exact topic! Likely not relevant for most followers here, but for the overlap of comic book lovers and this blog post it would be a perfect fit...
Will Rogers long ago said something along these lines: Everyone Is ignorant only on different subjects. This clearly applies to B Caplan. He is out of his lane regarding this subject matter.
I have many hesitations regarding forced treatment, starting with lobotomies, induced seizures, bloodletting, insulin comas, etc but might also include electric shock, drug side affects, etc. Who knows what we are doing today that will be looked at as abhorrent in the future. That said, increased treatment as an alternative to long-term confinement might have some merit.
Bryan needs to explain why someone with schizophrenia who is in the midst of a psychotic episode is fundamentally different than someone in the midst of an epileptic seizure shaking on the floor, in the sense than in both cases the person's brain is in a highly abnormal state which causes various behaviors we wouldn't normally expect. Does the epileptic have a preference for flailing around on the ground? Obviously not.
One central problem (as I see it) is Bryan's belief in free will, which totally clouds his entire analysis. Many of the conditions we are talking about systematically warp and distort peoples' decision-making and judgment. Viewing the mentally ill as just making different choices based on different preferences is the kind of things I would expect to hear from someone who has never actually met a severely mentally ill person in their lives, which I suspect may actually be the case for Bryan (but that's just my suspicion from the way he talks about this stuff).
Martin, I think you missed the word "most." Let's ignore the possibility that schizophrenia might be brought on by environment. And let's ignore that maybe the hypothesis addresses something somewhat less than 50% of mental illness. And while we are at it we might as well ignore that some people are probably more susceptible to some or many mental illnesses. Given that, what percent of mental illness is more like epilepsy and what percent is more like depression? Personally, I'd focus this discussion on ones more like depression.
quote "Bryan needs to explain why someone with schizophrenia who is in the midst of a psychotic episode is fundamentally different than someone in the midst of an epileptic seizure shaking on the floor, in the sense than in both cases the person's brain is in a highly abnormal state which causes various behaviors we wouldn't normally expect. Does the epileptic have a preference for flailing around on the ground? Obviously not."
Both scenarios you describe are of people with physical illnesses. Therefore the epileptic and the schizophrenic you describe are not fundamentally different in any way. If someone has a disease of the brain, i.e., an atypical or "abnormal" brain, then they have a physical illness, not a mental illness.
Whether you think people with physical illnesses should have treatment forced upon them or not is a separate question. I suspect B.Caplan and T.Szasz would not force people to treat their physical illnesses. But that is not the topic at hand.
The topic at hand is about "mental illness" and whether it is or is not based on physical abnormalities of the body like the name implies. We do not use physical abnormalities of the brain to diagnose schizophrenia, depression, or ADHD. If we did, these would be brain illnesses. Instead, we diagnose "mental illnesses" based on people's behaviour. In other words, the decisions people make based on their preferences.
If people's behaviour is socially disapproved of or atypical, these people are "diagnosed" with "mental illnesses". The word illness is there to add medical effect where it does not exist. And this medical effect carries with it the authority to subjugate people to treatment which they do not want.
We force schizophrenics to undergo treatment without their consent. We do not force epileptics to do the same. People with physical diseases, like epilepsy, cancer, or broken bones, can choose whether to accept or decline medical treatment. Often, people with mental illnesses cannot.
A diagnosis is the identification of the nature and cause of a certain phenomenon, often in the context of medical or psychological conditions. Specifically, the term is often used to determine which disease or condition explains a person's symptoms and signs.
A psychological diagnosis of mental illness is nothing more than a moral judgement which states that someone else's behaviour is immoral. And because behaviour is made up of the decisions one makes based on their preferences, mental illnesses falsely portray people's preferences as disease. Diseases for which they must seek treatment against their will. Hence, mental illness is a tool of social control.
I think this links up with Lott’s comment below. What you’re essentially saying is that for certain “choices” (socially disapproved preferences) the person should not be allowed to do so because it is not in their best interest regardless of what they will, because what they will is objectively wrong.
It’s paternalistic and anti-libertarian, but maybe it’s justice in some cases.
Saying “the outside judge could get it wrong” is true but that’s an argument for caution, not for letting the mentally I’ll run wild because your afraid of being judgemental.
"maybe it’s justice"
Every dispute about this stuff will boil down to a question of "the good," and the people in this conversation (you, Kling, Caplan, SA) have no common ground to discuss that and reach anything like a persuasive conclusion.
Good post. Caplan's framing of these issues is way too reductive in my opinion. I think the big issue here is executive function. Many people with those "preferences" Caplan describes wish they had different preferences. Their conscious mind wants one thing but they find themselves behaving in a way that thwarts those conscious goals or desires. A gun to the head can certainly help someone like that override compulsions, but wouldn't it also be nice if they could do that for themselves, without extreme duress?
Gordon,
A person who wants to change her self-defeating desires may enter treatment voluntarily. A key issue in Arnold's post is forced treatment.
Separately, a case might be made for subsidies for voluntary treatment — if such subsidies might be cost-effective and/or humane.
If the person engages in behaviors that harm others (crime, public nuisance), and credibly makes a case that she wishes otherwise but finds herself backsliding, then law officers may offer her a choice between treatment and confinement.
Great points.
An additional note that I think adds to this framework: generally, treatment can make sense when someone’s immediate preferences differ from *their own* long-term preferences.
So someone on fentanyl/etc might have a strong preference for murder in the moment, but if you surveyed the person at many different points in their life, the person over time, as a whole, would probably choose treatment such that they would never be on fentanyl or have that momentary preference to murder to begin with.
When we consider victimless preferences like trans, the question (perhaps not easy to answer) should also be to ask what their long-term self wants.
1) Re: "the philosophically fraught issue of the extent to which others are entitled to force such treatment on such an individual."
Your 3 examples — Brinton, the unruly child in school, & Neely — are instances of wrongdoers (indeed, chronic wrongdoers). Coercion would be justified on several grounds:
* Retribution (to restore a balance).
• Incapacitation (to prevent the wrongdoer from harming innocent persons again).
• Individual deterrence (to convince the wrongdoer that it would be imprudent to offend again).
• General deterrence (to caution observers that it would be imprudent to engage in such wrongdoing).
• Rehabilitation (to change the wrongdoer's preferences for the better, from a social point of view).
• Social communication (to express to the wrongdoer and to observers, 'This is how wrong what you did is.')
Compare "treatment" and these standard justifications of coercion (listed above):
Treatment might be an instance of Incapacitation, if, say, a drug blocks the unlawful behavior.
Or treatment might be an instance of individual deterrence, if the treatment — say, electroshock therapy or a very unpleasant drug — induces aversion (operant conditioning) in the offender, causing her to refrain from the unlawful behavior that she now deeply fears will trigger new treatment.
Or treatment might be an instance of rehabilitation, if, say, talk therapy changes the offender's beliefs and preferences away from harming others.
Or treatment might mainly be social communication, perhaps cloaked in one or another of the other rationales.
The point is that, in Arnold's 3 examples, the putatively mentally ill person has engaged in wrongdoing — theft, public nuisance, aggression — that harms others. Harms to others are what justify coercion.
If a person, who is putatively mentally ill, hasn't engaged in wrongdoing — particularly, chronic wrongdoing — that harms others, then coercion (incarceration and/or forced treatment) isn't justified. What is philosophically fraught here?
2) Re: "In the case of ADHD, I do not believe that anyone other than the child’s parents should actually force the child to go on medication. But I think you have to allow a school to tell parents that the child cannot continue to attend without obtaining treatment."
Given the astonishingly high prevalence of "ADHD" diagnosis among male schoolchildren, the better part of wisdom would be allow much more flexible education; education that reasonably lets boys be boys. A more fundamental diagnosis of "institutional illness" applies to the school system!
I think (2) is an absolute NO for libertarians because it violates the sovereignty of a person -- even a child or "crazy" person -- to refuse any technological intrusion into his mind.
But I would not have any problem with locking up either the luggage thief or Jordan Neely and offering each of them early release *if* he accepts treatment *and* the doctors come to believe it has worked.
Caplan also believes that parents have little influence on their children (beyond the genetic contribution). As if parents have no role in providing the care, structure, education, and moral values of their children....and as if parents and family life have no influence on the incidence of mental illness and behavioral problems in children. Libertarianism has little to say about family life, and therefore IMO has little to say about how we should live.
Oops. It seems he has views that are rather contradictory. ...unless he thinks parents simply don't have skills to make a difference.
I, too, doubt that Bryan Caplan has ever had anything to do with serious mental illness.
Will be interesting to see what (if anything) Freddie deBoer has to say about Caplan's piece.
Check the comments.
Comments at Caplan.
This is a needed article for the world and for me personally as I work in the school system.
I'm much more skeptical than you of how effective "treatment" is. Robyn Dawes' "House of Cards" discussed how his colleagues in psychology/psychiatry ignored their own research and persisted in believing that their experience gave them insight when it did not, and that students were just as effective as experienced professionals in treating people. Psychology has more recently been the epicenter of the replication crisis (Scott Alexander on 5-HTTLPR* is worth reading). Physical medicine itself was pseudoscientific crankery until basically the 20th century and is still not nearly scientific enough, but psychology had pseudoscientists like Freud & Jung as its leaders much more recently and is particularly prone to political distortion. Greg Cochran would say that it's a discipline full of people who WANT to get the wrong answer, lacking in anyone interested & capable of "carving reality at the joints" (as Eliezer Yudkowsky would put it).
* https://slatestarcodex.com/2019/05/07/5-httlpr-a-pointed-review/
If someone sprains their ankle, they walk with a limp to take pressure off the injury. I suspect if I offered them a billion dollars to walk without a limp, most people would find a way. Yet there is actual tissue damage so the limp is not merely a preference.
I think if we had an MRI-like machine that could detect the “tissue damage” in the brain that leads to mental illnesses (or the lack thereof), it would be obvious Bryan is wrong in many cases (but also that he’s right in some). But we don’t. So we’re left to speculate whether there is actual damage or if it’s only imagined.
These examples are great and lead to Lenin's important question "What is to be done?"
Bryan totally fails to answer this question, instead "the game Caplan is playing with definitions" is an attempt to avoid the question, or distract away from it.
Innocent people need to be protected from criminals, those whose behavior has been legally defined as against the law. Whether a thief steals because he's mentally ill or merely wants the thrills is less important than socially asserting that such bad behavior is unacceptable - that some social coercion is acceptable and just (or at least not unjust). Similarly with a crazy guy who sometimes punches innocents on a subway but more often is threatening to do, whose (mentally ill???) "free will" chooses to avoid treatment or confinement.
The well-behaved kids shouldn't have to put up with badly behaving kids, but that's also a huge social mistreatment -- setting up a school system for good female behavior and punishing males for being lousy females. Tho even in an "ideal" school, what to do about bad behaving students remains an issue, whether it's due to an illness or merely preference.
Incentives should be attempted first, then treatment, then protection of the innocent thru confinement.
Neely had committed several serious crimes before his death.
There might be edge cases where we consider depriving thus far innocent crazy people of their liberti. Neely is not one of them.
Funnily enough we did an episode of our show on “what if marvel was real?” Talking about the implications of forced treatment with respect to super powered heroes and villains from the 1960s. We touched on this exact topic! Likely not relevant for most followers here, but for the overlap of comic book lovers and this blog post it would be a perfect fit...
https://www.superserious616.com/p/e201-lobotomy-or-death-tales-to-astonish
Will Rogers long ago said something along these lines: Everyone Is ignorant only on different subjects. This clearly applies to B Caplan. He is out of his lane regarding this subject matter.
I have many hesitations regarding forced treatment, starting with lobotomies, induced seizures, bloodletting, insulin comas, etc but might also include electric shock, drug side affects, etc. Who knows what we are doing today that will be looked at as abhorrent in the future. That said, increased treatment as an alternative to long-term confinement might have some merit.