Niall McLaren

PHILOSOPHY FOR MEDICAL STUDENTS - CHAPTER 4

Mon, 21 Mar 2011 12:39:59 +0000

Philosophy and Science.

Psychoanalysts claimed their theories were scientific. Marxists claimed their theories were scientific. Behaviorists claimed their theories were scientific. All those doctrines have vanished like the morning mist. When the leucotomy was announced (lobotomy, if you must), it was proclaimed as a gigantic breakthrough in the science of mental disorder. It has since gone the way of leeches, which were once thought to represent a science of therapeutics. Nowadays, we have domestic science, political science, sports science, social science, military science, retail science, management science and so on. The Nazis even had a racial science. What is this strange thing called science that everybody wants a bit of the action? What is its attraction, what is its power over people? When we look at all the dreadful things that have been done in the name of science, you really would wonder why anybody would bother, but still they come.

We should stand a long way back and have a cool, unhurried look at it just to try and sort it out. Perhaps we could start by finding out what is common to all fields that claim to be science, and then maybe look at what scientists do, how they work out what is good science and what is bad, and so on. By doing that, we would be looking more at the form of any science rather than its content. Taking a long, cool, distant look at the form of science is known as metascience, but we usually refer to it as the philosophy of science. The philosophy of science is not a science in its own right, but there could be several philosophies of science, in which case, by comparing them, we would end up with a meta-metascience.

In the introduction to this essay, I suggested you should read at least a short history of Western science, and preferably a longer history of human science. The Western story starts, once again, with those restless Greeks, who separated the abstract study of things from technologies such as metal-working and ship-building. Ballistics, as the study of moving objects, was separated from the art of building catapults for war. They focused their efforts on mathematics but weren’t averse to a bit of biology as well. The ancient idea of the brain as the body’s cooling system is probably Greek, as is the idea of four ‘humors’ or fluids as the basis of life (similar ideas pop up in other cultures, of course; theorizing about the unknown is a human attribute, not Hellenic). Other essential Greek ideas include concepts of evolution, of atomic theory and of materialism.

However, the notion of science as something you do by looking at the world took a severe beating from the spread of the central idea behind the “religions of the Book,” namely that the nature of the universe was fixed at its creation and all necessary information about the universe was to be found in “The Book.” By contrast, for the Greeks, religion was a relatively private matter with no fixed dogma and no centralized priesthood. Neighbors could practice quite different religious beliefs just because they always had, or because they came from different regions. This meant that there were no squads of “thought police” peering over everybody’s shoulders and no neighborhood spies, as there were in most of the major religions. To a large extent, the spread of religion homogenized thought, imposing a uniform belief system on all under its sway. As institutionalized Christianity arose in the West, so independent thought and enquiry declined. The entire Western world, from the far eastern borders of what became Russia down to the Eastern (Greek) Christian lands of the Byzantine Empire, and across to the shores of the Atlantic, fell into a state of suspended intellectual animation. Upholding the Divine Mystery was more important than penetrating it.

During these “Dark Ages” (they were only dark in the west, not in the Eastern Empires or the Caliphate), if anybody had any concern for the phenomena of the world, he was restricted in the evidence he could use to answer his questions (i.e. to the Bible and the classic Greek texts) and to the form of his deliberations. More or less the only way he could advance knowledge was by use of the process of deductive reasoning, of which the Aristotelian syllogism stood as the exemplar. Deduction is a particular form of reasoning or inference, in which the conclusions of the argument are contained within the premises. That is, deduction leads to one answer, and one only, because the answer could not be otherwise. For example:

This animal is a dog;
All dogs have four legs; Therefore:
This animal has four legs.

(It is written with the second premise underlined and ‘therefore’ is usually omitted).

In the act or process of deduction, the items of information in the premises are joined in such a way as to lead to a conclusion which is not stated in the premises. The conclusion is both novel and inevitably correct.

This is how things remained for the better part of a millennium and a half until, in 1453, the expanding empire of the Muslim Ottoman Turks finally conquered Byzantium. Actually, it wasn’t much of an effort on their behalf. The Eastern Empire at that stage was corrupt and effete and simply slid gracefully under Turkish control. However, many of the libraries of the Empire were emptied and shipped west to save them from the new rulers, who had very strict ideas on idolatory, i.e. the worship of physical representations. So the west suddenly became home to ancient texts from classical Greek times that had long been forgotten. This happened at the time of rapid commercial expansion in the western kingdoms due, as much as anything, to the development of ocean-going vessels and better methods of preserving food. For example, in 1492, Columbus reached the New World while, in 1498, Vasco da Gama rounded the Cape of Good Hope and reached India. Money, technology and ideas began the intellectual ferment in Europe known as the Renaissance and, in this setting, scientific thinking broke free of the restraint of the Church. That is, people who wanted to know about the natural world were gripped by the revolutionary idea that they should actually look at it, as distinct from the old idea of reading “the authorities,” i.e. the Bible and the ancient texts.

Throughout the sixteenth century, there were rapid changes as people realized there were, for example, many more lands and peoples, and vastly more plants and animals, than their teachers had believed. The first of the systematic observations placing the sun at the center of the universe were undertaken in northern Europe, and were soon reinforced by Galileo and his bothersome telescope. In England, the politically influential Sir Francis Bacon (1561-1626) devised a method for investigating the natural world. Now, generally known as Baconian Induction, this consisted of amassing more and more detailed lists of observations and drawing general laws of nature from them. Induction is another form of reasoning but it differs from deduction because which the conclusion is not contained in the premises. An inductive conclusion is based, not on watertight reasoning, but on limited observations of the world. The student of nature attempts to draw general laws of nature based on a limited set of observations, i.e. to make predictions about future incidents based on an imperfect or incomplete data base. This is the case of the “Xmas turkey.” A young turkey heard rumors that, one day, the sun would rise but would not set so, each morning, he awoke wondering if this would be that terrible day. One day, he decided that he had enough evidence to say that, yes, the sun inevitably rose and set each day and that this represented a general law of the universe. He rushed around telling all the other turkeys who were greatly relieved. Unfortunately for them, the date was December 24th.

Baconian induction held sway for a long time but its deficiencies, and those of deduction, gradually became more apparent. For example, in the case of the dog, people started to wonder how we could be sure that this was a dog, and how anybody could guarantee that all dogs had four legs; was a three-legged dog not a dog? That is, they didn’t worry so much about the syllogism itself, because that was considered impeccable, but about the nature of the premises. If there was one three legged dog in the world, then the syllogism, and all of the structure of science that it supported, broke down. Bacon himself had listed four faults that stood in the way of perfect general laws. He called these the Four Idols, the first of which was the tendency of humans to see order where there was none, and was due to people allowing their preconceptions of the nature of things to dominate their observations. The second was their tendency to interpret things in line with their personalities, and their likes and dislikes (not so different from the first). The third was due to confusion in the use of language, where different meanings of words influenced the selection of evidence. The last was a direct challenge to the authority of the church, in that people allowed academic dogma to influence their observations and questions. We would now see these tendencies as examples of cognitive bias, how people habitually interpret neutral or novel events in accordance with their preconceptions.

The problem for Baconian induction is just that its data set is incomplete. If this were not so, if it were complete, then the natural philosopher (later, the scientist) would be able to formulate the precise law of nature without making a leap of faith. Needless to say, the universe isn’t quite so obliging. Practically everything we do depends on our perception of what is likely to happen, based on our experience of what has gone before, but it can go wrong. Over the centuries, various people have tried to formulate rules for induction so that it can be as reliable as deduction but they have all failed. If we could set up the process of induction such that it could be completely reliable, then it would either not be empirical or it would not be based on incomplete data sets. Either way, it wouldn’t be induction.

One of the world’s greatest scientists, Charles Darwin, used induction but was very aware of its deficiencies, so he amassed huge empirical support for all of his work. For the open-minded, the mass of supportive information standing behind the modern Darwinian model is now overwhelming but that is not the problem with evolution. The problem is not the people who are perhaps keen to be convinced but those who argue (justifiably): “You have not accumulated incontrovertible support; therefore, I do not feel compelled by overwhelming argument to accept your case.” Now the problem here is that this is disingenuous, meaning insincere, because the evidence is in support of a theory, and not a formal rule of nature. Theories, by definition, are never complete, and the evidence for them is necessarily full of gaps. Take another example, the theory of gravity. This is strongly supported by a wide range of evidence from many sources, but it is a theory nonetheless because it is still an incomplete explanation of the phenomena. Given that it is not overwhelmingly supported, would the people who reject evolution, because it is an incomplete theory, also reject the theory of gravity because it is incomplete? Would they, for example, be prepared to buy shares in my company which hopes to patent the world’s first anti-gravity machine? Just think how profitable it would be so join the queue, friends, and have your money ready. No? Well, how come you buy shares in creationism?

This leads us to the critically important question of the nature of a theory. At this point, it would be easier for me to finish this chapter and go to bed but so much depends on this question that we will have to soldier on. In brief, a theory is an intellectual exercise designed to make sense out of our incomplete set of observations of the natural universe. Humans are curious creatures; we need to know what is going on behind the scenes. On the one hand, we have a set of observations; on the other, we want to know why just that set of observations holds forth and not another, i.e. what is the hidden mechanism generating just those observations and no other? For example, in northern Europe hundreds of years ago, it was noticed that swallows, which skim the water of ponds and rivers, disappear during winter. Somebody decided that they must spend the cold season asleep in the bottom of the ponds, protected from the storms by the ice above them. That is a theory, a postulated mechanism to explain the observations. A more sensible alternative would have been that they spent their winters roosting in the thatched rooves of the peasants’ huts. However, nobody ever found them there, and they had no way of searching the bottoms of the frozen ponds (absence of evidence, you see), so that idea won. Why did nobody suggest they flew thousands of kilometers each year to warmer climates? Probably because nobody presumed they were strong enough to fly those enormous distances in the limited time available. We now know that they rely on storm fronts for assistance but nobody knew about storm fronts in those days.

The principle behind any theory is that it is a suggestion (hypothesis, in science-talk) of an unseen causative mechanism which is one dimension removed from the observations themselves, and for which there is incomplete or circumstantial evidence only. A scientific theory is one cast in the tradition of western materialist science, i.e. the unseen mechanism must be couched in terms of the laws of the time-space continuum and must positively exclude any and all supernatural elements. In addition, there must be no unexplained gaps in the causative chain that are not potentially capable of explanation within the laws of physics. Thus, the idea of swallows spending their winters cuddled in little mud nests in the bottom of ponds was a perfectly rational, scientific theory. It just happened to be wrong (cf. HL Mencken: “For every complex problem, there is an answer that is clear, simple, and wrong”).

This leads us to the next question: how do we choose between theories? Given two suggested mechanisms which seem to explain the observations equally well (sleep in the mud vs. fly south), which should we choose? Well, despite anything the relativists or post-modernists might like to say on the topic, it is not a matter of flipping a coin. The whole point about being a scientist, as Bacon recognized, is to separate human prejudice and foibles from the serious business of coming up with the correct explanation of things as they are. Here, we will jump several hundred years of confusing philosophy, to come to the late nineteenth century and the early part of the twentieth. This was another period of remarkable intellectual development, in so many fields: mathematics, chemistry, physics, biology, astronomy, geology, archeology, anthropology and so on. While the progress of physics and chemistry affected most people’s lives, they were not especially contentious because most people neither knew nor cared about the atomic theory of matter, or whether the ether existed. It is true there were many theories advanced at the time which flowered briefly and then vanished without a trace. These days, with the advantage of hindsight, we would class many of them as crackpot notions but, at the time, they seemed to make sense (to illustrate, see how many modern theories you can find that will turn out to be loopy; it isn’t that easy).

As long as scientists regularly served up bigger steel ships or improved telegraphs, nobody was much concerned with their arcane theories. However, in one area, this was not the case: Darwin’s theory of evolution. This provoked the most ferocious controversy, one which is still raging a hundred and fifty years later. Darwin’s theory was very unusual. In the first place, it was based on massive and overwhelmingly detailed observations. Nobody could argue against his empirical observations, because they were nearly faultless. In this sense, he was a very good inductionist in the Baconian tradition. However, his observations went much further. They supported a theoretical account of speciation which, firstly, was of no direct value to anybody (not like the huge industries supported by chemistry), and second, it drove a stake directly into the heart of human self-perception. Not only was this perception derived from Church authority, but it also served to reinforce that authority.

At the end of the nineteenth century and long after, Darwin’s work was widely accepted in the scientific community but remained under sustained attack outside (see the celebrated “Scopes Monkey Trials” of 1925, in the US state of Tennessee, in which a school teacher, John Scopes, was charged with teaching evolutionary theory, which was then illegal. Fundamentalists supported the prosecution on the basis that the revealed word of God, as written in the Bible, trumped any and all human knowledge). Slowly, it dawned on evolutionists that, no matter how much evidence they found to support Darwin’s revolutionary idea, their opponents could always find fault, which allowed them to reject it.

At about the same time, in Vienna and other mittel-Europa cities, philosophers were increasingly concerned with the nature of theories themselves, and how to distinguish good theories from bad. In briefest terms (a rule the philosophers themselves never followed), a good theory was one that imparted knowledge. Specifically, the propositions that comprised that knowledge had meaning insofar as they could be verified. The principle of verification stated that the meaning of any sentence just is its method of verification, which quickly sorted all possible sentences into two groups. On the one hand, there was the group of sentences which could be verified by empirical observation and, on the other, there was all the rest. “All the rest” amounted to the very large group of propositions or claims which had no empirical support, namely, the very large part of human knowledge which was considered metaphysical. The difference between scientific and metaphysical propositions was just this: metaphysical claims could not be verified but were accepted as an article of faith. They were therefore dismissed as meaningless by the group, who became known as the Vienna Circle of logical positivists (don’t ask). They were fairly sure that this distinction was of real value in defining science.

It wasn’t long before a younger Viennese philosopher who was not part of the group raised an objection. Karl Popper realized that some claims, put forward as perfectly sensible solutions to unsolved problems, were not amenable to verification, which meant that, in the tight sense of the Vienna Circle, they were not scientific claims at all This did not strike him as very sensible because, even at that late stage, Darwin’s theory of evolution really could not be verified. Sure, there was evidence supporting it but, for every item of supportive evidence, there was at least one, if not a deluge, of counter-claims: just ask the knuckle-dragging fundamentalists who were rampaging around in Tennessee schools, making sure the little dears didn’t learn anything too modern. The problem was partly practical, that the process of evolution took place over eons, and also partly theoretical, in that there was no mechanism known that could account for the genetic changes on which it depended. Impasse. That meant that, by the strict regime of the logical positivists, evolution was not a scientific theory. Popper’s idea was that the criterion distinguishing science from non-science could not be just the method of verification of its claims, but that a theory must be open to verification in principle.

Thus, a theory such as “angels exist” was clearly open to verification and, therefore, was itself scientific. This troubled Popper greatly. The statement “angels exist” could only be verified by catching an angel but, if they were half the beings they were supposed to be, nobody would ever be able to catch one. He therefore excluded what he called “existential statements” from the field of science. They were of a form that may have no end. Theories, he argued, had to be in a form that allowed us to test them before we have done much work on them. However, a test which was positive provided no solid evidence because we would not be able to prove that it was a general truth about the universe. That is, we would never know whether the evidence was just a special case – or even random luck – rather than a general truth. On the other hand, a theory that failed a test just once told us something important: that it was not a general truth at all. This discrepancy or asymmetry between the evidence that could be used in science gave him what he wanted, a reliable means of distinguishing between claims that were potentially of scientific value compared with those that could consume resources endlessly and go nowhere.

The criterion or feature he chose to demarcate science from non-science (otherwise known as metaphysics, meaning propositions accepted on faith) was that the claim was capable of being refuted. Metaphysical claims are of a form that can never be refuted (how can you prove that angels do not exist?). It further followed, he argued, that the process of science was one of proposing bold, highly unlikely theories and then submitting them to stringent testing to see if they could be proven wrong. If a theory passed all the tests, it moved to a “higher level,” meaning it was no longer mere conjecture but had some scientific standing. However, any and all scientific theories can be overthrown by new evidence, and this is how science progresses. Metaphysical theories are fixed and are not subject to criticism or revision so they do not advance or develop. He warned that we need to be very careful of theories which always seemed to be one jump in front of refutation, the “yes but” mode. A theory can always be “immunized” against refutation by a constant flow of minor revisions and changes and this also represents non-science at work.

By this standard, is the theory of evolution capable of refutation? It most definitely is. If a new species suddenly sprang into existence today, with no evidence that it had evolved from a previously known species, then it would probably be fatal to Darwin’s hypothesis. New species are discovered all the time but nobody has ever found one that didn’t have relatives nearby or in the fossil record. Even the bizarre organisms that live in deep oceanic thermal vents have relatives in thermal springs on land. A case of backward evolution would also be severely problematic for the theory: if the frill-necked lizards that live in my yard suddenly started breeding baby Triceratops, the theory of evolution would be in trouble. Fortunately, evolutionary theory is now immeasurably strengthened by the new science of molecular genetics. We are no longer in the difficult position of having no “*unseen causative mechanism* which is one dimension removed from the observations themselves.” Agreed, it takes special scientific instruments to “see” genes at work but they are simply functioning as extensions to our eyes.

What, then, is the difference between a theory and a model? In simple terms, a theory is a statement of an unseen generative mechanism which can potentially account for the observations. Starting with an undisputed observation, it is set out in the form of a series of inter-related propositions, and it proceeds from there. Each new proposition must follow from the preceding set with no conceptual gaps in the causative chain. Finally, it must generate testable predictions with real consequences in the material world. A theory exists in the form of words only. Mathematical theories exist in the form of functions.

A model is the instantiation of the theory in simplified form. The bare essentials of the theoretical statement are used to build a simplified physical representation of a machine that exemplifies part of the postulated mechanism. A model never includes all the elements of the theory, only the bare bones, as it were, but there must be a one-to-one relationship between the theoretical elements and the mechanisms of the model. Mathematical models are similar. They take the essential constructs of the theory (which may itself exist only in mathematical form) and show how they would interact in the real world by generating outcomes that can be compared with reality. A computer model of the weather is a good example of the instantiation of a mathematical model.

Thus, we have a theory of heavier-than-air flight, namely, that bodies of air moving at different speeds show different pressures. If the bodies can be separated by a physical barrier, then that barrier will tend to move to the area of lower pressure, meaning the area of higher speed. If the lower pressure is on the upper surface, the surface will tend to move against gravity. A model of heavier-than-air flight uses the different speeds on either surface of a moving aerofoil to generate a pressure differential. This means the lower pressure is on the upper surface, so the aerofoil will generate lift: the rest is just a matter of balancing the forces of lift and gravity to produce a stable aerial machine. A model of heavier-than-air flight is a physical object that flies through the air – and crashes. This is Popper’s point: our theories and their models are expendable. We can have a theory of instant transport but we would use a mouse in a scaled-down model before testing it on a human.

Two other points should be mentioned. Firstly, there is potentially an infinite number of theories that can be devised to generate a particular outcome; in real life, we will only be interested in the few of them that can do it economically (Occam’s razor again). Second, and flowing from it, each theory can give rise to dozens of models that may solve the physical problem. For example, heavier-than-air flight can be achieved the conventional way, by having a tube to carry the passengers supported by wings sticking out sideways. However, the tube creates very significant drag. A more efficient way is to combine the two functions of a heavier-than-air machine, i.e. lift and transport. Thus, the surface of the tube also is the lift-generating surface. There are several examples of this, including the “flying wing” (e.g. the Northrop YB-49 and the B2 stealth bomber) and, more recently, the more complex “blended wing” such as the Boeing X-48 (as an aside of no relevance, a static model of a flying wing airliner failed the most important test: passengers hated it. They disliked sitting in an amphitheater. Even though it is far safer for aircraft seats to face rearward, they wanted to be in a long, narrow structure facing forward with their own windows).

It is important to distinguish between a theory as a set of statements or propositions, and a model as just one working example of a simplified version of those statements. A theory of nuclear fusion says that, under suitable conditions of temperature and pressure, a plasma can form leading to fusion. A corollary to the theory indicates that magnetic forces can create those conditions sufficient to test the theory. A working model is devised which might produce fusion for only a few microseconds but it is enough to show that the plan has potential. Needless to say, these programs often acquire a momentum of their own. If nuclear fusion is needed to keep up with our increasing consumption of energy, perhaps the money would be better spent on finding ways to conserve energy, to reduce consumption instead of finding expensive ways to increase it. So there are usually different ways of achieving a single goal. The theory usually doesn’t predict the outcome at this level, mostly because nobody thought of it.

Let’s look at my own field, mental disorder. For an outsider, the most striking feature is the stunningly complex jargon that psychiatry uses. This is overwhelming: nobody but a psychiatrist has a clue what it all means, especially as it seems to change as time goes by. In the past, psychiatrists talked ‘Freud-speak,’ which nobody understood, but now they talk the impenetrable language of ‘DSM and brain-speak,’ and nobody is any the wiser (“I used to think I was anal retentive but now I’ve got OCD”). However, there is a problem for medical students in that nobody ever talks of an actual model of mental disorder. Needless to say, students do not notice this as nobody in their brief careers has ever talked to them of models of anything. Starting in school, and then in university, they have been drilled in a single approach to knowledge, which is called reductionism. The peculiar point is that not one of their teachers has ever explained to them what reductionism is, and the reason for this omission is simple: not one of them knows, either. So perhaps we can finish this section with a brief look at reductionism and its application to mental disorder.

If we have something big and complex to explain, the usual method is to take it to bits. That is, we reduce it to its parts and show how they relate to each other, then we put it back together and, hey presto, it works (mostly, except for the bits left over). In Western science, this is universal, but not by accident. The whole point of Western science is that it is concerned with the matter-energy relationships in the universe, and the proper way to understand matter-energy relationships is to see how energy and matter move each other by virtue of their physical structure. Any machine, no matter how simple or complex, has a static physical structure, with inputs (of matter and energy) and outputs. We can track the inputs through the machine, as they move, combine, separate and recombine in different forms to produce the specific output of that machine. Without much effort, we can work out exactly what is happening at any particular time and, more importantly, we can then predict what will happen in the future. We do this by detailed understanding of the matter-energy paths within the machine. For example, the internal combustion engine in your car cannot produce an output of eggs from an input of kitchen scraps, even though a chicken costing a few dollars can. Similarly, the chicken cannot carry four people at 120km per hour for four hours. The thermodynamic relationships defined by the chicken’s workings are of the wrong order to achieve this goal. A machine, be it a human artifact or a biological machine such as a yeast cell, can do only what its physico-chemical pathways permit. The job of a reductionist scientist is to understand, in minute detail, the contribution of each of the pathways to the final output. In ontological reductionism, we are mapping the precise matter-energy interactions throughout the machine because these specify the output.

There is no lower limit to reductionism. The properties of a car are explained by its engine, wheels, steering, transmission and braking systems, not to forget the seats and roof for keeping dry. Each of those parts is further explained by the properties of the bits from which it is made, and they from their materials, and the materials by their molecules, and the molecules by their atoms, and they by their subatomic particles… et cetera. We do not know where it ends. A car cannot do anything its parts do not permit, and they in turn are constrained by their molecules etc. Even though a car does nothing its molecules would not do themselves, the unique structure of the car allows us to manipulate the laws of thermodynamics to achieve an outcome that would be vanishingly unlikely if its molecules were not in that particular configuration. For example, there is no thermodynamic law that says humans can’t travel 480km in four hours, it is just exceedingly unlikely without a very strong tail wind or a car. By using energy (increasing entropy), the machine called a car works against the thermodynamic gradient to achieve what, at first glance, is an impossible outcome.

Similarly, there is no reason why H2O and CO2 molecules in the air should not combine randomly to form sucrose molecules, it is just exceedingly unlikely. However, given the particular structure of that clever little machine called a chloroplast, molecules of H2O and CO2 can be brought into close proximity such that they can utilize ambient solar energy to build the complex sugar molecules which the plant then uses to lift its leaves closer to the sun and, finally, to reproduce itself. Again, the matter-energy pathways for this process are understood in great detail; that is the goal of reductionism, to reduce a complex machine to its most minute properties in order to show exactly how it does just what it does and nothing else. A leaf in the sun cannot produce vanilla icecream just because those particular pathways are not represented in its biochemical pathways.

All of this you have learned in much greater detail than was available to students of my generation, but the principle of reductionism hasn’t changed one iota. It is part and parcel of our perception of the universe, something we have accepted with every breath of air for longer than we can remember. If there is one thing we can do that chimps can’t, it is that we understand that every big thing is made of little things which work in harmony to produce its outcome. So of course none of our teachers ever explained that they were teaching the particular ontological approach to life called “reductionism,” because they weren’t told about it either: fish don’t know they live in water (oh, and chimps aren’t strong on metaphors). So maybe for the first time in your life, you are hearing this explicitly stated: “As a medical student, you were trained in, and totally submerged in, biological reductionism from the moment you entered school. Congratulations, it is probably the most successful intellectual program in human history. It has brought you GPS satellites that can guide a drone to drop a tactical nuclear weapon on you in a thunderstorm at night with an accuracy of millimeters in a thousand kilometers. What more could you ask?”

Well, you could ask this: does biological reductionism explain mental disorder? With a warm, caring smile, your professor will say, “Yes, Virginia, of course it does. We have fMRI scanners and genome assays and probes and radioimmunoassay to detect chemical imbalances, they tell us all we need to know about brain disorders.” Reassured, you go off for tea but something isn’t quite right. Next day, you approach him again. “Can you tell me,” you ask hesitantly, “the name of the model of mental disorder you use in your daily practice, your teaching and your research, which allows you to say that biological reductionism will tell us all we need to know about mental disorder with no unexplained bits left over?” Your professor will look at you uncertainly, then a frisson of perplexity will cross his normally urbane features. With a nervous glance around, he will mutter: “I don’t know what you mean,” and scurry off. (If you want to know, that response came from an eminent professor from Harvard who is heavily involved in DSM-5).

Does the theory of biological reductionism explain mental disorder? That is to say, can we formulate a general statement of an “*unseen causative mechanism* which is one dimension removed from the observations…” of mental disturbance in terms of the matter and energy of the brain? Agreed, biological reductionism explains the fluid retention of acute glomerulo-nephritis very well. We are closing in on some of the mechanisms of cancer and the function of the HIV, but can reductionism also explain the phenomena of mental disorder by reducing them to matters of chemistry? If so, what would a model of mental disorder look like? The assumption in psychiatry is that biological reductionism is the correct theoretical stance, so therefore a model of mental disorder will not differ substantially from a model of acute glomerulo-nephritis; only a few minor details have to be amended to shift the focus from nephrons to neurons. That is to say, can we reduce the products of the human mind to questions of the properties of molecules? Can, for example, the enjoyment of poetry or the distress of grief be fully explained as properties of the physical structure and function of the brain? I don’t believe they can, and no orthodox biological psychiatrist has ever shown that they can. Worse still, no orthodox biological psychiatrist has ever shown the slightest awareness that this might actually be a question worth considering. Where there should be a reductionist theory of mental disorder, there is an intellectual void. Therefore, we are forced to accept that the widespread faith in biological reductionism as a theoretical explanation for mental disorder is nothing more than an ideological commitment, because it is not a theory in any accepted sense of the word.

This is very strange, you might say; how could so many highly-educated, charming, cultured, caring and liberal professors be so egregiously wrong in their apprehension of the nature of mental disorder? This is not a trivial question. It leads us to another area in the philosophy of science, which is perhaps less philosophy than the sociology of competitive groups.

I’m not sure how science is taught in schools these days but, in my time, we gained the impression that science was a long, wide and straight road leading from the darkness of the Olden Days (i.e. when my parents were younger) into the glorious, sunlit uplands of the Technofuture. Scientists were the wise, caring and rather unworldly creatures who were shepherding humanity along the path to health, wealth and a life of ease. Of course, no teacher would have said as much but this notion was loud and clear. For somebody interested in science, as I was, being part of the Technofuture meant studying hard at school in order to get a place in that somewhat mysterious world called “a laboratory.” In the late 1960s, when I was studying medicine at university, the molecular biological revolution was in full swing and technology was powering ahead. By the time I began training in psychiatry, the biological juggernaut seemed unstoppable. When our professors stated, as they repeatedly did, that biotechnology was on the verge of delivering the last few secrets of the human mind, we had no reason to doubt them.

Now, decades later, we are no closer than in those halcyon days. If anything, we seem further from a full understanding of the human mind because we now know much more about the incomparable complexity of the brain, and simplistic technologies such as behaviorism have vanished. Meanwhile, the audience in the rear seats keeps up a barrage of catcalls and peanuts, mocking science as something as irrational as politics or sport, which is likely to lead to the earth cooking before too long. Science is no longer the solution to our problems; it is a major part of the problem itself. So who is right?

These problems were not considered widely before 1962, when a small book by an obscure physicist-turned-historian started to attract interest. Thomas Kuhn’s aptly named Structure of Scientific Revolutions quickly started one. In brief, he argued that the progress of science isn’t as clear-cut and straightforward as we might like to think. In fact, it has been punctuated by unpredictable revolutions, during which an old science is abruptly swept away to be replaced by a completely new way of looking at things. His account starts with a period of what he called ‘normal science.’ Normal science is more or less what you might expect, with collections of scientists in different centers studying their bit of the natural world according to their perception of it. This particular perception or understanding he termed their ‘paradigm,’ which originally meant the systematic set of all inflections of a word or model. He used it to mean their systematic set of all beliefs about their work. Scientists are trained in a particular paradigm, and their job is to extend it, to study it and fill in the gaps until it becomes complete. This sort of work is rather pedestrian and unexciting but it leads steadily toward the goal of a mature science.

Kuhn’s historical training, however, showed that scientific reality was never quite as smooth as that ideal. What happened was that, as they beavered away, the scientists came across discrepancies or inconsistencies their model couldn’t explain. Most of them simply ignored these little annoyances and pressed on, fairly sure that they would later be explained as perhaps errors in the machines, or exceptions which turned out to support the model. Gradually, the discrepancies built up until it finally became apparent that the model was in serious trouble, except that the old guard, who held the reins of power, would fight the complaints vigorously. Then something dramatic happened. Somebody would find something totally unexpected or, more likely, a new interpretation of the data would burst upon the scene and the old model would be shown to be totally inadequate. Within a very short time, the old order would be overturned. The old guard would suddenly find themselves shunted to one side as the supporters of the new model raced ahead in demonstrating its remarkable reach and scope. By the time the next generation of students entered the field, they would be taught entirely in the new model and would laugh at the folly of anybody who had been so short-sighted as to think the old one could do anything.

Kuhn used a number of historical examples to demonstrate his point, including the Copernican revolution, the Darwinian period and the change from Newtonian to relativistic physics. He made a number of dramatic points that shocked the scientific establishment and provoked quite a lot of hostility. Firstly, he argued that science isn’t as rational as we would like to think. Ignoring discrepancies is not rational, and modifying a model repeatedly to try to incorporate other observations can be silly. During the revolutionary period, the new model would not be able to explain some things as well as the old one, so the choice of one model over another may be no more than the personal preference of the head of the laboratory. Second, he was of the view that the revolutionary period in any field of science would most likely be precipitated by either an outsider or a newcomer. The old guard had been trained in a particular viewpoint, so they were incapable of seeing when it was in trouble, and how. They dismissed its failings as minor quirks which their industrious research would eventually overcome, and were blind to their true significance as fatal anomalies. When a new model was announced, they would fight it bitterly, and Kuhn quoted the great Max Planck who said a scientist could never hope to convince his opponents, he could only wait for them to die. Finally, when the revolution was established, the new generation of scientists would see the world through different eyes and would be unable to understand the old men’s point of view. Successive models used in the same field are not different, they are intellectually incommensurate. They are not just talking different languages, they are living in totally different worlds.

This attempt to summarize Kuhn’s life work in one page barely does him a service but it should show why the scientific establishment was outraged by his thesis. Despite the wealth of historical evidence he used, the Grand Old Men were particularly incensed by his view that they didn’t have much to contribute to the development of a new field. Worse still they were very often actually obstructive to, if not destructive of, the work of their juniors who were ushering in the new generation of thought. Kuhn’s efforts to educate scientists as to the actual conduct of their business were not helped by the post-modernists and various other antagonistic groups who seized on his work as an authoritative vindication of their rabid anti-rational and antiscientific beliefs. Kuhn resented their interpretation of his careful historiographic analysis of the conduct of science but there wasn’t much he could do about it. They wanted to believe that “anything goes” in science but refused to accept that his work may, in fact, apply equally well to their own, loosely-defined fields as to the more disciplined life in a laboratory. In any event, Thomas Kuhn brought the philosophy of science to the forefront in what we might even call a “Kuhnian revolution in the philosophy of science.” We cannot go back to the old view.

For myself, I was re-educated in the notion that science is not so rational as its publicists would have us belief. It has its dark side, and scientists themselves are very often far from “wise, caring and rather unworldly creatures shepherding humanity along the path to health, wealth and a life of ease.” I have no trouble with this, which is probably very helpful when it comes to dealing with my own specialty, psychiatry. Anybody who takes the longer view of modern psychiatry will be shocked by the elastic way it always seems to include itself on the platform of the sciences, even though its ticket changes every generation or so. Once, you had to be a psychoanalyst to gain entry to the palaces of science, then it was behaviorism but now, it is biological psychiatry. Biopsychiatry’s cheerleaders parade around the country with drums and whistles (mostly paid by the drug industry), keeping up a mesmerizing barrage of claims, testimonials and seminars in an endless flood of TV and press “infomercials” that alternately terrify and inspire the general public into believing that, look out, you or your children may be next but don’t worry, here comes biopsychiatry to the rescue. It is all rubbish.

It is the case that, by any rational process of analysis, orthodox psychiatry fails to meet the minimal criteria for a science. It has no agreed, articulated model of its field of mental disorder, and not even a whisper of agreement as to what actually constitutes its field. It lurches from crisis to crisis, the latest being the vast and systematic corruption of academic psychiatry by the drug industry. The psychiatric publishing industry is both corrupt and incompetent, a prisoner of its own myths, while the general public sees only a profession that can’t make up its mind about anything except that everybody is mentally ill and need lots of expensive drugs. It is also the case that, by any measure, psychiatry is ripe for a Kuhnian revolution but the establishment seems to have been alerted as they are redoubling their efforts to make sure that no hint of dissatisfaction reaches the ears of medical students and trainees. Which is just as Kuhn predicted.

Philosophy for Medical Students - Chap 3

Wed, 16 Mar 2011 14:07:46 +0000

KNOWING.

In a celebrated case in 1997, now known as the Norfolk Four, four young members of the US Navy, stationed at Norfolk Naval Base in Virginia, USA, were charged with the rape and murder of the wife of another sailor while he was at sea. They were convicted solely on the basis of their confessions: after interrogation, each man had admitted the ghastly crime and signed statements describing in detail the events of the homicide. Despite the violent and grotesque sexual nature of the offences, no forensic evidence was ever found to incriminate them. Subsequently, another man whose DNA matched the crime scene, and who knew the details of the case intimately, confessed to the crime but insisted he had acted alone. Even though he was convicted of the same offence and sentenced to several life sentences, the four men were not released until 2010, and then only conditionally, i.e. the convictions stood.

Philosophy for Medical Students

Philosophy for Medical Students - Chap 2

Wed, 16 Mar 2011 14:04:36 +0000

In talking about the concept of mind, it is probably easiest to start with the simplest version, the one our grandmothers all acquired early in their lives. This is what has been termed the ‘folk psychology’ version of the mind (the name comes from Wilhelm Wundt, who compiled twenty thick books about it). As mentioned in the previous chapter, the notion is of a ‘little man’ (or ‘little woman’) residing in the head and doing everything that humans do that we can’t already understand as something ducks and dogs do. So, language, creativity, art, chivalry and so on have to be explained in terms other than of simple mechanisms bumping into each other. But, the inquisitive child will invariably ask, where does the little man come from? “God,” says grannie in a tone that says “and that is the end of your questions, run off and play.” Perhaps the child goes to the priest and says: “Where does the little man come from?” “God,” replies the priest, “and bless you, my son, but I have a sermon to prepare.” So the child goes along the road and wonders: If humans have little men inside them, perhaps animals do, too. What about trees? Everybody knows trees are very noble things, they should have one, too. And so this train of thought leads directly to two ancient ideas, animism and panpsychism.

Philosophy for Medical Students

Philosophy for Medical Students - Chap 1

Tue, 15 Mar 2011 02:55:24 +0000

Until fairly recent times, one of the biggest problems faced by philosophers was
the looming shadow of religion. The Church came complete with its own ontology and churches in general (or synagogues, temples or mosques) are never kindly disposed toward competition. Christian ontology built on what went before, namely, pagan beliefs, which were intimately related to what we would now call folk psychology. That is, every person, no matter how clever or educated or sophisticated, has an immediate and direct knowledge of what it is like to be human: it feels like something.

Philosophy for Medical Students

Introduction
Chapter 1 New

Philosophy for Medical Students - Introduction

Mon, 14 Mar 2011 14:20:46 +0000

Most of the words students have trouble with are not taught in medicine; they come from the discipline called philosophy. Unfortunately for medical students and other busy people, if you do not use a word regularly, it is often difficult to remember exactly what it means. This can be troublesome as words are tools; they allow us to explore the full meaning of a concept and understand why it means just that and nothing else. It is more of a problem in psychiatry than in other fields because the concepts we are relying on are often hidden. Even when they are dragged out into the full light of day, they are slippery notions that are difficult to pin down. Partly, this is because medical people are not used to thinking in terms of abstract concepts (there isn’t a lot of abstraction in a microscope slide) and partly because the concepts themselves may not be clearly understood anyway.

The introduction to “Philosophy for Medical Students” is available here.

Critical Theory and Psychiatry

Sun, 13 Mar 2011 13:45:57 +0000

An examination of the fundamental claims of modern biological psychiatry shows emphatically that it has no scientific basis whatsoever. At best, psychiatry is a protoscience while, at worst, it is mere pseudoscience. As a branch of medicine, psychiatry lacks a tradition of criticism of the fundamental tenets of its practice. At the same time, orthodox medicine shows no interest in criticizing psychiatry for failing to develop a science of mental disorder. This means that the mentally-disturbed are being compelled to take drugs for which there is no true rational basis.

Introduction

Putting aside considerations of the ontological status of mental disorder, it is the case that, at some stage in their lives, a large part of the population acquires a diagnosis of mental disorder. Most surveys of general (family, primary) practice indicate that approximately one third of all self-referrals for medical help are primarily motivated by psychological factors. If we follow the modern trend and broaden the category of mental disorder, we can include as mentally disturbed all cases of substance abuse, many examples of violent or other criminal behavior, the very large numbers of people who consult alternative or complementary therapies, and even a proportion of apparently successful people. In all, it would probably be fair to say that some forty percent of the population of any modern, westernized nation will, at some stage or other, be sufficiently distressed or disabled to meet the criteria for a psychiatric diagnosis. When we include their concerned relatives, it is possible that, at some stage in life, mental disorder directly or indirectly affects something like 75% of the population. If we wish to take the case further, and argue that war, deprivation and other civil disturbances, as well as certain cultural and religious practices, are manifestations of mental disorder, then the numbers of people who could genuinely claim to be utterly untouched by mental troubles would be small indeed. Consequently, it is a matter of grave public import whether or not these people are being managed fairly, effectively, humanely – or even managed at all.

The history of society’s reactions to and management of mental disturbance is not particularly edifying ¹. Similarly, the history of society’s attempts to understand the nature of mental disorder does not match the success of other technical fields. In short order, we have ranged from mental disorder as a supernatural phenomenon (possession states and other occult influences), to moral failure, a result of social pressures (social labeling), a purely psychological phenomenon (behaviorism, psychoanalytic theory) and, what is now the dominant approach, a manifestation of a physical disorder (biological psychiatry). Indeed, in any city in the world, one can readily find practitioners of all these approaches and more. There seems little doubt that this level of theoretical pluralism reflects more on the lack of certainty than on its opposite. Governments, however, be it in the most highly-developed western countries or in marginalized countries with rudimentary public health services, are very strongly inclined to favor the biological approach. Strictly speaking, even in the heyday of the Freudian and behaviorist models, this was the case: while the rich may have been able to indulge their creativity on an analyst’s couch, the poor were herded into huge depositories. There, out of sight and out of mind, they were treated en masse, often by poorly trained and supervised staff, using physical methods based in a rigidly biological perception of mental disorder, methods contaminated to a greater or lesser extent by the staff’s moralistic inclinations. If we judge a society on the basis of its treatment of its most unfortunate members, then most societies stand damned by their treatment of the mentally-disabled.

Given the plethora of ideological positions on the nature and causation of mental disorder, it is of more than passing academic interest to explain why, at present, one of them has achieved its preeminent status. The biological approach to mental disorder now has effective control of the public mind – and the public purse. Throughout the world, there would not be a single public mental health service that does not put 98% or more of its resources directly in the service of the notion that “mental disease is brain disease.” Similarly, private psychiatric practice, whose stereotype, many years later, remains the analyst’s couch, is now dominated by a curt pharmacologic approach whose stereotype (“Take more of the blue tablets and come back in a month”) is probably closer to the truth than the picture of a balding, bewhiskered man doodling in a pad ever was. On television, we are subjected to a steady diet of advertisements urging people with all manner of conditions to “see your doctor for help” (where doctors, as all know, prescribe medication). The internet in particular yields a flood of self-help groups for even the most cryptic of disorders – websites which, all too often, betray a level of sophistication which would ordinarily elude the average “soccer mom.” Almost all of them urges sufferers to take this or that drug (prescribed or otherwise) while a careful scrutiny of the site will often reveal that it is kindly supported by one or other of the big pharmacy manufacturers.

In schools and prisons, psychotropic medication is almost de rigueur. In some areas, as many as 40% of the children are taking powerful psychotropics after assessments which even the most partisan reviewer would have to admit are very often cursory to the point of insult. Where once the caricature was of a “neurotic housewife” in the suburbs surreptitiously taking her “mother’s little helper,” now we have queues of boys outside the school nurse’s office for “my dexies.” If the tablets are not enough, we also have swarms of energetic therapists of various schools eager to advise on diet, massage, brain, eye and ear exercises and so on, all designed to suppress the effects of one or other “central processing disorder” which, if untreated, will most assuredly devastate the child’s life. “Let a hundred schools blossom,” so long as every one of them assents to the fundamental principle that, first and last, mental disorder is a “chemical imbalance of the brain.” If ever there were a hegemonistic reduction of a complex human question to the level of inanity, biological psychiatry is it. How did this come about?

Even though medicine lies wholly within the materialist ethos (i.e. that there is nothing in the universe other than matter and energy), the idea of mental disease being just a special case of brain disease was once regarded as unchallenging, if not an abdication of intellectual responsibility. In psychiatry itself, analytically-oriented private practitioners accepted without demur that they were the crème de la crème, with university staff and their clunky behaviorist programs a rather poor second best. Bringing up the rear, in more ways than one, were the “bin doctors,” the rather drab, tired and unmodish psychiatrists who had surrendered their place in the intellectual limelight for the easy life of a public service physician in an outlying mental hospital. Even when I began my training, these medical staff worked decidedly genteel hours in semi-rural settings, walking home for extended lunches in their very comfortable old government houses set in extensive gardens maintained by hospital gardeners. Compared with general hospitals and university departments, they were paid handsomely with generous fringe benefits but this, everybody knew, was a sop for their ignoble status. They spent their days writing prescriptions and giving electroconvulsive treatment (ECT) in huge, noisy and smelly wards. If they needed more excitement, they could try to encourage a neurosurgeon to operate on their charges.

However, starting in the mid-seventies and accelerating rapidly thereafter, all this changed. Psychoanalysis is dead, even psychologists don’t bother with behaviorism and young trainees in psychiatry get no exposure to psychotherapy. At the school of medicine, University of New South Wales, in Sydney, the course in psychiatry for medical students includes a one hour lecture on ECT (which almost none of them will ever see, let alone administer) – and one hour on the psychotherapies. This is despite the fact that, as general practitioners, many of them will spend 33% of their time dealing with psychological disturbances which could not, in any event, warrant ECT.

The near-total dominance of psychiatry by the biological model arose for a number of intellectual and social reasons. The collapse of the psychodynamic approach to mental disorder was inevitable once its lack of scientific status became clear ², and once its figures were themselves analyzed. Governments and insurers could perhaps forgive analysts for their lack of a rational model of mind, but they dare not overlook the astounding costs and the inequity of distribution that it entailed. Ironically, behaviorism, which had long mocked psychoanalysis for its irrationality, also collapsed abruptly when its fundamental assumptions were subject to detailed philosophical scrutiny ³. So within psychiatry, the dominance of the biological approach was partly by default: everything else had fallen into disrepute. At that stage, it may have been appropriate for the profession to approach governments en bloc and announce that, since they no longer had a viable model of mental disorder, the vexatious area ought to be handed to another profession, leaving the psychiatrists to return to their medical fold and the nurses to rename themselves (as they had done before). That, however, is not how specialist guilds work so, in a manner reminiscent of Orwell’s dystopia, they stopped claiming that Freudian theory conferred on them the right to call themselves specialists and found another theory which, mirabile dictu, accorded them the same unassailable status for totally different reasons. Indeed, from the medical point of view, it was, in certain respects, very much better. Psychologists, for example, could train as psychoanalysts but, in the arcane new world of brain enzymes, drugs and genes, they could never be more than the sorcerers’ assistants.

Psychiatrists rushed to embrace the new-old paradigm because it was familiar, it solved a huge number of complex questions about the nature of mental disorder (there were no longer any) and, above all, it was scientific. By bringing them back into mainstream medicine, it silenced the critics such as the psychologists who had always yearned to be accepted as hard core scientists themselves but had never passed Neurophysiology 101. During the 1970s, psychiatry was transformed from a bit of a joke to just another medical specialty. Powerful new diagnostic tools such as CT and MRI scanners and new research techniques such as PET and fMRI scanning joined forces with the impeccably modern nosology (system of classification) of the DSM-III. Shortly after, the methods of molecular biology were turned on the ancient questions of insanity just as new generations of safer, milder, more effective and more specific drugs became available. With the human genome project, it seemed just a matter of time until the dictum of Samuel Guze, one of the architects of the modernist revolution, came true: “There cannot be a psychiatry which is too biological” ⁴. With the dawning of the new millennium, psychiatry’s resurrection seemed complete when a psychiatrist was awarded the Nobel Prize for Medicine and Physiology. In his acceptance speech and many times thereafter, Eric Kandel detailed the way of the future: molecular genetics would show how the “biology of mind” would integrate psychiatry and psychoanalysis to build a new science of mind ⁵. Needless to say, Kandel’s work was extremely popular with orthodox psychiatrists: even if they were a little rusty as to the finer details of neuronal function, they entertained not the slightest doubt that perfectly ordinary, routine science would soon lead to total cures of all mental disease. Ten years into the new century, the modern scientific psychiatry, meaning biological psychiatry, has no competition. Or has it?

Critical Theory and Psychiatry

It is not my place to define for the readership the nature of and notions behind the new criticisms of the institution of science. The very intellectual basis of modern science, so long accepted without hesitation by its practitioners, is now open to stringent analysis from a number of different points of view. In the first place, the broad assumptions of the modernist drive have been called into question: is there an objective reality? Can we ever know it, can we separate our beliefs from our observations, or can we even be trusted with this type of knowledge? Outside the narrow (and sometimes unreflective) world of science, the solid rocks of the foundations of the modernist project are being rolled aside for inspection. What emerges isn’t quite what the historic greats perhaps imagined. Thomas Kuhn’s historiographic analysis ⁶ showed that change is often not rational after all, and resistance to change is almost never rational, i.e. scientists can be as irrational as anybody else. The idea that science and business are joined in a self-interested alliance with a militarized government, formalized in the farewell speech of Pres. Dwight D Eisenhower ⁷, is unresolved half a century later. Even language itself, the very basis of our capacity to abstract from our experiences, is no longer seen as inherently objective and unbiased ⁸. This may explain the growth of interest in critical studies in departments of English which formerly evinced little regard for the productions of any but the giants of literature.

Taken together, these notions form the basis for a sustained critical reappraisal of the broader scientific project which has adopted a number of viewpoints. The relativist view says that what is taken as “objective knowledge” is, in fact, relative to the position of the culture in which it arose. This can be a major culture, such as national or religious groups, or even a microculture seen in small groupings such as specialist areas. What one group will see as a catalogue of objective facts will, from another standpoint, appear to be no more than an arbitrarily assembled narrative, even a mythology. Feminist critics challenge the validity of the received view of the world on the basis that it arose in the context of a sexist culture which must itself be analyzed for unsuspected biasing influences. These days, it would be fair to say that scientists are generally aware of these arguments and shape their research agendas accordingly, at least because most researchers are more interested in furthering their projects than they are in losing their funding due to avoidable controversy. Does this indicate that the ideal of external criticism has achieved its goal in producing a more human and less conceited science? Regrettably, I believe this is not the case. My field, psychiatry, appears to have been remarkably unaffected by the so-called “science wars,” to the extent that major conceptual debates and even egregious ethical breaches have hardly excited comment.

It should be taken as read that biological psychiatry is both dominant and unreflective. The major psychiatric journals are crammed with either genetic and biochemical minutiae or statistics, for example:

Abnormalities in MRI signal intensity in schizophrenia associated with idiopathic unconjugated hyperbilirubinaemia (Gilbert’s Syndrome) ⁹.

Einheitspsychose? Adjudicating endophenotypes for schizophrenia and bipolar disorder ¹⁰.

Association between COMT (Val158Met) functional polymorphism and early onset in patients with major depressive disorder in a European multicenter genetic association study ¹¹.

Titles such as these are absolutely typical of the modern psychiatric literature. However, what is missing from the literature is any sense of reflection or self-criticism. In a survey of ten years of published papers in the Australian and New Zealand Journal of Psychiatry (calendar 1996-2005), I found that among some 1196 original papers and reports, there were just three papers critical of mainstream psychiatry ¹². Two of these came from overseas authors and one was mine. Among Australian psychiatrists, this gives a cumulative rate of self-criticism of approximately 0.08% in ten years, an annual rate of about 0.0000027% per psychiatrist per year. In some vital sense, this seems to evade the more onerous point of Popper’s notion of science as “bold conjectures and stringent attempts at their refutation” ¹³. Indeed, any survey of the recent psychiatric literature will fail to find anything approximating an institutionalized role for criticism. My own research shows that this is not accidental: it is in fact a function of the stated publishing policies of the major psychiatric journals. For example, the publishing policy of the Australian and New Zealand Journal of Psychiatry consists solely of the editorial board’s perception of “…the quality and originality of the research, and its significance for our readership” ¹⁴. As detailed elsewhere ¹², there is nothing distinctively scientific about this: it could equally be the publications policy of any journal of political or religious extremism. Bearing in mind the central role of criticism in advancing the scientific endeavor, this leaves psychiatry in a position unique in the entire field of medicine, if not in science as we know it: psychiatrists have no means of detecting whether their theories are flawed and, if so, of correcting those flaws. It might be argued that the modern avatar of psychiatry has no need for self-criticism as it is precisely correct, but I see no cause for such optimism.

Does this matter? I believe it does matter, because a correct critical attitude to modern biological psychiatry will show that it has no scientific basis whatsoever. Biological psychiatry reigns just because a powerful clique has taken control of the profession and is driving it in a particular direction purely for non-scientific (social) reasons. The significance for the safety of the consumers of modern psychiatric medicine is just this: How do they know that “mental disorder is just a chemical imbalance of the brain”? If it isn’t, then taking large doses of highly toxic (and expensive) drugs in the long term is reprehensible.

The Status of Modern Psychiatry

Psychiatry, as currently conceived by the “opinion-makers,” is wholly a matter of biology. With the excited encouragement of neurophysiologists such as Kandel in the US, Crow in the UK ¹⁵ and Bennett in Australia ¹⁶, psychiatry teaches its students and trainees that a detailed knowledge of brain function will inevitably lead to a detailed understanding of all matters of psychiatry, with no questions unresolved ¹⁷. These are heroic claims and, having wearily sat through many such lectures, I can aver that they are delivered with a confidence verging on revivalism. Students, however, are “voting with their feet” ¹⁸. Increasingly, the new generation of medical students and practitioners sees psychiatry as boring, inhuman, disorganized and lacking a scientific basis. Applications for post-graduate training in psychiatry are declining, training posts are vacant and the average ages of psychiatrists and, more ominously, of trainees, are rising (these figures should, of course, stay constant). Within psychiatry itself, the proportion of service hours dedicated to clinical practice is declining sharply, as more psychiatrists move to teaching, research and administrative positions, as well as working part-time.

My case is that this is inevitable. Psychiatry as we know it has no rational basis whatsoever, its claims are narrative at best and, all too often, pure mythology, and the whole endeavor is poisoned by the vast sums of money involved. While psychiatry has the trappings of science (laboratory-based research programs, a jargon, specialist conferences and journals, grants and funding programs, degrees, prizes, elaborate gowns and other academic rituals etc), it is no more than a protoscience, more likely a pseudoscience just because it lacks the sine qua non of any science, an agreed model of mental disorder to guide practice, teaching and research. I justify this rather shocking claim in the following manner.

1. The influence of the psychodynamic theories and of behaviorism in psychiatry have all but disappeared. New trainees receive no education in Freudian theory while the therapeutic elements of behaviorism have been incorporated in an essentially atheoretical technology, loosely bundled together as Cognitive-Behavioral Therapy. In Australia, CBT is largely the province of psychologists, social workers, nurses and general practitioners. Psychiatrists generally take the condescending view that it is little more than occupational therapy – for clients and staff – to keep everybody quiet while the drug treatment takes grip. While older psychiatrists may, from time to time, still correctly use terms such as ego mechanisms of defense, acting out and conversion, there is little chance that their junior colleagues will have any more than the dimmest understanding of the precise, technical meanings of these expressions. Most tellingly (and perhaps sadly), those expressions have totally lost their cachet. Acting out is little more than a term of abuse: I hear it bandied about by prison officers when I visit the local prison in this small, isolated city.

2. The claim ‘mental disorder is brain disorder’ does not exist in an intellectual vacuum. It is a very high-order ontological claim and, as such, is inevitably nested in a welter of interlocking assumptions and presumptions. Psychiatry does not, at any point, render these explicit; rather, it is assumed that the claim sits comfortably among the other claims of reductionist medical science and to question one would be to question all, which is too silly for words. I have tested this claim only once: I asked a young female psychiatrist of decidedly biological inclination whether breathing disorders necessarily implied lung disorders. She looked at me briefly with what could only be described as pity, then walked away. The matter should not be dismissed quite so easily. The term ‘mental disorder’ implies very clearly that we have a precise understanding of the expression ‘mental order,’ meaning, in the broadest possible sense, a workable theory of mind. This is not true. Psychiatrists have absolutely no training whatsoever in the philosophy of mind and are prone to the most egregious schoolboy howlers whenever they venture an opinion outside the (narrow) limits of their specialty. As an example of immediate significance, I point to the long-overdue debate on the limits to the concept of depression ¹⁹. Since the publication of DSM-III in 1981, the concept of depression has broadened explosively to the point that antidepressants are now the most commonly prescribed class of drugs in western countries. This happens just because psychiatry is totally ignorant of normal mental life, especially when it includes normal life in other cultures or even subcultures. Entire swathes of knowledge, such as anthropology, personality theory, and even the history of mental disorder in our own culture, are not so much a closed book to psychiatrists, but simply don’t exist.

Another major claim is that we can validly separate normal mental function qua personality from abnormal, meaning personality disorder. Psychiatry has no theory of personality disorder but assumes that the same, unseen and unknown (biochemical and genetic) processes which are taken to cause the classic mental illnesses will also explain all we need to know about abnormal personality. In fact, the problem is now being resolved by “creeping medicalization,” in which the types of behavior previously accepted as indicating personality abnormality are reclassified as indicative of mental illness, especially ADD/ADHD and Bipolar Disorder. In Australia and, presumably, in most other western countries, there has been an explosion in the rate of diagnosis of these two entities, just as the rate of diagnosis of personality disorders has plummeted. From a rarity thirty years ago, the incidence of diagnosis of Bipolar Disorder has risen 4,000% and similar figures will be seen for childhood diagnoses. Children under five are now given antipsychotic drugs ²⁰ and it is not unknown for children in the US (especially children in care) to be receiving as many as seven separate psychotropic drugs ²¹, hugely expensive drugs with many side-effects and of dubious efficacy ²², for diagnoses which did not exist when I started psychiatry. Moreover, prescribing drugs has the effect of closing off further attempts to understand the behavior: if it is biological, there is nothing to understand. Prescription rates for drugs used in these diagnoses are up by as much as 5,000% and even 10,000%. Drugs are commonly commenced by general practitioners or pediatricians without any psychiatric or psychological assessment or management and, once started, will simply continue indefinitely. The benefits for those who manufacture and sell the drugs cannot be underestimated. The risks have never been assessed. These matters are, however, the results of the claim ‘mental disorder is brain disorder,’ not the cause or justification. The cause is the collapse of alternative explanations, ‘biology envy’ among psychiatrists, and money.

With regard to money, I need only point to the scandals surrounding the behavior of a number of senior psychiatric researchers and trend-setters in the US over the past few years. Psychiatrists Charles Nemeroff, at Emory University, Melissa DelBello, of Cincinatti, and Joseph Biederman and Timothy Wilens ²³, at Harvard, were subjected to intense scrutiny in a Senate inquiry when they failed to declare income from drug companies. Further, it appeared that some of them and others had done little more than sign research papers designed, financed, conducted and ghost-written by drug companies. Other empirical research throws a glaring and unwelcome light on the systematic suppression of results unfavorable to the funding agencies or the ideological stance of the researchers [24,25]. My view is that, while this type of behavior might not actually be condoned by the psychiatric establishment, it is a predictable outcome of the fact that psychiatry has no agreed model of mental disorder to guide practice, teaching and research ²⁶. Where there is no science, there can be no scientific ethic.

I do not believe these are trivial matters blown out of proportion by a well-known querulous provincial. Putting a child on drugs for life, with all that it entails in cognitive performance, self- and group-perception, physical health, etc, is not a matter of the same order as thinking Santa Claus is real. Even if it is true that ADD/ADHD is a myth, myths certainly have real consequences. However, my concern has always been the cause of this unhappy situation, to which I now turn.

3. Can there be a biological model of mental disorder? A crucial conceptual requirement is the availability of rational methods by which the subjective phenomena of mental disorder can be transmuted into the material stuff of biological science. This conundrum, the ancient mind-body problem, should be resolved before the research program starts but matters are rarely so rational. There are four possibilities by which the subjective element of mental disorder can be equated with the material substrate of the brain. These are mind-brain identity, mind-brain reductionism, functionalism and biological naturalism. Each of these monist theories is an attempt to evade the critical question of how an insubstantial mind can interact with the physical body. Each of them fails.

The Status of Biological Psychiatry

1. Mind-brain identity theory ²⁷ states that, as a matter of contingent fact, mind and brain are one and the same thing. Its value is that it legitimates the claim that mental disorder is brain disorder. This theory was popular in the 1950s to 60s but soon fell into disrepute when it was realized that mind and brain are not identical just because each has properties that the other does not. Moreover, human mental function depends on its symbolic properties and the essential point of symbols is that they are not the thing they represent. It is therefore not possible to draw a one-to-one connection between brain events and mental events, so the claim fails. If mental disorder is to be seen as a special case of brain disorder, some other means is required.

2. Reductionism is the basis of all physical science, especially the biological sciences ²⁸. It comes in many forms but the most important here are ontological and behavioral reduction. Ontological reduction says that the properties of a higher-order entity will be fully explained as the direct product of the properties of the lower-order entities from which the first is composed. In order to explain something, we look at its constituent parts. A problem arises when some properties cannot be explained on this basis: they are emergent, meaning could not be predicted in advance. Similarly, behavioral reduction says that the behavior of a higher order entity is the predictable outcome of the behavior of its subsystems, and they in turn of their components. Almost invariably, when psychiatrists claim that neurophysiology will give a full explanation of human behavior, they have one or other form of reductionism in mind. Psychiatrists are medical practitioners and, from day one, they are trained in reductionism, which is certainly the most successful intellectual program in human history. So Kandel [5, p7] could talk of “…a meaningful and sophisticated understanding of the biology of the human mind,” confident that his audience understood and agreed wholeheartedly with him: that by peering down a microscope, we will soon explain everything from aggression to xenophobia, by way of culture and madness.

This claim also breaks down on the point of human symbolic function, meaning reductionism cannot give an account of language, one of the most decisively human functions of all. Interesting answers to the major questions of human behavior will not derive from neurophysiology, including molecular genetics etc. Science may be able to explain how we speak, but it will never be able to explain what we say. The explanation of these functions lies outside the reach of reductive materialism.

3. The most influential form of functionalism is attributed to the American philosopher, Daniel Dennett ²⁹. Dennett was determined to write a theory of mind that did not fall into the trap of substance dualism, which he openly despised. Functionalism is not the most transparent of theories but, in any event, it fails his major ambition. The model of mind Dennett assembled over many years is frankly dualist in nature and leaves the mind-body problem intact, albeit well and truly hidden under a pile of science stuff ³⁰. In particular, it denies the significance of the private mental life and offers no clues whatsoever as to how it can generate a model of mental disorder.

4. The final monist model to be considered here, John Searle’s biological naturalism, suffers the same fate ³⁰. Far from writing a material theory of mind, Searle’s model is dualist to the core. Without realizing it, he, too, has used dualist concepts to complete the causal chain in his non-dualist explanation. Neither Searle’s nor Dennett’s theories offer any points of contact with neurophysiology, which is the essential ‘grounding point’ of any theory of mind.

5. There is one further possibility to save the biological program in psychiatry. That would happen if and only if unique primary biochemical defects were found to be associated with each and every mental disorder, defects which were both necessary and sufficient for the condition. This would not, however, account for the borderland of psychiatry, such as personality disorder and the problem of medicalizing normal human states, such as sadness, as outlined by Horwitz and Wakefield ¹⁹. We would still not be able to say a condition was a mental disorder by giving the patient a blood test, the ultimate goal of any biological program.

The significance for psychiatry is that, as it is presently formulated, biological psychiatry is a form of monism. That is, the concept of “biochemical imbalances of the brain” as the cause for all mental disorders depends on an indefensible philosophical claim. This means biological psychiatry can never be nested in a larger, formal theory of mind that justifies its essential claim. It is, we could say, an orphan concept, an unjustifiable claim hanging in ontological space with no points of contact with a larger theory. It is an urban myth, albeit a myth with a very large price tag. In the US in 2008, 164million prescriptions were written for antidepressants alone, at a total direct cost of nearly $11billion ³¹ (this does not include indirect costs such as consultations, sick leave, side effects and overdoses).

Critical Theory and Psychiatry

While orthodox psychiatry likes to see itself as very much part of the standard medical project of biological reductionism, an objective and dispassionate program to determine “facts as they are” independently of human foibles, there is no reason to believe this is the case. The biological program is an unhealthy mixture of promissory materialism, wishful thinking and the usual academic and intellectual shortcomings. As I have shown above, criticism from within psychiatry is practically unknown. Unfortunately, and despite the compelling importance of mental disorder to every citizen, so is criticism from without. I will briefly consider this anomaly from the point of view of whether society lacks the time, the intellectual capacity, the conceptual tools or the motivation to analyze the central claims of biological psychiatry.

Do we have the time to look closely at the current project of placing a very sizeable proportion of our youth on powerful, addictive drugs? I raise this question only to dismiss it immediately: if we have time to run sporting competitions, we have time to look at all the people who will never be able to join in the games.

Do we have the intellectual capacity to understand the nature of mental disorder? I believe we do, but this is not the same question. The question under consideration is this: Can the fundamental ontological beliefs of the biological program in psychiatry generate a model, any model, of mental disorder? There is no doubt that it cannot. The reductionist program cannot generate a model of mind, so it cannot go further to model an account of mental disorder. This should have been considered before the first dollar was spent but, as is so often the case, it wasn’t. The program was up and running while everybody was still dazzled by its claims. It is of interest that, every time the biological research program seems to be heading into the doldrums, a new technology is advanced as ‘the key to understanding mental disorder.’ No sooner had the human genome project failed to deliver the long-awaited genes for mental disorder than we plunged into epigenetics and now endophenotypy. Readers should not worry about these terms, their use by psychiatry is scientism, i.e. the inappropriate application of scientific methods and procedures to questions with no empirical content. As it happens, I believe we do have the capacity to understand the nature of mental disorder, and have set out my case elsewhere ²⁸, but biological psychiatry is and will always remain an intellectual dead-end.

Do we have the conceptual means to look into the nature of the claims in the biological program? We most certainly do. They are nothing more than the techniques every person or reasonable sense and integrity should use every day: criticize the fundamentals of the claim, especially the hidden assumptions, extrapolate every claim to its limit, look for the unstated motives, look for inconsistencies or internal contradictions, and so forth. In short, don’t fall for propaganda. The entire discipline of critical theory as applied in science and technical studies is built on these techniques, not to forget science itself. As it happens, the briefest review shows that claims that the new generations of drugs are “safer, milder and much more effective and specific” is not sustained by research.

Finally, do we have the motivation to look closely at the institution of psychiatry? It is at this point that doubt intrudes. The scandal surrounding undeclared payments to some prestigious names should have raised much broader questions than “mere greed.” These questions do not appear to have been asked. To test this, I examined the tables of contents for each edition of a number of critical and science and technology studies journals, starting in January 2006 through to March 2010. If there had been any examination of the larger issues, it should have appeared in this time. The journals included Social Text, Social Theory, Social Studies of Science, British Journal of Sociology, Current Perspectives in Social Theory, New Humanist, Dissent, Configurations and Skeptical Inquirer.

There was nothing. Granted, Social Studies of Science devoted an issue to looking at some aspects of psychiatry (April 2004) but these were largely about marketing, and not one addressed the crucial question of whether psychiatry has a scientific theoretical basis.

This is cause for the greatest of concern, if not outright alarm. If the practitioners of an alleged science have no demonstrated capacity for self-criticism, the subjects of their science occupy the lowest rungs of the social power structure, some people make fortunes from the status quo, and governments wish the matter would simply go away, who will plead their case?

Discussion

Orthodox biological psychiatry is essentially an unreconstructed modernist program. That is, it is based in attitudes and ambitions originating in early Enlightenment thinking which persist essentially unmodified to the present. The central attitude driving the program is that an objective knowledge of mental disorder is not just feasible, but will derive from the same principles of reductionism that have been so successful in understanding, say, excretion in sea slugs (Aplysia spp). The concept of mental disorder is itself seen as a human universal, totally independent of culture in both the patient and the psychiatrist. It can be recognized quite as easily and objectively as, say, a strep throat or a brain tumor. This is because mental disorder is equated with genetic disturbances and, as everybody knows, genes are uninfluenced by culture. Manifestly, this begs the question that the research is supposed to answer but psychiatry does not give credence to this type of criticism. By this means, the human experience of being mentally-disabled is discounted in favor of a rigid, reductive materialism: non-sentient biochemical causation necessarily (and reasonably) negates the effects of life experiences. The drive for scientific objectivity is seen to entail a blanket rejection of the worth or value of subjectivity in apprehending the nature and causes of disability, i.e. the patient’s distress is not a valid thing in itself but is merely a ‘surface marker’ of the underlying chemical lesion. It follows that the patient’s role in recovery is one of inert acquiescence.

Anybody reading the daily press, searching the internet or following the specialist psychiatric literature will not be aware of these types of problems. All they will find is a breathless excitement relating to yet another incipient technological breakthrough. A sizeable part of this information is fed to the news services by interested parties, although negative views are starting to seep through [18,32]. Psychiatry itself is hostile to criticism ¹², be it from within the profession or without, while governments prefer to hide behind expert committees as the ‘least awful’ option. Meanwhile, the mentally-disabled themselves are seen either as consumers or as antagonists. The term ‘consumers,’ which is rapidly gaining currency, is completely false in view of the ontology in which it is embedded. It is false because it somehow implies that the mentally-disabled have a choice, a choice which, of course, the very notion of having a chemical lesion of the brain denies. If, in my daily role as a psychiatrist, I tell you that your daughter has a chemical imbalance of the brain, I am speaking to you from a position of unassailable authority. Essentially, I am saying to you: Do as I say, or she dies. Only an ideologue would attempt to deny my statement, because no member of the general public has anything like the knowledge that could possibly refute the claim. For ordinarily courteous and deferential people, who are terrified to inertia by what is happening, the sight of a calm and confident figure who knows is more than a godsend, it is a ‘science-send,’ one could say. Fanatics may argue in favor of a realignment of the sufferer’s energy field, but they do that for ideological reasons, not for reasons that can challenge psychiatry’s claims of biochemical omniscience.

The other reason why the concept of choice is false is simply that, if a ‘consumer’ decides not to ‘consume’ what is on offer, he can readily be compelled to do so by legislation passed by the government on advice from the same expert committees who stand to gain most from the status quo. It is worth recalling that something like half the psychiatrists and other experts who served on the original DSM-III committees were being subsidized by drug companies ³³. DSM-III, of course, made sense only in the context of a biological approach to mental disorder [27, Ch.7], whose predictable outcome was the recent explosion in prescription rates for psychotropic drugs. In this sense, the drug companies must surely feel that their investment was well-directed. I am not suggesting there is no place for medication in the management of mental disorder, but am strongly in favor of much better and safer drugs developed by research programs arising from a formal, articulated model of mental disorder.

This, however, is after the event of my major claim, which is that modern psychiatry is not a science in any convincing sense of the term:

Psychiatrists have long attempted to convince the general public, the funding bodies and, most significantly, the younger generations of students and psychiatrists that the profession has articulated a rational model which grants it special and unique knowledge of the etiology and phenomena of mental disorder. Yet all along, we have known, or ought to have known, that there is no such model, thereby exposing ourselves to charges of intellectual turpitude. It is my view that a reasonable person could claim that we are guilty either of the grossest intellectual neglect or of outright scientific fraud. For myself, I can see no defense against either accusation ³⁴.

The physicist, Alan Sokal, has listed five criteria which may identify a pseudoscience:

1. It makes assertions about real or alleged phenomena and/or real or alleged causal relations that mainstream science justifiably considers to be utterly implausible;

2. It attempts to support these assertions through types of argumentation or evidence that fall far short of the logical and evidentiary standards of mainstream science;

3. Most often (though not always), pseudoscience claims to be scientific and even… claims to relate its assertions to genuine science, particularly cutting edge scientific discoveries;

4. It involves not a single isolated belief, but rather a complex and logically coherent system that “explains” a wide variety of phenomena (or alleged phenomena);

5. Practitioners undergo an extensive process of training and credentialing [35, p348].

The entry in Wikipedia ³⁶ also lists numerous features that can be used to distinguish science from anything less reliable but I am using the term differently here. Sokal’s first point indicates that ‘regular’ science is keen to separate itself from the false field, and the classic examples are astrology, phrenology, telekinesis, telepathy, and so on. More recently, fields which were accepted as (more or less) scientific are later shown to be invalid, such as psychoanalysis and (controversially) behaviorism. Others are seen as dubious or even fallacious from the beginning (EMDR, rebirthing, QEEG, primal therapy) and never gain entry to the establishment. The important point is that the larger scientific community guards its prerogatives jealously, and actively repels or expels the interloper.

Psychiatry, however, is different. Not only does conventional science take next to no notice of what psychiatrists are doing, but it makes (somewhat amused) room for them in medical schools, health budgets and other sources of legitimacy. Nobody in the scientific field disputes the claims for scientific status made by biological psychiatrists. Indeed, as mentioned above, some paragons of scientific respectability, such as Kandel and Bennett, advance the agenda of biological psychiatry by making very firm claims on its behalf. Kandel, for example ⁵, has repeatedly made the very strong claim that the neurosciences (for which he was awarded his Nobel Prize) will transform psychiatry and psychoanalysis: “…to understand behavior, one had to apply to it the same type of radical reductionist approach that had proved so effective in other areas of biology” [37, p236] “…the underlying precept of the new science of mind is that all mental processes are biological…Therefore, any disorder or alteration of those processes must have a biological basis” (p336, his emphasis). By this means, there is no suspicion directed at the claims of biological psychiatrists. They are accepted just as medical practitioners accept, say, veterinary or dental surgeons; rather like poor cousins, they are tolerated at the party, but not excluded.

For their part, as mentioned above, psychiatrists are quick to endorse any and all claims made on their behalf by such eminent authorities, such as the claim that Kandel won his prize as a psychiatrist. This does not stand up to close investigation. According to his autobiography ³⁷, Kandel graduated in medicine in 1956, having interrupted his course to undertake a year of research in an eminent neurophysiology laboratory. After completing a three year research internship at the NIH, he joined the psychiatry training program at Harvard Medical School, but spent a large part of his time actively pursuing pure laboratory research (on the neuroendocrine cells in the hypothalamus of the goldfish, as it happens, p155). The psychiatric training was essentially psychoanalytic and clearly of an outdated standard: “…most (of our teachers) discouraged us from reading the psychiatric or even the psychoanalytic literature because they thought we should learn from our patients and not from books” (p154). After two “disappointing” years, he left for full time basic research with results that will remain part of the neurosciences for ever. He did not complete a recognized training course, he did not sit his examinations, he did not practice as a psychiatrist, does not teach psychiatry as such and has never published anything that constitutes psychiatric research. He is a renowned professor in the department of psychiatry at Columbia University, NY, but every department of psychiatry has non-psychiatrists as professors. The claim that psychiatry has recently been awarded a Nobel Prize does not stand up to scrutiny. So let us see whether psychiatry is a science or a pseudoscience.

Sokal’s fifth point, that psychiatrists “undergo an extensive process of training and credentialing,” is correct. In this country, medical students study six years, then must complete an internship before registering as a medical practitioner. Most graduates will work either in hospitals or in general practice for a few more years before beginning their psychiatric training, which is a further five years. In the US, students complete a basic premed course of three years, followed by four years of medical school. On graduating, they must complete their internship before beginning training as a psychiatric resident, which takes three or four years. Further specialist training (child or forensic psychiatry etc) can add to this. Medical training is demanding and burdensome but not, in any formal sense, intellectually demanding in the sense of, say, mathematics or philosophy. At all times, students are under surveillance for the types of behavior which are likely to put patients at risk or bring the profession into disrepute, especially drug or alcohol abuse or dishonesty.

Psychiatry “…involves not a single isolated belief, but rather a complex and logically coherent system that ‘explains’ a wide variety of phenomena…” Sokal’s fourth point is perfectly correct. The phenomena of mental disorder are (at least vaguely) familiar to all medical practitioners, but most have little or no understanding of, and little or no interest in, its manifestations. Psychiatric factors interfere with their real interest, meaning orthodox physical medicine in sensible patients of good moral standing. This is not unexpected: orthodox medicine is a fascinating, challenging and fast-moving field and the last thing a busy surgeon wants is to have to deal with such ephemera as fears (for god’s sake). So when psychiatrists say they have a theory which can deal with the whole, messy aggravation of personality and such like, orthodox practitioners are not going to look closely at their justification.

From the medical point of view, psychiatry doesn’t “…makes assertions about real or alleged phenomena and/or real or alleged causal relations that mainstream science justifiably considers to be utterly implausible” (his first point), it is the patients who do that. For example, a plastic surgeon will repair the lacerated tendons and nerves following a slashed wrist, then gratefully hand the specimen over to the psychiatrists. The claim, heard every night in an emergency department, “My boyfriend left me so I want to die,” is, in the clear, rational world of most medical practitioners, utterly implausible. Why would anybody do a thing like that? Just get another boyfriend. The phenomena (of overdoses, delusions, etc) are real, it is the patients who are implausible so, like sewer workers, psychiatrists perform an essential service. Psychiatry offers to clean up the mess the patients have created with their irrational dramas, and orthodox physicians are very pleased to accept their offer.

Psychiatry “…attempts to support these assertions through types of argumentation or evidence that fall far short of the logical and evidentiary standards of mainstream science.” There are two aspects to Sokal’s second criterion. Firstly, orthodox medicine has no interest in what psychiatry claims, as long as it isn’t actually embarrassing (such as the Freudian nonsense about penises) and it does the job of clearing the overdoses from the ED. Secondly, psychiatry makes practically no claims on the credibility of orthodox practitioners. All it does is echo the standard claims that every medical graduate has been immersed in since high school, that reductionist biology will provide the answers. Medicine only became suspicious when the Freudians claimed too much. If they’d kept quiet, they could still be in business. The types of papers listed above (Section II) do not raise any doubts among physicians; they are simply a familiar way of approaching a problem they don’t care about.

Kandel emphasized this in his anthology “Psychiatry, Psychoanalysis and the New Biology of Mind,” published by the American Psychiatric Association and it is worth quoting him at length, just because it is so utterly conventional and non-threatening:

“…the classification of mental disorders must be based on criteria other than the presence or absence of gross anatomical abnormalities. The absence of detectable structural changes does not rule out the possibility that more subtle but nonetheless important biological changes are occurring… To clarify these issues it will be necessary to develop a neuropathology of mental illness that is based on anatomical function as well as anatomical structure. Imaging techniques such as positron emission tomography and functional magnetic resonance imaging have opened the door to the noninvasive exploration of the human brain at a level of resolution that begins to approach that which is required to understand the physical mechanisms of mentation and therefore of mental disorders” [5, p47-48].

Finally, psychiatry “…claims to be scientific and… relates its assertions to genuine science, particularly cutting edge scientific discoveries.” Again, Sokal’s third point is true. Biological psychiatry certainly claims to be “genuine science” in every sense of the term, as the quote from Kandel shows. It freely uses the familiar technology of physical medicine, simply applying it to a field which is both real and of no interest to anybody else. Critically, the nature of psychiatry’s biological claims are not examined. The evidence adduced in this type of work is beyond reproach; we simply have to concern ourselves with the nature of the claims for which the evidence is supposed to be supporting. Is it true that a full understanding of the human brain will yield a full understanding of all mental disorder with no unanswered questions? This is a metaphysical question, meaning a question which cannot be answered by empirical evidence. The question-begging nature of the entire biological program in psychiatry is rendered explicit in Kandel’s quote, and it is on this point that I claim the entire biological program in psychiatry lurches into the realm of pseudoscience. The medical methodology is remarkably successful when applied to questions of matter and energy. Similarly, from the medical point of view, the methodology of conventional psychiatry (statistics, genes, scans, drugs) is faultless. All that remains is whether it can legitimately be applied to questions of a metaphysical nature. At no point in the last one hundred years have orthodox psychiatry or its apologists offered any evidence to suggest they have considered this question or, indeed, that they are even aware that such a question could exist. The full implication of Kandel’s claim is crystal clear: Humans are real, mental disorder is real; therefore, what works in one field should work in the other. QED.

The question now arises: how come, armed with their superior methodology, the advocates of phenomenology, post-modernism and relativism, and of critical theory in science and technology studies, did not discover this themselves? Unfortunately, as a psychiatrist, I cannot answer this. I can offer suggestions, but they will be generated from within my specialty and may not be considered objective. The least I can say is that they were distracted by their own interests; from the point of view of the mentally-ill, they have been sleeping on their well-paid university jobs.

Conclusion

Orthodox psychiatry is pursuing a biological program with no justification. The claims made by biological psychiatrists are not of a nature which can be answered from within the conventions of materialist medical science. Because of its nature and lack of interest, orthodox medicine will not discover this. Similarly, because psychiatrists are trained in a particular and highly successful ontology, and because medical training does not encourage criticism, there is no reason to believe that orthodox psychiatry will encourage a process of self-criticism sufficient to examine its most fundamental premises. At the same time, students of the sociology and epistemology of science, who claim to have the unique intellectual tools that conventional scientists lack, appear to have contributed very little, if anything, to the question of what is the correct model of mental disorder. This should be cause for the very greatest concern but, if nothing happens, it will be cause for despair.

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25. Young NS, Ioannidis JPA, Al-Ubaydli O (2008) ‘Why Current Publication Practices May Distort Science’. PLoS Med 5(10): e201 doi:10.1371/journal.pmed.0050201
26. McLaren N. (1996) The myth of eclecticism. Australasian Psychiatry 4: 260-61.
27. McLaren N. Humanizing Madness: Psychiatry and the Cognitive Neurosciences. (Ann Arbor, Mi.: Future Psychiatry Press) ISBN 978 1 932690 39 2.
28. McLaren N. (2009) Humanizing Psychiatry: The Biocognitive Model (Ann Arbor, Mi.: Future Psychiatry Press). ISBN 978 1 615990 11 5.
29. Dennett DC. (1993) Consciousness Explained. (London: Penguin Books)
30. McLaren N. (2010) ‘Monist models of mind and biological psychiatry’. Ethical Human Psychology and Psychiatry (in press).
31. Dimond PF (12/ 24/2009). ‘Questions remain about whether antidepressants really work’ http://www.genengnews.com/specialreports/sritem.aspx?oid=71818308
32. Begley S. (2/8/2010) ‘The depressing news about antidepressants’ Newsweek, p38-42.
33. DSM-III and drug company influence http://www.search.com/reference/Diagnostic_and_Statistical_Manual_of_Mental_Disorders
See also: http://www.nytimes.com/2010/04/01/business/01payments.html on payments to medical practitioners by Pfizer.
34. McLaren N. The biopsychosocial model and scientific fraud. Paper presented to annual congress, RANZCP, Christchurch, May, 2004. Revised version: ‘When does self-deception become culpable?’ Ch.8 in Ref. 27.
35. Sokal A (2008). Beyond the Hoax: Science, Philosophy and Culture. (Oxford: University Press).
36. Pseudoscience, in Wikipedia: http://en.wikipedia.org/wiki/Pseudoscience Cited April 2nd 2010.
37. Kandel ER. (2006) In search of memory: the emergence of a new science of mind. (New York: Norton)