From Michael Specter, in the May 30th issue of The New Yorker:
In the early eighteen-seventies, a smallpox pandemic that accompanied the Franco-Prussian War killed more than half a million Europeans. Smallpox claimed the lives of tens of thousands of French soldiers, yet the Prussians lost fewer than five hundred men. That was because Prussia vaccinated its entire Army against the virus, and France did not. There has never been a more dramatic demonstration of a vaccine’s power to alter the course of history.
Specter uses his review of Pox: An American History, by the Brandeis historian Michael Willrich, as an opportunity to look at the complex ethics of mandating medical care. Smallpox has now been eliminated from the Earth, with the exception of samples held in vaults in the United States and the Soviet Union.
Because small pox was so deadly, U.S. health authorities thought little of vaccinating people against the disease, whether they chose to be vaccinated or not. In the 1890s, U.S. marshalls armed with needles “rode from town to town,” vaccinating the healthy and quarantining the sick. “The logic …was straightforward: the good of the community had to outweigh objections raised by a minority.” Those who did not want to be vaccinated–and there were many–were vaccinated anyway.
Vaccination has become controversial again, and some argue that they have a right not to be vaccinated. Specter acknowledges that, but does not confuse that with the question of the effectiveness of vaccines–which is indisputable. “Modern vaccination is a triumph of medicine,” he writes. While some make a case against vaccination, nobody argues that getting smallpox is a choice some people might like to make.
The issues are far less clear in another piece in the same issue of The New Yorker, a moving but fundamentally flawed piece by Rachel Aviv about compulsory treatment of psychiatric disorders–in which she suggests, at various points, that having schizophrenia is a choice some people might make.
Aviv circles repeatedly around the notion of “insight” as applied to people with psychiatric ailments. Many people with such illnesses don’t think they are sick. In psychiatric terms, they lack insight into their conditions. Aviv misunderstands the concept.
Aviv’s piece follows the sad final years of Linda Bishop, who, from 1999 until her death in 2008, “drifted between homeless shelters, hospitals, and jail.” She was repeatedly diagnosed as psychotic, but refused to accept that. It’s a paradox for psychiatry, Aviv claims: “an early sign of sanity is the ability to recognize that you’ve been insane.” And she goes on to note that “a ‘correct attitude'” for “most Western psychiatrists” would exclude diagnoses involving “spirits, demons, or karmic disharmony.”
“A correct attitude?” Aviv writes about this as if it’s what psychiatrists choose to believe, not the product of a century of careful observation and study. And putting “correct” in quotes suggests that theirs is not the only acceptable attitude–that spirits, demons, and karmic disharmony deserve equal time.
If the facts in this account are correct, Linda Bishop is an unfortunate woman with a terrible psychiatric illness. (The diagnosis shifted between schizoaffective and bipolar disorder, Aviv writes.) Recognizing that she is sane is not a paradox, but an indication that she is stepping outside the psychotic delusions that plagued her for years. Indeed, that’s a sign she’s getting better, and there is nothing paradoxical about it.
Psychiatry, Aviv writes, “is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than an authentic wish.” So? It’s the field that deals with people whose mental faculties are corrupted. Refusal of treatment can be a wish in some patients, and it can be a manifestation of disorder thinking and illness in others. Again, what is Aviv’s insight here? The subtext seems to be that psychiatric illnesses are not real illnesses. These are simply a group of people who think differently from the rest of us–and they should be allowed to do so, rather than be forced to conform to “correct attitudes.”
Aviv quotes an anthropologist who refers to “the biomedical model” of psychiatric illness. Again, the suggestion is that there are other models. There are–spirits, demons, and karmic disharmony, which led to the creation of asylums in which mentally ill people were horribly mistreated for centuries. Should we reject the “biomedical model” in favor of that?
“There are many valid reasons that people choose to refuse treatment,” Aviv writes. Linda Bishop “chose” to refuse treatment and starved to death alone in an empty house during the winter of 2007-2008.
Her sister sued the hospital that had released her, and the attorneys representing the hospital argued that Linda “was making a reasoned decision to pursue an alternative life style.”
That might have been true for the thousands of French who died of smallpox in the Franco-Prussian War. Their opinions were not corrupted and distorted by psychiatric illnesses. Aviv is wrong to leave readers with the impression that Linda Bishop chose to starve to death, or that she could have foreseen the consequences of remaining alone in that house.
Next time, perhaps, Aviv or her editor should run the copy by Michael Specter, a seasoned science writer who could have saved them some embarrassment.
– Paul Raeburn
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