The Limits of Psychiatry
How do you solve a problem like aporia?
The hard thing about psychiatry is that it’s about the brain. This is just bad luck for psychiatrists. They’d have a much easier time if their field concerned a simpler part of the body. Instead, they’re stuck trying to figure out the most complex thing in the universe and what to do when it malfunctions.
As evidence of the brain’s complexity, consider how much variation there is in psychiatric diagnoses. Such variation is what Daniel Kahneman, Olivier Sibony, and Cass Sunstein call noise, which they discuss in their book Noise.
It works like this. If I give a student’s paper a B but another professor would give it a C, this is noise. Similarly, if I give a paper a B, then regrade it a few weeks later and give it a B+, this is also noise. Kahneman, Sibony, and Sunstein show that noise is everywhere. It’s a problem in education (grading, admissions), but also in the justice system (different judges give different penalties for the same crime), hiring practices (people can’t agree on whom to hire), and medicine.
It’s noise when multiple psychiatrists give different diagnoses to the same patient. And noise is bad, since diagnoses come in better and worse forms and call for different treatments. Research finds that the reliability of psychiatric diagnoses is improving, but the level of noise is still shockingly high for some disorders.
Take major depressive disorder. A large, multi-site study found that “highly trained specialist psychiatrists under study conditions were only able to agree that a patient has depression between four and fifteen percent of the time.” In fact, in some cases, the DSM-V led to less consistency than the DSM-IV: the trials found “decreased reliability in all major domains, with some diagnoses, such as mixed anxiety-depressive disorder, so unreliable as to appear useless in clinical practice.” Lack of reliability has led other researchers to conclude that psychiatry should abandon diagnostic classification altogether, calling it “a disingenuous categorical system.”
For decades, selective serotonin re-uptake inhibitors (SSRIs) such as Prozac and Zoloft were prescribed on the theory that depression is caused by low serotonin levels. Last year, Joanna Moncrieff and colleagues received a lot of media attention for a paper showing that the chemical-imbalance theory is false. Although SSRIs are sometimes helpful in treating depression, this isn’t because people with depression have low serotonin levels. (SSRIs are very effective at treating premature ejaculation, though.)
What should we make of all this? When it comes to assisted dying, people sometimes point to psychiatry’s limits when opposing assisted dying for people with mental illnesses. In a recent Reuters article, Sonu Gaind, chief psychiatrist at Sunnybrook Health Sciences Centre, makes this appeal. “We don’t even understand the biology of most mental illnesses,” he said.
Given the uncertainty of diagnosing and treating mental illness, the risk is higher that someone will have an assisted death who could have been treated instead. Since wait times are so long, this might be because the person wasn’t able to receive the right type of care in time.
Or, as also happens, a person receives treatment for years but doesn’t improve. This has been Lisa Pauli’s experience. As the Reuters article describes, she has had treatment for her anorexia for years, but hasn’t gotten better. Now she wants an assisted death, and will likely qualify for one next year when Canada begins allowing assisted dying for people whose sole underlying condition is a mental illness.
The objection to assisted dying is that, since we don’t understand mental illness well, we shouldn’t be offering assisted dying to people with mental illness. I don’t find this persuasive. Psychiatry’s limited understanding of the biology of most mental illnesses, the high rate of noise in diagnosis, and poor treatment outcomes of many who do receive psychiatric care could all constitute reasons for assisted dying. Up to 60 percent of people with a psychiatric disorder experience a treatment-resistant form. “We don’t know what’s wrong and, even if we figure it out, there’s a good chance we won’t be able to help much” isn’t much of an argument against assisted dying.
When it comes to making important medical decisions, we want patients to be as informed as possible. This includes knowing about uncertainty. We make decisions under uncertainty all the time: the drug might cause these side effects, the cancer might go into remission, you might be able to walk again. What we should do with this information is, as always, something that should be left up to the patient.
I have a fair bit to say here, but I'll begin with this quote: "What we should do with this information is, as always, something that should be left up to the patient."
That is often a good value to have, but in the case of mental illness, it most definitely is not. It assumes that the patient is capable of making generally rational, all-things-considered judgements. For a great many sufferers of mental illness, this just isn't true. I don't mean psychosis here--I'm talking about the typical cognitive distortions caused by various kinds of mental illness, of many kinds (i.e., not just depression or other mood disorders).
To think that most people suffering from mental illnesses/disorders are capable of making appropriate judgements according to their all-things-considered values is just false. Which means that it would be wrong to take those judgements at face value and pursue medical options on their basis.
One aspect of these cognitive distortions show up in the following way. Many people, including myself, have experienced points in time when our mental illness has seemed so inexorable and impossible that it seems like nothing will ever change, it will not get better, and so on, only for this to not be true weeks or months later, typically after a significant intervention from psychotherapy, a new drug regime, and so on. But in those moments, it seems we will never get better.
Obviously, treatment-resistant mental illnesses exist and are bad for those who have them. However, treatment resistance is not the same as *no progress*. Just to use my own case again (noting the dangers of generalizing from a sample of n = 1), while my mental illness has most definitely been resistant to treatment over the long term (I have never 'gotten better'), I have undoubtedly made major progress and improved the quality of my life. And indeed, I am not the only person to whom this has happened. Furthermore, one never knows when a new treatment will arise, when one's life circumstances will change in a fortutious way, when a perceptive professional will provide a re-diagnosis that leads to more effective treatment, etc.
The objection to make to mental illness being a category elligible for MAID is not that we don't understand mental illness well enough to treat it. Rather, the objection is that it is not an appropriate response to the nature of mental illness as something people suffer. We are more or less good at treating it in different circumstances, but it is never an all-or-nothing situation; there are always possibilities, there are always new ideas, new personal breakthroughs, re-assessments and re-diagnoses.
Indeed, the confusion around specific diagnoses IS a reason for scepticism regarding MAID for mental illness, but not for the reason presented here. Rather, it shows that because mental illness is not like cancer, or ALS, or other illnesses we can reliably identify and treat in a way that either works or it doesn't, we need to be alive to the possibility that for a particular patient, the situation has been mis-read and needs rethinking. This can happen over time, too--people's particular manifestations of an illness/disorder can change, and in changing it can be become clearer how to treat them in a way that improves quality of life.
Things are a lot more fluid, dynamic, and changable in mental illness. This, combined with the cognitive distortions to which many/most sufferers are prone, means that a singular, irreversable, existentially maximally-significant decision like ending one's life is: i) not something that a patient can typically be disposed to consider in a sober way, and ii) not an appropriate response to having mental illness, even of a "treatment resistant" kind. To allow MAID for mental illness reasons is to let the illness wrongly dictate the patient's values and preferences, to misunderstand the nature of mental illness as compared with other illnesses, and to deny people the triumph of the spirit that comes from facing this particular kind of adversity.
Are there people who suffer so much, and so irremediably, that something like MAID should be available to them? Well, aside from the unknown of irremediability -- an issue that, in this context, is very different from "well, maybe in 2 years they'll find a cure for your disease", since, as I mentioned, the form of the illness is not the same -- I can imagine that there are such people. However, it seems to me that there is no way to create a system that can differentiate these cases, given the unique nature of mental illness. The success (and I agree it is largely a success) of MAID for physical illnesses is not readily transferable to mental illnesses, for the reasons I've discussed here.
Indeed, we should not think of mental illnesses like other physical illnesses, just being "of the brain" rather than other body systems. For they are not merely disorders or diseases of the brain. Not like, say, Lewy-body dementia. That's another flaw in both the argument you are critiquing and your counter-argument. Psychiatry is not just about the brain; nor is psychology. It is about the *person*, and their mind. And the mind is not just the brain, but rather it is the central mental features of a whole embodied person embedded in an environment, both natural and socio-cultural. This is one of the major reasons why mental illnesses and disorders are not straightforwardly like non-mental ones.