Review of Pharmacracy. Medicine and Politics in America by Thomas Szasz. Prager: London, 2001

The latest addition to the plethora of books by Thomas Szasz does not appear to advance his treatise on psychiatry. It does, however, serve as a lucid summary and clarification of his views.

He focuses on what he sees as medicine's threat to human liberty, which he coins "pharmacracy". Medical killing in Nazi Germany is seen as an example of paternalistic state protection of incompetent individuals in the interests of health. Szasz sees modern medical practice as infused by the same ideology. As far as he is concerned, many human problems are illegitimately transformed into "diseases".

Consequently much of the book concentrates on the nature of disease and in particular mental illness. Historical, scientific and clinical aspects of the related concepts of illness, disease, disability and disorder are discussed. Philosophical issues are raised for Szasz to sweep away all alternative views to his own. He concludes in the final chapter by condemning the therapeutic state, arguing against state intervention in health as much as state intervention in the economy.

The book is a diatribe but it does have value in its elucidation of conceptual issues about illness. Even if some of Szasz's conclusions are incorrect, his analysis of these themes is incisive and useful.

The outset of his argument is that disease is defined as a physical lesion. The proposition that mental disorders are brain diseases therefore is a "big lie". Mental disorders are diagnoses not diseases.

Alongside this, secondly, Szasz acknowledges that belief in mental illness as a disease of the brain is a negation of the distinction between persons as social beings and bodies as physical objects. As he says, there is something positively bizarre about the modern, reductionist denial of persons. There is reflected in the widespread acceptance of unproven claims of physical causes of mental illness.

Thirdly, Szasz recognises that literalising the metaphor of mental illness by suggesting that it has a physical basis serves as the justification for psychiatric interventions and institutions. To deny that mental illness is a physical disease may therefore be seen as dangerous as it seems to undermine this practice. For example, failure of a physician to prescribe antidepressants for depression has been seen as a disciplinary offence.

Szasz makes clear that his regarding mental illness as an illusion does not deny the reality of the behaviours to which the term points. Nor does he forego the possibility that certain behaviours now called "mental illnesses" may at some time in the future qualify as medical diseases if neuropathological correlates are discovered

Although Szasz's argument against reductionism arises out of the definition of disease as physical pathology, in fact it is not dependent on this proposition. Psychiatry would be in real difficulties if its practice could only be defended by such a view, and this of course is Szasz's contention. His criticism of the widespread tendency to reduce psychiatry to neurobiology is justified because of the nature of human action and the relationship between mind and body. Ideological conflict about this issue is unavoidable and Szasz states his position trenchantly.

Yet Szasz goes on to also reject as false the definition of illness as dysfunction. He is a materialist in this respect because he wants to restore free will and responsibility to individuals for their behaviour. For Szasz, categorisation as a mental patient does not diminish legal competence. Responsibility for using the sick role for personal gain should be acknowledged. Involuntary treatment is violence defined as beneficence.

Szasz's unashamedly materialistic position may be anachronistic and naïve. He opposes all psychiatric coercion with consistency and integrity. The problem is that such a thoroughgoing attitude detracts from his attack on reductionism and the cultural critique of medicine and psychiatry. The views of Szasz and other criticisms of the reductionistic tendency within psychiatry have been conflated and identified together as "anti-psychiatry". This has led to confusion about the cultural critique of psychiatry. To his credit, Szasz has not added to this confusion as he has stated his views clearly.

Psychiatry does need to account for its practice. For Szasz, psychiatric practice is unjustifiable. For others who accept the critique of reductionism, psychiatric practice is a moral and ethical practice whose nature cannot be hidden behind medical scientism.

Medicine inevitably poses a threat through social control. The answer for Szasz is to promote human freedom. His notion of free will is too simple. Power and influence in human relationships appear more complex and multifaceted than the polarisation of the individual and the state.

As Szasz suggests, mental illness may be better described as problems in living. But not all life problems are described as mental health problems. For example, poverty is an economic problem. It may or may not lead to mental health problems. Is there a sense in which Szasz makes too much of the difference between the concepts of life problems and health problems?

The point is that he should not imply that mental dysfunction is unreal. He agrees with biological psychiatry in defining pathology as physical. He does not consider the validity of the notion of mental pathology. Such avoidance allows biological psychiatry to dismiss his criticisms of its excesses. His materialistic stance undermines the validity of his criticism of reductionism. His dogmatism detracts from the validity of his criticism of psychiatry.