Defining Disease

At a time when Washington can't seem to decide to what extent government should participate in health care decisions, psychiatrist Thomas Szasz reaches beyond the familiar rhetoric in his provocative book, Pharmacracy: Medicine and Politics in America. He offers stern warnings about the dangers of too much government involvement in the medical process, echoing arguments that conservatives are making on prominent health care policy issues such as patients' rights, Medicare, and the uninsured.

But Szasz's observations run deeper. Government has become much too involved in personal health care decisions by "medicalizing" what used to be considered bad behavior, he says. Politicians, he asserts, are dictating what is and what is not a disease, influencing—for better or worse—how the courts, health care professionals, and individuals respond to these "diseases." Szasz offers an exhaustive comparison of physical and mental illness, and complains that the two categories have become confused.

Such confusion can't be good for members of Congress and administration officials who are now trying to decide whether health insurance companies should be required to cover mental health care as generously as physical health care. Both the House and Senate are considering so-called mental health parity bills, and President Bush has said he will sign some sort of parity legislation.

In essence, Szasz says, politicians are granting people permission to shirk responsibility for their actions and behaviors. They give medical names to human problems, he asserts, blaming society and creating harmful regulations that don't promote change. "In the past, politicians seized power by declaring national emergencies," the author says. "Now they do so by declaring public health emergencies....The government declares war on drugs, cancer, heart disease, obesity, mental illness, poverty, racism, sexism, suicide, and violence. However, drug addicts refuse to abstain from drugs, the obese overeat, the mentally sick reject being treated as patients, and the poor refuse to adopt the habits of the rich."

Part of the problem, he says, is that there is no clear definition of the word "disease"—so politicians can define it as they wish. That is why the country fruitlessly debates whether drug addiction, clinical depression, pathological gambling, social anxiety, and so on are or aren't diseases. And what about treatments? he asks. Are abortion, sex-change operations, and euthanasia "treatments" for "diseases"? Indeed, supporters of mental health parity legislation have struggled to determine which mental health problems should be covered.

Szasz devotes a great deal of time to determining what should qualify as a disease and to classifying disorders as physical illness, mental illness, or behavior. He argues that clear definitionsestablished by health care professionals-would improve treatment outcomes and reduce the risk of letting criminals off the hook in court.

Szasz is also critical of the way Congress wrote the Americans With Disabilities Act. Recognizing mental illnesses as bona fide diseases, legislators decided which would be protected under the act and which would not. As a result, claustrophobia and personality problems are covered, but kleptomania and pyromania are not, even though the American Psychiatric Association recognizes both of the latter as mental disorders. Szasz suggests that politicians are now making their decisions based not on medical science, but on their ideas of what kinds of behaviors they want to prosecute as crimes. But identifying some mental disorders as diseases and exempting others distorts public policy approaches, he says.

Szasz's thorough preachings reflect current conservative ideology promoting individual responsibility and smaller government. Consider the welfare reform bill of 1996, which cut welfare rolls in half and required virtually all beneficiaries to work in some capacity, as a way of forcing individuals to recognize and overcome their shortcomings. Now, if welfare recipients don't get to work within about two years, most are cut off from the dole, forcing them to take responsibility and make decisions about how their families will live: Get a job? Or live on the streets and receive handouts? Indeed, Szasz appears to promote the right to be physically or mentally ill, as long as it doesn't threaten public health.

Szasz is a professor of psychiatry at the State University of New York Upstate Medical University in Syracuse. His other books include The Myth of Mental Illness, Our Right to Drugs, The Meaning of Mind, and Fatal Freedom. He hints at the applications of his theories on the last page of Pharmacracy. Politicians are simply responding to constituent demands to medicalize problems, Szasz writes. "Pandering to this passion, politicians assure them they have a 'right to health' and that their maladies are 'no-fault diseases'; promise them a 'patients' bill of rights' and an America 'free of cancer' and 'free of drugs'; and stupefy them with an inexhaustible torrent of mind-altering prescription drugs and mind-numbing anti-disease and anti-drug propaganda-as if anyone could be for illness or drug abuse."

Szasz has plenty of blame for all parties and offers little hope for redemption: "Formerly, people rushed to embrace totalitarian states. Now they rush to embrace the therapeutic state. When they discover that the therapeutic state is about tyranny, not therapy, it will be too late."