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Emotional Intelligence
The consequences of truth
Why Americans are nihilists.
Posted September 2, 2008
Those who are on the warpath against the pharmaceutical industry, and its collaborators in academic medicine, betray a deep philosophical commitment: postmodern nihilism. This is the concept that Larry Diller wanted to discuss to start our CrossTalk discussion. This fact comes across in recommendations such as that of Marcia Angell, former editor of the New England Journal of Medicine (and author of the soberly titled The Truth about the Drug Companies: How they deceive us and what to do about it. http://www.amazon.com/Truth-About-Drug-Companies-Deceive/dp/0375760946/…). Angell ends her book with some practical recommendations for patients, including that patients should ask their doctors whether they ever interacted at all with pharmaceutical companies, including receiving a pen or a note pad, much less giving lectures or receiving honoraria. If they had any such relationship ever, Angell recommends that patients should fire their doctors and get a new one! This would be like all Americans saying they would never vote for any politician that ever received a single dollar from any interest group. There would be no politicans left to vote for.
This nihilism is also reflected in the Marxian adage so blithely pronounced by our antipharmaceutical sages (like John Abramson in the scholarly tome Overdosed America http://www.amazon.com/Overdosed-America-Promise-American-Medicine/dp/00…): "Follow the money." In other words, if a researcher is funded by a pharmaceutical company, the study will be biased in favor of that company; any such results can be discounted as false. (It is interesting that studies funded by private foundations are not claimed to be similarly biased, nor studies funded by the government. Perhaps another aspect of the anti-capitalism that underlies this thinking: the government is sound and clean; private industry is dirty and evil.) One also hears clinicians frequently say: "I don't know who to believe any more. One study says X, the other says the opposite; and they are always funding by opposing companies. I will disbelieve them all." And go on practicing based on my own false opinions as all unscientific physicians have done since time immemorial.
The problem is that as a physician, you are not supposed to believe anyone. You are supposed to assess the evidence yourself and make an informed judgment, based on your two decades worth of formal education. Now you may say that physicians cannot be expected to understand the statistical details of medical research. This would be like saying that physicians cannot be expected to understand the physiological details of kidney function. You cannot be a physician unless you have basic knowledge relevant to medical practice, or unless you are able to augment your basic knowledge with further knowledge as your experience or practice demand. Medical statistics is part of medicine now, and no physician is a competent physician who does not have basic understanding of it.
Back to nihilism: If you say that money solely drives results, and you completely ignore the content of the research, then you are reducing the research to the money. There is no truth to the research that is being done; it all about making a buck. Similarly if you say that a physician's competence is nullified by pharmaceutical associations, you are saying that he has no inherent abilities that he can ethically put into practice; it is all about making a buck.
The reason so many doctors and patients and clinicians can think this way is because they have become nihilists; they no longer believe in objective truths; everything is a relative combat between interest groups seeking power and wealth. This idea is at the root of postmodernist thinking. Briefly, as Larry described, the modernist label is given to the tradition that most of us know about in philosophy and the humanities: the Renaissance, the Enlightenment, Jefferson, Washington, Lincoln, the French and American Revolutions, the Victorian era, Darwin, the rise of science and technology, the industrial revolution. Basically all of Western history until the first and second world wars: those two tragedies demonstrated to many Westerners that this fine tradition could not prevent genocide and a universal war worse than ever previously imagined, now that the tools of science and technology were available.
The result: a rejection of the Western tradition - post modernism. The main thinkers here were Nietzsche, then Heidegger, later a large French school (Lacan, Derrida) culminating in Michel Foucault (pictured). What is interesting about Foucault is that he weaved his postmodernist ideology firmly on a critique of psychiatry as his prime example of the errors of traditional thinking (Madness and Civilization: http://www.amazon.com/Madness-Civilization-History-Insanity-Reason/dp/0…).
This may all seem distant, but Emerson once noted that philosophies are no longer remembered when they become part of our bones. Many of these postmodernist views have become part of American culture, especially after the rejection of traditional values in the 1960s and 70s, followed by the failure of the idealisms of that era. Allan Bloom (The Closing of the American Mind : http://www.amazon.com/Closing-American-Allan-David-Bloom/dp/0671479903/…) well captures that evolution in the 1980s.
The philosophical falsity of postmodernist nihilism is being increasingly recognized by prominent contemporary thinkers, like the philosopher of mind Daniel Dennett (Postmodernism and Truth: http://ase.tufts.edu/cogstud/papers/postmod.tru.htm). We can discuss this aspect in more detail later. But the practical implications of postmodernist nihilism need to be highlighted: This kind of thinking arose before and after World War II: the Nazis first adopted its approach in formulating the Big Lie; since there is no objective truth, repetition would establish the truth as wished by the Fuhrer. There was no Science, as George Orwell reminded us, only German Science and Jewish Science; hence the Fuhrer could determine what science was (http://www.amazon.com/Collection-Essays-George-Orwell/dp/0156186004). In fact, Orwell's whole life work can be seen as a battle against the nihilism in thinking that abets and leads to totalitarianism. Heidegger was himself a Nazi for a time, and Nietzsche was the favorite philosopher of National Socialism. (This is not to say that those thinkers are evil; I am trying to show where their ideas played out historically). Moral relativism allowed space for the banality of evil that led to Jewish genocide.
Nihilism lost the war, but it won the peace; the West became relativist, although in the context of American culture. As Bloom argues, it became superficial and personal, rather than totalistic and political: "American nihilism is a mood, a mood of moodiness, a vague disquiet. It is nihilism without the abyss." Elsewhere he writes: "We have here the peculiarly American way of digesting Continental despair. It is nihilism with a happy ending." But its political implications are not minor. We ought to keep in mind that this kind of postmodernist thinking is exactly opposed to the commitments of the Founding Fathers; if Americans take seriously their patriotism around the principles of the Revolution, if they really think Jefferson and Lincoln were mostly right, then they must reject postmodernism root and branch.
So back to the pharmaceutical industry and academic medicine: it is all about money and power only if you place no value on anything else, namely an objective truth. When I said that a lithium level of 4.0 is toxic and kills, and this is a truth that is not relative or a matter of opinion, I was trying to make the point that medical practice, of all places, shows that postmodernism is false. A lie is not really a truth when the patient dies. Larry added that Ritalin also makes cognition better, and said that these facts did not impress him because we have overlooked psychosocial approaches. I agree with him on the clinical point, but he misses the conceptual point. (I too avoid amphetamines as much as possible and advocate psychosocial treatments for ADHD). The issue is not that this or that matter is true; the point is there are truths, and it is not all about the pharmaceutical companies manipulating us, or physicians seeking wealth. (As an aside and in reply to Larry's post: My book the Concepts of Psychiatry - http://www.nassirghaemi.com/work1.htm - makes these points and argues for an alternative way of thinking that is neither nihilist nor traditionalist; Paul McHugh wrote the foreword to the book, which is the same in the recent paperback version; I attack the biopsychosocial model because it is relativist and leads to the same harmful consequences as postmodernism. To provide the full context of my critique, I am writing a sequel, tentatively titled The Rise and Fall of the Biopsychosocial Model, which is to be published by Johns Hopkins Press next year. We can discuss these matters more also.)
If we accept that simple fact - that there are truths which cannot be reduced to power and money - then we must reject all simplistic critiques of the pharmaceutical industry and of academic medicine.
