Truth, Nihilism and Psychiatry

My colleague, Nassir Ghaemi, in response to my challenge of his notion of "truth" in psychiatry, unfortunately, responds with media's "third rail" -- connecting this discussion to the advent of the National Socialist Party or Nazis of Germany. He states that post-modernism was a reaction to the modernist thinking that led to the two world wars of the previous century (yet apparently Nazi theorists were post-modernists). I do not want to pursue this highly emotionally laden and volatile example (my parents were Holocaust survivors incidentally) because I see it as arousing unnecessarily inflammatory feelings.

Also the quick link to a vigorous attack on the critics of conflict of interest in medicine strikes me as an underlying agenda. True most of us cheat on taxes, but there are degrees. A drug company pen or pad is one thing (though in a reaction to the gross abuses of late, they may be a thing of the past). Ten of millions of drug company dollars for the maintainance of psychiatry departments, national conventions, conferences to define diagnoses, drug studies, consulting and speaking fees add up considerably compared to the book sales of a Marcia Angell. Whether Nasser agrees or not, the real or just appearance of conflict of interest, threatens to undermine doctor's professionalism. Major reform is in progress.

So I don't want to talk more of Nazis and drug companies. Rather, I remain concerned about how concentrations of power influence the "truth". Russell Barkley, (the ADHD expert, not the philospher) has stated that "No scientific undertakings or hypotheses are completely divorced from the social values of their time and place." All I am suggesting is that doctors and patients recognize that "science" exists within a context so that when Nassir might cite some study to prove a biochemical point I know a priori that the study's most basic assumptions on diagnosis and treatment are also the most challengeable. That doesn't mean that I can't utilize the information from the study but I remain aware of the possible biases introduced in any science.

Mary Bateson, daughter of Gregory Bateson, and a committed relativist, once said, "If a tree falls in the forest I don't say 'I experienced a tree falling'. I say 'A tree fell in the forest.' I am aware that there may be multiple factors involved in my experience so that you and I could agree or disagree about that tree, but for practical and semantic ease I say 'The tree fell in the forest.'" I have no problem with a lithium level being too high at 4.0 mcg and recognizing that appropriate actions need to be taken clinically at that moment. But I remain semi-aware of an entire ideological structure that has set up my experience of that patient's behavior so that I even bother to prescribe lithium and obtain a blood level to monitor it.

I suspect Nassir and I agree clinically on many things but philosophically I worry that his ideas of "truth" and realism have been the instruments of power and exploitation more than my ideas of relativism and post-modern thinking. The latter philosophies do not preclude a moral and legal system -- yet maintain that the moral system is also based upon relativist and power-based agreements. I do not see this as nihilism. I worry about strict constructionists. I've had the opportunity to try to instruct Antonin Scalia, the Supreme Court justice on the difficulties of drawing a line between extremes of normal and the abnormal (we were on an ethics panel together). He just couldn't get it. "Either it's a disorder or it's normal," he insisted. I'm not sure I'll do any better with Nassir.