The Therapeutic State.

• Author: Szasz, Thomas
• Position: America's health policies

The Tyranny of Pharmacracy

One of the symbols of sovereign states is the postage stamp. Traditionally, U.S. stamps have depicted a famous American or an important historical scene. In 1893, to increase revenues, the U. S. Post Office began to issue commemorative stamps. The first stamps with health-related themes--for example, a stamp depicting children playing and smiling, commemorating the centennial of the American Dental Association--appeared in 1959. In 1999, the Postal Service unveiled two stamps emblematic of the escalation of America's wars on diseases. On one, the inscription recommended, "Prostate Cancer Awareness: Annual Checkups and Tests"; on the other, it exhorted, "Breast Cancer: Fund the Fight. Find a Cure" (Woloshin and Schwartz 1999).

The Medicalization of Politics

Webster's Third New International Dictionary defines the state as "The political organization that has supreme civil authority and political power and serves as the basis of government." Instead of offering definitions of the state, political scientists prefer to identify its characteristic features, such as the possession of "organized police powers, defined spatial boundaries, or a formal judiciary" [and] "a deep and abiding association between the state as a form of social organization and warfare as a political and economic policy" (Fried 1968, 143, 149). I regard monopoly of the legitimate use of force as the quintessential characteristic of the modern state. In this article, I focus on the beliefs and values that justify the possession of such force and the aims it serves.

The need to justify the use of force seems instinctive. For the child, the parents' power to coerce--by word or deed, intimidation or punishment--appears justified by their superior wisdom and by the child's innate lawlessness and socially imposed duty to become domesticated. The combination of the natural authority of the superiors, the natural nonconformity of the subordinates and their need to learn the rules of the game and to adhere to them, and the supreme importance of the welfare of the group (family, society, nation), which rests on conformity to social convention, form the template for religious, political, and medical justifications of coercive domination.

Three familiar ideologies of legitimation result: theocracy (God's will); democracy (consent of the governed); and socialism (economic equality, "social justice"). In 1963, in Law, Liberty, and Psychiatry, I suggested that modern Western societies, especially the United States, are developing a fourth ideology of legitimation: "Although we may not know it, we have, in our day, witnessed the birth of the Therapeutic State" (212). Since then, in articles and books, I have described and documented the characteristic features of this polity: medical symbols playing the role formerly played by patriotic symbols and the rule of medical discretion and "therapy" replacing the rule of law and punishment (see Szasz 1965, [1970] 1977, 1980, 1982, 1984, 1994a, 1994b, 1995, 1996).

It is undeniable that the state is primarily an apparatus of coercion with a monopoly of the legitimate use of violence. "Government," warned George Washington, "is not reason; it is not eloquence. It is force. Like fire it is a dangerous servant and a fearful master" (qtd. in Cato Newsletter, June 1, 2000, 1). Hence, as the reach of the legitimate influence of this "fearful master" expands, the sphere of personal liberties contracts. What, then, ought to belong to the state, and what to the individual? The history of the West may be viewed in part as the history of the growth of freedom, characterized by a lively debate about where to draw the line between the state's duty to safeguard the interests of the community and its obligation to protect individual liberty. Accustomed to hearing phrases such as "freedom of religion," "freedom of speech," and "the free market," we recognize that each refers to a set of activities free from interference by the coercive apparatus of the state. Should we similarly possess "freedom to be sick," "freedom to make ourselves sick," "freedom to treat ourselves," "freedom to obtain medical care," and so forth?

Informed debate about where to draw the line between the welfare of the community and the health of the individual requires that we be clear about the legal distinction between public health and private health. Edward P. Richards and Katharine C. Rathbun--a law professor and a public-health physician, respectively--explain: "Public health is not about making individuals healthy; it is about keeping society healthy by preventing individuals from doing things that endanger others" (1999, 356). Hence, preserving and promoting public health often require coercion, whereas preserving and promoting private health require liberty and responsibility. "Persuading people to wear seatbelts, treat their hypertension, cat a healthy diet, and stop smoking," Richards and Rathbun continue, "is personal health protection. Stopping drunk drivers, treating tuberculosis, condemning bad meat, and making people stop smoking where others are exposed to their smoke is public health.... Public health should be narrowly defined in terms of controlling the spread of communicable diseases in society" (1999, 356, emphasis added). Instead of confronting the differences and conflicts between public health and private health, politicians, physicians, and lay people debate slogans, such as the right to health, a patient's bill of rights, patient autonomy, war on drugs, and war on cancer.

Medical Ideology and the Total State

In the nineteenth century, when scientific medicine was in its infancy, disease was defined by pathologists; effective remedies were virtually nonexistent; the term treatment meant medical care sought and paid for by the patient; and the state showed little interest in the concept of therapy.

Today, when scientific medicine is a robust adult, physicians routinely effect near-miraculous cures; politicians and their lackeys, led by Surgeons General, define disease; the state shows intense interest in the concept of disease; and the term treatment is often used in lieu of the term coercion.

Fifty years ago, few Americans others than politicians and physicians knew there was a bureaucrat in America called the Surgeon General. Today, he is America's Physician General, preaching ceaselessly from the bully pulpit--a symbol and symptom of pharmacracy and of the growing power of the therapeutic state. Dan E. Beauchamp, an emeritus professor at the State University of New York at Albany, hails the sudden prominence of the Surgeon General as a sign of the "democratization" of health policy. He writes: "The role that democratic discussion now plays in health policy is perhaps best illustrated by the radical redefinition of the role of the U.S. Surgeon General from head of a rather obscure commissioned officer corps of the Public Health Service to our leading national spokesman on public health issues" (1988, 136).

Rudolf Virchow (1821-1902), the father of modern pathology, longed for a future in which the physician qua Platonic philosopher would serve as a guide to the politician-king. "What other science," he asked rhetorically, "is better suited to propose laws as the basis of social structure, in order to make effective those which are inherent in man himself?" ([1849] 1958, 66, emphasis added). He suggested that "Once medicine is established as anthropology ... the physiologist and the practitioner will be counted among the elder statesmen who support the social structure" (66, emphasis added). Virchow was politically naive: he thought the future doctor would be a solid scientist and a wise leader instead of, as is the case, a bureaucratic toady ignorant of scientific medicine. Furthermore, if the physician's task is to support the social structure, his actual job may be to harm, not help, the person called the "patient."

We know that the proposition that medical practice is a science cannot be true (see Szasz 2001, chap. 3 and 5). Nevertheless, the idea is superficially attractive, even plausible. To resolve human problems, all we need to do is define them as the symptoms of diseases and, presto, they become maladies remediable by medical measures.

Medicine and the Metaphor of War

The illnesses first understood and conquered by scientific medicine were the infectious diseases. Because the response of the immune system to pathogenic microorganisms is readily analogized to a nation resisting an invading army, the military or war metaphor has become congenial in thinking about illness and treatment. When we speak about microbes "attacking" the body, antibiotics as magic "bullets," doctors as "fighting" against diseases, and so forth, we use metaphors to convey the idea that the doctor is like the soldier who protects the homeland from foreign invaders. However, when we speak about the war on drugs or the war on mental illness, we use metaphors to convey the idea that the state is like a doctor when it uses doctors as soldiers to protect people from themselves. In one case, we speak about doctors helping patients to overcome diseases, in the other about doctors preventing citizens from doing what they want to do.

In the case of infectious diseases--the microbe as alien pathogen threatening the host (the patient's body)--the war metaphor helps us understand the mechanism of the disease and justifies the coercive segregation (quarantine) of contagious persons, animals, or materials. In the case of psychiatric diseases--the war metaphor casting the mental patient in the role of alien pathogen threatening the host (society)--the metaphor prevents us from understanding the problem misidentified as a disease: it convinces the patient's family, society, and sometimes the patient himself that the mental patient is (like) a pathogen, justifying the coercive segregation of the subject as "dangerous to himself...