Thomas Szasz takes on his critics.

• Author: Pies, Ronald
• Position: Letters - Letter to the Editor

I appreciated Jacob Sullum's thoughtful and generally balanced review of Szasz. Under Fire ("Thomas Szasz Takes on His Critics," May). But it is critical to distinguish Szaszian claims about the nature of "disease" from claims regarding the appropriate medical, legal, and social response to disease.

Citing my example of migraine headaches as a medical condition diagnosed almost exclusively on the basis of the patient's subjective reports, Sulhun objects that "migraine sufferers are not treated against their will." Neither are most patients with schizophrenia and bipolar disorder at least, most are not treated under some kind of court-ordered mandate or commitment. If one of the symptoms of migraine were, say, severe self-mutilation, does anyone seriously believe that involuntary commitment would not at least be considered for a migraine patient who refused admission to a hospital?

Sullum finds disingenous my claim that commitment decisions are ultimately judicial, not psychiatric. But most psychiatrists have been involved in many cases in which their petition for commitment was flatly turned down by the judge. Moreover, such petitions may also be brought to the court by police officers, next of kin, other physicians, psychologists, social workers, or even "interested parties."

Sullum wrongly asserts that psychiatric diagnoses "generally imply that the 'patient' either does not properly understand his own interests or is not capable of acting on them" and that therefore "the threat of involuntary treatment always bangs in the background." Providing a psychiatric diagnosis--even a serious one, such as schizophrenia categorically does Hot entail a claim that the patient does not understand his own interests or is in some pervasive way "incompetent."

Indeed, the notion of competence is fundamentally a legal, not a psychiatric one. Surely a diagnosis of delirium, rendered by an emergency room

physician, carries a much higher connotation of mental incompetence and also presents the "threat" of involuntary treatment. Yet we do not find many screeds condemning the motives or practices of such emergency room physicians.

Ronald Pies, M.D.

Clinical Professor of Psychiatry

Tufts University School of Medicine

Boston, MA

It is not accurate to say that I was "once a Szasz admirer," as reason's review of Szasz Under Fire suggests. I continue to admire him for his outspoken criticism of many psychiatric practices. These include "diagnosis creep," whereby...