In response to:
'The Corpse in the Elevator': An Exchange from the April 28, 1983 issue
To the Editors:
Professor Lewontin’s reply to my letter [NYR, April 28] misrepresented my views, and misstated certain matters; I must reply.
I completely agree with Lewontin that there are (1) limits to reductionism, (2) that “diseases” should be studied in total-systems contexts: that many are not one-way “arrows of causation” (e.g., post-trauma litigated chronic pain).1 Now my points:
The phrase ” ’cause’…necessary but [not] sufficient” was misread to mean does not cause. Let me be clearer: The TB bacillus is one of many causal factors of the several kinds of TB (“miliary,” etc.). I completely agree that such factors include wages, factory conditions, etc. They were “strikingly absent” only because Lewontin’s review had already over-stressed the social ones; a fair balance was needed.
I “do not…cannot” deny the biochemical school of schizophrenia: we do such research at my hospital. Of course I did not include pre-frontal lobotomies as treatments: justly discredited, they are no longer done—nor are bleeding and using ducking stools.
Now to ECT. The dig, “benign guise,” was followed by the erroneous statement, “awful destruction of memory, personality [etc.].” As chairman of San Francisco’s mental health commission, I held public hearings (with former patients) on California’s ECT control bill. I helped word it: I know that ECT, like antibiotics, surgery, etc., can be mis-used. However, I quite agree with the conclusions of a massive (three year) review of forty-five years of data by the American Psychiatric Association: when properly done, ECT is a “safe…effective…valuable treatment in some types of affective disorders (esp. psychotic depressions).” (The review discusses all the actual side effects, legal protections, etc.)2
Now to Vacaville hospital: Per [Lewontin’s] suggestion, I contacted them directly.3 [His] indirectly obtained accusation of “aversive conditioning…torture…carried out [now]” is a falsehood. The truth follows:
(1) No such activities are occurring, nor are any such being contemplated: “There are no esoteric or experimental treatment procedures…most go to long term group psychotherapy.”4
(2) Psychosurgery has never been done, nor will it ever be done. Neurosurgery has been done for brain tumors, injuries and intractable epilepsy.5
(3) During 1967-early 1968, as a “last resort” method to help control uncontrollable severe self-mutilations (with suicide/murder), sixty-four inmates signed “contracts” for a clinical Anectine program; nine received it. It was cancelled: too complex, with equivocal results.6 Not only Lewontin thinks it harrowing: so do I and so do the present Vacaville staff; they have no intentions to ever repeat it.
I repeat: most clinicians facing their only givens (symptoms: “chief complaint,” “behavior,” etc.) try to do their best.7 Likewise, with their givens, so do most researchers. There are bad/ignorant/faddish persons in both areas,8 but this should not deter the others from being allies in trying to understand and help humankind.
Francis J. Rigney, MD
Pacific Medical Center
San Francisco, California
R.C Lewontin replies:
Dr. Rigney and I seem to have got into a needless struggle from which I hope we can extricate ourselves. In large part, it is because he has gotten the impression from my remarks on various medical matters that I am generally hostile to physicians and their practice and that I condemn them as callous and ill-willed. That is certainly not my position, nor do I share with Illich the belief that doctors do, on balance, more harm than good. I agree with Rigney that the vast majority of physicians are conscientiously trying to help their patients and are, in the process, reasonably decent and humane.
The problem for physicians is that the conceptual and practical tools with which they are provided by their training bear the strong impress of the vulgar reductionism that characterizes so much of our intellectual life. They and we are not more victimized by this reductionism in medicine than in, say, economics. Medical science is almost entirely dominated by the search for a drug, a medicine, a diet, or an operation, a magic bullet that will drill clearly through the cause and leave the rest miraculously untouched. The point of my review was that the reductionism is a problem not just for medicine, but for all of natural science.
One consequence of the reductionist model is that simplistic fads pass through medicine, even when they require humane people to do inhumane things. Lobotomies and amygdalectomies are a case in point. They cannot be passed off as just another discredited treatment like bleeding or ducking stools, because they do not come out of a prescientific ignorance of the physical world, but from the very bowels of scientific medicine. They represent not a breakdown of the system of narrow rationality, but its inevitable product.
The argument over electroconvulsive therapy is particularly revealing. The reader should understand that ECT does not come out of some deep theoretical understanding of how the brain works, but is the latest in a long line of shock therapies that goes directly back to the ducking stool.9 They are all based on the principle that a sufficiently severe jolt to the central nervous system—in the case of ducking the confrontation with near death by drowning—will somehow clear the system, rather like a mental enema. The treatment when done “properly” may indeed be “safe” (i.e., not cause broken bones, as it used to), “effective,” and “valuable,” but that does not speak to the issue of whether there are other undesirable results of electroshock. On the very day I received Dr. Rigney’s letter, former ECT patients and their families were picketing a meeting of the American Psychiatric Association in New York, protesting the “violence” they claimed had been done to them. Of course, maybe they are just crazy.
There has been a recent campaign to defend ECT, but even in an article summarized by the authors as showing that “ECT has survived blind public criticism and is commanding increasing respect and recognition from mental health professionals,” it is admitted that there are more or less severe memory losses, especially from bilateral treatments. 10 The attitudes of psychiatrists toward such side effects is epitomized in the remark of a psychiatrist friend who told me in a discussion of the problem: “Patients don’t really lose their memories; they just think they do.” How’s that for Cartesian dualism? The point is that psychiatrists, faced with patients in terrible psychic pain, welcome a treatment that relieves that pain in some patients, enabling them to work again and function socially. The other results of the treatment are called “side effects,” a rhetorical device of reductionist science that immediately renders them of a second order of importance unless they are positively lethal.
I am delighted to learn that prisoners at Vacaville are no longer tortured with Anective (a chemical ducking stool that induces the sense of drowning in the victim). That fact does not excuse its previous use nor make me guilty of perpetuating a falsehood. Dr. Rigney writes: “It was cancelled: too complex, with equivocal results.” Are we to suppose that if it had been less complex and more clearly efficacious that it would continue to this day? Its termination, like the cancellation under public pressure of the plan for psychosurgery on prisoners, seems to have had little to do with questions of humanity. I am not reassured by Dr. Rigney’s assertion that psychosurgery will never be used on prisoners. When humane people are willing to be complicit in inhumanity as a “last resort,” nothing is barred. Police and tyrants always appeal to the “last resort” to justify their violence. It is an irony of the state of medical science that healers must make the same appeal. We should all remind ourselves that “last resorts” are perilously close to “final solutions.”
June 30, 1983
See entire issue, Journal of Mental and Nervous Disease, July 1982. ↩
Electroconvulsive Therapy: Task Force Report 14, September 1978, American Psychiatric Association, Washington, DC. See also (“consent”) American Journal of Psychiatry 140:4, April 1983. ↩
Personal contact with Luke Kim, MD, Ph.D., chief of Professional Education, California Medical Facility, Vacaville, California 95696-2000. ↩
“A Brief Review of Psychiatric Controversies at CMF,” (signed) Edward P. South, MD, Assistant Superintendant, November 5, 1976, p. 2; also Dr. Kim. ↩
South, “A Brief Review,” pp. 2-3; also Dr. Kim. ↩
Arthur L. Mattocks and Charles C. Jew, “Assessment of an Aversive ‘Contract’ Program with Extreme Acting-Out Criminal Offenders,” unpublished paper, 1971. (Example of “self-mutilation”: one swallowed six-inch sharpened wires; post-abdominal surgery, he tore open the wounds.) ↩
The disease process sometimes is determined only at autopsy (“pathological findings”); even then, not always. ↩
For a horrifying example (clinicians and researchers), see James M. Jones, Bad Blood: The Tuskegee Syphilis Experiment (Free Press, 1981). ↩
The original article on ECT by Cerletti and Bini in 1938 was titled, simply, “A New Method of Shock Therapy, Electroshock.” ↩
F.H. Frankel and T.C. Fleming, “Electroconvulsive Therapy: Dispelling the Myths,” Drug Therapy, April 1983, pp. 84-92. ↩