Trigger warning: Ableism, bigotry, dehumanization, institutionalization, Islamaphobia, racism, zombies
Rachel Cohen-Rottenberg over at the disabilityandrepresentation.com blog wrote a post Scapegoating Schizophrenia: Paul Steinberg’s Shameful New York Times Op-Ed Column today that alerted me to some irresponsible comments by Dr. Paul Steinberg in a New York Times Op-Ed piece. Dr. Steinberg’s comments are an example of why I felt compelled to create the Ask an Aspie blog. After the recent shootings, some in the media irresponsibly suggested that Asperger’s is to blame. This prompted a flurry of articles refuting the misinformation and explaining why the public has nothing to fear from people like me – a responsible, caring husband, father, grandfather and autistic person – just because I have Asperger’s. The level of misinformation, fear, hate and ignorance showing up in comments to these articles is why this blog exists and why I have been writing more lately.
But the comments that prompted me to start this blog were from lay persons and students. The notion that a credentialed psychiatrist would write something so irresponsible, or that the New York Times would stoop so low as to publish it, are shocking.
Any patients of Dr. Steinberg should consider carefully his own statements:
- The civil rights of people with “horrifically distorted thinking” should be abridged.
- The doctor has publicly declared his willingness to violate the ethical standards required of him by the American Psychiatric Association
People don’t see a psychiatrist unless they believe their thinking is at least somewhat “distorted”. What are the criteria by which Dr. Steinberg defines “horribly” distorted thinking? Do you qualify under his definition? How do you know?
More importantly, if he believes you to be dangerous, will he tell you or will he take preemptive action into his own hands? If Dr. Steinberg concludes your thinking is “horribly distorted”, what guarantee do you have that the doctor will preserve your privacy or liberty given the position he has articulated so eloquently? Since he has publicly declared his willingness to breach what he considers to be the less important ethical standards of his professional licensing body, is it possible that he has rationalized and justified in his own mind any other ethical violations? Which of the ethical standards he has taken a vow to uphold has he cherry-picked and justified in his own mind as irrelevant? Again, how would you know?
Dr. Steinberg obviously feels justified in acting irresponsibly with regard to patients not under his own care. Should you believe that he draws the ethical line at patients who are under his care? He holds large populations of strangers in such low esteem as to feel justified in breaching his professional ethics to their detriment. If his justification for doing this is that he doesn’t know them personally then you, the patient he does know personally, are safe. But that would require the doctor to believe that his ethical and professional constraints are not universal principles but rather that they are situational and that personal acquaintance is a perfectly valid criteria on which they might hinge. Is that the kind of physician to whom you would trust your mental health?
A more reasonable assumption is that Dr. Steinberg believes ethics to be broadly applicable and not subject to such arbitrary distinctions as personal acquaintance. That is the traditional interpretation of how ethics should constrain a psychiatrist’s actions. However in this case, it is the more disturbing option. Under this definition, the doctor’s ethical obligations are to the entire patient population and not merely to his own patients. One of these obligations is to respect confidentiality so as not to risk causing harm to any patient, whether under his care or not. Although lay persons tend to interpret confidentiality as applicable to what they tell their psychiatrist, it also applies to any specialized knowledge a doctor has of a patient. If a doctor is consulted by a colleague, the doctor-patient relationship is created even though the patient is personally unknown to the second doctor and not under his care. When Dr. Steinberg made diagnostic and prescriptive public statements, these established a doctor-patient relationship between himself and the people on whom he saw fit to comment. Why? Doctors do not ever get to diagnose or prescribe outside of their professional and ethical framework.
Furthermore, the justice and legislative systems are accountable to the safety of the public. These bodies are expected to advocate for the public good, even above individual rights where these conflict. The psychiatric profession is expected to advocate for individual rights, even above the interests of the general public, should they conflict. This arrangement provides checks and balances between the opposing interests. Participants in all of these systems must understand their roles and the constituencies to which they are accountable or else the checks and balances break down. The role of the psychiatric profession should be to inform the legislative and justice systems from an objective, non-partisan perspective. The inherent conflict of interest in attempting to simultaneously represent the interests of individual patients as well as advocate for the public good should be obvious to qualified practitioners in any of these professions, especially those who hold themselves out as leaders and authorities in their field.
Dr. Steinberg laments that “After mass murders, our airwaves are filled with unfounded speculations about video games, our culture of hedonism and our loss of religious faith, while psychiatrists, the ones who know the most about severe mental illness, are largely marginalized.” Of course they are, with regard to public opinion or public policy. This is by design. The airwaves are the constituency of politician. The psychiatrist’s constituency is individual patients. Psychiatric advocacy requires dialogs between the psychiatrist and the patient or between the psychiatrist and the politician. Why would any psychiatrist attempt to impose himself between the politician and the public to influence their dialog?
There are criteria on which the doctor’s ethical obligations to patients can change. Doctors are expected to take steps when a patient is deemed “a danger to self or others.” With any other doctor, we know what type of extraordinary action the doctor may take in this situation because his obligations in that case are defined by the ethical oath on which his license is conditioned. One such obligation is to document the specific indicators on which the doctor bases his belief that a patient poses an imminent danger. I realize this doesn’t sound “extraordinary” but consider that for Dr. Steibnerg, it apparently is.
His article posits an imminent danger posed by a broad population as a justification for public policy changes. By definition, “imminent danger” requires specificity. With the possible exception of zombies, such a broad and indistinct classification will undoubtedly include large numbers of false positives. More importantly, caring about those false positives is a core belief of our justice system. Blackstone’s Formulation “better that ten guilty persons escape than that one innocent suffer” is the foundation upon which presumption of innocence rests. No broad and indistinct population can possibly meet the specificity required to declare them an imminent danger on psychiatric grounds. Again, I’ll concede an exception for zombies, despite the absence of any formal research into that population. Until such research is performed, we won’t know for sure whether zombie preference to eat human brains is grounded in malicious intent or a unique dietary restriction. I withhold any comment as to whether Dr. Steinberg is qualified to participate, either in the field of zombie psychiatric research or as a likely target of foraging zombies.
Returning to Dr. Steinberg’s argument, if the logic were sound, then it would apply to any such broad population to which a correlation with crime or violence exists, regardless of how weak that correlation is. Should we go back to a public policy that assumes all black people are criminals? Should we treat all of Isalm as terrorists? Why stop at spree killers? There is a very high correlation between genocide and national leadership. Shall we march all newly elected officials straight from their inauguration to a jail cell? I doubt even Dr. Steinberg would make these arguments but they are essentially the same proposal he now makes with respect to the mentally ill.
Aside: My examples refer to our official laws and policies, not how we actually behave towards people of color or of the Islamic faith. I’m not suggesting those problems have been solved. However, the notion that heads of state should lead from within a jail cell and that their eventual release be dependent on their performance in office does have some merit. I’m OK with placing the burden of a proof of innocence on them, same as for zombies.
Let’s be clear on this. Remedies that reduce civil liberties, freedom, or equal protection under the law clearly apply after the law has been broken. Compassion for perpetrators may be useful but at this point it is too little too late for victims. Remedies that increase civil liberties, freedom, or equal protection under the law clearly apply before the law has been broken. Here, compassion for at-risk populations can prevent escalation of anti-social behavior, can be applied to large populations, is both less expensive and cheaper the earlier it is provided, and benefits potential victims as well as potential perpetrators.
There are plenty of authoritative documents at the state level and few at the national level. However, the US Department of Education’s Restraint and Seclusion: Resource Document describes the role and intent of psychiatric care consistent with the principles I’ve described of maximizing compassion, civil liberty and freedom of the patient.
These principles stress that every effort should be made to prevent the need for the use of restraint and seclusion and that any behavioral intervention must be consistent with the child’s rights to be treated with dignity and to be free from abuse. The principles make clear that restraint or seclusion should never be used except in situations where a child’s behavior poses imminent danger of serious physical harm to self or others, and restraint and seclusion should be avoided to the greatest extent possible without endangering the safety of students and staff.
So when Dr. Steinberg complains that over the last 50 years we have had “too little institutionalizing of teenagers and young adults (particularly men, generally more prone to violence) who have had a recent onset of schizophrenia” and that “we have too much concern about privacy, labeling and stereotyping, about the civil liberties of people who have horrifically distorted thinking,” he is arguing the other side’s case. It is for politicians and administrators to argue that curtailing of individual civil liberties is necessary for the public good. The psychiatrist’s role is to advocate for expansion of the civil liberties of their patients and equal treatment under the law. Only with vigorous and competent representation of both constituencies in an informed debate can public policy arrive at a balanced outcome. Who shall argue for compassion and civil liberties of the patients once psychiatry takes up the politician’s cause in the debate?
Dr. Steinberg has publicly declared his willingness to deviate from what constitutes a doctor-patient relationship, from the accepted definition of what constitutes an imminent danger, and from the ethical standards that define the range of acceptable responses available to him. Furthermore, the bias under which he operates this ethical vacuum is focused specifically on the population he is supposed to serve and over whom his role as doctor affords him extraordinarily intimate knowledge and some measure of elevated legal and emotional power. If I were his patient, I would have canceled all my appointments and started looking for another doctor the moment I read his article.
Dr. Steinberg’s blog reveals a pattern of activism in which he uses his psychiatric expertise to further a specific political agenda and to justify public policy changes. That alone should disqualify him as a disinterested analyst, at least for me. Since patients with opposing political views would doubt his objectivity, it is likely his patients either are unaware of his activism or align closely with his views. If that is true then the common bias he and his patients share shifts the zero reference point for normal to the right of center. The greater the offset, the more such a bias masks the evil which populates the extremes of the political spectrum. That is the reason we hold the psychiatric profession to rigorous standards of ethics and objectivity and why the Goldwater Rule “directs psychiatrists not to comment on someone’s mental state if they have not examined him and gotten permission to discuss his case” as Dr. Steinberg explains. His call to eliminate the Goldwater Rule, and his choice to violate it even while it stands, indicates the degree to which his reference for normal has drifted from an objective center to the point that he can rationalize his deliberate breach of the rule as good rather than evil.
I would hope that the psychiatric profession continues to recognize its role as the advocate for the individual rights of its patients. However, if Dr. Steinberg wishes to update the ethical requirements and primary mission of his profession, there are accepted ways of having that discussion, working within the framework of the profession and with regard to the well being of the patients under care of that profession. The first step in that process is to build a consensus among his peers. The changes should at least receive provisional approval, hopefully become fully ratified, before any new standards are applied to patients. But Dr. Steinberg has chosen a different path. He intends to change the boundaries by first breaking them and then beckoning from below. “Hey! The view of the valley from over here is great! We should move the safety barrier so it encloses the position I have taken. I’ll wait here, everyone else grab a piece of the fence and drag it over.” One wonders whether he will change his position if the group does not agree or if he will continue to independently explore the territory outside the stated boundaries of the psychiatric profession. Time will tell.
Please understand, I am not arguing against entertaining a discussion of Doctor Steinberg’s suggested changes. I don’t agree with his position but the only way to preserve the integrity of the professional framework is to inspect it closely from time to time. Were I in the profession, I would welcome such scrutiny and trust the group to make the right decision. Hopefully the rest of the psychiatric profession realizes that Dr. Steinberg has chosen to explore the slippery slope by venturing onto it perched atop a garbage can lid and they will take a more cautious approach to changing the boundaries, if in fact that conversation is needed. The view of the valley is indeed wonderful and exciting whilst hurtling down the slope without brakes or steering. Let us know, Dr. Steinberg, whether you hit anything on the way down and what the view looks like from the bottom if you reach it intact.