Should Computers Replace Physicians?

In 2012, at the Health Innovation Summit in San Francisco, Vinod Khosla, Sun Microsystems co-founder and venture capitalist, declared: “Health care is like witchcraft and just based on
tradition.” Biased and fallible physicians, he continued, don’t use enough science or data — and thus machines will someday rightly replace 80 percent of doctors. Earlier that same year, Khosla had penned an article for TechCrunch in which he had made a similar point.
With the capacity to store and analyze every single biological detail, computers would soon outperform human doctors. He writes, “there are three thousand or more metabolic pathways, I was once told, in the human body and they
impact each other in very complex ways. These tasks are perfect for a computer to model as ‘systems biology’ researchers are trying to do.” In Khosla’s
vision of the future, by around 2022 he expects he will “be able to ask Siri’s great great grandchild (Version 9.0?) for an opinion far more accurate than the one I get
today from the average physician.” In May 2014,

Khosla reiterated his assertion that computers will replace most doctors
. “Humans are not good when 500 variables affect a disease. We can handle three to five to seven, maybe,” he said. “We are guided too much by opinions, not by
statistical science.”

The dream of replacing doctors with advanced artificial intelligence is unsurprising, as talk of robots replacing human workers in various fields — from eldercare to taxi driving — has become common. But is Vinod Khosla right about medicine? Will we soon
walk into clinics and be seen by robot diagnosticians who will cull our health information, evaluate our symptoms, and prescribe a treatment? Whether or not the technology will exist is difficult to predict, but we are certainly on our way there. The IBM
supercomputer Watson is already being used in some hospitals to help diagnose cancer and recommend treatment, which it does by sifting through millions of patient records and producing treatment options based on previous outcomes. Analysts at Memorial Sloan Kettering Cancer Center are training Watson “to extract and interpret
physician notes, lab results, and clinical research.” All this is awe-inspiring. Let us generously assume, then, for a moment, that the technology for Khosla’s future will be
available and that all knowledge about and treatment options for medical problems will be readily analyzable by a computer within the next decade or so. If this is the future, why
shouldn’t physicians be replaced?

There are several errors in Khosla’s way of thinking about this issue. First of all, modern health care is not “like witchcraft.” Academic
physicians, for example, use evidence-based medicine whenever it is available.
And when it isn’t, then they try to reason through a problem using what biologists know about disease presentation, physiology, and pharmacology.

Moreover, Khosla mischaracterizes the doctor-patient interaction. For Khosla, a visit to the doctor involves “friendly banter” and questions about symptoms. The
doctor then assesses these symptoms, “hunts around … for clues as to their source, provides the diagnosis, writes a prescription, and sends you off.” In Khosla’s estimation the entire
visit “should take no more than 15 minutes and usually takes probably less than that.” But the kind of visit Khosla writes about is an urgent care visit wherein quick and minor issues are addressed: strep throat or a small laceration requiring a
stitch or two. Yes, these visits can take fifteen minutes, but so much of medicine does not involve these brief interactions. Consider the diabetic
patient who has poorly controlled blood sugars, putting her at risk for stroke, heart attack, peripheral nerve destruction, and kidney failure, but who hasn’t
been taking her medications. Or consider a patient addicted to cigarettes or on the verge of alcoholism. Consider the patient with Parkinson’s disease who wonders how this new diagnosis
will affect his life. And what about the worried parents who want antibiotics for their child even though their child has a viral infection and not a
bacterial infection? I can go on and on with scenarios like these, which occur hourly, if not daily, in nearly every medical specialty. In fact,
fifteen-minute visits are the exception to the kind of medicine most physicians need to practice. One cannot convince an alcoholic to give up alcohol, get
a diabetic patient to take her medications, or teach a Spanish-speaking patient to take his pills correctly in fifteen minutes. In addition, all this is impossible without “friendly banter.”

As Dr. Danielle Ofri, an associate professor of medicine at the New York University School of Medicine,

wrote in a New York Times blog post, compliance with blood pressure medications or diabetic medications is extremely difficult, involving multiple factors:

Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the
patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make
it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots — on top of remembering to take the morning pills
and then the evening pills each and every day.

Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the
doctor’s recommendations.

Because of the difficulties involved in getting a patient to comply with a complex treatment plan, Dr. John Steiner argues in an article in the Annals of Internal Medicine that in
order to be effective we must address individual, social, and environmental factors:

Counseling with a trusted clinician needs to be complemented by outreach interventions and removal of structural and organizational barriers. …[F]ront-line clinicians, interdisciplinary teams, organizational leaders, and policymakers will need to coordinate efforts in
ways that exemplify the underlying principles of health care reform.

Therefore, the interaction between physician and patient cannot be dispensed with in fifteen minutes. No, the relationship involves, at minimum, a
negotiation between what the doctor thinks is right and what the patient is capable of and wants. To use the example of the diabetic patient, perhaps the
first step is to get the patient to give up soda for water, which will help lower blood sugars, or to start walking instead of driving, or taking the
stairs instead of the elevator. We make small suggestions and patients make small compromises in order to change for the better — a negotiation that helps
patients improve in a way that is admittedly slow, but necessarily slow. This requires the kind of give-and-take that we naturally have in relationships with other people, but not with computers.

This kind of interaction also necessitates trust — trust regarding illicit drugs, alcohol, tobacco, and sexual activity, all of which can contribute to or
cause certain medical problems. And a computer may ask the questions but cannot earn a patient’s confidence. After all, these kinds of secrets can only be
exchanged between two human beings. David Eagleman, a neuroscientist at the Baylor College of Medicine, writes in his book Incognito that when we reveal a secret, we almost always feel that “the receiver of the secrets
has to be human.” He wonders why, for example, “telling a wall, a lizard or a goat your secrets is much less satisfying.” As patients, we long for that human reception
and understanding that a physician can provide and use to our advantage in coming up with a diagnosis.

Khosla neglects other elements of medical care, too. Implicit in his comments is the idea that the
patient is a consumer and the doctor a salesman. In this setting, the patient buys health in the same way that he or she buys corn on the cob. One doesn’t need friendly banter or a packet of paperwork to get the best corn, only a short visit to the
grocery store.

And yet, issues of health are far more serious than buying produce. Let’s take the example of a mother who brings her child in for ADHD medication, a
scenario I’ve seen multiple times. “My child has ADHD,” she says. “He needs Ritalin to help his symptoms.” In a consumer-provider scenario, the doctor gives the
mother Ritalin. This is what she wants; she is paying for the visit; the customer is king. But someone must explain to the mother what ADHD
is and whether her child actually has this disorder. There must be a conversation about the diagnosis, the medication, and its side effects, because the consequences of these are lifelong. Machines would have to be more than just clerks. In many instances, they would have to convince the parent that, perhaps, her child does not have
ADHD; that she should hold off on medications and schedule a follow-up to see how the child is doing. Because the exchange of goods in
medicine is so unique, consequential, and rife with emotion, it is not just a consumer-cashier relationship. Thus computers, no matter how
efficient, are ill-fitted to this task.

Khosla also misunderstands certain treatments, which are directly based on human interactions. Take psychiatry for example. We know that

cognitive behavioral therapy and medication combined are the best treatment for a disease like depression
. And cognitive behavioral therapy has at its core the relationship between the
psychiatrist or therapist and the patient, who together work through a depressed patient’s illness during therapy sessions. In cognitive behavioral therapy, private
aspects of life are discussed and comfort is offered — human expressions and emotions are critical for this mode of treatment.


To be sure, Khosla is right about quite a lot. Yes, technology ought to make certain aspects of the patient visit more efficient. Our vital signs may one day easily be taken with the help of our mobile phones, as he suggests, which
would save time checking in to a clinic and could help give physicians constant and accurate measurements of blood pressure in hypertensive patients or EKG
recordings in patients with heart disease. Technology of this sort could also indicate when an emergency is happening or how a patient ought to alter medication
doses.
Furthermore, Khosla correctly identifies some of the limitations of human physicians: “We cannot expect our doctor to be able to remember everything from medical
school twenty years ago or memorize the whole Physicians Desk Reference (PDR) and to know everything from the latest research, and so on and so forth.”
True, the amount of information accumulated by modern medical research is beyond the capability of any human being to know, and doctors do make mistakes because they forget or are not up on the latest research. In a 2002 study in the Journal of Neurology, Neurosurgery and Psychiatry, investigators found that 15 percent of patients with a diagnosis of Parkinson’s disease do not
necessarily fulfill criteria for the disease and 20 percent of patients with Parkinson’s disease who have already seen medical providers have not been diagnosed.
These are large percentages that have profound implications for people’s lives. And this is exactly why physicians must use technologies like Watson to do a
better job, not necessarily abdicate the job altogether. Most of us already carry smartphones or tablets on rounds, to look up disease processes or confirm
our choice of antibiotic.
Lastly, Khosla wisely points out that physician bias can negatively affect a patient’s treatment. As he writes, “a physician’s bias makes all these
personal decisions for patients in a majority of the cases without the patient (or sometimes even the physician) realizing what ‘preferences’ are being
incorporated into their recommendations. The situation gets worse the less educated or economically less well-off the patient is, such as in developing
countries, in my estimation.” Undoubtedly, this dilemma is real. I have spent many of my posts on this blog writing about the issue of remaining unbiased or level-headed in the face of difficult patient interactions.
study published in Obesity in 2013 found that physicians “demonstrated less emotional rapport with overweight and obese patients … than for normal weight patients,” which may
“weaken the patient-physician relationship, diminish patients’ adherence to recommendations, and decrease the effectiveness of behavior change counseling.”
And

as Tara Parker-Pope remarks in the New York Times
, “studies show that patients are far more likely to follow a doctor’s advice and to have a better health outcome when they believe their doctor empathizes
with their plight.” If bias exists in lieu of empathy, it makes sense that patients have worse outcomes. What makes doctors most valuable,
their humanity, can have negative consequences.
But people can learn from studies, alter their behavior, and remain human. Computers or robots can learn from studies and alter their behavior, but they will
always be robots. They will never earn the trust of the chronically ill drug addict. They will never be able to negotiate with the most difficult patients
who demand specific treatments but may not be entirely sure why. An ideal system would not be one built solely on fallible human doctors but one
in which new tools significantly augment human physicians’ skill and knowledge. A measured combination of these will put all the information at a doctor’s
fingertips while keeping the art of medicine alive.

The Problem with the New Patient Autonomy

The neurology team shuffled single-file into the patient’s small room. The patient, probably in his 30s, had black hair, brown eyes, and an unsettling
demeanor. He glared icily at us from his bed, the blankets covering him up to the neck. His pale brow furrowed even more noticeably as all nine of us
intruded on his privacy. In a scene out of a futuristic movie, EEG (electroencephalogram) leads on his scalp connected his
head via wires to a screen showing squiggly lines representing brain activity; a small video camera attached to the screen monitored the patient’s movement. He had come to the hospital overnight after falling and shaking, a story worryingly suggestive of a seizure.

Brain waves on EEG
Image via Shutterstock

An electroencephalogram records neuronal signals in the brain and is used by neurologists to diagnose seizure activity. When a
patient has a seizure, which can manifest as full-body convulsions, a family member in the room pushes a button on the machine which starts the video
camera recording the patient’s movements. Then, neurologists examine the movements in the video and the waves tracked by the EEG to see if they are consistent with seizures.

There are different kinds of seizures depending on which part of the brain is affected. Symptoms range from a loss of attention for a few seconds (absence seizures) to full-body convulsions
which we typically associate with seizures (generalized tonic-clonic seizures). Different conditions can cause these events — for instance, high fever as a child (febrile seizures) and brain tumors can induce
hyper-excitability in the brain. If the seizure does not stop, a patient can enter status epilepticus, a state of prolonged epileptic activity that can cause permanent damage.

Having a seizure, then, can be very serious business. Physicians must perform a medical work-up to ensure that the patient is not at great risk. In
addition to an EEG, our patient’s neurologist ordered labs and a CT scan of the brain. However, these tests were all negative. Even overnight, when the patient and his mother both claimed that the patient seized, there were no abnormal
electrical discharges on the EEG.

Indeed, not all physical manifestations of seizures indicate the presence of legitimate seizure activity in the brain, which is why the EEG is such a valuable diagnostic
tool. It turns out that certain patients may believe they are having seizures when they are actually having pseudoseizures or psychogenic non-epileptic seizures. To most observers,
pseudoseizures look exactly like generalized tonic-clonic seizures. Patients shake, tense up, and flail violently and frighteningly. However, certain
differences exist that distinguish them from each other. During pseudoseizures, EEGs show no abnormal brain activity, patients do not bite their tongues (this can occur with real seizures), and patients do not
respond to anti-epileptic or anti-seizure medications. It’s not that patients undergoing pseudoseizures aren’t sick, it’s just that their sickness has nothing to do with neurological pathology or seizure activity.

Frequently, patients who experience pseudoseizures do have underlying psychiatric disorders, like anxiety or PTSD, but not always. Other risk factors and
triggers include interpersonal conflicts, childhood abuse, and past sexual abuse. Seemingly, then, a pseudoseizure is a symptom of a psychiatric illness. Another factor that distinguishes pseudoseizures is that patients are conscious during the events. I’ve seen one attending push down hard on a patient’s hand during a pseudoseizure while telling the patient he was going to do so. The
patient suddenly awoke before the attending pushed hard enough to hurt the patient. (If the patient was having a generalized seizure, he would
not have felt anyone pressing on his hand nor would he have heard anyone giving him a verbal warning of it.)

In explaining the concept of pseudoseizures to a patient who has them, one must take great care. If a physician tells a patient, “these are not real — it
is in your head, so grow up,” no one will benefit. Psychiatric illness cannot be fixed with a stern rebuke. One must explain that these are not
seizures and that it will take time to fix whatever is happening, but anti-seizure medications will not help. (While there are no medications for pseudoseizures, behavioral therapy can be efficacious.) Through this
conversation, one hopes the patient will seek help from a psychiatrist.

The patient we saw that morning did have pseudoseizures rather than seizures, as the EEG and the video of his body movements indicated. Additionally, and
tragically, he had a horrific childhood and had been physically abused by his father. The attending explained all this very gently in the course of nearly
twenty minutes. When he finished, the patient and his mother both burst out indignantly: How could this physician ignore the symptoms? How could he be so
callous as to dismiss this disease? Why wouldn’t he prescribe medications? Why did he not order an MRI of the patient’s brain (an expensive type of imaging) to further investigate the
cause of this? In the patient’s words: “I’m not believing any of this bullshit.” Although the physician calmly tried to explain everything again, the patient
refused to listen and eventually the team left to continue rounding. Still enraged, the patient called the customer-service department of the
hospital and continued to argue with the team throughout the day. Eventually, after numerous disputes, our attending physician caved (and who could blame him given that there were nineteen other sick patients on the service who needed his attention?): the patient got what
he wanted, an MRI study which showed nothing abnormal.

Unfortunately, this
is a weekly if not a daily experience in hospitals across the country. Patients frequently make inappropriate requests of physicians, which are subsequently granted. What has brought our system to the point where a patient issues orders and the
physician must about-face from a medically sensible course?

*   *   *

In ancient times, patients had very little, if any, autonomy, as R. Kaba and P. Sooriakumaran point out in their 2007 article, The Evolution of the Doctor-Patient Relationship in the International Journal of Surgery. Doctors decided what was good for patients and what wasn’t. There was no informed consent — a doctor told a
patient what the patient needed and expected him or her to comply.

This interaction may have evolved from the ancient Egyptian “priest-supplicant” relationship, in which magicians and priests with access to gods conjured up
cures for various medical disorders. The patient, without a modicum of holiness, had to supplicate to the priest, or father figure, in
order to get well. Even for the Greeks, who developed slightly more scientific ways of approaching disease and more ethical ways of approaching the patient
(see the Hippocratic Oath), the doctor was a paternalistic figure granting “hard-line
beneficence” to the patient. All this was akin to a parent-child relationship, a model for the doctor-patient interaction that was considered normal even in the
mid-twentieth century, as I wrote in my essay on vaccines for The New Atlantis:

The unchecked authority of medical experts in those days allowed doctors to trammel the rights of both patients and research subjects. Many of those whose
research laid the foundations for modern vaccines, such as Jonas Salk, Maurice Hilleman, and Stanley Plotkin, tested their vaccines on mentally
retarded children. Starting in the mid-1950s and continuing for about fifteen years, the infectious-disease doctor Saul Krugman fed hepatitis virus to
severely disabled residents of the Willowbrook State School in order to study the virus. The enshrinement of patient autonomy in the 1970s was in part a
response to these very serious ethical problems.

Recently, though, things have changed:

Over the past few decades, however, the boat has tipped to the other side. Now, patients rate doctors online at sites like Healthgrades or Yelp or Vitals
the same way one rates a restaurant. This puts pressure on physicians to give patients what they want rather than what they need in order to garner more
business. The government bases Medicare reimbursements, in part, on patient satisfaction scores, putting further pressure on physicians to make patients
happy [In fact, patient satisfaction score surveys

play a significant role in determining how much money hospitals receive from Medicare
.] Dr. Richard Smith, former editor of the British Medical Journal, has explained that the increasing power of patients is bringing us to a point where
“there is no ‘truth’ defined by experts. Rather there are many opinions based on very different views and theories of the world.” If a patient wants a test
or procedure, he or she can have it. The same goes for refusing it, even against the advice of doctors.

This modus operandi of allowing patient satisfaction to dictate medical care is becoming more and more common. It is even encouraged. Kai Falkenberg, a
journalist, notes in a must-read 2013 article in Forbes,

Nearly two-thirds of all physicians now have annual incentive plans, according to the Hay Group, a Philadelphia-based management consultancy that surveyed
182 health care groups. Of those, 66% rely on patient satisfaction to measure physician performance; that number has increased 23% over the past two years.

And that’s not all, according to her article. These metrics encourage physicians to do things that are not always in the best interests of the patient:

In a recent online survey of 700-plus emergency room doctors by Emergency Physicians Monthly, 59% admitted they increased the number of tests they
performed because of patient satisfaction surveys. The South Carolina Medical Association asked its members whether they’d ever ordered a test they felt
was inappropriate because of such pressures, and 55% of 131 respondents said yes. Nearly half said they’d improperly prescribed antibiotics and narcotic
pain medication in direct response to patient satisfaction surveys.

Satisfying patients and practicing good medicine are not always the same. Data on this abounds. A 2013 study by physicians at Johns Hopkins demonstrated little evidence that patient satisfaction
corresponds to the quality of surgical care. Furthermore, in a 2012 study,
physicians at UC Davis found that increased patient satisfaction scores were associated with higher health care expenditures and even increased
mortality.

Of course, I’m not arguing against patient autonomy or patient satisfaction. People ought to have a voice in their healthcare. But attributing excessive importance to patient satisfaction scores stymies medicine and encourages confusion among patients who don’t necessarily know what is and
isn’t medically appropriate, thus putting them at risk. This is borne out in the story of our pseudoseizing patient, and in the data from studies. If we,
as physicians, merely do what the patient asks of us, we are no longer practicing medicine; we are technicians for hire, something I pointed out in a previous post on the purpose of medicine.
Evidently, then, the push for patient autonomy can hurt both patients and doctors.

Indeed, the solution is not to incentivize the physician to give the patient what he or she wants. Nor is it to force the patient to do only what the
physician demands. What we need is balance. As suggested in a 1996 article in the Annals of Internal Medicine, what we need is not a consumer model but a model that promotes “an intense collaboration between patient and physician so that patients can autonomously
make choices that are informed by both the medical facts and the physician’s experience.” Doctors don’t have a monopoly on medical truth but they have
years of education and experience and they must help patients to make a reasoned choice.

Physicians need to provide patients with information, evidence, and guidance. They need to negotiate with patients, just as patients need to negotiate with
doctors. And sometimes physicians need to draw a hard line. If a doctor encounters a patient who demands something a physician is not comfortable with or if the “chosen course violates the physician’s fundamental values” despite negotiations and
conversations, “he should inform the patient of that fact and perhaps help the patient find another physician.”

Yes, final choices belong to patients and not doctors. But both must invest a lot in order to allow patients to make informed decisions. We should not let the mistaken primacy of satisfaction surveys and radical autonomy obstruct this negotiation — there is more at stake for all of us than just an
extraneous MRI.

Denying and Romanticizing Mental Illness

Reactions to mental illnesses or disorders vary. (I wrote about some of them
in a 2012 essay in
the pages of The New Atlantis
.) I’ve noticed, however, that some of
the responses among physicians differ from their reactions to other medical
pathologies. There are several reasons why this might be the case, having to do
with the fact that psychiatric pathology is far more difficult to comprehend
and thus more easily misunderstood than the pathology of other diseases we
usually associate only with the body, such as cancer or pneumonia.

Image via Shutterstock

Unlike bodily illnesses, mental disorders primarily affect patients’
emotions and actions. As a consequence, our implicitly held beliefs about human
behavior, especially our views of free will, can color how we react to people
suffering from mental illness. A strong belief in free will helps validate a
sense of justice and morality: generally speaking, people choose their actions
and are thus responsible for them. So if a person with a psychiatric diagnosis
commits suicide, kills another person, or runs onto a highway screaming at
imaginary beings, it is easiest to hold the person morally responsible if we
believe he acted freely. Or, in the case of suicide, we might say that the
person “should have done” this or that to make life better: he should have seen
a psychiatrist, or he should have realized how wonderful his life was. We want
to hold the person responsible for his actions rather than deal with an illness
that so often makes people completely irrational and incapable of choosing
their actions.

Additionally, the fact that most medical pathology is visible to us makes it
simpler to understand. In the emergency room we easily see the
effects of a chopped-off leg
. We can feel
a large spleen
, hear an irregular heartbeat, or view an abnormal lab
finding. Psychiatric pathology, however, is not palpable in the same way. With
schizophrenic patients, for example, we cannot see the beings they see. We do
not inhabit the world they inhabit. Nor can we easily visualize their brain
chemistry. It is as if we are looking for the culprit in a pitch-black world.

With these difficulties in understanding psychiatric disease, some
physicians, patients and observers dismiss mental illness as a product of the
weak-willed or obstreperous. Or they romanticize it, focusing on the
interesting and provocative aspects of mental illness. These are minority
views, but they are not without influence — which is unfortunate, because if
they are followed, they can lead us to deny treatment to those who need it.

Dr. Robert Youngson, a British doctor-turned-author,
is an instructive example of someone espousing dangerous views of this sort. In
his 1999 book, The
Madness of Prince Hamlet and Other Extraordinary States of Mind
, he
writes:

Doctors and lay people talk, quite casually, of ‘mental
illness,’ the implication being that conditions like schizophrenia are much the
same as conditions like tuberculosis or meningitis. In fact, they are not.
Mental disorders have hardly anything in common with organic physical
disease…. The observable changes occurring in the body — including the brain —
in the course of organic disease are called pathology. So far as current
research can demonstrate, there are no corresponding organic changes causing
schizophrenia.

Dr. Youngson goes on to assert that we classify schizophrenia as an illness
in order to maintain a society of “normal” people. He claims that British
psychiatrists “carry out a tidying-up function much more closely equated with
that of the police and the judiciary than with that of the medical profession.”
Then he asks, disturbingly, whether there is “really any difference between
what happened in Russia, when political dissidents were deemed to be mad and
were incarcerated in mental hospitals, and what happens in Britain and America
when people who do not conform to current social mores are legally certified
and locked up.”

For support of his position, Dr. Youngson refers the reader to the work of the
late Thomas Szasz, who,
as a professor of psychiatry at the State University of New York Upstate
Medical University at Syracuse, New York, published a number of controversial
books arguing that mental illness is a myth. The status quo of medical practice
that considers mental conditions like schizophrenia as illnesses, Dr. Youngson
writes, is a “convenient fiction about a state of the mind.” (A critical essay
about Dr. Szasz appeared
in The New Atlantis
in 2006.)

But Dr. Youngson’s premise, that schizophrenic patients lack cerebral
pathology, is wrong. We know, for example, that patients with schizophrenia
have a disruption in certain neurotransmitters in their brains. Dopamine is
increased in patients with schizophrenia, and this possibly relates to the
effects of genetic alterations. There are specific (and multiple) gene
variants associated
with this disease. Furthermore, medications do sometimes
work, as I explained in another
recent post
. They inhibit dopamine’s actions on certain receptors in the
brain and, despite their side effects, can rid patients of awful and
belligerent visions and voices. If there were truly no pathology, why would
blocking receptors work? If there were truly no pathology, why would there be
significant elevations of certain neurotransmitters? There is indeed pathology
here — Youngson apparently just chooses to ignore it because it contradicts his
preferred explanations.

Dr. Paul McHugh, a
professor of psychiatry at Johns Hopkins University School of Medicine, wrote
about this particular topic in a 1995
issue of The American Scholar
. He argues that “the context of a life
should not be confused with the cause of all mental disorders or made the sole
focus of therapeutic attention as though guidance were always synonymous with
cure.” Unfortunately, “the assumption that something must have happened
if a mental disorder is present has provided an entry for zealots and
charlatans into psychiatry.” If we believe that mental disorders like
schizophrenia or depression are always rooted in life experiences and never in physical
pathology, we can easily misunderstand patients, their families, and the
possibilities for therapies. Not only is Dr. Youngson’s view wrong; it is injurious
to those whom it is meant to help.

Dr. McHugh also addresses the romanticization of depression in a 2005 Commentary
essay
(which I quoted in another
recent post
). McHugh reviews Andrew Solomon’s book The
Noonday Demon: An Atlas of Depression
(2001), in which Solomon writes
about his own experiences with depression. Solomon, McHugh argues, romanticizes
depression by making it seem mysterious like sex and curable most effectively
by a sheer act of will. Similar to Dr. Youngson, Solomon mischaracterizes a
terrible sickness. As McHugh writes,

the particular disorder at issue here is a disease,
an affliction that disrupts a natural function of emotional control. This
disease, like other diseases both physical and mental, renders the afflicted
person impaired in ways that are essentially the same from case to case….
[Depression] is not a you but an it, a thing unto itself and not
just the dark side of human emotion.

Again, depression, like schizophrenia, clearly involves pathologies in the
brain. It is a real disease that tears apart human lives.

What’s so striking about these cases is that those who are denying or
romanticizing mental illnesses are familiar with the diseases. Surely, Dr.
Youngson saw schizophrenics in his family practice. Solomon experienced
depression himself. And Dr. Szasz also saw patients with these disorders.
Seeing or experiencing the illness, then, is not enough to understand it. An
understanding of disorders of the mind requires that we not only learn about
symptoms, social context, and pharmacology, but also that we understand the
underlying pathology.