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From Our Readers

Determinism Versus Free Will: What Do We Choose?
I am so glad Dr Pies raised the question of free will in psychiatry ("Hume's Fork and Psychiatry's Explanations: Determinism and the Dimensions of Freedom," Psychiatric Times, August 2007 and "Psychiatric Naturalism and the Dimensions of Freedom: Implications for Psychiatry and the Law," Psychiatric Times, October 2007). How we answer the question determines the whole basis of our understanding of psychopathology. In other words: do patients choose their symptoms?

The concept of free will makes no sense to me because it implies that our choices have no determinants. But how can anything come from nothing? Empirically, don't we find reasons for what we do? And what would psychiatry have without the assumption of influences? If we are to assume, "You have major depression because you choose to. To recover, decide to change your mood," then why bother with psychotherapy, which is basically a way of getting people to change?

Most reject this strong determinism because they think it makes us automatons and because we have the experience of making choices. Psychiatrists certainly know how convictions, such as intentionality, can be erroneous.

However, we are not automatons because 2 of the determinants of how we think, feel, and act are experience and intelligence. A trained plumber "chooses" how to deal with plumbing problems differently from someone who is not a plumber. All learning is a determinant. All the unique experiences I have are determinants.

A person with an intellectual disability will make different "choices" than a person with normal intelligence. If strict determinism means our experiences and intelligence are involved in our decisions, what more do we want? What more would a belief in free will give us? Strict determinism brings many benefits. It gives us reason to adopt a nonjudgmental, humane attitude toward our patients (and ourselves) while maintaining a helpful outlook.

Arthur Rifkin, MD
Manhasset, NY

Dr Pies responds:
I welcome Dr Rifkin's astute comments. He may not realize it, but he seems to be "channeling" the great philosopher Baruch Spinoza, who also argued for strict determinism and "substance monism" (ie, what we call "mind" and "body" are actually different ways of conceiving or des- cribing the same underlying "substance"). Spinoza did not see determinism—essentially, the laws of the universe—as vitiating human freedom. Rather, he believed that the moment we accept being a part of the causal, physical universe, we free ourselves from a false (contracausal) notion of "free will." In effect, for Spinoza—as perhaps for Dr Rifkin and myself—genuine freedom begins when we accept our limitations and acknowledge that we humans are not as exceptional as we sometimes like to believe. And, insofar as we can do that, we are exceptional, indeed!

Ronald Pies, MD
Boston

Dimensions of Freedom and Criminal Responsibility: A Conundrum
In his October 2007 editorial ("Psychiatric Naturalism and the Dimensions of Freedom: Implications for Psychiatry and the Law," Psychiatric Times,), Ronald Pies, MD, discusses criminal responsibility in relation to verdicts in forensic psychiatry. He argues that criminal acts committed by those with psychiatric disorders may demonstrate varying degrees of freedom and responsibility. As a practicing forensic psychiatrist, I see a conundrum in Dr Pies' analysis, relating to defendants who show evidence of a dissociative disorder. Based on my experience interviewing several defendants accused of murder, it seems to me that the presence of possible dissociative symptoms, such as inability to "remember" elements of the alleged crime, complicate any attempt to assess degrees of responsibility. In patients with severe dissociative disorders, the legal system may need more sophisticated methods of determining culpability than those described in Dr Pies' analysis.

Leonard R. Friedman, MD
Revere, Mass

Dr Pies responds:
I very much appreciate Dr Friedman's thoughtful response to my editorial, as well as his long experience dealing with forensic cases. There is, indeed, a conundrum. My analysis of freedom implicitly presumes that in each of us there is an entity corresponding roughly to what we would call the "self"—something the ancient Greeks referred to as hegemonikon (roughly, the governing or agential faculty). If we accept this premise, it is then plausible to argue (as I did) that the self may be impeded, coerced, or impaired to varying degrees, depending on external or internal constraints.

For example, alcohol intoxication or a frontal lobe tumor may compromise the agential powers of this putative unitary self to varying degrees. But the situation is muddied when, as Dr Friedman observes, the self appears to be "divided" or fragmented in the way that the old concept of "multiple personality disorder" (dissociative disorder [DD]) implied. A patient's putative "amnesia" for events of a criminal nature further complicates both our appraisal of his or her "degrees of freedom" and one's assessment of his culpability. Leaving aside the thorny issue of malingering or false claims of amnesia, how does my analysis of freedom and responsibility apply to someone with DD?

In the most basic terms, our job as psychiatrists is to help the legal system understand the degree to which such a patient (or defendant) in fact lacks a unitary self. To the extent that this is known or reasonably believed to be true, we might advise the legal system that this person's agential powers and "freedom" were probably compromised.

Let's suppose that we had well-founded knowledge (not easy to come by with DD) that Mr Jones had 37 "alters" (subpersonalities) that asserted themselves repeatedly into his thought processes. We might opine that whatever rudimentary "core" personality Jones possessed (ie, to whatever degree there is a "Jones" at all!) was severely impeded or impaired, with respect to its agential capacities. (Of course, this still presumes that there is such a core personality.) For many in the legal system, the very notion of DD is still quite a stretch and, frankly, I doubt many juries would be persuaded by such "expert" psychiatric testimony. Fortunately, the determination of culpability is not within our purview as psychiatrists. That is the onerous and unenviable task of judge and jury.

Ronald Pies, MD
Boston
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