This example may seem absurd, but it suggests that there are moral consequences to placing biomedicine on an ideological pedestal—some researchers have suggested that biomedical approaches to trauma have the potential to systematically disenfranchise victims of social injustice and political violence.5 It would be easy to argue that a biological model of mental illness cannot furnish moral judgments, but models are employed by human beings who possess moral agency. In this example, adherence to the biomedical model reflects a choice to avoid engaging in moral questions concerning the person who pulled the trigger. The connection between political violence and its psychiatric consequences may be more nebulous than a gunshot, but if I chose to describe those consequences in biological terms then I believe this is no less an abdication of my ethical duty of beneficence.
I place a special emphasis on choosing one model over another, because no doctor is limited to the biomedical model. In fact, although the biomedical model informs all medical specialties, no medical specialty could function without equally relying on other models of illness.6 Chief among these is the clinical model, which emphasizes the patient-doctor dyad and lies at the heart of the therapeutic relationship. One of its essential functions is to ensure that patients are not blamed for their illnesses, even when their own genes or behaviors adversely affect their health. This does not always mean there is no one to blame, however, and in my view the Holocaust represents a situation in which the perpetrators of social injustice are to blame. In this context, emphasizing biological causes removes the focus from social injustice and may become an insidious form of blaming the victim.
Advocates of pure biological psychiatry counter that social problems lie beyond the purview of medicine. However, this argument ignores another key paradigm that is intrinsic to medical practice: public health.6 The public health model is essential for translating biomedical knowledge into social policies that reduce the burden of illness on society. To illustrate this, consider the example of coronary artery disease. In treating patients with myocardial infarction, physicians discovered that smoking was a risk factor for heart attack. Although coronary artery disease is a medical illness, this did not release doctors from their ethical obligation to help initiate anti-smoking campaigns to reduce the toll of tobacco on cardiovascular health.
As I wandered near the silent ruins of Auschwitz’s infamous crematoria, I could not escape the moral import of the Holocaust: what happened there was wrong. But by simple analogy to smoking, genocide—whatever else it may be—is a risk factor for mental illness. Unfortunately, this recognition has not led to widespread public information campaigns aimed at reducing the incidence of political violence in the present day. Focusing public attention on the plight of genocide victims is perhaps asking too much of psychiatry, but as a medical specialty we still have a duty to inform public policy in a world that is increasingly globalized. It does not seem unreasonable that we should carry out this duty in a way that—at the very least—does not offer a view of mental illness that discourages policymakers and their constituents from trying to address nonbiological causes of mental illness.
The biomedical model is unequivocally useful—my patients at the Holocaust survivor clinic were grateful for the somatic treatment they received, and many benefited from it. But is that the end of the story? If I closed my eyes, it would be easy to imagine that treating survivors was all psychiatrists had to do, and that we had no obligation to fight the conditions that made our patients ill. But my eyes are open, and I am not convinced.