Lawrence Hartmann, MD

: Many members of my family were shot by the Bolsheviks, and most of the rest were part of the mass exodus of “white” Russians in 1917. But, typical of the Russian Ã©migrÃ©s, there was always a certain “nostalgia” for mother Russia. Growing up in the US, I remember the great interest that my parents, grandparents, and their Ã©migrÃ© friends had for anything that was happening in the Soviet Union-the excitement they felt when they learned that Cliburn had won the first Tchaikovsky competition, their excitement that Yevtushenko was coming to the US to give readings of his poetry-but in particular, the fate of dissidents who found the strength to speak out about the government and were either sent off to the gulag or imprisoned in psychiatric hospitals and force-fed psychotropics to keep them quiet.

 were thinking of doing a series of articles from our archives, I came across this article from our January 1988 issue. I found it especially compelling and thought it might still be relevant today, particularly so given the state of today’s Russia, which seems to have, once again, lost many of its freedoms under Putin’s rule. And I wondered, could this abuse of psychiatric patients on the basis of political dogma again be happening without anyone knowing or caring if it is? In an 

 published in the February 2014 issue of 

, the authors state, “In Russia, treatment of the psychiatric population is at the mercy of government and society.”

[[{"type":"media","view_mode":"media_crop","fid":"41352","attributes":{"alt":"Â© ALEXSKOPJE/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_5904711283388","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4354","media_crop_rotate":"0","media_crop_scale_h":"104","media_crop_scale_w":"175","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© ALEXSKOPJE/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]“Don’t trust them,” Dr Anatoly Koryagin said of officials in the Soviet government. “You’d have to be an idiot to love the kind of power that imprisons normal people.”

“What about some skeptical optimism?” I asked him. “Isn’t some glasnost better than none?”

“Very skeptical optimism is OK,” he said, “but they’re still at it. How many real, factual changes have there been? They’ve freed me, and they’ve freed a few others; there are still hundreds of ‘psychiatric’ political prisoners; they are still abusing truth, and abusing innocent people.”

Anatoly Koryagin is an astonishing and refreshing man. I have met him twice, once in May 1987 at the APA meetings where we spent an hour and a half together (with Boris Zoubok as a fine interpreter) and again in October, with and without interpreters, when Koryagin gave a lecture in Boston and was my house guest for a day.

Imprisoned for many years in the Soviet Union essentially for being an excellent psychiatrist, Koryagin recently came to the United States for the second time, receiving an award from the American Academy of Psychiatry and Law and giving a series of lectures. He is now living in Switzerland with his wife and 3 teenage sons trying to write an autobiography and a book on Soviet psychiatry.

Koryagin’s major crime in the Soviet government’s eyes was that he, a well-trained, establishment Russian psychiatrist, objected to the political abuse of psychiatry in special Soviet psychiatric hospitals and did something about it: He psychiatrically examined the most prominent political dissidents that the Soviet government was calling mentally ill. These dissidents were usually diagnosed as having “sluggish schizophrenia” and were hospitalized and medicated against their will. Koryagin established and documented that these dissidents were not mentally ill and then published his findings in the British medical journal 

Now physically and mentally vigorous, he was considered near death last year in prison where he was subjected to treatment that would certainly be called abusive in most of the civilized world. He was, for instance, repeatedly kept in freezing solitary confinement. “The cold made it impossible to sleep,” he recently wrote. “Night becomes endless torment. Sleep consists of brief moments dozing brought to an end by fits of uncontrollable shivering and all-pervasive cold. One’s feet freeze solid. One’s head is shaved bare for the isolation cell. Every cell in one’s body suffers from the cold. Cold seeps through the window, the iron door, the cement floor, the cracks. During the day one’s head is like lead . . . Hopelessness and frustration, outbursts of depression and anger . . . these are common emotions in the isolation cell.”

Koryagin helped other prisoners medically and often remained remarkably self observant. He documented fascinating and painful episodes of being starved and of psychiatric medication (given him against his will) and its withdrawal symptoms. He was force-fed during hunger strikes, handcuffed while a nasogastric tube was inserted. Instead of lubricant, he claims, the jailers used a corrosive coating on the tube, causing great pain.

Koryagin attributes his being freed from prison early in 1987 partly to persistent effects by American and British psychiatrists and others on his behalf. Innumerable letters were written to him, to Soviet psychiatric leaders (who still have not admitted psychiatric abuse), and to Soviet politicians. His name was prominent in the continuing effort to make the World Psychiatric Association take ethics and abuse of psychiatry seriously. He was made an honorary fellow of the APA and was nominated for the Nobel Peace Prize. Some of this activity he heard about while in prison; much of it he has learned since. He claims it helped him to survive, and he is grateful.

What else helped him to survive and to prevail? He acknowledged that he has been for much of his life a person of clear ideas and will; his wife was also crucial. In May, jet-lagged from a trans-Atlantic flight, his wife was sitting beside him when I first met him. He said eagerly and with a light in his eyes, “You know, without her I never would have made it. I knew she was with me. All the time in prison, I knew it. Some of the others-good people-broke down in prison; but I knew I had her with me, and that was terribly important in helping me to survive.”

Koryagin spoke of many other aspects of Soviet psychiatry and special psychiatric hospitals. We discussed “sluggish schizophrenia,” a uniquely Soviet diagnosis promulgated by one of the leaders of the Soviet psychiatric establishment, Andrei Snezhnevsky. That diagnosis, I had assumed, was tailored pretty well to fit political dissidents. “Not quite!” Koryagin exclaimed. “Even by Snezhnevsky’s own criteria of sluggish schizophrenia, those political prisoners didn’t fit.”

He asked about Chile, which I had visited recently, and was intrigued by differences between Soviet and Chilean handling of political dissidents. He was astonished that there were human rights groups in Chile, in which doctors and lawyers help document and treat victims of government torture. “They’d never allow anything like that in the Soviet Union.”

Meeting Koryagin again this fall, I was again struck by his vigor and moral passion. He gave lectures almost daily, in Cleveland, Washington, DC, Ottawa, Boston, and New York. He spoke publicly with an interpreter giving an English translation after every sentence or two, but his expressions and voice managed to convey a lot even before the translation.

His Boston lecture at Harvard Medical School was sponsored by Physicians for Human Rights and the Massachusetts Psychiatric Society. He discussed his experiences, Soviet psychiatry, and medical ethics, urging the audience to be skeptical of 

 and of independent-seeming Soviet professional groups. He asked us to do everything possible to enforce medical and human rights standards and to try to visit those in Soviet psychiatric hospitals. He said international organizational pressure has helped to make political abuse of psychiatry less comfortable for the Soviets. Despite these institutionalized abuses, however, Koryagin did note that there is a large area of Soviet psychiatry that does treat patients decently.

He is cautious about the significance of the recent shift of special psychiatric hospitals from direct KGB control to nominal Ministry of Health control, since he assumes that little real control has actually shifted.

“They imprisoned me and sent me away because I stood against the ill use of psychiatry,” he said, “but there are other ill uses, and they would send me away for standing against those, too. They made me emigrate because I told the truth. That was done under Gorbachev.” When Koryagin was freed from prison, he was told to sign a paper saying he would refrain from political activity and public discussion. He refused, stating he would go on just as before. He was released anyway.

On our walk around Cambridge the morning after the lecture, he wanted to be photographed in front of a fine old house where George Washington had lived for a year and where Longfellow had lived for 30 years a century later. He didn’t know who Longfellow was, but he knew who Washington was, and he liked the association.

Dr Hartmann chairs the APA Human Rights Committee. He practices in Cambridge, MA, and teaches at Harvard Medical School. 

Articles

Here: the ordeal of a Russian psychiatrist who objected to the political abuse of psychiatry in the Soviet Union-and did something about it.

Koryagin, Suspicious of Glasnost, Recounts Ongoing Soviet Abuses

What counts as participation in capital punishment? Is it possible for a medical activity to be ethical in one context, but a similar one not ethical in another? Is death different? Are there neat and universal ethical rules that will always guide us wisely, or are there inevitable clashes among various legitimate and important values? Is it ethically possible that a forensic psychiatrist is not a psychiatrist, as Dr. Paul Appelbaum has argued? How strongly should physicians protect their duty to always help and not harm all individual patients in the face of many pressures to do otherwise?

All these questions bear on the current debate as to whether it is ethical for a psychiatrist to perform a competency-to-be-executed evaluation.

My position (a widespread and traditional position [Freedman and Halpern, 1996], is that it is not ethical. Alfred Freedman, M.D., and I argued this point against Paul Appelbaum, M.D., and Ken Hoge, M.D., at the American Psychiatric Association annual meeting last May. Internationally, as evidenced by the positions of the World Medical Association, the World Psychiatric Association, the British Medical Association and others, the position still prevails that it is not ethical. However, Appelbaum and others led an important movement to change this in the mid-l990s, and succeeded in getting a significant and even radical shift of position in the APA Council on Psychiatry and Law, and the APA itself. I find that shift disturbing and interesting. This debate now probably reflects a significant division of opinion among American psychiatrists, and the issues involve some subtlety and facing of value conflicts (Rothstein, 1995). 

The position of forensic psychiatrists on this issue is not necessarily the same as the position of the whole field of psychiatry, and that is a problem. Appelbaum, an excellent forensic psychiatrist, has in his writings swept aside much of medical and Hippocratic Oath tradition, and has substituted an ethic of "truth," and a claim that forensic psychiatrists do not function as physicians. I think this is never quite honest, and never ethically possible. As Alan Stone, M.D., said: "The advancement of [justice] is a noble goal, but when doctors give it greater weight than helping their patients or doing no harm, they lose their ethical boundaries." Appelbaum has suggested that this competency debate-dealing with few cases-is really a covert debate to abolish capital punishment. I disagree: One can consider physician participation unethical without wishing to abolish capital punishment. He has also suggested that not participating would mean less patient care. I disagree. It would, I think, mean better, clearer and more care.

Central to our debate is the issue of taking part in capital punishment. It is fairly universally accepted that physicians should not do that. But what is "taking part?" How directly? Treating to restore competence to be executed falls at the edge of that, and is widely considered wrong. Final evaluation falls at the edge, and is, to many of our minds, also wrong, because it is too directly taking part in execution. As Gregg Bloche (1993) points out, "the use of psychiatric skills in this context so compromises medicine's therapeutic and compassionate aims that it ought to be regarded as ethically unacceptable.

I urge readers to consider the inevitable value clashes involved and to agree that it is unethical for psychiatrists to participate in competency-for-execution evaluations.

American Medical Association Council on Ethical and Judicial Affairs (1995), Physician participation in capital punishment: evaluations of prisoner competence to be executed: treatment to restore competence to be executed.
 

Bloche MG (1993), Psychiatry, capital punishment, and the purpose of medicine. Int J Law Psychiatry 16(3-4):301-357.
 

Freedman A, Halpern A (1996), The erosion of ethics and morality in medicine: physician participation in legal executions in the United States. New York Law School Law Review XLI(1):169-188.
 

Rothstein DA (1995), Psychiatrists' involvement in executions: arriving at an official position. AAPL Newsletter 20(1):15-17.
 

Stone A (1984), Law Psychiatry and Morality: Essays and Analysis. Washington: American Psychiatric Press.

Lawrence Hartmann, MD

Articles

Koryagin, Suspicious of Glasnost, Recounts Ongoing Soviet Abuses

Is It Ethical for Psychiatrists to Participate in Competency-To-Be-Executed Evaluations?