Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

Ronald W. Pies, MD

“Come now, and let us reason together.”

"Reason is, and ought only to be, the slave of the passion."

A few weeks ago, having been fully vaccinated against COVID-19, I ventured out for a long-postponed haircut without wearing a mask, knowing that the pleasant but tempestuous woman who regularly cuts my hair had received the single-shot Johnson & Johnson vaccine. But when I told her I had received 2 doses of the Pfizer vaccine, she looked horrified. “Oh, no!” she said, “That vaccine is going to rewrite your DNA and leave your immune system damaged for life!” I decided this was not the time to challenge her or to explain that, no, the m-RNA vaccines do not rewrite one’s genetic code or destroy the immune system—especially with her scissors 3 inches from my face.

Then, a few days ago, I read about the increasing use of so-called 

 in California, which is experiencing extreme drought conditions. According to the 

, these “water dowsers” claim that they can “…locate streams of water in the fractures in the earth’s bedrock, using 2 L-shaped rods that together resemble an old-fashioned television antenna.”

 These individuals are now heavily booked and well-paid for their services, despite the fact that hydrogeologists describe water dowsing as “

The common thread in these personal vignettes is, of course, a deep-seated denial of science and a mistrust of scientific 

—a word that is nowadays pronounced with a kind of dismissive hiss. Indeed, experts in epidemiology and infectious disease, such as Anthony Fauci, MD, are not merely doubted by a substantial proportion of the public—they are threatened with bodily harm for advocating vaccination against COVID-19.

It is easy to explain away such science denial as the result of mistaken information and biased reasoning, exacerbated by 

grossly misleading claims on social media

 To be sure, these factors do contribute to science denial and the derogation of scientific authority. As physicians, we have an obligation to provide our patients with accurate information that might 

counteract such irrational and unfounded beliefs

But as psychiatrists, we know that reason has its limitations, absent a deep understanding of the feelings—indeed, the 

—that shape human belief and behavior. The great Scottish philosopher, David Hume (1711-1776) understood this well, arguing, in his 

reason is, and ought only to be, the slave of the passions.”

 According to philosopher AT Nuyen, Hume was not negating the importance of reason in shaping human belief and behavior, but merely putting it in proper perspective—arguing, in effect, that “…reason alone does not move one to act. The force that propels one to action is the passion, whether it be love, or anger, or pride, or envy, or fear, or desire.”

Hume’s great insight has been amply confirmed by modern-day psychological research, notably that of 

, a professor of neurology and neurosurgery at Stanford University.

 Sapolsky’s studies of cognitive function have convinced him that, “You can’t reason somebody out of something they weren’t reasoned into in the first place,” and that “…We’re certainly set up to only have resonating in our head the stuff we want to hear.” He adds that, “…people who are least curious, most unwilling to explore novelty, [and] most reflexively hostile about it are people who are anxious.”

And who better to empathize with and explore anxiety than psychiatrists? Indeed, Sapolsky urges us to emulate the teenager, whose “…deeply felt sense of empathy” is often lacking in adults. Had I been doing therapy with someone like the woman who cuts my hair, I would have homed in on the anxiety that probably underlay her unfounded beliefs about COVID vaccines. If I were working therapeutically with the rancher or vineyard owner shelling out good money to a “water witch,” I might focus on the understandable feelings of despair and desperation driving that behavior. Yes, I would also gently guide these individuals to sources of accurate information—but only after connecting with them on an 

 (1623-1662) wisely put it, “The heart has its reasons which reason knows nothing of... We know the truth not only by the reason, but by the heart.”

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of

(2007-2010). He is the author, most recently, of

1. Nuyen AT. David Hume on reason, passions and morals. 

2. Albeck-Ripka L. Two rods and a ‘sixth sense’: in drought, water witches are swamped. 

. July 17, 2021. Accessed July 21, 2021. 

https://www.nytimes.com/2021/07/17/us/california-drought-water-witches.html

3. Mello MM, Greene JA, Sharfstein JM. Attacks on public health officials during COVID-19. 

4. Ortutay B, Seitz A. Defying rules, anti-vaccine accounts thrive on social media. 

. March 12, 2021. Accessed July 21, 2021. 

https://apnews.com/article/anti-vaccine-accounts-thrive-social-media-e796aaf1ce32d02e215d3b2021a33599

5. Pies RW, Pierre JM. Believing in conspiracy theories is not delusional. 

. February 4, 2021. Accessed July 21, 2021. 

https://www.medscape.com/viewarticle/945290#vp_1

6. Robert Sapolsky on how to become ‘less twitchy,’ embrace empathy. FRED Leadership. Accessed July 21, 2021. 

https://static1.squarespace.com/static/5de939086957252759882614/t/5e332ad18d20f734ba38a27c/1580411601821/Robert-Sapolsky-story-for-FRED.pdf

https://wiselifelesson.com/quotes/the-heart-has-its-reasons-which-reason-knows-nothing-of-we-know-the-truth-not-only-by-the-reason-but-by-the-heart-blaise-pascal/

Brumfiel G. Anti-vaccine activists use a federal database to spread fear about COVID vaccines. June 14, 2021. Accessed July 21, 2021. 

https://www.npr.org/sections/health-shots/2021/06/14/1004757554/anti-vaccine-activists-use-a-federal-database-to-spread-fear-about-covid-vaccine

Articles

How can you reason with someone who is determined to believe misinformation? One doctor shares his reflections.

Anti-Vaxxers and Water Witches: Mistrust of Science and the Limits of Reason

We would like to respond to the article "

 Their article in turn addresses an earlier essay on 

Strouse et al place forms of actively hastening death under the rubric of medical aid in dying (MAID), noting that 10 states and the District of Columbia have now legalized MAID, and that “all current state laws explicitly stipulate that such deaths are not suicide.” Their letter argued for a distinction between decisions to “directly hasten one’s own death” in the context of terminal illness, and what they called “conventional suicides.” Citing work including a statement from the American Association of Suicidology (AAS), Strouse et al argued that suicide is not the same as physician aid in dying, and that—allowing for some overlap—the 2 acts differ on the level of psychopathology. They further suggested clinicians distinguish between conventional suicide and MAID, so that they may “work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.”

We respect Strouse and his colleagues’ clinical experience and humane intentions. However, as psychiatrists, medical ethicists and a palliative care physician (Dr Geppert), we find this thesis deeply troubling. In particular, the focus on state laws ignores the central ethical question of whether physicians’ helping patients kill themselves is ever justified in the context of terminal illness or in any other circumstance.

The notion that 22% of the US population live in a state where MAID is legal is a demographic fact, not a value claim. As Daniel P. Sulmasy, MD, has observed, “data cannot tell a society or a profession what ought to be done” and neither can legislation. This is a consequence of what philosophers call the 

. Sulmasy has said, “Whether just 1 person or 100,000 persons legally avail themselves of lethal prescriptions cannot tell us whether the practice is right or wrong.”

The mere fact that some state legislatures have passed statutes redefining suicide, such that MAID is not suicide, does not prove that this redefinition is conceptually or ethically justified; in fact, several judicial decisions have held this opinion. In 2017, the New York Court of Appeals held that “suicide has long been understood as ‘the act or an instance of taking one’s own life voluntarily and intentionally’ ... Aid-in-dying falls squarely within the ordinary meaning of the statutory prohibition on assisting a suicide.”

 Similarly, in 2016, the New Mexico Supreme Court held that the prohibition against assisted suicide unambiguously covered self-induced death in situations such as those described by Strouse et al.

 (521 US 702, 1997), the US Supreme Court permitted laws prohibiting assisted suicide because of the states’ compelling interest in suicide prevention, effectively equating assisted suicide with suicide.

While redefining suicide averts legal liability for physicians providing MAID, it does not change the essentially unethical nature of the act itself. The term 

 fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term 

 Perhaps even more significant, following a comprehensive evaluation by the Council on Ethical and Judicial Affairs, the American Medical Association (AMA) House of Delegates rejected the term 

 Indeed, the process typically described as MAID in no sense aids dying; on the contrary, it rapidly converts an ill individual into a dead one. This is substantively different than the withdrawal of heroic but nonbeneficial or inappropriate measures, such as the use of ventilators that merely prolong the dying process in the final stages of a terminal illness.

Finally, statutorily declaring that self-induced death via a physician’s assistance is not suicide may soothe the consciences of legislators and allow payouts on life insurance policies; but, perversely, it may also incentivize some terminally ill patients to kill themselves. Furthermore, as Sulmasy

 notes, preliminary reports suggest increased rates of suicide in the general population of states that have legalized PAS. Specifically, “legalizing PAS has been associated with an increased rate of total suicides relative to other [non-PAS] states, and no decrease in non-assisted suicides.”

 Similarly, suicide rates in the Netherlands (where medical euthanasia is legal) have accelerated, compared to neighboring countries that have not legalized medical euthanasia.

Redefining suicide to exclude PAS in the context of terminal illness represents a radical linguistic maneuver that flies in the face of ordinary language, expressed over thousands of years. The Latin 

from which the English word suicide is derived—means the act of killing oneself intentionally or voluntarily. To be clear: we do not deny that there are often psychological and motivational differences between those with terminal illnesses who take their own lives and those who do so in the context of severe psychiatric illness, as the AAS statement details. But in both instances, the act is that of suicide

[A] s a philosopher, I feel an obligation to point out that, as a conceptual matter, there is nothing inaccurate or false about stating that a person who takes a drug, knowing that it will cause her death, and takes it because it will cause her death, is committing suicide on any reasonable conceptual analysis of what suicide is.

The hijacking of ordinary language is becoming increasingly common, such that comforting euphemisms like 

 have replaced the more troubling ordinary language term 

 Accordingly, one might reasonably wonder if the insistence that MAID not be described as suicide betrays some cognitive dissonance regarding the practice, especially on the part of psychiatrists whose duty is to prevent suffering patients from taking their own lives. The 

of many physicians who carry out MAID has been well-documented.

Cognitive Distortions, but No Mandated Treatment

Furthermore, most MAID laws do not require treatment for serious medical conditions, even when it is available to the patient. For example, a patient whose metastatic cancer stands a reasonably good chance of remission with aggressive treatment, but who nevertheless 

, is not required by state laws to undergo the treatment.

 Choosing assisted suicide in such a scenario may superficially appear to be a rational choice; but may instead represent a decision grounded in certain cognitive distortions that also characterize so-called conventional suicide. Importantly, this may be so, even in the absence of a diagnosed psychiatric disorder.

For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, noted that some cancer patients may make erroneous assumptions, like, “No one can help me” or “No one understands what I am going through.”

 Such cognitive distortions may respond favorably to cognitive behavioral interventions and potentially avert or abort a request for PAS. Indeed, it has been found that “Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided.”

Unfortunately, in almost every US jurisdiction where PAS is allowed, no attempt to offer treatment by a mental health professional is required by law; and the psychiatrist’s role is typically relegated to ruling out mental illness and 

The Issue Is Not Intractable Pain and Suffering

As Daniel P. Sulmasy, MD, PhD, noted, “Despite public arguments that PAS is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control.”

 These are forms of psychological distress which, in our view, are best managed with supportive and empathic counseling and/or cognitive behavioral interventions, provided to patients and their families—not by prescribing lethal drugs. Indeed, as Levin and Applebaum pointed out

[T]he root of many patients’ desire for a hastened death may reside in dysfunctional thoughts such as, ‘I get claustrophobic in small spaces like coffins’ and ‘I deserve to die.’ Exploring such cognitions by asking, ‘What are your biggest fears about death and dying?’ will allow the cognitive therapist to reframe dysfunctional thoughts. For example, if the patient worries that death is always painful based his perception of his grandfather’s death in 1975, the therapist might explore how good pain management can facilitate a more peaceful death and contrast the state of palliative care in 1975 versus the advances of the present day.

Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories of physician aid in dying and conventional suicide.

 Accordingly, we believe that the same precautionary principle that governs public health ought to apply to MAID requests.

This means erring on the side of caution and treating MAID requests from patients with terminal illnesses with the same degree of psychiatric scrutiny and concern that we would bring to any patient’s expressed wish to die. However, in most states, psychiatric assessment is not mandated in the MAID process and does not occur unless specifically requested by the evaluating physician who has initiated the MAID process.. This rarely happens. For example, in Oregon in 2020, only 0.8% of patients who were 

 were referred for psychiatric evaluation.

Moreover, the fairly subtle cognitive distortions described by Levin and Applebaum are unlikely to be detected in a superficial assessment of mental competence. It is no contradiction or paradox to argue, as we have, that pronouncing a patient qualified or competent for MAID is a violation of psychiatric ethics, since this unethically colludes with the process of aiding a patient’s suicide. Psychiatric involvement in end-of-life care is indeed essential, but it should remain well outside the procedures and processes involved in MAID deliberations.

Reducing Stigma vs Shifting it to the Other

Strouse et al emphasized that, “Most importantly, they [MAID laws] are intended by lawmakers to help avoid the stigma of suicide.” we agree that there is societal stigma associated with suicide, as the AAS recognizes. This, the AAS asserts, is in contrast to attitudes surrounding physician aid in dying

: “Death by suicide is often associated with substantial social stigma... [whereas] where it is legal, PAD is typically well accepted within the community and society at large.”

We infer from their commentary that Strouse et al would agree with the AAS claim (and co-author Margaret Battin, PhD, is a signatory to the AAS statement). Although well-intentioned, the AAS position and that of Strouse et al may have the unintended effect of increasing stigma directed toward those who attempt or complete a non-MAID suicide. In our view, creating a binary distinction between MAID and conventional suicide tends to marginalize individuals in the conventional group as “the Other.” This position may suggest to the general public that suicidal individuals with mental illness value their lives less than those with terminal physical illnesses—a claim we reject.

Indeed, as numerous suicide prevention websites 

: “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.”

 We would suggest that the same may be said of at least some individuals with cancer who seek MAID. Whenever complex ethical dilemmas are formulated as black-and-white categories, the many grey instances are often misclassified, with tragic consequences.

In short, the AAS position may have the perverse effect of merely shifting societal stigma from one group—those with terminal medical conditions—to those whose suicidal behavior occurs in the context of psychiatric disorders. We do not need such a 2-tiered classification, in which there are good and bad methods of taking one’s own life.

Moreover, we believe that such a dichotomy would likely magnify disparities in end-of-life care in resource-poor areas, where MAID would be far less expensive than sustaining palliative care. The AAS position may also weaken the motivation and rationale for suicide prevention, during a period when suicide rates have been rising in the US.

 We believe that efforts to promote MAID would be better directed toward destigmatizing the mental illnesses that underlie the majority of suicides and toward bolstering the availability of state-of-the-art palliative care.

The American College of Physicians has said

Physician-assisted suicide is neither a therapy nor a solution to difficult questions raised at the end of life. On the basis of substantive ethics, clinical practice, policy, and other concerns, the ACP does not support legalization of physician-assisted suicide. … However, through high-quality care, effective communication, compassionate support, and the right resources, physicians can help patients control many aspects of how they live out life's last chapter.

Like the ACP, we reject the implication that merely legalizing MAID somehow means that it is consistent with ethical medical practice. Quite the contrary. As physician and ethicist 

, MD, has pointedly cautioned: “We must care for the dying, not make them dead.”

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of 

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana. 

is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is also a health care ethicist with the Ethics Consultation Service of the Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College, and serves as the Ethics Editor for 

is Director, Forensic Psychiatry Fellowship, University of Maryland, Baltimore, MD.

1. Strouse T, Battin MP, Bostwick MJ, et al. A new question in end-of-life ethics. 

. June 11, 2021. Accessed June 20, 2021. 

2. Myers CJ, Retamero C. Suicidal ideation and behaviors in oncology patients. 

3. Sulmasy DP. Physician-assisted suicide and the perils of empirical ethical research. 

6. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide. 

7. Sabin J. Opinion of the council on ethical and judicial affairs. Proceedings of the 2019 Annual Meeting of the American Medical Association. 2019:235. Accessed June 23, 2021. 

8. Jones DA, Paton D. How does legalization of physician-assisted suicide affect rates of suicide? 

9. Boer T. Does euthanasia have a dampening effect on suicide rates? Recent experiences from The Netherlands. 

10. Dworkin G. Suicide, strictly speaking. 3 Quarks Daily. July 22, 2019. Accessed June 23, 2021. 

11. Koch T. The ethicist as language czar, or cop: "end of life" v. "ending life". 

12. Pies RW. How does assisting with suicide affect physicians? 

. January 7, 2018. Accessed June 20, 2021. 

13. To live each day with dignity: a statement on physician-assisted suicide. United States Conference of Catholic Bishops. June 16, 2011. Accessed June 23, 2021. 

14. Levin TT, Applebaum AJ. Acute cancer cognitive therapy. 

15. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2019 Data Summary. February 25, 2020. Accessed June 23, 2021. 

16. Loggers ET, Starks H, Shannon-Dudley M, et al. Implementing a death with dignity program at a comprehensive cancer center. 

17. Cerel J, Battin MP. Statement of the American Association of Suicidology: “Suicide” is not the same as “physician aid in dying.” American Association of Suicidology. October 30, 2017.

18. Martuzzi M, Bertollini R. The precautionary principle, science and human health protection. 

19. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2020 Data Summary. February 26, 2021. Accessed June 23, 2021.

20. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. 

21. Macomb County Suicide Prevention Coalition. Holding onto life toolkit. Accessed June 23, 2021. 

22. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999-2018. 

23. Snyder Sulmasy L, Mueller PS, Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians Position Paper. 

A comparison of physician-assisted/Death-with-Dignity death and suicide patterns in older adult women and men

Are physicians who assist in suicide betraying their professional values?

. June 15, 2021. Accessed June 23, 2021. 

Pies RW, Hanson A. Twelve myths about physician assisted suicide and medical aid in dying. 

https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide

Should psychiatrists help patients end their own lives, even if it is technically legal? 

Against Assisted Suicide 

by Richard M. Berlin, MD; DOS Madres Press, 2021

Poetry can be dangerous. Plato knew the potentially subversive power of poetry and banned poets from his authoritarian utopia, the 

. With the exception of some poetry that extolled the state, Plato feared that poetry would “

corrupt youth and incite the passions instead of the faculties of reason

 Sigmund Freud—whose theories of infantile sexuality were themselves viewed as subversive by Victorian society—appreciated the power and psychological depth of poetry, famously writing, “Everywhere I go, I find that a poet has been there before me.” Indeed, this is the epigram that begins Richard M. Berlin, MD’s latest collection of poems, aptly titled 

 readers know Dr Berlin’s work from his monthly “Poetry of the Times” columns, which have been an enlivening feature of this publication since 1997. As a friend and colleague of Dr Berlin, and as a contributor to 

 since forever, I have been privileged to witness the evolution of his poetry over nearly a quarter century. Rich is widely regarded as one of the foremost physician-poets writing today, and has been the recipient of several awards, including the 2010 John Ciardi Prize in Poetry for his collection 

. His latest collection represents a worthy addition to his body of work—and, given Dr Berlin’s many medically-situated poems, the word 

Dr Berlin’s world of medicine is no place for starry-eyed idealists or worshippers at the shrine of Doctor God. If there is one feature that runs like a dark thread through Berlin’s poetry, it is his own doubts, fallibility, and perceived weaknesses. In his poem, “Confessions/Prayer,” he writes of “…an altar where I worship and pray / For mercy for all my failings;” and “how I hide behind my white coat’s / illusion of purity and perfection…” He prays “…to remember the healer / I yearned to become when I started / my studies…” There is, indeed, a kind of lamentation that runs through this collection of poems. To be sure, Dr Berlin’s medical vocation gives him a sense of deep pride and personal satisfaction, but also a wistful sense of what might have been. He feels drawn to the wider life beyond medical care. In “Daydreaming,” Berlin writes, “It’s hard to listen to patients / when songbirds sing outside / my open window and laughter / drifts up from families strolling / the shop-lined street.”

And, not surprisingly, there are complaints that will strike a chord with many practicing physicians: the endless battles with “the insurance mob…demanding records of patients’ private confessions”; the insurance company reviewer “who always wins”; and the ambiguities of psychiatric diagnosis (“all the old Borderlines and angry / adolescents melted down to Bipolar/slush.”).

What becomes of old Freud in Dr Berlin’s hands? The striking cover of the book shows a leather-upholstered couch floating in a swirling sea of brown-toned fabric. The dream-like image seems quite fitting for a book titled, 

. In the 3 linked poems of the same title, Berlin takes us into the many-layered world of the father of psychoanalysis, from his “twelve years deep into coca”; to the odor of the cigars Freud ceaselessly smoked; to his hiking through the Dolomites with his young daughter, Anna. 

Of course, Richard Berlin the man is more than Berlin the physician. He is also a husband, father, and sometime jokester. His poem “Sleeping Daughter” strikes the poignant chords that epitomize a father’s love for his daughter, “…desperate to protect her any way I can.” I recall here one of the formative poems of my own development as a poet: W.D. Snodgrass’s, “

,” and its epigram drawn from Irish legend: “…an only daughter is the needle of the heart.”

 In “Psychiatrist Baseball Cards,” Dr Berlin allows himself and his colleagues a bit of good-natured fun: “So take heart, dear colleague, misses / and swings are part of The Show.” Finally, Dr Berlin provides the reader a few pages of helpful notes that explain some of the less familiar medical and biographical terms that appear in the poems.

I suspect that for his frankness, honesty, and humor, Rich Berlin would have been among the poets banned from Plato’s 

. Plato’s loss, our gain. I believe that 

 will ennoble the physician’s calling and deepen both the medical and nonmedical reader’s perspective on our profession—even as Dr Berlin casts a cold eye on some of our collective shortcomings.

. Poetry Foundation. Accessed June 30, 2021. 

https://www.poetryfoundation.org/articles/69373/from-the-republic

2. Snodgrass WD. Heart’s needle. Poetry Foundation. Accessed June 30, 2021. 

https://www.poetryfoundation.org/poems/42794/hearts-needle

Frankness, honesty, and humor make this doctor’s poetry collection special.

Freud on My Couch

Of the many canards directed against psychiatry in the late 20th century, one of the most enduring was the claim that psychiatric disorders are never included in pathology textbooks. For example, in 1998, a psychology professor confidently wrote: “If ‘mental illness’ is really a brain disease, it would be listed as such in standard textbooks on pathology. It is not listed as a brain disease because it does not meet the nosological criteria for 

However, as I argued in an article published more than 

 psychiatrists need not assert that the serious conditions we treat are brain diseases—only that conditions like schizophrenia and bipolar disorder represent bona fide disease, and that the term 

 is most usefully understood as a collection of highly distressing and dysfunctional conditions of individuals, not just their brains.

Brains, of course, may show cellular pathology, but this is merely the physical substratum of some 

 Cellular pathology is not disease in the holistic and experiential sense that so deeply concerns physicians and their patients. Indeed, those who argue that disease necessarily requires known structural abnormalities or cellular pathology should ponder this sweeping statement in the 8th edition of 

Harrison’s Principles of Internal Medicine

: “The clinical method has as its object the collection of accurate data concerning all the diseases to which human beings are subject; namely, all conditions that limit life in its powers, enjoyment, and duration.”

The editors go on to aver that the physician’s “primary and traditional objectives are utilitarian—the prevention and cure of disease and the relief of suffering, whether of body or of mind.”

In so arguing, the editors were implicitly invoking the 12th century physician-philosopher 

, who taught that “a physician does not treat a disease; he rather treats a sick person.”

Why Should We Care What Pathology Textbooks Say?

In my 2008 article, I presented several examples of pathology or neuropathology textbooks that recognized schizophrenia as a bona fide form of disease.

 In this article, I can update the list of pathology texts that clearly recognize schizophrenia as an instantiation of disease. To be clear: this is quite different than claiming that schizophrenia is a single, discrete disease like, say, pneumococcal pneumonia; it almost certainly is not.

Schizophrenia has been recognized as a form of disease for a long time. Eugen Bleuler, MD, referred to “the schizophrenias” (plural) more than 100 years ago, and most academics today see schizophrenia as a heterogeneous group of 

 as a kind of proxy for severe mental illness, which may include bipolar disorder, posttraumatic stress disorder, autism, and several other conditions.

But why bother with this exercise in the first place? I believe that the issue has great relevance to the place psychiatry occupies in the overall field of medicine. The voices of antipsychiatry are intent on extruding and excluding psychiatry from the realm of legitimate medical specialties, and they attempt to do so by denying that the conditions we treat qualify as genuine 

 Antipsychiatry invokes the putative authority of pathology texts to make its case, as if only pathologists can fathom the true nature of disease. This deification of pathology should be viewed as the triumph of scientism over science.

Pathology Texts that Recognize Schizophrenia

If some pathology textbooks recognize psychiatric conditions like schizophrenia as legitimate examples of disease, antipsychiatry’s case is radically weakened. With that in mind, here are some updated entries from several pathology texts that recognize schizophrenia as bona fide disease.

: “Multifactorial inheritance does not have a well-defined recurrence risks, but tends to run in families, and is more characteristic for diseases such as diabetes or schizophrenia.”

Practical Surgical Neuropathology: A Diagnostic Approach

: “Human disease is increasingly appreciated to have an underlying genetic basis. This is particularly true of neurologic disease, where genetic variants have been shown to increase risk or directly cause schizophrenia, autism spectrum disorder and neurodegenerative diseases.”

Pathology: Oxidative Stress and Dietary Antioxidants

: “Schizophrenia is a mental illness that comprises positive, negative and cognitive symptoms. Hyperactive dopaminergic signal transduction in the mesolimbic system and OS [oxidative stress] among other factors, are associated with the neurobiology of schizophrenia.”

: “There are no specific biochemical or morphological changes in common acquired mental diseases due to mental stress, strain, anxiety, overwork and frustration; eg, depression, schizophrenia.”

Note how this last sentence gives the lie to 3 cardinal (and bogus) tenets of antipsychiatry: 1) real disease must be physical or bodily, not mental; 2) real diseases must demonstrate specific biochemical or morphological deviations from normal; and 3) schizophrenia and depression are not real diseases. That the author views mental diseases as acquired due to mental stress is certainly open to revision and refinement, but this is no obstacle to considering schizophrenia a type of disease.

To be clear: the reality of psychiatric disease is not dependent on what textbooks do or do not include as diseases. That reality is demonstrated every day in the suffering and incapacity of 

 Nevertheless, it is important for psychiatry, as a profession, to correct the misrepresentations of its ill-informed critics—particularly those who seek to marginalize psychiatry by denying the reality of the diseases that grievously afflict our patients.

 is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of 

. August 22, 1998:A12. Accessed April 22, 2021. 

2. Pies R. Psychiatric diagnosis and the pathologist's view of schizophrenia. 

3. Reese DM. Fundamentals--Rudolf Virchow and modern medicine. 

, 8th ed. G.W. Thorn et al, eds. McGraw-Hill; 1977.

5. Kottek SS. Toward becoming an accomplished physician: Maimonides versus Galen. 

7. Alnæs D, Kaufmann T, van der Meer D, et al. Brain heterogeneity in schizophrenia and its association with polygenic risk. 

8. Benning TB. No such thing as mental illness? Critical reflections on the major ideas and legacy of Thomas Szasz. 

9. Klatt EC, Kumar V. Diseases of infancy and childhood. In: Robbins and Cotran, eds. 

10. Solomon DA. Integrating molecular diagnostics with surgical neuropathology. In: Perry A, Bratt DJ, eds. 

11. M. Moretti, LS Rodrigues. Ascorbic acid as an antioxidant and applications to the central nervous system. In: Preedy V, ed. 

12. Mohan H. Cellular adaptation and cell injury.

 Textbook of Pathology + Pathology Quick Review

, 8th edition. Jaypee Brothers Medical Publishing; 2018:33-69.

What is “disease”? Implications of chronic fatigue syndrome

Ronald W Pies, MD, considers the evidence from pathology textbooks—and answers the critics. 

Ronald W. Pies, MD

Articles

Anti-Vaxxers and Water Witches: Mistrust of Science and the Limits of Reason

Against Assisted Suicide

Freud on My Couch

Do Psychiatrists Treat Diseases?

Poor DSM-5—So Misunderstood!

Reimagining the 15-Minute Med Check Through A Poet’s Eyes

Denial, The Capitol Takeover, and a Tragic American Legacy

What We Tell Patients about Depression, and What They Say They Have Been Told

Psychiatry and the Dark Night of the Soul

Is Depression a Disease?