Contributor Post Created with Sketch. Recommended by Ricochet Members Created with Sketch. Contra Caplan on Physical Illness, Too

 

In 2006, insouciant economic imperialist Bryan Caplan published a paper outlining a consumer-choice model of mental illness designed to rehabilitate the anti-psychiatry of Thomas Szasz. Caplan claimed this model shows that mental illness should not to be understood as a “real illness” (and therefore as a matter for medical rather than moral treatment) at all, but that mental illness should be understood as a weird preference rational actors persist in despite their preference being a poor match for functioning in society.

From the perspective of Caplan’s model, mental-health treatment is a form of rent-seeking designed to paper over the interpersonal conflicts that arise when somebody won’t relinquish a preference grievously at odds with society, rent-seeking that, on the one hand, provides the “mentally ill” with official-sounding excuses for their weird preferences while, on the other hand, providing the families of the “mentally ill” with medical justification for treating sufficiently “ill” family members against their will. In October 2015, the blogger Scott Alexander, himself a psychiatrist, published “Contra Caplan on Mental Illness”, an essay pointing out why, from his perspective, it seems so strange to call mental illness merely a weird preference. Given Caplan’s framework, I would like to point out how strange it is to call physical illness not a “weird preference”, albeit a weird preference most of us take pity on out of belief that it arises from physical derangement that we don’t expect sufferers to be able to compensate for completely.

Caplan’s paper contains several illuminating sketches of the mentally ill, perhaps the most interesting being of John Nash. Before I get into the technical weeds, I’ll summarize Caplan’s portrait of Nash, a strangely sympathetic portrait – in that you have to be strange to find it sympathetic (although I do). According to Caplan, Nash, though a brilliant man, was a frustrated mathematician, frustrated enough that escaping into a world of delusion seemed preferable to dealing with reality. The rest of the world might understandably wonder, how frustrated a mathematician could Nash be? After all, Nash has been honored with both a Nobel (in economics) and an Abel (mathematics) prize. Here’s how Caplan puts the matter:

What about paranoid schizophrenic John Nash, who in fact did win a Nobel prize? Surprisingly, he fits Szasz’s profile, because Nash’s great ambition was not to earn a Nobel prize in economics, but the coveted Fields Medal in mathematics. In 1958, he failed to win it, and given his age he had little hope of ever doing so. As his biographer Sylvia Nasar (1998: 229) explains: ‘One can almost imagine a sniggering commentator inside Nash’s head: ‘‘What, thirty already, and still no prizes, no offer from Harvard, no tenure even? And you thought you were such a great mathematician? A genius? Ha, ha, ha!’’’. And Nash’s personal problems – a gay or bisexual man, unhappily married, and expecting a child – were at least as serious as his professional disappointments.

Since, as Nash later observed, ‘rational thought imposes a limit on a person’s concept of his relation to the cosmos’, he escaped into a world of fantasy, where his failures no longer mattered. His biographer confirms the subjective benefits: ‘For Nash, the recovery of everyday thought processes produced a sense of diminution and loss . . . He refers to his remissions not as joyful returns to a healthy state, but as ‘‘interludes, as it were, of enforced rationality’’’ (Nasar 1998: 295). His choice to abandon his academic career was much in the spirit of Robert Frank’s (1985) Choosing the Right Pond : If Nash could not be a Fields Medalist, his next choice was to be Emperor of Antarctica, not a second-rate mathematician.

Caplan observes that Nash himself described his recovery from mental illness as mostly an act of willpower, as going on a “diet” from crazy-making thoughts. Nash’s returns to reality, Caplan observes, were thus a choice. Ergo, Nash’s flights into schizophrenia must have likewise been a choice (since Nash demonstrated that, with enough effort, he could choose differently) rather than an illness. This leads me to wonder whether Caplan views diabetes, hypertension, celiac sprue, allergies, or any number of physical diseases where the willpower to stick to a restricted diet (whether from certain foods or other triggers) might be all that’s necessary for complete remission, as “merely” choices. But I promised technical weeds, so here they come:

Consumer choice theory seeks optimal ways to satisfy preferences given budget constraints. Which is to say, problems in consumer choice theory are constrained optimization problems where some constraints (the budget constraints) have much greater priority over others (the preference constraints). Give an economist a set of constraints and tell him some are budget constraints, and he’ll make sure those constraints are completely satisfied. The preference constraints? Eh, he’ll satisfy them to the degree it contributes to “overall utility”. “Budget” and “preference” are not objective categories, though. Rather, they reveal subjective truths about our priorities. All of us intuitively understand this, based on how we budget our own money. When we set ourselves a grocery budget, we also reveal how much we prefer spending money on groceries rather than other things. Most of us quite sensibly would consider a Maserati “out of our budget” if the only way we could afford one was to live off Ramen noodles for twenty years. But a guy who really wanted a Maserati? Maybe he’d chose the Ramen. Maybe he’d choose all sorts of privations, if he thought those gave him a shot at someday owning a Maserati. “Budget constraints” can have all sorts of implicit preferences built in, and we should be leery of those claiming an iron curtain between “budget” and preference”.

Which is of course exactly the curtain which Caplan proceeds to claim in his paper. For Caplan, the distinction between organic illness and “mental illness” (which Caplan asserts is not really illness at all) is the distinction between having tighter budget constraints and just having weird preferences. As Caplan puts it, the “truly ill” suffer constraints which put certain normal human activities outside their “budget set”: the paraplegic can’t walk, the deaf can’t hear, and so on. Whereas humans who merely have weird preferences aren’t really ill at all, since merely having a weird preference cannot prove that your budget set has been restricted. Caplan acknowledges, however, that the distinction between budget constraint and preference isn’t always obvious at first. For that reason, he suggest the following “Gun-to-the-Head-Test” as a surefire (ha!) way to illuminate the difference:

Can we change a person’s behavior purely by changing his incentives? If we can, it follows that the person was able to act differently all along, but preferred not to; his condition is a matter of preference, not constraint. I will refer to this as the ‘Gun-to-the-Head Test’. If suddenly pointing a gun at alcoholics induces them to stop drinking, then evidently sober behavior was in their choice set all along.

So, for example, if you put a gun to a deaf man’s head and threatened to shoot him if he didn’t get a cochlear implant to restore his hearing, or if you threatened to shoot a gymnast who’d broken her ankle if she refused to attempt a vault, and both chose cooperation over death, you would… prove that deafness and broken ankles can’t be illnesses because they aren’t really budget constraints?… No, that can’t be right.

Instead, what you’d demonstrate is that the physically ill aren’t facing the budget constraints Caplan posits, either. They, too, possess some capacity to overcome their difficulties if the stakes are high enough, though they likely must overcome their difficulties at greater cost (in dollars for cochlear implants, in worsening injury for injured gymnasts who refuse to quit) than healthy people do. The same behavior Caplan believes is a “tell” for the mentally ill not “really” being ill – that the “mentally ill” can amend their behavior when the stakes are high enough – is also a “tell” for many people experiencing physical illness, too.

Kerri Strug is of course the gymnast who vaulted on an injured ankle, and they didn’t even have to threaten to shoot her to get her to do it! Helping her team win gold in the Olympics proved incentive enough. When the stakes are high enough, it’s very common to find ways to muscle through very real, very physical, infirmities, infirmities we wouldn’t bother overcoming otherwise. I’m used to doing so myself, though of course far less heroically than Strug. So when I read Caplan’s pronouncement that, “If you have the common cold, the good of ‘not-sneezing’ suddenly falls on the wrong side of your budget set,” I burst out laughing.

Anyone involved in theater or music for any length of time learns that sneezes and coughs aren’t something whose avoidance simply falls “in” or “out” of your “budget set”, but reflexes that, with a lot of effort, can be suppressed. Not suppressed with 100% certainty, but suppressed hard enough that the odds of them spoiling a performance become low enough to go on with the show. A group I was in once recorded a CD while I had lung trouble bad enough to leave every cell of my body aching for some nice, juicy, hacking. I had to go to extremes to not cough during recording, but I succeeded. The extremes weren’t pretty, but that’s my point: not-coughing was still in my “budget set”, I just had to resort to costly, “abnormal” extremes to accomplish it.

Caplan observes that the AD(H)D criterion “‘has difficulty’ ‘sustaining attention in tasks or play activities’ could just as easily be described as ‘disliking’ sustaining attention.” Similarly, I observe, “has difficulty not coughing” during lung trouble could be described as “disliking” not-coughing. And it’s true – I really did dislike it. I really would have preferred to cough. Not yielding to my disruptive preference took considerable fortitude.

When Caplan’s claims, “Obviously most physical diseases would pass the gun-to-the-head test,” sorry, it’s not obvious. Not obvious at all. Yes, a great many impairments could pass Caplan’s gun-to-the-head test, but many of our most humdrum experiences with illness and injury (colds, back pain, headaches, heartburn) would probably fail Caplan’s test much if not most of the time.

Caplan’s goal in writing his paper was, of course, not just to promote his own economic model, but to rehabilitate the work of Szasz, whom Caplan quotes approvingly,

I maintain that we do not need, and should not try, to account for normal behavior one way (motivationally) and for abnormal behavior another way (causally).

and

We may be dissatisfied with television for two quite different reasons: because the set does not work, or because we dislike the program we are receiving. Similarly, we may be dissatisfied with ourselves for two quite different reasons: because our body does not work (bodily illness), or because we dislike our conduct (mental illness).

Szasz’s two quotes together suggest that mental illness isn’t illness because it’s “just” a conduct problem, a problem rooted in motivation rather than a some other, “properly medical” cause. But this, too, fails to distinguish mental illness from physical illness. Quite often, those with bodily illness aren’t frustrated nearly as much by their physical symptoms as they are by their overall conduct – their lost productivity, their being “out of it” and out of sorts. If you think your conduct is holding up well in light of the constraints you face (whether bodily or otherwise), you can be pretty damn well pleased with yourself and happy with life. You might have a physical abnormality, but you won’t be miserable. No, the misery caused by bodily illness is very much about disliking your own conduct under its influence. The latest pain science research describes pain not as mere bodily signal, but as an emergent motivational state. Sick animals (and we’re animals, too) exhibit “sickness behavior” – a systematic pattern of altered conduct. Indeed, altered conduct is typically what leads us to suspect someone’s ill in the first place. Since physical illness is also typified by altered motivational states leading to weird alterations in behavior, dismissing mental illnesses as not really illness, since they’re “just” unusual motivations leading to weird behaviors, becomes suspect.

Perhaps the one thing you could say for physical illness is that we expect the changes in motivation and behavior brought about by physical illness to correlate with objective signs and symptoms. As Caplan himself points out, though, there’s no inherently physical distinction between physically-rooted preferences we don’t regard as illness and the physically-rooted preferences we do regard as illness.

Suppose Person A and Person B both strongly prefer to avoid cats, to the point where they’ll sacrifice considerable convenience and sociability to do so. Human olfaction shows strong genetic variation. Perhaps Person A carries a gene which makes him so sensitive to litterbox aromas that even trace amounts strike him as disgusting as a garbage dump in August, while Person B gets the sniffles when he’s around cats. A great many of us would rather deal with some sniffles than with overwhelming stench, and yet we regard Person B as having an (admittedly mild) illness, while Person A “just” has a very strong preference. I don’t see why we can’t regard A and B as both having physically-rooted preferences, preferences which may be very difficult to mitigate through willpower alone (but hey, at least B has allergy shots and antihistamines on his side), one preference manifesting in overwhelming disgust (A), and the other in the more “obviously physical” sign of sniffles (B).

A great many undisputedly organic illnesses present as “weird preferences”. Maybe you have this weirdly strong preference for avoiding cats or peanuts or cigarette smoke – you know, this weird preference we call an allergy. Sure, we can speculate that this weird preference comes from a mixup in your immune system which makes it vastly more likely (though not certain) you’ll experience what society approves of as “objectively” noxious sensations and debility whenever you’re not avoiding the allergens that trigger you. But if we’re going to be hard-nosed and Caplanesque about it, revealed preference only cares that a preference has been revealed, not why that preference might have been revealed. Some people might avoid wheat or meat “merely” because they worry it’ll make them fat. Some people might avoid those foods because they dislike gout attacks or diarrhea. While allergies are the most blatant manifestation of human illness as weird bodily preference (“allergy” comes from allos ergon, “weird activity”), they sum up the point that “being ill” means living in a body has revealed to itself that it prefers to do something different from what we think of as “being healthy”. A great many people genuinely do not know why this or that seems to leave them feeling better or worse: they can only observe they have a preference for or against this or that, perhaps a very strong preference, difficult to change, and they have to make the best of having it.

I suspect Caplan might reply that the difference between preferring to avoid wheat because it chains you to the toilet and preferring to avoid wheat for other, less obvious, reasons, is that the first preference can be thought of not as a preference against wheat itself, but as the very natural preference against having your overall budget diminished by the costs of diarrhea. We can imagine a perfect blackboard world where the economist really is God, able to know everything about everything, able to see every factor going into a rational actor’s total budget, able to see the rational actor’s total, “true” utility function. And to be sure, economists are permitted to believe that, if they truly had a God’s-eye view of the cosmos, this is what they would see.

But economists are also supposed to be champions of intellectual modesty, of reasoning well on incomplete information. Is there any economist who doesn’t also see the world in terms of risk analysis? – that is, in terms of knowing that we don’t know it all with certainty, and so must be content with reasoning from uncertain knowledge? As Scott Alexander pointed out, we cannot presume to know with certainty that another person’s very strong preference isn’t also a preference against having their “overall budget” diminished in some way we simply cannot see. Most of us find predicaments that overwhelmingly contradict our dearly-held preferences “depleting”, as if they were a drain on some metaphorical “existential budget”. Though we can imagine some grand total of resources and constraints that goes into our “overall budget” of life, none of us knows it for sure. I don’t object to doing economics on metaphorical constructs, let’s just not get too cocksure of ourselves when we do.

Illness isn’t about being able to prove that some good falls outside of your budget set, it’s about living with weird bodily preferences that cause you to face less forgiving trade-offs than “normal” people do. Got a heart condition? Maybe your trade-off is between heart medicine whose side effects you hate and high risk of sudden death. Hey, it is a trade-off. Ask Caplan point-blank, he’d tell you it is. You got a bad cigarette allergy? Then congratulations, you get to choose between how sick you’ll get if you don’t avoid ciggy smoke and how inconvenient it is to plan your life around avoiding something so very common. You got diabetes, either through bad luck, or because your old self made some bad choices? You get to choose between a restricted diet and possibly costly drugs, and making yourself really sick or prematurely dead. As I pointed out earlier, diabetes is hardly alone in being an illness where self-discipline (dieting, exercise, etc) is standard treatment. All sorts of physical illnesses are managed through self-discipline, including “diets” from crazy-making thoughts not too different from the “diet” Nash described: one of the biggest challenges of managing chronic illness is that chronic debility and discomfort tend to make people (surprise!) more anxious and gloomy, meaning that they, like Nash, must exert more effort to enforce mental hygiene.

That details what it’s like to be ill. What’s it like, socially, to infer that someone else is ill?

We infer others are ill primarily through their weird behavior. People who are sick do weird, socially unacceptable things like fall short of obligations (pretty much any “significant” illness), act dazed and “out of it”, scratch themselves (rashes, hives), hide themselves away (headaches, fatigue), whisper when we expect clear speech (laryngitis), make “abnormal” quantities of rude bodily emissions (sneezing, belching, etc)… We decide these people are ill, rather than merely badly-behaved, when we believe these weird behaviors are sufficiently “not their fault”. Small children, for example, might belch just because they think it’s funny, or scratch when they don’t really “need to”. We teach them they can – and should – learn to control their weird behaviors, at least to some extent. To some extent. How far does “some extent” go?

Caplan has no surefire way of knowing, and neither do we. The truth is, “You could help it if you just tried hard enough,” is a diagnosis of exclusion, and quite a subjective one at that. How hard does “hard enough” have to be?

Of course there are skeptics and cynics (Caplan is obviously one) who worry that labeling something an “illness” is a game to evade moral responsibility. But living well in the face of illness is in fact a matter of profound moral responsibility. Asthmatics, diabetics, and so forth have more, not less, to be morally responsible for if they want a shot at a “normal” life. Having “illness” may not be your “fault”, but it still ends up being your responsibility. Even when we can say, with confidence, “This weird behavior I inflict upon the world is my body’s preference, not ‘mine’. The ‘real me’ doesn’t want to prefer it, and would choose differently if it could,” we still have to exercise moral responsibility in controlling the behavior as best we can. How is that so different from having to control the behavior arising from the “weird preferences” Caplan posits as distinguishing mental from physical illness?

 – for Scott Alexander at Slate Star Codex and @mikeh

There are 47 comments.

  1. Joe P Member

    I’ve never met anybody with paranoid schizophrenia who enjoyed hallucinating that car headlights were mind control signals deployed by the people who wanted to sell their children into sexual slavery in third world countries. What exactly would the preference for strangeness be there?

    Maybe we should see if Gun-to-the-Head therapy cures Bryan Caplan of… whatever you summarize this idiocy as.

    I used to like Bryan Caplan before this.

    • #1
    • August 18, 2017, at 10:12 AM PDT
    • 8 likes
  2. GrannyDude Member

    I could tell Mr. Caplan any number of vivid and horrible stories about severely mentally ill people who did, indeed, have guns pointed at them and who nevertheless could not decide to stop hallucinating and put down the knife.

    • #2
    • August 18, 2017, at 10:13 AM PDT
    • 12 likes
  3. GrannyDude Member

    Joe P (View Comment):
    I’ve never met anybody with paranoid schizophrenia who enjoyed hallucinating that car headlights were mind control signals deployed by the people who wanted to sell their children into sexual slavery in third world countries. What exactly would the preference for strangeness be there?

    This sort of thing is so arrogantly sloppy…and so deeply inhumane.

    • #3
    • August 18, 2017, at 10:14 AM PDT
    • 7 likes
  4. Midget Faded Rattlesnake Contributor

    Kate Braestrup (View Comment):

    Joe P (View Comment):
    I’ve never met anybody with paranoid schizophrenia who enjoyed hallucinating that car headlights were mind control signals deployed by the people who wanted to sell their children into sexual slavery in third world countries. What exactly would the preference for strangeness be there?

    This sort of thing is so arrogantly sloppy…and so deeply inhumane.

    It is sloppy – and inhumane. But I think it’s sloppy because Caplan misunderstands physical illness as well, heck misunderstands that, as much as conservatives dread the phrase, illness (including physical illness) really is “socially constructed”.

    As I observed, a gene that makes you find an odor abnormally disgusting isn’t considered an abnormality resulting in “illness” while a gene that would cause you to get the sniffles from the same odor would be considered an “illness”, albeit a mild, hopefully trivial one.

    • #4
    • August 18, 2017, at 10:25 AM PDT
    • 6 likes
  5. Profile Photo Member

    The funny thing is, many people with schizophrenia agree with Caplan: they don’t think they really have an illness either, and in their more lucid moments (usually when they are back on their meds) they often believe that if only they develop a stronger will, or figure out their psychological issues, they can cure themselves. I used to believe that too, and I put my family through total hell for about 5 years until finally, under extreme duress, I agreed to stay on my medicine. Towards the end of those five years, I ran into a quack therapist who told me that her therapy could cure my schizophrenia so I wouldn’t have to take the medicine anymore; her “therapy” consisted basically of telling me that I was a horrible person over and over again; I escaped from her “therapy” pretty quickly and relatively unscathed, but a more vulnerable person might not have.

    • #5
    • August 18, 2017, at 10:46 AM PDT
    • 10 likes
  6. Sabrdance Member

    Midget Faded Rattlesnake (View Comment):

    Kate Braestrup (View Comment):

    Joe P (View Comment):
    I’ve never met anybody with paranoid schizophrenia who enjoyed hallucinating that car headlights were mind control signals deployed by the people who wanted to sell their children into sexual slavery in third world countries. What exactly would the preference for strangeness be there?

    This sort of thing is so arrogantly sloppy…and so deeply inhumane.

    It is sloppy – and inhumane. But I think it’s sloppy because Caplan misunderstands physical illness as well, heck misunderstands that, as much as conservatives dread the phrase, illness really is “socially constructed”.

    As I observed, a gene that makes you find an odor abnormally disgusting isn’t considered an abnormality resulting in “illness” while a gene that would cause you to get the sniffles from the same odor would be considered an “illness”, albeit a mild, hopefully trivial one.

    I don’t think I’d go so far as to say socially constructed, but perhaps arbitrarilly catalogued would work. The range of “normal” is probably larger than we generally think, an on that fringe is probably a lot of normal but uncomfortable things.

    Mental illness may play with that line -as the massive spike in ADHD diagnoses might indicate. But so do things like aching joints and “slowing down with age.”

    These tend to make me think medicine still retains many of its arts components, despite the massive increase in the science of medicine.

    • #6
    • August 18, 2017, at 10:50 AM PDT
    • 6 likes
  7. Midget Faded Rattlesnake Contributor

    Joe P (View Comment):
    I’ve never met anybody with paranoid schizophrenia who enjoyed hallucinating that car headlights were mind control signals deployed by the people who wanted to sell their children into sexual slavery in third world countries. What exactly would the preference for strangeness be there?

    The preference isn’t necessarily enjoying it, just finding it better than the alternative. If your life is miserable either way, at least feeling like the victim of conspiracy theories makes makes it miserable but meaningful. Or that is Caplan’s argument.

    Even among perfectly ordinary people, there’s a tendency to use paranoia to convince yourself of your own importance, and that life isn’t meaningless. “The universe really is out to get you” seems to be, for many, a much more consoling alternative to “the universe just doesn’t care”. For everyone, healthy or ill, good mental hygiene means resisting this tendency. But Caplan’s model is so binary, rather than acknowledging that the differing degrees of difficulty people may have in resisting matters.

    Maybe we should see if Gun-to-the-Head therapy cures Bryan Caplan of… whatever you summarize this idiocy as.

    I used to like Bryan Caplan before this.

    Eh, he’s still interesting. Just really, amazingly wrong about this, and amazingly stuck in a “blackboard economics” model of the world. We also have to remember this paper is an attempt to rehabilitate Szasz, and it’s possible Caplan would not have talked himself into errors I think he’d usually catch without Szasz’s help.

    • #7
    • August 18, 2017, at 10:58 AM PDT
    • 5 likes
  8. Hang On Member
    Hang On Joined in the first year of Ricochet Ricochet Charter Member

    @midge Very well stated and argued.

    I can remember seeing one of Szasz’s lectures back what seems like a hundred years ago. I couldn’t stop laughing later.

    The problem is basically I don’t buy Skinner or Sartre/Szasz on determinism and free will, which is what all of this boils down to. I think they represent two extremes and neither is very satisfactory.

    • #8
    • August 18, 2017, at 11:10 AM PDT
    • 5 likes
  9. Midget Faded Rattlesnake Contributor

    Sabrdance (View Comment):
    I don’t think I’d go so far as to say socially constructed, but perhaps arbitrarilly catalogued would work. The range of “normal” is probably larger than we generally think, an on that fringe is probably a lot of normal but uncomfortable things.

    Mental illness may play with that line -as the massive spike in ADHD diagnoses might indicate. But so do things like aching joints and “slowing down with age.”

    These tend to make me think medicine still retains many of its arts components, despite the massive increase in the science of medicine.

    It definitely does. Caplan wishes it wasn’t, but medicine is still, at its base, a moral science, whose purpose is to help people live well in the bodies they have, whether by modifying those bodies (the stereotypical medical treatments) or by helping people cope with what can’t be modified (what a lot of medical treatments end up being).

    As @therightnurse, @vicrylcontessa, and any other hospital nurse or doctors know, plenty of hospital patients present with “dyscopia” in the tongue-and-cheek sense. They’re not there because of infirmity, they’re there because they’re not coping with it well. Which makes sense: if you were coping with an infirmity well, you’d be managing it on your own, with no-fuss outpatient care if you needed it, you wouldn’t be so desperate that sentencing yourself to the hospital sounded like a good idea.

    • #9
    • August 18, 2017, at 11:10 AM PDT
    • 9 likes
  10. Mike H Coolidge

    I think this is an important question to get to the bottom of. There is obviously some intuitive appeal to Caplan’s construction of (at least some) mental illness, but at the very least he was insufficient in articulating the difference between a “budget constraint” and a “preference.” Maybe if he was willing to deap dive into his logic again he’d come away with a more convincing model of what I imagine he believes is crystal clear.

    It seems like every great thinker has a blind spot, that one (or several) ideas that speaks to you so strongly that it clouds your normal abilities to discern reality. This might be Caplan’s blind spot, but if it is I want him either to realize it, rearticulate what he thinks the truth is, or convince me he’s right.

    I’ll also forward this to Scott when it gets to the Main Feed. I’m fairly confident he’ll totally agree.

    • #10
    • August 18, 2017, at 12:23 PM PDT
    • 2 likes
  11. Midget Faded Rattlesnake Contributor

    Mike H (View Comment):
    I think this is an important question to get to the bottom of. There is obviously some intuitive appeal to Caplan’s construction of (at least some) mental illness, but at the very least he was insufficient in articulating the difference between a “budget constraint” and a “preference.” Maybe if he was willing to deap dive into his logic again he’d come away with a more convincing model of what I imagine he believes is crystal clear.

    Caplan is, as far as I know, quite correct that, when you’re setting up a standard problem in consumer-choice economics, the distinction between how you handle “budget” and “preferences” is crystal-clear. But the clear distinction is an artifact of setting up the problem with the standard mathematical tools, not a guarantee that there is only one meaningful way to apply the standard mathematical tools.

    Mr R is the one with the fancy Chicago degree, not I, but I believe somewhere in Mr R’s old econ notes, he has a discussion of of scenarios where it seems natural for there to be some choice in what the problem-solver wishes to count as “budget” and what he wishes to count as “preference”.

    It seems like every great thinker has a blind spot, that one (or several) ideas that speaks to you so strongly that it clouds your normal abilities to discern reality. This might be Caplan’s blind spot, but if it is I want him either to realize it, rearticulate what he thinks the truth is, or convince me he’s right.

    I’ll also forward this to Scott when it gets to the Main Feed. I’m fairly confident he’ll totally agree.

    Oh, thanks so much! I hope Scott will find it interesting!

    • #11
    • August 18, 2017, at 12:33 PM PDT
    • 1 like
  12. Gary McVey Contributor
    Gary McVey Joined in the first year of Ricochet Ricochet Charter Member

    This is a deep intellectual think piece, but I got through it because Midge mentions a female gymnast. That’s enough to hold my attention.

    • #12
    • August 18, 2017, at 1:12 PM PDT
    • 7 likes
  13. Bryan G. Stephens Thatcher
    Bryan G. Stephens Joined in the first year of Ricochet Ricochet Charter Member

    I am horrified I share a name with someone this misguided. Considering we have brain scans that can look at physical elements of mental illness, this is just nuts. Depression and psychotic disorders appear to cause a reduction of brain matter over time. Use of addictive drugs change the pathways in the brain.

    This is one long attempt to blame mental illness on the person or society. It is wishful thinking. A manic episode is not being “weird”. A Manic episode is a brain racing. The person does not sleep, and cannot be rational.

    This man is a horrible as someone saying that vaccination causes autism. What a monster.

    • #13
    • August 18, 2017, at 2:46 PM PDT
    • 8 likes
  14. Mike H Coolidge

    Kate Braestrup (View Comment):
    I could tell Mr. Caplan any number of vivid and horrible stories about severely mentally ill people who did, indeed, have guns pointed at them and who nevertheless could not decide to stop hallucinating and put down the knife.

    He would probably say that was a likely but not definite budget constraint.

    • #14
    • August 18, 2017, at 3:02 PM PDT
    • 1 like
  15. Shawn Buell (Majestyk) Contributor

    I was going to say that FMRI imaging of people’s brains who suffer from some of these issues display different behavior than “normal” people. The notion that this isn’t a physical, structural or biomechanical problem in these people’s minds is just bananas.

    • #15
    • August 18, 2017, at 3:11 PM PDT
    • 8 likes
  16. bridget Inactive

    I have enough of a medical background – patient side, not physician side – to say that this is ridiculous.

    There are some illnesses that are the result of bad choices. Many are not. Our choice is how to treat our bodies to reduce (not eliminate) that risk, and, if we do fall ill or get injured, whether or not to seek treatment. The “gun to the head” argument is absurd: there are innumerable medical problems that are not fixed by willpower alone. Willpower and a sane thought process get you to the point wherein you want to fix it, but hardly means you never have problems in the first place or are always cured.

    As for mental illness specifically: it’s more than garden-variety sad or stressed. There comes a point in which it is entirely involuntary, crippling, and horrible.

    • #16
    • August 18, 2017, at 3:31 PM PDT
    • 5 likes
  17. Midget Faded Rattlesnake Contributor

    Majestyk (View Comment):
    I was going to say that FMRI imaging of people’s brains who suffer from some of these issues display different behavior than “normal” people. The notion that this isn’t a physical, structural or biomechanical problem in these people’s minds is just bananas.

    So, this is actually a complicated issue.

    To the extent Caplan’s paper addresses it, he’s pointing out that a trait having biomechanical or biochemical origins doesn’t have to be an illness, since many traits do without being illness. Caplan is right that showing biological cause is not the same thing as showing a trait is an illness.

    When it comes to fMRIs in particular, there’s the “dead salmon” problem. But I think we can presume they’ll fix that problem. The other, more important, problem are the chicken-or-egg problem and the stumped radiologist problem:

    The chicken-or-egg problem is that humans are learning machines, and learning can change tissues: when is a tissue change causing maladaptive behavior, and when is it the result of maladaptive behavior? (Of course it can be both, in a vicious cycle.)

    The “stumped radiologist” problem refers to the fact that even with something as apparently “mechanical” and “basic” as back pain, if you give radiologists imagery of a group of middle-aged adults, half with bad backs, half without, but don’t give the radiologists information about which imagery corresponds to patients who complained of back pain, the radiologists will be “stumped”: unable to reliably tell the difference. On the surface, this might seem the same as the “dead salmon” issue: maybe technical improvement of imaging techniques will fix it, and we’ll be able to see lesions there we couldn’t before. But it might also be telling us that pain/dysfunction is weird, and that we might not really know what to look for yet, even as we try to develop lab/imaging tests that can discriminate between a healthy state and an unhealthy state.

    I do agree with you that these states are embodied, though, that if we knew where to look for the material differences, we’d see differences between humans in different states. As would Caplan.

    • #17
    • August 18, 2017, at 3:40 PM PDT
    • 3 likes
  18. FloppyDisk90 Member

    So should we hold alcoholics criminally responsible if they drink and drive?

    Note: please read this as an honest question and not snarky “gotcha.”

    • #18
    • August 18, 2017, at 3:45 PM PDT
    • 2 likes
  19. Mike H Coolidge

    Bryan G. Stephens (View Comment):
    I am horrified I share a name with someone this misguided. Considering we have brain scans that can look at physical elements of mental illness, this is just nuts. Depression and psychotic disorders appear to cause a reduction of brain matter over time. Use of addictive drugs change the pathways in the brain.

    This is one long attempt to blame mental illness on the person or society. It is wishful thinking. A manic episode is not being “weird”. A Manic episode is a brain racing. The person does not sleep, and cannot be rational.

    This man is a horrible as someone saying that vaccination causes autism. What a monster.

    Yeah, Caplan’s right up there with Stalin. He’s not simply mistaken, he’s practically calling for the death of innocents!

    • #19
    • August 18, 2017, at 4:00 PM PDT
    • 1 like
  20. Midget Faded Rattlesnake Contributor

    FloppyDisk90 (View Comment):
    So should we hold alcoholics criminally responsible if they drink and drive?

    Note: please read this as an honest question and not snarky “gotcha.”

    The law can punish those who need vision correction for driving without their glasses. Yes, if you don’t take steps to mitigate a driving impairment you know you have, no matter why you have it, and you drive anyhow, you are responsible for it.

    This always makes me nervous, because I have some physical issues which are a mild driving impairment (like, I dunno, “talking on the phone while driving” level of impaired) often enough that I should plan for them, but which very, very rarely – and rather unpredictably – can become pretty serious. For example, once I turned my head to check my blind spot and passed out, because my body decided turning my head that way was something it didn’t want me doing. Fortunately, it was in a parking lot, and my poor victim just got some paint scraped off his car. Only accident I’d ever caused, and the harm was minor. But yeah, the harm had both an accidental (it almost never happens and I do my best to avoid driving when I think it might) and a culpable (I did know it could happen, and eventually it did) feel to it. I felt very guilty, although I don’t think the culpability in that case rose a level punishable by law.

    • #20
    • August 18, 2017, at 4:01 PM PDT
    • 2 likes
  21. Midget Faded Rattlesnake Contributor

    Midget Faded Rattlesnake (View Comment):
    The law can punish those who need vision correction for driving without their glasses. Yes, if you don’t take steps to mitigate a driving impairment you know you have, no matter why you have it, and you drive anyhow, you are responsible for it.

    My license is marked “needs glasses”, although my glasses aren’t very strong (I mostly don’t have to wear them, except for driving). In urgent situations, I won’t refuse to drive without my glasses. But especially since I’m already accident-prone for other reasons, I’d hate to think of what would happen to me, liability-wise, if I got into an accident when I wasn’t wearing them without a very good excuse (like rushing a family member to the ER).

    Even if, from a God’s-eye view, the accident was really some other party’s fault, not wearing the glasses you need while participating in an accident is of course going to raise the suspicion of culpability – and why wouldn’t it?

    • #21
    • August 18, 2017, at 4:11 PM PDT
    • 2 likes
  22. Gumby Mark (R-Meth Lab of Demo… Thatcher

    Thanks for your post. I am a regular reader of Caplan and find him to be consistently interesting and thought-provoking even when I disagree with him. I’ve read several of his articles on Szasz and mental illness and have two reactions; one that relates generally to his views and the second specific to mental illness.

    The first, that his worldview is heavily theoretical which can sometimes lead to some great insights, but because it is also often unimpaired by real world experience, or any sense of emotional insight, can make it seem oddly inhuman and detached at times.

    Secondly, as it relates specifically to mental illness and Szasz, Caplan’s overall focus is on individual autonomy and in opposition to anything that impinges on that autonomy. The treatment of the mentally ill by the state fundamentally offends him and Szasz’s theories provide him a ready handle for that instinctive aversion to how the mentally ill are categorized and treated. In other words, it fits his predispositions.

    When you combine those, his lack of feel for what schizophrenia is becomes apparent, as he seems to view it as merely a type of neurosis.

    As to Szasz, I read him in the 70s and was more impressed with him when I was young and had less experience with the world. As someone who was primarily responsible for a schizophrenic family member for 25 years (or at least as responsible as one could be in the circumstances), I now find his views to be nonsense.

    • #22
    • August 18, 2017, at 7:04 PM PDT
    • 8 likes
  23. She Thatcher
    She Joined in the first year of Ricochet Ricochet Charter Member

    Gumby Mark (View Comment):

    As to Szasz, I read him in the 70s and was more impressed with him when I was young and had less experience with the world. As someone who was primarily responsible for a schizophrenic family member for 25 years (or at least as responsible as one could be in the circumstances), I now find his views to be nonsense.

    Yep. That’ll do it.

    The damage that fools like Szasz have done, and the misery they have caused, to both the seriously, chronically, mentally ill and their families and communities, is incalculable.

    • #23
    • August 19, 2017, at 6:24 AM PDT
    • 3 likes
  24. Bryan G. Stephens Thatcher
    Bryan G. Stephens Joined in the first year of Ricochet Ricochet Charter Member

    FloppyDisk90 (View Comment):
    So should we hold alcoholics criminally responsible if they drink and drive?

    Note: please read this as an honest question and not snarky “gotcha.”

    Yes. And if someone is manic and kills another it is murder. We have to have standards of behavior. And, I think this applies especially if you have a Dx and have been told to take your meds.

    • #24
    • August 19, 2017, at 6:47 AM PDT
    • 4 likes
  25. Bryan G. Stephens Thatcher
    Bryan G. Stephens Joined in the first year of Ricochet Ricochet Charter Member

    Gumby Mark (View Comment):
    Secondly, as it relates specifically to mental illness and Szasz, Caplan’s overall focus is on individual autonomy and in opposition to anything that impinges on that autonomy. The treatment of the mentally ill by the state fundamentally offends him and Szasz’s theories provide him a ready handle for that instinctive aversion to how the mentally ill are categorized and treated. In other words, it fits his predispositions.

    The liberty argument this sort of person makes is the one made by some ivory tower thinker. He should come be with a family, desperate to get help for a loved one who does not want help. I have been part of those battles for clients. To watch a loved one dying because their brain is so messed up they cannot make the rational choice to get help is a unique type of pain. And the law so leans on liberty, there is no way to force help.

    • #25
    • August 19, 2017, at 6:49 AM PDT
    • 2 likes
  26. Bryan G. Stephens Thatcher
    Bryan G. Stephens Joined in the first year of Ricochet Ricochet Charter Member

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):
    I am horrified I share a name with someone this misguided. Considering we have brain scans that can look at physical elements of mental illness, this is just nuts. Depression and psychotic disorders appear to cause a reduction of brain matter over time. Use of addictive drugs change the pathways in the brain.

    This is one long attempt to blame mental illness on the person or society. It is wishful thinking. A manic episode is not being “weird”. A Manic episode is a brain racing. The person does not sleep, and cannot be rational.

    This man is a horrible as someone saying that vaccination causes autism. What a monster.

    Yeah, Caplan’s right up there with Stalin. He’s not simply mistaken, he’s practically calling for the death of innocents!

    Pretty sure I did not compare him to Stalin. I did compare him to Andrew Wakefield. I’ll stand by that. Anyone encouraging someone with Schizophrenia to not get treatment for a disease that damages their brain with every episode is a monster. If one person listens and refuses, that is one too many.

    • #26
    • August 19, 2017, at 6:54 AM PDT
    • 3 likes
  27. Mike H Coolidge

    Bryan G. Stephens (View Comment):

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):
    I am horrified I share a name with someone this misguided. Considering we have brain scans that can look at physical elements of mental illness, this is just nuts. Depression and psychotic disorders appear to cause a reduction of brain matter over time. Use of addictive drugs change the pathways in the brain.

    This is one long attempt to blame mental illness on the person or society. It is wishful thinking. A manic episode is not being “weird”. A Manic episode is a brain racing. The person does not sleep, and cannot be rational.

    This man is a horrible as someone saying that vaccination causes autism. What a monster.

    Yeah, Caplan’s right up there with Stalin. He’s not simply mistaken, he’s practically calling for the death of innocents!

    Pretty sure I did not compare him to Stalin. I did compare him to Andrew Wakefield. I’ll stand by that. Anyone encouraging someone with Schizophrenia to not get treatment for a disease that damages their brain with every episode is a monster. If one person listens and refuses, that is one too many.

    To say that Szasz or Caplan encourage people to not get treated shows an incorrect understanding of their position.

    • #27
    • August 19, 2017, at 9:25 AM PDT
    • Like
  28. She Thatcher
    She Joined in the first year of Ricochet Ricochet Charter Member

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):
    I am horrified I share a name with someone this misguided. Considering we have brain scans that can look at physical elements of mental illness, this is just nuts. Depression and psychotic disorders appear to cause a reduction of brain matter over time. Use of addictive drugs change the pathways in the brain.

    This is one long attempt to blame mental illness on the person or society. It is wishful thinking. A manic episode is not being “weird”. A Manic episode is a brain racing. The person does not sleep, and cannot be rational.

    This man is a horrible as someone saying that vaccination causes autism. What a monster.

    Yeah, Caplan’s right up there with Stalin. He’s not simply mistaken, he’s practically calling for the death of innocents!

    Pretty sure I did not compare him to Stalin. I did compare him to Andrew Wakefield. I’ll stand by that. Anyone encouraging someone with Schizophrenia to not get treatment for a disease that damages their brain with every episode is a monster. If one person listens and refuses, that is one too many.

    To say that Szasz or Caplan encourage people to not get treated shows an incorrect understanding of their position.

    What is their position?

    • #28
    • August 19, 2017, at 10:02 AM PDT
    • 1 like
  29. Mike H Coolidge

    She (View Comment):

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):
    I am horrified I share a name with someone this misguided. Considering we have brain scans that can look at physical elements of mental illness, this is just nuts. Depression and psychotic disorders appear to cause a reduction of brain matter over time. Use of addictive drugs change the pathways in the brain.

    This is one long attempt to blame mental illness on the person or society. It is wishful thinking. A manic episode is not being “weird”. A Manic episode is a brain racing. The person does not sleep, and cannot be rational.

    This man is a horrible as someone saying that vaccination causes autism. What a monster.

    Yeah, Caplan’s right up there with Stalin. He’s not simply mistaken, he’s practically calling for the death of innocents!

    Pretty sure I did not compare him to Stalin. I did compare him to Andrew Wakefield. I’ll stand by that. Anyone encouraging someone with Schizophrenia to not get treatment for a disease that damages their brain with every episode is a monster. If one person listens and refuses, that is one too many.

    To say that Szasz or Caplan encourage people to not get treated shows an incorrect understanding of their position.

    What is their position?

    I believe Szasz’s position was that no one should be forced to get treatment. He acknowledged that treatment does often help people and there’s nothing wrong with getting treatment.

    Bryan’s position (and this is mostly Szasz, too) is that often what we call mental illness are simply socially unacceptable preferences at the tail ends of the normal distribution. And that we label them “mental disorders” sometimes to shame people but more often to excuse bad behavior. The “motte” (easily defendable) position is things like alcoholism. It’s obvious someone can choose not to drink even if they are a definitional alcoholic. The “bailey” (controversial, actual) position is that things like schizophrenia are also best modeled as socially unacceptable preferences.

    • #29
    • August 19, 2017, at 11:19 AM PDT
    • Like
  30. Bryan G. Stephens Thatcher
    Bryan G. Stephens Joined in the first year of Ricochet Ricochet Charter Member

    Mike H (View Comment):

    She (View Comment):

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):

    Mike H (View Comment):

    Bryan G. Stephens (View Comment):
    I am horrified I share a name with someone this misguided. Considering we have brain scans that can look at physical elements of mental illness, this is just nuts. Depression and psychotic disorders appear to cause a reduction of brain matter over time. Use of addictive drugs change the pathways in the brain.

    This is one long attempt to blame mental illness on the person or society. It is wishful thinking. A manic episode is not being “weird”. A Manic episode is a brain racing. The person does not sleep, and cannot be rational.

    This man is a horrible as someone saying that vaccination causes autism. What a monster.

    Yeah, Caplan’s right up there with Stalin. He’s not simply mistaken, he’s practically calling for the death of innocents!

    Pretty sure I did not compare him to Stalin. I did compare him to Andrew Wakefield. I’ll stand by that. Anyone encouraging someone with Schizophrenia to not get treatment for a disease that damages their brain with every episode is a monster. If one person listens and refuses, that is one too many.

    To say that Szasz or Caplan encourage people to not get treated shows an incorrect understanding of their position.

    What is their position?

    I believe Szasz’s position was that no one should be forced to get treatment. He acknowledged that treatment does often help people and there’s nothing wrong with getting treatment.

    Bryan’s position (and this is mostly Szasz, too) is that often what we call mental illness are simply socially unacceptable preferences at the tail ends of the normal distribution. And that we label them “mental disorders” sometimes to shame people but more often to excuse bad behavior. The “motte” (easily defendable) position is things like alcoholism. It’s obvious someone can choose not to drink even if they are a definitional alcoholic. The “bailey” (controversial, actual) position is that things like schizophrenia are also best modeled as socially unacceptable preferences.

    That is not my position at all! I am against that. Do not liable me.

    • #30
    • August 19, 2017, at 1:17 PM PDT
    • 1 like