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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).
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