An Epidemic of Mental Illness?

“It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it. The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades. Mental illness is now the leading cause of disability in children, well ahead of physical disabilities like cerebral palsy or Down syndrome, for which the federal programs were created.

A large survey of randomly selected adults, sponsored by the National Institute of Mental Health (NIMH) and conducted between 2001 and 2003, found that an astonishing 46 percent met criteria established by the American Psychiatric Association (APA) for having had at least one mental illness within four broad categories at some time in their lives. The categories were ‘anxiety disorders,’ including, among other subcategories, phobias and post-traumatic stress disorder (PTSD); ‘mood disorders,’ including major depression and bipolar disorders; ‘impulse-control disorders,’ including various behavioral problems and attention-deficit/hyperactivity disorder (ADHD); and ‘substance use disorders,’ including alcohol and drug abuse. Most met criteria for more than one diagnosis. Of a subgroup affected within the previous year, a third were under treatment—up from a fifth in a similar survey ten years earlier.

Nowadays treatment by medical doctors nearly always means psychoactive drugs, that is, drugs that affect the mental state. In fact, most psychiatrists treat only with drugs, and refer patients to psychologists or social workers if they believe psychotherapy is also warranted. The shift from ‘talk therapy’ to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs. That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came to market in 1987 and was intensively promoted as a corrective for a deficiency of serotonin in the brain. The number of people treated for depression tripled in the following ten years, and about 10 percent of Americans over age six now take antidepressants. The increased use of drugs to treat psychosis is even more dramatic. The new generation of antipsychotics, such as Risperdal, Zyprexa, and Seroquel, has replaced cholesterol-lowering agents as the top-selling class of drugs in the US.

What is going on here? Is the prevalence of mental illness really that high and still climbing? Particularly if these disorders are biologically determined and not a result of environmental influences, is it plausible to suppose that such an increase is real? Or are we learning to recognize and diagnose mental disorders that were always there? On the other hand, are we simply expanding the criteria for mental illness so that nearly everyone has one? And what about the drugs that are now the mainstay of treatment? Do they work? If they do, shouldn’t we expect the prevalence of mental illness to be declining, not rising?”

This is from an important two-part review essay by Marcia Angell in the New York Review of Books: “The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry.”

Image: From Bobby Baker’s Diary Drawings, Wellcome Collection Exhibition (March 19 – August 2, 2009) London.

G.A. Cohen’s Critique of Rawls’s Difference Principle: From Intuition to a Utopian Conception of Justice

I’d like to share the (lamentably) late G.A. Cohen’s conclusion from his discussion in Rescuing Justice and Equality (2008) of the “incentives argument” (sans notions of entitlement and desert)[1] with regard to Rawls’s formulation of the “difference principle.”[2] It’s clear that Rawls believed the latter to be consistent with the former, and I think Cohen persuasively argues that Rawls was wrong on this score. Cohen’s own position is described by Elizabeth Anderson as “luck egalitarianism”[3], a characterization he accepts, making plain that this conception is, non-pejoratively speaking, utopian in so far as “it is not a constraint on a sound conception of justice that it should always be sensible to strive to implement it, whatever the factual circumstance may be,” and this utopian conception of justice is distinct from Rawls’s constructivist principle(s) of social design wherein a scheme of social institutions, e.g., the “basic structure of society,” may be deserving of the appellation “just.” In fact, there is tension or ambiguity if not contradiction here (at least on the ‘strict interpretation’ of the principle) insofar as Rawls believed that in a “well-ordered” society each individual “acts out of a sense of justice informed by the principles of justice [expressing their nature as ‘free moral persons’]” while also unqualifiedly endorsing unequal incentives as when, for example, talented people have the power to demand and the expectation of “high salaries whose level reflects high demand for their talent (as opposed to the special needs or special burdens of their jobs).” Cohen elaborates, drawing a distinction between a “strict” and “lax” interpretation of the difference principle:

“On the lax interpretation of what the difference principle demands, it is satisfied when everyone gets what she can through self-seeking behavior in a market whose rewards are so structured by taxation and other regulation that the worst off are as well off as any scheme of taxed and regulated market rewards can make them. On my view of what it means for a society to institute the principle, people would mention norms of equality when asked to explain why they those like them are willing to work for the pay they get. This strict interpretation conflicts with Rawls’s unqualified endorsement of unequalizing incentives. Yet…the strict interpretation of the principle coheres with a number of significant general characterizations of justice to be found in Rawls’s work.”

The interpretive warrant for a “lax understanding” of the difference principle is likewise found in Rawls, in which case the dignity of the worst off is said to be honored, “since, so he says, they know that they are caused to be as well off as they could be.” In reply, Cohen exquisitely comes to the point: “But that is an illusion. For they are as well off as they could be only given self-seekingness of those who are better off, and maybe far better off, than they.”

It follows from a “strict interpretation” of the difference principle that “free moral persons,” those whom Cohen terms “high fliers,” are motivated in their daily lives to act from the principles of justice. Sufficient introductory material in place, we’re prepared to read and consider Cohen’s conclusion:

“My principle contention about Rawls is that high fliers would forgo incentives properly so-called in a full compliance society governed by the difference principle and characterized by fraternity and universal dignity. I have not rejected the difference principle in its lax reading as a principle of public policy: I do not doubt that there are contexts where it is right to apply it. What I have questioned is its description as a basic principle of justice, and I have deplored Rawls’s willingness to describe those at the top end of a society governed by it as undergoing the fullest possible realization of their moral natures. My own socialist-egalitarian position was nicely articulated by John Stuart Mill in his Principles of Political Economy. Contrasting equal payment with incentive-style payment according to product (‘work done’), Mill said that the first

appeals to a higher standard of justice, and is adapted to a much higher moral condition of human nature. The proportioning of remuneration to work done is really just, only in so far as the more or less of the work is a matter of choice; when it depends on natural difference of strength or capacity, this principle of remuneration is in itself an injustice: it is giving to those who have; assigning most to those who are already most favoured by nature. Considered however, as a compromise with the selfish typed of character formed by the present standard of morality, and fostered by the existing social institutions, it is highly expedient; and until education shall have been entirely regenerated, is far more likely to prove immediately successful, than an attempt at a higher ideal.

Rawls’s lax application of his difference people means ‘giving to those who have.’ He presents the incentive policy as a feature of a just society, whereas it is in fact, and as Mill says, just ‘highly expedient’ in society as we know it, a sober ‘compromise with the selfish type of character’ formed by capitalism.* Philosophers in search of justice should not be content with an expedient compromise. To call expediency justice goes against the regeneration to which Mill looked forward at the end of this fine passage.”

*The following (further references omitted) is from a footnote to this material:

“According to Mill, ‘the deep-rooted selfishness which forms the general character of the existing state of society is so deeply rooted only because the whole course of the existing institutions tend to foster it.’”

Notes:
[1] See chapter 1, “The Incentives Argument,” in G.A. Cohen, Rescuing Justice and Equality. Cambridge, MA: Harvard University Press, 2008: 27-86, but especially 68-86 with regard to Rawls.
[2] For a brief introduction, see the section on the “difference principle” in Lamont, Julian and Christi Favor, “Distributive Justice,” The Stanford Encyclopedia of Philosophy (Fall 2008 Edition), Edward N. Zalta (ed.), http://plato.stanford.edu/archives/fall2008/entries/justice-distributive/. The difference principle is the first part of Rawls’s second principle of justice: “Social and economic inequalities are to be arranged so that they are both: (a) to the greatest benefit of the least advantaged, consistent with the just savings principle, and (b) attached to offices and positions open to all under conditions of fair equality of opportunity.” For an introduction that also addresses Cohen’s earlier criticisms, see chapter 3, “The Second Principle and Distributive Justice,” in Samuel Freeman, Rawls. New York: Routledge, 2007: 86-140.
[3] In Cohen’s words, “Luck egalitarians seek to render precise an intuition about distributive justice, which says, roughly, that inequalities are just if and only if certain facts about responsibility obtain with respect to those inequalities.” In particular, on this conception, an allocation within the rubric of distributive justice “extinguishes inequalities that are due to luck rather than to choice.”

Addendum: I thought perhaps it might be important to specify exactly what I meant by calling Cohen’s conception of justice “utopian” (in a non-pejorative sense). As Cohen says in a later chapter, “justice is justice, whether or not it is possible to achieve it, and that to conform our conception of justice to what is achievable creates distortions in our thought and also in our practice.” The adjective utopian is intended precisely in the sense spelled out by William Galston (from his 1980 book, Justice and the Human Good) in our introductory post on utopian thought and imagination. (That Galston might be judged a quintessential Liberal political philosopher is irrelevant.) Rawlsians, on the other hand, could be said to subscribe to “utopianism” in a pejorative sense. In other—and Cohen’s—words, they believe “justice must be so crafted as to be bottom-line feasible, they believe that it is possible to achieve justice, and I am not so sanguine. It follows from my position that justice is an unachievable (although a nevertheless governing) ideal.” In conceiving of justice in this way, Cohen could be said to be a utopian who thereby avoids the charge of “utopianism.” Finally, Cohen might be fairly described as a Platonist in the following sense: The Platonic construction of normative utopian models are not intended to point to some future political reality or indicate decisive historical telos, rather, they serve to remind us of both the indeterminacy of Platonic Forms (like ‘Justice’) that inspire or motivate utopian discourse and the significance of contingent historical conditions and political variables that make for relativity and plurality, as well as the necessity of judgment, in the domain of realization (or positivization), in which case, for example, justice is never fully realized, retaining its “ideal” status however much or in spite of the degree of instantiation or embodiment. All the same, they remain indispensable to the critical political and legal tasks of specification, justification, and evaluation as adumbrated by Galston.

A Succinct Explanation of the Ideological and Philosophical Appeal of “The Entire Rawlsian Achievement”

“…[Rawls’s] argument is the natural response of a liberal who has read Pigou and Keynes seriously. He appeals to those who believe in the desirability, efficiency, and justice of capitalist markets, recognize they may not always function well and may generate serious inequities for some, and want to find efficient ways of addressing those inequities without altering the essential nature of the system. The ambiguous moral status of Keynesianism and welfare economics has always inhered in the fact that they appeal to the short-term interests of the disadvantaged (such as unemployed workers and firms on the verge of bankruptcy during recessions) by ensuring subsistence, creating employment, and expanding credit, yet these policies are geared in the medium term to sustaining the system which generates those very disadvantages—hence the ironic force of Joan Robinson’s quip that the one thing worse than being exploited is not being exploited at all. [….]

Keynesian macroeconomics and Pigouvian welfare economics diverged from the mainstream of neo-classical economics over how to achieve [‘well functioning capitalist markets’]. The Keynesian consumption function entailed that ‘rational’ individual economic behavior would have by-products or ‘externalities,’ incidentally felicitous or infelicitous to others; thus the collective results of competitive individual self-interested behavior may not, and often will not, be socially optimal. Private enterprise, ‘even when it operates under simple competition, often leads to a distribution of resources less favorable to the national dividend than some other possible distributions’ (Pigou).

Both Keynesian macroeconomics and Pigouvian welfare economics were thus born of an acceptance of the goals of neo-classical equilibrium theory but a rejection (for different reasons) of its axiomatic assumption that competitive individual behavior would produce Pareto-optimal collective results in practice. The claims of these newer orthodoxies seemed to many to be vindicated by the events of the Depression, the persistence of poverty with growth, and the seemingly congenital tendency toward periodic recession—the ‘boom-bust’ model of growth—that appeared to prevail throughout the capitalist world between the wars. Furthermore, the counter-cyclical prescriptions of Keynesian macroeconomics seemed to work. The New Deal and Keynesian eras ushered in astonishing levels of growth that did not begin seriously to slow until the late 1960s. [….] [The faith in Keynesian macroeconomics was in some measure undermined in the 1970s, which] brought serious economic stagnation throughout the advanced industrial world.

Keynesian demand management also brought renewed political optimism based on a new social-democratic consensus, because this new ‘managed capitalism’ had a human face. A by-product of its fiscal policies was the welfare state and its safety net that redressed the worst diseconomies and externalities of capitalist competition. Thus the mixed economy with an active state, attentive but subordinate to the needs of the market, could seem to many to be morally desirable and practically efficient, to effect the rights-utility synthesis in the face of market failure. Rawls’s argument naturally falls into this broadly Keynesian vision, which explains its inspirational appeal to so many liberals and the belief among many who perceive difficulties with his particular formulations, that something like it must nonetheless be true and salvageable.” Ian Shapiro, The Evolution of Rights in Liberal Theory (1986): 152-154.

Or, as the late G.A. Cohen put it pithily in Rescuing Justice and Equality (2008: 11): “But among what contributes to the greatness of A Theory of Justice, and of the entire Rawlsian achievement, is that, to put the matter as Hegel would have done had he agreed with me, John Rawls grasped his age, or, more precisely, one large reality of his age, in thought. In his work the politics of liberal (in the American sense) democracy and social (in the European sense) democracy rises to consciousness of itself.”

Accounting for the Dearth of Ex Ante Ethical Reasoning with Regard to Technology

“When you see something that is technically sweet, you go ahead and do it and you argue about what to do about it only after you have had your technical success.”—J. Robert Oppenheimer

I found this remark quoted in Amartya Sen’s The Idea of Justice (2009): 211. See: In the Matter of J. Robert Oppenheimer: USAEC Transcript of the Hearing before Personnel Security Board (Washington, DC: Government Publishing Office, 1954).

Consider: [….]

NEWTON: Möbius. What about the—the Principle of Universal Discovery?

MÖBIUS: Yes, something on those lines, too. I did it out of curiosity, as a practical corollary to my theoretical investigations. Why play the innocent? We have to face the consequences of our scientific thinking. It was my duty to work out the effects that would be produced by my Unitary Theory of Elementary Particles and by my discoveries in the field of gravitation. The result is—devastating. New and inconceivable forces would be unleashed, making possible a technical advance that would transcend the wildest flights of fancy if my findings were to fall into the hands of mankind.

EINSTEIN: And that can scarcely be avoided.

NEWTON: The only question is: who’s going to get at them first?

MÖBIUS laughs.

MÖBIUS: You’d like that for your own Intelligence Service, wouldn’t you, Kilton, and the military machine behind it?

NEWTON: And why not? It seems to me, if it can restore the greatest physicist of all time to the confraternity of the physical sciences, any military machine is a sacred instrument. It’s nothing more nor less than a question of the freedom of scientific knowledge. It doesn’t matter who guarantees that freedom. I give my services to any system, providing that system leaves me alone. I know there’s a lot of talk nowadays about physicists’ moral responsibilities. We suddenly find ourselves confronted with our own fears and we have a fit of morality. This is nonsense. We have far-reaching, pioneering work to do and that’s all that should concern us. Whether or not humanity has the wit to follow the new trails that we are blazing is its own look-out, not ours.

[….]

MÖBIUS: Extraordinary. Each of you is trying to palm off a different theory, yet the reality you offer me is the same in both cases: a prison. I’d prefer the madhouse. Here at least I feel safe from the exactions of power politicians.

EINSTEIN: But after all, one must take certain risks.

MÖBIUS: There are certain risks that one may not take: the destruction of humanity is one. We know what the world has done with the weapons it already possesses; we can imagine what it would do with those that my researches make possible, and it is these considerations that governed my conduct. I was poor. I had a wife and three children. Fame beckoned from the university; industry tempted me with money. Both courses were too dangerous. I should have had to publish my researches, and the consequences would have been the overthrow of all scientific knowledge and the breakdown of the economic structure of our society. A sense of responsibility compelled me to choose another course. I threw up my academic career, said no to industry, and abandoned my family to its fate. I took on the fool’s cap and bells. I let it be known that King Solomon kept appearing to me, and before long, I was clapped into a madhouse.

NEWTON: But that couldn’t solve anything.

[….]

MÖBIUS: You must stay with me here in the madhouse.

NEWTON: What! Us?

MÖBIUS: Both of you.

Silence.

[….]

MÖBIUS: You inform your superiors that you have made a mistake, that I really am mad.

EINSTEIN: Then we’d be stuck here for the rest of our lives. Nobody’s going to lose any sleep over a broken-down spy.

MÖBIUS: But it’s the one chance I have to remain undetected. Only in the madhouse can we be free. Only in the madhouse can we think our own thoughts. Outside they would be dynamite.

NEWTON: But damn it all, we’re not mad.

MÖBIUS: But we are murderers.

They stare at him in perplexity.

NEWTON: I resent that!

MÖBIUS: Anyone who takes life is a murderer, and we have taken life. [….]

From Friedrich Dürrenmatt’s play, The Physicists (James Kirkup, tr.) (New York: Grove Press, 1964 [1962]).

Utopian Thought & Imagination (updated June 22, 2011)

I adapted and revised material from several previous posts here at Ratio Juris on “utopian thought and imagination” from 2008 and 2009 here (and cross-posted here).

The second and concluding post is here (and cross-posted here).

From “Cricketing in Compton” to “The Cricketing Marxist”

I never cheated, I never appealed for a decision unless I thought the batsman was out, I never argued with the umpire, I never jeered at a defeated opponent. [….] If I caught myself complaining or making excuses I pulled up. If afterwards I remembered doing it I took an inward decision to try not to do it again. From the eight years of school life this code became the moral framework of my existence. It has never left me.—C.L.R. James[1]

“It’s Sunday in Compton, one of the world’s most notorious and violent drive-by capitals. Sergio Pinales pulls on a white vest, leaving starkly bare the tattoos that indelibly coat swaths of his skin. He positions a baseball hat atop his shaved head, grabs the leash of his pit bull and leaves his house, slamming the front door behind him. There’s a look of purpose about him as he climbs into his father’s Pontiac, which has been loaned to him for the outing. On this day, there is only one thing on his mind—cricket. ‘I guess you could say I switched my gun for a bat,’ says Pinales, 32, breaking into a smile that transforms him instantly from tough to teddy bear. ‘I mean, shit, what would I be doing with my time if I wasn’t playing cricket? I probably woulda ended up in jail. Or in some kinda bad situation. Cricket really turned things round for me.’” [….]

For the rest of this article by Lucy Broadbent for the LA Times Magazine, please see here.

I’ve never played cricket, and I know very little about the sport apart from the loyalties and passions it inspires among both players and spectators around the world, as well as the fact that this was perhaps one of the more innocuous if not beneficent by-products of British imperialism. As the article makes clear, it is conspicuous in particular for explicitly encouraging fidelity to the “spirit” of the game, in addition to the rules, and in a way that gives support to virtuous behavior generally:

“Cricket is a unique game where in addition to the laws, the players have to abide by Spirit of the Game. The standard of sportsmanship has historically been considered so high that the phrase ‘it’s just not cricket’ was coined in the 19th Century to describe unfair or underhanded behaviour in any walk of life. In the last few decades though, cricket has become increasingly fast-paced and competitive, increasing the use of appealing and sledging, although players are still expected to abide by the umpires’ rulings without argument, and for the most part they do. Even in the modern game fielders are known to signal to the umpire that a boundary was hit, despite what could have been considered a spectacular save (though they might be found out by the TV replays anyway). In addition to this, some cricket batsmen, like Sachin Tendulkar and Adam Gilchrist have been known to ‘walk’ when they think they are out even if the umpire does not declare them out. This is a high level of sportsmanship, as a batsman can easily take advantage of incorrect umpiring decisions.” [emphasis added]

One of the leading black (‘Afro-Trinidadian’) intellectuals of the 20th century I’ve long admired is C.L.R. (Cyril Lionel Robert) James (1901-1989), aptly christened “The Cricketing Marxist.” His “partially autobiographical book,” Beyond a Boundary (1963), reveals the extent to which James questioned the adequacy of Marxism to treat topics outside of history, politics and economics,

“to deal with certain ‘large areas of human existence that my history and my politics did not seem to cover.’ These ‘areas’ encompassed such questions as ‘What did men live by? What did they want? What did history show that they wanted?’ To come to grips with these questions, James seems to be saying, Thackeray needed to be read together with Marx; and politics and economics needed to be supplemented by deep studies in social history.”[2]

In Beyond a Boundary, James explored a generous conception of “the political” through lens fashioned by cultural historians and social theorists. For a number of reasons, cricket became the subject that allowed him a unity of theoretical perspective and heuristic focus, “offer[ing] him an ideal terrain on which to examine the issues that interested him at a moment in his life, the mid-1950s, when certain assumptions that had guided him up to then turned out to be insufficient.” It was a work that polished a reputation during his lifetime as both “the black Plato” and “the black Hegel.” With Rosengarten, we might ask, “Why cricket?”

“Because this was a sport where many of the problems of social life were made manifest in the racial and class composition of the teams James played on and wrote about, in the significance which people of all ages attributed to the game, and in the qualities demonstrated by the sport’s greatest players: endurance, courage, strength, and above all, in James’s view, boldness and individuality. But there was another reason why cricket played such a prominent part in James’s life, and why he chose it as the main focus for his new book, and that was what he called his ‘Britishness,’ which he never foreswore. Throughout the book, James takes pains to valorize those English mores and values which were reinforced by traits of character that he had assimilated from his family. These were what he called his rigorous code of ethics on and off the playing field, and his ‘Puritan restraint,’ whose harmful effects he recognized but to whose basic standards he tried to adhere. Britishness also included an enormous respect and passion for the English literary tradition. One soon becomes aware that James would not have been the man and critical intellectual that he was without Shakespeare, Milton, Hazlitt, Shelley, Dickens, and Thackeray. Nor would he have been the man he was had he not been exposed to the Oxbridge teaching faculty at Queen’s Royal College.”[3]

Notes
[1] Quoted in Dave Renton, C.L.R. James: Cricket’s Philosopher King. London: Haus Books, 2007: 23.
[2] Frank Rosengarten, Urbane Revolutionary: C.L.R. James and the Struggle for a New Society. Jackson, MS: University Press of Mississippi, 2008: 234.
[3] Ibid., 236.

A Jain-like Approach to Ethics?

“What a fully grown-up moral philosophy might attempt is an account of morality that embraces the full gamut of moral predications, seeing them as mutually irreducible and mutually indispensable, allowing no primacy to character traits or virtues or practices or acts or states of affairs—or allowing primacy to all at once.”—David Wiggins

The above passage is from Wiggins’ fairly sophisticated yet eminently readable introduction to ethics in the Western philosophical tradition: Ethics: Twelve Lectures on the Philosophy of Morality (2006). Attracted to what has been aptly described as “a rationality of reconciliation”[1], as found in the Jaina worldview,[2] I suppose it is not surprising that I think Wiggins has proffered a worthy task for moral philosophy, one that cannot be dismissed out of hand, at least prior to the earnest attempt to bring it to fruition. The Jaina conception of rationality is premised upon both an ontological doctrine regarding the “many-sidedeness” of reality and a correlative “epistemology of perspective” or what we might term epistemic relativity or pluralism (nayāvada and syādvāda).[3] In short, Wiggins has—provocatively and (if I’m not mistaken) originally—suggested a Jain-like approach to moral philosophy, the beginnings of which he exemplifies in the above volume. Nothing follows from Wiggins’ suggestion that we gloss over or ignore any differences or contradictions between the various ethical theories (utilitarianism or consequentialism or ‘welfarism’ [as it is understood in economics], virtue ethics, Kantian moral theory, ‘ethics without principles,’ or an ‘ethics of care and empathy,’ religious ethics, what have you) or fail to account for their respective shortcomings or blind spots.

[1] On the meaning of a “rationality of reconciliation” in the Jain tradition, please see Jonardon Ganeri’s chapter, “Rationality, harmony, and perspective,” in his book, Philosophy in Classical India... (2001): 128-150.
[2] On the relevant aspects of the Jaina worldview of interest here, please see chapters 5 and 6 on the history and philosophy of the Jaina doctrines of relativity in Jeffery D. Long, Jainism: An Introduction (2009): 118-171.
[3] For a brief introduction, please see this earlier post at Ratio Juris: A Jaina Propaedeutic for Metaphysical Relativism, Perspectival Rationalism, and Contextual Pluralism.