This article was originally published on The Conversation, here. I have altered the styling slightly.
In the late nineteenth century, Sigmund Freud’s colleague Wilhelm Fleiss successfully diagnosed an illness in one of Freud’s relatives, without even having met them. Freud was so impressed by Fleiss’s “diagnostic acumen” that he went on to advocate the method in certain circumstances. Freud would write that diagnosing someone without personally examining them was acceptable where the features of certain disorders, such as paranoid schizophrenia (then known as dementia paranoides), made the interview process counterproductive. Here, Freud noted that “a written report or a printed case history can take the place of personal acquaintance with the patient.”
Now, a controversial debate about the ethics of diagnosis at a distance or long-distance diagnosis has arisen in the US. It has come about as commentators have proposed that President Donald Trump suffers from narcissistic personality disorder(NPD) and attention deficit hyperactivity disorder (ADHD), among other conditions. Health professionals have weighed in as well. Psychotherapist and former assistant professor of psychiatry John D. Gartner has been particularly vehement in his assessment of the President. Gartner asserts that Trump suffers from malignant narcissism, a specific manifestation of NPD.
According to the DSM-5—the authoritative psychiatric manual—this condition is characterised by various “traits of antagonism”, including “manipulativeness, deceitfulness, [and] callousness.” Notably, the DSM-5 names the condition only once throughout its hundreds of pages; and some academic psychiatrists say the disorder is understudied and its features largely unsettled, with no treatment yet established.
Despite this, Gartner is convinced that the president’s conduct fulfils the criteria of malignant narcissism—even without having interviewed him:
We’ve seen enough public behaviour by Donald Trump now that we can make this diagnosis indisputably.
Recently, the American Psychoanalytic Association (APsaA) issued a memo to its more than 3,500 members, advising they were “free to comment about political figures as individuals”, and that the APsaA did not regard “political commentary by its individual members an ethical matter.”
By contrast, the American Psychiatric Association (APA) has long maintained a strict ethical stance on the open discussion of public figures’ mental states. Enshrined in the so-called Goldwater rule, the APA’s prescription cautions psychiatrists against diagnosis at a distance. As former APA President Herbert Sacks put it, psychiatrists should avoid engaging in “psychobabble,” especially when it comes to politicians. He said that, when “reported by the media,” such diagnostic speculation only “undermines psychiatry as a science.” Although the Goldwater rule is not enshrined in Australian law, a code of ethics provides guidance to Australian psychiatrists about their conduct in the media.
What is the Goldwater Rule?
The Goldwater rule is named after an incident involving Republican presidential nominee Barry Goldwater. Having been defeated in the 1964 US election, Goldwater sued the editor of the shortlived political magazine Fact for defamation. Just one month before the election, Fact’s front page had printed a controversial declaration:
1,189 psychiatrists say Goldwater is psychologically unfit to be president!
Fact had conducted a broad but clinically invalid survey, providing questionnaires to more than 12,000 psychiatrists whose details the magazine had obtained from the American Medical Association’s membership list. Of the 2,417 responses it received, some 1,189 psychiatrists asserted Goldwater was unfit for office.
In the feature article, Fact purported to quote many of the psychiatrists it had surveyed, and used their words to suggest that Goldwater was a “megalomaniac, paranoid, and grossly psychotic”, and even suffering from “schizophrenia.” In the trial that followed, Goldwater was awarded some US$75,000 in punitive damages—enough to ensure that Fact never published another issue. The ruling raised disturbing questions for the APA, threatening not only the reputation of the psychiatric profession, but the future livelihoods of practitioners. In slightly different circumstances, a psychiatrist might face similar civil action, whether “for invasion of privacy or defamation of character.”
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general.
However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.
The Rule in Dispute
Many academic psychiatrists disagree with the rule. Some have suggested that breaking the Goldwater rule is ethical when it’s necessary to diagnose “mass murderers” from afar, or when “the importance of the diagnosis of an individual … rise[s] to the level of a national threat.” Others have criticised the rule more generally, calling it “an excessive organisational response” to “an inflammatory and embarrassing moment for American psychiatry.” And one psychiatrist has recently described the prescription as “American society’s gag rule.” In February this year, the New York Times published a letter signed by some 33 psychiatrists who blamed the rule for silencing them at this “critical time”. They wrote that “too much [was] at stake to be silent any longer”, and that Donald Trump’s “emotional instability” had made him “incapable of serving safely as president.”
The tension between the APA and its members, and between the APA and the APsaA, partly reflects the history of the two disciplines. Since the 1940s, psychiatry has increasingly focused on medical interventions, while tending to neglect the “in-depth talk therapies” which, despite their general decline, remain central to the psychoanalytic method.
But the situation is still more complicated than this. After all, the methods of psychiatrists and psychoanalysts often overlap. In many practices, for instance, psychiatrists employ intuitive reasoning in the diagnostic process. For some diagnosticians, the so-called “Praecox-Gefühl” or “praecox feeling” remains at the “clinical core” of diagnosing schizophrenia, despite the method’s varied reliability. First described in the 1940s, the praecox feeling is a complex, emotionally charged intuitive sense that a psychiatrist sometimes gets when detecting the subtle symptoms of an emergent psychosis.
What now for the Goldwater rule?
That psychoanalysts may wish to distinguish themselves from psychiatrists on the Goldwater rule, and vice versa, is unsurprising. In countless ways—more than can be named here—psychoanalysts and psychiatrists adopt different views of their roles in the diagnostic process. This is the result of their different training backgrounds, histories, and professional cultures.
Less expected, however, is the growing feeling among psychoanalysts and psychiatrists alike, that today, more than ever, the Goldwater rule should be set aside. While neither group may wish to admit it, the Trump era may have brought psychiatrists and psychoanalysts closer together—at least on this point.
I recently submitted the following abstract to the organisers of a conference called Neuroscience and Society: Ethical, Legal and Clinical Implications of Neuroscience Research, an event scheduled for mid-September, 2017, in Sydney. Since there’s apparently only a very limited pool of speakers, I’m not sure if my paper will be accepted for presentation. But the organisers have also noted that they will invite some attendees to develop posters for the conference; so, if I’m asked to do so, perhaps I’ll make a poster to outline my findings. (It would neatly dovetail my interest in design and research.) Some speakers will also be invited to submit their papers to Neuroethics—one of the journals I had in mind when I began this work (another was the Journal of Law and Medicine). Even if I’m not one of the lucky speakers, I think I’ll ultimately submit the article (of which this abstract forms a part) to Neuroethics.
As always, please do not use or reproduce this work without my express consent or permission. If you wish to quote from this work, please cite this website and this post. In CMoSstyle (for instance), use the following citation: Chris Rudge, “Pain in the Brain: Worker’s Compensation Claims for CRPS-I in Australia (Abstract),” Literature Law, Psychiatry, Politics: Notes by Chris Rudge (blog), July 18, 2017, http://www.rudge.tv/pain-in-the-brain/.
Pain in the Brain: Worker’s Compensation Claims for CRPS-I in Australia
Neuroscientists disagree about the underlying mechanisms of chronic regional pain syndrome (CRPS), a debilitating neurological condition characterised by severe pain in the limbs. In CRPS type I, the patient typically suffers from an acute form of pain—one that is frequently not accompanied by any tissue damage or nerve lesion, and is typically disproportionate to the trauma that has incited the condition. These clinical paradoxes make CRPS-I a confounding disorder not only for scientists in medical settings, but for judges, tribunals, and claimants in legal settings.
My analysis of Australian neurolaw, undertaken in the context of working on the Australian Neurolaw Database, has revealed the high incidence of worker’s compensation claims brought in Australia by plaintiffs diagnosed with CRPS-I. While the majority of these plaintiffs are unsuccessful in attaining compensation (with most injuries found to be psychological or psychiatric, not physical or neurological, impairments), this paper analyses these tribunals’ processes, together with the legislative schemes that shape their statutory interpretation of neuroscientific evidence, to show how the legal system impacts on the assessment of chronic pain disorders, and raises crucial questions of great neuroethical import.
To compare these Australian legal cases to developments in the US, this paper will also detail a fascinating US worker’s compensation dispute of 2007 in which both the plaintiff and the defendant appointed separate pain experts to give evidence for their legal claims. What followed was a public disagreement between two distinguished professors of neuroscience about whether the plaintiff’s chronic pain could be detected in BOLD-contrast images (via fMRI). When the judge rejected a motion brought by the defence that that the plaintiff’s evidence was inadmissible—evidence that proposed chronic pain could be detected by fMRI—the defence settled the claim for an amount reportedly more than ‘ten times’ its original offer.
Camporesi, S., B. Barbara, and G. Zamboni. 2011. Can we finally ‘see’ pain?: Brain imaging techniques and implications for the law. Journal of Consciousness Studies 18 (9–10): 257–276.
Davis, K.D. 2016. Legal and ethical issues of using brain imaging to diagnose pain. PAIN Reports 1 (4): e577.
Salmanowitz, N. 2015. The case for pain neuroimaging in the courtroom: Lessons from deception detection. Journal of Law and the Biosciences 2 (1): 139–148. doi: 10.1093/jlb/lsv003.
Wager, T.D. 2015. Using Neuroimaging to Understand Pain: Pattern Recognition and the Path from Brain Mapping to Mechanisms.” In The Brain Adapting with Pain: Contribution of Neuroimaging Technology to Pain Mechanisms, ed. V. Apkarian. 23–36. Philadelphia: Wolters Kluwer.
Below is a transcript of a paper I delivered in April, 2017, at the Sixth International Aldous Huxley Symposium in Almería, Spain. Held at the University of Almería, the symposium was organised by Bernfried Nugel and the Aldous Huxley Society. There I met and became friends with a number of the scholars I cite in the paper, including Sam Deese and Jerome Meckier. Running for three days, it was a wonderful event, and I am grateful to the Aldous Huxley Society for inviting me to attend.
Please do not use or reproduce this work without my express consent or permission. If you wish to cite this work, please specify that it was originally delivered as a conference paper and give details of this website. I also prepared a presentation, which is accessible here.
I have decided to speak a little about Huxley’s relationship to modern neuropsychiatry—not an easy subject, since Huxley was never directly engaged in the brain science as it emerged in the ’50s and ’60s. Nevertheless, some modern scholarship has drawn the connection.
Most directly, Nicholas Langlitz has sensed the way in which Huxley’s interest in the psychedelic experience relates to neuroscience in an article subtitled “Fieldwork in Neuro- and Perennial Philosophy.” Langlitz compares Huxley’s perennial philosophy—a philosophy of religion he describes as a “major form of philosophical thought”—to the neurophilosophy of Thomas Metzinger, who offers a more “modern philosophy of mind.”1 Salient differences between the thinkers, however, derive from the histories from which their ideas spring. For one, Metzinger’s neurophilosophy is a product of his “participation in the counterculture of 1970s Frankfurt,” as Langlitz notes. Huxley, by contrast, never witnessed the efflorescence of the counterculture after World War II. (Of course, some have suggested that the Californian counterculture was partly inaugurated by Huxley, so profound was his influence on the founders of the Esalen Institute; on this, for instance, see Jeffrey Kripal’s book, Esalen.2) But Huxley would likely have had mixed, even disdainful, feelings about both the Californian and Frankfurt countercultures. Huxley preferred that drugs were used intelligently and safely, expressing misgivings about mescaline in, among other essays and writings, Heaven and Hell. 3 And while Huxley provisionally approved of Timothy Leary’s early experiments (he participated in his Harvard Project with psilocybin as subject no. 11 in November 1960, and attended, with Leary, the 14th Annual Congress of Applied Psychology in Copenhagen in August, 1961 (see figure 1)), this did not seem to last long—and probably would not have lasted any longer had he lived beyond November 1963.4
Huxley is sure to have rejected the chaos of Leary’s 1963 Millbrook mansion, notwithstanding (or perhaps because of) its abstract resemblance to Crome Yellow, the locus of his eponymous novel of 1921. Huxley had modelled “Crome” on Garsington Manor, Lady Ottoline Morell’s mansion, near Oxford (see figure 2).
But what is the relevance of the counterculture in distinguishing Huxley from Metzinger? Langlitz notes: Since Metzinger’s philosophy of brain emerges from the Frankfurt counterculture after the Second World War, it is outwardly antithetical to “biologism” and eugenics, both of which he associates—as do we all—“with Nazi ideology.”5 And here the lines are drawn. Because Aldous’s neurophilosophy, if it may be called that, cannot be described as antithetical to biologism. His ideas are so profoundly connected with improving the body—with cultivating the “non-verbal humanities,” with educating the amphibian’s senses and emotions—that it must come to grips with biology, which is to say both with the human’s potential and limitations. Sexual selection, a subset of natural selection, must come into Huxley’s equation. Hence Huxley’s abiding interest in biological determinism: bodily functions and their failures underline all of Huxley’s thought.
But then, Huxley rarely describes sexual fitness. In his early satires, he is more concerned with vomiting and flatulence. These bodily responses determine their characters’ personalities—and even their religiosity—which makes it even more ironic that Huxley so rails against Swift’s satires, including his poem “The Lady’s Dressing Room,” for being so “unclean and unsavoury.”6 In After the Fireworks (1930), Miles Fanning considers the extent to which, after drinking excessively and vomiting, one becomes more pious. “Christians,” he thinks, paraphrasing Pascal, “ought to live like sick men; conversely, sick men can hardly escape being Christians” (444). In Crome Yellow, Denis Stone realises that all his life he has been using the word “carminative,” which refers to an agent that relieves one from flatulence, in place of a word that describes something that engenders profound insights (223–24). As with the vomiting example, Huxley’s comedic and ironic suggestion, here, is that something that relieves the body, that can cause one to break wind, can indeed also be profound, and can enable one to penetrate mental impasses. Miles Fanning and Denis Stone’s mistakes express, for Huxley, a greater truth: the body’s movements and warblings are the sources of new insights. The brain, it seems, is thoroughly embodied—and absurdly so.
When it came to eugenics, Julian was more attentive than Aldous. Julian sought to reposition eugenics as “an applied form of human genetics in the 1950s.”7 But by the 1970s, the subject had become anathematic to mainstream scientists. With eugenics denounced, the British Eugenics Society’s journal Eugenics Review rebranded as Journal of Biosocial Science, and is still known by that title today. (See figure 3, below.)8 But Julian’s interest continued, his ideas reaching an apex when he and Ernst Mayr, two venerable biologists, co-authored a paper on the evolutionary persistence of schizophrenia with two young and then less renowned psychiatrists, Humphry Osmond and Abram Hoffer. The paper was titled “Schizophrenia as Genetic Morphism.”9 Aldous, of course, had introduced his brother to Osmond.10
The story of that paper is fascinating. It influenced Nobel Prize winning chemist Linus Pauling, who adopted part of the molecular component of the quartet’s research into his own treatment model, “orthomolecular psychiatry.”11 Although intuitively ingenious, this method has been comprehensively rejected by mainstream chemists and scientists.12
Julian had long been a proponent for “racial improvement,” writing of its importance in the 1920s for “education, for health, for self-development in adult life, and for the steadily increasing amount of leisure which will be available in a planned society.”13 Living in France in this part of the ’20s, however, Aldous had no such “formal connections with the Eugenics Society,” as David Bradshaw notes.14 But the connection between Osmond and Julian develops a different picture: Aldous’s experiments with mescaline, and with LSD through Osmond, reflected his keen interest in an evolutionary theory of mental illness, and his handing over the scientific reins to Julian reflects a delegation of that interest.
And Julian and Aldous had always collaborated on what might advisedly be called eugenical projects. Exercised by the intellectual debates of the time, Aldous was curious about the topic in the ’20s, and his interest “no less fervid than that of his fellow-writers,” as Bradshaw notes. Proper Studies includes a “Note on Eugenics” that cites Leonard Darwin’s The Need for Eugenic Reform (1926), and among Aldous’s friends then was the psychiatrist Carlos Blacker, then General Secretary of the Eugenic Society.15 In the ’40s, Aldous introduced Julian to the German chirologist (palm reader) Charlotte Wolff and arranged for her to compare the handprints of zoo animals, caged in the London Zoo, whose gardens Julian managed, with those Wolff called “mental defectives.”16
Sam Deese masterfully summarises Julian and Aldous’s shared view about evolutionary biology in his 2014 book We Are Amphibians. Setting the pair’s common view against that of the less mystical D. H. Lawrence, Deese writes that
Even as they arrived at very different conclusions, Julian and Aldous Huxley each sought to articulate a worldview that was religious in its depth and power and yet fully compatible with both the long-standing methods of scientific research and the most current discoveries of evolutionary biology.17
But their methods differed as much as their conclusions. Trained in zoology, Julian exemplified the new empiricism, while Aldous’s scientific commentary was always political. He opens “Madness, Badness, Sadness” by recalling that “Goering and Hitler displayed an almost maudlin concern for the welfare of animals.”18 The tyrants’ ironic antipathy towards human animals revealed to him the “state of chronic and almost systematic inconsistency” of “the world,” a defect that, for him, even science—and even eugenics—couldn’t ever mend.19 Blinded as a seventeen-year-old, now unable to use microscopes, his plan for a medical career thwarted, Aldous set about writing cautionary tales and romans à clef—and later, works in this same genre again but now disguised as essays: broadsides against modern biopolitical life, and barbarous, even vindictive lamentations on the turpitudes to which humans have stooped.20
For whatever optimism we discover in his general vision of human potentialities, Huxley expresses as much pessimism in the details of his writings, everywhere pointing out our malice and wrongness. Jerome Meckier’s portrait of Huxley’s transition from “poet to mystic” is but one confirmation that Huxley never abondoned his youthful cynicism so much as came to refine it. If he experienced an “artistic and spiritual growth,” it was “from a parodic formative intelligence into a volatile blend of satirist and sage”—although, even Huxley’s sagacious traits are underlain by his dark, satirical odium. And as he grew older, Huxley’s views ossified, his ludic playfulness transmogrifying into, at times, a mild cantankerousness, so that, in both the satirical and mystical stages, this negative impulse is there. Meckier describes it as a happy willingness to “furnish an explanatory hypothesis for the nature of things provided it was negative, i.e. meaninglessness as, paradoxically, the meaning of modern life.”21 And this same, cold pessimism underscored his attitude to the mind and brain’s evolution, together with our potential to understand it.
Within Huxley’s own magnificent philosophy perrenialis thus lie the traces of its malevolent other, a philosophy of depravity. It is especially marked in his treatment of scientific progress. Again in “Madness, Badness, Sadness,” he mourns the fact that surgical interventions have subsumed “Animal magnetism and hypnotism,” two of Huxley’s favourite alternative therapies.
It had all happened before, of course. Cutting holes in the skull was an immemorially ancient form of psychiatry. So was castration, as a cure for epilepsy. Continuing this grand old tradition, the Victorian doctors removed the ovaries of their hysterical patients and treated neurosis in young girls by the gruesome operation known to ethnologists as “female circumcision.”22
Huxley’s views strike those familiar with biopolitics, both before and after its founder, Michel Foucault, as very modern: even today, debate continues in biopolitical discourse about the ethics of female genital cutting.23 Huxley does not name Africa as the locus of his critique but fulminates against Victorian England; he resented much of the Victorian period, railing against the repressed sexualities of Victorians in the essay “Battle of the Sexes,” and jesting the deceptive Romantic poets in his satires (they were poets who, according to Meckier, he could not quite emulate), including by hailing the modernist zeitgeist in his essay “The New Romanticism.”24 The point, however, is that, for Huxley, circumcision—and castration—is a gruesome substitute for our own ignorance about the human psyche, and its elaboration as a medical procedure likewise no better than what he called, in a brilliant 1925 essay, Freud’s “hocus pocus.”25
Huxley resists these physicalist aetiologies, and these physicalist treatments, because they take too little account of the mind and overlook many aspects of the psyche. Where psychology has been advanced, similarly, it takes too little account of the body: “The basic Freudian hypothesis is an environmental determinism that ignores heredity, an almost naked psychology that comes very near to ignoring the physical correlates of mental activity” (LAS, 97). Thus, ovaries have as little to do with hysteria as men’s desires for their mothers have to do with their neuroses. Huxley advocates a middle approach—a science of the “mind-body”—and urges we become more agnostic about the relations of mind and matter, neither physicalists nor psychologists exclusively. In Literature and Science, he claims that
Men and women are much more than the locus of conscious and unconscious responses to an environment. They are also unique, inherited patterns (within a unique, inherited anatomy) of biochemical events; and these patterns of bodily shape and cellular dynamics are in some way related to the patterns of an individuals’ mental activity. Precisely how that are related we do not know, for we have as yet no satisfactory hypothesis to account for the influence of matter upon mind or mind upon matter (LAS, 82).
Seemingly technical, Huxley’s expression “cellular dynamics” is a curious reference to neuroscience. Published in 1963 before he died, Literature and Science might reflect Aldous’s attention to the work of his half-brother, Andrew Fielding, who had described the dynamics of cells and neurons in a mathematical model, the “Hodgkin–Huxley model,” in 1951, and had won the Nobel Prize in for it in 1963 with his co-author.26 I admit I haven’t reviewed Grover Smith’s edited Letters recently—Huxley might have congratulated Sir Andrew—but it seems possible Huxley used the term “cellular dynamics” with his half-brother’s work in mind. But then, Huxley must have thought too little of it to regard it as a “satisfactory hypothesis” in accounting for the influence of matter upon the mind.
It is typical for Huxley to use the best sounding nomenclature to introduce a topic only to then characterise it as altogether inarticulable—as inexpressible in language, mathematics, or any form. He had done so when he disavowed Euclidean geometry in Do What You Will, announcing ironically that “God is no longer bound… to obey [Euclid’s] decrees promulgated… in 300 BC.” And even when embracing Einstein and Riemann’s new geometric models of nature as “among the latest products of the human spirit,” Huxley would go on to question, and to mock, geometry’s fundamental truthfulness, its potential to reveal any real understanding.
An exceptional reification amid all this occurs in the Doors of Perception, where Huxley uses the expression “satisfactory hypothesis” to venerate Bergson’s model of “the brain… as a utilitarian device for limiting… the enormous possible world of consciousness… ”27 This is about as far as Huxley ever goes in the way of stamping his imprimatur on a neuroscientific theory of the mind. Enticing as it is, the assumption that we underuse our brains has long been discredited; Bergson, Broad and William James likely adopted the notion, consciously or not, from the concourses of Franz Gall and Johann Spurzheim.28
Huxley likely would have appreciated my disavowal, even of Bergson, as, for him, ignorance was not so much blissful as truthful. “Total awareness” he wrote in Knowledge and Understanding, “starts, in a word, with the realization of my ignorance and my impotence. How do electro-chemical events in my brain turn into the perception of a quartet by Haydn or a thought, let us say, of Joan of Arc? I haven’t the faintest idea — nor has anyone else.”
Huxley’s repeated denunciation of the Science of Man—which, like language, is too politicised and too technological—together with his advocacy of alternative therapies such as hypnotism and the Bates method, and his belief in animal magnetism, ESP, psi, and other parapsychological notions, constitutes his framework for developing the mind and brain for its evolution. His views presage the contemporary idea of neuroplasticity: the principle that novel processes that initiate new transmissions in the brain come to be entrenched as new capabilities. Modern neuropsychiatry accepts that just as the brain can be damaged or injured, so can its functions be improved, its fitness enhanced; it has partially come to embrace what Julian Huxley called transhumanism in 1951.29 But if Julian was quick to embrace population control and eugenics, Aldous suspected more was to be discovered through personal improvement. Educating the amphibian to deal with technological pressures could improve the future of the species. And while he burlesques neo-Lamarckians in his early satires, including in Antic Hay, where he parodies one biologist who has “found a way of making acquired characteristics . . . heritable,”30 many of Huxley’s ideas are compatible with the soft Lamarckism that is today, in spite of Darwinism’s long and continuing reign, embraced by many geneticists.31