The unexamined life is not worth living

This post is a re-posting of a previous post on the PLoS Mind the Brain blog. As part of my re-focusing on this blog I will bring here relevant posts that I've published elsewhere. The goal is to have this blog as a one stop station for all my more philosophically flavored musings on psychiatry.

... states Socrates [through Plato] in his Apology. You might think this is a metaphorical statement. And thus the surprise when Socrates chooses to drive this most important point home by proceeding to drink the poison that literally ends his life.

From the psychiatrist's corner this looks a bit like suicide by cop. Socrates has the ability but not the willingness to save his life; one may argue that he effectively leads the jury to condemn him to death and then carries out his own sentence.

Is this a reasonable decision and course of action? Or alternatively, did Socrates have capacity?

For starters, Socrates' view of life as being worth living under a certain set of circumstances [but not others] is at odds with the view of modern [read Western] psychiatry which emphasizes the absolute value of life regardless of its circumstances.

Arguably, the majority view nowadays is that the ideal mental health is a state where the drive to live prevails no matter what. As a consequence, those who are ideally "mentally fit" would have the potential to overcome and survive whatever circumstances and challenges life would throw in their way. Which pretty much means they will make the choice to live regardless or they would prize life above anything else.

This view of life as having an absolute value is at odds with moral systems that consider life's value as contingent on the fulfillment of other norms and values. In middle age Europe chivalry valued bravery above living, in Japan the samurai Bushido code recommends suicide by seppuku as preferable to living without honor. And of course Socrates argues that is better to die than to life an un-examined life.

Along this line of thinking, choosing an honorable death over a shameful life can be understood as the logical consequence of subscribing to a clear moral code - and as such can be accepted as proof of competency in making life/death decisions.

However Socrates reaches his final decision following a moral code that is dictated by his daemon, in essence an auditory hallucination.

There is ample evidence that Socrates experienced auditory hallucinations in addition to what might be considered as a very specific set of compulsions. In his De Genio Socratis Plutarch states that...

"Socrates' sign was a sneeze, his own and others; thus, when another sneezed at his right, whether behind or in front, he proceeded to act, but if at his left, desisted; while of his own sneezes the one that occurred when he was on the point of acting confirmed him in how he had set out to do, whereas the one occurring after he had already begun checked and prevented his movement".

Now,  in the context of concurrent psychiatric symptomatology, when one's life/death decision follows the prompting of an auditory hallucination - even if in accordance with a pre-specified moral code - does it meet criteria for capacity?

Or would the consulting psychiatrist recommend starting a neuroleptic and holding off on proceeding with the execution until the medication will take effect?

© Copyright Adrian Preda, M.D.

Notes on Jaspers

Jaspers in quotes:

"The question of what underlies all phenomena in general used to be answered in the old days by the notion of evil spirits. These later turned into disease entities that could be found by empirical investigation. They have proved themselves however to be mere ideas’.

The mere ideas of evil spirits or neurotransmitter abnormalities are explanatory models based on [to date] insufficient evidence. Such models serve as temporary organizing models for mental disorders until enough evidence accumulates against the model to demonstrate its inadequacy. Enough experimental evidence has accumulated to convincingly demonstrate that the evil spirits model is inadequate; almost enough evidence has accumulated to demonstrate the neurotransmitter model is inadequate. Looking at the relationship between theoretical models and their translation in practice, it appears that most of the time, until a conceptual model is invalidated, the model tends to be seen as valid and used as if it is valid in day to day practice. Psychiatry is no exception to this rule.

‘We have intuitions of a whole which we call schizophrenia but we do not grasp it; instead we enumerate a vast number of particulars or simply say “ununderstandable”, while each of us only comprehends the whole from his own experience of actual contact with such patients’.

Our understanding of the unintelligible is filtered through the lenses of our own experience. While what is clear is clear to everyone in the same way, what is unclear is unclear to each individual in a individual way. 

Concepts to compare and contrast:

• psychopathology of "the sick human individual" vs. psychopathology of "human sickness" [Musalek 2013]
• superficial checklists of diagnostic criteria vs. understanding of a patient's experience of his illness [Musalek 2013]
• • professional, authoritarian, expert monologue vs. therapeutic, democratic dialogue [Musalek 2013]
• expert opinion vs. genuine curiosity
• see patients as they are vs. "through the distorting prism of our own preconceptions" [Sims 2013]