The Perversion of Autonomy, Part I

THE OPEN MIND
Guest: Willard Gaylin
Title: “The Perversion of Autonomy”, Part I
VTR: 7/9/96

I’m Richard Heffner, your host on The Open Mind. And my guest today is Dr. Willard Gaylin, Clinical Professor of Psychiatry at Columbia University, and the co-founder and longtime president of the Hastings Center, America’s pioneering institute for the study of society, ethics, and the life sciences. In his new Free Press book, “The Perversion of Autonomy: The Proper Uses of Coercion and Constraints in a Liberal Society”, written with Bruce Jennings, now the executive director of the Hastings Center, Dr. Gaylin says it right up front, answering with his usual candor and directness the question I’ve often asked my guest at this table, thought quite unavailingly. “We are our brother’s keeper,” he writes. “Cain lacked this sensibility. Most Americans possess it,” he adds, “so far.” But just how far, we wonder, and are told that the morality of interdependence and mutual responsibility has been clashing with respect for autonomy with increasing frequency and harshness for the past 30 years. And autonomy has won in these clashes too often. Well, we’re assured, however, that reason does not require that autonomy be abandoned; only that its balance with other individual and communal values be restored.

Now, you should know that Dr. Gaylin and I go back a long way together. Just about 20 years here on The Open Mind. On issue after issue, indeed, on Gaylin book after Gaylin book. On “Feelings: Our Vital Signs” in ‘78. On “The Killing of Bonnie Garland” in ‘82. On “The Rage Within: Anger in Modem Life” in ‘84. On “Rediscovering Love” in ‘86. And though I’m experienced with his ups and downs, nothing in his intellectual past leaves me surprised at Will Gaylin’s conclusion to the perversion of autonomy, namely, that we must reach beyond the philosophical and psychological framework of autonomy to understand properly the ethics of social control and the proper uses of coercion in a liberal society.

And so I would ask my guest: If the line from then to now, from our beginning together to this moment, has been as straight and as consistent as it seems to be here on the sidelines? Will, is there a switch? Is there a change in Will Gaylin’s approach to the world?

GAYLIN: I don’t think so. I’ve never thought of myself as having a long trajectory. So that when you ask a question like; that, it’s interesting to me. In retrospect, I think I’ve seen each step building on the step before. I’m not a philosopher; I a man of the world. I believe in common sense. I deal with people. I don’t have the luxury, as a psychiatrist, to project to some abstract futures. The now, the present, the everyday is important. But I think I’ve been moving in this direction. And only as you said it now did I try to recall how and why. Obviously, as a psychiatrist who earns his living dealing with individual problems, I have respect for the individual. But the blatant and dramatic submerging of almost every other value under the value of autonomy has started to seem spooky to me and scary. And I realize, only now as you said it, that’s where I started from, that’s really where it was all about. I had two tasks really As a psychiatrist, I wanted to find human nature in a very special way. And secondly, I wanted to translate it into something that was useful in the real world, to look at the real world and see how the individual fit in. I think both of those have taken me to the realization that what we call autonomy now, the current culture of autonomy, is itself a perversion of human nature and is a perversion of a good society

HEFENER: What do you mean, “perversion of human nature?”

GAYLIN: Well, I have two objections to autonomy. One, I don’t like the fact that it’s now treated as a sole virtue. Me, I, my feelings, express yourself, let it all hang out. You know, that goes back a long time, my saying, “Why should it all hang out?” I’m not an emesis basis for you to vomit into, nor is the society. Remember in the old days I used to talk about bad language and profanity and ugly manners as a kind of littering, and couldn’t understand how the liberals who hated littering tolerated graffiti and all the intellectual littering that went with it. These were my colleagues. So that what I object to in autonomy is two things, really. One is that it acts as though it’s the only virtue. Give you one example: the honesty thing. I started writing years ago about my concern about what I call “truth dumping.” That because doctors had been paternalistic, and because they had been beneficent, then had overreached. But now we wanted them to lay it all out, as it was. And what they did was they just dumped the truth on people. Now, I found that less humane than the old way, and not serving any particular purpose. There are some people who say truth uber alles. When the Jews are in the basement and the Nazis are knocking on the door and you answer and they say, “Any Jews here?”, truth prevails. Well, truth does not prevail in all things. It doesn’t mean I don’t value truth. So I don’t like the setting up of one virtue over all other virtues.

Secondly, it’s a kind of joke. The definition of autonomy that is used in both philosophical and political purposes totally ignores modem psychology. There is no isolated self, and there certainly is no rational self. At least not as a good Freudian, I don’t believe there is.

HEFFNER: But, wait a minute, wait a minute. You say, “As a good Freudian.” And the next question I was going to ask you, and probably I’ve asked you this question over 20 years now: Don’t you, or at least doesn’t your profession, have to take a great deal of responsibility (to use that much-maligned word) for everything hanging out? No?

GAYLIN: Absolutely. Absolutely. Look, I think I started writing in this area as an apologist for my profession. I love psychiatry and psychoanalysis in terms of what it does to help suffering human beings. I am not thrilled with its contribution to the weltanschauung. First of all, it does a couple of totally contradictory things. On the one hand, it doesn’t believe in accidents. If I were to spill this water on you, you’d say, “Why’d you do that?” If you were a good psychiatrist, you’d say, “That was an accident. Oh, no, there are no accidents. You know, that’s a latent hostility.” So that, in a sense, every act is intended, and so you’re responsible for everything. On the other hand, if you’re mother hadn’t done this, and your father hadn’t done that and your grandfather hadn’t come from here, and they hadn’t done that, all that exculpation coming from the past means no one’s responsible for anything. So that indeed it has. The conflict, as a psychoanalyst, is I have to encourage my patients to do in the office what I do not want them to do in everyday life: to concentrate on me, me, me, because that’s what they’re there for, themselves, and to introspect and to see. I want to get them to the point where they reflexively do the proper and the good thing to find by their purposes. What’s a good life? I don’t set that for them. They set it for themselves. And so I want to work it. So you’re absolutely right. Psychoanalysis has indeed contributed. I don’t think it’s the worst factor of contribution. But the whole libertarian times have done that. You go from the Sixties on. Psychoanalysis happened to be the darling of an issue that was ripe and ready to be moved into the forefront.

HEFENER: Yes, but you just said you don’t set the standards, the level of morality of your patients. But isn’t that, in a sense, a copout? Doesn’t the psychiatrist do that to a much greater extent than you and your colleagues have admitted?

GAYLIN: Yeah. I forgot who was interviewing me. And you’re right.

HEFFNER: [Laughter]

GAYLIN: That’s the simple person. I don’t want to get Jesuitical or Talmudic. But you’re absolutely right. To a certain extent, the psychiatrist does not serve his patient’s desires. He serves a concept called “health.” He hopes that the patient shares it with him. Now, I would not allow a patient to say, “Oh, I want to remain sick,” or, “I enjoy my psychosis,” or, “Let me be manic.” That’s an interesting one, because patients do love the manic phases of a manic/depressive psychosis. I wouldn’t. I assume, no, no, no, I’m the doctor, I know the values and how to get to them. Now, if you have different values from me, what do we do? That would be interesting. And the way I’m using values, they’re broad enough that in health, most people don’t want to be sick. Most people prefer to be healthy. And the broad, general definitions of health of most of my patients would comport with my definitions.

HEFFNER: Tell me why. Because you’ve chosen them as your patients?

GAYLIN: In a peculiar way, that’s part of it. But also we share a common culture. And the kind of person who goes into psychoanalytic therapy, which is what I’ve been dealing with most of my life, tends to come from a very select segment of society, intellectual, often academic, upper middle-class. It’s one of the defects of psychoanalytic therapy is that it hasn’t been able to reach down to do emergency kind of repair work, first-aid sort of things. ICs part.: of the reason why the field is in decline.

HEFFNER: When you talk about “share a common culture,” I thought you were talking literally about something else. And I was going to say to you: But if we talk about sharing a common culture, your anger, or your distress… In the book, you wrote about the rage inside. You’re talking about a common culture. You’re talking about our culture. You’re talking about who we are. We’re not separate from it, Will. How do you…

GAYLIN: No, we’re certainly not. And some of us see it in one way or another, but certainly all of the literature about our culture, even coming from the right and from the left, each of them being unhappy with some aspect of the other, but most of them point to a common concern, and that is there is a kind of narcissistic… Go back to Christopher Lasch’s “The Culture of Narcissism.” I think we’ve past the narcissistic point. I think it came out in my “Anger” book. I think we’re entering into a real paranoid stage in our culture where everyone’s going around feeling just a little bit screwed in life, and a little bit unhappy. Now, partly, the culture of autonomy has contributed to it. We have raised the expectations so high, everybody has entitlements, everybody has rights, with very little mention of duties, obligations and responsibilities. As soon as you mention duties, obligations and responsibilities, you’re labeled, in decent society, as a conservative; with the dialecticians you’re a fascist or you’re a pig or whatever. You dare not use those words. And yet those are the balancing acts of a social animal. Yet everything is rights, rights, rights. So that people have been expecting more and more. And paranoia or… I’m not using it in the clinical sense. I have to apologize. Being a psychologist, I don’t want people…

HEFFNER: [Laughter] You don’t have to apologize for that, Will.

GAYLIN: … to think that I’m using this the way I would to the paranoid patient. But paranoia, distrust, resentment, it really goes back to the old Max Scheler idea of “resentment.” And Max Scheler, at the turn of the century, had a brilliant article. He was writing about Germany in the early 1900’s, but it reads like it was for America. And he says, “You know, the discontent and the resentment, the solemn resentment of the society has nothing to do with actual privation. It’s the distance between what you were led to believe you were going to get and what you actually got.” And we have raised the expectations of everybody so high. And yet most of us go around feeling deprived these days. We had a deprived black minority. They were a deprived minority. Then you have a deprived group in the gay population. They were indeed persecuted, or still are. Then you cast women as a deprived minority. And you’ve got so… Then the handicapped are a deprived minority and disempowered minority. So now you’ve got the handicapped, the mentally ill, the emotionally ill, gays, and women. You have managed to make the majority feel like a deprived minority. Now, in actuality, one of the things I go on in this book is what we really have done is taken the poor, blue-collar worker, and made him now feel a deprived minority too, because he feels no understanding particularly for his pursuits, he’s plagued by the rules, somehow or other it hasn’t worked out. So I think what is happening is we’re beginning to see everyone feel something isn’t working. I didn’t get what I wanted. I deserve more. And I must say that the language of rights… And don’t forget the change that occurred there. It’s very important for people to realize that the original concept of rights coming out of the Civil Rights Movement, it was clear what the blacks wanted. They wanted, in a sense, to be left alone, to be declassified. They wanted blackness not to be a distinguishing feature any more than eye color was a distinguishing feature.

HEFFNER: What happened?

GAYLIN: Well, then rights went from the right to be left alone, that wonderful line of Justice Brandeis in the Olmsford case in which he says, “Our greatest right under the Constitution is the right to be left alone,” to the concept of claims. So rights became: Look, I have an entitlement to be on the streets the way everyone else is, but I’m in a wheelchair, therefore you must do such and such and such and such. So we moved rights into positive claims rather than just the right to be left alone. The original Civil Rights Movement, and the Women’s Movement, I might say, indeed did follow that parallel: just don’t think of me as a black or as a women; as another person. But then we went to claims. And now we’re in the middle of this imbroglio of the black movement being caught up in a peculiar contradiction. You see it in the whole voting-district debate that’s as current as yesterday’s paper and last week’s Supreme Court decision. Originally that right was to be left alone to he considered other. Then, because they still didn’t find proper empowerment, it was somehow or other we have to treat you as black and make a special category. I don’t know. Fortunately, that’s not the major dilemma of this book. But that is a tough one for our society to decide.

HEFFNER: How do you describe the major dilemma of this new hook, which I, as I said to begin with, I see a continuum, the relationship between this and the Bonnie Garland hook and what came before then too.

GAYLIN: Well, here I try to do two things: to show that freedom is more complicated than mere autonomy, which means self-choice; and also to try and explain what a normal human being is, and that he doesn’t exist in splendid isolation. If you destroy the community, the metaphor that I’ve used is these nets that fishermen use. You seem to see a lot of knots, and the net is the culture. You start untangling the network, you break down the network, and the knots disappear. They’re really illusions. It’s an interesting thing. The Bible started with Adam and Eve. Maybe Adam was given precedence in one version of Genesis, but not in the other. And William James, hundreds of years later, based as a morality and two human beings on a rock. You have a moral universe there, but it has to be two human beings. So I don’t like the separation of the individual, and I don’t like the whole concept of autonomy simply being self-choosing. There are five or six examples I wanted to use here. AIDS was one very good one. Euthanasia was one which I cut out because the book couldn’t be 700 pages long. But the homeless was one I certainly got involved with. And the whole idea that somehow or other the teenage mother with no father — I hesitate to use the word “mother” because often she doesn’t act in that role — but the pregnant teenage girl, the 13-year-old who has a baby, you can say that was freely chosen (if she weren’t raped, and often she is raped), but is that her free choice, and is she free? I remember a debate at the Hastings Center about the uses of Norplant. “Oh, we must not invade the privacy of these girls. We must not do that. We must not invade their autonomy.” And after the debate, Joycelyn Elders, who was then our — and certainly was concerned about teenage pregnancy and was black herself and a physician — said, ‘Who calls that free? You’re going to tell me that a 14-year-old girl with two children is truly free?” And I don’t believe they are free, in the same way that I don’t feel an uneducated person is free; and in the same way our society forces, compels a child to education regardless of what his parent wants, compels him because we know that the concept of freedom which doesn’t include knowledge is a very shallow and very corrupt version of freedom. And autonomy just takes that one self-selection: “I want to get doped-up. I want to drink. I want to do this.” That’s not freedom. The doped-up person isn’t free. And then, and from my field, there’s the other case, of a mentally ill person. To call someone who has an impairment of his mind free is simply ludicrous. And yet, in the deinstitutionalization that led to the problem of “homelessness” – I tend to put “homelessness” in quotes because, as you know from having read the book, I think that’s a con. To call them “homeless” is to imply that it’s some kind of a real-estate problem. If only we had enough real estate to go around. Well, it isn’t – what has happened there is, with the autonomy movement and the deinstitutionalization movement (maybe I should go a little into that), we dump the mentally ill onto the streets of the cities. If you take… It’s hard to define mental illness, so I’m going to be very exact on this. If you took the most limited definition of mental illness, you get different estimates. I mean sick, psychotic. That’s what I mean by mentally ill. And that would be schizophrenia, primarily. You get estimates of 20 to 40 percent. If you then add alcohol…

HEFFNER: Of the people on the street.

GAYLIN: Of the people on the street, 20 to 40 percent. And probably it’s closer to the 40 if I have examined the data as objectively as I can. If you then include drug addiction and alcoholism in it, you’ve got 70-80 percent of the homeless are people that… We do. And we do include alcohol and drug addiction as a mental illness. You’ve got the mentally ill. That’s who the homeless are. Now, to call them “homeless” is one step up from calling them Bowery bums, and I prefer “homeless” to that. But it was a con. It was an invention. Even the numbers of it were invented. And they got there through a disaster. They got there because the right and the left got together, and the left wanted to press autonomy. We shouldn’t hospitalize anybody against their will. The Russians were doing that. Indeed, the Russians were, and it was a serious problem. The right-wing thought, “Geez, we’re looking for a place to save money. What could be better? We can close down these state hospitals.” In addition, new drugs had come along: Thorazine, which made the psychotic individual tractable. It didn’t cure him, but it made him less frantic, less agitated, and safer. So we began to dump these people onto the streets of the cities, and that’s where you see the homeless now. Then, of course, it became a political football.

HEFENER: But, Will, you describe the process by which notions of autonomy led to diminishing notions of responsibility. Tell me about the reversal. Are you hopeful? Do you have any notion whatsoever that we can reverse this? I mean, you just described an enormous political and personal problem, the homeless, meaning the people who are…

GAYLIN: Oh, yes, I do. I can take the simple problem. If you give me the isolated case, ifs pretty easy. Now, when I jet into the cultural thing, my solutions are scary. But let take the homeless. Recognize that they’re mentally ill. Recognize that in the past we may have erred by not allowing them sufficient autonomy. Have the decency to acknowledge a certain beneficent need that they have. Step in against their will for a short, limited period, and test them out on modem treatments. This is the golden age of psychiatry in terms of psychotic individuals. Maybe neuroses and psychoanalysis hasn’t progressed; but in terms of treating the desperately ill, it’s a golden age. With all of the drugs that we have available to us, we can get them into tractable form, we can get them into thinking more reasonably, and we can get them to utilize their own resources.

HEFFNER: So we’ve rounded them up, we’ve been more efficient and productive with our drugs. Then what?

GAYLIN: And then we manage to get them out of a psychotic state. None of these people necessarily have the advantage of those treatments. And then we have some kind of control mechanism for them, either voluntarily, or we mandate. And that’s where people get upset. We mandate a once-a-month, a once-every-two-weeks, a once-whatever follow-up visit to see that they’re taking their drugs. I don’t have any trouble with that.

HEFENER: But that was the theory to begin with. The notion was the community was going to do “something” with these people. The notion wasn’t just let them out of the institution. We never did that as a society.

GAYLIN: No.

HEFFNER: We didn’t meet our responsibilities.

GAYLIN: No, we didn’t. The community health movement was one of the great shams. The left-wing and the liberal people said, “Let’s let them out in the community health.” The right wing said, “Let’s let them out,” but meantime, when the money came for the community health programs, they weren’t there. And they didn’t work. Something akin to it, not quite as grandiose as that, might work. But first we have the right to hospitalize now. I get parents all the time calling saying that their son’s threatened to commit suicide or to kill someone. You can’t get them into a hospital in most states. You can’t. Even, I had a call from California, someone who wanted, who was worried about his son threatening to kill him and his dean, the dean of the school, and then he finally, he was applying for a gun permit. He couldn’t stop him from getting the gun permit, legally. We talked about ways that men of influence (and this was a man of influence) can work around the law. Well, that’s dreadful to have to say, but that’s what he did to protect his son from killing someone and becoming a murderer. So that we won’t allow… No one can go to a hospital unless you can prove that they’re sick, unless you’ve proved that they’re capable of doing harm to themselves or others. That’s just stretching autonomy too far. Now, that does not mean that I still don’t prefer our system to the Russian system where you hospitalize, where you define mental illness as being against the state. Now, that’s one simple example. Others, from the book… I mean, these are all unfashionable ideas, but I’m sorry about that The idea that we can prevent the spread of AIDS to babies and won’t do it because in order to test the newborn or the about-to-be-born, we would have to reveal to the mother her HTV status which her autonomous rights would claim the rights of privacy that she need not know if she doesn’t want is, it seems to me, stretching autonomy to an outrageous point. The AIDS debate throughout has been one in which autonomy has ruled everything. And you had to wait for the gay community to come to step in for their own rights. When we wanted to close, those people who were concerned about the spread of AIDS (and I was one of them), wanted to close those San Francisco bath houses, it couldn’t he done. We said it’s a cesspool and a spread of what was then a fatal, invariably fatal disease, or seemed to be. It couldn’t be done, because the explanation coming out of that group in San Francisco was, “The bath houses are a part of a culture. They may not conform to the culture of heterosexuality to the straight culture, but it’s part of our gay culture, and it’s our autonomous right to do this and to risk our health.” Well, hell, I think that was ridiculous. And what was really shameful was not that private doctors didn’t come to the fore, but public health physicians didn’t come to the fore. They too were part of the culture of autonomy. “No, they don’t want it, we can’t do it.” Now, fortunately… And it was, in great part, after Randy Schultz’s book came out in which he chastised his own friends and said, “Where were we? Where was our head? What about protection? What about protection of our colleagues, our friends, our lovers? What about all of that?” Well, now, when it’s protection of the newborn or the child, the innocent child, we have always had special stretches in the law for that. It’s outrageous that we still, in New York – or, we’re just on the border of doing something about it — it’s outrageous that we won’t mandate testing for these newborns.

HEFFNER: Dr. Gaylin it’s clear that we are living in a psychotic society and it’s clear that we have to do something about it. We’ve just begun this discussion. I love to listen to you, you’re so morally indignant. Stay where you are if you will. We’ve come to the end of this program.

GAYLIN: Fine.

HEFFNER: Thank you for joining me today on the Open Mind. And thanks, too, to you in the audience. I hope you join us again next time. If you’d like to share your thoughts about our program today, please write: The Open Mind, P. 0. Box 7977, FDR Station, New York, New York 10150. For transcripts, send $4.00 in check or money order. Meanwhile, as another old friend used to say, Good night and good luck’.