The Self and Mental Illness: Commentary on Omonzejele and Ratanakul
- Frank J. Leavitt, Ph.D.
Chairman, The Centre for International Bioethics
Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
Eubios Journal of Asian and International Bioethics 14 (2004), 169-170.
A few years ago I worked in a health survey together with the Jnana Prabhodini organization, in Velhe Block, Maharashtra, India. We took an interest in Allopathic (Western) and Ayurvedic (ancient Indian) medicine, as well as in local, traditional midwives and healers. Both the Allopathic and the Ayurvedic doctors were quite critical of local traditional healers. Their criticism was convincing, especially because of many traditional healers' lack of understanding of sanitary conditions. This seems to be a major problem among the local "bonesetters". I was, on the other hand, favourably impressed by the local, traditional psychotherapy, or rather, treatment methods which are used for mental problems, family problems, and medical problems for which no cause or cure is known. As it was explained to me, the healer while sitting with the patient puts rice and ashes in a winnowing fan. He or she then shakes the pan and studies the pattern which appears. On the basis of the pattern the healer sends the patient to meditate at the temple of a specific Hindu god. The patient then returns and reports his experience to the healer who uses it as the basis for a conversation aimed at working out the patient's problems. Although this may appear to some as superstition, the process may be explainable in terms which are familiar to many in technologically developed countries with advanced Western-style medical systems.
In Israel many people today take a serious interest in some techniques which do not seem too different in principle from the winnowing fan. Many use a pendulum to help decide what specifically may be troubling themselves or others. The pendulum is also used to help decide what foods or medicines to take or avoid. People who practice Bach Flower healing sometimes use a pendulum to pick the remedy for a specific case. Another kind of therapy which should be mentioned is "One Brain Therapy", in which the therapist asks the patient a series of questions during physical contact with the patient, usually by touching the patient's hands or forearms. The therapist can detect subtle differences of movement, tension or relaxation in the patient's limbs, in response to various questions. This helps the therapist pinpoint the specific cause of the patient's problem. There does not seem to be anything mysterious about these procedures. It seems that the healer picks up subtle hints to the patient's condition. In the case of One Brain Therapy this seems to be quite intentional and systematic. In the case of the pendulum and the winnowing fan, the process seems more subconscious or semi-conscious. In none of these cases is it impossible that a scientific explanation might be discovered. I am quite enthusiastic about non-conventional psychotherapy as a field from which we might learn a lot.
Against this background I was eager to read Professor Omonzejele's paper. I was looking forward to learning more about non-Western psychotherapy. I would have liked to learn more details of African psychotherapy. But I have to admit that I was a little disappointed because, although the author supplies us with a bibliography which should be quite useful, the paper itself is more critical than explanatory. And I am afraid I cannot agree with the criticism.
Omonzejele criticizes the strong role of the family in African psychotherapy. It seems to him to be a violation of the principle of autonomy. But like many other bioethicists today, I am not convinced of the supposed sanctity of autonomy, especially when it comes to the role of the family in medical decision making. Indeed it is strange that autonomy should be touted as such an unquestionably important value more than ten years after Naoko Miyaji's critique of autonomy and Western individualism, as compared with the Japanese emphasis on the family, in terminal care (Miyaji, NT. The power of compassion: truth-telling among American doctors in the care of dying patients. Soc. Sci. Med. Vol. 36, No. 3; 1993)
Naoko pointed out that when decisions are made by the family as a whole the patient is actually much stronger than when considered strictly as an individual. The ideology of autonomy can be, and actually is used to isolate the patient from the family context. This may make it much easier for the physician to influence the patient's decisions. Indeed, we should always remember that a patient is a sick person, perhaps in pain, uncomfortable, drugged, depressed, mentally compromised and in general not in full possession of decision-making facilities. (Cassell EJ, Leon AC, Kaufman SG. Preliminary evidence of impaired thinking in sick patients. Annals of Internal Medicine. 2001;134: 1120-112; Glock RS, Goldim JR. Informed consent in gerontology. EJAIB. 2003;13:6-8). When the family is included in the decision, sometimes even making the decision without consulting the patient or even in contradiction to the patient's expressed desires, this may give the patient more genuine freedom. The reason is that when our decision-making facilities become weak, or when we lose them altogether, others - especially loved ones - may know what we want better than we know ourselves, and may be more critical and perspicacious in discussing and deciding whether to accept the doctor's recommendations.
The ideology of autonomy in Western bioethics is part of the general capitalistic and market-oriented ideology of Western society. Outside and inside the medical context, profit interests want to sell us things, whether they be automobiles, electronic goods, cosmetics, holiday travel, a course of treatment, or pharmaceuticals. They have to convince us that we "need" these things. Sometimes we do really need them, and sometimes we don't. But in either case, autonomy propaganda can make their work easier. Imagine a young person, just out of high school, who has earned or inherited a sum of money. The parents want him or her to save it for university education. But advertising and peer pressure are working on the youth to "be autonomous", "be an individual", "be free", "ignore your parents and spend your money on a fast car, the latest DVD, body piercing, a tattoo, and maybe a good supply of marijuana". Which decision will help this youth be freer in a genuine sense of freedom: the family decision or the "individual" decision which is really mostly formed by social and commercial pressure. Asian, African and other non-Western family life may help a youth be more of a free individual than Western "individualism". Indeed Western individualism may simply sacrifice family influence in favour of the really enslaving influence of profit interests. Similarly, patient autonomy may sacrifice the help which families can give in deciding what the patient really needs, in favour of allowing the physician to influence the patient to make the decision which the physician wants.
But let us return to the subject of psychoanalysis in order to clarify a point in my discussion with Pinit Ratanakul on the question whether the abiding "self" or "ego" is an illusion or may really exist. (See the previous issue of EJAIB.) Let us assume that I have various emotional problems because of a traumatic event which happened to me ten years ago. In order to be clear, I am going to take a very simple example which although perhaps a bit facetious and overly simple, may contribute a little clarity to the discussion. Let us assume that that I have an inexplicable dislike of bioethicists. Every time I meet a bioethicist I become uneasy, quick to anger, and have trouble digesting my food. Finally I go for psychoanalysis. It does not matter for my example whether I go to African, Asian or Western psychoanalysis, or whether I go for One Brain or pendulum-assisted therapy. I might even just have a long, deep talk with my friends. As a result of this process I come to remember that twenty years ago a bioethicist insulted me cruelly and publicly. As time went on I forgot this incident. In fact it was so painful for me that forgetting it was convenient. But the experience did not disappear entirely. It lingered and expressed itself through this pathological hatred of bioethicists. Psychoanalysis, or deep discussion with friends, however, helped me see the root of my problem. I took control of myself, changed my ways, taught myself to smile when I see a bioethicist, to buy bioethicists gifts of good Israeli wine and brandy, even to have a good time at their international conferences. Finally, I am cured.
Now let us consider two "Frank Leavitt's": the unhappy Frank with the pathological hatred of bioethicists and the happy Frank who loves bioethicists. Are these the same person or two different people? Pinit, who believes that there is no continuous self, would say that these are two different people. And there is a lot to be gained in regarding them as two different people. I want to renounce my old self, to free myself of the old, unhappy and hateful Frank, to become another person altogether, a new person, a happy person.
We are debating whether or not Buddhism, as Pinit represents it, is right in claiming that there is no such thing as the same person existing over a period of time. Surely this Buddhist doctrine is a healthy doctrine to believe. Just as it is healthy to achieve humility by letting go of belief in the ego, it may be healthy to achieve calmness and cheerfulness by totally renouncing one's former self, by denying that it even existed. But our question is not whether or not Buddhism is healthy. Our question is whether or not Buddhism is true. And it is hard to understand what goes on in the psychoanalytic process unless we recognize that it is one person who goes through the change. What sense is there in my getting a hold of myself and changing my behaviour unless the old self whom I am trying to renounce is my old self? What sense does it make to say that I have renounced my old self unless my old self is in some sense me? What sense is there in saying that I have been cured unless we allow that I who exist today am the same person but nonetheless an improved person over what I was some time ago? In a sense I am only repeating Aristotle's point that if something goes through a change then there must remain something which changes.
One further point in my debate with Pinit. Pinit refers to "Frank's comment". Since I am Frank, I assume he is referring to my comment which I made in the last issue of EJAIB. But according to the Buddhist doctrine of no-self as Pinit represents it, I who write today did not even exist when the last issue of EJAIB was published. So if Pinit is right then there can be no reason to refer to "Frank's comment".
It is, by the way, amazing how close Asian and Western philosophies are. This entire discussion of whether or not an abiding "self" exists can be found in Hume's Treatise of Human Nature. It actually goes back to the general question of abiding substance in Greek philosophy, in particular Heraclites, and Aristotle's critique of him. I once presented a paper on the international influence of Asian bioethics, in which I proposed an intentionally extremist hypothesis that all that is deep in Western thought actually started in Asia. African origins should also be considered. But it will take much more scholarship than I am capable of to sort out the details.
Go back to EJAIB 14 (5) September 2004
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