NAÏVE DUALISM AS A FORM OF MADNESS IN HEALTH POLICY AND SERVICES

It is not enough to have a good mind; the main thing is to use it well.

Rene Descartes, Le Discours de la Methode, 1637

Those readers with even a bare smattering of Western philosophy will know of the dominant theory in the philosophy of mind from the mid-17^th to at least the mid-19^th century – interactional, or Cartesian, dualism.

‘Cartesian’ because, famously, the idea was brought to its intellectual apogee and propagated by the French rationalist philosopher and mathematician, Rene Descartes, whose main works, Meditations on First Philosophy and Discourse on the Method, first appeared in the short period between 1637 and 1644.

Dualism in the philosophy of mind is the hypothesis that mental phenomena are, in some or all respects, non-physical, or that the mind and body are not identical. The idea is that the body works like a machine; that is, it has only material or physical properties. The mind, on the other hand, is nonmaterial and is not subject to the laws of nature.

The key idea in interactional dualism is that, the above notwithstanding, mental states such as beliefs and desires causally interact with physical states; a view that appeals to our common sense or folk-psychological view of ourselves and our conscious experiences.

Descartes, in a speculative leap that today looks foolhardy at best, argued that the mind interacts with the body at the pineal gland; which, many readers will know, actually produces the serotonin derivative melatonin, a hormone that affects the modulation of sleep patterns and seasonal functioning.

Astute and interested readers, even if untrained in analytic philosophy, will I trust also have detected a wider and more fundamental problem with the interactional hypothesis. Indeed it is so well known and commonly taught to first year philosophy students that it has a name – the Link Problem in interactional dualism.

The Link Problem emerges directly from the Cartesian view of the body and the mind – the former is physical, extended, divisible and unconscious; the latter is spiritual, unextended, indivisible and conscious. The problem is this: how could two such fundamentally different sorts of things – one subject to physical laws, the other not – causally act on each other?

Moreover, for Descartes, while minds have no general physical properties, they are located in space and time. But how does this spooky non-physical entity, the mind, get tugged around by and causally interact with the rest of us, the body, to which it is notionally linked?

In the mid-20^th century the Oxford philosopher, Gilbert Ryle, dubbed Cartesian dualism the dogma of the ghost in the machine, wherein ‘the body and the mind are ordinarily harnessed together, but after the death of the body the mind may continue to exist and function’. Ryle’s purpose was to highlight the absurdity of dualist systems like Descartes', in which the means of interaction are without explanation.

As Ryle argued, it is a doctrine false not in detail but in principle. Mind and body are not separate things to be linked. To believe them to be so is not just a factual error; it entails what philosophers call a category mistake. Mental activity is not linkable with physical states – it is (something like) a function of (some) physical states; thus, if there is no physical stuff (eg a brain), then there is no mental activity.

In this light, to maintain a commitment to interactional dualism would be like asserting that cars can be linked to motoring. It may be cute as a metaphor, but as a scientific grounding for the study of transport, it manages to be both pointless and misleading.

Whatever one’s religious or metaphysical views might otherwise be, naïve dualism is not a candidate for the deeper understanding of our mental and physical states. And so, a fortiori, it should not feature in the grounding of health services for Homo sapiens in the 21^st century, any more than do voodoo or occult medical practices languishing from a pre-scientific culture. But alas it does.

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Mental Disorders and Physical Health: Linking body and mind

TheMHS Summer Forum, UTS Sydney, 21-22 February 2013

While it is not likely, as far as I know, that the imminent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), will list as evidence of a disorder the belief in interactional dualism, reliance upon it in dividing the mental health world from the physical health world is in my view a form of social or institutional madness. Why so?

It is instructive to consider a scenario put to the above forum by a psychiatrist with an interest in physical health, Dr Jackie Curtis: we can call the scenario, the emergency response to the torso and the head. Imagine two teams of emergency clinicians on the pavement outside your local ED, one team dealing with the torso of a patient, the other a few metres away, examining the head.

It’s a silly scenario, of course – and it’s meant to be. It’s meant to throw into relief the folly of dealing with mental health problems in isolation from physical health problems. And as far as it goes it highlights the point fairly effectively. The problem is, it doesn’t go nearly far enough. The division of mental health from physical health is starkly more absurd than that.

How come? Well, for two reasons: the detached head is still the locus of ophthalmology, ENT, head and neck, maxillofacial and neurological surgery, et alia. And mental health, if it is to be represented as separate even from neurology, needs to have a third team in the scenario; one attending, if Cartesian dualism were right, an entirely mysterious entity ‘hovering’ who knows where.

Ryle’s attack was against not just philosophers – he targeted the views then prevalent among a wide range of theorists, including psychologists and religious teachers. And, as whacky as some even relatively recent (ie 20^th century) psychiatric theories have been, naïve dualism still conveniently dwells in customary thinking not only in mental health but also in the wider health field.

For reasons that Dr Curtis and fellow speakers in the Summer Forum on Mental Disorders and Physical Health otherwise amply demonstrated, this matters for consumers of health services. If we are to treat people as whole individuals, whose mental and physical life is one, we need to integrate health services. But resistance to this change remains ingrained on all sides of the various clinical fences, and the naïve belief in dualism helps entrench it.

Part of the reason for this is of course the prominent role that religious institutions had and to an extent still have in the provision of health services. And many practitioners in health care, their scientific education notwithstanding, retain a degree of personal if not professional religious affiliation. Some, I dare say, privately even believe in such things as the immortality of the soul.

Mostly in their working lives they keep these quaint ideas in check; separate from their roles and opinions as health professionals. But occasionally these notions leak out.

These philosophical poltergeists are especially prone to emerge from their closets in debates about the roles and relationships of various parts of those complex social entities we call health services; and can do so even inadvertently, as would appear in the title of the forum, Linking body and mind.

Why do I say these views are mad, rather than just wrong? Because, as I trust DSM-5 would have it, the beliefs are not in accord with reality and have a propensity to cause harm to self or others. But what’s the harm? It is the deleterious impact on the structure, relationships and effectiveness of health services, and therefore on the optimisation of health outcomes for whole human beings.

Within the Australian health system, there are some notable and forward-thinking exceptions, such as the Brain and Mind Research Institute at the University of Sydney. But even its thinking is a fair way, I suggest, from seeping through the core of health services policy and practice. Despite 20 years or more of mainstreaming in mental health, almost all health services, and a great deal of health policy, still turn on dualist notions of the incommensurability of mental and physical health.

I implied in the title of this piece that only naïve dualism is a form of madness. But there I was being excessively generous. Without glossing over the last 60 years of the philosophy of mind too lightly, it can be rightly said that the only competing views with any prospect of success have been some take or other on physico-functionalist accounts.

And the advances in the neurosciences generally over the same period have simply served to strengthen the case for non-dualist accounts of the mind*. Thus, any form of dualism that permeates health policy and practice in the 21^st century is in reality mad.

We’ve largely moved on from the beliefs about medical and health sciences of the 17^th, or even the 18^th or 19^th, century. We need to do the same with the philosophical views of human nature that underpin health and medical policy and practice. So let’s get motoring.

Dr Enrico Brik

March 2013

* The only notable remnant of dualism in analytic philosophy in the late 20^th century, New Epiphenomenalism (itself a more sophisticated re-articulation of 19^th century Epiphenomenalism), is rightly seen by most in analytic philosophy as dualism’s last gasp.