A Way Forward? Or, Libertarianism Is Not Equal to Indifference

In his powerful commentary, Allen Frances suggests that there may be a stalemate between libertarians and people who work with those who suffer from mental illnesses. He shows the reality of people with these diseases, and it calls out for a response. I am not a libertarian philosopher, but I’d like to explore why a stalemate exists and make some modest suggestions for how a way forward could be compatible with libertarian philosophy and with the best interests of people who suffer from mental illnesses.

At its best, libertarian theory aims to exalt the human personality by granting its greatest scope for freedom. It aims to accomplish this through a particular vision of individualism that rests on freedom from subordination to a collective. Ayn Rand, writing during the rise of fascist and totalitarian states, witnessed the oppression of the coercive collective, of policies that brutally subordinated individuals and entire populations. In Rand’s philosophical response, people would never be cogs in a collective machine because they would never submit to an enterprise designed to further some putative greater good.

Whether all communities are necessarily more coercive than empowering or whether this kind of individualism is practicable remain open for debate amongst thoughtful people. But libertarians and non-libertarians alike can agree that libertarianism is intended to be a theory of respect for individual autonomy, necessarily including cases where individuals use their autonomy badly.

Libertarian theory gets entangled with issues of mental illness—and makes the mentally ill a kind of prop in this political discourse—in the following way: If one credits that people with mental illnesses are expressing disease symptoms, not authentic individual choice, that appears to crack the strong-form libertarian argument that all individual choice must be respected. For if we should not respect the choices of mentally ill Person A, then perhaps we also should not respect the choices of Person B, who is not clinically mentally ill but isn’t quite mainstream either. It is hard to draw a bright line dividing mental illness from non-disease-based mental and social difference; thus, crediting that the mentally ill need help appears to lead to a slippery slope. This only appears to be a slippery slope, however, because increasingly rigorous definitions of disease will continue to separate those who are socially deviant from those who are medically ill and, within that, to determine degrees of affliction.

Libertarian theory and denials of the reality of mental illness go hand-in-hand because of the fear of this likely illusory slippery slope. If there is no such thing as mental illness, and if “mental illness” is just a term for bad behavior, then—poof!—the problem of constructing a responsible libertarian approach to such people goes away. It defines away the problem.

Defining away the problem is certainly easier than constructing an answer to it, but it’s a dodge, a rhetorical feint that avoids the hard philosophical and practical questions of what a libertarian response should be to people whose mind/brain are compromised. Defining away the problem allows indifference to suffering to wear the mantle of respect for autonomy. Imagine the following: You’re out hiking one day and you find a person who is trapped under a boulder. He is pretty far gone and can’t communicate with you. You have two choices: You could remove the boulder, freeing him. Or you could shrug and say, “Hey, he must have chosen to be under that rock. That’s not my problem.” Is the latter choice really libertarian? Or is it window dressing for indifference, the easier path dressed up as philosophy?

If we don’t define away the problem, then the real challenge for libertarianism appears. The hard question arises if the behavior of severely mentally ill people is itself the product of coercion—the coercion perpetrated upon them by a physical impairment, like a boulder fallen upon an unwitting traveler. If these people labor under the coercion of an illness, then the liberty-promoting path is to help them be freed of the illness, to lift the boulder.

There are many potentially liberatory and libertarian (or at least libertarian-compatible) ways of approaching this problem. Serious mental illness may be the nail, but we have a lot more in our toolkit than the hammer of coerced treatment (a hammer, I hasten to add, that does have its place in extreme situations but that is not a general-use tool). I will not hold myself out as a libertarian philosopher, but I can suggest a few approaches, for what they’re worth:

  • Let’s make treatment more accessible so that mentally ill people who present themselves at hospitals asking for help aren’t turned away
  • Let’s work together to integrate inpatient and outpatient treatment, so that ill people who get out of hospitals don’t need a PhD and a team of administrative assistants to figure out how to continue their care at home
  • Let’s train our first responders how to deal with mentally ill people so that they don’t over-arrest them due to miscommunications
  • Let’s design prison-release protocols that match up released offenders with voluntary services outside of prison, so that they don’t wind up back in prison in a matter of days or weeks
  • Let’s treat people with mental illnesses with dignity and with a desire that they may maximize their human potential, as we do with people with intellectual and physical disabilities and as we ought with all people.

There are many other potential approaches that are liberty-promoting (and quite possibly cost-saving). I would appreciate hearing other ways forward from the erudite and accomplished participants in this debate. Libertarian theory is not, or is not supposed to be, a cover for indifference to other human beings. And indifference—“Hey, it’s their choice. Not my problem”—is not a political theory. The harder but more worthy endeavor is to figure out a set of libertarian responses that engage with the realities of the mentally ill.

Also from This Issue

Lead Essay

  • Strategies of Psychiatric Coercion by Jeffrey A. Schaler

    Professor Schaler notes that mental illness differs in several important ways from physical illness, and these ways make a mockery of conventional diagnosis. Nonetheless mental illness plays an important role in our legal system; it permits psychiatrists to exercise a significant degree of coercion. Schaler challenges this arrangement and argues that those whom we may classify as mentally ill are still deserving of their liberties, including the liberty to refuse treatment. Schaler also questions whether “insanity” is an appropriate legal fiction at all.

Response Essays

  • A Clinical Reality Check by Allen Frances

    Professor Frances agrees that mental disorders are not diseases properly speaking, but he maintains that they are nonetheless useful analytic constructs. As to coercive psychiatric treatment, he argues it can indeed be a horrific abuse. Still, in some especially desperate cases it will be necessary to save lives and to prevent even greater harms. He recommends several practices designed to minimize the frequency and risks of coercive treatments.

  • Psychiatrists Create Their Own Reality by Jacob Sullum

    Jacob Sullum asks the mental health establishment for consistency: If mental disorders are not diseases, what justifies involuntary treatment? Evidence of criminal conduct is a matter for law enforcement, not mental health. And how is it that we punish sexual predators (on the theory that they are responsible) — then treat them afterward (on the theory that they aren’t)? Psychiatric diagnoses are ultimately arbitrary, Sullum argues, and they lead to the arbitrary exercise of power.

  • Calling Mental Illness “Myth” Leads to State Coercion by Amanda Pustilnik

    Amanda Pustilnik argues that the most profound violations of liberty in this area don’t come from coercive psychiatry, but from the warehousing of the mentally ill in our criminal justice system. Such people aren’t more likely to commit crimes, but they fare badly in the criminal justice system, where unusual behavior leads to convictions, longer sentences, parole violations, and reincarceration.

The Conversation