A Fragile Truth

My four-week psychiatry rotation at Western State Hospital landed smack in the middle of peak general election season. And, oddly enough, these two experiences have yielded remarkable similarities. In both cases, I have been forced to entertain various versions of the truth.

Many of the patients here at Western State are psychotic. Our known and stated goal, then, is to return these patients to reality-based thinking. Only then might they qualify for discharge. This exercise has presented philosophical challenges. Certainly, sometimes, our job is easy. One of our patients, who signs her forms as Michelle Obama Prince Harry Elizabeth Queen Zealand, communicates with Russia, Germany, Berlin, Jerusalem, East Germany, West Germany, South Germany, and Russia, by radio, television, and satellite, including the satellite in the backyard of her palace, which she built, and in which we currently reside. Another patient, though, gave me pause. “I’m 52 years old,” she said, clearly and thoughtfully, “and I don’t belong here.” She continued, “You lock up people like me, even though I’m raising two kids and finishing my masters degree, which I’m now missing out on, because I’m here. You even lock up children. You diagnose them with ADHD and pump them full of medications. It’s not right. It’s just not right.” She might have a point, I thought. She broke my musings with: “I don’t care if I said my whole family was vampires. Fine, you don’t like the word vampire? Try alien. They’re alien. The aliens are here, too; your staff aren’t real doctors. They have long slender fingers, long fangs, and forked tongues. They lurk in the corners, and make me feel certain ways. And don’t try to tell me you don’t feel it, too!”

The issue wasn’t whether or not her thinking was reality based–it wasn’t. What challenged me was the clarity with which she expressed the belief that she was the sane one, and we were locking her up unfairly. I knew that she believed she was right as strongly as we believed we were. So what made our truth the right truth? Well, somehow, it was. We held her against her will, and medicated her over objection. But what, fundamentally, gave us the right to do so?

In front of the television, I’ve encountered similar feelings of self-doubt. I might hold certain views to be false. But on what grounds? This election has rendered these questions newly-challenging, by shining all-too-bright a floodlight onto beliefs weird and wacky, which, until now, have moldered in the dark shadows of obscurity.

Alex Jones and his ilk, for example, believe that Obama and Hillary are demons which smell of sulfur, and a whole pile of garbage beyond. Many of Trump’s supporters believed that Obama was a Muslim, or still do; that he’s gay; that Michelle Obama could be a man; and that Obama’s children actually belonged to another family before they were kidnapped. Interestingly enough, the woman featured in this particular Washington Post article was, at one point, hospitalized psychiatrically for her beliefs, which included possible homicidal ideation against Obama. “It never crossed my mind that I’m losing it,” she said after her release. Trump himself has called Hillary Clinton “the devil”, and believes she founded ISIS.

Conspiracy theories certainly aren’t new. What’s new is not the theories, but rather, the extent to which they’re approaching the mainstream. Now, we seem to have arrived at contradiction in terms. What do we call a conspiracy theory which comes to be held by the majority?

Nowadays, the truth, it seems, amounts to no more than consensus. Whether in the psych ward or the debate hall, the truth is chosen by popular vote.

Surely, though, we can do better. In fact, we can and do, in that some votes are worth more than others. For example, a single psychiatrist could overrule an entire ward’s wish for discharge. And we give extra credence to the voices of “Harvard researchers,” or “journalists with the New York Times.”

No institution better exemplifies the notion of “weighted votes” than does the scientific peer review process. When a paper is submitted to a journal for publication, the author’s peers review the quality of the work–essentially, they vote on it. However, it’s not that simple, as some scientists are more reputed than others, in that they have histories of publishing valuable results. If several well-reputed scientists attest to the quality of a recent result, it itself is likely to be regarded as valuable. Some journals are better-regarded than others, too, and well-reputed scientists tend to sit on the editorial boards of these journals. The collective reputation of scientists, journals, and institutions fosters a high standard for acceptability. The end result, then, is that a paper published in Lancet is almost certainly valuable, and its proclamations are almost certainly true. “Published in Lancet” achieves a higher standard for truth than “featured on InfoWars,” because the former received weightier votes.

Even this approach to defining truth, though, is easily defeated. Sure, I value the opinion of Lancet. Others, just as easily, do not. Consider the example of Lancet’s 2010 retraction of Dr. Andrew Wakefield’s earth-moving, but deeply problematic, treatise on the link between vaccines and autism. In the years following its publication, it was found that Dr. Wakefield’s research had been funded by lawyers for parents seeking to sue vaccine makers for damages, a relationship which was not initially disclosed; and that Dr. Wakefield had patented a measles vaccine before his research’s publication which would have served as an alternative to the current vaccine were it withdrawn. He had subjected children to unnecessary and unwanted tests without institutional approval. A medical panel declared that Dr. Wakefield had been “dishonest, violated basic research ethics rules and showed a ‘callous disregard’ for the suffering of children involved in his research.”

No institution is perfect, Lancet included. Though its contents might not always be true, the journal tries as hard is it can to ensure that they are. For this reason, it retracted Wakefield’s pile of refuse. However, though Lancet is beholden to the truth, the same may not be said of its detractors. Thus, the journal’s retraction of Wakefield’s paper only served to embolden them. “Attacking scientists and attacking doctors is dangerous,” said Jim Moody, a director of SafeMinds, an anti-vaccine group. “This is about suppressing research, and it will fuel the controversy by bringing it all up again.” Moody went on to say that the retraction would strengthen Dr. Wakefield’s credibility with many parents.

So, here we have it. Retraction from Lancet is an asset to their case, not a blow to it. We find ourselves in a strange world where proof against X, to some groups, isn’t only not proof against X, but, in fact, proof for X. My votes solution achieves no ground, because the value of the votes themselves, along with the facts they arbitrate, are, just the same, up for debate.

Let’s try a different strategy. Can’t we eschew opinion altogether, and rely on the particles of logic alone? Euclid’s Elements, a landmark work in the history of mathematics, has significance which transcends its discipline. Elements is regarded in the philosophy of knowledge for its aim to produce definitions and axioms that are not only mathematically “true”, but, in fact, absolutely, or fundamentally, true. Euclid showed that truth is achievable. And such a notion, Nautilus Magazine writes, has proved alluring in the political sphere, of all places. John Locke, for instance, was heavily influenced by Elements, and sought to produce laws which were “as incontestable as those in mathematics”, the justness of which was “as certain as any demonstration of Euclid.” Across the Atlantic, Thomas Jefferson, influenced by Locke’s philosophy, opened the declaration of independence with, “We hold these truths to be self-evident, that all men are created equal.” A century later, Abraham Lincoln, working as a lawyer in 1850s Chicago, carried Elements in his saddlebag. And he brought Euclid’s axiomatic approach to his politics. “If A can prove, however conclusively, that he may, of right, enslave B,” Lincoln wrote in an 1854 essay, “why may not B snatch the same argument, and prove equally, that he may enslave A?” Slavery was unsupportable, in a proof by contradiction.

Indeed, under Lincoln, the truth was irreproachable. Called a liar by his opponent, Douglas, Lincoln returned, “If you have ever studied geometry, you remember that by a course of reasoning, Euclid proves that all the angles in a triangle are equal to two right angles.” “Now,” he continued, “if you undertake to disprove that proposition, and to show that it is erroneous, would you prove it to be false by calling Euclid a liar?”

I might pose the same question to Alex Jones. Alas, we already know the outcome. Truth itself–even the logical particles of it–are of no avail. Apparently, men like this existed even in Lincoln’s time. “If a man will stand up and assert, and repeat, and re-assert, that two and two do not make four, I know nothing in the power of argument that can stop him.”

Sometimes, convictions are, indeed, held above truth itself. Dostoevsky, famously, had the insight to articulate this very stance. In a letter to a friend, he wrote:

This creed is extremely simple; here it is: I believe that there is nothing lovelier, deeper, more sympathetic, more rational, more manly, and more perfect than the Saviour; I say to myself with jealous love that not only is there no one else like Him, but that there could be no one. I would even say more: If anyone could prove to me that Christ is outside the truth, and if the truth really did exclude Christ, I should prefer to stay with Christ and not with truth.

It’s refreshing to hear such a position articulated; indeed, it’s liberating. Maybe it’s not a question of what’s true, after all, but rather, a question of the importance of truth itself. Perhaps that’s what Trump’s supporters have done all along. They haven’t perverted the truth; rather, they, albeit unknowingly, disregarded it.

If accurate, this realization would put the truth on my side. However, I’d still be left with the task of justifying my right, as a healthcare provider, to detain and medicate patients against their will.

Dostoevsky, in fact, would fare quite well at the psychiatrist’s table. Disregard for the moment, that, ironically, Dostoevsky may well have suffered from a neurological condition that lies somewhere between personality trait and mental illness. Actually, psychiatry makes a well-known exception for those espousing commonly-held-but-not-necessarily-evidenced-based beliefs, including religious ones.

Even the religious exemption, though, gets hairy. We had a patient at Western State who was a Seventh-day Adventist. Roman Catholicism is a Babylonian mystery sex-cult, he explained; the pope is the devil, and his hat indicates the number 666. After the patient left the room, I turned to my attending psychiatrist with incredulity. He shook his head, with a laugh, and then explained that, consequential to his children’s enrollment in a particular school, he had found himself at Seventh-day Adventist church services. “Those beliefs—those are, actually, exactly in line with the Seventh-day Adventist Church’s official teachings.” This patient, apparently, was covered by the religious exemption.

But should he have been? Psychiatrist Joseph Pierre advocates for, in the above-linked Faith or Delusion? At the Crossroads of Religion and Psychosis, the recognition of “the possibility of entire delusional subcultures”. Our Seventh-day Adventist patient may not be free to go after all. Neither, necessarily, are Trump’s supporters.

When does disregard for the truth become pathologic? Ultimately, we fall back to functional status. This particular patient was committed, not because of his beliefs, but because he wasn’t functioning well in society. He was going from hotel to hotel each night, for fear that freemasons were after him, trying to rape him. He had become distanced from his friends, dropped out of school, had several run-ins with the law, and lost his driver’s license and job. It didn’t matter what he believed. It mattered how he behaved.

Here, we leave the issue of the truth behind altogether. It doesn’t matter whether or not you believe in Euclidean axioms. Functionality becomes our one and only standard. This is why Dostoevsky, Geschwind syndrome notwithstanding, is let off the hook.

In a way, the newfound preeminence of functional status should not be surprising. What do we have, after all, to justify beliefs, or to refuse to do so, besides the impact of said beliefs? We find that the end-result of beliefs is indicative of, and perhaps, inseparable from, the truth of these beliefs. Vaccines save lives, and don’t cause brain disease. Dostoevsky was a brilliant writer. Truth may be elusive, but outcomes are less so. Outcomes are concrete. They are difficult to dispute.

If we’ve discovered anything from this discussion, it’s that the line between religious and hyperreligious, or between opinionated and delusional, is blurry. It’s difficult to parse normal from abnormal behavior a priori. Indeed, acute mania is probably just an extension of normal behavior. It’s easy to see the evolutionary advantage of grandiosity, religiosity, goal-directed behavior, and a tendency to make connections between otherwise separate spheres (which might manifest as delusionality). The question of the truth-hood of such behaviors, then, becomes rather incoherent. Instead, we’re just left with behaviors which improve functionality, and those which don’t. Indeed, at the psychiatrist’s table, this measure is the closest to truth there is.