A Psychiatric Will self-destructive behavior (which, ex- voke it with any patient, nor, ob-

perience told me, they would live to viously, has it been subjected to any
Alan J. Pollack regret), I decided to develop this con- legal tests. I have not yet offered it to
Permanente Medical Group tract. The majority of my patients other types of patients, although I
Southern California have been quite desirous of giving me plan on keeping the possibility in
I present my version of the "psychi- authority to hospitalize, while a few mind.
atric will." It is a simple contract be- have rejected the idea or have re-
tween my patient and me. I developed mained ambivalent. I generally do not
it about a year ago in response to my offer it until after I have established
frustration in working with the re- some rapport and after the patient has
currently manic patient. Torn be- demonstrated behavior (i.e., during The Psychiatric Will: II.
tween my personal, noncoercive phi- an acute manic episode) that would Whose Will Is It Anyway?
losophy, the state's legal require- warrant a therapeutic move of this
ments, and distress over my patients' kind. To date, I have not had to in- Thomas S. Szasz
State University of New York
Upstate Medical Center, Syracuse
SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP My article on the psychiatric will
6855 DE SOTO STREET WOODLAND HILLS. CALIFORNIA 91367 TELEPHONE (213) 884-3724 (Szasz, July 1982) elicited a large vol-
ume of mail, including a communi-
cation from Paul S. Appelbaum, call-
To whom it may concern: ing my attention his letter to the ed-
itor of The New England Journal of
Dr. Alan Pollack has discussed with me that there may be times when my emotional
condition deteriorates to a point where I am functioning very poorly and because of Medicine in 1979. In that letter, Ap-
this, may jeopardize my job, my health, my relations with family and friends. At such pelbaum (1979) proposed a type of
times, my judgment about the need for intensive medical care, in the form of hospi- psychiatric will, without calling it
talization, can be quite impaired. Despite my serious disability, I may not fully meet that, whose function is the exact op-
the criteria which would legally require Dr. Pollack to hospitalize me involuntarily; posite of the will that I proposed. I
namely, I am neither suicidal, nor homicidal, nor unable to provide for food, clothing was unaware of his communication,
and shelter. Nevertheless, with this document 1 am hereby requesting that Dr. Pollack which deserves comment, and would
place me in a Kaiser designated psychiatric facility on a 72 hour hold if: 1) in his therefore like to offer some brief re-
judgment he believes I am seriously jeopardizing my job, health, and/or relationships marks about it.
because of a relapse in my emotional condition; 2) I am rejecting the offer of voluntary
hospitalization; 3) he has the concurrence of whom I may ask him Appelbaum proposes a living
to confer with. will allowing a person to appoint a
surrogate who, should the person be-
I understand that after 72 hours, I am free to leave the hospital provided that I continue come psychotic, would give consent
to not meet the legal criteria for involuntary hospitalization. Or, I may choose to remain for his or her psychiatric treatment.
voluntarily for continued care. This would permit the psychiatrist to
I hereby release Dr. Alan Pollack from any liability for doing this which I have requested impose involuntary treatment on a
of him. psychotic patient with valid consent,
inasmuch as the patient consented to
I understand that I may withdraw this request at anytime other than during those times
of impaired functioning as described above. it when the patient was not psychotic
and appointed a proxy to implement
consent in his or her "absence." Ap-
(Signature of Witness) (Signature of Patient) pelbaum's version of the psychiatric
will thus expresses the beliefs of a psy-
chiatric protectionist: In case of psy-
(Relationship) (Date) chosis, treat. His communication il-
lustrates how the language of coercive
psychiatry precludes the psychiatrist
I have read the forgoing and choose not to give Dr. Alan Pollack the authority described.
Rather, I hereby release him from any liability for damages that may accrue because from formulating any other policy.
of my impaired mental state which, tho impaired, does not fully meet the legal re- I shall consider the key pieces of
quirement for Dr. Pollack to hospitalize me against my will. Appelbaurn's argument, sentence by
sentence, adding brief comments as
I go along.
(Signature of Witness) (Signature of Patient) 1. "Many psychiatric illnesses induce acute
psychotic episodes, during which the need
for treatment is frequently denied."
(Relationship) (Date)
If psychosis is a disease (of the
mind or brain) that renders the pa-
cc: patient
chart tient irrational and incompetent, then
one would expect it to have a random
AP/bjs effect on decisions concerning illness

344 March 1983 American Psychologist

and treatment; that is, one would ex-
pect half the patients to deny illness
and to refuse treatment and half of
them to affirm illness and to accept
treatment. Appelbaum simply asserts
that psychotics deny the need for
treatment, thus denying the possibil-
ity of a conflict between psychiatrist
and (alleged) psychotic.
2. "These episodes are interspersed among
more lucid intervals. Patients with affec-
tive disorders, such as recurrent depres-
sion, bipolar manic-depressive illness and
schizo-affective illness, as well as patients
with schizophrenia whose chronic course
is punctuated by acute exacerbations, are
likely, if recent trends in the legislature and
in the courts continue, to have the right
to deny themselves the treatment that they
need when they are psychotic, no matter
how greatly their nonpsychotic selves would
desire aid."
Appelbaum here attributes to
the nonpsychotic selves of psychotic
patients a belief in, and desire for,
psychiatric treatment that many
nonpsychotic persons clearly lack.
Presuming objective and universal
validity for his belief in psychiatric
treatment (type unspecified), Appel-
baum actually transforms the protec-
tionist psychiatrist's desire to give
treatment into the uncooperative psy-
chotic patient's desire to get it.
Moreover, Appelbaum attributes
a desire for psychiatric treatment to
the nonpsychotic selves of all psy-
chotic persons (who are not necessar-
ily patients) without exception. But
physicians sometimes make mistakes
in diagnosis. Appelbaum makes no
allowance for this possibility and hence
offers no protection for persons who
might be diagnosed psychotic by mis-
take. He also fails to consider the pos-
sibility that psychiatrists might dis-
agree about the diagnosis, even though
this is a frequent occurrence. In the
case of John W. Hinckley, Jr., for ex-
ample, the defense psychiatrists di-
agnosed Hinckley as severely psy-
chotic, whereas the prosecution psy-
chiatrists diagnosed him as not
psychotic at all.
Finally, by tightly bracketing the
concept of a "nonpsychotic self" with
the decision of a "desire for aid," Ap-
pelbaum locks himself into a self-val-
idating word game. His language pre-
cludes the possibility of a "nonpsy-
chotic self" desiring no aid, illustrating
Sir James Fitzjames Stephen's (1873/
1967) perceptive observation that
March 1983 American Psychologist
"men have an all but incurable pro-
pensity to try to prejudge all the great
issues which interest them by stamp-
ing their prejudices upon their lan-
guage" (p. 176).
3. "The clinician, along with the patient,
is faced with the dilemma posed by a so-
ciety that values the right to exercise im-
paired autonomy over the right to recover
true autonomy."
By creating the paired concepts
of "impaired autonomy" and "true
autonomy" and asserting that we live
in a society that values the former
more highly than the latter, Appel-
baum has escalated his self-validating
rhetoric. Who can be for "impaired
autonomy" .or against "true auton-
omy"? Appelbaum gives a good name
to choosing treatment and a bad
name to rejecting it. In the conflict
between psychiatrist and psychotic,
according to Appelbaum, agreement
with the psychiatrist signifies sup-
porting the patient's "true auton-
omy," and disagreement with the psy-
chiatrist signifies the opposite. Is that
"truth" or a self-serving tautology?
4. "The alternative offered by the living
will, the appointment of a surrogate to give
a proxy consent for treatment when phy-
sicians attest that the patient's psychosis
has recurred, is clearly an attractive one
in this climate. It would permit rational
treatment based on the patient's own ra-
tional wishes."1
Clearly, Appelbaum is not talk-
ing about a real will at all. He is talk-
ing about a mechanism to enable psy-
chiatrists to impose treatment on in-
voluntary mental patients whenever
they, the psychiatrists, consider such
treatment to be indicated. That is how
it used to be in the good old days, and
that is the arrangement Appelbaum
seems to want to restore.
Let us keep in mind here that the
executor of a last will does not make
decisions in lieu of the testator who
can no longer make decisions because
of death. Instead, the executor exe-
cutes the testator's decision when the
latter can no longer do so because he
or she is dead. If Appelbaum were
describing a genuine psychiatric will,
he would have the proxy carrying out
the decisions that the psychotic per-
son has made during a lucid interval.
Instead, Appelbaum repeats his word
game, calling the decisions he ap-
proves "rational," dismissing those he
disapproves as "irrational."
5. "There are legal obstacles to such a
course. Unlike comatose patients, psy-
chotic patients are in a position to chal-
lenge actively their previously expressed
intentions. To maintain the integrity of the
'living will,' the courts will have to set some
limits on the 'right to change one's mind.' "
This problem is the product of
Appelbaum's own perspective. It does
not arise if we take people and their
promises (contracts, wills) seriously.
The nonpsychotic person who antic-
ipates his or her own future psychosis
and requests treatment for itnot-
withstanding the person's own antic-
ipated rejection of it in a future psy-
chotic statemust, of course, be
treated in accordance with the request
(assuming that a psychiatrist is willing
to so treat this person). Such a person
could not change his or her mind after
being declared psychotic, just as the
person who has consented to being
anesthetized for an operation cannot
change his or her mind after being
strapped to the table and having be-
come semiconscious from the anes-
thetic. On the other hand, the nonpsy-
chotic person who, anticipating the
same contingency, rejects treatment
would have to be guaranteed com-
plete security from unwanted psychi-
atric treatment.
6. Appelbaum concludes by urging the
adoption of the living will he proposes as
a way of avoiding having to "surrender to
the patient's desire to be allowed to remain
psychotic . . ."
However, the issue before us is
not the "patient's desire to remain
psychotic" but the right, when
nonpsychotic, to refuse psychiatric
coercion (called "treatment" only if
1
It is interesting to recall in this con-
nection Karl Jaspers's (1913/1964) re-
marks about "rational treatment" for in-
voluntary patients: "Rational treatment is
not really an attainable goal as regards the
large majority of mental patients in the
strict sense. . . . Admission to hospital
often takes place against the will of the
patient and therefore the psychiatrist finds
himself in a different relation to his patient
than other doctors. He tries to make this
difference as negligible as possible by de-
liberately emphasizing his purely medical
approach to the patient, but the latter in
many cases is quite convinced that he is
well and resists these medical efforts" (pp.
839-840).
345
one accepts the psychiatric premises).
Whose will is Appelbaum talking
about? The "patient's," when nonpsy-
chotic? The "patient's," when psy-
chotic? Or the patient's alleged sur-
rogate's, when he or she is carrying
out what is in effect the psychiatrist's
will?
If a competent person makes a
will, it is foolish to ask who has made
the will. Obviously, the individual
has. But Appelbaum does not 'talk
about persons. He talks about psy-
chotic and nonpsychotic selves, im-
paired and unimpaired autonomies.
While acknowledging that a person
subject to what Appelbaum regards
as periodic or recurrent psychoses is
not always or permanently psychotic,
he nevertheless denies such a person
the option of "rationally" rejecting
psychiatric treatment. In his zeal to
correct the psychotic's impairment,
Appelbaum's argument overrides the
logic of his own premises that would
require that he treat a nonpsychotic
person as a nonpsychotic person.
Appelbaum has sought a fresh
legal mechanism for increasing the
psychiatrist's power over the psy-
chotic patient and has proposed a
mechanism consistent with that goal.
I have sought a fresh legal mechanism
for increasing the psychotic patient's
freedom and responsibility and have
proposed a mechanism consistent with
that goal.
Straightening the Record
R. Abbot Hunter
The other day, while meandering
through the stacks of our local Car-
negie Library looking for a copy of
Lester G. Crocker's abridged trans-
lation of Miguel de Cervantes Saa-
vedra's Don Quixote, I ran across
something which has inspired me to
take pen to paper and write of what
may be a written wrong. What I'm
referring to is a dog-eared, paper-cov-
ered, spiral-bound copy of a basic
psychology textbook entitled Elemen-
tary Principles of Behavior, written by
two fellows named Whaley and Mal-
ott. It's very much like the Skinnerian
type of books I remember from years
ago when I was a student at the Uni-
versity of Washington and took Pro-
fessor Donald M. Baer's course in
developmental psychology. The book
346
For those who believe in psychi-
atric illness, psychiatric treatment is
a "good." For those who believe in
individual liberty, personal responsi-
bility is a "good." Unfortunately, the
effort to maximize one of these goods
sometimes conflicts with the effort to
maximize the other. It is dishonest to
pretend that we can solve this di-
lemma. But though we cannot solve
it, we can resolve it, by making a
moral choice and assuming respon-
sibility for its consequences.
The psychiatric will I have pro-
posed resolves the problem of invol-
untary psychiatric treatment by com-
ing to grips with the hidden agenda
behind it, namely, the presumptions
we make about the "initial situation"
of the patient or subject. Do we as-
sume that he or she is sane or insane,
rational or irrational?
In law, a defendant must be pre-
sumed innocent or guilty. In Anglo-
American law the presumption is that
the defendant is innocent (until proved
guilty); in Continental law the pre-
sumption is the opposite. In psychia-
try we are faced with the same sort
of choice: A person must be presumed
sane or insane, rational or irrational,
competent or incompetent. In 19th-
century asylum psychiatry the patient
was presumed insane (until proved
sane); in the modern office practice
of psychotherapy the presumption is
the opposite.
was different from those of my stu-
dent days because it was written in a
humorous and entertaining fashion
with lots of cute phrases and funny
anecdotes and examples. But now I'd
better get on with my story, because
I know how valuable journal space is
and how trees must die in order for
careers and science to progress.
What I want to bring to the at-
tention of the readers of Ihe American
Psychologist and Whaley and Malott
has to do with setting the record
straight about one of the latters' cute
and humorous stories about a profes-
sor who was conditioned by his class,
or more exactly, the students in his
class, using the operant method.
Whaley and Malott's telling must be
about the twentieth time I've heard
the story in as many years. It is high
time that somebody, for the sake of
history and for those who will never
March 1983 American Psychologist
Each of these presumptions car-
ries with it certain advantages for the
individual and certain disadvantages
for society, and vice versa. A free so-
ciety is one in which persons are pre-
sumed to be rational, and defendants,
innocent. However, a society may be
based on the opposite assumptions
and may still be a civilized society.
But when a society operates capri-
ciously and unpredictably, making it
impossible for the individual to know
in advance which of these presump-
tions will govern his or her future
dealings with the state (and with the
psychiatrist acting as an agent of the
state), then that society ceases to be
either free or civilized and deserves to
be called despotic.
REFERENCES
Appelbaum, P. S. Michigan's sensible "liv-
ing will" [Letter to the editor]. New En-
gland Journal of Medicine, 1979, 103,
788.
Jaspers, K. General psychopathology. Chi-
cago: University of Chicago Press, 1963.
(Originally published, 1913.)
Stephen, J. F. Liberty, equality, fraternity.
Cambridge, England: Cambridge Uni-
versity Press, 1967. (Originally pub-
lished, 1873.)
Szasz, T. S. The psychiatric will: A new
mechanism for protecting persons
against "psychosis" and psychiatry.
American Psychologist, 1982, 37, 762-
770.
be likely to experience the thrill of
victory or agony of defeat, should tell
it the way it really may have hap-
pened.
It was 1962 and JFK was presi-
dent. Sid Bijou gave away his whole
pipe collection. William S. Verplanck
was a visiting professor. And physio-
logical-psychology graduate student
Ronald Pool was teaching an intro-
ductory psychology course through
the extension department of the U.
of W. I was at Washington at that time
and through a close acquaintance I
became privy to the events occurring
during those two fateful, historic
nights in that summer of '62.
As he was known then to the stu-
dents of that night class in introduc-
tory psychology, Mr. Pool was a con-
scientious, sensitive, and thoughtful
person, just as he most certainly con-
tinues to be to this day. Now college