by Bandy X. Lee
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This work is dedicated to my grandfather, Dr. Geun-Young Lee, who believed medical practice always involves social responsibility, and to my mother, Dr. Inmyung Lee, who continued the tradition.
FOREWORD
Our Witness to Malignant Normality
ROBERT JAY LIFTON, M.D.
Our situation as American psychological professionals can be summed up in just two ideas—we can call them themes or even concepts: first, what I call malignant normality, which has to do with the social actuality with which we are presented as normal, all-encompassing, and unalterable; and second, our potential and crucial sense of ourselves as witnessing professionals.
Concerning malignant normality, we start with an assumption that all societies, at various levels of consciousness, put forward ways of viewing, thinking, and behaving that are considered desirable or “normal.” Yet, these criteria for normality can be much affected by the political and military currents of a particular era. Such requirements may be fairly benign, but they can also be destructive to the point of evil.
I came to the idea of malignant normality in my study of Nazi doctors. Those assigned to Auschwitz, when taking charge of the selections and the overall killing process, were simply doing what was expected of them. True, some were upset, even horrified, at being given this task. Yet, with a certain amount of counseling—one can call it perverse psychotherapy—offered by more experienced hands, a process that included drinking heavily together and giving assurance of help and support, the great majority could overcome their anxiety sufficiently to carry through their murderous assignment. This was a process of adaptation to evil that is all too possible to initiate in such a situation. Above all, there was a normalization of evil that enhanced this adaptation and served to present participating doctors with the Auschwitz institution as the existing world to which one must make one’s adjustments.
There is another form of malignant normality, closer to home and more recent. I have in mind the participation in torture by physicians (including psychiatrists), and by psychologists, and other medical and psychological personnel. This reached its most extreme manifestation when two psychologists were revealed to be among architects of the CIA’s torture protocol. More than that, this malignant normality was essentially supported by the American Psychological Association in its defense of the participation of psychologists in the so-called “enhanced interrogation” techniques that spilled over into torture.
I am not equating this American behavior with the Nazi example but, rather, suggesting that malignant normality can take different forms. And nothing does more to sustain malignant normality than its support from a large organization of professionals.
There is still another kind of malignant normality, one brought about by President Trump and his administration. Judith Herman and I, in a letter to the New York Times in March 2017, stressed Trump’s dangerous individual psychological patterns: his creation of his own reality and his inability to manage the inevitable crises that face an American president. He has also, in various ways, violated our American institutional requirements and threatened the viability of American democracy. Yet, because he is president and operates within the broad contours and interactions of the presidency, there is a tendency to view what he does as simply part of our democratic process—that is, as politically and even ethically normal. In this way, a dangerous president becomes normalized, and malignant normality comes to dominate our governing (or, one could say, our antigoverning) dynamic.
But that does not mean we are helpless. We remain a society with considerable openness, with institutions that can still be life-enhancing and serve truth. Unlike Nazi doctors, articulate psychological professionals could and did expose the behavior of corrupt colleagues and even a corrupt professional society. Investigative journalists and human rights groups also greatly contributed to that exposure.
As psychological professionals, we are capable of parallel action in confronting the malignant normality of Trump and his administration. To do so we need to combine our sense of outrage with a disciplined use of our professional knowledge and experience.
This brings me to my second theme: that of witnessing professionals, particularly activist witnessing professionals. Most professionals, most of the time, operate within the norms (that is, the criteria for normality) of their particular society. Indeed, professionals often go further, and in their practices may deepen the commitment of people they work with to that normality. This can give solace, but it has its perils.
It is not generally known that during the early Cold War period, a special governmental commission, chaired by a psychiatrist and containing physicians and social scientists, was set up to help the American people achieve the desired psychological capacity to support U.S. stockpiling of nuclear weapons, cope with an anticipated nuclear attack, and overcome the fear of nuclear annihilation. The commission had the task, in short, of helping Americans accept malignant nuclear normality. There have also been parallel examples in recent history of professionals who have promoted equally dangerous forms of normality in rejecting climate change.
But professionals don’t have to serve these forms of malignant normality. We are capable of using our knowledge and technical skills to expose such normality, to bear witness to its malignance—to become witnessing professionals.
When I did my study of Hiroshima survivors back in 1962, I sought to uncover, in the most accurate and scientific way I could, the psychological and bodily experience of people exposed to the atomic bomb. Yet, I was not just a neutral observer. Over time, I came to understand myself as a witnessing professional, committed to making known what an atomic bomb could do to a city, to tell the world something of what had happened in Hiroshima and to its inhabitants. The Hiroshima story could be condensed to “one plane, one bomb, one city.” I came to view this commitment to telling Hiroshima’s story as a form of advocacy research. That meant combining a disciplined professional approach with the ethical requirements of committed witness, combining scholarship with activism.
I believe that some such approach is what we require now, in the Trump era. We need to avoid uncritical acceptance of this new version of malignant normality and, instead, bring our knowledge and experience to exposing it for what it is. This requires us to be disciplined about what we believe we know, while refraining from holding forth on what we do not know. It also requires us to recognize the urgency of the situation in which the most powerful man in the world is also the bearer of profound instability and untruth. As psychological professionals, we act with ethical passion in our efforts to reveal what is most dangerous and what, in contrast, might be life-affirming in the face of the malignant normality that surrounds us.
Finally, there is the issue of our ethical behavior. We talk a lot about our professional ethics having to do with our responsibility to patients an
d to the overall standards of our discipline. This concern with professional ethics matters a great deal.
But I am suggesting something more, a larger concept of professional ethics that we don’t often discuss: including who we work for and with, and how our work either affirms or questions the directions of the larger society. And, in our present situation, how we deal with the malignant normality that faces us. This larger ethical model applies to members of other professions who may have their own “duty to warn.”
I in no way minimize the significance of professional knowledge and technical skill. But our professions can become overly technicized, and we can be too much like hired guns bringing our firepower to any sponsor of the most egregious view of normality.
We can do better than that. We can take the larger ethical view of the activist witnessing professional. Bandy Lee took that perspective when organizing the Yale conference on professional responsibility,1 and the participants affirmed it. This does not make us saviors of our threatened society, but it does help us bring our experience and knowledge to bear on what threatens us and what might renew us.
A line from the American poet Theodore Roethke brings eloquence to what I have been trying to say: “In a dark time, the eye begins to see.”
Robert Jay Lifton, M.D., is Lecturer in Psychiatry at Columbia University and Distinguished Professor Emeritus of John Jay College and the Graduate Center of the City University of New York. A leading psychohistorian, he is renowned for his studies of the doctors who aided Nazi war crimes and from his work with survivors of the atomic bombing of Hiroshima. He was an outspoken critic of the American Psychological Association’s aiding of government-sanctioned torture and is a vocal opponent of nuclear weapons. His research encompasses the psychological causes and effects of war and political violence and the theory of thought reform.
PROLOGUE
Professions and Politics
JUDITH LEWIS HERMAN, M.D., AND BANDY X. LEE, M.D., M.DIV.
Professions can create forms of ethical conversation that are impossible between a lonely individual and a distant government. If members of professions think of themselves as groups … with norms and rules that oblige them at all times, then they can gain … confidence, and indeed a certain kind of power.
Timothy Snyder, On Tyranny: Twenty Lessons from the Twentieth Century (2017)
Soon after the presidential election of 2016, alarmed by the apparent mental instability of the president-elect, we both separately circulated letters among some of our professional colleagues, expressing our concern. Most of them declined to sign. A number of people admitted they were afraid of some undefined form of governmental retaliation, so quickly had a climate of fear taken hold. They asked us if we were not wary of being “targeted,” and advised us to seek legal counsel. This was a lesson to us in how a climate of fear can induce people to censor themselves.
Others who declined to sign our letters of concern cited matters of principle. Psychiatry, we were warned, should stay out of politics; otherwise, the profession could end up being ethically compromised. The example most frequently cited was that of psychiatrists in the Soviet Union who collaborated with the secret police to diagnose dissidents as mentally ill and confine them to prisons that fronted as hospitals (Medvedev and Medvedev 1971).
This was a serious consideration. Indeed, we need not look beyond our own borders for examples of ethics violations committed by professionals who became entangled in politics. We have recently witnessed the disgrace of an entire professional organization, the American Psychological Association, some of whose leadership, in cooperation with officials from the U.S. military, the CIA, and the Bush White House, rewrote its ethical guidelines to give legal cover to a secret government program of coercive interrogation and to excuse military psychologists who designed and implemented methods of torture (Hoffman et al. 2015; Risen 2014).1
Among the many lessons that might be learned from this notorious example, one in particular stayed with us. It seemed clear that the government officials responsible for abusive treatment of prisoners went to some lengths to find medical and mental health professionals who would publicly condone their practices. We reasoned that if professional endorsement serves as important cover for human rights abuses, then professional condemnation must also carry weight.
In 2005 the Pentagon organized a trip to the Guantánamo Bay detention camp for a group of prominent ethicists, psychiatrists, and psychologists. Participants toured the facility and met with high-ranking military officers, including the commanding general. They were not allowed to meet or speak with any of the detainees.
Dr. Steven Sharfstein, then the president of the American Psychiatric Association, was one of the invited guests on this trip. Apparently, what he saw and heard failed to convince him that the treatment of detainees fell within the bounds of ethical conduct. “Our position is very direct,” he stated on return. “Psychiatrists should not participate on these [interrogation] teams because it is inappropriate” (Lewis 2005). Under Dr. Sharfstein’s leadership, the American Psychiatric Association took a strong stand against any form of participation in torture and in the “interrogation of persons held in custody by military or civilian investigative or law enforcement authorities, whether in the United States or elsewhere” (American Psychiatric Association 2006).
Contrast this principled stand with the sorry tale of the American Psychological Association. Its involvement in the torture scandal illustrates how important it is for leaders in the professions to stand firm against ethical violations, and to resist succumbing to the argument that exceptional political circumstances, such as “the war on terror,” demand exceptions to basic ethical codes. When there is pressure from power is exactly when one must abide by the norms and rules of our ethics.2
Norms and Rules in the Political Sphere
Norms and rules guide professional conduct, set standards, and point to the essential principles of practice. For these reasons, physicians have the Declaration of Geneva (World Medical Association 2006) and the American Medical Association Principles of Medical Ethics (2001), which guide the American Psychiatric Association’s code for psychiatry (American Psychiatric Association 2013). The former confirms the physician’s dedication to the humanitarian goals of medicine, while the latter defines honorable behavior for the physician. Paramount in both is the health, safety, and survival of the patient.
Psychiatrists’ codes of ethics derive directly from these principles. In ordinary practice, the patient’s right to confidentiality is the bedrock of mental health care dating back to the ethical standards of the Hippocratic Oath. However, even this sacrosanct rule is not absolute. No doubt, the physician’s responsibility is first and foremost to the patient, but it extends “as well as to society” (American Psychiatric Association 2013, p. 2). It is part of professional expectation that the psychiatrist assess the possibility that the patient may harm himself or others. When the patient poses a danger, psychiatrists are not merely allowed but mandated to report, to incapacitate, and to take steps to protect.
If we are mindful of the dangers of politicizing the professions, then certainly we must heed the so-called “Goldwater rule,” or Section 7.3 of the APA code of ethics (American Psychiatric Association 2013, p. 6), which states: “it is unethical for a psychiatrist to offer a professional opinion [on a public figure] unless he or she has conducted an examination and has been granted proper authorization for such a statement.” This is not divergent from ordinary norms of practice: the clinical approaches that we use to evaluate patients require a full examination. Formulating a credible diagnosis will always be limited when applied to public figures observed outside this intimate frame; in fact, we would go so far as to assert that it is impossible.
The Goldwater rule highlights the boundaries of practice, helps to preserve professional integrity, and protects public figures from defamation. It safeguards the public’s perception of the field of psychiatry as credible and trustworthy. It is re
asonable to follow it. But even this respectable rule must be balanced against the other rules and principles of professional practice. A careful ethical evaluation might ask: Do our ordinary norms of practice stop at the office of president? If so, why? If the ethics of our practice stipulate that the health of our patient and the safety of the public be paramount, then we should not leave our norms at the door when entering the political sphere. Otherwise, a rule originally conceived to protect our profession from scandal might itself become a source of scandal. For this very reason, the “reaffirmation” of the Goldwater rule in a separate statement by the American Psychiatric Association (2017) barely two months into the new administration seems questionable to us. The American Psychiatric Association is not immune to the kind of politically pressured acquiescence we have seen with its psychological counterpart.
A psychiatrist who disregards the basic procedures of diagnosis and treatment and acts without discretion deserves reprimand. However, the public trust is also violated if the profession fails in its duty to alert the public when a person who holds the power of life and death over us all shows signs of clear, dangerous mental impairment. We should pause if professionals are asked to remain silent when they have seen enough evidence to sound an alarm in every other situation. When it comes to dangerousness, should not the president of a democracy, as First Citizen, be subject to the same standards of practice as the rest of the citizenry?
Assessing dangerousness is different from making a diagnosis: it is dependent on the situation, not the person. Signs of likely dangerousness due to mental disorder can become apparent without a full diagnostic interview and can be detected from a distance, and one is expected to err, if at all, on the side of safety when the risk of inaction is too great. States vary in their instructions. New York, for example, requires that two qualifying professionals agree in order to detain a person who may be in danger of hurting himself or others. Florida and the District of Columbia require only one professional’s opinion. Also, only one person need be in danger of harm by the individual, and the threshold is even lower if the individual has access to weapons (not to mention nuclear weapons).