A Modern Socratic Dialogue on Psychiatric and Medical Research

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Socrates: Congratulations, Phaedrus, on your recent graduation.
Phaedrus: Please don’t mention it, Socrates.
Socrates: Now that you are a physician, what are you going to do?
Phaedrus: I am applying for a research post.
Socrates: In what specialty?
Phaedrus: Psychiatry, the healing of the soul—of course! I have my job interview tomorrow. Will you help me prepare for it?
Socrates: Very well, my good friend. I shall interview you as though I were an eminent professor of psychiatry. Are you ready?
Phaedrus: I am!

Socrates: Our university has a large and highly rated department of psychiatry. How many people do you think it employs?
Phaedrus: You mean the research department and not the hospital?
Socrates: Yes, just the research department. Forget about the clinical services.
Phaedrus: I’d guess about 50.
Socrates: Are you counting just principal investigators? Or are you also including senior researchers, junior researchers, course organizers, personal assistants, receptionists, cleaners, and so on?
Phaedrus: OK, well maybe about 200 then.

Socrates: Let’s go with 200. What’s their average annual salary?
Phaedrus: Before or after tax?
Socrates: Before tax.
Phaedrus: Well, I suppose an eminent professor could make perhaps $500,000 per year…
Socrates: Don’t include payments from pharmaceutical companies.
Phaedrus: Then maybe $250,000. At the other extreme, some staff may be paid no more than $20,000. So maybe, what, $50,000 on average?
Socrates: Yes, that sounds reasonable. Let’s stick with that. So, in total, how much is spent on salaries every year?
Phaedrus: 200 staff multiplied by an average salary of $50,000. Give me just a moment… $10,000,000.

Socrates: $10,000,000, just on salaries. How much do you suppose is spent on the actual research? More or less?
Phaedrus: I would assume that most of the money in a typical research grant is spent on research rather than on salaries.
Socrates: How much more do you think?
Phaedrus: Maybe twice as much.
Socrates: So twice $10,000,000, or $20,000,000, on research projects. Do you agree?
Phaedrus: Yes, that seems fair.
Socrates: So how much is spent in total, on both salaries and research projects?
Phaedrus: $10,000,000 plus $20,000,000: $30,000,000.

Socrates: So, according to you, our department spends $30,000,000 a year. Assuming that our budget has remained constant over the years, how much have we spent since 1960?
Phaedrus: Do you mean in today’s dollars.
Socrates: Yes.
Phaedrus: Well, 53 years multiplied by $30,000,000, which is, what, about $1,600,000,000?
Socrates: Yes, $1.59 billion to be exact.
Phaedrus: Amazing.

Socrates: Right. Now tell me: what was our most significant discovery in these past fifty-three years?
Phaedrus: Let me think.
Socrates: Or any one of our more significant discoveries.
Phaedrus: I’m ashamed to say that I cannot name any.
Socrates: Why are you applying for a position in our department when you cannot even name any of our breakthroughs?
Phaedrus: I wish I could!
Socrates: Fret not, it’s not your fault.
Phaedrus: How do you mean?
Socrates: I mean, there have been no breakthroughs to speak of.
Phaedrus: Oh dear!

Socrates: If, since 1960, we have spent $1.6 billion in one single psychiatry research department, how much do you think we have spent in every psychiatry research department in the country?
Phaedrus: It must be several times that, maybe $50 billion.
Socrates: Yes, or more than that. And how much have we spent in every psychiatry research department in the world?
Phaedrus: Several hundred billion, no doubt.
Socrates: Does that include the research budgets of pharmaceutical companies?
Phaedrus: No, not at all.

Socrates: Now, can you name me one important breakthrough in psychiatry since 1960?
Phaedrus: SSRI antidepressants.
Socrates: Many intelligent people, including within psychiatry, argue that SSRIs are no more effective than a placebo.
Phaedrus: Yes, and they seem to have the figures to prove it.
Socrates: What’s more, SSRIs have disturbing side effects, whereas placebos do not.
Phaedrus: What about second-generation antipsychotics? They have fewer disturbing side effects than first-generation antipsychotics. Surely they must count as an important breakthrough.
Socrates: Some people argue that the only difference between the one and the other is that second-generation antipsychotics are administered at considerably lower doses—which explains why they have fewer disturbing side effects.
Phaedrus: Yes, and, in any case, they remain very dirty drugs. I heard someone argue that they only work because they knock you out.

Socrates: Phaedrus, are you saying that, despite having spent hundreds of billions on research, there has not been a single breakthrough in psychiatry in these past fifty or sixty years?
Phaedrus: You have given me no choice but to say it.
Socrates: And yet, you wish to pursue a career in psychiatric research. Perhaps you fancy that you, of all people, will be the one to make the breakthrough?
Phaedrus: In the cold light of what has just been said, my chances do indeed seem very slim. But perhaps medical science is more about making small steps than giant leaps.
Socrates: Small steps forwards or small steps backwards?
Phaedrus: How do you mean!

Socrates: When do researchers make small steps backwards rather than small steps forwards?
Phaedrus: When they publish research that misleads. There is a saying, is there not, that to do the wrong thing is worse than to do nothing at all.
Socrates: Do they put out misleading research because they are lacking in intelligence?
Phaedrus: No, it’s more that they are under a silent pressure to publish.
Socrates: In what way?
Phaedrus: Researchers need to publish results to appear successful and advance their careers, and, more subtly, to justify themselves to themselves. Positive results are more likely to be published than negative results, and so there may be a tendency, however subconscious, to arrive at results that are slightly positive.
Socrates: If only positive results are ever published, then negative results are hidden from view, deceiving us into thinking that a particular phenomenon is present when it is not, or that a particular treatment or intervention is effective when it is not.
Phaedrus: And that gives rise to false theories, false constructs, and false paradigms: blind alleys in which other researchers lose themselves.
Socrates: Not just other researchers, Phaedrus, but also physicians, science writers, journalists, and so on.
Phaedrus: Not to forget the patients themselves.

Socrates: That’s absolutely right. How else might we be misled?
Phaedrus: Commercial interests.
Socrates: How do you mean?
Phaedrus: Well, for example, there are pharmaceutical companies that have been known to selectively publish research with positive findings, while spinning, doctoring, or suppressing any research with negative findings. This creates the impression that their products are more effective than they are.
Socrates: Or that their products are effective when they are not.
Phaedrus: Yes, it misleads the research community, who create or adjust explanatory models to fit the “findings”.
Socrates: Which creates even more confusion.
Phaedrus: On top of all this, pharmaceutical companies spend large sums of money promoting their products to physicians and end consumers.
Socrates: How do they promote their products to physicians?
Phaedrus: By meeting with them and “educating” them about a particular product or range of products, sponsoring their conferences, contracting them as speakers or consultants, and such like. They target the most influential physicians, so-called ‘key opinion leaders’.
Socrates: So the physicians they target are those in leadership positions.
Phaedrus: Yes, just those who are driving the research!

Socrates: Well then, Phaedrus, if, after all this, you still wish to pursue a career in psychiatric research, you must take great care to avoid all these pitfalls and make small steps forwards rather than small steps backwards. Otherwise, you will have thrown away your education. You will have wasted your life. And you will leave this world, to which you owe so much, having done it more harm than good.

Invisibility Cloaks and the Ring of Gyges

George Eleftheriades and Michael Selvanayagam, researchers at the University of Toronto, have designed and tested a new approach to invisibility cloaking. Their method involves surrounding an object with miniature antennae emitting an electromagnetic field that cancels out waves reflecting back from the cloaked object. Although their tests showed the cloaking system to work with radio waves, they see no reason why, as the necessary antenna technology matures, it could not also work with light waves.

All this opens the way for a Harry Potter-style invisibility cloak that is thin, scalable, and adaptable to different types of objects. Some of the uses being touted for this quasi magical cloak include hiding military vehicles and conducting surveillance operations. But what if the cloak falls, as it surely will, into the wrong hands? Have the scientists really thought through the consequences? The infamous banker Bob Diamond spoke of ethics as ‘what you do when nobody’s looking’. If bankers, politicians, and even churchmen can no longer be trusted to do the right thing, then who can? But beyond this, the cloak of invisibility raises important questions about human nature: do intelligent people do the right thing because it is the right thing or because they fear being caught, judged, and punished? More fundamentally, is man innately good, under the direction of his conscience and sense of guilt, or is his restraint rather the product of fear and coercion instilled by a Hobbesian social contract that serves to keep him in check?

In Greek mythology, the Cap of Invisibility or Helm of Darkness is a helmet or cap variously worn by Athena, Hermes, and Perseus to make themselves invisible to gods, heroes, monsters, and men. In Book II of the Republic, Plato discusses the Ring of Gyges, which, according to legend, makes its bearer invisible. The ring was once given to the shepherd Gyges who used it to seduce the Queen of King Candaules and thereby usurp the throne of Lydia. In the Republic, the character of Socrates asserts that justice is the excellence of the soul without which a man cannot live well and be happy, and, therefore, that justice is inherently desirable. However, Glaucon doubts whether to be just is always better than to be unjust. All goods, he says, can be divided into one of three classes: harmless pleasures that are desirable in themselves; goods such as gymnastics, the care of the sick, or the various ways of making money that are desirable for what they bring; and goods such as knowledge, sight, or health that are desirable both in themselves and for what they bring. To which of these three classes does justice belong?

Socrates replies that justice belongs to the third class, but Glaucon points out that most people would disagree and place it firmly in the second class. Indeed, most people think that to do injustice is good, but that to suffer injustice is evil; as the evil outweighs the good, they agree among themselves not to do injustice. If a just man got hold of the Ring of Gyges, he would most certainly behave unjustly, proving that he is just only because he is weak and fears retribution, and not because justice is desirable in itself. The truly just man who cares only for justice and not for the appearance of justice will be thought unjust and suffer every kind of evil until the day he finally understands that he should not be, but only seem, just. In contrast, the unjust man who is resourceful enough to seem just will be thought just and always get the better of everyone and everything. Adeimantus adds that when people praise justice, they praise it for what it brings rather than for itself. Realizing this, the superior man devotes himself not to justice itself but only to its appearance.

Adeimantus claims that he does not truly believe his argument, but is nonetheless pressing it to provoke Socrates into taking its other side and demonstrating that justice is desirable in and of itself. As part of his lengthy reply, Socrates famously conjures up an idealized Republic to help him define justice (or, as he puts it, “locate justice within the State”). After having defined justice in the state and justice in the individual, Socrates asserts that the just man orders his inner life in such a way as to be his own master and his own law. The soul of such a man can be said to be healthy, for justice and injustice are to the soul as health and disease are to the body: virtue is the health and the beauty of the soul, vice its disease and debility. If justice is the health of the soul, and if health is desirable in and for itself, then, by analogy, justice too is desirable in and for itself.

This is as far as Plato gets in the Republic. Notice that his conclusion that justice is intrinsically desirable does not in itself answer the original question, which was whether an intelligent person would still behave justly if he no longer feared being caught and punished. From Plato’s other writings, the answer is surely yes, even if Plato defines ‘intelligent’ in such a way that only he and some of his friends at the Academy actually meet the criteria. These select men are, of course, the famous philosopher-kings.

Book Review: AC Grayling’s Friendship

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It is striking that the great thinkers, from Aristotle to Augustine and Mencius to Montaigne, devoted so much of their time and thought to friendship, but almost none of either to marriage. Grayling’s timely treatise reacquaints us with a great but forgotten good that promises to fulfil so many of our practical, intellectual, emotional, and metaphysical needs. The book principally consists of a history of the philosophy of friendship capped by an account of canonical, often homosexual or homosocial friendships such as that of Achilles and Patroclus and Jonathan and David, who, in the Bible, describes the love of Jonathan as “better even than that of women”. Throughout, Grayling seeks to define friendship and, in so doing, explores its many forms, facets, charms, and consolations.

Perhaps in a desire to be modern, relevant, or politic, Grayling seems to reject the classical notion that, at its best and most meaningful, friendship is a highly elitist good. For the greats, only virtuous men can be ideal friends. Aristotle famously says that, while there are many ways for men to be bad, there is only one way for them to be good, and it is precisely in this sense that an ideal friend is ‘another self’—a historically important notion that Grayling severally dismisses. Because they are all one and the same, virtuous men are predictable, reliable, and therefore worthy of one another’s friendship. In contrast, bad people are in some way unlike themselves, and just as likely to hate other bad people as anyone else.

In my opinion, Plato, whom Grayling underrates, advances by far the most subtle and sophisticated of all theories of friendship, one far superior even to that of Aristotle. Despite the extravagant praise that he lavishes upon friendship, Aristotle is quite clear that the best and happiest life is not that spent in friendship, but in the contemplation of those things that are most true and therefore most beautiful and most dependable. There is a contradiction here: if the best life is a life of contemplation, then friendship is either superfluous or inimical to the best life, and therefore undeserving of the high praise that Aristotle lavishes upon it. It may be, as Aristotle tentatively suggests, that friendship is needed because it promotes contemplation, or that contemplation is only possible some of the time and friendship is needed the rest of the time, or even that a life of friendship is just as good as a life of contemplation. So much for Aristotle, one might say.

Plato’s Lysis may seem to fail in its task of defining friendship, but one should never take Plato or his mouthpiece Socrates at face value. There is far more to the Lysis than a couple of interesting but misguided thoughts on friendship. By discussing friendship with Lysis and Menexenus as he does, Socrates is not only discussing friendship, but also demonstrating to the youths that, even though they count each other as close friends, they do not really know what friendship is, and that, whatever friendship is, it is something far deeper and far more meaningful than the puerile ‘friendship’ that they share. In contrast to the youths, Socrates knows perfectly well what friendship is, and is only feigning ignorance so as to teach the youths: ‘…and I, an old boy, who would fain be one of you…’ More than that, by discussing friendship with Lysis and Menexenus as he does, Socrates is himself in the process of befriending them. He befriends them not with pleasant banter or gossipy chitchat, as most people ‘befriend’ one another, but with the kind of philosophical conversation that is the hallmark of the deepest and most meaningful of friendships. In the course of this philosophical conversation, he tells the youths that he should ‘greatly prefer a real friend to all the gold of Darius’, thereby signifying not only that he places friendship on the same high pedestal as philosophy, to which he has devoted (and will sacrifice) his life, but also that the kind of friendship that he has in mind is so rare and uncommon that even he does not possess it. If friendship ultimately escapes definition, then this is because, like philosophy, friendship is not so much a thing-in-itself as it is a process for becoming. True friends seek together to live truer, fuller lives by relating to each other authentically and by teaching each other about the limitations of their beliefs and the defects in their character, which are a far greater source of error than mere rational confusion. For Plato, friendship and philosophy are aspects of one and the same impulse, one and the same love: the love that seeks to know.

Just as philosophy leads to friendship, so friendship leads to philosophy. In the Phaedrus, Plato’s most important work on friendship (although not generally recognized as such—Grayling fails to mention it), Socrates and Phaedrus go out into the idyllic countryside just outside Athens and have a long conversation about the anatomy of the soul, the nature of true love, the art of persuasion, and the merits of the spoken over the written word. At the end of this conversation, Socrates offers a prayer to the local deities. This is the famous Socratic Prayer, which is notable both in itself and for the response that it elicits from Phaedrus.

Socrates: Beloved Pan, and all ye other gods who haunt this place, give me beauty in the inward soul; and may the outward and inward man be at one. May I reckon the wise to be the wealthy, and may I have such a quantity of gold as a temperate man and he only can bear and carry. —Anything more? The prayer, I think, is enough for me.

Phaedrus: Ask the same for me, for friends should have all things in common.

Plato may fail to define friendship in the Lysis, but in the Phaedrus he gives us its living embodiment. Socrates and Phaedrus spend their time together enjoying the beautiful Attic countryside while engaging in honest and open philosophical conversation. By exercising and building upon reason, they are not only furthering each other’s understanding, but also transforming a life of friendship into a life of joint contemplation of those things that are most true and hence most beautiful and most dependable. If only on the basis of his response to the Socratic Prayer, it is obvious that Phaedrus is another self to Socrates, since he makes the same choices as Socrates and even justifies making those choices on the grounds that their friendship requires it. Whereas Aristotle and Grayling try to tell us what friendship is, Plato lets us feel it in all its allure and transformative power.

My New TED Talk: In Praise of Idleness

To do nothing at all is the most difficult thing in the world, the most difficult and the most intellectual.

—Oscar Wilde

An Analysis of Altruism

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Altruism has been thought of as an ego defense, a form of sublimation in which a person copes with his anxiety by stepping outside himself and helping others. By focusing on the needs of others, people in altruistic vocations such as medicine or teaching may be able to permanently push their needs into the background, and so never have to address or even to acknowledge them. Conversely, people who care for a disabled or elderly person may experience profound anxiety and distress when this role is suddenly removed from them.

Altruism as an ego defence should be distinguished from true altruism—one being primarily a means to cover up uncomfortable feelings and the other being primarily a means to some external end such as alleviating hunger or poverty. However, many psychologists and philosophers have argued that there is, in fact, no such thing as true altruism. In The Dawn,the 19th century philosopher Friedrich Nietzsche maintains that that which is erroneously called ‘pity’ is not selfless but variously self-motivated.

Nietzsche is in effect agreeing with Aristotle who in the Rhetoric defines pity as a feeling of pain caused by a painful or destructive evil that befalls one who does not deserve it, and that might well befall us or one of our friends, and, moreover to befall us soon. Aristotle surmises that pity cannot be felt by those with absolutely nothing to lose, nor by those who feel that they are beyond all misfortune.

In an interesting and insightful aside, Aristotle adds that a person feels pity for those who are like him and for those with whom he is acquainted, but not for those who are very closely related to him and for whom he feels as he does for himself. Indeed, says Aristotle, the pitiful should not be confounded with the terrible: a man may weep at the sight of his friend begging, but not at that of his son being led to death.

Altruistic acts are self-interested, if not because they relieve anxiety, then perhaps because they lead to pleasant feelings of pride and satisfaction; the expectation of honor or reciprocation; or the greater likelihood of a place in heaven; and even if neither of the above, then at least because they relieve unpleasant feelings such as the guilt or shame of not having acted at all.

This argument has been attacked on various grounds, but most gravely on the grounds of circularity— altruistic acts are performed for selfish reasons, therefore they must be performed for selfish reasons. The bottom line, I think, is this. There can be no such thing as an ‘altruistic’ act that does not involve some element of self-interest, no such thing, for example, as an altruistic act that does not lead to some degree, no matter how small, of pride or satisfaction. Therefore, an act should not be written off as selfish or self-motivated simply because it includes some inevitable element of self-interest. The act can still be counted as altruistic if the ‘selfish’ element is accidental; or, if not accidental, then secondary; or, if neither accidental nor secondary, then undetermining.

Need this imply that Aristotle is incorrect in holding that pity cannot be felt by those with absolutely nothing to lose, or who feel that they are beyond all misfortune? Not necessarily—although an altruistic act is often driven by pity, this need not be the case, and altruism and pity should not be amalgamated and then confounded with each another. Thus, it is perfectly possible for someone lying on his deathbed and at the very brink of death, who is compos mentis and whose reputation is already greatly assured, to gift all or most of his fortune to some deserving cause, not out of pity, which he may or may not be beyond feeling, but simply because he thinks that, all things considered, it is the right thing to do. In fact, this goes to the very heart of ancient virtue, which can be defined as the perfection of our nature through the triumph of reason over passion. The truly altruistic act is the virtuous act and the virtuous act is, always, the rational act.

Spectator Review of ‘Plato: Letters to my Son’

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Why Crying Makes You Look Good

In many cultures, especially for men, crying is considered to be undignified and infantile behavior, except in certain specific circumstances such as mourning the loss of a close friend or relative. After adolescence, men shed tears much less often than women. On average, men cry once a month and women about five times a month, especially before and during the menstrual cycle. Men not only cry less often but also for shorter periods at a time, 2-4 minutes compared to about 6 minutes for women. And they sob less too, in only 6% of cases versus 65% for women.

There are in fact three types of tear, two of which are rather uninteresting: basal tears which lubricate and protect the eye and reflex tears which flush out irritants such as smoke particles or onion vapors. The third type of tear is, of course, shed in response to emotion, and differs from basal and reflex tears not only by its cause but also by its chemical composition, being considerably richer in certain substances such as prolactin and adrenocorticotropic hormone.

All animals shed basal and reflex tears, but only human beings shed emotional tears. So maybe women shouldn’t feel so bad at crying all the time, since this surely makes them more human than men. Some people believe that some animals, in particular elephants and chimpanzees, can also shed emotional tears, but this is difficult to verify. On the other hand, we can be pretty sure that crocodiles do not cry. The expression ‘to shed crocodile tears’ has its roots in an ancient Greek legend according to which crocodiles pretend to weep to either lure or mourn their prey.

Damage to the ophthalmic branch of the trigeminal nerve renders the surface of the eye insensitive and thereby prevents the production of reflex tears. However, it is the parasympathetic division of the facial nerve that is actually responsible for making tears, and damage to the facial nerve, as in Bell’s palsy, can lead to a decrease in tear production. Reflex and emotional tears are produced by the lacrimal gland and drained through the nasolacrimal canal into the nose. Any excess fluid spills out of the eyelid and trickles along the side of the nose or surface of the cheek, whereby teardrops.

Human beings shed emotional tears in response to sadness and grief, but also in response to a range of other, sometimes positive, emotions such as elation, laughter, love, frustration, pain, anger, and surprise. Crying activates both the arousing sympathetic nervous system and the sedating parasympathetic nervous system. However, the latter is activated for a longer period, which no doubt explains why people tend to remember crying as a calming and cathartic experience.

But could there also be other reasons for people to cry? Tears may have a number of social functions, in particular (1) communicating our emotions while emphasizing their depth and sincerity, (2) attracting attention, sympathy, and help at a time of danger, distress, or need, and (3) serving as a signal of appeasement, dependency, or attachment (for example, by blurring our vision and handicapping our aggressive and defensive actions). Given all this, it should be no surprise that tears can also be used to manipulate and to deceive, cf. the crocodile tears of lore.

Tears may also have some more boring physiological functions, at first priming the body for action through the sympathetic fight or flight response and then, as we have seen, relieving stress and distress through parasympathetic activity. In ancient and mediaeval times, physicians commonly believed that crying purged excess humors from the brain. Similarly, some modern scientists believe that it serves to remove toxins, in particular stress hormones, from the blood stream. 

I like to think that tears can have a psychological function too, serving as a mechanism for a person’s unconscious to tell his conscious that a particular problem or situation actually means a lot to him and that he needs to make the effort to address or at least to process it. As the markers of strong emotion, tears signal moments of existential importance in our lives, from sharing a first kiss to grieving the loss of our partner. To deny them or to hold them back is foolish in the extreme, not only because it denies us the moment and the chance to be (and look) our best, but also because a better attitude or perspective is so often the result of a good old cry. In the words of Goethe, ‘If you’ve never eaten while crying you don’t know what life tastes like.’

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