Fear, diagnosis, and the erosion of human agency

Anthony Daniels chose the name “Theodore Dalrymple” because he wanted something that sounded, as he puts it, “old-fashioned and bad-tempered.” There was also a practical reason. When he began writing about patients he had seen in prisons and hospitals, he needed some disguise, and there was no Theodore Dalrymple on the British medical register who could emerge from obscurity and object.

The disguise eventually became the better-known identity. Daniels notes that Eric Blair became George Orwell in much the same way; for readers of City Journal, The Spectator, and his many books, Anthony Daniels became Theodore Dalrymple. The pseudonym fits the prose. He has spent decades applying an old-fashioned faculty, judgment, to institutions that increasingly distrust the act of judging.

Medicine provides some of his best material. Daniels points out that Western societies have achieved levels of health and safety that would have astonished our grandparents, yet the appetite for medical catastrophe has hardly diminished. His father was born in England in 1909, when male life expectancy was about 47 and infant mortality in his London borough was 124 per thousand. Within something close to living memory, those figures became almost unimaginable.

“I think you could define human beings as the only species that enjoys contemplating its own extinction.” Daniels sees a paradox in modern safety: as ordinary mortal dangers retreat, exceptional dangers can become psychologically larger. Illness itself begins to feel anomalous. The patient asks why this happened to him, as though health were the natural entitlement and disease a breach of contract.

Politics makes the problem worse. A politician warned of a possible epidemic faces an asymmetric choice: restraint can be blamed for identifiable deaths, while the injuries caused by excessive intervention are diffuse and difficult to assign to anyone. “So his default position, I think, is to overreact,” Daniels says. Every policy has bad effects as well as good ones, but only some effects arrive with a name, a photograph, and an accusation.

The recurring population scares make the pattern almost comic. Paul Ehrlich warned of mass famine; wealthy societies now worry about falling fertility and aging populations. Daniels does not merely laugh at one failed prediction. He asks why the need for prediction persists after the predicted disaster fails to appear. “Extreme fear does at least give you a purpose in existence. It does give you a feeling of significance.”

His book False Positive brought the same skepticism into medical literature. Daniels read the New England Journal of Medicine week after week and found himself surprised by what passed through a journal he had once regarded almost as holy writ. Correlation slipped into causation; relative risk appeared without enough attention to absolute risk; elaborate statistics gave weak findings an appearance of solidity.

The consequences reach beyond journals. Daniels remembers an old report suggesting a relationship between green potatoes and spina bifida. Decades later he still sees a green potato and thinks of spina bifida. “These things are easy to insinuate in the mind, but they’re difficult to remove from the mind.” A provisional association enters a newspaper, becomes advice, and eventually settles into cultural memory long after anyone remembers the quality of the original evidence.

The same mistrust of judgment appears in education and social policy. Daniels distinguishes moral equality from literal sameness, a distinction modern egalitarianism often blurs. “When we say that people are equal, we mean something in the metaphysical sense, that people should be treated as ends and not as means.” A man of modest intelligence has the same human worth as Mozart; that proposition does not require pretending that everyone could have been Mozart given the correct childhood.

Psychology carries the argument closer to Daniels’s psychiatric training. He accepts that neurological and psychiatric disorders can alter behavior; he gives pathological gambling in Parkinson’s disease as an example where a neurological mechanism may matter. The trouble begins when that model spreads across ordinary human conduct. “Once you do that, then you cease to be an autonomous person.”

In Admirable Evasions, Daniels argues that psychology can place a theoretical lens between a person and his own experience. The individual begins to regard himself as a case, almost as his own patient, and his conduct becomes something that happens to him. “The psychologization of life in my opinion has been disastrous,” Daniels says, while allowing that psychology can sometimes help particular people.

ADHD and depression show the difficulty. Daniels has seen children whose behavior seemed so extreme that something medical appeared to be occurring; he has also seen the diagnostic boundary expand because no biological marker cleanly separates disease from bad behavior, temperament, distraction, or immaturity. He makes a similar distinction between classical melancholia, in which a patient might turn his face to the wall, stop eating, develop peculiar delusions, and die, and the vast modern category of depression.

Doctors once had to exercise judgment across those boundaries. Judgment can fail in either direction, which makes abandoning it tempting; classify everyone together and one no longer has to tell a patient that disappointment, grief, indiscipline, or ordinary misery may remain part of life. The system then acquires its own incentives, because diagnoses bring treatment, accommodations, benefits, professional work, and institutional expansion.

Daniels adapts an old Soviet joke to the arrangement: “We pretend to be ill, and you pretend to diagnose us.” It is funny because both parties can receive something from the transaction. It is darker because a culture organized around explanations for conduct can gradually lose the language with which people understand themselves as agents capable of choosing otherwise.

Daniels is sometimes criticized for describing social pathologies without supplying a program for their cure. He answers with characteristic dryness: his preferred solution is that everyone read his books and undergo something approaching a religious conversion. The joke leaves the serious proposition intact. Before medicine, psychology, education, or government can repair human beings, they might have to recover the distinction between explaining a man and absolving him.