The sacred and the profane

I have no religion. As a young man, my opposition to religion was strident, but I have mellowed in this respect (actually, more or less everything I believed as a young man was stridently expressed). These days I do not really care what other people believe, so long as they do not impose it on me or on anyone else. I think Richard Dawkins is a bad atheist, because he mimics the worst aspects of religion, namely proselytization and intolerance. This is a mashed-up multicultural world, and we need to find ways to live together. Trying to get everyone to believe the same thing is not terribly helpful.

A couple of weeks ago, I returned from a late summer holiday and dived straight into the autumn conference season. The Royal College of Psychiatrists Philosophy Special Interest Group held a three-day conference at the end of September on the theme “moral and legal responsibility in the age of neuroscience”. I gave a talk about secularism. I was sorry that I was only there for one day, because the other talks were excellent, and people seemed interested in what I had to say too. There was a session on the last day about the Prevent programme that I especially regretted missing. The abstract of my talk is at the end of this blog (I know. Putting an appendix at the end of the blog suggests that I do not understand the nature of the medium).

My tendency to bang  shoes on metaphorical tables has got me into a lot of trouble over the years, but I never expected to find myself at the centre of a protracted controversy over religion. Active opposition to religion was part of my childhood, but I thought I had moved on. I grew up in a family that believed in rationalism. We had a strong atheist identity and we tended to think that this meant that we occupied the moral high ground. My parents were not as strident about religion as my paternal grandfather, who told my father that his greatest disappointment was that my parents got married in a church (a consequence of my atheist mother’s attachment to nice buildings and proper ceremony). Arthur Poole worked unstintingly on behalf of the Socialist Party of Great Britain in pursuit of a classless, moneyless society for four decades. His toil had no noticeable effect on the capitalist system. You would have thought that a church wedding was a relatively trivial disappointment by comparison, but then he did show the family weakness of hyperbole.

In 2008 there was an article in the Psychiatric Bulletin by Harold Koenig that said psychiatrists should take a spiritual history from all patients, that they should challenge unhealthy religious beliefs and support healthy ones, and that sometimes they should pray with their patients, albeit cautiously. What alarmed me was the supportive commentary that accompanied the article, written by Sheila Hollins, who was President of the Royal College of Psychiatrists at the time. I felt that someone needed to say that religion and clinical practice do not mix, and, correctly surmising that no one else would, I did so. I wrote a letter with a number of colleagues. Several of the signatories were active in a religious faith. Our concern was not driven by atheism; it was about professional boundaries and the protection of patients when they are vulnerable.

The impact of that letter on my subsequent career has been profound. I appear to have become an international atheist. When I die, the obituary in the BMJ will not say he saw loads of patients, or mention a well-written but little read blog. It probably will not mention my mastery of slide guitar. It will say that I stirred things up about atheism and religion. I have never wanted to be defined by something that I do not believe in, but it is too late. I probably am.

One of my conceits is that I can write to a high standard. When I write polemic, I take no prisoners. If you believe that your point of view is correct and you want to win the argument, there is no point in doing otherwise. This is completely different to the disgraceful and increasingly common practice of making ad hominem attacks in the guise of academic debate. Unfortunately, my adherence to a set of rules of decency (which, it must be said, I thought up) does not prevent people from getting upset, and those who want religion to play a greater part in clinical practice have duly been offended. This is partly because of my insistence that good intentions do not protect patients from harm.

Fortunately, after several years of hard debate, we have moved from rhetoric to empirical evidence. Professor Reverend Chris Cook and Dr Robert Song, from Durham University, with Professor Catherine Robinson and me from Bangor University, have been working on this for a few years, and we are analysing data right now. It is too soon to tell you what we have found, but it looks increasingly likely that the results will not be entirely to my liking. Meantime, close attention to issues I had not really thought about before has made me realise that the penetration of religion into psychiatry is greater than I had supposed. This is what I talked about at the conference.

Psychiatry is not the only thing that is helpful to people when they have mental health problems. Religious faith helps some people. When psychiatrists do try to help, we should stick within the parameters of our expertise, which is scientific. I am no longer certain that psychiatry is best placed to determine whether people are responsible for their actions or not, as this is a moral question, albeit one where the answer may be informed by an understanding of the scientific issues.

I have come to feel that the Mental Capacity Act is problematic, and I think that this is because it follows a theological model of mind, filtered through the British legal system. I do not deny that there was a need for a new law to address issues of decision-making, but a model of choice that assumes an uncomplicated process of understanding and retaining information, weighing it up, making a decision and communicating this does not work so well in theory or in practice. It is logical, but does not correspond with what happens in the real world. It assumes that people have authentic wishes that are stable. It is the same model of decision-making as the one set out in the Bible, exemplified by Adam’s unfortunate collapse in the face of temptation.

The Stanford and Milgram experiments showed that decisions are profoundly effected by social context. There was no moment when Milgram’s participants decided to cross the line and continue with apparently lethal experiments. Offered their dilemma in a different way, they would probably have acted differently. The Mental Capacity Act is difficult to apply where people keep changing their minds; or where decisions are clearly influenced by relationships; or where the patient’s judgement is impaired but their cognition is not, as can happen after head injury. In years to come, we are going to have to re-evaluate the underlying concepts of the Mental Capacity Act.  The point here is that the integration of religious-legal and scientific paradigms is not really possible. In my opinion, we have enough problems in this regard already, without bringing more religion into psychiatry.

So my stance is in support of tolerance and patient-centeredness. I wrote the following on the subject of tolerance five years ago. Although it was written in a conscious parody of Gramsci, it captures what I think about the struggle between the religious and the secular:

“We are in a transitional epoch where an old world of separate nations, classes, ideas, religions and cultures, and relatively stable power structures, is rapidly moving towards a complex global network of free movement, free communication and intermingling. The result during the transition is chaos in all aspects of human affairs, characterised by instability, war and fear for the future.

Religion and science are both based upon rationalist systems of thought. They are trying to retain a role in a world where the central concept of rationalism is under threat. New intellectual alliances are being formed in the struggle, and new schisms are appearing. Throughout recorded history progressive thinkers have adhered to an overarching value: that human beings share much more than divides them. I continue to believe that the future of humanity will be secure if we can agree on what we share and accommodate to our differences. This is a huge task that has to be managed at the individual and personal level, and it touches on the true nature of tolerance”.

This is neatly summarised by a song that has stayed with me since I was 18. It is Track 1, side 1 of the 1974 LP The New Favourites of Brinsley Schwartz, What’s so funny about peace love and understanding’.


My presentation: Moral and Legal Responsibility in the Age of Neuroscience