“I’m less moved by that philosophical question of whether anything exists than by something more concrete.”
“OK, good,” I say, “What about free will?”
“You call that more concrete?” he laughs with a bit of mock indignation.
Nonetheless, free will is still a hot topic of debate between philosophers and a large school of neuroscientists who believe it doesn’t exist, that every choice we make is predetermined by the neurophysiology of the brain.
“I think that consciousness is real and efficacious and not an epiphenomenon [a minor collateral effect],” he says, “and it gives us a way of unifying experience and understanding it and comparing with the past and planning for the future, which is not possessed by an animal with less consciousness. And I think one aspect of consciousness is the illusion of free will.”
The “illusion of free will.” Whoa! That was a slap in the face. How can one tell, especially one who has written a book about hallucinations, whether free will is an illusion—a hallucination of choice, in effect produced by various material deterministic forces in the brain that actually give you no real “choice”—or a reality?
He doesn’t put it that way and in fact comes up with what I think is an important insight, the kind of wisdom I was seeking with these abstract questions: “I think,” he says, “we must act as if we had free will.” In other words it’s a moral imperative to take responsibility for our choices—to err on the side of believing we can freely choose, and not say “my neurons made me do it” when we go wrong.
At last I found a subject both concrete enough for Sacks and very much on his mind in a troubling way. One of the most controversial issues in the neuropsychiatric community—and in the community of tens of millions of Americans who take mood disorder pills—is the DSM, the Diagnostic and Statistical Manual of Mental Disorders, which is now being revised. Through its coded diagnosis system based on supposedly objective, quantifiable “criteria” for mental illness, the DSM is the primary tool in reshaping the way we think about what is “normal” and what is “malfunctioning.” This is because the health insurance industry demands a certifiable DSM diagnosis from a psychiatrist before it will agree to subsidize payment for medication and treatment. So to get their patients any affordable help, doctors must fit each case into the diagnostic code.
Sacks has big problems with the DSM and the culture of simplistic diagnosis it’s given birth to. He argues that this has been an unfortunate development leading to often-crude, falsely “objective” definitions of patients’ maladies that effectively treat the delicate processes of the mind with a sledgehammer rather than a scalpel, obliterating questions such as what is the difference between “justified” sadness and clinical depression—should we be allowed to feel bad in any way or must we maintain a state of “normality,” even when it is mind-numbing?
“I gave a talk recently on ‘the case history,’” Sacks says. “I have seen clinical notes in psychiatry charts crash in the last 30 years, since the first DSM.”