IX. CONCLUSIONS

Excuses and rationales can always be found to explain why doctors become involved in human rights abuses of various kinds, such as in physician-assisted executions,²⁷⁵ "medical supervision" over torture sessions, the procurement of transplantable organs from executed criminals' bodies,²⁷⁶ and also politically repressive psychiatry. These range from the claim that expert medical involvement is required, in the case of torture and executions, in order to limit or alleviate the sufferings of the subjects of these procedures; through the more instrumental argument that, in the case of organ transplants and certain types of execution, the procedures themselves are of an inherently medical nature; to the construction of elaborate, pseudo-scientific theories that posit, as in the case of political psychiatry, false medical justifications for the State's enlistment of doctors in the criminal justice and law enforcement process. All these practices entail, however, a fundamental corruption of the basic tenets of medical ethics - notably the principle that medical skills should be deployed only for the improvement of life and health, as summed up in the Hippocratic injunction "Do no harm."

In this article, we have briefly indicated two of the more obvious reasons why Chinese psychiatrists allow themselves to be pressed into the unethical deployment of their skills for State-directed purposes of political and religious repression: first, the professional acculturation process, in which psychiatrists learn from the official medical literature at the outset of their training that certain types of ideologically nonconformist behavior are attributable to severe and dangerous forms of "mental pathology;" and second, the more insidious element of personal and professional fear, inspired by a wider culture involving decades of individual and institutional experience, of the severe negative consequences of departing from the official "political line" laid down by the authorities in such matters. There are surely, in addition to those enumerated above, other more subtle reasons why Chinese psychiatrists become active partners in the political corruption of their profession.

The question remains, however: why do the authorities themselves bother? Indeed, why would any repressive regime go through such elaborate and often costly steps as adopting coercive psychiatric measures against a certain number of its political and religious opponents, when other much simpler methods of neutralizing such troublesome people - for example, execution or lengthy imprisonment - have always been readily available, and, in the case of both the Soviet Union and China, were frequently used? One possible reason has to do with the changed political landscapes that emerged, both in the USSR after the death of Stalin, and in China after the death of Mao: in these countries, the former totalitarian solution of the physical liquidation of political enemies was ended by the emergence of reformist leaderships dedicated to the curtailment of past policy "excesses." For dissidents of various kinds, this meant that being arrested by the security police no longer entailed their permanent physical removal from society, but rather long terms of imprisonment from which they had a reasonable chance of emerging alive; a sustained dissident network or movement therefore could, and did, come into being in both these countries after the deaths of their respective "great dictators." For the successor authorities, Khrushchev and Deng, however, this represented an unwanted complication of their new "liberalizing" dispensations, and more elaborate mechanisms of inducing long-term fear in the ideological enemies of the State thus had to be found. There are surely few more potent deterrents to dissident activity of any kind than the threat of permanent or semi-permanent forced removal to an institution for the criminally insane. A potential Chinese dissident or religious nonconformist may be prepared to face imprisonment for his or her beliefs, but indefinite psychiatric custody is probably quite another matter. Additionally, psychiatric labeling of this kind serves to stigmatize and socially marginalize the dissident in a way that regular criminal imprisonment, in the present era at least, often fails to do.

Another reason why "liberalizing" Communist governments tend to engage in such practices may derive from the amour propre, or self-justificatory vanity, found in historically repressive regimes of this type when they attempt to dispense with nakedly terrorist methods of dealing with ideological dissent or nonconformity. Such phenomena must still, in the official view, be crushed, but it better serves the government's self-image at such times to adopt more sophisticated and where possible, scientific means and approaches to the fulfillment of this task. Thus, the perceived ideological enemies of the regime are officially said, in some cases, to be merely ill, rather than always or necessarily ill intentioned. While this general rationale for the use of political psychiatry may seem to contradict the "deterrent" argument outlined above, in practice they are not mutually incompatible. Rather, the dissident's fear of being branded mentally ill and condemned to a lunatic asylum serves as a more subtly powerful deterrent to any further oppositional belief or activity, while the reforming government, for its part, can rest satisfied in the belief that it is acting more humanely and scientifically than its unreconstructed predecessor ever did.

A closely related reason has to do, no doubt, with the country's international image and prestige. Naked repression as conducted in the old days becomes, in the more forward-looking era of "opening and reform to the outside world," a source of increasing international embarrassment for the government. Hence, the former overtly political crimes of "engaging in counter-revolution" are reborn under the more internationally acceptable rubric of "crimes of endangering state security," while particularly flagrant or uninhibited political protestors, and more recently sample groups of Falun Gong religious detainees, are sent to mental hospitals to be "treated," rather than simply jailed as before. Again, this may appear to be paradoxical or even self-defeating governmental behavior, given the widespread international public awareness that now exists about the malign political uses of psychiatry in the former Soviet Union and certain other countries. But the surprising fact remains that in China there has been, thus far, virtually no public discussion or dissemination of information of any kind concerning the history of psychiatric abuse elsewhere in the world, let alone of the strong reaction to such abuse that has been generated internationally over recent decades. In all the Chinese books and journals on psychiatry that have been consulted for this article, only one explicit and very brief reference to the history of political psychiatric abuse in the former Soviet Union, and none to that of other countries, has been found.²⁷⁷ In this regard, the Chinese medico-legal authorities may unknowingly have been a victim of the government's longstanding policy of censoring and controlling the flow of sensitive news information from around the world.

All of the above reasons may partly explain the existence of political psychiatric abuse in China today, but they cannot directly account for the fact that such practices existed there long before the inauguration of the Deng Xiaoping "new era" in the late 1970s. Here, both systemic and also more contingent factors appear to have played the determinant role. First, there was the fact that Chinese forensic psychiatry largely owed its existence, as a discipline, to the fraternal efforts and advice of Serbski Institute-trained experts from the Soviet Union in the 1950s; Chinese psychiatry thus "benefited" from psychiatric doctrines characteristic of the Khrushchev era, but at a time when China itself was still firmly in the grip of its own unreconstructed Marxist leader. This would clearly explain why the basic doctrines of political psychiatry arose at a seemingly "inappropriate" time in China's political development, and why they continued to hold significant sway in Chinese forensic psychiatry both up to and beyond the death of Mao.

Second, however, there appears to be a deeper and more systemic explanation for the phenomenon, one that has applied almost throughout the history of the People's Republic. In brief, the main underlying reason, observable throughout the official psychiatric literature from the late 1950s onwards, for why some political dissidents and other kinds of ideological nonconformists are singled out - from among the much broader ranks of their prison-bound "counterrevolutionary" or "state security endangering" colleagues - for special treatment in the form of legal-psychiatric diagnosis and forced committal, appears to be that they lack, in the experienced and discerning eyes of the police, the prerequisite hallmark of dissent "street credibility." That is to say, they express their oppositional or contrarian viewpoints openly and with no attempt to disguise their true identities, and when detained by the police on political charges they make no effort to deny their activities or pretend that they weren't really making fundamental criticisms of the regime. As the official literature makes clear, this represents, to China's seasoned enforcers of the "dictatorship of the proletariat," a rarely encountered and inexplicable form of behavior characterized by a perplexing absence of any normal instinct for self-preservation, and thus one that can be perceived only as mentally abnormal. In the authorities' view, "proper" political dissidents and other ideological enemies behave covertly and conspiratorially, because they know the dire penalties for being caught. To act otherwise strikes the authorities, no doubt quite genuinely, as being sheer political lunacy.

This more consistent and longstanding element in the Chinese official conception of criminal-psychiatric deviance or pathology is, in turn, reflective of a fundamental hallmark of Chinese-style Marxism, namely the strong emphasis always placed by Mao upon "correct thinking."²⁷⁸ In China, even more so than in Russia, the objective or material Marxian prerequisites for advanced socialism were conspicuously absent in the first half of the twentieth century, and Mao's solution to this revolutionary resource deficit was to transfer the pivotal role away from the economy and towards ideology and other such "superstructural" factors: that is, from being to consciousness, from the objective to the subjective, from the material to the spiritual, and from process to will.²⁷⁹ The Soviet guardians of the faith, people like chief Party ideologist Mikhail Suslov, decried all this as anti-materialist "voluntarism" on the part of their Chinese colleagues, and even Serbski School-trained forensic psychiatrists might have demurred at the extensive underlying use made by their Chinese counterparts of the basic Soviet medico-legal theory of ideological deviance.

Another important difference, rather ironically, between the two systems was that whereas the Soviets never admitted that psychiatric abuse had been practiced, the Chinese profession acknowledged that it had frequently occurred during the Cultural Revolution. But here again, the Maoist stress on ideological factors meant that the post-1978 reexamination of "past excesses" within the profession was mainly limited to a critique of the categories and specific content of the "politically deluded" ideas that had been identified - wrongly, it was now said - as being symptomatic of criminal mental pathology. No significant challenge was raised to the core notion that thought and speech could constitute crimes, or that in certain cases these could amount also to "political lunacy" in a forensic medical sense. At an important level of official Chinese discourse for the past half century, therefore, there has existed a clear and persistent epistemological identification or elision between, on the one hand, the social concept of correct political thought and action, and on the other, the ascription, in individual cases, of basic mental health and stability. All this represents the deeper and more intractable defining layer or facet of "political psychiatry with Chinese characteristics."

The reality today, however, is that most Chinese, and certainly those of the younger generation, would no sooner think of taking to the streets and staging political protest manifestations - especially in the form of sticking up "big character posters," the most commonly cited symptom of Chinese-style "political lunacy" - than they would think of studying Das Kapital or memorizing the poems of Mao Zedong. The right to engage in street-level politics of this kind, so characteristic of the Maoist era, was excised from the Chinese Constitution in 1982, and there now exists a panoply of legislation that severely criminalizes all such unauthorized forms of political expression by China's citizens; the same is true of all types of unauthorized religious activity. What was formerly a central part of Chinese political culture is now, in the post-Tiananmen era, little more than a folk memory for most people. This fact alone would probably suffice to account for the officially recorded decline, since the1980s, in "cases of a political nature" in Chinese forensic psychiatry.²⁸⁰

One important issue should be raised in this connection, however. The official statistics on this question never included, and still today omit, a range of other activities that are elsewhere generally seen as being quite civic-minded or at least socially permissible in nature: persistent petitioners and complainants of various kinds (the so-called litigious maniacs), people who seek to expose corruption or malfeasance in the workplace and in government administration (the "whistleblowers," or those with so-called paranoid delusions), and also nonconformist religious or spiritual practitioners of various kinds, such as the Falun Gong (the so-called dysphrenics). As China continues to develop and expand both its legal system and the overall principle of rule by law, and as a greater degree of rights consciousness correspondingly takes hold among the populace as a whole, examples of the former kinds of behavior are bound to increase dramatically; thus far, however, there has been no reported decrease in the numbers of such cases dealt with as constituting crimes by the mentally ill. Similarly, although for somewhat different reasons, religious sectarianism or spiritual nonconformism is now rapidly on the rise in most parts of the country, and the authorities' recent extension of the "mental pathology" model to significant numbers of Falun Gong adherents thus further lengthens the shadow over any hopes or optimism that political psychiatry may be destined soon to disappear from the Chinese law-enforcement scene.

In conclusion, we return to the question of whether or not those dealt with in China as being dangerously mentally-disordered political or religious offenders really are, as the authorities claim, suffering in significant numbers from any recognizable form of mental illness. Ultimately, this is an irrelevant question to be asking in the ostensible context of the practice of forensic psychiatry, since the acts in question are not only absent from the internationally accepted definition of crime, but also specifically protected under international law as clear examples of the exercise of the right to freedom of expression. Indeed, it is this that defines the Chinese authorities' practices in this general area as constituting a fundamental abuse of human rights. If for the sake of argument, however, one suspends all disbelief, takes the official case reports and statistics at face value and accepts that all of those dealt with in this way were in fact seriously mentally ill, then another conclusion arises: that Chinese-style "political lunacy" represents a genuinely new, post-1949 "culture-bound syndrome" of considerable size and extent, and one that therefore deserves formal recognition in the country's official classification of acknowledged mental disorders. It is certainly true that the incessant mass political campaigns waged by the Chinese Communist Party over the past fifty years has claimed countless lives and driven large numbers of people insane. It may well also be true that the deeper cultural effects of this longstanding history of political witch-hunts and persecution have caused many of those suffering from genuine mental illness to exhibit their disorders in the form of politically colored language, thought, and behavior.²⁸¹ For China's medico-legal authorities to charge psychiatrically disturbed individuals of this kind with committing serious offenses and then send them to institutes for the criminally insane, however, is clearly to add insult to injury.

The challenge for the international psychiatric community now is to find ways of exerting its influence to ensure that China's secretive Ankang system and other custodial psychiatric facilities around the country can no longer be used by the security authorities as a long-term dumping ground for political and religious nonconformists who, for one reason or another, they find it awkward or inconvenient to bring to criminal trial. As an indispensable first step towards this goal, both the World Psychiatric Association and its constituent national professional bodies should begin seeking direct access to the Ankang network and other places of psychiatric custody in China, with a view to independently monitoring conditions and practices therein.²⁸² Advocacy efforts by local and international psychiatric bodies would also greatly assist in encouraging individual Western governments and the European Union to take up the issue, notably by placing the issue of political psychiatric abuse in China on the formal agenda of the various bilateral human-rights dialogue sessions that have become, in recent years, a central and regular feature of Sino-Western relations.

²⁷⁵ For a detailed study of this topic, see Breach of Trust: Physician Participation in Executions in the United States, a joint report by the American College of Physicians, Human Rights Watch, the National Coalition to Abolish the Death Penalty, and Physicians for Human Rights (New York, March 1994).

²⁷⁶ See, for example, Human Rights Watch, Organ Procurement and Judicial Execution in China (New York: Human Rights Watch, 1994).

²⁷⁷ See Jia Yicheng, Shiyong Sifa Jingshenbingxue, p.15. The passage referred to the Soviet psychiatric practice of labeling political dissidents as suffering from "sluggish schizophrenia" and incarcerating them in mental hospitals for long periods. It added that this practice had been "severely criticized by representatives from other countries at an international academic conference on psychiatry in 1976." (It is unclear to which conference the author was referring; it was likely a mistaken reference to the WPA's Sixth World Congress at Honolulu in August 1977, the first major international event at which Soviet political psychiatry was exposed to international criticism, and where the historic Declaration of Hawaii [see above, Section II] was passed by the WPA General Assembly.) Significantly, however, the passage in the Jia Yicheng volume itself contained no criticisms of the Soviet practices in question.

²⁷⁸ This same emphasis had, of course, much older antecedents, namely the traditional Confucian concern for correct speech and behavior, as expressed for example in the value-concepts of "propriety" (li) and "rectification of names" (zheng ming).

²⁷⁹ As Stuart Schram, the leading Western expert on Mao's thought and philosophy, has written:

Mao's contribution to the theory and practice of revolution is also characterized by an extreme voluntarism. To be sure, "voluntarism," in the sense of an accent on conscious action, is by no means absent from Marx himself. But there is no doubt that it is carried much further in Lenin, and further still in Mao Tse-tung, and in the ideology of the Chinese Communist Party. This voluntarism attained a kind of apotheosis in the theory of the permanent revolution. Consider, for example, a passage such as this (by Mao, 1958):

"Men are not the slaves of objective reality. Provided only that men's consciousness be in conformity with the objective laws of the development of things, the subjective activity of the popular masses can manifest itself in full measure, overcome all difficulties, create the necessary conditions, and carry forward the revolution. In this sense, the subjective creates the objective."

(Stuart R. Schram, The Political Thought of Mao Tse-tung [Harmondsworth: Pelican Books, 1971], pp.135-136 [emphasis added by Schram].)

²⁸⁰ This decline in the official social acceptability of the "big character wallposter" culture in China may also, however, make it even more likely that those who still persist in such activities and behavior will be viewed by the authorities as being mentally disturbed in some way, and thus liable for forensic psychiatric examination and committal. A further important point concerns the current rapid increase in China of all types of forensic psychiatric appraisal cases; with the passage (as described above) of a series of relevant countrywide rules and regulations in recent years and the concomitant institutional build up of the legal-psychiatric appraisals system, the absolute number of such cases is now multiplying annually in China. A decline in the percentage incidence of "political" and other such cases does not necessarily mean, therefore, that fewer actual cases of these types are being dealt with under the system. The overall trend may even be in the other direction.

²⁸¹ In the case of the Soviet Union, when Western psychiatric delegations were finally, in 1989 and 1990, allowed access to alleged mentally ill dissidents held in psychiatric custody, a minority of those examined were found to be suffering from some form of mental disorder or other. In most such cases, however, these were deemed by the Western experts to be little more than harmless borderline conditions, and of a kind that should not have occasioned even civil psychiatric committal, let alone compulsory forensic-style custody. For details of the findings of one of these expert delegations, see Bonnie and Polubinskaya, "Unraveling Soviet Psychiatry," pp.279-298; see also Richard J. Bonnie, "Soviet Psychiatry and Human Rights: Reflections on the Report of the U.S. Delegation," Law, Medicine and Health Care, vol. 18 (1990), pp.123-131.

²⁸² Initial steps have already been taken in this direction. In May 2000, for example, the American Psychiatric Association's Committee on the Abuse of Psychiatry and Psychiatrists passed a resolution at the APA's annual conference in Chicago "recommending that the World Psychiatric Association investigate the alleged wrongful detention of Falun Gong practitioners in psychiatric hospitals" ("APA Committee Calls for Investigation of Chinese Psychiatric Abuses," Psychiatric News, June 16, 2000, available at http://www.psych.org/pnews/00-06-16/chinese.html). According to a subsequent report, "The Board [of APA Trustees] also referred this matter to the APA Commission on International Psychiatry and the Committee on Misuse and Abuse of Psychiatry for monitoring the progress of the WPA's investigation" (Psychiatric News, June 16, 2000, available at http://www.psych.org/pnews/00-08-04/board.html). Additionally, when an APA delegation of sixty-five American psychiatrists attended the Second Sino-American Conference on Psychiatry in Beijing in April 2000, "[The U.S. psychiatrists] Herbert Peyser, [Allan] Tasman, [Jeffrey] Geller and other psychiatrists met with Chinese Society of Psychiatry leaders informally to convey their concerns about Falun Gong practitioners being allegedly detained involuntarily in psychiatric hospitals and injected with harmful medications for political reasons" (Psychiatric News, June 16, 2000, available at http://www.psych.org/pnews/00-06-16/china.html).