Medicine and Mind-Body Dualism: A Reply to Mehta's Critique.

Neeta Mehta recently advanced the thesis that medical practice is facing a crisis today. In her paper "Mind-body dualism: a critique from a health perspective" she attributes the crisis to the philosophy of Descartes and set out to understand why this dualism is still alive despite its disavowal from philosophers, health practitioners and lay people. The aim of my reply to her critique is three-fold. First, I draw attention to a more fundamental problem and show that dualism is inescapable-scientifically and commonsensically. I then focus on the self-conscious emotions of shame, guilt and remorse, and argue that the self is not identical with a brain. The third section draws attention to the crisis in psychiatry and stipulates some of the main reasons why this is so. Contrary to Mehta's thesis, the health profession faces a crisis because of physicalism and biological reductionism.

Introduction

News that the field of medicine, including psychiatry, is facing a crisis today is neither new nor unjustified, considering the fact that we can only adequately decide how something ought to be treated once we know what it is. Accordingly, the single most important question is what is a human person? Neeta Mehta, a professor of psychology, recently advanced the thesis that mind-body dualism, specifically, the substance dualism of Descartes, is the cause of the crisis facing the health profession today. In her paper “Mind-body dualism: A critique from a health perspective” she set out to “understand why this dualism is still alive despite its disavowal from philosophers, health practitioners and lay people” (Mehta, 2011[41]). Indeed, researches have shown that dualistic views, attitudes and approaches remain common among clinicians (Demertzi et al., 2009[17]; Miresco and Kirmayer, 2006[42]). Also, of all the professions, according to psychiatrists such as Kendlar (2001[31]) and Van Staden (2006[62]), psychiatry is most concerned with the relationship of mind and brain.

The aim of my reply to Mehta's critique of substance dualism is three-fold. First, I draw attention to a more fundamental problem: Physicalism and biological reductionism. I hope to show that dualism is inescapable — scientifically and commonsensically. I will then focus on the self-conscious emotions of shame, guilt and remorse, and argue that the self is not identical with a brain. In the third section, I will draw attention to the crisis in psychiatry today, and briefly stipulate some of the most important reasons why this is so.

But why the focus on the self and brain?

Physicalism and biological reductionism

It is astonishing that morality and what it is that clinicians are treating remain problematic topics within psychiatry (Lewis and Whitley, 2012[37]; Pearce and Pickard, 2009[49]; Sadler, 2009[51]). David Crossley recently argued that psychiatrists are treating the self but unfortunately evade broader questions about the self. He therefore suggests that psychiatrists use shame as a departure point for understanding the self and psychiatric care because “our task as psychiatrists is in trying to understand the multifaceted implications of hearing our patients say they are not who they want to be” (Crossley, 2012[16], p. 100). But what is this “self” which terms such as “self-awareness,” “self-evaluation,” and “self-knowledge” presuppose to exist?

For now it suffices to say three things. First, I regard the concept of the self to be synonymous with selfhood or personhood (Moreland, 1998[43]), which was historically associated with a person or immaterial soul — a “substance which is capable of consciousness” (Hoffman and Rosenkrantz, 1997[28], p. 5). Thus, if the soul or person is the locus of consciousness; if dualism is the commonsense ontological understanding of ourselves (as we shall shortly see it is); and if the commonsense belief that life after death is true, then the soul is the bearer of its own life and mental capacities (e.g., thought, believe, desires, and feelings). Thus, and second, in contrast to Descartes, the mind is not identified with the soul; the mind is a faculty within the soul which causally interacts with the body and brain and, although dependent on a functioning brain, is not reducible to it. Lastly, the person (soul) that is self-conscious or self-aware is a simple, although complex entity, in the sense that it has no separate parts like a computer, body or brain, which has separable or divisible parts (Barnett, 2008[1]). That this view is not an aberration is recognized by several non-dualist philosophers of mind (cf. Nagel, 1986[46], p. 43). Braine (1992[9]) captures the simplicity of the self in the following words: “[T]here is no question of dividing an “I” … into parts. The “I” … presents itself as undivided and indivisible” (Braine, 1992[9], p. 315) It is important to emphasize that those philosophers are noting the features of first-person self-awareness which explain why many physicalists regard ordinary persons as mind-body dualists, as we shall shortly see. It means that they are not foisting an invention on the ordinary person. But why then are physicalists opposed to dualism if that is their natural intuition about themselves and other people?

Currently, the views of the constitutional nature of human persons which dominate both scientific and philosophical discussions are known as biological reductionism in medicine and psychiatry (Cohen, 1993[13]), and physicalism (or materialism) in neuroscience (Beauregard and O’Leary, 2007[3]) and the philosophy of mind (Botterill and Carruthers, 1999[8], p. 4). Proponents of these views hold that “What you see is not really there; it is what your brain believes is there…your brain makes the best interpretation it can” (Crick, 1994[15], p. 30, 32); “You are your brain” (Greene and Cohen, 2004[26], p. 1775, 1779); “You are your synapses” (LeDoux, (2002[36], p. ix), and “it is the brain, rather than some nonphysical stuff, that feels, thinks, and decides” (Churchland, 2002[12], p. 1). So you, a brain, are the thing that thinks, feels, decides, and so on; the brain is “the structural correlate of the mind, and the mind the functional correlate of the brain” (Singh and Singh, 2011[54], p. 6). In other words, “mind” is the word denoting functions of the brain or what a brain does. For now three points deserve mention.

The first is that in psychiatry, reductionism gave rise to what has been described as “the standard response” among psychiatrists, namely to translate mental disorders into diseases of the brain (Fulford, 2002[23], p. 360), which makes sense if a person is a brain. The second is that “physicalist monism” is the philosophical doctrine that everything that exists is physical; the world consists of only one kind of stuff. It follows that talk of immaterial entities such as souls, spirits and minds will make no sense, unless they can be reduced to matter (cf. Churchland, 2002[12]). And the third is that physicalists need identity to make their case for reductionism. Thus, if we can say just one thing true of an immaterial soul and mind that is not true of a material brain, or vice versa, then physicalism is false. But physicalists have much to explain.

On the one hand, we need an explanation for the notion that it is the brain that makes the mind, or that the mind is the physical correlate of the brain. Why? It is the assumption that guides the day-to-day activities of most physicians, psychiatrists and neuroscientists. However, his in-depth review of the most relevant scientific literature that purportedly support that assumption, led William Uttal (2011[59], p. 4, 5) to conclude as follows:

No one knows how the brain makes the mind (p. 4), and

The assumption “is without any compelling empirical foundation; none of the required tests of necessity or sufficiency have ever been carried out to confirm it generally and specifically” (p. 5).

So mind-brain monism is just what it is, namely, an unconfirmed hypothesis (see also Crawford, 2008[14]; Van Horn and Poldrack, 2009[60]; Van Orden and Paap, 1997[61]). We shall later see that a related problem is the inability of scientists to explain how a brain can cause a self-consciousness person to exist.

On the other hand, we need an explanation for the behaviour of physicalists. Physicalist philosopher John Searle's (1992[52]) critical examination of the various physicalist views of human persons led him to write that

Acceptance of the current views is motivated not so much by an independent conviction of their truth as by a terror of what are apparently the only alternatives. That is, the choice we are tacitly presented with is between a ‘scientific’ approach, as represented by one or another of the current versions of ‘materialism,’ and an ‘antiscientific’ approach, as represented by Cartesianism or some other traditional religious conception of the mind. [But Searle also says this:] If we are to think of the philosophy of mind over the past fifty years as a single individual, we should say of that person that he is compulsive neurotic, and his neurosis takes the form of repeating the same pattern of behaviour over and over (Searle, 1992[.

Most revealing is that Searle is telling us that the “compulsive-neurotic individual” — that is, the philosophy of mind informed by physicalism/materialism — cannot be treated with direct refutation of his views: “Direct refutation simply leads to a repetition of the pattern of neurotic behaviour. What we have to do is go behind the symptoms and find the unconscious assumptions that led to the behaviour in the first place” (ibid, p. 31[52]). So what is the cause of this behaviour? Searle says it is “a terror” of the only alternatives to physicalism, namely dualism and “the belief in the immortality of the soul” (ibid, p. 3[52]).” Searle is by no means the only physicalist who reached this assessment of physicalist behaviour. Thomas Nagel says that “nervousness” (i.e., a fear of religion and the belief in God, which he referred to as the “cosmic authority problem”) is “not a rare condition and is responsible for much of the scientism and reductionism of our time” (Nagel, 1997[47] p. 130-131). Further examples are unnecessary.

These insights do not make it unreasonable to think that the crisis facing medicine is a psychological problem rather than the so-called mind-body problem. But since it is postulated that a brain feels, thinks and decides, shall we conclude that the terror and nervousness experienced by physicalists are disorders of their brains? If so, why should a brain as opposed to a person feel terror and be nervous about dualism, the immortality of the soul, or the existence of God when the existence of these entities is denied by physicalists? What does it feel like for a brain to be in fear of something? Do we know as opposed to knowing how a person feels about those things? How does a person know what his or her brain thinks or feels when no person has access to his or her brain? I hope to address some of these questions in this paper.

I shall now proceed to show why I think that soul-body or mind-brain dualism is inescapable.

The inescapability of mind-body dualism

The scientific evidence that people, including very young children, are mind-body dualists is overwhelming (Bering, 2006[6]). Paul Bloom (2004[7] p. 19) also reviewed the literature of developmental and cognitive researchers who investigate people's conception of themselves. It leads him to state that “we are dualists who have two ways of looking at the world: In terms of bodies and in terms of souls” (p. 191[7]). In other words, they think of biological and psychological causes of phenomena as ontologically distinct. The critic may object to the scientific findings. She might say that just because people think or believe that a human being is constituted by a soul and body does not necessarily make it true. Indeed, but neither does the objection rule out the evidence in support of such a belief. At the very least, it provides support in favour of the presuppositions of our commonsense conceptual scheme or psychology, as we shall shortly see. The point not to be missed, however, is that young children do not have to be taught to be dualists; they have no conceptual understanding of or access to their own brains, yet they are well aware of what they themselves think and believe about themselves and other objects, including the causal relation between themselves and their bodies. Moreover, the scientific evidence should not strike us as something novel, and therefore as surprising. The idea that human beings have an immaterial soul distinct from the material body is at least as old as Plato and later echoed by Descartes.

The understanding of Plato and Descartes of the soul-body relationship can be characterized as dualistic interactionism. Although both were convinced that the soul is ontologically distinct from the body, and contrary to what most scientists and philosophers would have us believe, neither of them thought of a human being as less than a unified whole. Plato had this to say: “For this is the great error of our day that in the treatment of the human body, physicians separate the soul from the body” (Galdston, 1953[25] p. 127). Descartes argue that the soul is “very closely united to it [the body], and so to speak so intermingled with it that… [soul and body] seem to compose… one whole” (Brown, 1988[10] p. 361). It is therefore not surprising, just as scientific research shows that adults and young children think about themselves in dualistic terms, that non-physicalist neuroscientists and psychiatrists find evidence for the interaction between the soul (what they refer to as the “mind”) and the brain in their scientific experiments.

Neuroscientist Mario Beauregard (2007[2]), for example, discovered that the intentionality (i.e., the “aboutness” or intentional directedness of one's consciousness) of the first-person perspective is an essential feature of all successful therapeutic work because it is guided to a large extent by the content of mental states such as thoughts and feelings. His investigation of the various scientific studies about the interaction between the mind and brain — understood as two distinct ontological entities — leads him to conclude that “Agentic factors, such as beliefs, goals, aspirations, desires, and expectations… cogently supports the interactionist view that the contents of subjective experience can causally influence physiological processes/events in the brain” (Beauregard, 2007[2], p. 233). Beauregard's conclusion is also consistent with experimental study of the effects of placebos and antidepressants in patients with major depression. For example, psychiatrist Helen Mayberg and six others found that placebos produce changes in the brain that are “indistinguishable from that seen with active antidepressant treatment” (Mayberg et al., 2002[39], p. 728). For them, placebos clearly demonstrate a mind-brain interaction that is guided by subjective mental factors such as beliefs, expectations, meaning, and hope. They therefore suggest that cognitive strategies that enhance awareness of self-defeating thinking styles and behavioural patterns that contribute to feelings of depression should be a primary goal in treatment (ibid, p. 731[39]). Two points should therefore be clarified.

First, these authors think of the mind as an entity (agent) with the psychological capacity for thinking, feeling and believing and as able to interact with the brain as a biological organism. In my view, as already been stated, the mind is a capacity of the immaterial soul, and I will shortly argue that the soul (person) is diffused throughout its body, including the brain. At this point, I can anticipate an objection from the biological reductionist. He or she might say that psychological functions themselves are brain functions. On the one hand, as already been noted, this reductionist assumption has no evidence to support the notion. On the other hand, just because an immaterial entity (soul/mind) cannot be seen does not automatically imply there is no such thing. Second, none of the authors, including me, imply that mental or psychological functioning is possible without a functioning brain. The point they are making, however, is that the brain is not the only cause of behaviour; the evidence shows that mental functions can and do cause and affect brain function. I will later distinguish between doing things and making things happen, which would indicate that a person can also make things to happen in his or her brain while unaware of it.

The scientific findings about what little children think and believe about themselves are, unsurprisingly, consistent with what physicalist philosophers have to say about people's commonsense intuitions. Philosophers such as Jackson (2000[29], p. 30) and Kim (2003[32]) believe that mind-body dualism is a very general belief. Kim (2003[32]) writes:

We commonly think that we, as persons, have both a mental and bodily dimension — or, if you prefer, mental aspects and material aspects. Something like this dualism of personhood, I believe, is common lore shared across most cultures and religious traditions, although such beliefs are not always articulated in the form of an explicit set of doctrines as in some established religions. It is often part of this “folk dualism” that we are able to survive bodily deaths, as “pure spirits”, and retain all or most of the spiritual aspects of ourselves after our bodies are gone (Kim, 2003[.

According to physicalist David Papineau (2008[48]), physicalists cannot help but think in dualist terms. He states:

Indeed I would say that there is a sense in which even professed philosophical physicalists, including myself, cannot fully free themselves from this intuition of distinctness. Of course, we deny dualism in our writings, and take the theoretical arguments against it to be compelling, but when we aren’t concentrating, we slip back into thinking of conscious feeling as something extra to the brain (Papineau, 2008[.

These observations are remarkable, for at least three reasons. Firstly, it should be evident that the statements of physicalists about the undivided and indivisible “I,” (Nagel, 1986[46], p. 43; Braine, 1992[9]), what a person is (i.e., a body or brain), and their acknowledgement of the commonsense view of ourselves are clearly at odds with each other. To argue, for example, as Bering (2006[6], p. 454) does, namely that mind-body dualism (he calls it the “folk psychology of souls”) is the product of an evolved cognitive “system” in the brain that is “dedicated” to “forming illusory representations,” would not do (for a critique of Bering's assumption, see pp. 462-463, 470 and 484-485 of his paper). His assumption is attractive only for those who already decided there is no room in their ontology for immaterial souls and minds, which is to say that his argument is convincing for those who already accept the conclusion of the argument.

Secondly, if we are to accept physicalist philosophers Joshua Hoffman and Gary Rosenkrantz's (1997[28], p. 5) depiction of the immaterial soul, namely as a “substance which is capable of consciousness,” then there seems to be little rational justification to exclude evidence for the belief in the existence of a disembodied soul after death. I offer two pieces of evidence. The first is found in the Christian faith. “Death” means separation of the soul (person) from the body, which turns into a corpse. Their sacred texts reflect several accounts of people who died and appeared to others in immaterial form (Habermas and Moreland, 1998[27]). By implication, in order to be able to separate from the body, the soul (person/self) must be metaphysically distinct from the material body and its organs. The second piece of evidence relates to scientific research of NDEs (Near Death Experiences). Documented accounts of people who experienced NDEs report seeing items, listening to conversations — in and outside the room where they were located — and most interestingly, of blind patients and those who were without heart or brain activity (Beauregard and O’Leary, 2007[3], p. 153-166; Kelly et al., 2007[30]).

Thus, and thirdly, if the scientific evidence in support of the believe that people can exist in a disembodied state are rejected by physicalists, which they are bound to attribute to the functions of the brain or an altered state of consciousness caused by the brain (cf. Beauregard and O’Leary, 2007[3], p. 150-180; even if the scientific evidence about how people think about themselves are rejected, and even if people's commonsense intuitions are misguided, we have at least strong evidence to believe that people do not think of themselves as brains.

Now if a person is nothing more and nothing less than a brain, then logically, when a person dies, the person ceases to exist, since the body together with the brain eventually decompose or decay. There is, however, another way to express the point. If a person's notion of selfhood is nothing more and nothing less than a brain function, then when a person dies, the brain dies, and the person's notion of selfhood also ceases to exist. What I wish to contend is that this is the case. The immaterial person — the bearer of selfhood and the animating principle of the body — continues to exist. This person/self, I call the soul or pure spirit. Even if there is no direct evidence for the soul, since it is an unseen entity, there is strong circumstantial evidence in support of the belief. At least it explains why at death the body turns into a corpse.

I therefore contend that the soul or pure spirit is capable of separating from its body at death, continues to exist, and only the body becomes a corpse.

This means that there must be a modal distinction between the soul and body, about which we can say at least three things:

The body is a mode of the soul, of which the mind is a faculty or power. To say “mode” means that the body is dependent on, inseparable from, and genuinely distinct from what it is a mode of (i.e., the soul);

There is non-identity between the soul and body; and

There is inseparability in the following sense: The soul can exist without the body, but not the body without the soul (Moreland, 2001[44], p. 22, 128).

This construal is at least consistent with physicalist intuitions that they, themselves, are distinct from their material bodies.

The foregoing does not make it unreasonable to conceive of a human being as an ensouled body. This conception of what a human being is, together with the foregoing arguments, has at least three implications or entailments. First, the soul is the bearer of its own life. Second, it explains why a person is not a brain or a material body. If a soul (person) is a body, as opposed to having a body, then a person who lost two legs, one eye, and one part of his brain has lost four parts of himself. However, the soul is a simple although a complex entity, in the sense that it has no parts (Barnett, 2008[1]). And third, my concept of a human being as an ensouled body suggests that the soul (person) as an immaterial mental and moral substance is diffuse throughout its body and therefore present in almost all of its parts (Moreland, 1998[43], p. 35). The reductionist or physicalist may ask whether there is any evidence for my suggestion.

We have already noted the scientific evidence in support of the interaction of the mind and the brain. In other words, in my construal of the ensouled body, whatever affects the body (and brain) will affect the soul (person/self), and vice versa. For example, thirst affects the body, but the person (not his or her brain) may worry if he or she discovered that the water he or she had is polluted with a toxin (see also Beauregard, 2007[2]; Beauregard and O’Leary, 2007[3]). The objector, the biological redutionist or physicalist, who believes that a brain is the thing that thinks, feels, and decide, might say that even thirst is a function of the body/brain, and that the brain causes drinking behaviour. Let us therefore assume that the brain believes that its body needs water, that it thinks that it is time to have some, and decide to act on its belief. Why am I capable of interfering with its beliefs, thoughts, and decisions? For example, by refusing to drink water and, say, because I wish to starve myself to death? Who or what was the cause of my death? It should be rather obvious: It must be me; my decision severely affected the biological processes of my body, and there is no reason not to think of the brain as well. I conclude that the brain is not the thing that thinks, feels, or decides. I (person/soul) do.

In support of the scientific evidence which has been noted and the intuitions of physicalists that are consistent with the commonsense view of ourselves, I shall next briefly focus on the nature of the self and the emotions of shame, guilt and remorse. By so doing, I hope to provide further evidence that the self (person) is not the same thing as a functioning brain, despite the fact that a person cannot function adequately without a brain. The relation between the person, his or her capacities, and brain is in many ways analogous to a fish and water. The water allows the fish to do certain things; it serves as a necessary condition for the fish's existence. But what it is that enables the fish to swim is its nature and capacities. Further, in terms of this analogy my visual sensation (perception) of my dog, together with my excitement at seeing him, is an experience and a state of myself and not a state of my eyeballs although a brain state may be observed by a neuroscientist when he looks at my brain on a computer screen. Eyes do not see and do not experience excitement; I do, and I see with or by means of my eyes. Eyes, ears, mouths, noses, and hands — the body in general, including the brain — are instruments a self (soul) uses to interact with and experience the environment. What I mean to say, therefore, is that there is a person or self who decides to do certain activities, and uses the brain and other body parts as instruments to carry them out. The brain, thus, is also an instrument, but not the central entity. The central entity is the person (soul) who not only has a body and brain but also animates the body and brain.

The self and moral emotions

The inclination to think that there can be no thought without a thinker, that there can be no feelings without a self or I who experience them, and that no hand can move a glass without someone (a self) deciding to move it, seems to be a very reasonable and responsible thing to think. At minimum, a self who is not conscious, self-conscious, able to self-reflect, and who is a subject of experiences, will be unable to give a report of those experiences to another person and evaluate them as appropriate, right or wrong, and good or bad. The same holds true of actions. By contrast, a self who is able to self-reflect is capable of self-evaluations leading to self-knowledge, an information-sensitive capacity that a self can cultivate or neglect. In short, the self (I, person, soul) is the subject of psychological attributes and the bearer of psychological capacities or powers.

Shame, guilt and remorse

The emotions of shame, guilt and remorse are referred to in the psychological literature as self-conscious emotions because they each involve a sense of self. They are called “moral emotions” because they involve moral standards and moral conduct, and are referred to as “negative emotions” because each of them can cause “intrapsychic pain.” These emotions are also often accompanied by “pangs of conscience” (Tangney et al., 1996[55], p. 1263; Tangney et al., 2007[56], p. 5). Consider now the characteristic features of each of these emotions.

Shame

Shamed people, following a wrongful action, typically focus on themselves. The reason is because objectionable behaviour is seen as a reflection of a defective or objectionable self; the I (the emphasis is on the “I”) did a horrible thing and the self is therefore experienced as bad. In other words, an error is attributed to one's own character. The feeling of shame is especially acute when the wrong committed causes a break in or a loss of intimacy with important others. This entails and implies that a shameful person is one who perceived or realized that he or she is no longer the kind of person others thought him or her to be. Typical self-reports of shamed persons are that they feel themselves exposed (Tangney et al., 2007[56], p. 5). Put differently, they are intensely self-aware and are ashamed of what they have become: Wrongdoers. It is therefore also typical of shamed individuals to hide themselves, to withdraw from or escape the scrutiny of important others. Alternatively, when under scrutiny, the shamed person will make attempts to shift blame, which could be indicative of a tendency to seek a scapegoat in order to justify him or herself (Tangney et al., 2007[56], p. 7).

Guilt

Whereas a shameful person focuses primarily on the self, the primary focus of guilty people seems to be their actions and the consequences thereof (Tangney et al., 2007[56], p. 4-6). Their concern is the offense committed, such as consciously breaking the law or having failed to comply with a rule, standard or protocol. Thus, if the guilty is aware of moral rightness in thought, word or deed, then it follows that the guilty must have perceived or realized that he or she has committed a moral wrong. A typical response of a guilty person would be to say, “I did that horrible thing,” with the emphasis on “did that” and “thing” (Tangney et al., 2011[57], p. 2). It may be indicative of a sense of responsibility, especially if the transgressor attempts to make reparation for his or her actions (e.g., seeking opportunities and ways to undo the harm caused). A typical example of such behaviour is the repentant sinner who acknowledges, confesses and asks for forgiveness for past transgressions. Another typical response of people with a deep-seated sense of guilt is to weep. In this way they express their sorrow, pain and regret — a feeling of deep disappointment and dissatisfaction with a certain state of affairs as a result of their actions. It is therefore arguably the case that a person can be guilty of an offense without feeling any regret, but difficult to imagine a person experiencing regret without guilt. Thus, in contrast to shameful people who seek separation or feel themselves alienated from those who disapprove of them, people plagued by guilt seem to seek reconciliation or connectedness with those they transgressed against (Tangney et al., 2007[56]).

Remorse

In contrast to the shameful person's primary focus on self, and the focus of the guilty on wrongful actions, the focus of the remorseful person seems to be mainly directed at other persons. It is not unreasonable to think that remorse can also involve harm caused to an animal (e.g., extreme cruelty or torture that led to its death). It follows that the well-being of those harmed would be the remorseful person's primary concern, in particular, the badness instead of the wrongfulness of an action (Tangney et al., 2007[56], p. 5). What they seem to be intensely aware of, in addition to how they themselves feel, and as a logical consequence of their concern, is the life or person that has been harmed. It could therefore be expected that feelings of remorse and regret will be especially acute when it involves the death of an innocent person and the realization that a life or person is irreplaceable (Gaita, 2004[24], p. xxi, 43-95).

The question now is whether the features of these self-conscious emotions can be predicated of a brain. It requires that I clarify what I consider to be a few conceptual confusions, and by so doing, establish whether a brain can be conscious, because feelings presuppose consciousness and self-awareness. The implication is not, however, that a person will be able to express conscious feelings without a functioning brain. By analogy, a fish is unable to swim without water, but the capacities to do so are those of the fish.

I begin with a few thoughts about the feeling of pain, since we increasingly hear from neuroscientists that pain is something that exists in a brain (Thacker and Moseley, 2012[58], p. 410-411). Commonsensically speaking, a pain is experienced by a person who is aware or conscious of it; if the person has toothache the person will readily point toward it to locate the source of the pain. But if the pain is in the person's brain, then we need to know how and where the person can point to, since the person is unable to access his or her own brain in order to do that. Of course, a person would not feel a pain unless the brain is operating properly. For example, a person would not feel toothache unless the nociceptor nerve terminals in the tooth pulp were excited, and this increased impulse firing was conveyed by the trigeminal nerve to the pons and then to the brain. But that does not at all imply that there is toothache in your brain or that your brain experiences (feels) toothache. However, the objector might say that pain does not exist in the brain, but is a sensation that is experienced in the brain. It does not make sense, however. If pain is experienced “in” the brain, then the brain must be able to experience relief from the pain, and it is difficult to comprehend how and why. The brain's function is to enable me to sense pain, just like a hand makes it possible for me to hold a glass. What we need to know from the objector is how a collection of millions of insentient neurons (McGinn, 2003[40], p. 438) can generate a pain and its subjective qualitative experience in self-awareness when we are told that the brain is not pain-sensitive (Restak, 2006[50], p. 35). In other words, how in the world does a self-conscious being (self/person/soul) arise from or is caused by a collection of insentient neurons (physical) things? A possible answer is to say that it is the whole brain that is conscious, or that consciousness arises because of the interactions among the neurons. But if the individual neurons are not conscious then we need an explanation of how the neurons as a whole could be. There seems to be an obvious problem. In the words of Chalmers (2007[11], p. 361): “Conscious experience is not directly observable in an experimental context, so we cannot generate data about the relationship between physical processes and experience at will. Nevertheless, we all have access to a rich source of data in our own case [i.e., the first-person perspective] (p. 361).” So it is simply assumed to be the case that a pain exists or is experienced in a brain, and that unconscious, insentient neurons can cause a conscious mental state of pain to exist, no matter how incoherent the notions may be. But perhaps the conclusion comes too quickly.

Let us consider what a neuroscientist sees when he looks at a scanner, say, when you are thinking about your pain. Bennett and Hacker (Bennett et al., 2007[5]) inform their readers that the only thing a brain scientist knows about a person when he is looking at a person's brain is “what goes on there while he is thinking; all fMRI scanners can show is which parts of his brain are metabolizing more oxygen than others when the person in the scanner is thinking” (p. 143 cf. also Bennett and Hacker, 2003[4], p. 83-84). Neuroethicist and molecular biologist Regina Kollek (2004[34]) makes the same point slightly differently. She writes:

Imaging techniques now enable us to monitor physiological activities and changes in the brain more directly. What we observe, however, are not cognitive processes or the mind, but electrical signals or patterns of blood oxygen and flow, which are, or may be, correlated with mind activities… Since processes associated with the self and other phenomena of the mind cannot be measured directly, the terms and concepts used to describe them are empirically undetermined (Kollek, 2004[.

In other words, the only thing a neuroscientist could discover are neural (brain) states that correlate with certain states of consciousness. “But that discovery cannot show that it is the brain that is conscious” (Bennett et al., 2007[5], p. 136). Therefore, the most plausible explanation, based on what the (non-reductionist) experts are telling us, together with what has been discussed in the previous section, is to say that it is the self (person) that is the subject of consciousness, despite the fact that brain damage will affect the expression of consciousness experiences.

This simple fact leads to another difference between a person and his or her brain. If a person is a brain, then there is no mental self; the brain is the only possessor of mental life — construed as physical processes, events or states of the brain. But a first-person point of view is the vantage point that a person uses to describe the world from his or her own perspective. So when I use the indexical “I”, then I use it to refer to what I, myself, know by a direct and immediate acquaintance with my own consciousness in acts of self-awareness. And it is precisely here where a problem arises for those who claim that we are our brains: No person has access to his or her own brain. Moreover, persons need not have access to their brains, or know what is going on in their skulls, or perceive it, unless a person is undergoing a brain scan and can see the scanner. This difference explains why a neuroscientist who is watching my brain on a computer screen while I am thinking has to ask me to give a report of what it is I am thinking about, and why. If I am a brain, as physicalists and reductionists believe I am, then the self-report I am providing him with will be a report of my brain In different words, a person has as little access to his or her brain as having access to his or her kidneys, lungs or heart.

We are told that “we perceive and understand only what our brains represent” (Farah and Heberlein, 2007[21], p. 40). Of first importance is to know where this confusing, unintelligible, and incoherent idea that a brain represents things originates from. Bennett and Hacker (2003[4]) provide the answer: “The idea was motivated, at least in part, by the thought that if the animal is to see, the brain must combine the information derived from the retinae to produce a representation of the visual scene. Undoubtedly, confusion was generated by the philosophical presuppositions of representationalism” (p. 142). Of second importance is to clarify the meaning of “representation,” and understand when one thing represents another thing. A ring in a tree trunk represents a year; a cartographer uses a map to represent the environment; a painter's picture represents a tree; a photo of grandma represents grandma; and I use language (symbols, words, sentences) to represent my thoughts, feelings, desires, and so forth. Now if the brain represents all these things, why have they never been seen or discovered in brains? Two points will suffice to answer the question.

First, when I look at a red rose, I perceive the red rose directly, and have it directly in consciousness in virtue of being a self-conscious or self-aware thinking, sensing, and experiencing subject. However, if a brain represents the rose and I perceive and understand only what my brain represents, then it means that I am not actually seeing the red rose before my brain represents it, and that is ill-conceived. Moreover, I will be unable to correct my belief about what it is that I have seen, since the idea that a brain represents objects implies that I will be trapped in my brain, behind my forehead. Put differently, if it is true that my brain represents objects before I perceive or understand them, then I can never directly inspect my dog in order to verify what I believe I know about him. But, reality teaches us something different. A painter first perceives a tree and then represents it in his painting. If he looks at my face, goes home and then paints it, then it will be because of his knowledge of my face which he retained in memory and was able to recall. Therefore, and second, for a person to perceive an atlas, photograph, or a painting is to perceive a representation. In sum, my brain is just as unable to paint a mental image of a snowy day as it is unable to paint my mother. A painter usually does that with a brush and paint on a palette, and there are no such things in a brain. There is another way to make the same point.

A person searches for an axe because the person knows what “axe” means and what its purpose is; the person recognizes it when the person perceives it, and feels a tremendous pain when it falls on his or her foot. For the brain to represent an axe, it must first be able to see the axe, but then, it must be able to go blind. But the brain is incapable of seeing or going blind; it can neither hear nor go deaf; it can neither sleep nor awake; it is unable to be thoughtful since it is unable to be thoughtless; and it is incapable of being decisive as it is incapable of being indecisive. So, too, the brain cannot be conscious simply because it cannot be unconscious. These things can only be predicated of a person. It is I who see and hear with or by means of my sense organs, and I am self-conscious. However, it does not suggest that changes in my brain cannot cause me to lose consciousness. In short, it is evident that there are a few things true of a person that is not true of his or her brain.

A final area of conceptual confusion relates to the concept of intentionality (the of-ness or about-ness of a person's mind), which, as already been noted, is a distinctive mark of mental states, especially thoughts (Beauregard, 2007[2]). Now, if a painter is looking at a tree and thinking about it, then the painter is consciously directing his or her mind at the tree, which the mental state of thinking is of or about. But that cannot be said of a brain, simply because a brain, like any other physical object, lacks intentionality. In other words, one brain can never be about another brain, and neither is one brain able to transfer thoughts to another brain. You and I, as persons, do that through gestures and language. From this follows that a brain is unable to analyze and prioritize information, or decipher images. To be able to analyze and decipher anything entail that the analyzer and decipherer must first have learned certain things (e.g., symbols), acquired knowledge, and retained the things learned and known in memory. We thus say that a person possesses knowledge, and things such as books, computers, and filing cabinets contain knowledge. In this sense, the brain neither possess nor contains anything; I am unable to open my brain like a book or access it like a library or filing cabinet to tell you what is in there.

By way of summary, moral emotions have formal and specific objects; their features show that they signal that something is wrong somewhere, that something needs to be attended to, and made right. A person is unable to attend to and make right whatever is wrong with his or her own brain, simply because the person cannot access his or her brain the way a person can access a room and tidies it. What ashamed people are ashamed of are themselves, not their brains. What causes shame is the disapproval of other persons, even if the brain enables a person to perceive or realize the approval of others [by now it should be clear that everything that I have said presupposes this fact]. To feel guilty is to recognize and acknowledge that one's actions was wrong, not one's brain, unless it can be shown that a person suffers from a brain disease. And what remorseful people deeply regret are the badness of their action and the harm caused to others, and not the badness of their brains. The moral pangs of conscience that accompany these emotions can therefore not be the pangs of a brain, but the pain of persons endowed with moral and mental capacities to experience feelings. It implies that moral emotions are rational; people who experience them experience them for a reason. Since it is a person who experiences emotions, it is unintelligible to think that a brain can have reasons to feel ashamed of itself. Self conscious moral emotions presuppose a person's capacity for self-awareness, including the ability to evaluate themselves (not their brains!), their actions as right or wrong and their affects on other people, whether good or bad. None of the mental and emotional states will function properly in the absence of brain function or when a brain is dysfunctional in some way: “Unquestionably the appropriate functioning of the brain is a central condition of feeling emotions” (Bennett and Hacker, 2003[4], p. 208; emphasis in the original). However, nothing of what has been said implies that shame, guilt, or remorse associated with brain functions and brain activity cannot be functions of or caused by a person whose emotions they are. To see that requires that we briefly consider a person as a first cause of events.

The person (soul) as a first unmoved cause

Two points deserve mention. Firstly, it does not follow from the fact that if the brain is the central condition for the feeling of emotion such as shame, guilt, and remorse that brain states are mental or emotional states of a person. Secondly, one can also feel “emotion without knowing anything at all about the activities of the brain” (Bennett and Hacker, 2003[4], p. 208), but that does not mean that the immaterial soul (person/self) is not the first cause of what is happening in the brain. I will attempt to clarify the points made with the following characterization:

A person is a substance that has the power (ability) to cause a broom to move. Although the brain makes it possible for the person to move the broom, it is not the brain that moves a broom, neither can it pick it up for it has not any arms and hands to do so.

A person exerts his or her power as a first mover (an uncaused cause of action) to cause or refrain from causing the broom to move.

A person caused the broom to move for the sake of some final cause (e.g., to clean the floor), which is the reason the person caused the moving of the broom.

I can also put the characterization this way: A broom moves the leaves but is itself moved by my hand that is moved by me, myself. In other words, I am the direct, primary, first unmoved caused of the leaves. We can see that both the broom and hand moving are events caused by me. However, a physicalist neuroscientist may object to this. He might say that we know from physiology that there are still other events causing my hand to move, for example, the muscles in my arm and the events taking place in my brain. He might add that if the brain moves muscles and caused the hand to move, then there is no point to appeal to an agent (self) as distinguished from a process or an event, for the whole thing is a matter of causal relations among events or states of affairs.

At least three things could be said in response.

First, there is a sense in which this objection is valid, for a person does not do anything with or to his brain (cf. Bennett and Hacker, 2003[4], p. 83-84), in the sense that he does with his hand and broom. Second, the objections do not imply that a person is not the first cause of whatever happened in his brain. To see this we need to draw a distinction between making something A happen and doing A. If I reach for a broom to pick it up, then one of the things I do is just that: I reach for the broom and pick it up. But if that is something I do, then it follows that it is something I know that I do. If you ask me whether I am doing something or trying to do something, I will immediately be able to tell you. However, during this whole process of me doing something, I made a whole lot of things to happen which are not in any sense things that I do: I would have made air-particles to move; I may have freed an ant heap from the pressure that had been upon it by the broom; I may also have caused a shadow to move from one place to another. Now, if these are merely things that I made to happen, as distinguished from what I do, then I may know nothing about them. Therefore, it is not to say that if I am not aware of making things to happen in my brain when I do or experience emotions of shame, guilt, or regret that I am not the cause of the events happening within it. And third, it helps us to explain the “I” and the sense of self. The pronoun I refers to a substantial self (soul/person) because such a self uses I in acts of self-reference, which makes the term I a personal pronoun in the first place. Selfhood is therefore the same thing as personhood, which refers to that range of properties and ultimate capacities that characterize all and only persons, for example, responsible agency, moral awareness (cf. the moral emotions), thoughts, beliefs, and desires. Therefore, if I am the bearer of my own properties, then the indexical “I” refers to what I, myself, perceive, think, believe, feel, desire, know and remember from a first-person perspective. Of course, the brain enables me to exercise these functions and acts.

This understanding of doings things and making things happening within myself and brain and body is borne out by studies which show that self-related emotions (shame and guilt) “can cause inflammatory products, and that shame may have specific immunological correlates” (Dickerson et al. 2004[18], p. 124). It has at least one implication for the medicalisation and treatment of moral problems. Medicalisation of moral problems may lure people into thinking that something else rather than themselves and their actions is the cause of their moral emotions (cf. Maturo, 2012[38]). In different words, from medicalisation of moral problems is a short step to thinking that moral pain or suffering is abnormal.

Which brings me to a short comment on a related topic: The crisis in psychiatry

The crisis in psychiatry

That psychiatry, as a branch of medicine and a profession is facing a crisis today, is beyond any doubt. Some of the most important reasons listed in the literature are as follows:

Biological reductionism: The brain is seen as the key to both the cause and treatment of personal and interpersonal problems (Cohen, 1993[13]; Erickson, 2010[20], Singh, 2013[53]), and the medicalization and over-diagnosis of these problems (Frances and Widiger, 2012[22]).

The outcome of “psychopharmacological medications, now many years old, seem less and less impressive” (Kleinman, 2012[33], p. 421).

The view that there is a “single way to diagnose any mental disorder — and don't let any expert tell you that there is…. There are no objective tests in psychiatry, no X-ray, laboratory, or exam finding that says definitely that someone does or does not have a mental disorder” (Frances and Widiger, 2012[22], p. 115, 116; Singh, 2013[53], p. 42, 58).

There is, after over 60 years of debate, no consensus about the concept of “mental disorder” and “mental illness” (Frances and Widiger, 2012[22]; Kleinman, 2012[33]).

The reliability and validity of most of the mental disorders are still questionable (Kutchins and Kirk, 1997[35]).

The overlap between and mischaracterization of character and conduct as mental illnesses or disorders are still contentious issues among psychiatrists (Erickson, 2008[19], 2010[20]; Sadler, 2009[51]).

There are serious concerns about the abuse of psychiatric diagnosis in the justice system (Erickson, 2008[19], 2010[20]).

Psychiatrists are continually accused of “disease mongering,” and the involvement of pharmaceutical companies in the classification and treatment of disorders is a cause of great concern among critics of psychiatry (Maturo, 2012[38]; Moynihan et al., 2002[45]).

After decades of investment in psychiatry, these points are both intriguing and significant. It seems fair to conclude that the so-called mind-body problem functions as a useful distraction from what is otherwise the more fundamental problem [Figure 1].

Figure 1

Flowchart of paper

Concluding Remarks

The evidence and arguments presented in this reply to Neeta Mehta's critique of mind-body dualism is contrary to her thesis: Mind-body dualism is inescapable, and endeavours to avoid its ontology are the cause of a whole gamut of unnecessary problems and debates. It seems fair to say that at the heart of the matter is an intellectual devotion to and fascination with physicalism and biological reductionism. The existence and the nature of the soul, and the belief in an afterlife are pretty much commonsense. At least, that is what physicalists are telling dualists. But the metaphysic (worldview) of physicalists do not allow them to admit that the world consist of more than just material entities. However, the first-person perspective, direct and immediate knowledge of oneself, scientific findings that support mind-brain causation, people's commonsense notions of themselves, the Christian Scriptures, and NDEs provide strong evidence to believe that a person is not a brain. To feel shame, guilt or remorse, what one must know are the objects of one's feelings: Things that a person needs to attend to and make right. Provided that a person has sufficient coping reserves and skills, is it not better to regard the emotional pain and pangs of conscience as crucial elements toward recovery? If that is the right way to proceed, then health practitioners are saddled with a daunting ethical responsibility: To respond to suffering individuals by helping them to attend to the roots of their suffering.

Finally, if a person strives to be a person of a certain sort, then interferences with that project will cause psychological distress. For anyone to ignore the role of conscience in distress would mean to ignore something central to normal human functioning. This implies that the distress is not a reason to medicalise a person's conscience. Put another way, if conscience derives its significance from a wrong committed, then a person who is seeking medication is not someone seeking a cure for a physiological (brain) disease. To make a person think otherwise is to mislead him or her. That, however, does not delegitimize psychiatric disorders, or the work that the psychiatric establishment is doing to mitigate psychiatric morbidity and mortality.

Take home message

Physicalists reduced the mind to what the brain does, thus as the thing that thinks, feels and decides. They use the so-called mind-body or mind-brain problem, which is in reality the soul-body problem, as a scapegoat and explanation for the problems health professionals are facing. But physicalists have much to explain. Instead of reducing a person to a brain and seeing the mind as a function of the brain, the position of this paper is that a human being is an ensouled body. A person (soul/self) has a mind, including a body. The body and its organs are instruments in service of the person to interact with the environment. Psychological researchers agree on one fundamental issue, namely, that shame, guilt, and remorse are inextricable woven with the concept of the self. The moral emotions indicate that there are things a person needs to attend to and make right. Healthcare and well-being are matters of the soul and the body, and together, the whole human being. Psychiatry is both a medical and moral science.

Questions that the Paper Raises

What do health professionals treat?

Is it physical disorders or mental disorders?

Is there a difference, and if so, which came first, and does it matter?

Is the so-called mind-body problem not a pseudo-problem?

Are the brain sciences parasitic on commonsense (folk psychology)?

Could so many people, including physicalists who agree that mind-body dualism is a basic feature of experience, all be wrong?

If mind-body dualism seems to be so natural, why not, then, let it be so?

If a human being is an ensouled body, what does inseparability and distinctness entail for brain studies and ethical medical practice?

If a person is a brain, does it still make sense to treat the whole human being as a biological, and psychological, and spiritual, and moral being situated in a social context?

How are the self-conscious moral emotions related to who a person wants to be and not to be?

About the Author

Callie Joubert holds a PhD (philosophy and ethics) from the University of KwaZulu-Natal (South Africa). His PhD research focused on metaphysics, the philosophy of mind and the ethics of care. He also holds a D.Phil (occupation psychology) from the University of Johannesburg (South Africa). His is an independent researcher and bioethicist in private practice. His research interests are in issues related to soul-body or mind-brain interaction (e.g., psychosomatic illnesses; neuroscience); moral psychology and philosophy; and ethical decision making, conflict management and problem solving in matters related to bioethics (e.g., brain-death and organ donation, euthanasia, abortion, infanticide, and so forth). He is author of the book Rethinking existence: The person and being-in-the-world (2006; Pretoria: Berea Publishing), and has also published in various peer reviewed journals.