Our bodies are physico-chemical machines. When the function of the machine deviates from what is generally considered normal and if we regard the deviation as harmful and unwanted, we call the event or process a "disease." Like all physical-chemical events, diseases have causes, which physicians call "etiology." The familiar causes of disease are pathogenic microbes, toxic chemicals, x-rays, genes (heredity), and trauma (injury).

Curiously, one of the most important causes of disease in the modern world-namely, the self, the body's owner-is not recognized as such by the medical profession. Many years ago I suggested that we call these diseases "autogenic," much as we call diseases caused by physicians or medical interventions "iatrogenic." (Webster's defines "iatrogenic" as "induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.")

There are many ways in which a person may cause himself to be ill, some innocent, others blameworthy, depending on the point of view of the person judging the agent's behavior. The classic example of autogenic illness is the soldier in the trenches during World War I who, in a desperate attempt to save his life, shoots himself in the foot. Called "malingering," this kind of dereliction of duty was usually punished by execution. Webster's still defines "to malinger" as "to pretend incapacity (as illness) so as to avoid duty or work." Prior to World War II, malingering was, by definition, a nondisease. Today, it is a "no-fault" (mental) disease: political-psychiatric correctness now decrees that the person called "patient" is, ipso facto, a "victim," not responsible for what ails him. (This may or may not be the case.) The idea of autogenic, or self-induced, illness negates this premise. Unsurprisingly, the idea has not caught on.

Thanks to the corrupting influence of psychiatry on medicine, faking illness is now officially classified as a disease, called "factitious disorder." The widely used Merck Manual (not a psychiatric text) states: "Patients may consciously produce the manifestations of a disease, e.g., by traumatizing their skin, injecting themselves with insulin. . . ." This is foolish. Persons intent on making themselves sick do not merely produce the "manifestations of a disease," they produce a disease, by mutilating or poisoning themselves, for example, with an overdose of Tylenol.

The American Psychiatric Association's definition of factitious disorder is even more foolish: "The essential feature is the presentation of physical symptoms that are not real. The presentation may be . . . self-inflicted, as in the production of abscesses by injection of saliva into the skin." If such abscesses are not real abscesses, then persons whose death is self-inflicted are not really dead.

Equipped with such profound neuro biological insight into the nature of human diseases, we are appropriately unprepared-or, perhaps more accurately, misprepared-to understand the epidemic of autogenic diseases that now plague us.

Obesity as a Paradigmatic Autogenic Disease

On December 16, 2003, the New York Times reported that the Food and Drug Administration has approved Xenical "for the treatment of obese teenagers." A spokesman for Hoffman-La Roche, the manufacturer, is quoted as having said that this was "good news for children who battle obesity" and that "we're thrilled with the approval." That this development is good news for the manufacturer of the drug is selfevident. That it is catastrophic for children who battle obesity and our society in general is less obvious but more ominous.

The body is a machine fueled by calories. We call the fuel "food" and the act of fueling "eating." If fewer calories are put into the body than it burns, then the body will gradually lose weight and die. If more are put into it, it will become heavier than "normal," that is, obese. Xenical, we learn, "has several unpleasant side effects, including problems with bowel control, and it works best when combined with a low-caloric diet that limits foods high in fat." A diet low enough in calories is, by definition, effective in preventing obesity.

Obesity is a typical autogenic illness. Eating and not eating are voluntary acts. If we do not expect children, as well as adults, to exercise self-control over the foods they eat, over which behaviors do we expect them to exercise self-control?

Obesity may be classified as a disease for two reasons: because it is an unwanted deviation from the norm and because it "causes" (leads to the development) of other diseases, among them diabetes and cardiovascular disease. To be sure, most people who overeat do so not to become obese but for other reasons, just as most people who smoke do so not to get cancer but for other reasons. Note, however, that we call smoking a disease, but do not (yet) call overeating a disease.

Is the individual who is obese or has lung cancer responsible for his illness? (Ignore, for the sake of argument, that some nonsmokers also get lung cancer.) Eating and smoking are behaviors under our conscious control. Either we assume responsibility for our behaviors and their consequences or we assign responsibility for them to others-the manufacturers and merchants who provide us with a high standard of living and comfort and amusement-and blame them. Thus do the food companies, tobacco companies, pharmaceutical companies, and so forth, become the causes of our diseases.

None of this has anything to do with medicine or science. All of this is the consequence of post-World War II political-economic developments: obfuscating the differences between the interests of the self and the interests of others and destroying the cash nexus in the delivery of medical services.

Formerly, Jones paid for the treatment of his lung cancer, just as he paid for his cigarettes. Today, he still pays for his cigarettes, but others (the insurance pool or taxpayers) pay for his medical care. If Jones's illness is an economic burden on others, then others have a rational interest in Jones's not making himself sick.

The result is a negation of the differences between dangerousness to self and dangerousness to others: the private sphere, free of state regulation, merges into the public sphere, the object of state regulation. The principle of "caveat emptor" is replaced by the principle of "caveat vendor." Welcome to the therapeutic state.

Thomas Szasz (tszasz@aol.com) is professor of psychiatry emeritus at SUNY Upstate Medical University in Syracuse. His latest works are Words to the Wise: A Medical-Philosophical Dictionary (January 2004) and Faith in Freedom: Libertarian Principles and Psychiatric Practices (May 2004), both published by Transaction.

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