Not long ago I asked a patient of mine how he would describe his own character. He paused for a moment, as if savoring a delicious morsel.
"I take people as they come," he replied in due course. "I'm very nonjudgmental."
As his two roommates had recently decamped, stealing his prize possessions and leaving him with ruinous debts to pay, his neutrality toward human character seemed not generous but stupid, a kind of prophylactic against learning from experience. Yet nonjudgmentalism has become so universally accepted as the highest, indeed the only, virtue that he spoke of his own character as if pinning a medal for exceptional merit on his own chest.
That same week I was consulted by another patient who had experienced even worse consequences of nonjudgmentalism, though this time not entirely her own. Her life had been that of the modern slum dweller: three children by different fathers, none of whom supported her in any way and the last of whom was a vicious, violent drunk. She had separated from him by fleeing with their two-year-old to a hostel for battered women; soon afterward she found herself an apartment whose whereabouts he did not know.
Unfortunately, sometime later she was admitted to the hospital for an operation. As she had no one to whom she could entrust the child, she turned to Social Services for help. The social workers insisted, against her desperate pleas, that the child should stay with his biological father while she was in the hospital. They were deaf to her argument that he was an unsuitable guardian, even for two weeks: he would regard the child as an encumbrance, an intolerable interference with his daily routine of drinking, whoring, and fighting. They said it was wrong to pass judgment on a man like this and threatened her with dire consequences if she did not agree to their plan. So the two-year-old was sent to his father as they demanded.
Within the week he and his new girlfriend had killed the child by swinging him against the wall repeatedly by his ankles and smashing his head. At this somewhat belated juncture, society did reluctantly make a judgment: the murderers both received life sentences.
Of course, the rush to nonjudgment is in part a reaction against the cruel or unthinking application of moral codes in the past. A friend of mine recently discovered a woman in her nineties who had lived as a "patient" in a large lunatic asylum for more than 70 years but whose only illnessas far as he was able to discoverhad been to give birth to an illegitimate child in the 1920s. No one, surely, would wish to see the return of such monstrous incarceration and cavalier destruction of women's lives: but it does not follow from this that mass illegitimacy (33 percent in the country as a whole, 70 percent in my hospital) is a good thing, or at least not a bad thing. Judgment is precisely thatjudgment. It is not the measure of every action by an infallible and rigid instrument.
Apologists for nonjudgmentalism point, above all, to its supposed quality of compassion. A man who judges others will sometimes condemn them and therefore deny them aid and assistance: whereas the man who refuses to judge excludes no one from his all-embracing compassion. He never asks where his fellowman's suffering comes from, whether it be self-inflicted or no: for whatever its source, he sympathizes with it and succors the sufferer.
The housing department of my city holds fast to this doctrine. It allocates scarce public housing, it says in its self-congratulatory leaflets, solely on the basis of need (give or take a nepotistic connection or twoafter all, even the nonjudgmental are human). It never asks how the need arose in the first place: it is there to care, not to condemn.
In practice, of course, things are a little different. It is true that the housing department makes no judgments as to the deserts of the applicants for its largesse, but that is precisely why it cannot express any human compassion whatever. Its estimation of need is mathematical, based on a perverse algebra of sociopathology. To return to the case of my patient whose child had been murdered: she was driven from her home by her neighbors, who felt that she was responsible for the death of her child and therefore acted as good, outraged citizens by twice attempting to burn down her apartment. Thereafter she found cheap lodgings in a house where there also lodged a violent drug addict, who forced his attentions upon her. When she applied to the housing department for help, it refused her on the grounds that she was already adequately housed, in the sense of having four walls around her and a roof over her head (and it would be wholly wrong to stigmatize drug addicts as undesirable neighbors), and also because she had no young dependentsher only young dependent having been murdered and therefore not part of the equation. Stones might have wept at my patient's predicament, but not the housing department: it is far too nonjudgmental to do so.
Curiously enough, my patient was perfectly ablewith a little encouragementto accept that her misfortunes did not come entirely out of the blue, that she had contributed to them by her own conduct and was therefore not a pure or immaculate victim. Taking the line of least resistance, as she had done throughout her life, she had consented to have a child by a man whom she knew to be thoroughly unsuitable as a parent. Indeed, she had known him to be violent and drunken even before she went to live with him, but she still found him attractive; and she lived in a society that promotes its own version of the Sermon on the MountSufficient unto the day is the attraction thereof. She had learned now from experience (better late than never)which she could never have done had she refrained from making judgments about both herself and others. As a result, she had rejected another violent lover, abjured her own habitual drunkenness, and decided to go to college.
In the clinic, of course, a kind of nonjudgmentalism does and should hold sway: doctors ought never to refuse treatment on the grounds of moral deficiency. Moses Maimonides, the twelfth-century rabbi and doctor, wrote: "May I never see in the patient anything but a fellow creature in pain"surely a noble aspiration, if somewhat difficult of achievement in practice.
But medicine is not just the passive contemplation of suffering: it is the attempt, by no means always successful, to alleviate it. And it cannot have escaped the attention of doctors that much modern suffering has a distinct flavor of self-infliction. I am not talking now of the physical illnesses that derive from habits such as smoking, but rather of the chronic suffering caused by not knowing how to live, or rather by imagining that life can be lived as an entertainment, as an extended video, as nothing but a series of pleasures of the moment. The whirligig of time brings in its revengesat least in a cold climate such as ours.
If the doctor has a duty to relieve the suffering of his patients, he must have some idea where that suffering comes from, and this involves the retention of judgment, including moral judgment. And if, as far as he can tell in good faith, the misery of his patients derives from the way they live, he has a duty to tell them sowhich often involves a more or less explicit condemnation of their way of life as completely incompatible with a satisfying existence. By avoiding the issue, the doctor is not being kind to his patients; he is being cowardly. Moreover, by refusing to place the onus on the patients to improve their lot, he is likely to mislead them into supposing that he has some purely technical or pharmacological answer to their problems, thus helping to perpetuate them.
For example, I am consulted at least once or twice a dayweek in, week out; year in, year outby women who complain of anxiety and depression, whose biographies contain obvious explanations for these unpleasant feelings. The women have often endured more than one violent sexual relationship, sometimes as many as four in succession, and have more than one young child to bring up. While they fear the loneliness of managing on their own, without help from another adult, they have come to the conclusion that all men are unreliable, even psychopathic. They are in an apparently insoluble dilemma: are they better off battered or alone?
Aided by a few simple questions, it doesn't take them long to analyze their situation, though at the outset they invariably ascribe their unhappiness to bad luck or fate. Such is the power of self-deception that even the most obvious considerations escape them. A few weeks ago a woman came to see me complaining of having been miserable and dissatisfied with her life for 20 years. Her husband treated her like a slave, and when he was not obeyed, he became aggressive, either throwing things about the room, smashing windows, or beating her.
"Why don't you leave him?" I asked.
"I feel sorry for him."
"Well, because he's not very bright, doctor, and he doesn't know how to read or write. He couldn't manage on his own; he can't do anything for himself. I even have to dial the telephone for him because he can't read the numbers."
"Does he work?"
"Yes, he's always worked."
"What does he do?"
"He's in charge of security at the Hall"a large Elizabethan stately home on the outskirts of the city, owned by the municipality.
"How many people work in the security department there?" I asked her.
"You mean, every time he has to make a telephone call there, he asks one of his staff to do it for him because he can't read the numbers? Or every time he receives a letter, he has to have someone read it out to him?"
My patient looked at me wide-eyed. Obvious as this was, she hadn't thought of it.
"It's not very likely, is it, that such a man would be made the boss," I added.
She had failed, through cowardice and self-indulgence, to think about the clear discrepancy between her husband's career and his supposed helplessness at home: for had she recognized it, she could no longer think of herself as a victim (with all the psychological comfort that victimhood brings) but rather as the co-author of her own misery. She wanted to avoid a painful dilemma: either to accept the situation as it was or to do something about it.
After two more conversations with me, she did something about it. She delivered an ultimatum to her husband: either he must modify his behavior or she would leave him. Further, if ever he laid a finger upon her again, she would call the police and press charges against him. Since then he has behaved and even done what for 20 years she believed him incapable of doing: he made a cup of tea for himself. Meanwhile she has gone to art classes instead of imprisoning herself in their apartment, awaiting his arbitrary orders.
This patient had only one violent man to contend with; many of my patients have had a succession of them. I ask where they met them, and almost without exception it was in a bar or a nightclub when they were both at a loose end, a previous relationship having broken up the week, or even the day, before. I ask what they had in common, apart from loss and loneliness. The invariable answer: sexual attraction and the desire for a good night out.
These are not contemptible in themselves, of course, but as the foundation of long-term relationships and parenthood, they are a little thin and soon wear even thinner. I ask what other interests the women and their lovers have in common, and invariably there are none. The day-to-day flux is their whole world: a little shopping, a little cooking, a little tidying up, a lot of television, a visit to the social security office, and a few hours in the pub while the money lasts. This aimless routine soon palls but nevertheless remains a subject for continual and acrimonious disagreement. Moreover, there is no pressureeither moral pressure from the community or economic pressure from the system of taxation and social security benefitsto keep couples together. Before long, neither necessity nor desire cements relationshipsonly inertia, punctuated by violence. For the violent man, to have a woman trembling in fear of him is his only guarantee of personal significance.
But how, the women ask, are they to meet men who are not like this? How is a woman to find someone who will not exploit her alternately as a meal ticket and an object for the relief of sexual tension, who will not spend his own social security money in a single night out and then demand to be given hers as well, despite the fact that this money is needed to feed the children? How is she to find a man who will actually provide something in return, such as companionship and unconditional support?
The answer necessarily involves an examination of how they have lived, from their childhood onward. For if, as I contend and they agree, it is necessary to have interests in common in order to achieve some depth in a relationship, how are such interests generated in the first place?
The woeful inadequacy of their upbringing, education, and outlook becomes apparent to them, perhaps for the first time.
"What are you interested in?" I ask. The question comes like a warning shot.
"Well . . . nothing, really," they reply. They recognize the unsatisfactory nature of their answerwhich is all too truthfulat once.
"Did you try hard at school?"
"What did you do instead?"
"Messed around, like everyone else."
Their peers discouraged, sometimes by physical violence, those few who showed some inclination to work. To have resisted the prevailing ethos would have required exceptional courage, as well as parental backing, which was invariably missing. It was better to go along with the crowd and enjoy the illicit pleasures of the moment. It didn't really matter: after all, there would always be enough to eat, a roof over one's head, and a television to watch, thanks to subventions from the state. Besides which, it is a truth universally acknowledged in the slums that there is nothing to be gained by individual effort, since the world is so unjustly organized. And in the absence of either fear or hope, only the present moment has any reality: you do what is most amusing, or least boring, at each passing moment.
In the absence of an interest or career, motherhood seems a good choice: only later does it become clear just how entrapping it is, especially when the fatherpredictably, but not predictedlytakes no share of parental duties.
With no experience or knowledge of the worlds of science, art, or literature, and deprived of the sheer necessity to earn their subsistence, my patients are rich in nothing but time on their hands, and so they embark upon the Liaisons Dangereuses of the slums. But the relationships in which they thus embroil themselves are incapable for long of sustaining the burden placed upon them, and the descent into misery, drudgery, squalor, and fear is almost immediate.
In their late twenties the most intelligent among them say to me, "There's something missing in my life, but I don't know what it is." They remind me of the young people I met behind the Iron Curtain, who had never known any other life than that under the Communists, who knew little of the outside world and yet knew that their way of life was both abnormal and intolerable.
My patients medicalize both their own misery and the terrible conduct of their violent lovers, a way of explaining their existential dissatisfaction that absolves them of responsibility. It takes little time, however, to disabuse them of their misconceptions, and the fact that I am often able to predict from very near the outset of our consultation how their lovers have behaved toward them astonishes them. Last week I saw a patient who had taken an overdose after her boyfriend beat her up. Our dialogue followed a set pattern.
"And, of course, he sometimes grabs you round the throat and squeezes and tries to strangle you?" I ask.
"How did you know, doctor?"
"Because I've heard it practically every day for the last seven years. And you have marks on your neck."
"He doesn't do it all the time, doctor." This is the universal extenuation offered.
"And, of course, he apologizes afterward and tells you it won't happen again. And you believe him."
"Yes. I really think he needs help, doctor."
"Why do you say that?"
"Well, when he does it, he changes completely; he becomes another person; his eyes stare; it's like he has a fit. I really think he can't help it; he's got no control over it."
"Would he do it in front of me, here, now, in this room?"
"No, of course not."
"Then he can help it, can't he?"
The woman's desire to avoid a painful dilemmalove him and be beaten, or leave him and miss himprevented her from asking herself the very obvious question as to why the "fits" happened only in the privacy of their apartment. Suddenly, inescapably, the responsibility for alleviating her misery became hers: she had to make a choice.
"But I love him, doctor."
The triumph of the doctrine of the sovereignty of sentiment over sense would have delighted the Romantics, no doubt, but it has promoted an unconscionable amount of misery.
"Your boyfriend is unlikely to change. He strangles you because he enjoys it and gets a feeling of power from doing so. It makes him feel big: I strangle her, but she still loves me, so I must be really wonderful.' If you leave him, he'll find someone else to strangle within the week."
"But it's difficult, doctor."
"I didn't say it was easy; I said it was necessary. There's no reason why what is necessary should also be easy. But you can't expect doctors to make you happy while your lover is still strangling you, or to make him stop strangling you. Neither of these things is possible. You must make a choice. There is simply no way round it."
To tell such a patient that she is responsible, both practically and morally, for her own life is not to deny her help; it is to tell her the truth. To force her to face her complicity in her misery is not to abandon her to her fate. On many occasions I have put such women in touch with lawyers, I have found them safe accommodation, I have found them places in colleges. Nor do I demand an immediate decision; what has taken years to develop is rarely undone in an hour or two. But I stick to the fundamental truth: that no doctor, no social worker, no policeman, can improve the quality of such a woman's life unless she is willing to forgo whatever gratification she derives from her violent boy-friend. There is no painless way of resolving the dilemma.
In almost all cases the women return a few weeks later much improved in their mood. The love they thought they felt for their tormentors has evaporated; they find it difficult in retrospect to distinguish it from the fear they felt.
What should we do now? they ask me.
How am I to answer them? Should I pretend to an agnosticism about what might constitute a better life for them and their children? Should I pretend that a promiscuous granting of their favors to the first man they meet in a pub is as good as taking a little care over such matters? Wouldn't that be the ultimate betrayal?
I advise them that their first responsibility is to do everything in their power to prevent their children from following in their footsteps; they should try to open horizons to them beyond the miserable and sordid ones visible from the slums. This will involve spending time with them, taking an interest in their schoolwork, learning to say no to them when the occasion arises, and above all, ensuring that they never again witness scenes of domestic violence.
As for themselves, they should try to go to college: for even if it fails to render them more employable, they will at least gain a sense of achievement and possibly an enduring interest. And if that means they have to break the rules governing social securitywhich decree that they should be theoretically available for work and therefore not engaged in full-time educationwell, I am not going to inform the authorities, who (it seems) prefer their dependents utterly passive.
They often take my suggestions. (One of my patients, beaten for 20 years, has since become a nurse, and many others work as assistants in nursing homes, the desire to help others being a corollary of their desire to help themselves.) I am probably the only person they have ever met to whom the violence of their lives is not as natural as the air they breathe but the result of human choices; I am the only person who has ever suggested to them that they can behave otherwise than they do behave.
It would be vain to suggest that this approach works in every case. Judgment is necessary, too, in selecting the cases; there are those who are too old, too psychologically fragile, or too young to bear the pain of accepting partial responsibility for their own misery. Alas, there is a period during the downward spiral of self-destruction when little can be done, as if self-destruction has a natural course of its own. Just as alcoholics and drug addicts may take years to accept first, that they are addicted, and second, that addiction is neither an excuse for their conduct nor a fate imposed upon them by circumstances, so the willful self-destruction that I see around me often runs a prolonged course, thanks to the powers of human self-deception.
It can rarely be nipped in the bud. For example, in the week in which the woman whose child had been murdered consulted me, two young women came to my notice, neither of whom gave any thought to the future or to the past, and both of whom sleepwalked through the present.
The first was barely 16, a white girl two months pregnant by a Muslim burglar. She was covered in bruises. They had met when he burgled her house, where she had been left alone for the night by her single mother, with whom she fought like a cat and a dog tied up in a sack over the time she should come home at night from clubs and discotheques (her mother suggesting the abominably early hour of midnight). The burglar asked her to come with him, and she did; thenceforth he locked her up, never allowed her out of the apartment, forbade all contact with others, beat her black and blue, kicked her regularly in the stomach, demanded her conversion to Islam (he himself was a drunk), and in general expected her to be his slave.
When he went into the hospital for a small operationthe repair of a tendon in his arm, injured in the course of housebreakingshe had an opportunity to escape. I offered her every facility to do so, from a safe house to the services of a lawyer paid for by the public purse.
"I can't leave him," she said. "I love him, and he said he'd kill himself if I leave him."
I know from experience that such a man might take an overdose as a form of emotional blackmail: the vast majority of male overdoses in my ward are of men who have beaten their womenthe overdoses serve the dual function of blackmailing the women into remaining with them and of presenting themselves as the victims rather than the perpetrators of their own violence. I also know from experience that the Muslim burglar would never actually kill himself. But when a young woman says she fears the suicide of her lover, she is in effect saying that she will not yet leave him, and nothing will induce her to change her mind.
While the Muslim burglar remained in the hospital, she appeared every day, dressed in Punjabi costume, to tend her tormentor-lover, to bring him his Indian delicacies and all the little comforts he lacked.
The second young patient was a black girl, now age 17, whose parents first knew of her liaison with a white boy a year older than she when her teacher brought her home from school at the age of 14, having been beaten up by the boy in the schoolyard. A few months later she gave birth to his child, and they went to live together. (No doubt future social historians will find the contradiction between our concern about sexual abuse, on the one hand, and our connivance at and indifference to precocious sexual activity, on the other, as curious as we find the contrast between Victorian sexual prudery and the vast size of the Victorian demimonde.) Fatherhood did not improve the young man's conduct: he broke her jaw, fractured her ribs, partially strangled her, punched her regularly, and used her head to break a closed window before pushing her out of it altogether. He did not work, took her money for drink, went to spend nights with other girls, and demanded his meals be ready for him to suit his convenience.
I offered her, too, every opportunity to leave, every legal protection it was possible to provide, but her cup of bitterness, like the first girl's, was not yet full ("It's all right for you; you don't love him!") and therefore not yet ready to be drained. All one could do was offer to help whenever she was ready to ask for it.
Neither of these young women was deficient in intelligence, far from it; and in a few years, when they appear again in my hospital, as inevitably they will, they'll be ready to examine the source of their suffering, having wasted so much time. I hope someone will have the courage and compassion to guide them to that source: for only if the veil of self-deception is torn from their eyes can they improve the quality of their lives.
Experience has taught me that it is wrong and cruel to suspend judgment, that nonjudgmentalism is at best indifference to the suffering of others, at worst a disguised form of sadism. How can one respect people as members of the human race unless one holds them to a standard of conduct and truthfulness? How can people learn from experience unless they are told that they can and should change? One doesn't demand of laboratory mice that they do better: but man is not a mouse, and I can think of no more contemptuous way of treating people than to ascribe to them no more responsibility than such mice.
In any case, nonjudgmentalism is not really nonjudgmental. It is the judgment that, in the words of a bitter Argentinean tango, "todo es igual, nada es mejor": everything is the same, nothing is better. This is as barbaric and untruthful a doctrine as has yet emerged from the fertile mind of man.