Alan A. Stone, MD: A Leader of Law and Psychiatry

IN MEMORIAM

Another of psychiatry’s giants recently passed away: Alan A. Stone, who died on January 23 at the age of 92.

As usual, I will rely on published public obituaries and my own personal knowledge for this eulogy. For this one in particular, there were many parallels, intersections, and convergences with parts of my career and life that I included for the personal perspective; I apologize if this seems inappropriate or too narcissistic.

He was the son of Jewish-Lithuanian families. His father became a lawyer. Later, he became an expert on the law as it relates to psychiatry, although he did not have a law degree. He taught classes with the well-known lawyer Alan Dershowitz, JD, for many years at Harvard. Dershowitz said that “for him, the world was never right or wrong. It was always why.”¹ What could be more psychiatric than the emphasis on why? I had a father and sisters who were lawyers and toyed with a similar idea, but I never followed up on it, instead focusing on psychiatric ethics. Despite his knowledge base, Dr Stone refused to be an expert witness; I tried to avoid that, too, sensing we were “hired guns” by one side, but I succumbed at times when I thought my knowledge base was useful.

Earlier than his focus on law and psychiatry, Dr Stone studied medicine at Yale, my alma mater too, and graduated in 1955. Yale encouraged free thinking, reflected in the policy of our times of no testing. His psychiatry residency was at McLean Hospital, and he went on to train in psychoanalysis at the Boston Psychoanalytic Society and Institute.

When I came to know him in the 1990s, I became involved as a participant/observer with managed care when ethical dilemmas and personal morality became paramount. In many ways, this was a major turning point for psychiatry and medicine. My view of managed care was published in the book The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997). Essentially, I concluded that managed care could help improve quality of care, but only if it was not-for-profit. Unfortunately, the for-profits have won out and business ethics come before health care ethics. Although the term managed care is not spoken much anymore, we are left with systems of care that seem to put profits over quality of care, putting obstacles and limitations on physicians, which have led to our epidemic rate of burnout.

Dr Stone saw all of this coming without being personally involved with managed care. He warned early on about how greed could come to dominate psychiatry. He foresaw how managed care could adversely control the doctor-patient relationship and decrease the role of psychiatrists.

Dr Stone was on the editorial board of Psychiatric Times^TM for many years, and Psychiatric Times^TM covered his perspectives on managed care. Anthony M. Diagostino, MD, wrote the article “Managed Care: The New Colonialism,” back in 1998.² The article covered the 1997 annual meeting of the American Psychiatric Association. I clearly recall the many emotional presentations about managed care: that it was evil and unethical, that psychiatrists who refused to participate in managed care were freedom fighters, and that maintaining the moral high ground would ultimately lead to victory. Dr Stone himself recognized that we were losing, and essentially lost in part because not enough colleagues and psychiatric organizations joined the cause.

In the Psychiatric Times^TM article “The Humanities and Psychiatry: The Rebirth of Mind,” James L. Knoll IV, MD, former editor-in-chief, discussed Dr Stone’s involvement in “an important historical moment of transition in modern psychiatry.”³ This historical moment had to do with Dr Stone’s debate with Gerald Klerman, MD, in 1990 for The American Journal of Psychiatry over a famous legal care suit, Osheroff v Chestnut Lodge. Dr Klerman emphasized the need for randomized controlled trials to justify the use of any form of treatment, whereas Dr Stone seemed to want to leave room for the freedom to use treatments that were more difficult to research than medication, like psychodynamic psychotherapies. Although they were not talking about managed care, as it paradoxically turns out, for-profit managed care grabbed onto Dr Klerman’s argument and basically limited psychiatrists to brief medication treatment. From my perspective, the most successful clinical psychiatrists often merged both points of view and knowledge, which was where Dr Stone rested his case back then.

Of course, there is much more that Dr Stone is renowned for: He was president of the American Psychiatric Association in 1979, where he guided the decision to remove homosexuality from the list of mental disorders; he was a film critic for the Boston Review; he protested the use of psychiatric treatment of oppressed minorities like Soviet Jews and the Falun Gong; he taught about Shakespeare and the law; and more.

How we psychiatrists combine our personal morality values, professional ethical principles, and the law as it pertains to psychiatry (which includes codified ethics) is inevitably reflected in how we live our lives. Dr Stone seemed to lead a very important life.

May his memory be a blessing.

Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times^TM.

References

1. Risen C. Alan A. Stone, 92, dies; challenged psychiatry’s use in public policy. The New York Times. February 1, 2022. Accessed February 3, 2022. https://www.nytimes.com/2022/02/01/us/alan-stone-dead.html

2. D’agostino AM. Managed care: the new colonialism. Psychiatric Times. 1998;15(12).

3. Knoll JL IV. The humanities and psychiatry: the rebirth of the mind. Psychiatric Times. 2013;30(4).