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Psychiatric Neuroethics
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Psychiatric
Neuroethics
Studies in Research
and Practice
Walter Glannon

1
1
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For Yee-Wah
 Advance praise

‘This book is extraordinary as it addresses central and sometimes

controversial issues in psychiatry, including its model of the mind–brain
relation and ethical issues such as euthanasia. Walter Glannon, one of the
leading experts in the philosophy of psychiatry, delivers an outstanding
book which will, I am sure, become standard reading in the field and
beyond.’
Georg Northoff
Mind, Brain Imaging and Neuroethics Research Unit
University of Ottawa Institute of Mental Health Research, Canada
‘As the big pharma have withdrawn from investing in the development of
psychopharmaceuticals, the therapeutic void needs to be filled, and one
of the ways to do so is by noninvasive and invasive neuromodulation.
Walter Glannon bravely takes the lead in addressing and providing
ethical guidance in how to embrace the new technology in real-world
settings. A must-read and highly needed work for everybody who is
interested or involved in the treatment of psychiatric brain disorders.’
Dirk De Ridder
Neurological Foundation Professor of Neurosurgery
University of Otago, New Zealand
‘In Psychiatric Neuroethics: Studies in Research and Practice, Walter
Glannon combines a philosophical sensibility with an appreciation
of psychiatry as a psycho-biological science of the brain as well as the
mind. With precision, Glannon adroitly teases out ethical conflicts,
treating a range of psychiatric interventions such as psychosurgery,
neuromodulation, control of psychopathic behavior, and rationales for
assisted suicide for psychiatric and neurodegenerative conditions. His
critical analysis is an original contribution to psychiatry and neuroethics.’
Laurence R. Tancredi
Clinical Professor of Psychiatry
New York University School of Medicine, USA
viii ADVANCE PRAISE

‘Walter Glannon’s Psychiatric Neuroethics provides keen insights into

the intersecting domains of brain science, mental health practice,
philosophy, ethics, and law. In addressing longstanding philosophical
questions about the nature of the mind, self, and psychiatry as a
discipline, Glannon presents a detailed examination of the ways in
which ongoing neuroscientific research has been used, or in some cases
misused, in the understanding, classification, diagnosis, and care of
mental illness. This book affords a prudent perspective on neuroethical
issues, questions, and possible solutions that are important in guiding
applications of brain science in the clinical practices of the field-in-
evolution that is psychiatry.’
James Giordano
Professor, Departments of Neurology and Biochemistry Chief,
Neuroethics Studies Program Pellegrino
Center for Clinical Bioethics Georgetown
University Medical Center, USA
 Acknowledgments

I thank my editors at Oxford University Press, Martin Baum, Charlotte

Holloway, and Janine Fisher, for supporting and guiding this project. Three
anonymous reviewers and the editors of the International Perspectives in
Philosophy and Psychiatry (IPPP) series gave me helpful comments on the
book proposal. For their comments on earlier versions of Chapter 5, I thank
Nicole Vincent, Allan MacCay, Karen Rommelfanger, and Syd Johnson. Special
thanks go to John Sadler for extensive and very helpful comments on earlier
versions of Chapters 3 and 4 and to Dirk De Ridder for equally extensive and
helpful comments on earlier versions of Chapters 4 and 5. Some sections of the
book have appeared previously in journal articles and book chapters. I have
benefited from the thoughtful and constructive reviews of the referees.
I presented some of the ideas in the book to audiences at the Neuroethics
Unit of the Institut de recherches cliniques de Montreal, a conference on
neuromodulation at the Brocher Foundation in Hermance, Switzerland, the
Department of Neurosurgery of the University of Zurich Hospital, a philosophy
colloquium at the University of Turku, and a conference on Neurointerventions
and the Law at Georgia State University.
For discussion and correspondence, I am grateful to Jean-Pierre Changeux,
Dirk De Ridder, Thomas Fuchs, Christian Ineichen, Nir Lipsman, Georg
Northoff, Roger Pitman, Ulrike Rimmele, John Sadler, Daniel Schacter, Sigrid
Sterckx, Teresa Yu, and Adam Zeman. I am especially grateful to John Sadler for
encouraging me to submit my project proposal for consideration in the IPPP
series and his continued support.
 Contents

Introduction 1
1 A paradigm for psychiatry 15
2 Disorders of consciousness, memory, and will 51
3 Treating psychiatric disorders: Less invasive and noninvasive
interventions 87
4 Psychiatric neurosurgery 135
5 Neuromodulation: Control, identity, and justice 185
6 Intervening in the psychopath’s brain 219
7 Euthanasia and assisted suicide for psychiatric disorders 251
8 Prediction and prevention 291
Epilogue: Psychiatry, neuroscience, philosophy 327

References 333
Index 369
 Introduction

In 2013, data from the World Health Organization (WHO) World Mental
Health Surveys indicated that mental illness constituted 7.4% of the global
burden of disease and that its incidence and burden would increase exponen-
tially in the future (Alonso, Chatterji, and He, 2013; Becker and Kleinman,
2013). This followed a 2012 estimate by the WHO that depression would be
the leading cause of the global burden of all diseases by 2030 (World Health
Organization, 2012). Schizophrenia, which is the most functionally disabling
psychiatric disorder, affects approximately 24 million people worldwide.
Mental illness is untreated or undertreated in many countries. These facts and
estimates underscore the need for continued research that will lead to a better
understanding of psychiatric disorders. This research may in turn lead to the
development of safer and more effective therapies that will relieve or prevent
the burden of disease experienced by millions of people.
Psychiatric Neuroethics is an analysis and discussion of questions at the in-
tersection of psychiatry, neuroscience, philosophy, and law that have arisen
from advances in psychiatric research and clinical psychiatric practice in the
last 30 years. Are psychiatric disorders diseases of the brain, caused by dys-
functional neural circuits and neurotransmitters? What role do genes, neu-
roendocrine and neuroimmune interactions, and a person’s response to the
environment play in the development of these disorders? How do different
explanations of the etiology and pathophysiology of mental illness influ-
ence diagnosis, prognosis, and decisions about treatment? How do psychi-
atric disorders affect consciousness and agency? Could the presumed salutary
effects of neural interventions for pathological thought and behavior change
one’s mental states in undesirable ways? What are the ethical and social jus-
tice issues regarding access to treatment and experimental and innovative
interventions for treatment-refractory conditions? What are the obligations
of clinicians and researchers to patients and research subjects in psychiatry?
Could the interests of society in preventing public harm override the cogni-
tive liberty of criminal offenders with a psychiatric disorder to refuse an in-
tervention in the brain? Would it be rational for a person with a chronic
treatment-resistant disorder to request euthanasia or assisted suicide (EAS) as
2 INtRoDuCtIoN

the only way to end his suffering? Could psychiatric disorders be prevented?
If so, then how could they be prevented? I raise and discuss these questions
in a comprehensive, systematic, and thematically integrated way. The book is
written for a multidisciplinary audience, including psychiatrists, neurologists,
neurosurgeons, philosophers, psychologists, legal theorists, and informed lay
readers.
These questions fall within the domain of neuroethics. This is an interdisci-
plinary field at the intersection of the brain sciences, radiology, cognitive psy-
chology, philosophy, and law. In a seminal paper, Adina Roskies distinguished
between two branches of neuroethics: the ethics of neuroscience and the neu-
roscience of ethics (2002, pp. 21–22). The first branch generally considers the
risks and potential benefits to patients and research participants whose brains
are mapped or monitored by structural and functional imaging, as well as when
they are altered by drugs, surgery, and electrical or magnetic stimulation. The
ethics of neuroscience also considers the decisions that patients and research
subjects make in receiving treatments and participating in research in light of
the potential benefits and risks. In addition, this branch of neuroethics pertains
to the obligations of clinicians and investigators to benefit patients and protect
them and research subjects from harm. The neuroscience of ethics generally
pertains to the neurobiological basis of the mental capacity for rational and
moral decision-making. In particular, this branch pertains to the capacity to
understand the nature of one’s medical condition and make informed decisions
to consent to treatment or participate in research. At a deeper level, Roskies
asked whether future developments in neuroscience might cause us to revise
our definition of “normal” behavior (2002, p. 22). She concluded by arguing
that neuroethics should not be confined to specialists in neuroscience, philos-
ophy, and law. It should also include public debate and broad social participa-
tion from all members of society in considering the implications of reading and
changing people’s brains (2002, p. 23).
While acknowledging that the ethics of neuroscience and the neuroscience
of ethics “can be pursued independently to a large extent,” Roskies noted that
“perhaps most intriguing is to contemplate how progress in each will affect
the other” (2002, p. 21). One example of overlap between the two branches
of neuroethics is when a patient with a psychiatric disorder, such as schizo-
phrenia or major depression, decides to accept or refuse an intervention in the
brain or participate in research. This requires informed consent from the com-
petent patient as an expression of his autonomy and ability to act in his own
best interests. Respect for patient autonomy obligates the clinician or researcher
to respect the patient’s decision regarding the intervention (ethics of neuro-
science). Competence and consent presuppose the cognitive and emotional
 INtRoDuCtIoN 3

capacity to weigh the potential benefits and risks of an approved or experi-

mental intervention, the reasons for or against it, and to make an informed
decision on this basis (neuroscience of ethics). This can be problematic if the
disorder is moderately severe or severe and involves significant impairment in
the relevant mental capacities. It may raise questions about whether the patient
can meet the criteria of consent to receive therapy or participate in research.
I construe “neuroethics” broadly to include more than questions about the
patient’s capacity to weigh the benefits against the risks of different interventions
in the brain and the obligations of clinicians and researchers to protect patients
and research subjects. In addition, neuroethics pertains to how psychiatric
disorders can harm people by distorting the content of their mental states,
impairing their will, and altering their identities. It also pertains to how certain
therapies can benefit people by restoring mental content, the will, and the self
to normal functional levels. In these respects, issues in the philosophy of mind
as well as normative ethical theory can influence how we assess ethical issues in
psychiatry. At the same time, psychiatry can influence how we assess questions
in the philosophy of mind and normative ethics. Some philosophers may ques-
tion the extent to which neuroscience and psychiatry can elucidate philosoph-
ical questions and provide guidance on how to address them. They may hold
that psychological explanations are sufficient and that appeals to the brain add
nothing to them. Yet the use of brain imaging in psychiatric research provides
evidence that neural circuits and networks mediate psychomotor, cognitive,
emotional, and volitional capacities associated with the mind, the will, and
identity. Although imaging has its limitations, techniques such as computed
tomography (CT), magnetic resonance imaging (MRI), positron emission to-
mography (PET), and functional magnetic resonance imaging (fMRI) showing
structural and functional abnormalities in these circuits and pathways can help
to explain why these capacities become impaired in major psychiatric disorders.
One of the best examples of how impaired reasoning and decision-making
is traceable to brain damage and dysfunction is the case of Phineas Gage. This
man lost many of his rational and moral capacities due to damage to his ven-
tromedial prefrontal cortex from a metal projectile that penetrated this region
of his brain while he was working on the Burlington and Northern Railroad in
Vermont in 1848. The changes in Gage’s personality and behavior were so sig-
nificant that “in the words of his friends and acquaintances, ‘Gage was no longer
Gage’ ” (Damasio, Grabowski, Frank et al., 1994, p. 1102). In addition, functional
neurosurgery on awake patients with neurological and psychiatric disorders
can confirm that cognitive and emotional processing is mediated by different
regions in the brain. Patients’ reports of their experiences from techniques
that probe and modulate neural circuits validate the neurobiological basis of
4 INtRoDuCtIoN

their mental states. They can also confirm when dysfunction at the neural level
manifests in dysfunction at the mental level.
Some cognitive psychologists and neuroscientists have claimed, or suggested,
that knowledge of brain structure and function and its effects on the mind can
completely explain, or explain away, the psychological aspects of concepts such
as free will and personal identity (Wegner, 2002; Seung, 2013). They ignore
the many ways in which the mind, body, and environment influence the brain,
which rejects the neuroreductionism behind these claims. Although neurosci-
ence in general and psychiatry in particular cannot provide a complete account
of the mind, they can yield a better understanding of ordered and disordered
mental states. As Georg Northoff points out, neuroscience enables us to “study
the unwell brain for clues about the healthy mind” (2016, p. ix). Because the
brain–mind relation underlies thought, identity, and agency, the implications
of psychiatry for these philosophical questions are significant (Kendler and
Parnas, 2012, 2014, 2017).
Since the declaration of the 1990s as the “Decade of the Brain,” much of
the research in psychiatry has endeavored to explain psychiatric disorders in
terms of dysfunctional neural circuits and neurotransmitters mediating motor
and mental functions (Insel, 2010, p. 188). The gradual shift in focus from
observed and reported symptoms in patients to the underlying neurobiology
of mental illness has driven the field of biological psychiatry (Walter, 2013). In
particular, this shift motivated the 2009 National Institute of Mental Health
(NIMH) strategic plan that included the Research Domain Criteria (RDoC) as
a research classification system for mental disorders (Insel, Cuthbert, Garvey
et al., 2010; National Institute of Mental Health, 2011; Casey, Craddock,
Cuthbert et al., 2013). While the RDoC focuses mainly on neural circuits,
it also examines how genetics, the environment, and other processes influ-
ence brain structure and function, and how a synthesis, or “matrix,” of all of
these factors can result in a better understanding of how psychiatric disorders
develop and persist in people. The neural circuit-based criteria of the RDoC
provide a necessary framework to complement the symptom-based criteria of
the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) (American Psychiatric Association, 2013) which until recently was
the dominant paradigm for conceptualizing and classifying mental illness
(Kendler and Parnas, 2017).
I avoid discussing mental disorders whose nosological status is ambiguous.
Instead, I focus on what have been classified unambiguously as major psy-
chiatric disorders. These include schizophrenia, major depressive disorder
(MDD), bipolar disorder I and II (BD I and BD II), obsessive–compulsive
disorder (OCD), generalized anxiety disorder (GAD), post-traumatic stress
 INtRoDuCtIoN 5

disorder (PTSD), and anorexia nervosa (AN). I mention other disorders as

well, though I consider them to be variants of the major disorders. I focus
mainly on moderately severe to severe psychiatric disorders because most
of the contentious ethical questions in psychiatry arise from predicting,
diagnosing, and intervening in the brains of people who are affected by them.
One possible exception to this categorization is psychopathy, which I discuss
in Chapter 6. Although it should not be included in the same category as
other disorders I have listed in terms of symptom severity and burden of
disease, psychopathy is included in the DSM-5 as a specifier for antisocial
personality disorder (p. 765). More importantly, this disorder has significant
implications for the field of forensic psychiatry, particularly regarding the
justification of interventions in the brains of criminal psychopaths to alter
their behavior.
I do not take “mental disorder” to be a natural kind. A natural kind is defined
in terms of how its properties combine in the natural world. It has an objective
ontological status and is not the product of concepts we apply to the world.
The criteria psychiatrists use to classify psychiatric disorders are the product
of these concepts. Psychiatric nosology is not a naturalistic but an interpre-
tive enterprise. It is objective in the sense that classification of major psychi-
atric disorders results from agreement among a community of researchers and
clinicians in psychiatry. This is not just an empirical process but also a normative
one. Psychiatrists interpret and agree, or disagree, on what data from brain im-
aging, overt symptoms, and other measures reveal about thought and behavior
in diagnosing and treating psychiatric disorders. John Sadler points out that
there are nonmoral and moral senses of normativity in psychiatry. He raises the
question of whether psychiatric disorders should be considered “moral bads”
warranting some form of moral judgment, or “nonmoral bads” like “medical
diseases or surgical injuries” (2004, p. 221). Sadler writes, “I would like to make
the, perhaps controversial, argument that mental disorders . . . should involve,
substantively, non-moral evaluations in the core concepts, and such normative
evaluations ‘filter up’ to define and constrain diagnostic criteria as well” (2004,
p. 221).
The “moral bad” attribution to major psychiatric disorders has diminished
over the last 50 years, thanks largely to research elucidating the processes
underlying their etiology and pathophysiology. This research has helped
to reduce some of the stigma attached to them (Sadler, 2009). Mental ill-
ness continues to be stigmatized to an unacceptable degree. Different
interpretations of some of the causal factors of psychiatric disorders have
impeded rather than promoted the elimination of stigma. Psychiatric genetics
is one example. Raising ethical concerns about translating psychiatric genomics
6 INtRoDuCtIoN

research into mental healthcare, Camilla Kong, Michael Dunn, and Michael
Parker state that “the genetic essentialism that is commonly associated with
the genomics revolution in health care might inadvertently exacerbate stigma
toward people with mental disorders” (2017, p. 1). In contrast, in their anal-
ysis and discussion of schizophrenia, Michael Owen, Akira Sawa, and Preben
Mortensen state that “a genetic diagnosis might . . . have psychological benefits
for patients and their families by reducing internalized stigma and self-blame”
(2016, p. 88). Each of these comments attributes too much of a causal role to
genetics in psychiatric disorders. How genes express themselves in the brain
and influence brain function depends on epigenetic and environmental factors.
This refutes any hint of genetic essentialism in psychiatry.
The idea of a genetic diagnosis based on identifiable mutations is equally
problematic. Thomas Insel points out that “the diversity and private nature of
these mutations preclude a simple genetic explanation for schizophrenia,” even
though “these findings may yield important clues to pathophysiology” (2010,
p. 188). Insel acknowledges that genetics is an important causal factor, but it is
not the only causal factor in this disorder. While the genetic component is more
significant in schizophrenia than in other psychiatric disorders, it is also a factor
in bipolar disorder and depression. Yet the same qualifications about the causal
import of psychiatric genomics in schizophrenia apply to these disorders as well.
What contributes to the persistence of stigma is a primary or exclusive focus
on one dimension of mental illness. Focusing solely or mainly on the psy-
chological dimension may facilitate the dismissive comment that psychiatric
disorders are “all in the mind.” The most effective way to reduce the stigma is
for researchers and clinicians to educate the public that psychiatric disorders
develop and persist not because of biological, psychological, or social processes
operating independently of each other, but because of the interactions be-
tween all of them. This education should emphasize that therapies can take
weeks, months, or even years to be effective. It should also point out that some
disorders are treatment-resistant. For example, as many as 20% of depressed
patients fail to respond to multiple treatments over many years (Holtzheimer
and Mayberg, 2010, p. 1437, 2011, p. 2). The rate of treatment-resistance is
even higher in other disorders. Knowledge of these facts could help to dispel
the view that controlling symptoms and “curing” mental illness is simply a
matter of taking the “right” pill. It could help to disabuse people of the atti-
tude that, if symptoms persist, then the patient must be taking the “wrong”
pill or otherwise doing something wrong. It may also help to emphasize that
no two people’s brains are alike. How genes and other biological factors shape
brain structure and function, how the brain responds to stress, and how it
responds to drugs or techniques can vary considerably from one person to the
 INtRoDuCtIoN 7

next. Ultimately, reducing stigma depends on families and colleagues of af-

fected individuals making the necessary effort to inform themselves of the
many causes and dimensions of mental illness (Thornicroft, Mehta, Clement
et al., 2016).
Methodologically and structurally, Psychiatric Neuroethics is divided roughly
into two parts. In Chapters 1 and 2, I examine and discuss different conceptions
of psychiatric disorders in terms of their etiology, pathophysiology, and symp-
tomatology and the ways in which they impair thought and behavior. In
Chapters 3 through 8, I describe different interventions in the brains of people
who have psychiatric disorders, as well as interventions in processes that occur
before they exist, and discuss the ethical and broader philosophical questions
these interventions raise. I interweave the science of psychiatry with the phi-
losophy of psychiatry. Philosophical questions can be appropriately addressed
only when they are appropriately framed by the science of the brain and mind.
These questions arise from less and more invasive interventions to control and
ameliorate symptoms. They become more pressing and controversial the more
resistant the disorder is to treatment and the more invasive the treatments
are. Most controversial is EAS for patients with treatment-resistant depres-
sion (TRD) and other disorders, where the intervention does not control but
eliminates symptoms by ending the life of the person who experiences them.
This underscores the need to prevent the onset of psychiatric disorders, or to
slow or stop their progression at an early stage.
My discussion of the normative dimensions of psychiatry is not driven by
a single ethical theory. Instead of selecting a theory and then discussing par-
ticular issues around it, I first raise the issues and then explicitly or implicitly
appeal to a theory to explain why a particular course of action or policy is justi-
fiable or unjustifiable. Questions about what to do in a particular case, or which
policy to adopt, drive the application of the theory, rather than the other way
around. A competent patient’s right to receive or refuse treatment or participate
in research is based on deontology, as is the duty of clinicians and investigators
to respect competent patients’ decisions and protect patients and research
subjects. Concern about treatment outcomes in ameliorating symptoms and
reducing side effects rests on consequentialism. Yet insofar as these outcomes
are in the best interests of consenting patients, nonconsequentialism may guide
ethical assessment of the key issues. Outcomes matter, but they are not the only
factor that matters in evaluating an action or policy. Indeed, deontological, con-
sequentialist, and nonconsequentialist considerations may all be relevant to a
single issue.
We have to assess which theory has more weight in adjudicating competing
moral claims about a course of action. In terms of the bioethical principles
8 INtRoDuCtIoN

corresponding to the ethical theories, I frame the ethical discussion by ap-

pealing to the standard principles of autonomy, nonmaleficence, beneficence,
and justice (Beauchamp and Childress, 2012, Chapters 4–7). While these
principles are limited in their scope of application to ethical debates in medi-
cine, they serve my framing purpose for psychiatric neuroethics as well as any
alternatives. Much of the discussion in this book addresses how psychiatric
disorders impair control of thought and behavior, and how interventions in
the brain can restore it. Control is a measure of autonomy in the sense that
one’s motivational states and actions are one’s own. Autonomy is also germane
to informed consent to participate in psychiatric research. This is significant
given that many interventions for psychiatric disorders are still experimental.
Nonmaleficence grounds researchers’ obligation to protect subjects enrolled
in clinical trials from harm. Beneficence grounds clinicians’ obligations to
provide patients with proven therapies consistent with best practices. Justice
is germane to the question of whether patients with treatment-resistant psy-
chiatric disorders have a right to participate in clinical trials testing exper-
imental drugs and neuromodulation techniques. It is also germane to the
question of whether subjects in clinical trials testing deep brain stimulation
are entitled to retain a brain implant after the conclusion of these trials. I base
most of my examples on actual cases, or hypothetical variants of them. This
gives substance to the principles and the ethical and broader philosophical
issues better than the fanciful thought experiments that are so common in
armchair philosophy.
In addition to ethical questions surrounding standard forms of psycho-
pharmacology, I examine some questions emerging from experimental
use of the psychotropic drugs ketamine, psilocybin, and 3,4-methylenedioxy-
methamphetamine (MDMA) for depression and PTSD. I discuss newer
closed-loop forms of deep brain stimulation (DBS) as a potentially safer
and more effective form of neuromodulation than open-loop DBS. I also
discuss optogenetics, focused ultrasound, and temporal interference as
novel neuromodulating techniques for a range of psychiatric disorders. My
discussion of ethical issues arising from historical, current and emerging
interventions in the brain and mind shows the evolution of psychiatric
neuroethics.
In Chapter 1, I define psychiatric disorders as disorders of the brain, mind,
and the person’s relation to the world. The etiology, pathophysiology, and symp-
tomatology of these disorders is influenced by interactions between the brain,
mind, immune and endocrine systems, the subject’s perception of the body,
and how the person responds to the environment. A biopsychosocial model
provides the best account of the development of these disorders and a guide
 INtRoDuCtIoN 9

for research and treatment. I discuss some of the merits and limitations of the
symptom-based DSM-5 and the more recent circuit-based RDoC and claim
that they can be complementary models in a paradigm for psychiatry research
and clinical practice. Noting the considerable overlap in pathophysiology be-
tween neurological and psychiatric disorders, I argue that there are sound
reasons for relaxing the strict distinction between the two disciplines. However,
there are distinctive features of psychiatric disorders that warrant treating them
separately in some respects. I defend nonreductive materialism as the theory
best able to account for the different dimensions of the brain–mind relation in
psychiatry. In addition, I propose that the self in psychiatry should not be de-
fined solely in terms of conscious mental processes but as a complex set of con-
scious and nonconscious processes that emerge from and are shaped by many
factors inside and outside of the brain.
I discuss major psychiatric disorders as disorders of consciousness, memory,
and will in Chapter 2. Schizophrenia, major depression, and OCD are disorders
of consciousness in the sense that they involve disturbances in how the brain
processes and integrates information about the body and external world.
Anxiety, panic, some forms of depression, and PTSD are disorders of memory
content. The emotionally charged representation of a memory of a traumatic
or disturbing experience can cause hyperactivation in the brain’s fear memory
system and result in maladaptive responses to environmental stimuli. The
distorted mental content in these psychopathologies impairs the capacity to
consider different action plans, and to form and execute particular plans in
particular actions. Dysfunctional mental states correlating with dysfunctional
neural states impair the capacity for flexible behavior and adaptability to the
environment. This dysfunction also impairs the capacity for insight into a psy-
chiatric disorder and understanding the need for and motivation to seek treat-
ment. In these respects, neural and mental dysfunction impairs free will. As
disorders of consciousness, memory, and will, psychiatric disorders disable the
capacity for autonomous agency.
In Chapter 3, I analyze and discuss different types of psychopharmacology.
I cite the view held by some psychiatrists that drugs targeting monoamines
to treat psychiatric disorders may be based on a mistaken hypothesis about
the pathophysiology of these disorders. I mention recent research on the role
of dysfunctional glutaminergic signaling and how novel pharmacological
treatments such as ketamine and psilocybin for depression, and MDMA for
PTSD, have considerable therapeutic potential. Questioning the distinction be-
tween noninvasive and invasive treatments in psychiatry, I point out that some
presumably noninvasive treatments could be described as invasive because they
can cause changes in the brain. This can occur in the absence of intracranial
10 INtRoDuCtIoN

surgery. I propose that the invasive–noninvasive distinction be replaced by a

distinction between less and more invasive interventions, where the degree of
invasiveness corresponds to the extent of changes the intervention induces in
the brain. I discuss the potential benefits and risks, as well as the limitations
of electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS),
and transcranial current stimulation (tCS). The indications for using TMS,
tCS, and psychotropic drugs to treat psychiatric disorders support reasons for
maintaining the distinction between therapy and enhancement. Placebos and
neurofeedback (NFB) are distinct from the other interventions I consider be-
cause the cognitive and emotional responses of the patient to the physician or
images of the patient’s brain can ameliorate symptoms without psychotropic
drugs or neurostimulation. While deception and potential erosion of trust are
the main ethical issues in using placebos, in some cases even deceptive use of
placebos can be justified in psychiatric treatment. I raise some social justice is-
sues regarding access to and affordability of NFB. Yet this and other techniques
that induce psychological responses from patients may not be effective in
treating moderately severe and severe forms of psychiatric disorders. With a
view to potential future therapies, I consider how the neurostimulating tech-
nique of temporal interference could potentially result in higher response rates
and better control of disease progression and symptoms.
I discuss a range of ethical issues in psychiatric neurosurgery in Chapter 4.
This is functional neurosurgery designed to modulate dysfunctional neural
circuits mediating sensorimotor, cognitive, emotional, and volitional
capacities. Because it is largely still experimental and investigative, functional
psychiatric neurosurgery falls within the domain of psychiatric research. It is
used for psychiatric disorders that have not responded to other interventions.
After surveying the history of this practice, I assess the comparative benefits
and risks of neural ablation and DBS as the two most invasive forms of
neuromodulation. This includes neural ablative techniques of radiofrequency
neurosurgery, Gamma Knife® radiosurgery, and high-intensity focused ultra-
sound. It also includes open-loop and closed-loop versions of DBS. I discuss the
question of whether individuals with a severe or moderately severe psychiatric
disorder have enough cognitive and emotional capacity to weigh the reasons
for and against DBS and give informed consent to undergo it. This question
includes consideration of whether some patients might be motivated by a ther-
apeutic misconception to participate in a functional neurosurgery clinical trial.
It also considers whether the idea of DBS as a treatment of “last resort” un-
duly influences their perception of risk. In addition, I discuss the obligation of
investigators conducting these trials to research subjects and the medical and
ethical justification for a sham control arm in psychiatric neurosurgery trials.
 INtRoDuCtIoN 11

Social justice issues are relevant here as well. I examine the issue of fairness in
patients having or lacking access to neurostimulation when it is the only in-
tervention that can control and relieve symptoms of a psychiatric disorder. In
the last section of the chapter, I describe the mechanisms of optogenetics and
discuss the therapeutic potential of this novel form of neuromodulation. The
ability of this technique to control gene expression in the brain and a broad
range of neural activity could make it a superior form of neuromodulation
to DBS. Yet the fact that optogenetics manipulates both genetic material and
neural circuits and has been tested only in animal models makes it unclear what
its benefit-to-risk ratio would be.
In Chapter 5, I address concerns that people with devices in their brains
regulating neural and mental functions are not in control of their thoughts and
actions. I argue that DBS or any other neuromodulating system that operates
safely and effectively does not undermine control or agency. Rather, by restoring
motor and mental capacities, DBS enables autonomous agency that has been
impaired or undermined by a psychiatric disorder. There is shared control be-
tween the person and the device, and this allows enough control for autonomy
and free will. Nor does neuromodulation necessarily cause substantial changes
in a person’s mental states and alter her identity. When it functions properly,
neuromodulation does not alter but restores the mental capacities impaired by
the disorder. Rather than disrupting psychological connectedness and conti-
nuity, DBS and other techniques can re-establish these relations and return the
patient to her premorbid self. Nevertheless, the control a patient has with a
device may entail certain expectations about operating it to maintain normal
neural and mental functions. I discuss whether these expectations impose an
unfair burden of control on these patients compared with people who do not
need a device to maintain these functions
Extending the discussion of interventions aimed at restoring control of mental
capacities in psychiatric disorders, I explore some of the implications of this
desired outcome for forensic psychiatry in Chapter 6. I discuss whether phar-
macological intervention in the brains of criminal psychopaths to modify and
enable them to control their behavior could be justified as an alternative to con-
tinued incarceration. I consider the question of whether treatment designed to
rehabilitate the offender could be forced on him against his wishes and whether
it would violate his cognitive liberty. One of the key issues is weighing the
interests and rights of the offender against the interests of society in preventing
recidivism and protecting the public from harm.
In Chapter 7, I discuss reasons for and against euthanasia and physician-as-
sisted suicide for patients with TRD or other psychiatric disorders. Although
these actions may seem anathema to the goal of treating psychiatric patients in
12 INtRoDuCtIoN

order to prevent suicide, there may be cases in which it would be permissible to

bring about or assist in the death of a person with one of these disorders. The
permissibility of these actions depends on four conditions. First, the patient
must be competent enough to weigh the reasons for and against EAS. Second,
the patient must make an informed and persistent request for it. Third, the suf-
fering the patient experiences from the disorder must be unbearable and in-
terminable. Fourth, the disorder must be resistant to all indicated treatments
given to the patient over many years. A corollary to the fourth condition is that
there must be a reasonable limit to the time a patient could be expected to wait
for a possible treatment to relieve symptoms. When these conditions obtain,
continued life may not be in the patient’s best interests. He could make a ra-
tional request for a psychiatrist or other physician to end his life or assist him
in ending it.
Shifting the focus from events occurring in early adulthood and adoles-
cence to events occurring perinatally and prenatally, I discuss different ways of
predicting and preventing psychiatric disorders in Chapter 8. After considering
reasons for and against intervening with psychotropic drugs during the prod-
romal phase of disease, I discuss how the identification of biomarkers for psy-
chiatric disorders in childhood or adolescence might predict who would be at
risk of developing them. Biomarkers could indicate which interventions could
reduce this risk or eliminate it altogether. I raise questions about the predictive
value of biomarkers in psychiatry and discuss some of the ethical and social is-
sues arising from how different parties might interpret them. In some cases, the
identification and interpretation of biomarkers may be more harmful than ben-
eficial to those who have them. Abnormal neuroimmune and neuroendocrine
interactions may disrupt normal rates of synaptic pruning and myelination in
childhood and adolescence and increase the risk of schizophrenia and other
disorders. I discuss how immune-modulating drugs could reverse this process
and how to balance the potential benefits against the risks of intervening in
the brain in this way. I speculate on the possibility of using focused ultrasound
to open the blood–brain barrier (BBB) to allow the infusion of growth factors
at an early stage of pathogenesis when neurodevelopmental abnormalities
may signal early neurodegeneration. This might reverse the disease process in
severe disorders such as schizophrenia and change what would have been a
life of mental illness into a life of mental health. I also consider noninvasive
interventions such as altering the environment to prevent epigenetic factors
from influencing gene expression in the brain and making a person suscep-
tible to mental illness. This could obviate the need for psychotropic drugs or
neurotrophic factors that could have permanent adverse effects in the brain.
In the last section of the chapter, I explain how prenatal and perinatal events
 INtRoDuCtIoN 13

can increase the risk of developing a psychiatric disorder in the second or third
decade of life. I consider different interventions before birth that might pre-
vent people from having a disorder after birth. These interventions include not
conceiving, terminating a pregnancy, or having and carrying a pregnancy to
term at one time rather than another. If potential parents knew that a child they
had would be at risk of developing a psychiatric disorder, then they could con-
trol to a certain extent whether they brought into existence a person who would
have a disorder or a different person who would not have it.
After briefly summarizing the main points from the preceding chapters, in
the Epilogue I consider whether an artificial or purely mechanistic model of the
brain could lead to a better understanding of mental health and mental illness.
It is doubtful that such a model could simulate the processes of a natural brain.
It is also doubtful that it could simulate the complex interactions between bio-
logical, psychological, and social factors necessary to explain how psychiatric
disorders develop and how they might be treated or prevented. In addition,
I point out that mental illness can be as disabling and impose more of a burden
on more people than physical illness. On grounds of fairness, diseases of the
brain and mind should have priority over diseases of the body in the alloca-
tion of funding for research into treatment and prevention. This is necessary to
relieve the burden of disease, enable functional independence for people with
major psychiatric disorders and ideally eliminate this burden altogether.
 Chapter 1

A paradigm for psychiatry

What type of disorder is a psychiatric disorder? What is it a disorder of? Are

schizophrenia, unipolar and bipolar depression, and other conditions diseases
of the brain? Are they diseases of the mind? Are they diseases of the brain and
mind? If they involve both neural and mental aspects, then how does the rela-
tion between the brain and mind influence the etiology, pathophysiology, and
symptomatology of these disorders? Are psychiatric disorders fundamentally
distinct from neurological disorders? Do they overlap in some respects? If they
overlap, then what are the diagnostic, prognostic, and ethical implications?
These questions drive my discussion of different concepts and categories in this
chapter in establishing a paradigm for psychiatry. The aim is not only to lay out
a nosology of psychiatric disorders but also to develop a framework that can
help to explain their causes and progression and guide therapeutic and preven-
tive interventions (Kendler and Parnas, 2017).
I discuss some of the merits and limitations of the symptom-based DSM-
5 and the more recent neural circuit-based RDoC. These models should be
considered complementary and together necessary to explain mental health
and illness as the result of neurobiological, psychological, and environmental
processes. The RDoC is the latest stage in the evolution of biological psychiatry.
I trace the history of the sciences of the mind from the nineteenth-century view
that neurology and psychiatry were not fundamentally different to the more re-
cent view that they form distinct disease categories. One of the consequences of
this distinction is the tendency toward a type of nosological dualism: neurolog-
ical disorders are disorders of the brain; psychiatric disorders are disorders of
the mind.
Following other neurologists and psychiatrists, I point out that most major
disorders of these two types have both neurobiological and psychological
features. This needs to be factored into assessment of the burden of diseases
of the brain and mind to provide a broader diagnostic and therapeutic frame-
work. One way of avoiding the problems associated with brain–mind dualism
and a rigid distinction between neurology and psychiatry is a merging of the
two disciplines into a single discipline of neuropsychiatry. Indeed, many clin-
ical and research neuroscientists now categorize diseases of the brain and mind
16 A PARADIGM FoR PSyChIAtRy

as neuropsychiatric disorders. However, noting that motor symptoms are more

common among neurological disorders and that cognitive and emotional
symptoms are more common among psychiatric disorders, I point out that
these disorders fall along a spectrum of motor and mental dysfunction. In cases
where the main symptoms are motor, and in cases where the main symptoms
are cognitive or emotional, there may be sound neuroscientific reasons for
upholding the distinction between neurology and psychiatry. In cases where
motor and mental symptoms overlap at the same or different times, there may
be sound neuroscientific reasons for adopting a less strict distinction.
The complementarity of the DSM-5 and the RDoC rests on a particular con-
ception of the brain–mind relation. The most plausible theory for understanding
how neural and mental processes maintain mental health, or how dysfunction
in these processes causes mental illness, is neither substance dualism nor re-
ductive materialism but nonreductive materialism. On this view, mental states
emerge from and are sustained by the brain but cannot be explained entirely
in neural terms. The mind can have a causal role in the neural dysfunction of
some psychiatric disorders. It can also restore some degree of normal function
in these disorders through its modulating effects on neural circuits. I propose a
conception of the psychiatric self. This consists of a set of continuous interacting
biological, psychological, and environmental processes with effects at con-
scious and unconscious levels. Interactions between all of these factors shape
the content of a person’s mental states and the experience of being embodied
and embedded in the environment. Psychiatric disorders are disorders of the
self in the sense that they distort a person’s perception of her relation to her body
and the external world (Gillett, 2009; Fuchs, 2012; Maiese, 2016). Psychiatric
disorders can also disrupt the psychological connectedness and continuity be-
tween mental states that shape the experience of persisting through time as the
same person. In addition, these disorders can impair agency by impairing the
affected person’s cognitive, emotional, and motivational capacity for rational de-
liberation and decision-making. A biopsychosocial model consisting of complex
interactions between the brain and genetic, immune, endocrine, psychological,
and environmental factors is necessary to explain the characteristic features of
these disorders (Engel, 1977). It is also necessary to explain how they develop
and how they might be more effectively treated or prevented.

DSM and RDoC

In 1918, the American Medico-Psychological Association (now the American
Psychiatric Association) attempted to develop a standardized nosology of
psychopathologies. This led to the first version of the DSM in 1952. Now in
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him with the fate of Stephen, had not the disciples heard of the
danger which threatened the life of their new brother, and provided
for his escape by means not less efficient than those before used in
his behalf, at Damascus. Before the plans for his destruction could
be completed, they privately withdrew him from Jerusalem, and had
him safely conducted down to Caesarea, on the coast, whence, with
little delay, he was shipped for some of the northern parts of Syria,
from which he found his way to Tarsus,――whether by land or sea,
is unknown.

his visit to tarsus.

This return to his native city was probably the first visit which he
had made to it, since the day when he departed from his father’s
house, to go to Jerusalem as a student of Jewish theology. It must
therefore have been the occasion of many interesting reflections and
reminiscences. What changes had the events of that interval
wrought in him,――in his faith, his hopes, his views, his purposes for
life and for death! The objects which were then to him as
idols,――the aims and ends of his being,――had now no place in
his reverence or his affection; but in their stead was now placed a
name and a theme, of which he could hardly have heard before he
first left Tarsus,――and a cause whose triumph would be the
overthrow of all those traditions of the Fathers, of which he had been
taught to be so exceeding zealous. To this new cause he now
devoted himself, and probably at this time labored “in the regions of
Cilicia,” until a new apostolic summons called him to a distant field.
He was yet “personally unknown to the churches of Judea, which
were in Christ; and they had only heard, that he who persecuted
them in times past, now preached the faith which once he destroyed;
they therefore glorified God on his account.” The very beginnings of
his apostolic duties were therefore in a foreign field, and not within
the original premises of the lost sheep of the house of Israel, where
indeed he was not even known but by fame, except to a few in
Jerusalem. In this he showed the great scope and direction of his
future labors,――among the Gentiles, not among the Jews; leaving
the latter to the sole care of the original apostles, while he turned to
a vast field for which they were in no way fitted, by nature, or by
apostolic education, nor were destined in the great scheme of
salvation.

his apostolic labors in antioch.

During this retirement of Saul to his native home, the first great
call of the Gentiles had been made through the summons of Simon
Peter to Cornelius. There was manifest wisdom in this arrangement
of events. Though the original apostles were plainly never intended,
by providence, to labor to any great extent in the Gentile field, yet it
was most manifestly proper that the first opening of this new field
should be made by those directly and personally commissioned by
Jesus himself, and who, from having enjoyed his bodily presence for
so long a time, would be considered best qualified to judge of the
propriety of a movement so novel and unprecedented in its
character. The great apostolic chief was therefore made the first
minister of grace to the Gentiles; and the violent opposition with
which this innovation on Judaical sanctity was received by the more
bigoted, could of course be much more efficiently met, and
disarmed, by the apostle specially commissioned as the keeper of
the keys of the heavenly kingdom, than by one who had been but
lately a persecutor of the faithful, and who, by his birth and partial
education in a Grecian city, had acquired such a familiarity with
Gentile usages, as to be reasonably liable to suspicion, in regard to
an innovation which so remarkably favored them. This great
movement having been thus made by the highest Christian authority
on earth,――and the controversy immediately resulting having been
thus decided,――the way was now fully open for the complete
extension of the gospel to the heathen, and Saul was therefore
immediately called, in providence, from his retirement, to take up the
work of evangelizing Syria, which had already been partially begun
at Antioch, by some of the Hellenistic refugees from the persecution
at the time of Stephen’s martyrdom. The apostles at Jerusalem,
hearing of the success which attended these incidental efforts,
dispatched their trusty brother Barnabas, to confirm the good work,
under the direct commission of apostolic authority. He, having come
to Antioch, rejoiced his heart with the sight of the success which had
crowned the work of those who, in the midst of the personal distress
of a malignant persecution, that had driven them from Jerusalem,
had there sown a seed that was already bringing forth glorious fruits.
Perceiving the immense importance of the field there opened, he
immediately felt the want of some person of different qualifications
from the original apostles, and one whose education and habits
would fit him not only to labor among the professors of the Jewish
faith, but also to communicate the doctrines of Christ to the
Grecians. In this crisis he bethought himself of the wonderful young
convert with whom he had become acquainted, under such
remarkable circumstances, a few years before, in
Jerusalem,――whose daring zeal and masterly learning had been
so signally manifested among the Hellenists, with whom he had
formerly been associated as an equally active persecutor. Inspired
both by considerations of personal regard, and by wise convictions
of the peculiar fitness of this zealous disciple for the field now
opened in Syria, Barnabas immediately left his apostolic charge at
Antioch, and went over to Tarsus, to invite Saul to this great labor.
The journey was but a short one, the distance by water being not
more than one hundred miles, and by land, around through the
“Syrian gates,” about one hundred and fifty. He therefore soon
arrived at Saul’s home, and found him ready and willing to undertake
the proposed apostolic duty. They immediately returned together to
Antioch, and earnestly devoted themselves to their interesting
labors.

“Antioch, the metropolis of Syria, was built, according to some authors, by Antiochus
Epiphanes; others affirm, by Seleucus Nicanor, the first king of Syria after Alexander the
Great, in memory of his father Antiochus, and was the ‘royal seat of the kings of Syria.’ For
power and dignity, Strabo, (lib. xvi. p. 517,) says it was not much inferior to Seleucia, or
Alexandria. Josephus, (lib. iii. cap. 3,) says, it was the third great city of all that belonged to
the Roman provinces. It was frequently called Antiochia Epidaphne, from its neighborhood
to Daphne, a village where the temple of Daphne stood, to distinguish it from other fourteen
of the same name mentioned by Stephanus de Urbibus, and by Eustathius in Dionysius p.
170; or as Appianus (in Syriacis,) and others, sixteen cities in Syria, and elsewhere, which
bore that name. It was celebrated among the Jews for ‘Jus civitatis,’ which Seleucus
Nicanor had given them in that city with the Grecians and Macedonians, and which, says
Josephus, they still retain, Antiquities, lib. xii. cap. 13; and for the wars of the Maccabeans
with those kings. Among Christians, for being the place where they first received that name,
and where Saul and Barnabas began their apostolic labors together. In the flourishing times
of the Roman empire, it was the ordinary residence of the prefect or governor of the eastern
provinces, and also honored with the residence of many of the Roman emperors, especially
of Verus and Valens, who spent here the greatest part of their time. It lay on both sides of
the river Orontes, about twelve miles from the Mediterranean sea.” (Wells’s Geography New
Testament――Whitby’s Table.) (J. M. Williams’s Notes on Pearson’s Annales Paulinae.)

Having arrived at Antioch, Saul gave himself, with Barnabas,

zealously to the work for which he had been summoned, and labored
among the people to good purpose, assembling the church and
imparting to all that would hear, the knowledge of the Christian
doctrine. Under these active exertions the professors of the faith of
Jesus became so numerous and so generally known in Antioch, that
the heathen inhabitants found it convenient to designate them by a
distinct appellation, which they derived from the great founder and
object of their religion,――calling them Christians, because the
heathen inhabitants of Syria were not acquainted with the terms,
“Nazarene” and “Galilean,” which had been applied to the followers
of Christ by the Jews, partly from the places where they first
appeared, and partly in opprobium for their low provincial origin.

The name now first created by the Syrians to distinguish the sect, is remarkable,
because being derived from a Greek word, Christos, it has a Latin adjective termination,
Christianus, and is therefore incontestably shown to have been applied by the Roman
inhabitants of Antioch; for no Grecian would ever have been guilty of such a barbarism, in
the derivation of one word from another in his own language. The proper Greek form of the
derivation would have been Christicos, or Christenos, and the substantive would have been,
not Christianity, but Christicism, or Christenism,――a word so awkward in sound, however,
that it is very well for all Christendom, that the Roman barbarism took the place of the pure
Greek termination. And since the Latin form of the first derivative has prevailed, and
Christian thus been made the name of “a believer in Christ,” it is evident to any classical
scholar, that Christianity is the only proper form of the substantive secondarily derived. For
though the appending of a Latin termination upon a Greek word, as in the case of
Christianus, was unquestionably a blunder and a barbarism in the first place, it yet can not
compare, for absurdity, with the notion of deriving from this Latin form, the substantive
Christianismus, with a Greek termination foolishly pinned to a Latin one,――a folly of which
the French are nevertheless guilty. The error, of course, can not now be corrected in that
language; but those who stupidly copy the barbarism from them, and try to introduce the
monstrous word, Christianism, into English, deserve the reprobation of every man of taste.

“Before this they were called ‘disciples,’ as in this place――‘believers,’ Acts v.

14――‘men of the church,’ Acts xii. 1――‘men of the way,’ Acts ix. 2――‘the saints,’ Acts ix.
13――‘those that called on the name of Christ,’ verse 14――and by their enemies,
Nazarenes and Galileans, and ‘men of the sect;’――but now, by the conversion of so many
heathens, both in Caesarea and Antioch, the believing Jews and Gentiles being made all
one church, this new name was given them, as more expressive of their common relation to
their Master, Christ. Whitby slightly alludes to the prophecy, Isaiah lxv.” (J. M. Williams’s
Notes on Pearson.)

While Saul was thus effectually laboring in Antioch, there came

down to that city, from Jerusalem, certain persons, indued with the
spirit of prophecy, among whom was one, named Agabus, who,
under the influence of inspiration, made known that there would be a
great famine throughout the world;――a prediction which was
verified by the actual occurrence of this calamity in the days of
Claudius Caesar, during whose reign,――as appears on the
impartial testimony of the historians of those times, both Roman and
Jewish,――the Roman empire suffered at different periods in all its
parts, from the capital to Jerusalem,――and at this latter city, more
especially, in the sixth year of Claudius, (A. D. 46,) as is testified by
Josephus, who narrates very particularly some circumstances
connected with the prevalence of this famine in Jerusalem. The
disciples at Antioch, availing themselves of this information,
determined to send relief to their brethren in Judea, before the
famine should come on; and having contributed, each one according
to his ability, they made Barnabas and Saul the messengers of their
charity, who were accordingly dispatched to Jerusalem, on this noble
errand. They remained in Jerusalem through the period of Agrippa’s
attack upon the apostles by murdering James, and imprisoning
Peter; but they do not seem to have been any way immediately
concerned in these events; and when Peter had escaped, they
returned to Antioch. How long they remained here, is not recorded;
but the date of subsequent events seems to imply that it was a
space of some years, during which they labored at Antioch in
company with several other eminent prophets and teachers, of
whom are mentioned Simeon, who had the Roman surname of
Niger, Lucius, the Cyrenian, and Manaen, a foster-brother of Herod
the tetrarch. During their common ministrations, at a season of
fasting, they received a direction from the spirit of truth which guided
them, to set apart Saul and Barnabas for the special work to which
the Lord had called them. This work was of course understood to be
that for which Saul in particular, had, at his conversion, been so
remarkably commissioned,――“to open the eyes of the
Gentiles,――to turn them from darkness to light, and from the
dominion of Satan to God.” His brethren in the ministry therefore,
understanding at once the nature and object of the summons, now
specially consecrated both him and Barnabas for their missionary
work; and after fasting and praying, they invoked on them the
blessing of God, in the usual oriental form of laying their hands on
them, and then bade them farewell.

“That this famine was felt chiefly in Judea may be conjectured with great reason from the
nature of the context, for we find that the disciples are resolving to send relief to the elders
in Judea; consequently they must have understood that those in Judea would suffer more
than themselves. Josephus declared that this famine raged so much there, πολλῶν ὑπό
ἐνδείας ἀναλωμάτων φθειρομένων, ‘so that many perished for want of victuals.’”

“‘Throughout the whole world,’ πᾶσαν τὴν οἰκουμένην, is first to be understood, orbis
terrarum habitabilis: Demosthenes in Corona, Æschines contra Ctesiphon Scapula. Then
the Roman and other empires were styled οικουμένη, ‘the world.’ Thus Isaiah xiv. 17, 26, the
counsel of God against the empire of Babylon, is called his counsel, ἐπὶ τὴν ὅλην οἰκουμένην,
‘against all the earth.’――(Elsley, Whitby.) Accordingly Eusebius says of this famine, that it
oppressed almost the whole empire. And as for the truth of the prophecy, this dearth is
recorded by historians most averse to our religion, viz., by Suetonius in the life of Claudius,
chapter 18, who informs us that it happened ‘ob assiduas sterilitates;’ and Dion Cassius
History lib. lx. p. 146, that it was λιμὸς ἰσχυρὸς, ‘a very great famine.’ Whitby’s Annotations,
Doddridge enumerates nine famines in various years, and parts of the empire, in the reign
of Claudius; but the first was the most severe, and affected particularly Judea, and is that
here meant.” (J. M. Williams’s notes on Pearson.)

his first apostolic mission.

Going from Antioch directly eastward to the sea, they came to

Seleucia, the nearest port, only twelve miles from Antioch, and there
embarked for the island of Cyprus, the eastern end of which is not
more than eighty miles from the coast of Syria. The circumstance
that more particularly directed them first to this island, was probably
that it was the native home of Barnabas, and with this region
therefore he would feel so much acquainted as to know its peculiar
wants, and the facilities which it afforded for the advancement of the
Christian cause; and he would also know where he might look for the
most favorable reception. Landing at Salamis, on the south-eastern
part of the island, they first preached in the synagogues of the Jews,
who were very numerous in Cyprus, and constituted so large a part
of the population of the island, that some years afterwards they
attempted to get complete possession of it, and were put down only
by the massacre of many thousands. Directing their efforts first to
these wandering sheep of the house of Israel, the apostles
everywhere preached the gospel in the synagogues, never forsaking
the Jews for the Gentiles, until they had been driven away by insult
and injury, that thus the ruin of their nation might lie, not upon the
apostles, but upon them only, for their rejection of the repeated offers
of salvation. Here, it would seem, they were joined by John Mark, the
nephew of Barnabas, who was probably staying upon the island at
that time, and who now accompanied them as an assistant in their
apostolic ministry. Traversing the whole island from east to west,
they came to Paphos, a splendid city near the western end, famed
for the magnificent temple and lascivious worship of the Paphian
Venus, a deity to whom all Cyprus was consecrated; and from it she
derived one of her numerous appellatives, Cypris being a name
under which she was frequently worshipped; and the females of the
island generally, were so completely devoted to her service, not
merely in temple-worship, but in life and manners, that throughout
the world, the name Cyprian woman, even to this day, is but a polite
expression for one abandoned to wantonness and pleasure. The
worship of this lascivious goddess, the apostles now came to
exterminate, and to plant in its stead the dominion of a faith, whose
essence is purity of heart and action. At this place, preaching the
gospel with openness, they soon attracted such general notice, that
the report of their remarkable character soon reached the ears of the
proconsul of Cyprus, then resident in Paphos. This great Roman
governor, by name Sergius Paulus, was a man of intelligence and
probity, and hearing of the apostles, soon summoned them to his
presence, that he might have the satisfaction of hearing from them,
in his own hall, a full exposition of the doctrine which they called the
word of God. This they did with such energy and efficiency, that they
won his attention and regard; and he was about to profess his faith in
Jesus, when a new obstacle to the success of the gospel was
presented in the conduct of one of those present at the discourse.
This was an impostor, called Elymas,――a name which seems to be
a Greek form of the Oriental “Alim” meaning “a magician,”――who
had, by his tricks, gained a great renown throughout that region, and
was received into high favor by the proconsul himself, with whom he
was then staying. The rogue, apprehending the nature of the
doctrines taught by the apostles to be no way agreeable to the
schemes of self-advancement which he was so successfully
pursuing, was not a little alarmed when he saw that they were taking
hold of the mind of the proconsul, and therefore undertook to resist
the preaching of the apostles; and attempted to argue the noble
convert into a contempt of these new teachers. At this, Saul, (now
first called Paul,) fixing his eyes on the miserable impostor, in a burst
of inspired indignation, denounced on him an awful punishment for
his resistance of the truth. “O, full of all guile and all tricks! son of the
devil! enemy of all honesty! wilt thou not stop perverting the ways of
the Lord? And now, lo! the hand of the Lord is on thee, and thou
shalt be blind, not seeing the sun for a time.” And immediately there
fell on him a mist and a darkness; and turning around, he sought
some persons to lead him by the hand. At the sight of this manifest
and appalling miracle, thus following the denunciation of the apostle,
the proconsul was so struck, that he no longer delayed for a moment
his profession of faith in the religion whose power was thus attested,
but believed in the doctrine of Jesus, as communicated by his
apostles.

“Seleucia was a little north-west of Antioch, upon the Mediterranean sea, named from its
founder, Seleucus.――Cyprus, so called from the flower of the Cypress-trees growing
there.――Pliny, lib. xii. cap. 24.――Eustathius. In Dionysius p. 110. It was an island, having
on the east the Syrian, on the west the Pamphylian, on the south the Phoenician, on the
north the Cilician sea. It was celebrated among the heathens for its fertility as being
sufficiently provided with all things within itself. Strabo, lib. xiv. 468, 469. It was very
infamous for the worship of Venus, who had thence her name Κύπρις. It was memorable
among the Jews as being an island in which they so much abounded; and among
Christians for being the place where Joses, called Barnabas, had the land he sold, Acts iv.
36; and where Mnason, an old disciple, lived; Acts xxi. 16.――(Whitby’s Table.) Salamis
was once a famous city of Cyprus, opposite to Seleucia, on the Syrian coast.――(Wells.) It
was in the eastern part of Cyprus. It was famous among the Greek writers for the story of
the Dragon killed by Chycreas, their king; and for the death of Anaxarchus, whom
Nicocreon, the tyrant of that island, pounded to death with iron pestles.”――(Bochart,
Canaan, lib. i. c. 2――Laert, lib. ix. p. 579.) Williams’s Pearson.

Proconsul.――The Greek title Ανθυπατος, was applied only to those governors of

provinces who were invested with proconsular dignity. ‘And on the supposition that Cyprus
was not a province of this description, it has been inferred that the title given to Sergius
Paulus in this place, was a title that did not properly belong to him. A passage has indeed
been quoted from Dion Cassius, (History of Rome, lib. liv. p. 523, edited by Hanoviae,
1690,) who, speaking of the governors of Cyprus and some other Roman provinces, applies
to them the same title which is applied to Sergius Paulus. But, as Dion Cassius is speaking
of several Roman provinces at the same time, one of which was certainly governed by a
proconsul, it has been supposed, that for the sake of brevity, he used one term for all of
them, whether it applied to all of them or not. That Cyprus, however, ought to be excluded,
and that the title which he employed, as well as St. Luke, really did belong to the Roman
governors of Cyprus, appears from the inscription on a coin belonging to Cyprus itself. It
belonged to the people of that island as appears from the word ΚΥΠΡΙΩΝ on the reverse:
and, though not struck while Sergius Paulus himself was governor, it was struck, as appears
from the inscription on the reverse, in the time of Proclus, who was next to Sergius Paulus
in the government of Cyprus. And, on this coin the same title ΑΝΘΥΠΑΤΟΣ, is given to
Proclus, which St. Luke gives Sergius Paulus.’ (Bishop Marsh’s Lecture part v. pp. 85, 86.)
That Cyprus was a proconsulate, is also evident ♦from an ancient inscription of Caligula’s
reign, in which Aquius Scaura is called the proconsul of Cyprus. (Gruteri Corpus
Inscriptionem, tom. i. part ii. p, cccix. No. 3, edited by Graevii Amsterdam, 1707.) Horne’s
Introd.

♦ “lrom” replaced with “from”

 his change of name.

In connection with this first miracle of the apostle of Tarsus, it is

mentioned by the historian of the Acts of the Apostles, that Saul
thenceforth bore the name of Paul, and the reader is thence fairly led
to suppose, that the name was taken from that of Sergius Paul, who
is the most important personage concerned in the event; and being
the first eminent man who is specified as having been converted by
the apostle, seems therefore to deserve, in this case, the honor of
conferring a new name on the wonder-working Saul. This
coincidence between the name and the occasion, may be justly
esteemed sufficient ground for assuming this as the true origin of the
name by which the apostle was ever after designated,――which he
applies to himself in his writings, and by which he is always
mentioned throughout the Christian world, in all ages. With the name
of “Saul of Tarsus,” there were too many evil associations already
inseparably connected, in the minds of all the Jewish inhabitants of
the east, and the troublesome character of those prevalent
impressions having been perhaps particularly obvious to the apostle,
during his first missionary tour, he seized this honorable occasion, to
exchange it for one that had no such evil associations; and he was
therefore afterwards known only by the name of PAUL.

Embarking at Paphos, the apostles, after doubling cape Acamas,

the most western point of the island, sailed northwestward, towards
the northern coast of Asia Minor,――and after a voyage of about two
hundred miles, reached Perga, a city in Pamphylia. This place was
not a sea-port, but stood on the west bank of the river Cestrus, about
eight miles from the sea. It was there built by the Attalian kings of
south-western Asia, and was by them made the most splendid city of
Pamphylia. Near the town, and on a rising ground, was a very
famous temple of Diana, to which every year resorted a grand
religious assembly, to celebrate the worship of this great Asian
goddess. In such a strong hold of heathenism, the apostles must
have found much occasion for the preaching of the gospel; but the
historian of their Acts gives no account of anything here said or done
by them, and only mentions that at this place their companion, John
Mark, gave up his ministration with them, and returned to Jerusalem.
Paul and Barnabas then went on without him, to the north, and
proceeded, without any material delay, directly through Pamphylia,
and over the ranges of Taurus, through Pisidia, into Phrygia
Katakekaumene, where they made some stay at the city of Antioch,
which was distinguished from the great capital of Syria bearing the
same royal name, by being called “Antioch of Pisidia,” because,
though really within the boundaries of Phrygia, it was often
numbered among the cities of the province next south, near whose
borders it stood, and was therefore associated with the towns of
Pisidia by those who lived south and east of them. At this place the
apostles probably arrived towards the last of the week, and reposing
here on the sabbath, they went into the Jewish synagogue, along
with the usual worshiping assembly, and took their seats quietly
among the rest. After the regular service of the day (consisting of the
reading of select portions of the law and the prophets) was over, the
minister of the synagogue, according to custom, gave an invitation to
the apostles to preach to the people, if they felt disposed to do so. It
should be noticed, that in the Jewish synagogues, there was no
regular person appointed to preach, the minister being only a sort of
reader, who conducted the devotions of the meeting, and chanted
the lessons from the Scriptures, as arranged for each sabbath.
When these regular duties were over, the custom was to invite a
discourse from any person disposed or qualified to address the
people,――the whole being always thus conducted somewhat on
the plan of a modern “conference meeting.” On this day, the minister,
noticing two grave and intelligent-looking persons among the
worshipers, joining devoutly in the service of God, and perceiving
them to be of a higher order than most of the assembly, or perhaps
having received a previous hint of the fact that they were well-
qualified religious teachers, who had valuable doctrines to
communicate to the people,――sent word to them, “Brethren! if you
have any word of exhortation for the people, say on.” Paul
then,――as usual, taking the precedence of Barnabas in speaking,
on account of his own superior endowments as an
orator,――addressed the meeting, beginning with the usual form of
words, accompanied with a graceful gesticulation, beseeching their
favor. “Men of Israel! and you that fear God! give your attention.” The
two different classes of persons included in this formula, are
evidently, first, those who were Jews by birth and education, and
second, those devout Gentiles who reverenced the God of Israel and
conformed to the law of Moses, worshiping with the Jews on the
sabbath. Paul, in his sermon, which was of considerable length,
began in the usual form of an apostolic discourse to the Jews, by
recurring to the early Hebrew history, and running over the great
leading events and persons mentioned in their sacred writings, that
might be considered as preparing the way for the Messiah. Then,
proceeding to the narration of the most important points in the history
of the new dispensation, he applied all the quoted predictions of the
inspired men of old, to the man Christ Jesus, whom they now
preached. The substance of his discourse was, that in Jesus Christ
were fully accomplished those splendid prophecies contained in the
Psalms, concerning the future glories of the line of David; and more
especially that by his attested resurrection he had fulfilled the words
spoken by the Psalmist, of the triumphs of the “Holy One” over the
grave and corruption. Paul thus concluded,――“Be it known to you
therefore, brethren, that through this man is preached to you
forgiveness of sins; and every one that believes in him is justified
from all things, from which you could not be justified by the law of
Moses. Beware therefore, lest that come upon you which is spoken
by the prophets,――‘See! you despisers! and wonder and be
amazed; for I will do a work in your days, which you shall not believe,
even if one should tell it to you.’” These denunciatory concluding
words are from the prophet Habakkuk, where he is foretelling to the
Israelites of his day, the devastating invasion of the Chaldeans; and
the apostle in quoting them, aimed to impress his hearers with the
certainty of similar evils to fall upon their nation,――evils so
tremendous, that they might naturally disbelieve the warning, if it
should give them the awful particulars of the coming ruin, but whose
solemn truth they would, nevertheless, too soon learn in its actual
accomplishment. These words being directed in a rather bitter tone
of warning to the Jews in particular, that portion of the audience do
not appear to have been much pleased with his address; but while
the most of them were retiring from the synagogue, the Gentiles
declared their high satisfaction with the discourse, and expressed an
earnest desire that it might be repeated to them on the next
sabbath,――a request with which ministers in these modern times
are very rarely complimented by their congregations. After the
meeting broke up, many of the audience were so loth to part with
preachers of this extraordinary character, that they followed the
apostles to their lodgings. These were mostly the religious proselytes
from the heathen who worshiped with the Jews in the synagogue,
but some even of the Jews were so well satisfied with what they had
heard, that they also accompanied the throng that followed the
apostles. Paul and Barnabas did not suffer this occasion to pass
unimproved; but as they went along, discoursed to the company,
exhorting them to stand fast in the grace of God. They continued in
the city through the week, and meanwhile the fame of their doctrines
and their eloquence extended so fast and so far, that when on the
next sabbath they went to the synagogue to preach according to
promise, almost the whole city came pouring in, along with them, to
hear the word of God. But when the Jews, who had already been
considerably displeased by the manner in which they had been
addressed the last sabbath, saw the multitudes which were
thronging to hear these new interlopers, they were filled with envy,
and when Paul renewed his discourse, they openly disputed
him,――denied his conclusions, and abused him, and his doctrine.
Paul and Barnabas, justly indignant at this exhibition of meanness,
that thus set itself against the progress of the truth among the
Gentiles, from whom the Jews, not content with rejecting the gospel
themselves, would also exclude the light of the word,――boldly
declared to them――“It was necessary that the word of God should
be first spoken to you; but since you have cast it off, and thus evince
yourselves unworthy of everlasting life,――behold, we turn to the
heathen. For thus did God command us, ‘I have set thee for a light to
the heathen, that thou mightest be for their salvation, even to the
uttermost part of the earth.’” And the heathen hearing this, rejoiced,
and glorified the word of the Lord, and many of them believed, to
their everlasting salvation. And the word of God was spread
throughout that whole country; but the opposition of the Jews
increasing in proportion to the progress of the faith of Christ, a great
disturbance was raised against the apostles among the aristocracy
of the city, who favored the Jews, and more especially among the
women of high family, who were proselytes; and the result of the
commotion was, that the apostles were driven out of the city. Paul
and Barnabas, in conformity to the original injunction of Jesus to the
twelve, shook off the dust of their feet, as an expressive testimony
against them,――and turning eastward, came to another city, named
Iconium, in Lycaonia, the most eastern province of Phrygia.

Lycaonia is a province of Asia Minor, accounted the southern part of Cappadocia, having
Isauria on the west, Armenia Minor on the east, and Cilicia on the south. Its chief cities are
all mentioned in this chapter xiv. viz., Iconium, Lystra, and Derbe. They spake in the
Lycaonian tongue, verse 10, which is generally understood to have been a corrupt Greek,
intermingled with many Syriac words.――Horne’s Introduction.

Iconium was the capital of Lycaonia, and is mentioned by the

Grecian and Roman writers, before and after the apostolic times, as
a place of some importance; but nothing definite is known of its size
and character. It appears, at any rate, from the apostolic record, that
this flourishing city was one of the numerous centers of the Jewish
population, that filled so much of Asia Minor; and here, according to
their custom, the apostles made their first communication of the
gospel, in the Jewish synagogue. Entering this place of worship, they
spoke with such effect, that a great number both of Greeks and Jews
were thoroughly convinced of the truth of the Christian doctrine, and
professed their faith in Jesus. But, as usual, there was in Iconium a
great residue of bigoted adherents to the Mosaic faith, who could
appreciate neither the true scope of the ancient dispensation, nor the
perfection of gospel truth; and a set of these fellows undertook to
make trouble for the apostles, in the same way that it had been done
at the Pisidian Antioch. Not having power or influence enough
among themselves to effect any great mischief, they were obliged to
resort to the expedient of exciting the ill-will of the Gentile inhabitants
and rulers of the city, against the objects of their mischievous
designs,――and in this instance were successful, inasmuch as “they
made their minds disaffected against the brethren.” But in spite of all
this opposition, thus powerfully manifested, “long time they abode
there, speaking boldly in the Lord,” who did not fail to give them the
ever-promised support of his presence, but “gave testimony to the
word of his grace, and caused signs and miracles to be done by their
hands.” The immediate effect of this bold maintenance of the truth
was, that they soon made a strong impression on the feelings of the
mass of the people, and created among them a disposition to defend
the preachers of the word of heavenly grace, against the malice of
their haters. The consequence of course was, that the whole city
was directly divided into two great parties, one for and the other
against the apostles. On one hand the supporters of the Jewish
faction were bent upon driving out the innovators from the city, and
on the other, the numerous audiences, who had been interested in
the preaching of Paul and Barnabas, were perfectly determined to
stand by the apostles at all hazards, and the whole city seems to
have been on the eve of a regular battle about this difference. But it
did not suit the apostles’ scheme to make use of such means for
their own advancement or defence; and hearing that a grand crisis in
affairs was approaching, in the opposition of the Jewish faction, they
took the resolution of evading the difficulty, by withdrawing
themselves quietly from the scene of commotion, in which there was
but very little prospect of being useful, just then. The whole gang of
their opponents, both Gentiles and Jews, rulers and commonalty,
having turned out for the express purpose of executing popular
vengeance on these odious agitators, by abusing and pelting them,
the apostles, on getting notice of the scheme, moved off, before the
mob could lay hands on them, and soon got beyond their reach, in
other cities.

These fugitives from popular vengeance, after having so narrowly

escaped being sacrificed to public opinion, turned their course
southward, and stopped next on their adventurous route at the city of
Lystra, also within Lycaonia, where they preached the gospel, and
not only in the city and its immediate vicinity, but also throughout the
whole surrounding region, and in the neighboring towns. In the
progress of their labors in Lystra, they one day were preaching in the
presence of a man who had been lame from his birth, being in
exactly the same predicament with the cripple who was the subject
of the first miracle of Peter and John, in the temple. This unfortunate
auditor of Paul and Barnabas believed the word of truth which they
preached; and as he sat among the rest, being noticed by the former
apostle, was recognized as a true believer. Looking earnestly on
him, Paul, without questioning him at all as to his faith, said to him at
once, in a loud voice, “Rise, and stand on thy feet.” Instantly the man
sprang up, and walked. When the people saw this amazing and
palpable miracle, they cried out, in their Lycaonian dialect, “The gods
are come down to us in the likeness of men.” Struck with this notion,
they immediately sought to designate the individual deities who had
thus honored the city of Lystra with their presence; and at once
recognized in the stately form, and solemn, silent majesty of
Barnabas, the awful front of Jupiter, the Father of all the gods; and
as for the lively, mercurial person attending upon him, and acting, on
all occasions, as the spokesman, with such vivid, burning
eloquence,――who could he be but the attendant and agent of
Jupiter, Hermes, the god of eloquence and of travelers? Full of this
conceit, and anxious to testify their devout sense of this
condescension, the citizens bustled about, and with no small parade
brought out a solemn sacrificial procession, with oxen and garlands,
headed by the priests of Jupiter, and were proceeding to offer a
sacrifice in solemn form to the divine personages who had thus
veiled their dignity in human shape, when the apostles, horror-struck
at this degrading exhibition of the idolatrous spirit against which they
were warring, and without a single sensation of pride or gratitude for
this great compliment done them, ran in among the people, rending
their clothes in the significant and fantastic gesture of true Orientals,
and cried out with great earnestness, “Sirs! what do you mean? We
also are men of like constitutions with yourselves, and we preach to
you with the express intent that you should turn from these follies to
the living God, who made heaven and earth and sea, and all that is
in them.――He, indeed, in times past, left all nations to walk in their
own ways. Yet he left himself not wholly without witness of his being
and goodness, in that he did good, and gave us rain from heaven,
and fruitful seasons, filling our hearts with food and gladness.” With
these words of splendid eloquence and magnificent conception
bursting from their lips in the inspiration of the moment,――the
apostles, with no small ado, stopped the idolatrous folly of the
Lystrans, who probably felt and looked very silly, when the mistake
into which they had been drawn by a mere mob-cry, was shown to
them. Indignant, not so much at themselves, who alone were truly
blamable for the error, as against the persons who were the nobly
innocent occasions of it,――they were in a state of feeling to
overbalance this piece of extravagance by another,――much more
wicked, because it was not mere nonsense, but downright cruelty.
When, therefore, certain spiteful Jews came to Lystra from Antioch
and Iconium, from which places they had been hunting, like hounds,
on the track of the apostles, and told their abusive lies to the people
about the character of these two strange travelers, the foolish
Lystrans were easily persuaded to crown their absurdity by falling
upon Paul, who seemed to be the person most active in the
business. Having seized him, before he could slip out of their hands,
as he usually did from his persecutors, they pelted him with such
effect that he fell down as if dead; and they, with no small alacrity,
dragged him out of the city as a mere carcase. But the mob had
hardly dispersed, when he rose up, to the great wonder of the
brethren who stood mourning about him, and went back with them
into the city. The whole of this interesting series of events is a firm
testimony to the honesty of the apostolic narrative, exhibiting, as it
does, so fairly, the most natural, and at the same time, the most
contemptible tendencies of the human character. Never was there
given such a beautiful illustration of the value and moral force of
public opinion! unless, perhaps, in the very similar case of Jesus, in
Jerusalem:――“Hosanna,” to-day, and “Crucify him,” to-morrow. One
moment, exalting the apostles to the name and honors of the highest
of all the gods; the next, pelting them through the streets, and kicking
them out of the city as a nuisance. The Bible is everywhere found to
be just so bitterly true to human nature, and the whole world cannot
furnish a story in which the character and moral value of popular
movements are better exhibited than in the adventures of the
apostles, as recorded by Luke.

Acts xiv. 12. “It has been inquired why the Lystrans suspected that Paul and Barnabas
were Mercury and Jupiter? To this it may be answered, 1st. that the ancients supposed the
gods especially visited those cities which were sacred to them. Now from verse 13, it
appears that Jupiter was worshiped among these people; and that Mercury too was, there is
no reason to doubt, considering how general his worship would be in so commercial a tract
of Maritime Asia. (Gughling de Paulo Mercurio, p. 9, and Walch Spic. Antiquities, Lystra, p.
9.) How then was it that the priest of Mercury did not also appear? This would induce one
rather to suppose that there was no temple to Mercury at Lystra. Probably the worship of
that god was confined to the sea-coast; whereas Lystra was in the interior and mountainous
country. 2. It appears from mythological history, that Jupiter was thought to generally
descend on earth accompanied by Mercury. See Plautus, Amphitryon, 1, 1, 1. Ovid,
Metamorphoses, 8, 626, and Fasti, 5, 495. 3. It was a very common story, and no doubt,
familiar to the Lystrans, that Jupiter and Mercury formerly traversed Phrygia together, and
were received by Philemon and Baucis. (See Ovid, Metamorphoses, 8, 611, Gelpke in
Symbol. ad Interp. Acts xiv. 12.) Mr. Harrington has yet more appositely observed, (in his
Works, p. 330,) that this persuasion might gain the more easily on the minds of the
Lycaonians, on account of the well-known fable of Jupiter and Mercury, who were said to
have descended from heaven in human shape, and to have been entertained by Lycaon,
from whom the Lycaonians received their name.

“But it has been further inquired why they took Barnabas for Jupiter, and Paul for
Mercury. Chrysostom observes, (and after him Mr. Fleming, Christology Vol. II. p. 226,) that
the heathens represented Jupiter as an old but vigorous man, of a noble and majestic
aspect, and a large robust make, which therefore he supposes might be the form of
Barnabas; whereas Mercury appeared young, little, and nimble, as Paul might probably do,
since he was yet in his youth. A more probable reason, however, and indeed the true one,
(as given by Luke,) is, that Paul was so named, because he was the leading speaker. Now
it was well known that Mercury was the god of eloquence. So Horace, Carmen Saeculare,
1, 10, 1. Mercuri facunde nepos Atlantis Qui feros cultus hominum recentum Voce formasti
cantus. Ovid, Fasti, 5, 688. Macrobius, Saturnalia, 8, 8. Hence he is called by Jamblichus,
de Mysteriis, θεὸς ὁ των λόγων ἡγεμὼν, a passage exactly the counterpart to the present one,
which we may render, ‘for he had led the discourse.’” (Bloomfield’s Annotations, New
Testament, Vol. IV. c. xiv. § 12.)

“They called Paul Mercury, because he was the chief speaker,” verse 12. Mercury was
the god of eloquence. Justin Martyr says Paul is λόγος ἑρμηνευτικὸς καὶ πάντων διδάσκαλος,
the word; that is, the interpreter and teacher of all men. Apology ii. p. 67. Philo informs us
that Mercury is called Hermes, ὡς Ἑρμηνέα καὶ προφήτην τῶν θειων, as being the interpreter
and prophet of divine things, apud Eusebius, Praeparatio evangelica, Lib. iii. c. 2. He is
called by Porphyry παραστατικὸς, the exhibitor or representor of reason and eloquence.
Seneca says he was called Mercury, quia ratio penes illum est. De Beneficiis, Lib. iv. cap.
7.――Calmet, Whitby, Stackhouse.
 All this pelting and outcry, however, made not the slightest
impression on Paul and Barnabas, nor had the effect of deterring
them from the work, which they had so unpropitiously carried on.
Knowing, as they did, how popular violence always exhausts itself in
its frenzy, they without hesitation immediately returned by the same
route over which they had been just driven by such a succession of
popular outrages. The day after Paul had been stoned and stunned
by the people of Lystra, he left that city with Barnabas, and both
directed their course eastward to Derbe, where they preached the
gospel and taught many. Then turning directly back, they came again
to Lystra, then to Iconium, and then to Antioch, in all of which cities
they had just been so shamefully treated. In each of these places,
they sought to strengthen the faith of the disciples, earnestly
exhorting them to continue in the Christian course, and warning them
that they must expect to attain the blessings of the heavenly
kingdom, only through much trial and suffering. On this return
journey they now formally constituted regular worshiping assemblies
of Christians in all the places from which they had before been so
tumultuously driven as to be prevented from perfecting their good
work,――ordaining elders in every church thus constituted, and
solemnly, with fasting and prayer, commending them to the Lord on
whom they believed. Still keeping the same route on which they had
come, they now turned southward into Pamphylia, and came again
to Perga. From this place, they went down to Attalia, a great city
south of Perga, on the coast of Pamphylia, founded by Attalus
Philadelphus, king of Pergamus. At this port, they embarked for the
coast of Syria, and soon arrived at Antioch, from which they had
been commended to the favor of God, on this adventurous journey.
On their arrival, the whole church was gathered to hear the story of
their doings and sufferings, and to this eager assembly, the apostles
then recounted all that happened to them in the providence of God,
their labors, their trials, dangers, and hair-breadth escapes, and the
crowning successes in which all these providences had resulted; and
more especially did they set forth in what a signal manner, during
this journey, the door of Christ’s kingdom had been opened to the
Gentiles, after the rejection of the truth by the unbelieving Jews; and
thus happily ended Paul’s first great apostolic mission.

Bishop Pearson here allots three years for these journeys of the apostles, viz. 45, 46,
and 47, and something more. But Calmet, Tillemont, Dr. Lardner, Bishop Tomline, and Dr.
Hales, allow two years for this purpose, viz. 45 and 46; which period corresponds with our
Bible chronology. (Williams on Pearson.)

the disputes on the circumcision.

The great apostle of the Gentiles now made Antioch his home,
and resided there for many years, during which the church grew
prosperously. But at last some persons came down from Jerusalem,
to observe the progress which the new Gentile converts were
making in the faith; and found, to their great horror, that all were
going on their Christian course, in utter disregard of the ancient
ordinances of the holy Mosaic covenant, neglecting altogether even
that grand seal of salvation, which had been enjoined on Abraham
and all the faithful who should share in the blessings of the promise
made to him; they therefore took these backsliders and loose
converts, to task, for their irregularities in this matter, and said to
them, “Unless you be circumcised ♦according to the Mosaic usage,
you can not be saved.” This denunciation of eternal ruin on the
Gentile non-conformists, of course made a great commotion among
the Antiochians, who had been so hopefully progressing in the pure,
spiritual faith of Christ,――and were not prepared by any of the
instructions which they had received from their apostolic teachers,
for any such stiff subjection to tedious rituals. Nor were Paul and
Barnabas slow in resisting this vile imposition upon those who were
just rejoicing in the glorious light and freedom of the gospel; and they
at once therefore, resolutely opposed the attempts of the bigoted
Judaizers to bring them under the servitude of the yoke which not
even the Jews themselves were able to bear. After much wrangling
on this knotty point, it was determined to make a united reference of
the whole question to the apostles and elders at Jerusalem, and that
Paul and Barnabas should be the messengers of the Antiochian
church, in this consultation. They accordingly set out, escorted