Saturday, November 15, 2008

Archive: WHiP: Philosophy of Psychiatry

In 1999, I wrote 5 monthly columns for a "Philosophy of Psychiatry" section of "What's Happening in Philosophy," which was part of the online "Philosophy News Service." Unfortunately it all folded soon after it started, and the site went down. (It was revived recently with different people running it.)
Here are those columns.
#1: August 1999

Conferences featuring Philosophy of Psychiatry

In the last year, philosophy of psychiatry has started to achieve noticeably more recognition from the academic philosophical establishment. In the US, during the summer of 1998. The National Endowment for the Humanities funded a six-week institute on Mind, Self, and Psychopathology, at Cornell University. Run by Jennifer Whiting of Cornell and Louis Sass of Rutgers, it featured about 10 well-known philosophers and psychiatric researchers engaging in discussion of philosophical problems in interpreting dissociation and multiple personality, autism, and schizophrenia. About 25 participants were drawn from many fields of academic life, including philosophy, psychology, history, and law. It was a brave if not totally successful attempt to foster serious interdisciplinary dialog.

This summer the European Society for Philosophy and Psychology devoted its opening symposium to Philosophy and Psychopathology. The meeting, held at the University of Warwick in Britain this July, as a whole featured such notable philosophers as Fred Dretske of Stanford and John Campbell of Oxford. The session on psychiatry consisted of talks by George Graham (University of Alabama, co-editor with Owen Flanagan of the MIT Press series Philosophical Psychopathology), Jose Bermudez of the University of Stirling in Scotland (author of The Paradox of Self-Consciousness), and Joelle Proust of CREA, France. Here I will briefly outline the talks to give a flavor of what kinds of issues preoccupy philosophers of psychiatry.

Graham talked about multiple personality and the self. He said that it is in this area that some of the most interesting work in philosophical psychopathology has been done. He explained that he is a realist about selves, although the conception of the self that he believes in is austere. Here he sets himself in opposition to theorists like Daniel Dennett, who advocate the view that the self is a fiction. Graham argued that once we realize that the self can be fuzzy, we can accept its existence. This is a relatively interesting idea, although it still raises many questions about what we mean by the “self” and what function the concept serves for us, and whether the term “the self” gets used in ordinary talk in the same way as it does when talking about the selves in multiple personalities. More interesting to me was a brief comment that Graham made about his experience of writing his book (co-authored with his colleague Lynn Stephens) When Self-Consciousness Breaks (forthcoming from MIT Press). He said that they had started out planning to write a grand synthesis of philosophy and psychopathology, but they found that this was too ambitious an aim. Finally, with the book two years overdue, they were ready to settle for a few relatively unadventurous philosophical claims. This reflects how difficult it is to do good philosophical work in psychiatry, since it requires so much empirical knowledge and so many interdisciplinary skills.

This touches on a theme explored by Joelle Proust, who raised the issue of the relation of philosophy and psychopathology. A naïve way of thinking about their relation, which Proust called the “Orthodox View,” is that we have philosophical theories of the mind and we can test them through the study of psychopathology. Associated with this view is that idea that philosophy can help psychological and psychiatric researchers to make conceptual distinctions. Furthermore, philosophers may, on this view, be occasionally able to suggest new empirical theories about causal connections between phenomena.

Proust raised two main problems for the Orthodox View. First, she claimed that the study of psychopathology is not a science. She gave several reasons to justify this claim, including the problematic inheritance of psychoanalysis and the uncertain taxonomy of the Diagnostic and Statistical Manual, with its focus on symptoms rather than syndromes. Her second objection to the Orthodox View is what she referred to as the interpretive plasticity or ambiguity of clinical data. The phenomena of psychopathology are not described, and may not be describable, in a theory-neutral way. The descriptions of what is sometimes called “phenomenological psychopathology” are already laden with theoretical and philosophical assumptions. Therefore, it is not possible to simply “read off” the philosophical implications of clinical data. The philosophical assumptions of the observer need to be examined and questioned before we can even begin to grasp the intricate relation between philosophical theories and psychopathological descriptions.

Finally, Proust warned against the danger that philosophers making implicit empirical assumptions in their investigation of psychiatry. She suggested that philosophers like to propose unwarranted causal hypotheses in the explanation of the phenomena of psychopathology. In particular, she thought that philosophers want to explain mental phenomena by reference to the beliefs and desires of the patient, what she called explanation at the personal level, as opposed to explanation at the subpersonal level, which would include brain modules and neurochemistry. Take, for example, the voices that a paranoid schizophrenic hears. The subpersonal explanation says that these are simply malfunctions of the brain. Proust is suggesting that some philosophers, like psychoanalysts, insist that there must be more to the phenomenon than that, and that the voices must be at least an expression of the patient’s beliefs and desires, and they might even be caused by the patient’s beliefs and desires. Her point about this is that philosophers are mistaken when they think that there must be an explanation of phenomena at the personal level. Sometimes problems, often classified as psychiatric, are simply malfunctions at a lower level of the brain.

Bermudez’s paper discussed some of the same themes as Proust, although from a very different angle. It was also the most technical of the three, and I suspect that most conference participants were as unfamiliar as I was with much of the psychiatric research literature he mentioned. His initial focus was on the distinction between neuropsychiatry and psychiatry. He said that it is often assumed that psychiatry is characterized by breakdowns in rationality, i.e. as problems at the personal level, while neuropsychiatry is concerned with breakdowns at the subpersonal level. With this as his background, he went on to discuss how to understand what happens in schizophrenia. Is schizophrenia best understood as a breakdown at the personal level or the subpersonal level? This is a very difficult question, and this is partly because it is so difficult to characterize accurately what makes a schizophrenic delusion a delusion. There have been many attempts, and Bermudez was partly showing the inadequacy of some recent attempts. These attempts distinguish between the positive and negative symptoms of schizophrenia, and link them to a distinction between epistemic and procedural rationality. In the short time available, it was not possible for me, nor I suspect, many other attendees, to fully grasp, let alone assess, the ideas he was setting out.

Other philosophy and psychology conferences this year also address issues from psychopathology. For instance, at the University of Copenhagen last May, there was Problems of the Self: Philosophical and psychopathological perspectives on self-experience. This August, there is the 1999 International Conference on Persons, featuring Louis Sass as keynote speaker, talking about his specialty, understanding schizophrenia as hyperreflectivity. The big conference to look forward to next year is Madness, Science and Society, to be held in Florence, in August of 2000. Sponsored by a number of different European organizations, it should be an important event for philosophy of psychiatry, with its focus on shaping the future of the field.

Related Links:
MIT Press Philosophical Psychopathology Series
Problems of the Self: Philosophical and psychopathological perspectives on self-experience, University of Copenhagen, May 28-30, 1999.

The 1999 International Conference on Persons

European Society for Philosophy and Psychology

Renaissance 2000: Madness, Science & Society

#2: September 1999

What’s Philosophical About Psychotropic Drugs?

This is only my second “monthly update” on philosophy of psychiatry, but I am already pondering that philosophy tends to move at a glacial pace, and a “yearly roundup” might be more appropriate. Despite my qualms, and in an effort the aid the integration of philosophy into the information age, this month I focus on a non-traditional arena of philosophical discussion, popular culture.

The media know what interests the public, and so they give plenty of attention to psychotropic drugs. Is Ritalin overprescribed? Are doctors and psychiatrists giving out too many antidepressants? Or are too many people with depression going untreated? I see reports on these topics often on the evening news, in the health section of my newspaper, and on the major health web sites. The publishing industry also knows that the public has an appetite for these issues: in addition to the usual flow of self-help books and memoirs of therapy and mental illness, there are also books highly critical of the psychopharmaceutical industry. Most notable is the psychiatrist Peter Breggin, who manages to write a book every year or so. In recent years he has produced Toxic Psychiatry, Talking Back to Prozac, Talking Back to Ritalin, and most recently, Your Drug May Be Your Problem (a title which strikes me as slightly comic—I can’t work out why though). Other authors have written antipsychiatry-flavored books with titles such as Running on Ritalin and Ritalin Nation.

The question of when to take psychotropic drugs might seem to be straightforwardly medical. Medicine, and the branch of medicine we designate as psychiatry, identifies pathological conditions and provides ways of ending the conditions or at least reducing their symptoms. Nevertheless, in fact the debate that continues to focus on these issues is not purely empirical: it involves profoundly philosophical issues.

Even standard medicine can be the proper subject of ethical scrutiny, for many sorts of reasons. Individual physicians sometimes act unethically, succumbing to temptations of personal gains at the expense of the patients. Furthermore, whole health care systems can be subject to ethical criticism, if they fail to live up to proper expectations. For example, much good work has been done showing how biased medicine has been with respect to gender.

These criticisms tend to operate from an internal perspective: they don’t challenge the fundamental aims of medicine, but rather they say that these aims are not being carried out in a fair way. Doctors are too ready to perform radical hysterectomies on women, ignoring how much effect his has on women and ignoring options that are more conservative. Maybe doctors in the US are too ready to recommend removal of the prostate in men with prostate cancer, when more conservative options are equally effective.

These internal criticisms can point to more global criticisms of medicine. It is a commonly made point that doctors can often focus too much on the disease rather than the patient, and in doing so they neglect the quality of life of the patient. By doing so, they start to forget what the whole point of medicine is. It is here that philosophical debates about the definition and ultimate purpose of medicine enter into the discussion. The whole discussion becomes more philosophical.

The sorts of worries concerning psychotropic drugs raised by the media tend to be internal. Is psychotherapy being denied to patients by their health maintenance organizations even when it would be the most effective treatment, because it is cheaper to prescribe drugs instead? Should talk therapists without medical degrees have the authority to prescribe psychotropic drugs to patients, or is a medical degree necessary for someone to be competent to prescribe drugs? Why is the rate of depression and suicide increasing in children?

However, we are now at a stage where we could move on to more global concerns about psychotropic drugs in psychiatry. It’s here that philosophy is in danger of missing its cue. This month’s update serves a prescriptive as well as descriptive function in discussing what’s happening in philosophy. Journals in medical ethics rarely discuss psychopharmacology. (I might mention here in shameless self-righteousness and self-promotion that I published a piece on prescribing Ritalin to children in Bioethics in 1997.) I have seen the issue discussed more at bioethics conferences, but still it gets far less attention than the more traditional debates over reproductive technology and physician-assisted suicide. It was a book by the psychiatrist Peter Kramer, Listening to Prozac, that has so far given one of the most thoughtful and philosophical discussions of these issues. Medical ethics does show some sign of addressing these issues under the general heading of human enhancement as concerns about genetic therapy and cosmetic surgery grow. Issues in psychopharmacology do certainly overlap with these other issues, but we need to remember that they also have some unique aspects.

Philosophical issues arising from psychopharmacology get even less attention in the more traditional journals such as The Journal of Philosophy, Ethics, Philosophy and Public Affairs, and Philosophical Review. This may reflect a general attitude of disinterest or even disdain concerning medical ethics from the philosophical establishment. Issues concerning medicine and psychiatry often get written off as “applied ethics,” which carries the implicit implication that real philosophers do pure ethics, who leave it to others to think through the implications of their abstract theories for the real world. It must be said that medical ethics often fuels this sort of disdain through a severe lack of quality control both at conferences and in journals. However, a look at the issue of psychopharmacology shows how wrongheaded this viewpoint is.

The philosophical issues that arise around psychopharmacology are certainly not purely moral in a narrow sense. Most obviously, we need to ask how we decide what should count as a pathological condition requiring treatment. How much unhappiness should count as clinical depression? How much restlessness and lack of concentration should count as attention deficit hyperactivity disorder? While some (mostly in the medical profession) still believe that these are purely medical questions, most recent discussion has agreed that criteria of mental disorder essentially involve value judgments. Social values and pragmatic considerations do and must enter into the deliberations both in drawing up the diagnostic criteria, and also in doctors deciding whether their patients meet those criteria.

Furthermore, larger questions soon enter into the discussion. Is the concern about psychotropic drugs based purely on their uncertain side and long-term effects? Clearly not: many people say that to live with one’s behavior and emotions regulated by a drug is to be less of oneself. The idea is that one’s personal identity is altered by these drugs. This is a metaphysical (in a non-pejorative sense!) claim, and belongs firmly in the camp of metaphysics and epistemology. Yet, philosophers have hardly scratched the surface of this issue.

Often philosophers like to see themselves at the vanguard of debate, asking difficult questions that the general population would prefer to ignore, yet need to face. It is therefore striking and a little ironic to see mainstream philosophy lagging behind popular debate in areas such as psychopharmacology. It is in editorials, magazine articles, and other discussions in popular culture that these important issues are being discussed. It is time for professional philosophers to add their expertise and careful methods to this debate.

The Enhancement Technologies Group:
Peter Breggin's Center for the Study of Psychiatry and Psychology:
Conference on the Science and Ethics of Human Enhancement:

#3: October 1999 (?)

The US Surgeon General recently published a report on Mental Health. It's actually an impressive 458 page book, with chapters on children, adults, older adults, the structure and financing of mental health services, confidentiality, and the future of the mental health profession.
I expect to be covering several aspects of this important report in future WHiP columns, but what first struck me about it was its laying blame in its Introduction on Descartes for our western dualism of mind and body and the stigma of mental illness. It refers to "the misguided split between mind and body first proposed by Descartes," (p. 6) and says, "This partitioning ushered in a separation between so-called 'mental' and 'physical' health, ..." (p. 5).
Coming, as it does, under the imprimaturs of the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, and National Institute of Mental Health, this report is set to be influential and has the ability to perpetuate myths. This view about Descartes smacks of stereotyping of a sophisticated philosopher.
Of course, the Surgeon General is simply repeating what has become a standard view. For instance, the very title of neuroscientist Antonio R. Damasio's best-selling book *Descartes' Error: Emotion, Reason, and the Human Brain* refers to such a view. Nevertheless, even a little thought about the issue shows that Descartes should not be painted as a villain here.
For one thing, Descartes was certainly not the first to suggest that there is a split between mind and body. The idea dates back at least to Plato, who argued that not only is the mind a radically sort of entity than physical matter, but also that our knowledge of the mind and its contents is very different from our knowledge of the physical world. Subsequent philosophers were certainly influenced by Plato, and it is a standard observation that early Christian theology had strong Platonic elements. Indeed, any religious view that holds that persons can go on living after their bodies have ceased to exist needs to have some account of personhood as logically independent of the body.
Furthermore, I wonder what ground there is for saying that Descartes had such a profound influence on western medical thought. Is it not more plausible to blame Christianity as the more powerful social force? It's easy to imagine that history would be little different if Descartes had never written a word of philosophy, but it is hard to know what our society would like if Christianity had never caught on.
But from a philosophical point of view, maybe what is most important is that this view perpetuated by the Surgeon General misunderstands Descartes. I'm no scholar of early modern philosophy, so I asked Lisa Shapiro, Assistant Professor of Philosophy at Hampshire College, to give her expert opinion. Her Ph.D. dissertation at the University of Pittsburgh was on "The Union of Mind and Body: Descartes' Conception of a Human Being," and I have heard her reaction on previous occasions when Descartes was held responsible for our seeing mind and body as radically split. Here's what she wrote:
"While Descartes does claim that mind and body are separable, he also claims that these two substances are united in a human being and through this union they have the power to affect one another. Indeed, he thinks that we experience this union everyday, in the course of leading our lives, just in having the sensations we do, and feeling the passions we do. While Descartes is often assigned a Platonic view, wherein the mind is lodged in a body like a sailor in a ship, he explicitly distances himself from this view in both the _Discourse on the Method_ and the _Meditations_. He does not think that that model can explain the quality of our sensations, for it is clear that we do not have the kind of knowledge of our bodies that angels would have. Moreover, it is clear from his correspondence with Princess Elizabeth of Bohemia that he does think that mind and body are tightly connected. He diagnoses her chronic illness as an effect of depression due to family problems, such as the beheading of her uncle Charles I of England. And admits to her that certain diseases can impair our free will and with it our capacity to reason well. The view about the radical separation of mind and body usually assigned Descartes is perhaps due to the philosophical problems he faces in articulating the union. Descartes was influential in shaping modern medicine, insofar as he, like Harvey and others who followed (La Forge, Malebranche, La Mettrie), was committed to describing the human body as a machine. But describing the human body in this way raises real questions for the status of the human mind. Are we do think of it as a feature of the machine as well (like Hobbes was inclined to)? If not, how are we to explain the relation of mind (non-material, non-mechanical) and body? The rise of mechanist science, and the application of that mechanism to biology then gave rise to a dilemma: We could deny that mind and body were two different things, and so be materialists. This option presents problems for the Christian doctrine of the immortality of the soul, however. To preserve the doctrine of the immortality of the soul, and the view of ethics and responsibility associated with it, we could preserve the distinction between mind and body, and to avoid the difficulties of explaining how they relate to one another assert that the well-being of one did not affect the well-being of the other. I would see Descartes as trying to steer a middle course between these two. Critics have shown him not to have been successful in doing so. History has shown him unsuccessful in getting credit for trying."

Mental Health:A Report of the Surgeon General
Lisa Shapiro
Biographical Information at School of Humanities, Arts and Cultural StudiesFaculty Biographies 1999-2000

#4: November 1999 (?)

Rationality, Psychopathology, and Emotions.

This year's annual conference of the Association for the Advancement of Philosophy and Psychiatry was on "Rationality & Mental Health." As usual, it met just before the huge American Psychiatric Association meeting, which this year was in Chicago. Many different psychiatric groups meet at the larger conference, and the financial power of pharmaceutical companies is apparent, for instance in their provision of rather lavish tables of food for these different groups. Unfortunately, or perhaps fortunately, the funding of AAPP is modest by comparison, and we mostly made do with cups of coffee, although there was some very good cheese and fruit available at the Saturday reception.

This was one of the most successful annual meetings AAPP has had, due to a thematic unity among the papers and more time left for discussion of each paper, which also meant that there were fewer papers, and thus that the average quality of papers was higher.

Broadly speaking, the papers divided into two groups: those that addressed the relation of emotions and rationality, and those that did not.

A few papers did not address the issue of emotions at all: my own paper discussed whether principles of charity in the interpretation of others required by prominent philosophers of mind such as Daniel Dennett and Donald Davidson placed conceptual limits on how extreme psychopathology can me. Louis Berger gave an interesting discussion of to what extent the transaction between a psychotherapist and a client can be captured in any model, and argued that the main theories of psychotherapy indeed do not entail or fully describe what happens in psychotherapy. In the question period, it became clear that he was committed to an even more radical view, that no human behavior can be fully modeled with a theory. David Graves, despite jet lag, breathtakingly set out an ambitious theory of "modular rationality," which drew on a number of different ideas from cognitive science and elsewhere.

James Phillips gave a wonderful paper on the problems of defining the psychiatric concept of delusion. It is often mistakenly thought that a delusion can be simply defined as a belief system strongly divorced from reality, but Phillips showed some of the problems inherent in such an approach, and made his own suggestions about a more promising approach -- among his ideas was that the definition of delusion does need to bring in a concept of affect.

Neither of the keynote addresses were particularly concerned about emotion. Drew Western, a Harvard psychiatrist, outlined the relevance of cognitive neuroscience for our understanding of rationality. Of greater philosophical interest was John Deigh's paper on "Moral Agency and Criminal Insanity," which gave both a very useful history of the insanity defense, and a careful study of the moral psychology of irrational action. It was a paper that tended to split the audience: the analytic philosophers delighted in the careful distinctions, while others seemed to feel it was hair splitting. Deigh concluded with a discussion of to what extent we can be considered morally responsible for our actions that are due to mental disorder. This theme was taken up by Sarah Hamady in her Harry-Frankfurtian discussion of external desires and self-defeating behavior. She engaged the issue of how we can transform ourselves and accomplish a unity of goals and desires.

Many papers did focus on philosophical issues concerning emotion. Some of them were traditional philosophical issues such as the relation between rationality and affectivity: to what extent is it rational to have emotions, when are emotions irrational, and what emotions are. More innovative were the papers that drew stronger connections to psychopathology and psychotherapy, although still focusing on emotions. Some papers discussed whether various forms of mental disorders involved problems with rationality or problems with emotions; others discussed the goal of psychotherapy, and cognitive-behavioral therapy (allied with rational-emotive therapy).

I'll mention three of the papers on emotion. In one of the more continental papers of the conference, George Agich argued that models of mental illness put too much emphasis on the idea of failures of rationality and autonomy. He urged that we need to understand the importance of affect in mental disorder. Patricia Greenspan, one of the program co-chairs, took a slightly unusual step considering her position, and criticized the assumption she saw of the division of rationality and emotion in the Conference's Call For Papers. She argued, continuing the research project she has pursued for several years, that emotions can be rationally evaluated. York Gunther gave one of the more technical and challenging papers of the conference. He claimed, and here I quote from his abstract, that "Emotional contents ... are unique because they resist inferential structure and generally fail to take binary connectives." In order to show this, he considered in some detail what one is rationally committed to in having an emotion. He used this to conclude that emotions cannot be specified independently of their attitudes, which is to say that emotions cannot be identified purely propositionally. With a wry smile, Gunther admitted that his method harkened back to the heyday of ordinary language philosophy, and was eager to learn of other methods that could help him reach the same conclusions.

Reflecting on the conference, I am struck by how the divisions between analytic philosophers, continental philosophers and clinicians seemed much less significant and problematic than they have at previous such conferences. Of course these divisions still existed, but on the whole participants did not seem to divide up neatly into rather predictable groups, as so often happens at such interdisciplinary events. Rather, the discussion managed to find common ground, or at least to explore the strengths and weaknesses of individual ideas without resorting to standard "party lines." The most heated exchange, between a psychiatrist and an academic psychologist, was about the role of drug companies in the modern profession and the extent to which "scientific studies" of therapy and drugs are fair and unbiased. The conference as a whole was provocative and interesting, and could serve as a model for interdisciplinary work.

Twelfth Annual Meeting of the Association for the Advancement of Philosophy & Psychiatry:

Books of relevance:
The Sources of Moral Agency : Essays in Moral Psychology and Freudian Theory by John Deigh
Emotions & Reasons : An Inquiry into Emotional Justification by Patricia S. Greenspan


#5: December 1999 (?)

Philosophers on Drugs (Again)

One of the latest issues of The Hastings Center Report has a number of short articles on "Prozac, Alienation, and the Self." The authors are Carl Elliott, Peter D. Kramer, David Healy, James C. Edwards, and David DeGrazia. Of this group of writers, three are professional philosophers, and psychiatrist Kramer’s book Listening to Prozac was surprisingly sensitive to philosophical issues. Healy, another psychiatrist, is author of a number of social/historical books on psychopharmacology; of these, The Antidepressant Era, published by Harvard University Press, has gained the most attention.

The standard worry about Prozac is that it is used too much and for the wrong sorts of reasons; specifically some worry that people who are not seriously depressed, but merely want a crutch to help them deal with life use it. Such a life is thought inauthentic; the happiness of such a life would be a result not of flourishing, but rather a result of chemical manipulation. Furthermore, there may be some circumstances where happiness is inappropriate, and a sense of alienation is a better reaction. Elliott embraces this sort of worry about Prozac, and more generally about the individualistic approach of psychiatry: if modern culture is alienating, he suggests that the best response is not to feel better by taking Prozac; it would be better to examine our values and change the way we live.

Peter Kramer expresses doubt, in response to Elliott, that modern alienation is a reaction to social conditions. Furthermore, he suggests that we have a cultural preference for the melancholic over the sanguine, identifying the perfectionism, pessimism and sensitivity of melancholy with intellectual traits.. He does not necessarily endorse this preference, and does not think it provides a strong reason to be suspicious of Prozac. Prozac could help as much as hinder social change: “If Prozac induces conformity, it is to an ideal of assertiveness.” Kramer wants us to be at least open to the possibility that melancholy is not necessary for critical stance towards our surroundings, and that we should indeed question our attachment to melancholy. That is to say, he thinks a person can engage in a profound philosophical questioning and still be happy. With deliberate provocation, Kramer questions what he sees as a philosopher’s prejudice, the idea that “melancholy is appropriate to modernity.”

The most straightforward critique of psychopharmacology in the journal comes from Healy. He emphasizes the power of the pharmaceutical corporations. He casts doubt on the empirical date supporting the effectiveness of Prozac in treating depression. He states flatly that Prozac does not work for severe depression. Ultimately he calls into question the “pseudoscientific” mystique that has grown up around Prozac, and suggests that the abstract philosophical debate about Prozac and alienation is missing the most important questions.

Edwards gives the mildest suggestion of the group. Using the framework of Foucault and Heidegger, Edwards considers the source of our worries concerning the use of Prozac as mood enhancer. He suspects that we are suspicious of happiness that is not earned through suffering – there is a virtue in bearing pain. Edwards tries to separate out two attitudes towards technology, one that embraces it and another that eschews it. He suggests both are worth thinking about and we need to understand what assumptions are built into each, and most importantly, we should realize that we don’t have to be swept up in the frenzy for technological progress.

DeGrazia, in the last article of the collection, emphasizes that one’s self is partly created, rather than merely discovered, by oneself. He argues that Elliott does not sufficiently appreciate this point, and that Elliott’s criticism of an enhanced life on Prozac as inauthentic assumed that the self is static and given. Instead of Prozac creating a false self, mismatched with one’s real self, it might be possible to identify with one’s new self. A central question for DeGrazia then is just how malleable the self is. He quickly distances himself from the extreme view of Sartre that we are entirely self-creating and utterly malleable. It takes only a little reflection to see that people have limits and that they cannot always become whatever they want. He points out that one long-standing form of self-creation is psychotherapy, and this mode of self-change hasn’t been accused of creating inauthentic selves. Given that, why should the use of drugs like Prozac be any more troublesome than psychotherapy? DeGrazia can see no legitimate difference between these modes of self-change vis-à-vis authenticity. He ends by acknowledging that there may be reasons for qualms about the prospect of a society in which most people use self-enhancing drugs. Nevertheless, he argues, it should not be up to individual psychiatrists to refuse medication to their patients if their reason is such use of medication is not good for society as a whole. It is not for the psychiatric profession to impose its grand vision of the good life on society: patients themselves should make such decisions.

I’m hopeful that the debate about performance-enhancing and mood-enhancing drugs will gather momentum, especially as it becomes clearer how much it overlaps with debates about genetic technology and the increasing use of computers in the body, sometimes known as "cyborg technology." Kudos to the editor of The Hastings Center Report for taking one of the early steps to advance this debate in medical ethics and the rest of philosophy.


Listening to Prozac, by Peter Kramer
The Antidepressant Era, by David Healy
Erik Parens, Editor Enhancing Human Traits: Ethical and Social Implications

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