I gave this paper at a conference at the University of Tennessee, Knoxville, in 2001.
Psychopharmacology and Personal Identity
Introduction: Philosophy Neglects Important Issues
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. 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. But in fact the debate that continues to focus on these issues is not purely empirical: it involves profoundly philosophical issues.
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. To give further examples: doctors are criticized as being are too ready to perform radical hysterectomies on women, ignoring the effect this has on women and failing to consider more conservative options. 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. Thus, 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 in the sense just indictated. 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. Journals in medical ethics rarely discuss psychopharmacology. 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.
These issues get even less attention in the more traditional journals such as The Journal of Philosophy, Ethics, Philosophy and Public Affairs, and The Philosophical Review. This reflects 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, and leave it to others to think through the implications of their abstract theories for the real world. But 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.
As an example of the way that philosophy of psychiatry can force bioethics and philosophy to cover new territory, I will focus on psychopharmacology and personal identity. The philosophical question can be stated quite simply, or so it first seems. Can taking a psychotropic drug change who you are? This suggests an approach which leads one through a rather predictable series of questions and answers:
Q: How do psychotropic drugs change a person’s emotional profile?
A: This varies from case to case. An antidepressant can end depression, and an anti-anxiety drug can reduce anxiety and panic attacks. Sometimes the changes are subtle, and sometimes they are major.
Q: Not all changes in a person are changes in “who the person is.” What changes in a person are important enough to change her personal identity?
A: “Identity” is a term that gets used differently in different contexts, so there is no unitary answer to this question. Consider legal and interpersonal moral contexts.
i) In legal contexts, it is rare for a court to acknowledge that a person has changed so profoundly that she is no longer the same person, legally speaking. Even when people go through major changes, they are still legally responsible for what they did in the past, before their change. There is no category of “not guilty by reason of change in personal identity.” Note here that a court is also likely to be especially unsympathetic to these kind of defenses because they are liable to faked. Contracts between two people are still valid even when one of the two people has gone through extreme personality change. Of course the changes may be relevant to the court’s dealing with a person: for example, true remorse will make a judge more likely to reduce a sentence.
ii) In interpersonal moral contexts, a profound change of character is sometimes enough for us to forgive someone who has wronged us, or for us to even say that “the person who did that bad thing no longer exists.” In the more relaxed social context of everyday interaction, we are willing to speak of changes of identity to others. For instance, in Jackie Lyden’s wonderful memoir of her manic depressive mother, Daughter of the Queen of Sheba, she writes as if the persona of her mother as the woman she calls “the Queen of Sheba” is in fact a different person from her real mother. She does not hold her mother responsible for what the Queen of Sheba did. Note that her mother does remember acting as the Queen of Sheba and also that she was not utterly delusional when she was acting extravagantly and recklessly.
Q: Do psychotropic drugs ever change people enough for us to legitimately say that they have become different people?
A: Our answer to this question will have to depend on context also. In a legal context, it is very unlikely that a change would ever be so profound as to make a court accept that the person had literally become a different person. In an interpersonal moral context, we do sometimes talk of the drastic effects of drugs changing the identity of a person, although it is not clear how literally we mean this.
These questions and answers are perfectly appropriate and correct as far as they go. However, they do not get to the root of the issue. When people worry about becoming different people, they are not thinking about the massive personality changes that I have been describing, and yet we still might want to take their concerns seriously. If we restrict ourselves to the apparatus provided by the existing literature on personal identity, we have to dismiss those concerns as philosophical misunderstandings, or as, at best, exaggerated ways of speaking. I want to spend the remainder of my time trying to tease out what I consider to be the real concerns at play when people worry that taking psychotropic drugs will change their personal identity.
I want to make two main points. First, that one problem with the debate up to now is that it treats sameness of personal identity as all-or-nothing. But often we think of change of personal identity as a person changes as a matter of degree. (Of course, identity is strictly speaking an all-or-nothing relationship, but this is ultimately no more than a linguistic point: it would be more accurate to move from talking of identity to using some other locution, such as "degree of sameness of person." However, I will continue to talk of identity, because it is simply the most natural way we have to refer to what we mean here.) Most philosophers at this point will say that we need to distinguish literal and figurative ways of talking, or between quantitative and qualitative change in identity. They will insist that when we say a person changes over time, we mean that she changes in her qualities, but not in who she is, literally speaking. They will back this up by pointing out that we don't treat her as a totally different person, and she does not treat herself that way. However, following the work of Derek Parfit, I have elsewhere explored and defended the possibility that we can accommodate into the way we think the idea that people do literally gradually change who they are as they change various qualities. The change in personal identity can be large or small. This then leaves open the idea that people do literally change who they are when they start taking psychotropic drugs, even if the change is relatively small.
The other point I want to make, and it is, I believe, the more subtle one, is that when talking of being a different person when taking psychotropic drugs, we are often talking of changes in the genesis of our actions, or our personal autonomy. It is not so much the change in outward behavior that we care about: it is the change in how we make our decisions, how we think, and what is important to us. Even if these changes are relatively small, they may still be very significant. I will now expand on this idea.
Autonomy of Action
Philosophers have coined the term “folk psychology” for the set of theoretical assumptions that are implicit in our ordinary understanding of each other. They have concentrated mostly on the folk psychology of belief and cognition, saying relatively little about the folk psychology of action. They discuss what it is to have a belief, whether computers and animals can literally have beliefs, and how physical objects like ourselves are able to create meanings with our use of language. Other philosophers, known as philosophers of action, have spent the last thirty to fifty years (depending on what you count as philosophy of action) discussing what it is to be an agent or actor, i.e., a performer of actions. For example, they discuss what the difference is between raising one’s arm and having one’s arm raised; whether one always tries to perform one actions prior to actually doing the actions, or whether one only tries to do something when one is having difficulty doing it. Many philosophers of action claim to be simply making clear the concepts that are already present in ordinary people’s understanding of themselves, although they have to admit that this understanding is at best implicit. Other philosophers of action don’t pretend to be setting out how people do in fact understand themselves, but instead they present their theories as explanations of how people should understand themselves if they were rational clear thinkers. That is, they don’t say that their theories are elaborations of the folk psychology of action: they are simply giving the true theory of action, which may or may not correspond to ordinary people’s self-understanding.
My own view here is that folk psychology has many threads, and they are not woven together into a seamless fabric. Instead, different people have different self-understandings. We don’t all agree amongst ourselves. Moreover, even individuals hold somewhat inconsistent sets of belief about themselves: their different ideas about themselves and their sense of themselves as agents in the world may well not fit well together.
I will spell out what I take to be a common folk psychological theory of self. It seems to me that some people have a sense of themselves as having a core of agency. This core may be associated with the religious idea of a soul as the essence of a person, but it need not be. It is in this core that all of a person’s most fundamental beliefs, feelings, and emotions reside. Some would call this their “true self.” This true self does not always make itself apparent: our actions and expressions of feelings can be distorted by outside influences. We feel we have to put up a front to please other people, for instance, and so we create a “false self” which gives the appearance of being how we think other people want us to be. Or sometimes we pretend to be other than we really are as a way to get what we really want. For example, it might be that I am in fact a very uptight and repressed Englishman who finds it intolerable for other people to know how I feel, but living in the United States, I have found that I have to pretend to be open and at ease with my emotions.
Now at the same time as we have these views of our true selves, we also take on board modern scientific knowledge about the brain. We know that our thoughts somehow reside in or start out in the brain. We know that our moods and thoughts can be affected by changes in the brain. These changes can be structural or chemical. We know very well that the brain is not like an onion with many layers: there is no core part of the brain where my “self” will be found.
For the most part, we allow these two models of the self to sit alongside each other without worrying too much what they mean to each other. Some people favor one over the other; for example, some people pay very little attention to the modern scientific understanding of the brain and psychology, and remain very much within old fashioned folk psychology. Others say that they see themselves purely as biological entities like other animals, and don’t have much truck with talk of “true selves” and “false selves.” Still others have very different conceptions of self.
But sometimes people are forced to confront the meeting of science with folk psychology, and a very instructive case in point is when people start taking psychotropic drugs. They know that the drugs affect their brain chemistry, but there is no simple conclusion about what it means for them. Some people think that medication is simply correcting a chemical imbalance in their brain, and returning them to their true selves. Others see it as affecting their very core, and thus significantly altering who they are in a profound way: somehow robbing them of their true selves.
We face a future when we will face many temptations and incentives to take more psychotropic drugs. These drugs will be able to make us more resilient to troubles, more cheerful, less irritable, with better memorization abilities, and quicker mental processes. But the worry arises that this brave new world will be one in which we are less true to ourselves; these drugs will perhaps be a form of brainwashing that make us better workers, serving the purposes of multinational corporations. These are deep worries.
Should philosophy endorse these worries, or can it dismiss them as irrational? There is considerable complexity in the issues, but here I want to focus on our understanding of our selves. Can philosophy show whether "performance-enhancing" drugs enhance or diminish our personal authenticity, our ability to be true to ourselves? Well, philosophers are going to disagree amongst themselves about this, so philosophy as an academic discipline will not settle the issues. Furthermore, the general public tends to be fairly impervious to the arguments of philosophers, so whatever philosophers say will not really affect how people feel about themselves in the psychotropic future.
What philosophy can offer is clarification, for those who seek it, of how different views of the self may relate to each other. I don’t believe that philosophers can show with any degree of certainty that one view of the self is right and another wrong, and it should encourage some general acknowledgment of the difficulties of the topic at stage – thus it should discourage dogmatism, on either side. It can promote understanding of what lies behind different models of the self, historically, politically, socially, and culturally.
Finally, and this is probably my most contentious suggestion, philosophy can encourage the realization that how we think of ourselves need not be so much a matter of discovery as creation. We are in some ways able to mold our self-understandings, and maybe more so the self-understanding of our children. What I am suggesting here is that self-understanding is not simply a matter of seeing how things, in this case ourselves, are, but rather creating a point of view which generates our selves. If this is right, then rather than worry what will become of us in the psychotropic future, we can decide what we will make of ourselves.