Strategies for Bioethical Discussion of Psychopharmacology
This is a paper from 1999, presented at a conference, probably under a different title.
Bioethics has largely neglected ethical issues raised by developments in psychopharmacology over the last three decades, despite intense public interest in these topics. There are some signs that this is starting to change, especially since some of the concerns that arise concerning psychopharmacology are congruent with those in other forms of biotechnology, and especially genetic therapy. This paper looks back to the 1970s and early 1980s at the public debate over anxiety, and its treatment with Valium and other drugs known as “minor tranquilizers.” While there was some public interest in the antipsychiatry movement and the feminist movement during this period, the criticisms of psychotropic drugs that came from these movements had very little effect. What had far greater effect was the worry that antianxiety agents such as Valium are addictive, since this linked to an increasingly prevalent concern about drug and alcohol addiction. I discuss what lessons might be learned for current bioethical discussion of Prozac and Ritalin. Specifically, I argue that the head-on attacks against psychiatry are unlikely to have much effect, and so, rather than try to stop the prescription of popular psychotropic drugs, it would be more productive to try to alter the way psychiatrists and patients talk about these drugs.
I have in many papers and conference discussions (foot)noted the fact that bioethics has neglected the important ethical issues that arise in modern psychopharmacology. Since this trend continues to persist, it strikes me that the silence of bioethics itself deserves scrutiny, and so I have made it the topic of this paper. My aim in writing this paper is primarily to spur more bioethical discussion of psychopharmacology, and secondarily to invite reflection on how bioethics creates its own agenda. I also hope to receive feedback about this paper to help me find out more about the often unwritten history of criticisms of psychopharmacology, and specifically Valium, in the 1970s and 1980s.
Bioethics and Psychopharmacology
Bioethics needs to face the future of psychopharmacology. Psychotropic drugs are now used for alleviating clinical depression, anxiety, phobias, insomnia, symptoms associated with menopause, pre-menstrual syndrome, and cravings for food and cigarettes. In the future, they will quite likely be used to boost memory abilities, quickness of thought, reduce anger, and help end other addictions, to name the most obvious possibilities. Psychotropic drugs will also become more available as skin patches in addition to pill form. They will be advertised in television commercials at primetime, on NBC Must-See TV, during Monday night football, and during the Superbowl. If current trends continue, they will be used increasingly by adolescents and children, with the permission and encouragement of their parents and guardians. There will doubtless be many scares about side effects, both mental and physical. There will also be many more issues of Newsweek and Time with cover stories on the latest drugs, (generally these are best-selling issues for these magazines), with some emotionally loaded picture and a caption raising concerns about the direction in which society is heading. (Probably in the same issues there will be full-page advertisements for the same drugs.) There will be many “in-depth” TV news magazine shows interviewing psychiatrists and patients about the latest drugs, some enthusiastic, some indignant, and some forecasting the end of humanity as we know it. There will be more books providing guides to the latest drugs, more alternative therapies, or analyses arguing that the conditions that we are treating with drugs are caused by the increasingly alienating condition of society. Doubtless the Internet will be increasingly blamed.
The Silence of Bioethics
But it isn’t clear what role bioethicists will be playing in what passes for “public debate” about health issues concerning these “mind-altering” drugs. Bioethics has said almost nothing about psychopharmacology. The bioethical journals have almost no articles about the issue, and no books by bioethicists have been published on these topics. Bioethicists may continue to go on as before, avoiding the issue. Why it is so neglected? I have no clear answer to this question, and I merely offer a few comments. An easy diagnosis is that the issue does not fit in with pre-existing formats for ethical problems: especially the tried-and-true battle between the good of society versus the autonomy of the patient. The reasons may go deeper than that: the controversy concerns the definition of mental disorder, which is one of the oldest in the young literature of bioethics. It also concerns the role of the psychiatrist as not just the curer of the sick, but also the social engineer. Maybe bioethicists think that the debates concerning such issues had their heyday in an earlier time.
Comparison With Genetic Ethics
However, these are precisely the issues which bioethicists are leaping to address when it comes to genetic ethics. There has been an explosion of debate about the ethics of human cloning, genetic therapy, genetic counseling, and transgenic engineering. This strongly suggests that it is not simply that psychopharmacological ethics does not deal with the kinds of debates that bioethicists are interested in. Indeed, it may well be that the best bet for those who want to promote the bioethical discussion of psychopharmacology is to piggyback onto the interest in genetic ethics, by specifically focusing on genetic screening for mental illness and the future possibilities of genetic enhancement for psychological traits.
Comparison with Dental Ethics
Is my gripe one that is shared by the many subfields of bioethics that do not get much limelight? I am sure that it is, but in order to make my case more substantial, I need to emphasize that there is something important about psychopharmacology that is not shared by other fields. I choose as an example the case of dental ethics. I have not seen any issues from dental ethics covered in any of the main textbooks of medical ethics. The books of case studies almost never include any cases of dental patients. Don’t dental ethicists have more to complain about that mental ethicists? I think not. The fact is that to deal with dental ethics, we can simply carry over what has been learned from other branches of medical ethics. With all due respect to dental ethicists, dental ethics is intellectually boring and trivial. However, the issues that arise in psychopharmacology cannot be solved by simply carrying over the lessons learned in other mainstream branches of medical ethics. The issues are new and intellectually challenging.
My Own Position
So far I have argued that bioethics needs to turn its attention to the issue of psychotropic drugs because they will have a major impact on western society and their widespread use will provoke a great deal of controversy and discussion in the popular culture. Furthermore, the problems raised by these drugs are rich in their content, and so should be a new intellectual challenge for medical ethics. They raise questions about our definitions of normality, mental disorder, and what it is to lead an authentic life. But I have carefully avoided stating my own view about whether the widespread use of psychotropic drugs should be prevented, encouraged, or more tightly regulated. This is because my argument here does not depend on my particular view about the rightness or wrongness of these drugs.
But for the record, and to help orient the reader to my general perspective, let me briefly state my own opinion. At the metalevel, I think that in order to understand psychiatry, and indeed the rest of medicine, one needs to go far beyond what is often called “the medical model,” because medicine and psychiatry are largely the product of a combination of scientific and social forces. Psychiatric models are especially prominent in displaying both implicit and explicit value judgments. I think we should be aware of the potential dangers of psychotropic drugs, both in regards to their direct long-term physical and psychological side-effects and also their effects on society. We need to be aware that there are huge amounts of money to be made from the creation of new markets for drugs, and multinational pharmaceutical corporations are likely to make their own profits their bottom line, rather than the well-being of society as a whole. However, with those cautions in mind, I want to distance myself from both antipsychiatry and much of critical theory. I also think that we should welcome the potential advantages that such drugs can bring, not just to help the treatment of mental disorders, but also to enhance human capabilities just as dramatic ways as have the printing press, electricity, and the silicone chip.
2. Strategies in Bioethical Discourse
As I have made abundantly clear, I want in this paper to urge bioethicists to consider the moral issues we face with psychotropic drugs. But I also want them to consider their strategies.
Bioethicists, maybe unlike their Philosophy Department colleagues, not only want to engage in a discussion about what the world is like and what it should be like, but also want to change the world. It is this feature of bioethics, and “practical” or “applied” philosophy more generally, that attracts some of its practitioners to it in the first place. Bioethicists perform a number of different social roles, apart from writing for their peers and teaching undergraduates. They are increasingly called upon to teach medical ethics to medical students and allied health professionals. Sometimes they become involved in public debate on national media; individuals at institutions like the Hastings Center and the Center for Bioethics at the University of Pennsylvania are often called upon to write or speak in magazines, radio, and TV. Occasionally bioethicists will take on the role of activists, working specifically to change public policy or public attitudes on controversial issues in medicine.
Yet bioethicists as a group rarely reflect on how much their ideas are heeded. There is some reason to be dubious that bioethicists do have much clout. For instance, when one looks at the standard histories in the US of the increasing rights of women concerning controlling pregnancy and abortion, or the increasing rights of adults to refuse unwanted treatment, one generally learns about the legal battles that occurred. Rarely is the work of bioethicists mentioned. (Sometimes Presidential Commissions do include bioethicists, and then they may have more influence. I am thinking especially on debates about the definition of death, and the funding of research on human cloning and genetics.) If we look back to the 1960s, 1970s and early 1980s, we find discussion about the new drugs that were called “minor tranquilizers” such as Valium and Miltown. It was also a time when psychiatry was under a great deal of attack from the antipsychiatry movement, which received considerable attention from the popular press. By considering what happened in the past, I want to make some suggestions about how we might go about stimulating productive debate about psychotropic drugs in the next millennium.
The issue is to do with the discourse of critique. There are plenty of critiques of psychiatry, and they often don’t seem useful. I want to avoid an analysis that ends up saying that any disempowered group should not bother complaining because it will not do any good, or it is not clear that it will do any good. My purpose is not to discourage social criticism. My political view is that there are structural problems in society which should be treated structurally; I find the discourse of “brain disease” highly problematic; people with mental illness, and especially depression, are often troubled because of the problems they face in their lives. Women experience depression more than men, and this is linked to the systematic reduction of options of women. But my point in this section is that the discourse of critique of psychotropic drugs has particular problems that need to be faced.
Controversies About Psychiatry
Let us briefly step back and take a larger look at the discussion of ethical issues in psychiatry.
Psychiatry as an Embattled Branch of Medicine
A striking feature of psychiatry is that it is always embattled, and has traditionally been one of the most vulnerable parts of the medical profession. Especially in the US, it has wanted to be classed with the rest of medicine, but is frequently seen as a poor cousin by other medical specialties, being soft and imprecise. Psychiatry has suffered frequent criticism from all sides. It was criticized during the era of antipsychiatry, with criticisms of its oppression of patients, long term stay psychiatric hospitals, the use of electroshock treatment. There was also always great suspicion of psychoanalysis, especially from feminism. (See Buhle (1998)).
Geographical Variation in the Suspicion of Psychiatry
There is still public suspicion of psychiatry, although there is more regional variation with this. Psychiatry tends to be more accepted in the US more on the east and west coasts, and is everywhere more accepted than in some other countries, such as the UK. There is a greater public for sophisticated criticisms in the UK. When looking at the shelves in a book shop in the psychology section, there are many more critiques from publishers such as Routledge and Penguin, and fewer self-help books or new-age books.
Psychiatry and the Reimbursement Industry
Psychiatry is also embattled in health coverage by insurance companies or national health policies, with mental illnesses not getting equal coverage as other medical problems. The same has been true in the gaining of legal rights against discrimination for the mentally ill, viz. the Americans with Disabilities Act.
Alternative Medicine and Psychiatry
Alternatives to mainstream psychiatry have existed for as long as psychiatry. Alternative medicine provides herbs such as St. John’s Wort, acupuncture, and there is a continual stream of alternative therapies the go through their different fads. Self-help books and now new-age books reach a wide public. This contributes to a general public sense that psychiatrists don’t have all the answers to mental health problems, and that they provide only a limited spectrum of solutions.
Current Criticisms of Prozac and Ritalin
The data about the astonishing rise in the use of antidepressants such as Prozac and stimulants such as Ritalin in the last decade should be reasonably familiar, so I will not repeat them. The main worries that have been expressed about Prozac are that it will lead to higher expectations of people and intolerance of differences between people.
The idea is that we should recognize that human life is made up of a large variety of emotions and most are natural responses to circumstances. For example, anger and grief after death or a divorce are natural. In fact, without the experience of these emotions, our overall appreciation of life becomes less rich and complex. We can compare the use of cosmetic surgery. If cosmetic surgery and other procedures become common, we will become intolerant of fat, wrinkles, unevenness, and variations from a narrow norm. This will also reduce our appreciation of human life in its diversity, and we will become shallower. Furthermore, the medicalization of expectable mental states such as depression enables the psychiatric profession to have more control over individual’s lives, and reduces some individual’s control over their lives. It is not ultimately empowering for many people.
There have been several published criticisms of Prozac and Ritalin. Most obvious and sensational is the work of Peter Breggin (Breggin, 1991; Breggin and Breggin, 1994; Breggin, 1998, Stein and Breggin, 1999). There are self-help books and natural remedy books that offer alternatives to the use of drugs (for example, Armstrong, 1997 and Hunter, 1995 for attention deficit disorder, and a host of other books on depression and St. John's Wort). Most recently, there have been two books on Ritalin, deGrandpre, 1999 and Diller, 1998, which feature more sophisticated criticisms of the diagnostic categories of attention deficit and hyperactivity and their relation to society. These critiques of Prozac and Ritalin will probably have very little effect. Indeed, they probably will elicit no reaction whatsoever from the psychiatric establishment. The fact is that many patients and psychiatrists find these drugs very useful, and the health reimbursement industry often encourages their use because they are thought to be cost-effective compared to other treatments such as talk therapy. Whatever their merit, the largely academic criticisms of psychopharmacology have little hope of success in changing patterns of prescription or the manner in which drugs are prescribed when faced with such powerful social forces.
3. Valium and the “Minor Tranquilizers”
In order to provide some justification for these claims about the impotence of academic criticism, I will briefly look at the history of the use of antianxiety psychotropic drugs, such as Valium. The facts about the “minor tranquilizers,” as they were known, will be less familiar than the recent history of antidepressants, so I will explain some of them.
In 1965 fewer than 5 million prescriptions were dispensed in retail pharmacies in England and Wales. By 1970 the number had increased to 12.5 million. There was a similar trend in the US. The prescription of antianxiety agents peaked in the mid 1970s, and steadily declined since then. In 1979, 30.7 million benzodiazepine prescriptions where dispensed in Britain, compared with 25.7 million in 1985 (16% decrease). This is largely due to a reduction in new prescribing, not discontinuation of long-term use. Between 27% and 45% of long-term users were dependent on their drugs. Since the early 1980s a growing number of studies have found that patients who agree or request withdrawal from long-term benzodiazepine use experience symptoms of physical dependence. In prescribing, doctors were likely to offer alternatives and were aware of the dangers of dependence. Patients were also aware of the options and dangers. Many patients felt ambivalent about taking the drugs.
Gender was a large factor in the prescription of tranquilizers. Twice as many women used tranquilizers as men. Women in traditional families were more likely than their spouses to be taking minor tranquilizers. Those women in non-intact families and those caring for a spouse were more likely to be taking tranquilizers. Long-term users were less likely to have a full time job, and the users who were employed were more likely to be ambivalent about the drug. Long term users were more likely to be divorced and not to have children living at home. Those users living with families were less likely than controls to find their families supportive and they had fewer opportunities for leisure.
There were increasing claims by scientific experts and patient representatives in the 1970s that the tranquilizers were being overused or misused. Gabe and Bury (1988) argue that the media in Britain played a major role in legitimating the concept of tranquilizer dependence as a social problem. This became aired on British TV and radio. That’s Life, a prime-time Sunday evening show, examined the issue 4 times between 1983 and 1985. Women were portrayed as victims completely taken over by the drug. This media coverage helped mobilize public opinion. This was helped by a pre-existing ambivalence about the taking of the drug among users, especially middle-aged women, and also by the growing concern about illegal drug use. However all this concern did not cause much response by the government, who implemented only minimal controls.
Is there any reason to think that prescription of minor tranquilizers led to less concern or covered up social issues concerning women? Could it have had the opposite effect and increased awareness? Gabe and Lipshitz-Phillips (1984) argue that this was quite possible. Furthermore, there was no evidence that the interaction between patient and doctor enhanced traditional gender stereotypes.
It is also worth noting that in the considerable popular literature critical of the mental health profession, largely fueled by the antipsychiatry movement and the women's movement, there was very little discussion of psychotropic drugs. It was only in the late 1970s and early 1980s that criticism of tranquilizers really came to grip the public attention. Indeed, even now, most of the books that criticize psychiatry from a feminist perspective still put little emphasis on the issue of psychotropic drugs.
Parallels with Prozac
One of the most striking features of the history of tranquilizers is the similarity of press coverage to the recent press coverage of Prozac. Tranquilizers were called by magazines "happy pills, "psychiatric 'aspirins,'" "peace of mind pills," and "emotional aspirin." This corresponds directly with much of the discussion of Prozac in popular magazines, and even to some extent the much more sophisticated discussion such as in Kramer (1993). The prospect of solving psychological problems with a pill tends to grab the attention of the public: national magazines can generally expect to have very strong sales when they put a picture of the latest wonderdrug on the cover. The initial reception of Prozac has been largely positive, even if there have been several negative articles in major magazines and negative press associated with claims that it was Prozac that caused some murderers to go crazy and some depressed people to kill themselves. The initial reception of tranquilizers in lay periodicals, starting in the mid 1950s, was also mixed, although by the mid 1970s it became largely negative. It is somewhat ironic that one of the worst pieces of press that Valium recieved was in 1980, on the TV show "Sixty Minutes." Mike Wallace accused the president of Roche of pushing Valium on the public and of allowing the easy accessibility of this addictive drug. It is the same Mike Wallace who has become a public advocate for antidepressants, widely proclaliming that he will remain on Zoloft for the rest of his life to prevent his depression from recurring.
It seems that the social critiques of Valium and other anti-anxiety drugs may have had some success, but largely because it was combined with the great concern over the addictive properties of the drug and the general worry about addictive non-prescription drugs. Women who took the drug were often informed about the dangers of the drug and kept on taking it because they found it useful. There is no good evidence that it led to the individualizing of social problems.
Given these findings, it seems that the prospects for a social critique of Prozac in the public arena are dim. Prozac has had much less controversy around it than Valium did. The main concern is that it can increase violence and induce manic states in people with bipolar mood disorders. The FDA and drug manufacturers deny that any such effect has been established despite careful research, but the worry refuses to completely die away. There is some long-standing unarticulated worry about taking drugs for psychological problems, but at present this does not seem to be having a significant slowing effect of the taking of the drug. So as far as Prozac is concerned, the only allies that feminists and other social critics could find in a public critique would be religious groups like Christian Scientists, and they are unlikely collaborators.
Like Valium, Ritalin has faced accusations of addictiveness, although recently these accusations have been downplayed. Ritalin has been available since the late 1960s, before Valium even came on the market. It has weathered storms of controversy and continues to be prescribed on a large scale.
In conclusion, I want to emphasize two points. First, there are important and interesting issues for bioethicists to discuss when it comes to psychopharmacology. These go beyond the potential dangers of psychotropic drugs, such as physical and psychological side effects leading addiction and violence. They include the issue of the definition of mental disorder, and the assessment of the effect that psychotropic drugs could have on our quality of life as they become part of the fabric of our day to day experience.
Second, we need to look at recent history to understand the discourse of psychopharmacology in popular culture. The lure and dangers of improving our psychology with a pill create a great deal of alarm and suspicion among some, especially those who suspect that the pharmaceutical industry does not always make the public good its first priority. Whatever the merits of the particular criticisms of psychotropic drugs, the history of Valium suggests that there are powerful dynamics that make most such criticisms ineffective. Despite well-publicized misgivings about the drug, it became highly prescribed. In the end, it was only when these misgivings were combined with worries about its addictiveness that prescription of the drug began to fall. Prozac, Ritalin, and their cousins have received on the whole better press than Valium, and they do not appear to be addictive in similar ways. Therefore, if bioethicists are to be realistic in raising worries about modern psychopharmacology, they should start to do more than criticize, and it is not enough merely to suggest alternative treatments. Instead, they should look for aspects of modern psychiatric practice which are more amenable to change, such as the kind of discussion that occurs between psychiatrists and patients when medication is prescribed, and the attitudes patients are encourages to take towards their medication. It is changes such as these that may have more actual chance of impacting on the ultimate effects that the growth of psychopharmacology has on our society.
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Lectures and Conference Papers:
Papers given at “Gender, Philosophy, Psychiatry,” AAPP Annual Meeting, May 1998.
· Philosophy, Postmodernism; Psychiatry, Progress, Patriarchy, Prozac, And The Politics of Posthuman Bodies. Bradley Lewis, MD
· Prozac, Gender, and the Micropolitics of Psychiatry. Camilla Griggers, Ph.D.
· Considering A Feminist Critique of Prozac? Take Valium and Wait. Christian Perring, Ph.D.
The fifth annual Healthcare Ethics Lectureship, Concordia College, Minnesota, featuring Dr. Carl Elliott, M.D., November 1997. "The Tyranny of Happiness: Prozac and the Meaning of Life."
 One of the few papers on Ritalin is by Perring (1997). See that for a literature review of the bioethical discussion of attention deficit disorder. The Hastings Center has been the main source of other bioethical debate on this topic. See Parens (1998), Whitehouse et al (1997), and Diller (1996). There have been some discussions in some of the more sober magazines, such as Wright (1994). Some of the most theoretically sophisticated work has been historical. Edward Shorter takes a somewhat critical perspective to the proliferation of mental disorders and the overprescription of Prozac in (1997) and (1998); Valenstein (1998) is also critical of biological psychiatry, while Healy (1998) is more accepting. One of the main avenues of discussion of these issues comes in longer reviews of books such as the ones I have just listed. For an up to date list of reviews, consult the Philosophy of Psychiatry Online Bibliography, at http://www.angelfire.com/ny/metapsychology/.
 There is a long and interesting tradition of psychiatric critique within feminism. Especially with writers like Elaine Showalter, Barbara Ehrenreich and Deirdre English, Nancy Chodorow, Carole Gilligan, Dorothy Donnerstein, Phyllis Chessler, and Paula Caplan. It ties in with the more abstract critiques from thinkers such as Foucault, Deleuze and Guatarri, antipsychiatrists like RD Laing and his colleagues, but often emphasizes real life more, and integrates personal experience with the more abstract analysis. So feminist critique is one of the most interesting and intellectually productive parts of the more general tradition of psychiatric critique. See Buhle (1998) for an extended discussion of feminist criticisms of psychoanalysis.
Thanks to Pauline O’Connor for articulating these worries in discussions with me.
 It is remarkable that despite a high profile and wide name recognition, the criticisms of psychiatry by Thomas Szasz and Peter Breggin have been basically ignored by the main psychiatric presses and journals. It is of course hard to know whether this is because the editors of the presses and journals simply did not have worthwhile submissions addressing the issues raised by these critics, or whether they made a deliberate decision to refuse to dignify these criticisms with a reply.
It is hard to assess the effectiveness of any given critique, and to decide what caused any particular change in psychiatric practice. There is variation in different countries too. For instance, antipsychiatry did have some dramatic effects on practice in Italy, with apparently disastrous effects. (See Isaac and Armat (1990) pp. 325-8.) There is plenty of discussion about what led to deinstitutionalization in the US, whether it was really the critique of asylums or alternatively the political desire to save money and the irrational belief that closing down of asylums would do so. Clearly the development of the psychotropic and especially antipsychotic medications had an important role, but it was not the only factor.
This information comes from Smith (1991) and Jonathan Gabe, "Personal troubles and public issues: the sociology of long-term tranquilizer use," in Gabe (1991). The first benzodizepines, Miltown and Equanil, were put on the market in 1956. Then there was Librium in 1960, and Valium in 1973.
It is probably impossible to gauge the effect of the Rolling Stones' song on the topic, "Mother's Little Helper.”
The authors write that there is “little support for tranquilizer’ involvement in the medicalization of everyday life in that there was little to indicate that the prescribing and the use of these drugs necessarily involved the individualization of social problems. The majority of doctors operated with multicausal rather than monocausal model when explaining their patient’s symptoms and seemed unlikely to impose individualized explanations on a patient if they felt that interpersonal factors were relevant to his or her predicament. The patient’s, on the other hand, were rather more likely both to perceive a single cause for their symptoms and to suggest physical and psychosomatic factors as their cause. This was, however, less the case with long-term users than with other patients.” (Gabe, 1991, p. 43)
See Agel (1971, 1973), Brown (1974), Chesler (1972), Gornick and Moran (1971), Ruitenbeek (1974).
See Hughs and Brewin (1979), Rosenblatt and Dodson (1981), Tranx (1984), Marks (1986), Snyder (1986)
See Showalter (1985), Astbury (1996), Ussher and Niccholson (1992), Ussher (1991). Even Russell (1995) in her explicit attack on biological psychiatry devotes very little attention specifically to the issue of psychotropic drugs. One of the few feminist discussion of Prozac is an extended book review, in Gardiner (1995), another is a magazine article, Hassibi (1995). Hamilton and Jensvold (1995) is a collection of mostly empirical studies and surveys, which does not touch on more theoretical issues.
See Smith (1991), p. 82.
 My thanks to John Mullen for useful comments and questions on an earlier draft of this paper.