Saturday, November 15, 2008

Worries about Psychotropic Medication: A Philosophical Guide

This paper dates from Fall 2001. I didn't work out where to submit it for publication, and it sat on my hard drive.

Worries about Psychotropic Medication: A Philosophical Guide

My aim in this paper is to explore reasons people may have to being worried about the widespread use of psychotropic drugs, and especially in cases when the drugs are not medically necessary. I will not take a strong position for or against this use, although I will express some skepticism towards some of the objections that have been made against the use of antidepressants. My motive for writing this paper is to try to encourage discussion of the issues, and in particular to get people who are against this use of medication to better articulate their reasons.
My approach here is solidly “bottom-up” as opposed to the alternative “top down” approach of starting with a certain sophisticated theoretical view and showing how it applies to particular cases, which I find to be of limited value. I will take some simple ideas and intuitions and try to develop them a little. Thus I will not start out with any discussion of great philosophers such as Aristotle, Hume, Kant, or Wittgenstein. Nor will I assume the truth of any fully worked out theories of the nature of nature, autonomy, or the good life. I will refer to some well known philosophical theories along the way, and I may argue that some have more plausibility than others, but my aim here is to be basically neutral in my stance among the various philosophical approaches that are relevant to this issue.

The Rise in Psychotropic Medication: Prozac and Ritalin
It is uncontroversial that there has been a massive increase in the use of psychotropic drugs. Eli Lilly boasts that 40 million people in 100 countries have taken Prozac. This maybe due to an increase in mental illness:
Millions of us are falling prey to what is now identified as a disease. Five million of us each year have some sort of depressive illness that would justify medical intervention. That's not much less than a tenth of the population. A third of those who go to the GP have underlying depression. The young, with the world ahead of them, should have the blithest hearts. Yet 12% of male students and 15% of female students at university are depressed. Yesterday, meanwhile, it emerged that university counsellors are reporting a dramatic increase in the number of students seeking help for severe mental problems. Just over a year ago, the World Health Organisation declared that depression had reached epidemic proportions. Within 20 years, the WHO said, it would be the world's second most debilitating illness after cardiovascular disease in terms of lost years of human productivity. [1]

The rise in psychiatric medication is especially noticeable among children. Between 1992 and 1998, in one study:
Prescription prevalence in school-aged children 6 to 14 years increased from 4.4% to 9.5% for stimulants during the study period, and from 0.2% to 1.5% for SSRIs. In 1998, stimulant prescription prevalence was highest for white school-aged males (18.3%) vs black females (3.4%) and SSRI prescription prevalence was highest for white school-aged males (2.8%) vs black females (0.6%).[2]

Furthermore, young people often use stimulants without a prescription.
Among the findings from a soon-to-be-published Massachusetts Department of Public Health survey: 13 percent of 6,000 high-school students and 4 percent of middle-school students admitted to an “illicit, unprescribed use” of Ritalin in anonymous, written surveys.[3]

They might do this for recreational use because they enjoy the experience, or possibly because it helps them study better, as often happens with students taking caffeine tablets. In this paper I am especially interested in the use of drugs to enhance one’s capabilities and to make up for one’s deficits, although if there are objections to the use of medication in these cases, they may also apply to cases in the gray area between illness and health, and even to treatment of cases of clear mental illness if there are alternative, non-medication treatments available.

Natural Remedies
There’s also an increase in the use of herbal remedies and vitamin supplements in the hope that they will improve one’s mental life.[4] One report that in the US, $400 million is spent on St. John’s wort each year. Furthermore, “Approximately 42 percent of U.S. health care consumers spent $27 billion on ``complementary and alternative medicine'' therapies in 1997, the most recent year for which data is available.”[5] “Americans spent $4.13 billion on all herbal supplement sales in 2000, with $248 million on top-seller gingko biloba, a product that presumably improves memory. They shelled out $210 million on echinacea, for its alleged immune boosting fighting ability; another $174 million on garlic, for its supposed infection-fighting properties; and $170 on St. John's wort, the so-called natural antidepressant.”[6] Sales are still growing, even though they are not growing at the same high rate as a few years ago.

Critiques of Psychopharmacology
Faced with this increased role of medication in our everyday lives, some social critics have suggested that it represents a deeply disturbing tendency. They have given various sorts of reasons, which can be divided into two kinds:

“Sociological Concerns” (based on assumptions about our society and other empirical claims)
Not addressing the real issues.
Many social critics have suggested that the rise in depression is a real phenomenon, but is a symptom of a deeper underlying problem. Generally, this problem is identified as the increasingly alienating nature of modern society, which involves less human contact, and more impersonal technology. However, there are other possible candidates for the “real problem”, including environmental toxins, the change in family structure due to the changes in women’s roles, or capitalism. This approach normally acknowledges that depression and anxiety are real, but point out that treating it on an individual basis rather than a social basis means that we never address the real problem, and indeed, mental health professionals may be perpetuating the problem or making it worse.
This is largely an empirical issue, although it may be hard to do studies that would decide which view is correct. Whether our society is really more alienating than it was one or two hundred years ago is hard to prove, since alienation is not an easy variable to measure, and there were no direct measures of alienation in previous centuries. Measures of the growth of the alienating nature of society have to be indirect, and are inevitably highly contestable. It is more feasible to do anthropological studies of alienation and depression, but even here, there’s a great deal of room for debate about what we can conclude from such studies. Cross-cultural comparisons introduce new concerns about what should count as depression, since symptoms of depression are often claimed to vary from culture to culture.[7] The alienation issue will arise again below, under “self” concerns.
The “increase in depression” is due to relabeling ordinary unhappiness
Some have suggested that the increase in the incidence of depression is not real: it is simply a result of lowering the criteria for what counts as depression, and also a result of introducing the category of dysthymia, chronic low level depression.[8] This is related to a claim that the reason for the change in criteria serves the interest of mental health professionals, because it brings them more work. As non-psychiatrists do more psychotherapy, psychiatrists find a need to preserve a role for themselves in modern society, and that role is to prescribe medication.
One might think that whether it is true that the official criteria for depression have become more liberal should be easy to determine: one could simply compare manuals from different decades. But in fact the criteria are relatively vague, and it’s debatable to what extent they determine the judgments of clinicians. It’s clear that what makes a difference is not what it says in diagnostic manuals and textbooks, but whether the actual criteria used by clinicians have changed, and this is especially hard to discover.
The Undue Influence of the Pharmaceutical Industry.
It’s clear that medication is big business, which in the US is now able to advertise direct to the public. Clinicians are given financial incentives to diagnose mental disorders and psychiatrists are given financial incentives to prescribe medication (rather than, or in addition to, suggesting psychotherapy). The facts about the power of the pharmaceutical industry are very impressive, but of course the industry itself would say it is providing needed and helpful resources for clinicians, and that it is performing a valuable service. There have been studies on the extent to which psychiatrists are influenced by perks, incentives, and free lunches offered by the pharmaceutical companies, and the results often show that the influence is strong.
However, there has been no proof that this sort of influence can explain the rise in the diagnosis of depression over the last fifty years. Even once we admit the potential power of the industry, we have not shown that this is in fact the correct explanation for the rise in the diagnosis of depression and the use of antidepressants. The most we will have shown is that it has played some role, but not how great a role.
The Side Effects of Medication
Some authors have argued that antidepressant medication has side effects that are underestimated.[9] The main idea is that these drugs are far more dangerous than people realize, and that the government drug trials used to test their safety are conducted over a short period and do not detect long-term effects or effects on children. These medications are used a great deal with children, but their long-term effects on children are unknown.
Although these criticisms are often put in alarmist form, they have been not received much attention, and have been largely ignored by the psychiatric establishment. There is often a pattern with popular drugs that after many years of use, it is found that they have unforeseen effects (e.g. Phen Fen, Valium) and they then become prescribed much less often, so it would not be very surprising if this criticism turned out to be true.[10] Nevertheless, it remains an empirical issue.

Distinct from the above concerns are three rather different ones, which I will call “Self Concerns.” They are more philosophical than empirical.
Dehumanizing Ourselves
First, it might be argued that in taking medication we are treating ourselves like machines, or like objects, rather than humans. I have heard people make this sort of argument, but it is clearly rather weak. Dehumanization cannot simply a matter of putting a foreign object into one’s body, because then eating would also be dehumanizing. It has to be a matter of ingesting technology, or possibly using technology to alter one’s emotional outlook. It would seem that this sort of view would mean that all manufactured medication is problematic, and this view seems highly problematic and far too extreme to be plausible. I turn quickly to a more sophisticated version of the objection.
Against the Natural Order
Some may argue that in medicating ourselves, we are going against the natural order. Christian Science religion takes such a view: they believe that God has his plans for us, and we should not resort to medicine in curing our illnesses because this goes against God’s plan. This view, I think, is implausible even for the theologically inclined, because it rests on unsupported Biblical interpretation. Nevertheless, to go back to the more general objection, the idea of a natural order is one that has a great deal of intuitive appeal. Many people have a sense that there is a natural way of being and that it is wrong or dangerous to interfere with this natural order, especially when one is considering mind-altering drugs. The problem comes when they try to articulate this sense, because the concepts of nature and the natural order are very hard to pin down or to justify.
Finally, there is the most plausible of the self-concerns, that taking mind-altering medication in some way reduced one’s autonomy or authenticity. At its crudest, this sort of objection relies on a problematic empirical claim that psychotropic drugs cloud one’s thinking or give one an emotional high[11]: while this may be true of alcohol, stimulants such as Ritalin or anti-anxiety drugs such as Xanax and Valium, (although it probably is not true when the medications are working as intended), there is very little reason to take this assumption seriously in the case of antidepressants. I speak partly from personal experience, having taken antidepressants myself, but more importantly, there is no scientific and little anecdotal evidence to support the ideas that one’s cognitive abilities are impaired by antidepressants or that one’s values are significantly altered (in ways unconnected with the depression) by the medication.[12] I have heard and read reports of people who say that antidepressants make them feel numb and incapable of feeling anything, and this is an important phenomenon.[13] This isn’t the intended effect of the medication, although it might be a clinically acceptable effect if it is the only alternative to agonizing depression. But for the philosophical objection to taking medication for enhancement to be interesting though, we need to consider the cases where the medication works well.
To make this “authenticity” objection plausible, one has two options. First, one can argue that the world is alienating, and thus that alienation and depression are rational responses to the world. To take antidepressants is then to interfere with a normal reaction, and can impair one’s ability to respond appropriately to the state of the world.
Secondly, one could argue that to bring in such radically foreign material into one’s central nervous system to affect the functioning of one’s brain is inherently to reduce one’s autonomy or authenticity. I will return to this at the end of the paper.

The Popular Media
Remarkably, the literature in medical ethics has largely ignored these concerns. The books that have most forcefully addressed these issues have been written by psychiatrists and psychologists. (A partial list would include David Healey’s Antidepressant Era, Peter Kramer’s Listening to Prozac, Lawrence Diller’s Running on Ritalin, Richard DeGrandpre’s Ritalin Nation, Lauren Slater’s Prozac Diary, and Peter Breggin’s series of books against psychotropic drugs. Shelves of less thoughtful self-help books have also been published on related topics.) Some might argue that these authors are indeed medical ethicists, and in a sense they are, but they are very much removed from the mainstream of medical ethics. They rarely publish their work in the prestigious medical ethics journals and they are not employed in bioethics institutes or centers.
The other main source of noticeable concern concerning psychotropic medication comes from mainstream media such as TV news shows and magazines such as Newsweek and Time. As we might expect, the analyses in these media are mostly shallow; what is interesting is that the bioethics establishment has done so little to follow up on the public concern expressed in popular culture.

Medical Ethics and Enhancement
Insofar as mainstream medical ethics has addressed the issue, although there has been some discussion of Prozac, the literature has mainly focused on how to make the distinction between curing a disease and enhancing a normal condition.[14] Certainly this is a very important distinction, and it seems that it is far less problematic to use medication to cure illness or to relieve the symptoms of illness than it is to enhance or alter a healthy person. It is worth discussing the relevance of this distinction to my main thesis here.
The general philosophical problem of the definition of disease is a long-standing and difficult one, which is still being discussed vigorously. Most people acknowledge that the categories of illness are value-laden, and there is much work to be done in finding in what ways the category of depression is value-laden. I’d prefer the claims of this paper to be independent of the debate about the definition of mental illness: whatever the correct definition, it’s clear there will be a large gray area between health and illness and that we will be able to get a good amount of intersubjective agreement about which cases constitute an enhancement of a normal person. My main point here is to do with cases of enhancement, although I am ready for the conclusion of the argument to be applicable to cases of taking medication to relieve depression. I am primarily interested in what could be philosophically problematic about taking medication, and I don’t believe this depends on the definition of mental illness.
It is worth also noting briefly that there have been empirical studies of “patient compliance” – i.e. the extent to which people are willing to follow their doctor’s instructions, as opposed to “disobeying” their doctor. It’s not unusual for people to accept a prescription, but then to not get it filled, or else to get their medication, but then to only take it for a week or two, rather than the recommended 4-6 weeks it takes to see if antidepressants are effective. Often there are pronounced side-effects of the drugs (e.g., dry mouth, nausea, fatigue or sleeplessness) that decline or disappear after a week or two of taking the medication regularly. One of the reasons that Prozac became a best-selling medication is that it has fewer side-effects than the older antidepressants, so patient compliance was improved, and this was demonstrated in studies. We should bear in mind though that these kinds of studies tend to be rather crude and operationalized, and certainly will give us little insight into people’s philosophical qualms about taking medication.

Genetic Ethics and the Suspicion of Technology
Some of the discussion concerning the morality of genetic engineering is applicable also to the use of psychotropic drugs. For this reason, I will make a small detour into the ethics of cloning. Philosophers such as Leon Kass have tried to articulate their reasons for a deep discomfort with our interfering with the natural order.
In his widely reprinted article “The Wisdom of Repugnance”[15] Kass argues that although to have a strong reaction to something is not an argument against it, but that repugnance can be an emotional expression of deep wisdom. He writes,
The repugnance at human cloning belongs in this category. We are repelled by the prospect of cloning human beings not because of the strangeness or novelty of the undertaking, but because we intuit and feel, immediately and without argument, the violation of things that we rightfully hold dear. Repugnance, here as elsewhere, revolts against the excesses of human willfulness, warning us not to transgress what is unspeakably profound. Indeed, in this age in which everything is held to be permissible so long as it is freely done, in which our given human nature no longer commands respect, in which our bodies are regarded as mere instruments of our autonomous rational wills, repugnance may be the only voice left that speaks up to defend the central core of our humanity. Shallow are the souls that have forgotten how to shudder. (page 19).

Kass goes on to set out some of the consequences that he holds to be repugnant, and I believe his argument is fairly weak because the supposedly awful consequences don’t seem so bad to me, certainly no worse than what we are already ready to accept in contemporary society. Nevertheless, his method and this passage in particular strike me as important, and it could be helpful for those who want to articulate their discomfort with the use of medication for enhancement. Note that his method is highly controversial. In a recent magazine article, Sheila Jasanoff of Harvard University’s Kennedy School of Government equates Kass’s method with expression of a “yuck” reaction, and prominent bioethicist Dan Brock is quoted as saying, “it doesn’t have any intellectual content.”[16] While I’m sympathetic to these criticisms, and certainly that there is a danger of this approach amounting to nothing more than the expression of mere opinion, I am also sympathetic to the possibility that we might be able to educate our moral sensibilities, and attune ourselves to moral reactions. Ultimately, I believe, moral sensibilities and intuitions play an important role in our moral epistemology, and so I am somewhat sympathetic to elements in the traditions of moral casuistry and moral particularism. Kass’s discussion of repugnance can be seen as an instance of particularist methodology. But even if we accept this approach, we still need some way to distinguish between irrational prejudices and reasonable moral perception. At a minimum, we should be able to articulate some similarity relation between fundamental intuitions, or some mutually supporting relation between intuitions and a plausible moral theory. Furthermore, it should not be possible to completely explain away the moral intuition as a prejudice or an effect of arbitrary moral conditioning. Furthermore, the stronger and more widespread a moral intuition is, the more reason there is to take it seriously.
Now it would be an exaggeration to say that people feel repugnance at the use to psychotropic drugs to enhance one’s abilities, (although some people do have strong negative reactions to the recreational use of drugs such as marijuana and cocaine, which may be related). I’d say that most people have qualms, worries, or reservations about the widespread of use of Prozac, Ritalin, and similar drugs. Even so, Kass’s approach could still be useful for this investigation.
Central to Kass’s thought here is his concern about using the body as an instrument of our will. Maybe this is a version of the idea of dehumanizing ourselves that I so swiftly dismissed earlier on, but at least this is a slightly more articulated approach. To take drugs to enhance one’s abilities could certainly be seen as treating one’s body as an object, although as I said previously, one needs to be able to distinguish this kind of case from that of consuming food and drink for sustenance. Presumably the distinction between the two kinds of cases rests on the idea that eating and drinking are natural activities necessary for living, while taking drugs is not.
It is worth briefly mentioning a related issue: some people have very strong intuitions against the use of genetically engineered food, body parts, or animals, often because they worry about the unforeseen results of such experimentation, but often simply because it is “messing with nature.” The worry about food can be strong when people consider that it means that they are ingesting something unusual and artificial. Many people say they only want to ingest natural foods.
One feature that distinguishes Prozac is that it is a designer drug, which makes it more parallel to the case of genetically engineered food and cloning. A great deal of research has gone into the creation of the drug: unlike most psychotropic drugs, it was not discovered by accident, but instead was created through years of research. This feature of Prozac makes it closer to the case of cybernetics, and I think people do have strong reactions, including repugnance, to this extremity of unnaturalness. We are facing the introduction of technology into our bodies and minds, and people do find this disturbing as well as exciting.

As I warned at the start of this paper, my aims have been modest: I simply aimed to explore the suspicion and worry people have about drugs that enhance our moods and cognitive capabilities. I have argued that there is a range of possible reasons for worry, some empirical, some philosophical; some plausible, some far more implausible. I want to end by suggesting that the three philosophical objections I have paid most attention to, that drugs are dehumanizing, unnatural, or inauthentic, are interconnected and may even amount to just one basic objection.
As I have suggested already, the idea that we treat ourselves as objects does not cause much concern if it applies equally to eating, drinking, showing concern for one’s body, and getting medical help. For the objection to carry much force, it needs to show that some kinds of treating oneself as an object are more problematic than others. It seems that the best way to do this is to distinguish between ordinary ways of manipulating oneself and extraordinary or unnatural ways of doing so: the more artificial the manipulation, the more worrisome it is.
But why should artificial manipulation of one’s mind be problematic? Of course, one might just say that the very fact it is unnatural is enough. Taking such a position would push one into the difficult position of having to say that one needs to live as natural a life as possible. Even if one could define what is natural, it would seem to leave one in an extreme position of rejecting much of modern life, and rejecting technology that could be very helpful to one. So I suggest that for this objection to be successful, it needs to bring in an extra element: it should limit itself to criticizing treating oneself as an object in an unnatural way when this reduces the person’s autonomy or authenticity. The immediate problem with this move is to give a non-circular account of the reduction of autonomy or authenticity: it is possible to just go in a tight circle, and say that one’s authenticity is diminished because one is treating oneself as an object rather than a subject.
I am not sure how to resolve this problem. Maybe the best option is to simply say that self-objectification, unnaturalness, and inauthenticity are a closely related group of concepts, and that they come as a package. They all become involved in a critique of the widespread use of psychotropic drugs.

The low country, Tuesday January 9, 2001, The Guardian
Arch Pediatr Adolesc Med. 2001;155:560-565, Jerry L. Rushton, MD, MPH; J. Timothy Whitmire, PhD
Pediatric Stimulant and Selective Serotonin Reuptake: Inhibitor Prescription Trends 1992 to 1998
[3] Ritalin Alert: As Abuse Rates Climb, Schools Are Scrutinized, Katy Abel. (Nov 17, 2000),1120,2-20061-0-1,00.html
Threatened by a herb, Jerome Burne, Thursday May 3, 2001, The Guardian
Tuesday, May 22, 2001, New studies may boost credibility of products, BY LISA M. KRIEGER, Mercury News.
[6] Friday May 11, 2001. Health - Study: Herbal Supplement Sales Down.
[7] For a summary of some cross cultural work on depression, see Richard J. Castillo, Culture & Mental Illness: A Client-Centered Approach. (Pacific Grove, CA: Brooks/Cole, 1997), Chapter 12.
[8] See the last chapter of Edward Shorter, A History of Psychiatry. John Wiley, 1998.
[9] Most notorious are the books of Peter Breggin, including Toxic Psychiatry and Talking Back to Prozac. More measured criticism is to be found in Joseph Glenmullen’s Prozac Backlash. Also directly relevant is David Healey’s The Antidepressant Era.
[10] See A Social History of the Minor Tranquilizers: The Quest for Small Comfort in the Age of Anxiety, Mickey Smith, PhD., Haworth Press, 1991.
[11] This is suggested by Louis Marinoff in Plato Not Prozac, [find reference] and Jeffrey Schaler [find reference]. It is also suggested in a slightly different way by Joseph Glenmullen.
[12] I should, in a fuller treatment of this issue, address the point that in some ways depressed people have more realistic expectations of the world than non-depressed people. Some studies have shown that depressed people rate probabilities of certain kinds of events or traits differently from normal people: normal people tend to have a rosy view of the world. For example, most people believe that they are better-than-average drivers and rather their children as above-average. For certain kinds of estimates, depressed people do not have this bias. However, note that in other ways depressed people have a distorted view of the world: they view their situations as hopeless, their lives as pointless, and they don’t think they have any friends.
[13] See the first person accounts in Living With Prozac: And Other Serotonin-Reuptake Inhibitors, by Debra Elfenbein, Harpercollins, 1995.
[14] The main example of this is Enhancing Human Traits: Ethical and Social Implications, edited by Erik Parens, Georgetown University Press, Washington DC, 1988. A recent issue of The Hastings Center Report was devoted to “Prozac, Alienation, and the Self,” Vol. 30, No. 2, 2000. Note that in this paper I have ignored the idea, propounded most forcefully by Carl Elliott in both these collections as well as in other work, that antidepressants are problematic because they lead us to treat alienation as a medical condition when it is really an insightful reaction to the world.
[15]The Ethics of Human Cloning, by Leon R. Cass and James Q. Wilson, AEI Press, 1998.
[16] The American Prospect. “Irrationalist in Chief,” by Chris Mooney. 12, #17, September 24 – October 8, 2001.

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