PPP Issue on Vice and Disorder

In the latest issue of PPP, John Sadler has put together a "philosophical case conference" on vice and the classification of mental disorders, which will be a great resource for future discussion of the area.
His target piece features discussion of some of the issues of classifying vice, by which he means criminal behavior and immoral attitudes. He sets out three cases. The first is a 12-year-old boy who is disobedient and troublesome, defying authority and lying. He gets diagnosed with conduct disorder. The second is of a mother who presents her mother who presents her child as ill and having breathing difficulties. It turns out that the mother smothered her child. She has a complicated case history, with a troubled past. The third case is Jeffrey Dahmer, who received diagnoses of Asperger's, paraphilias, alcohol abuse, depressive disorder not otherwise specified, and personality disorder not otherwise specified. The rest of the paper sets out some of the issues in dealing with the vice-mental disorder relationship in DSM-UV-TR, under the headings of "Inconsistencies in How Wrongful Conduct is Classified," "Impoverishment of Some Criteria Sets for Vice-Laden Disorders," "Hierarchical and Comorbidity Issues," and "Metaphysical Ambiguities." The main theme is that DSM-IV-TR is not consistent and is not clearly formulated when it comes to the relation between vices and disorders. The paper does not set out a theory of what this relation should be.

There is an unusual number of peer commentators for this target paper:
Jeffrey Geller (U Mass Medical School)
Gwen Adshead
Nancy Nyquist Potter and Peter Zachar
Christopher Heginbotham, University of Central Lancashire
Michael First
Christopher Williams
Lloyd Wells (Mayo Clinic)
Stephen Morse
It is a diverse collection of responses. I'm a little disappointed that there was not more discussion of the cases. Geller writes about some of the history of the topic. Adhead expands on the discussion of Case 2, which was her example in the first place. Potter and Zachar give a rather general discussion. Heginbotham gives a brief discussion of the cases and proposes an approach rooted in the social model of disability. First gives a more extensive discussion of the topic and the cases, allowing that vices can also be indicative of disorders. Williams sketches some issues in identifying the causes of behavior. Wells endorses an approach that mixes medicalization and moralization, and discusses this in several cases of his own. Morse emphasizes the difficulty of examining the issues in the absence of quite well developed theories of what counts as a mental disorder and a theory of morality.

Adshead complains about the "muddling" of social, psychological, and legal discourses, as if it were possible to keep them separate, but she is open to the possibility that vice and disorder need not be mutually exclusive. Yet even here, she seems to think that the mental disorder itself could not explain violence to others completely, and that one needs other elements in the explanation. She is especially sensitive to the danger that explaining an action with a diagnosis would take away a person's sense of agency. Adshead gives the impression that she needs a more fully fledged theory of action and mental disorder in order to avoid conceptual problems. Most of the other authors embrace the fact that the moral and the medical overlap, and that people can responsible for their symptomatic behavior even when they have mental illness.

With this and all the other commentaries, it is clearly impossible for them to set out a detailed view about such a complex area. So they are able to raise a few points but one does not get a strong sense of deep engagement with issues raised by the target article, and none of the authors sets out anything like the robust theories that Morse says are needed. This is all to the good, meaning that there is still plenty of work to be done in this area. Sadler ends with the suggestion that it might be possible to do without some theories, by taking a pragmatic stance. This is an idea that I'm sympathetic with, but I'm not sure that it is possible to bypass the theories altogether, and justifying the pragmatic stance without the theory is going to take lots of discussion, if not theorizing.

Review of Self-Transformations: Foucault, Ethics, and Normalized Bodies by Cressida J. Heyes

This review appeared in Philosophy in Review, Volume 28, Volume 4 (2008), pages 267-269.


Cressida J. Heyes Self-Transformations: Foucault, Ethics, and Normalized Bodies.
New York: Oxford University Press 2007. Pp. 175. CDN$110.95/US$99.00 (cloth ISBN-13: 978-0-19-531053-5); CDN$33.95/US$29.95 (paper ISBN-13: 978-0-19-531054-2).

This is a work in feminist ethics about our relations to our bodies. In five main chapters, Heyes sets out a theoretical framework, and then examines three central cases of bodies that are considered in need of changing: transgender people, overweight people, and people who want cosmetic surgery. She finishes with a proposal of a Foucauldian way for us to care for our bodies.
Heyes takes her theoretical resources primarily from feminist theory and the philosophy of Foucault. She places herself in her text, not just setting out her own views, but also giving some details of her own life and her own experiences in joining Weight Watchers, as well as discussing some of the problems she faces theorizing about other people of whose experience she has limited understanding. Thus it may be reasonable for me as reviewer to disclose more in this review than I would do in other cases, especially since my review will make some criticisms of the book. I am sympathetic to much of the feminist project but I don’t ally myself strongly with the theoretical standpoint of Foucault. Furthermore, I’m a male who has no direct experience of being transgender, being overweight or having or wanting cosmetic surgery.

The writing in this book does not rely excessively on jargon, and style is relatively straightforward. Chapters are divided into titled sections and Heyes summarizes her main points at the end of each chapter. She surveys a great deal of literature in the process of discussing each subject, and gives a sympathetic summary of each view relevant to the discussion, even when she disagrees with it. Furthermore, Heyes’ approach brings a set of theoretical approaches to issues such as weight loss and cosmetic surgery that are more sophisticated than in most other discussions in much feminist theory and certainly than in standard medical ethics. For that, she deserves a great deal of credit. On top of this, she advances existing debates in constructive ways. So there’s much to admire about this work.

One of the most important themes running through the book is the need to go beyond the dichotomy of either seeing people who engage in bodily changes such as sex change operations, dieting, or cosmetic surgery as either simply acting autonomously and therefore beyond criticism, or else acting out of false consciousness and therefore oppressed by gender stereotypes. Heyes acknowledges the importance of prior feminist critiques of idealized women’s bodies, and the problems with the pressures experienced by women to emulate those ideals. However, she also wants to acknowledge the importance of the care of the self, and the way that such focus on one’s own body can contribute to such self-care. In this, she draws especially on the last work of Foucault in the final two volumes of The History of Sexuality and some interviews.

In the chapter on Weight Watchers, probably the most accessible in the book, Heyes discusses in some detail the work of Susan Bordo and Sandra Bartky on the construction of femininity and the ways that focus on conforming to norms of beauty can oppress women. Heyes acknowledges their analyses of disciplinary practices relating to dieting, but she counterbalances these with a discussion of ‘the active, creative sense of self-development, mastery, expertise, and skill that dieting can offer’ (78). In her chapter on cosmetic surgery, she analyzes the issue through a discussion of the TV show Extreme Makeover. Again, she acknowledges the insight of influential feminist discussions of the representation of work on the body, in this case by Susan Bordo and Kathy Davis. Heyes finds no positive element of cosmetic surgery to counterbalance its problematic nature, but she does argue that current feminist critiques are not sufficient as forms of resistance or as solutions for women considering changing their bodies using medical technology.

The most provocative chapter in the book is the final main one where Heyes explores the possibility of caring for the self in a socially conscious, non-narcissistic way that would not contribute to oppressive practices. She defends Foucault from critics who accuse him of betraying his former political and ethical commitments in his final work, and she finds his discussion inspiring but elusive. She turns to the recent work of Richard Shusterman on somaesthetics for a more fully elaborated idea of what such caring for the self might look like, but still she does not find sufficiently concrete discussion. She finishes the chapter by considering three cases that might be considered as forms of caring for the self that might be ethically and politically admirable: bodily modification, British shipyard workers who practiced ballet, and yoga. She describes and evaluates each of these somewhat briefly, and she indicates that this topic is where her future work will be.

The theoretical position set out by Heyes is promising in its overall form, but her argument lacks enough detail to be convincing. In her short book, she covers philosophical methodology, sociology, cultural studies, feminist theory, medical ethics, and ethical theory. Her first main chapter uses Wittgenstein and Foucault to set out a way of thinking about the body in contemporary society, but really Heyes does no more than gesture at a theoretical position rather than develop a sustained argument.

While the earlier theoretical sections give some indication of how one might ground her approach, they don’t help much in explaining her later suggestions. Heyes is stronger in her discussion of mutual relevance of theory and personal experience or popular culture. Her positive suggestions about how we might understand an ethical approach to the care of the self are tentative and vague. I wish she had been bolder in her claims and had spent more time developing the ideas hinted at in her final chapter, especially those concerning yoga. Just when this book starts to get interesting, it finishes, and the reader is left wondering whether Heyes’ project for conceptualizing a progressive way to care for the self is indeed viable.

Christian Perring
Dowling College

Review of In Praise of Blame by George Sher

This review appeared in Philosophy in Review, Volume 27, Number 5, (2007) pages 375-377.

George Sher In Praise of Blame. New York: Oxford University Press 2006. Pp. 160. US$35.00 (cloth ISBN-13: 978-0-19-518742-7).

In this excellent monograph Sher sets out a defense of the practice of blaming people for wrongdoing. He argues that there is a need for such a defense because it has become increasingly common in contemporary society to claim that blaming is counterproductive and even neurotic. While punishment and even retribution continue to receive plenty of philosophical scrutiny, the attitude of blame itself has remained relatively unexamined in the literature.

Sher approaches his topic systematically. The argument is divided into six main chapters. In Chapter 2, Sher argues against the Humean claim that we blame people for bad actions that derive from their bad character, and the associated claim that we blame them because those bad actions derived from their character. Sher’s counterargument considers different cases of people who act in cruel or hurtful ways and whom our moral intuitions would cause us to blame, despite the fact that we would not deem them cruel or hurtful people.

In Chapter 3, Sher examines how the disapproval of a bad action can be extended to the blame of the agent without appeal to the notion of character. He points out that an action is the joint product of the desires, beliefs, and dispositions, and he claims that these items make her who she is. Thus there is a close connection between the person's action and her identity, and so it is conceptually coherent to blame her for her actions. He employs the fact that actions stem from a large network of desires and beliefs, and this makes his claim that they are strongly related to the person’s identity more plausible, although he says very little about when changes to a person’s beliefs, desires and dispositions could be said to lead to a change in the person’s identity.

In his fourth chapter Sher, taking the surprising route that it can be reasonable to blame people for aspects of themselves that they cannot change, argues that it can be morally reasonable to blame people for their character traits. He agrees that we should not blame people for accidents over which they had no control, but if their action proceeded from their bad traits, such as cruelty, then we can blame them. He first shows that claims that people should not be blamed for what they cannot control have not been well defended. He then proceeds to defend his view positively, by pointing out there is such a strong connection between a trait and a person’s identity that to believe a trait is reprehensible comes to the same thing as believing that the person herself is reprehensible, and thus blaming her for her bad trait.

Sher moves on to the nature of blame. In Chapter 5, he begins by addressing some views he believes to be mistaken. First, he shows the flaws in the utilitarian view that to blame someone is to express disapproval for an action or character as a way to change the person’s actions or improve her character. Here the argument proceeds swiftly, because it is possible to blame people without communicating one’s blame. So Sher is able to move to the position that blame is an attitude. But the question is: which attitude? Sher rejects any identification of blame with a simple belief, whether it be that the person acted badly, or that the person has stained her character. He next considers the idea, put forward by Peter Strawson, that blame is fundamentally an affective phenomenon. Sher agrees that emotions are an important common feature of blame, and need to be accounted for. However, he argues that this Strawsonian approach cannot adequately account for the blameworthiness of actions, and cannot adequately distinguish appropriate blame from inappropriate blame. Furthermore, he argues that there can be instances of blame which are not affective at all. It is possible to hold an attitude of blame to someone while experiencing no emotions of anger or hostility whatsoever.

The positive account of the nature of blame comes in Chapter 6. Sher’s theory is simple: blame of someone for an action or a character trait starts from the belief that the action or character trait is bad, and from the corresponding desire that the person had not performed the action or did not have that character trait. In order to make this account plausible, Sher needs to show how this belief-desire combination can give rise to the emotions and dispositions that are so closely linked to blame. A central problem for this account is that since it is impossible to change the past, then when blame includes a wish that an action had not happened, it means wishing for the impossible, which seems to make blame irrational or at least futile. In order to ameliorate this problem, Sher proceeds with a discussion of our reactions to frustrated desires and their links to future-oriented dispositions. He does not pretend to be giving a conceptual analysis of blame, so he does not present necessary and sufficient conditions for when a person has an attitude of blame. However, he does hold that a person with standard psychological dispositions and the appropriate belief-desire pair will go on to have the characteristic emotional reactions that we associate with blame.

The final chapter takes on the question of blameworthiness. Sher argues that to give an account of what it is to be blameworthy, it is not enough just to point out that person has acted badly or has a bad character. He claims that acceptance of a moral principle is conceptually linked to having the desire to blame someone when that person violates the moral principle. Thus, to explain a person’s blameworthiness we must refer to the moral principle as well as the relevant bad action or character.

Sher’s writing style is straightforward and methodical, although his arguments might have been clearer if he had stated his theory at the start and proceeded to justify it, rather than proceeding to his own view through a process of elimination of other positions. The topic of blame is important and Sher’s views are interesting and original. While there is still plenty of room for disagreement with many of his claims, he has made a valuable contribution to the literature.

Christian Perring
Dowling College

Strategies for Bioethical Discussion of Psychopharmacology

Strategies for Bioethical Discussion of Psychopharmacology

This is a paper from 1999, presented at a conference, probably under a different title.

Abstract
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.

1. Introduction
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.[1] 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.[2] (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.[3]

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.[4] 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.[5] 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.[6]

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.[7] 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.[8] 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.[9] It was only in the late 1970s and early 1980s that criticism of tranquilizers really came to grip the public attention.[10] Indeed, even now, most of the books that criticize psychiatry from a feminist perspective still put little emphasis on the issue of psychotropic drugs.[11]

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.[12] 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.

4. Conclusion
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.[13]

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Agel, J. (editor). (1973) Rough Times. Ballantine Books, New York.

Armstrong, T. (1997) The Myth of the A.D.D. Child : 50 Ways to Improve Your Child's Behavior and Attention Span Without Drugs, Labels, or Coercion. Plume.

Bargmann, E., Miwolfe, S. and Levin, J. (1983) Stopping Valium: and Ativan, Centrax, Dalmane, Librium, Paxipam, Serax, Tranxene, Xanax. Warner Books, NY.

Breggin, P.R. and Breggin, G. R. (1994) Talking Back to Prozac: What Doctors Won’t Tell You About Today’s Most Controversial Drug. St. Martin’s Press, New York.

Breggin, P. R. (1991) Toxic Psychiatry: Why Therapy, Empathy, and Love Must Replace the Drugs, Electroshock, and Biochemical Theories of the “New Psychiatry. St. Martin’s Press, New York.

Breggin, P. R. (1998) Talking Back to Ritalin: What Doctors Aren't Telling You About Stimulants for Children. Common Courage Press, 1998.

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Brown, P. M. (1974) Toward a Marxist Psychology. Harper Colophon Booka, New York.

Buhle, M. J. (1998). Feminism and Its Discontents: A Century of Struggle with Psychoanalysis. Harvard University Press, Cambridge, MA.

Chesler, P. (1972) Women & Madness. Avon Books, New York.

DeGrandpre, R. J. (1999) Ritalin Nation: Rapid-fire Culture and the Transformation of Human Consciousness. Norton, NY.

DeGrandpre, R. J. and White, E. (1996) Drugs: In the Care of the Self. Common Knowledge, V5 N3, pp. 27-48.

Diller, L. H. (1996) The run on Ritalin: attention deficit disorder and stimulant treatment in the 1990s. Hastings Center Report. Mar-Apr; 26(2): 12-18.

Diller, L. H. (1998) Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill. Bantam Doubleday.

Drummond, E. H. (1997) Overcoming Anxiety Without Tranquilizers: A Groundbreaking Program for Treating Chronic Anxiety. E. P. Dutton.

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Gardiner, J. K. (1995) Can Ms. Prozac Talk Back? Feminism, Drugs, and Social Constructionism. Feminist Studies, 21, no. 3, 501-517.

Gornick, V & Moran, B. K. (editors). (1971) Woman in Sexist Society: Studies in Power and Powerlessness. Basic Books, New York.

Hamilton, J. A. and Jensvold, M. F. (editors) (1995) Psychopharmacology from a Feminist Perspective. Haworth Press.

Hassibi, M. (1995) Why Change the World . . . When You Can Have a Prozac Moment? On The Issues Summer. Available Online at Error! Reference source not found.

Healy, D. (1998) The Antidepressant Era. Harvard University Press, Cambridge, MA.

Hughs, R. and Brewin, R. (1979) The Tranquilizing of America: Pill Popping and the American Way of Life. Harcourt, Brace and Jovanovich.

Hunter, D. (1995) The Ritalin-Free Child: Managing Hyperactivity & Attention Deficits Without Drugs. Consumer Press.

Isaac, R. J. and Armat, V. C. (1990) Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill. Free Press, New York.

Kramer, P. K. (1993) Listening to Prozac. Viking Press, New York.

Marks, J. (1986) The Benzodiazepines: Use, Overuse, Misuse, Abuse 2nd edition. Kluwer Academic.

Parens, E. et al. (editors) (1998) Enhancing Human Traits: Ethical and Social Implications (Hastings Center Studies in Ethics). Georgetown University Press, Washington DC.

Perring, C. D. (1997) Medicating Children: The Case of Ritalin. Bioethics, 11(3&4), 228-240.

Rosenblatt, S. and Dodson, R. (1981) Beyond Valium: The Brave New World of Psychochemistry. Putnam’s Press, New York.

Ruitenbeek, H. M. (editor). (1972) Going Crazy: The Radical Therapy of R. D. Laing and Others. Bantam Books, New York.

Russell, D. (1995) Women, Madness & Medicine. Polity Press, Cambridge, UK.

Shorter, E. (1997) A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. Wiley, New York.

Shorter, E. (1998) How Prozac Slew Freud. American Heritage, Sept. v. 49, n5 p. 42 (8).

Showalter, E. (1985) The Female Malady: Women, Madness, and English Culture, 1830-1980. Penguin.

Smith, M. C. (1991) A Social History of the Minor Tranquilizers: The Quest for Small Comfort in the Age of Anxiety. Pharmaceutical Products Press, New York. (Originally published as Small Comfort: A History of the Minor Tranquilizers. Praeger Publishers, 1985.)

Snyder, S. (1986). Valium: The Tranquil Trap. Chelsea House.

Stein, D. B and Breggin, P. R. (1999) Ritalin Is Not the Answer: A Drug-Free, Practical Program for Children Diagnosed With ADD or ADHD. Jossey-Bass.

Tranx. (1984). Minor Tranquilizer, Major Problems. Do It Now Foundation.

Ussher, J. (1991). Women's Madness: Misogyny or Mental Illness? University of Massachusetts Press, Amherst, MA.

Ussher, J. M & Nicolson, P. (editors). (1992) Gender Issues in Clinical Psychology. Routledge, London.

Vallenstein, E. (1998) Blaming the Brain: The Truth About Drugs and Mental Health. Free Press, New York.

Whitehouse, P. J., Juengst, E., Mehlman, M, Murray, T. H. (1997) Enhancing cognition in the intellectually intact. Hastings Center Report. May-Jun; 27(3): 14-22.

Wright, R. (1994) The coverage of happiness: when Prozac meets universal coverage. New Republic. Mar 14; 210(11): 24-29.

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."


[1] 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/.
[2] 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.
[3]Thanks to Pauline O’Connor for articulating these worries in discussions with me.
[4] 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.
[5]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.
[6]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.
[7]It is probably impossible to gauge the effect of the Rolling Stones' song on the topic, "Mother's Little Helper.”
[8]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)
[9]See Agel (1971, 1973), Brown (1974), Chesler (1972), Gornick and Moran (1971), Ruitenbeek (1974).
[10]See Hughs and Brewin (1979), Rosenblatt and Dodson (1981), Tranx (1984), Marks (1986), Snyder (1986)
[11]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.
[12]See Smith (1991), p. 82.
[13] My thanks to John Mullen for useful comments and questions on an earlier draft of this paper.