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Beyond Therapy: Biotechnology and the Pursuit of Happiness


Table of Contents

The President's Council on Bioethics
Washington, D.C.
October 2003
www.bioethics.gov


Chapter Five

Happy Souls

Who has not wanted to escape the clutches of oppressive and punishing memories? Or to calm the burdensome feelings of anxiety, disappointment, and regret? Or to achieve a psychic state of pure and undivided pleasure and joy? The satisfaction of such desires seems inseparable from our happiness, which we pursue by right and with passion.

According to the Declaration of Independence, the right to pursue happiness is one of the unalienable rights that belong equally to all human beings. Indeed, the American Founders held that governments exist mainly to safeguard this right-along with the rights to life and liberty-against those who would seek to deny or suppress it. Life, the foundational good, is good also because it makes liberty possible. And liberty is good both in itself and as the prerequisite for pursuing happiness in ways that each of us may freely choose for ourselves.i Our interest in happiness is not, however, merely one interest among many. It is an overarching interest in our complete and comprehensive well-being.

For this reason, the pursuit of happy souls is not simply, in this report, just another case study. At the same time it implicates or points to something final and all-embracing. For it is ultimately our desire for happiness-for the fulfillment of our aspirations and the flourishing of our lives-that leads us to seek, among other things, better children, superior performance, and ageless bodies (and minds). Yet the contribution of those proximate and subordinate ends to the ultimate and supreme end of happinessii is partial and indirect. Having better and more accomplished children or a more vigorous and well-working body surely can contribute to our happiness, but they are not the thing itself: there are people with splendid children and perfectly toned bodies who are nonetheless miserable. Superior performance, though perhaps more integral to our own flourishing, is likewise not the whole story: everything depends on how it fits into the larger psychic, moral, and spiritual economy of our lives-what we long for and how well we attain it, and whether we are satisfied with ourselves in relation to our ideals, aspirations, and actual achievements and experiences.

Such self-satisfaction and sense of fulfillment are, needless to say, not easily attained. On the contrary, obstacles to human happiness abound, ranging from overt illnesses of brain and psyche, through grief and guilt, shame and sorrow, to simple frustrations of hopes and plans. Dementia, depression, disappointment, and despair are, alas, all too common, and many-perhaps most-people are more often bent on overcoming these and other impediments to happiness than on seeking it in its positive fullness.iii In these efforts at peace of mind, human beings have from time immemorial sought help from doctors and drugs. In a famous literary instance, Shakespeare's Macbeth entreats his doctor to free Lady Macbeth from the haunting memory of her own guilty acts:

Macbeth.

Canst thou not minister to a mind diseas'd,
  Pluck from the memory a rooted sorrow,
  Raze out the written troubles of the brain,
  And with some sweet oblivious antidote
  Cleanse the stuff'd bosom of that perilous stuff
  Which weighs upon the heart?
Doctor. 

Therein the patient

  Must minister to himself.

Ministering to oneself, however, is easier said than done, and many people have found themselves unequal to the task without some outside assistance. For centuries, they have made use of external agents to drown their sorrows or lift their spirits. Alcohol, in different measures, can accomplish both. So, too, certain naturally occurring psychotropic agents, from the mythical lotus flower described in Homer's Odyssey to the very real euphoriants derived from the opium poppy. Yet until recently, biotechnological aids to psychic flourishing have been relatively feeble and non-specific. Drugs for soothing bad memories have been utterly lacking. And drugs to brighten mood or raise self-esteem have been imperfect: unsafe, inadequately effective, transient, liable to side effects, and frequently illegal or stigmatized. Thanks to recent breakthroughs, however, the situation is changing rapidly. The burgeoning field of neuroscience is providing new, more specific, and safer agents to help us combat all sorts of psychic distress. Soon, doctors may have just the "sweet oblivious antidote" that Macbeth so desired: drugs (such as beta-adrenergic blockers) that numb the emotional sting typically associated with our intensely bad memories, and "mood brighteners" (such as serotonin reuptake inhibitors) that lift and stabilize our general disposition and make us feel good (or better) about ourselves.

To be sure, these agents-and their better versions, yet to come-are, for now at least, being developed not as means for drug-induced happiness but rather as agents for combating major depression or preventing post-traumatic stress disorder (PTSD). Yet once available for those purposes, they could also be used to ease the soul and enhance the mood of nearly anyone. Should this occur, further research and development of drugs helpful to the direct pursuit of happier souls-surely a profitable business venture-would very likely take place. As a result, our pursuit of happiness and our sense of self-satisfaction will become increasingly open to direct biotechnical intervention. Such possibilities raise many large questions.

By directly inducing changes in our subjective experience, the new psychotropic drugs create the possibility of severing the link between feelings of happiness and our actions and experiences in the world. Who would need better children, superior performance, or more youthful bodies if medication could provide the pleasure and sense of well-being that is the goal of so many of our aspirations? Indeed, why would one need to discipline one's passions, refine one's sentiments, and cultivate one's virtues, in short, to organize one's soul for action in the world, when one's aspiration to happiness could be satisfied by drugs in a quick, consistent, and cost-effective manner?

Yet it is far from clear that feelings of contentment severed from action in the world or from relationships with other people could make us truly happy. Would a happiness that did not flow from what we do and say, usually in association with others, be more than a simulacrum of that happiness for which our souls fit us? More generally, would the pharmacological management of our mental lives draw us toward or estrange us from the true happiness that we seek? It is hard to answer in the abstract. In some cases, it might bring us nearer, by restoring our natural ability to take satisfaction in joyous events and satisfying deeds. In other cases, it might estrange us, by substituting the mere feelings divorced from their natural and proper ground.

The currently available drugs to alter memory and mood, and the new drugs and their uses that may be just around the corner, invite other large questions about the character of human life. By using drugs to satisfy more easily the enduring aspirations to forget what torments us and approach the world with greater peace of mind, what deeper human aspirations might we occlude or frustrate? What qualities of character may become less necessary and, with diminished use, atrophy or become extinct, as we increasingly depend on drugs to cope with misfortune? How will we experience our incompleteness or understand our mortality as our ability grows to medically dissolve all sorts of anxiety? Will the availability of drug-induced conditions of ecstatic pleasure estrange us from the forms of pleasure that depend upon discipline and devotion? And, going beyond the implications for individuals, what kind of a society are we likely to have when the powers to control memory, mood, and mental life through drugs reach their full maturity and are widely used?

On one level, as observed above, these questions are already with us, and have been for centuries. Alcohol, marijuana, cocaine, and other consciousness-affecting drugs offer temporary pleasures and escapes, and they can surely alter behavior and sense of self. But the difference (or potential difference) with the biotechnical interventions explored in this chapter is their capacity for more precise, long-term, and sought-after alterations in the human psyche. While current drugs may have more-or-less predictable effects, psyche-altering agents of the future, devised unlike those of the past on the basis of exact knowledge of the brain, will permit more refined and effective interventions. While current drugs used in moderation may give those who use them the feeling states they desire, these feeling states quickly wear off and the psyche returns to normal. And while current drugs used in excess may have long-term effects on the trajectory of one's life, these effects are typically destructive-not the effects we seek. Thus, while some of the ethical questions explored in this chapter surely apply to current drugs-which is not, of course, a reason to dismiss them-the core issues involved with recreational drugs and new psychotropic biotechnologies are, in important respects, psychologically and ethically distinct.

To be sure, the answers to the important questions raised above must in some measure be speculative, at least for now. They will depend on many factors: the pace of biotechnological developments; the range of physiological and psychological effects of the new drugs; debatable opinions about the hierarchy of human aspirations or the happiness most appropriate to the human soul; and the actual consequences, individual and social, of the drugs used and the purposes served. In due course, the answers about consequences can be found only by careful empirical social and psychological research. Yet figuring out which effects social scientists should investigate requires prior reflection and thoughtful analysis of the possible results and their likely human significance. And, despite lack of foreknowledge, we are obliged now to address these questions to the best of our abilities, if we wish to act responsibly regarding the biotechnical future that we might be, willy-nilly, in the midst of creating for ourselves and our descendants.

This chapter explores some of the questions connected with possibilities for directly altering our psychic state of well-being, using technologies that affect our memories (section II) or our moods and dispositions (section III). But before turning to these prospects, we begin with questions about the goal itself: What is a "happy soul"? As with the goals discussed in the previous three chapters, the goal here too is fraught with rich ambiguity.

I. WHAT ARE "HAPPY SOULS"?

The nature or meaning of happiness has always been a contested matter. Near the start of his inquiry into the supreme human good, Aristotle remarks that everyone agrees regarding its name-"happiness" or "flourishing"-but regarding what it is, most people do not give the same account as the wisest.1 Some equate it with pleasure, others with honor or recognition, wealth or power, while still others locate it in virtuous deeds, love, or understanding. Adjudicating these competing claims is, of course, beyond the scope of this report. But a few pertinent questions about the character of happiness may prove useful for what is to come. Is happiness a feeling, sensation, or mood, or is it rather an activity? Is it a state of restful contentment or of focused and energetic striving? Some people, especially those who are troubled by the obstacles to happiness, equate it with peace of mind or an untroubled soul. Others demand something more: not just the absence of distress or discomfort, but a fullness or richness or flourishing of being. What, then, is the relation between being happy and being (merely) satisfied? Between being satisfied and being (merely) content? Between being content and being not discontent, or between the latter and being not dissatisfied? And in the face of all the obstacles to human happiness, isn't it happiness enough not to be genuinely miserable, not to be "uneasy"? Formally speaking, one might suggest that happiness consists in a coincidence between one's desires and one's power to satisfy them. But, as the well-known rejoinder has it, desires come in all sizes: Is it better to be a pig satisfied or Socrates dissatisfied? If the content matters as well as the form, how is happiness materially related to the activities of love and friendship, work and play, song and worship? Are social ties and activities important, or is happiness a purely solitary endeavor?

Whatever answers one might give to those questions, there are two further questions especially pertinent to the present inquiry: Is happiness a momentary matter or is it something experienced only over time, or even only over a complete life? And how can one tell the difference between true and false happiness, between the real thing and the mere likeness?

The first question introduces us to perplexities about the subject or bearer of happiness, here called, for lack of a better term, "soul"-a term no less problematic than "happiness." By "soul" we mean something psychological rather than theological: indeed, "soul" is the exact English translation of the Greek psyche, a term we sometimes use directly as its equivalent, as well as in the compounds "psychology" ("the account or science of the soul") and "psychiatry" ("the doctoring of the soul"). We mean here by "soul" or "psyche" the interacting powers of "mind and heart"-powers of reason, speech, understanding, intuition, memory, and imagination, as well as of desire, passion, and feeling-powers that make us human, powers that we know from the inside that we enjoy (and that dead or inanimate bodies lack). We mean also not just these generically human powers, but our particular and unique constellation of them, shaped by our own experiences, aspirations, attachments, achievements, disappointments, and feelings. We mean at once that which makes all of us human and that which makes each of us individually who we are. Because the happiness we seek we seek for ourselves-for our self, not for someone else's, and for our self or embodied soul, not for our bodies as material stuff-our happiness is bound up with our personhood and our identity. We would not want to attain happiness (or any other object of our desires) if the condition for attaining it required that we become someone else, that we lose our identity in the process.

The importance of identity for happiness implies necessarily the importance of memory. If experiencing our happiness depends upon experiencing a stable identity, then our happiness depends also on our memory, on knowing who we are in relation to who we have been. A person with Alzheimer disease, no matter how cheerful his mood, we hesitate to call happy precisely because, in some important sense, he is no longer altogether there as himself. His actions in the present are severed, through the loss of memory, from the actions and experiences that made him who and what he was and is. Indeed, much of the dread of this disease is connected with the erosion of personal identity that the loss of memory brings with it.

But if enfeebled memory can cripple identity, selectively altered memory can distort it. Changing the content of our memories or altering their emotional tonalities, however desirable to alleviate guilty or painful consciousness, could subtly reshape who we are, at least to ourselves. With altered memories we might feel better about ourselves, but it is not clear that the better-feeling "we" remains the same as before. Lady Macbeth, cured of her guilty torment, would remain the murderess she was, but not the conscience-stricken being even she could not help but be.

The second question takes us directly to mood, and to its link with the truth of things. In the pursuit of happiness, human beings have always worried about falling for the appearance of happiness and missing its reality. We are all too familiar with desires that lead astray, pleasures that cause serious harm, temporary satisfactions that leave us depleted and diminished. Yet however routinely we may mistake a fleeting sense of happiness for the real thing, we regard distinguishing between the two as crucial to our happiness. And for good reason. We don't really believe that ignorance is bliss; we say it ruefully to bolster spirits in the face of a sudden encounter with a painful truth. We may manage to convince ourselves that cheating is better than losing or that love based on a lie is better than no love at all. But seldom do those who win by cheating or who love by deceiving cease to long for the joy and fulfillment that come from winning fair and square or being loved for who one truly is. Many stoop to fraud to obtain happiness, but none want their feeling of flourishing itself to be fraudulent. Yet a fraudulent happiness is just what the pharmacological management of our mental lives threatens to confer upon us.

Anticipating the ethical analyses that come later in this chapter, we identify a two-fold threat of fraudulent happiness. First, an unchecked power to erase memories, brighten moods, and alter our emotional dispositions could imperil our capacity to form a strong and coherent personal identity. To the extent that our inner life ceases to reflect the ups and downs of daily existence and instead operates independently of them, we dissipate our identity, which is formed through engagement with others and through immersion in the mix of routine and unpredictable events that constitute our lives. Second, by disconnecting our mood and memory from what we do and experience, the new drugs could jeopardize the fitness and truthfulness of how we live and what we feel, as well as our ability to confront responsibly and with dignity the imperfections and limits of our lives and those of others. Instead of recognizing distress, anxiety, and sorrow as appropriate reflections of the fragility of human life and inseparable from the setbacks and heartbreaks that accompany the pursuit of happiness and the love of fellow mortals, we are invited to treat them as diseases to be cured, perhaps one day eradicated. Instead of recognizing contentment, pleasure, and joy as appropriate reflections of the richness of human life and inseparable from the fulfilling activities and attachments that are the heart of human happiness, we are invited to treat them as ends in themselves, perhaps one day inducible at will.iv

To be sure, our emotions can play cruel tricks on us and fail us in myriad ways. They often wax and wane without reason, and they are not in themselves given to maintaining proper measure. And for those afflicted by debilitating memories of traumatic events, or who chronically suffer depression, despair, or a sense of deep unworthiness, the new drugs are likely to prove a great boon, by repairing crucial capacities for a normal and fitting emotional life. Nevertheless, it behooves us to explore the potential uses and misuses of these new drugs carefully, for drugs that erase memories or alter our temperaments and emotional outlooks deal with that which is most us, our hearts and minds. If we, as individuals and as a society, fail to proceed responsibly, the pharmacological management of our mental lives could seriously impair our ability to pursue that happiness for which our hearts long and to which our minds guide us.

II. MEMORY AND HAPPINESS

At first glance, the pursuit of happiness-a forward-looking activity-might seem to have little to do with memory-the remembrance of things past. Yet a closer look reveals some deep connections. Could we be happy if we were unable to remember our own past, if we lived only day-to-day, one moment to the next? Could we be happy if we were unable to assimilate present experience into the remembered narrative of previous experience? Could we be happy in the absence of happy memories? Conversely, could we be happy in the presence of terrible memories, memories so traumatic and so life-altering that they cast a deep shadow over all that we do, today and tomorrow? As these questions imply, both our capacity to remember-our ability to recall and recollect-and the content of what we remember-the banked "traces" of specific past experiences-may well be crucial to our prospects for happiness.v

A good memory is necessary even to do the little things that contribute to our happiness: preparing the foods we like, riding a bicycle, finding our way home or to the home of friends. Guiding us with little conscious effort, such memories are silently yet deeply part of who we are. Memory is also indispensable for our ability to learn new things: the name of a new acquaintance, the title of a new book, the contours of a new place. This forward-looking but memory-dependent readiness to capture and incorporate the not-yet-known and the not-yet-lived makes possible new pursuits, new associations, and new ways of getting along in the world-in a word, new ways of becoming happy.

Memory is important not only for retaining knowledge of what we can do. It is important also for allowing and enabling us to "know"-virtually without any deliberate effort on our part-who we are. Our memory, by its own activity, preserves for us the complex web of lived experiences that furnish our sense of self: the shared memories of living side-by-side with loved ones; the class long ago that changed our lives; the days we spent in sickness and celebration; our finest moments and most shameful acts. The memories and the "self" they shape are acquired over time. At each moment, our then-existing web of memories shapes the way we face and understand our everyday lives. But this web of memories is, paradoxically, not permanently fixed, unlike an image recorded on a photograph. As we give new meaning to old happenings and try to fit them within the larger narrative of our unfolding existence, it changes over the course of life. Our experiences at age sixteen will have a different meaning to us when remembered at age eighteen, and a very different meaning yet again when remembered at age fifty. As we grow older, memories become less vivid, but perhaps their significance becomes more clear; although they are less immediate, they are now part of the larger story of who we are. We can consciously re-examine the meaning of remembered events and, as a result, change how they are remembered. Yet the memories themselves set limits on how much can be re-written, and much of the "re-construction" or "re-membering" of our remembered lives results from undirected "editorial" work. Astonishingly, memory itself selectively retains and deletes, reconfigures and reintegrates, the experiences that comprise who we have been and, therefore, are. Our identity or sense of self emerges, grows, and changes. Yet, despite all the changes, thanks to the integrating powers of memory, our identity also, remarkably, persists as ours.

If the capacities of remembering are crucial for preserving the "my-ness" of any happiness that comes our way, the content of the memories are crucial for our happiness itself. We do not wish merely to remember having had satisfying experiences; we wish to remember them with satisfaction. We desire not only even-keeled memories, but also memories with feeling and with sense: we relish the memory of devoted parents, of first love, the birth of a child; we delight in recalling beautiful sights seen, good deeds done, worthy efforts rewarded. We especially want our memories to be not simply a sequence of disconnected experiences, but a narrative that seems to contain some unfolding purpose, some larger point from beginning to end, some aspiration discovered, pursued, and at least partially fulfilled.

Memory is central to human flourishing, in other words, precisely because we pursue happiness in time, as time-bound beings. We have a past and a future as well as a present, and being happy through time requires that these be connected in a meaningful way. If we are to flourish as ourselves, we must do so without abandoning or forgetting who we are or once were. Yet because our lives are time-bound, our happiness is always incomplete-always not-yet and on-the-way, always here but slipping away, but also always possible again and in the future. Our happiest experiences can be revivified. And, as we reminisce from greater distance and with more experience, even our painful experiences can often acquire for us a meaning not in evidence when they occurred.

The place of memory in the pursuit of happiness also suggests something essential about human identity, a theme raised in various places and in different ways throughout this report: namely, our identities are formed both by what we do and by what we undergo or suffer. We actively choose paths and do deeds fit to be remembered. But we also live through memorable experiences that we would never have chosen-experiences we often wish never happened at all. To some extent, these unchosen memories constrain us; though we may regret the shadows they cast over our pursuit of happiness, we cannot simply escape them while remaining who we really are. And yet, through the act of remembering-the act of discerning and giving meaning to the past as it really was-we can shape, to some degree, the meaning of our memories, both good and bad.

The contribution of good memories to happiness, presented in this overly rosy account, makes clear how bad memories can undermine happiness, indeed, can cause misery. We can lose our memory through injury or illness; we can be plagued by terrifying, shameful, or guilty memories. Even for the fortunate and virtuous, life is not a bowl of cherries. To live, as we emphasized in the last chapter, is to age and decline, in memory as well as in muscle. To aspire is to risk disappointment. To love is to risk loss, and eventually to lose what one loves altogether in death. Bad memories, present inevitably to all of us, can not only mar present happiness; if sufficiently grave, they can overwhelm us and crush the prospect of seeking happiness any time in the future. Memory is not always a friend to happiness.

For this reason, people interested in happiness are interested, among other things, in better memories. Precisely because, in order to be happy, we need to be able to remember, we would like to find ways to keep our memory capacity intact, against the dangers of senility. Precisely because we desire happier memories, we might be tempted to "edit out," if we could, those memories that most disturb us or even to seek a new life history entirely.vi For understandable reasons, we might seek to restore the innocence or peace of mind that our actions or our sufferings have disrupted.

Until recently, the prospect of altering our remembrance of things past-and doing so with precision, getting the better memories we desire without compromising memory as a whole-was a mere fantasy. But in the near future that may not be so. Much memory research over the past decades has focused on finding the causes and then the remedies for forgetfulness, in the first instance to forestall or treat the senile dementias, but, in the second place, to prevent also the annoying lapses of memory in the elderly and middle-aged, who have trouble remembering, for example, where they left the house keys. Although the field is full of promise,vii there is little of practical value to report at the present time. Should such remedies for failing memories be found, their use would be welcomed by most people as a great boon. Assuming that there were no physical or mental side effects-a large assumption-there is little obvious reason to be concerned about the ethical or social implications.viii

Scientists have also sought ways to alter the content and feeling tone of specific memories, with the goal of helping people whose lives are crushed by remembered trauma. This research has yielded some novel pharmacological interventions, still rather limited in their effect but perhaps a harbinger of things to come, that change the way we remember the most emotionally affecting experiences of life, specifically by "numbing" the discomfort connected with the memory of our most painful experiences. The capacity to alter or numb our remembrance of things past cuts to the heart of what it means to remember in a human way, and it is this biotechnical possibility that we focus on here. Deciding when or whether to use such biotechnical power will require that we think long and hard about what it means to remember truthfully, to live in time, and to seek happiness without losing or abandoning our identity. The rest of this discussion of "memory and happiness" is an invitation to such reflection.

A. Good Memories and Bad

If happiness requires better memories, how would we improve them if we could? What would be an excellent or perfect memory?

The most obvious answer is "perfect recall." An individual with a perfect memory, forgetting nothing, would remember every fact, face, and encounter, every mistake he ever made, every injury suffered at the hands of others. But even a little reflection shows that indiscriminate and total recall is not a blessing but a curse. Those who have it suffer like the Jorge Luis Borges character, "Funes, the Memorious," who describes his "all-too-perfect" memory as "a garbage disposal"; or like the famous memory patient Shereshevskii, whose photographic memory prevented him from forming normal human relationships.2 "Perfect memory" makes those who possess it miserable and dysfunctional.

An excellent memory might instead mean the ability to remember things as they really are or as they actually happen. Yet mere accuracy of recall without guidance about what is worth remembering would burden us with an inability to separate the important from the trivial. Perhaps, then, an excellent memory would recall accurately only those things that are meaningful, important, or worth remembering. Yet the significance of past events often becomes clear to us only after much rumination in light of later experience, and what seems trivial at one time may appear crucial at another. Neither can an excellent memory be one that remembers only what we want to remember: sometimes our most valuable memories are of events that were painful when they occurred, but that on reflection teach us vital lessons.

Speaking loosely, one might suggest that remembering well is remembering at the right pitch: neither too much, engulfing us in trivia or imprisoning us in the past, nor too little, losing track of life's defining moments or of knowledge needed for everyday life; neither with too much emotion, allowing past misfortunes to haunt or consume us, nor with too little emotion, recalling what is joyful, or horrible, or inconsequential, all with the same monotone affect.

The difficulty of describing an "excellent memory" makes this a problematic target for those seeking to improve human memory. They will find more likely targets in the various forms of "bad" memories, which are more easily described.

Curiously, some apparent weaknesses of memory are in fact integral to its sound functioning; some of memory's "vices" are inextricably linked to its "virtues." "Sometimes we forget the past and at other times we distort it; some disturbing memories haunt us for years," writes psychologist Daniel Schacter. But these failings of memory, he suggests, are "by-products of otherwise desirable and adaptive features of the human mind."ix Put differently, to isolate and seek to "cure" each of memory's individual failures would risk distorting the way memory works as a whole, weaving past, present, and future together in a meaningful way.

Yet many defects of memory are not adaptive but destructive, diminishing life, not facilitating it. Some people just have weak memories; owing to inborn or acquired defects, they fail to develop normal powers of memory. There is, for the foreseeable future, little anyone can do to help these people.

A far more common problem is memory loss. Indeed, most people gradually lose their capacity to remember (especially recent events) as they age, but some do so much more severely. Patients with Alzheimer disease sense early on that memory is beginning to slip away. As the disease progresses, they suffer loss of self-consciousness itself-of life lived, people loved, and the world once known-and cease to live as the persons they once were. The amnesias, caused by trauma and much rarer than dementia, produce some similar results.x

Finally, there are terrible memories, a class of destructive memory problems most relevant to the present inquiry concerning happy souls. These troubles result from the lived experience of dreadful events (for example, violent crime or war) or one's own awful deeds (for example, betrayal of a friend or abuse of spouse or child), amplified by the harrowing ways those events or deeds are remembered by especially vulnerable individuals. In certain cases, traumatic memories grossly distort and disfigure the individual's psyche: such people are diagnosed with PTSD. In the most severe cases, the traumatic memories cast a shadow over one's whole life, making the pursuit of happiness impossible.

Whereas weak memory (and weak cognition generally) limits one's ability to become the person one might wish to be, and lost memory destroys one's ability to know who one is, these traumatic memories can make it extremely difficult to live with oneself and with one's life as remembered. All these "bad memories" jeopardize happiness, and, in principle, all offer potentially worthy targets for biotechnological efforts to improve memory. But only the last-the use of drugs to erase or blunt the emotional content of our memories-would give rise to the most serious ethical and social questions. We therefore confine our attention, for the remainder of this analysis, to the emerging pharmacological means for altering our memory of traumatic events.

B. Biotechnology and Memory Alteration

It is a commonplace observation that, while some events fade quickly from the mind, emotionally intense experiences form memories that are peculiarly vivid and long-lasting. Not only do we recall such events long after they happened, but the recollection is often accompanied, in some measure, by a recurrence of the emotions aroused during the original experience. The usefulness-but also the danger-of this natural strengthening of emotionally charged memories was observed already by Descartes more than 350 years ago.xi But it is only in our time that scientists have begun to understand the mechanisms by which emotion and memory are linked.

A body of recent research on the formation of long-term memory has established two crucial facts about this phenomenon. First, immediately following a new experience there occurs a period of memory consolidation, during which some memories are encoded in the brain with more lasting impact than others. Second, strong emotional arousal is attended by the release of certain stress hormones (such as epinephrine, also known as adrenaline), and the presence or absence of these hormones in the brain during the period of memory consolidation greatly affects how strong and durable a memory is formed.

By the early 1990s, research on animals had shown that these stress hormones enhance the encoding of memories by activating the amygdala, a small almond-shaped region of the brain deep inside the temporal lobe.xii Experiments on rats showed that the memory of an experience can be strengthened if epinephrine (which produces high arousal) is injected into the amygdala immediately afterwards; conversely, such memory can be weakened by injecting into the amygdala drugs (called beta-blockers)xiii that suppress the action of epinephrine.3

Research with human subjects broadened these results and shed further light on the neuromodulatory processes that regulate the encoding of memories in the brain. Studies of patients with amnesia confirmed the crucial role of the amygdala in the consolidation of emotionally charged memories. People who have suffered damage to the amygdala typically have no difficulty remembering recent mundane events, but they do not exhibit the enhanced long-term memory normally produced by emotionally arousing experiences. Furthermore, a person with a damaged amygdala will typically recall emotional experiences without the normal repetition of the original emotion. In healthy subjects, fearful experiences are encoded with fearful memories, but subjects with amygdala damage often exhibit "abnormal fear response": they have difficulty learning to fear (and hence avoid) dangerous situations because they do not recall fearful events with the appropriate emotion. Evidently, the activation of the amygdala by stress hormones during highly emotional experiences leads to the encoding of memories that are not only more persistent but also more apt to return with the appropriate emotional accompaniment.

The results described above may help to explain what happens when, after living through particularly horrifying experiences, some people experience symptoms of PTSD. When a person experiences especially shocking or violent events (such as a plane crash or bloody combat), the release of stress hormones may be so intense that the memory-encoding system is over-activated. The result is a consolidation of memories both far stronger and more persistent than normal and also more apt, upon recollection, to call forth the intense emotional response of the original experience. In such cases, each time the person relives the traumatic memory, a new flood of stress hormones is released, and the experience may be so emotionally intense as to be encoded as a new experience. With time, the memories grow more recurrent and intrusive, and the response-fear, helplessness, horror-more incapacitating. As we shall see, drugs that might prevent or alleviate the symptoms of PTSD are among the chief medical benefits that scientists expect from recent research in the neurochemistry of memory formation.

In fact, the discovery of hormonal regulation of memory formation was quickly followed up by clinical studies on human subjects demonstrating that memory of emotional experiences can be altered pharmacologically. In one particularly interesting series of experiments, Larry Cahill and his colleagues showed that injections of beta-blockers can, by inhibiting the action of stress hormones, suppress the memory-enhancing effects of strong emotional arousal. The researchers showed their subjects a series of slides and told them one of two stories to explain the events depicted; one story was mundane and emotionally neutral, the other was tragic and emotionally gripping. Two weeks later, the participants were asked to recall the story, and those who had heard the emotionally arousing story were found-as expected-to recall what was depicted in the slides in far greater detail than those who had heard the mundane version. The experiment was then repeated, except that half the participants were given an injection of the beta-blocker propranolol and half were injected with a saline placebo one hour before the slide show. What they found was that, after two weeks, those who had heard the more mundane version of the story had the same level of recollection regardless of whether they had received the beta-blocker or the placebo. But of the subjects who had heard the more arousing version of the story, only those receiving the placebo showed an enhanced level of recollection. Those who heard the arousing story after receiving the beta-blocker found it extremely sad and emotional at the time, but two weeks later they remembered it at the same emotional level as the group that had heard the neutral story.4

Thus, taking propranolol appears to have little or no effect on how we remember everyday or emotionally neutral information. But when taken at the time of highly emotional experiences, propranolol appears to suppress the normal memory-enhancing effects of emotional arousal-while leaving the immediate emotional response unaffected. These results suggested the possibility of using beta-blockers to help survivors of traumatic events to reduce their intrusive-and in some cases crippling-memories of those events. In 2002 Roger K. Pitman and his colleagues published a pilot study reporting the use of propranolol administered to emergency room patients within six hours after a traumatic experience (mostly car accidents) and for an additional ten days thereafter. The patients-both those taking the drug and those taking placebos-were tested for their psychological and physiological response to a re-telling (with related images) of the traumatic event. One month after the event, those taking propranolol showed measurably lower incidence of PTSD symptoms than the control group. And three months later, while the PTSD symptoms of both groups had returned to comparable levels, the propranolol group showed measurably lower psycho-physiological response to "internal cues (that is, mental imagery) that symbolized or resembled the initial traumatic event."5

This study, while very preliminary, suggests that drugs may become available that will enable us not only to soften certain powerful memories but to detach them from the strong emotions evoked by the original experience. Propranolol and other currently available beta-blockers may not be able to do the whole job,xiv and, until more evidence is acquired, we do well to regard them as weak precursors of subsequent drugs that might be more powerful and effective. Yet the prospect of such "memory numbing" drugs has already elicited considerable public interest in and concern about their potential uses in non-clinical settings: to prepare a soldier to kill (or kill again) on the battlefield; to dull the sting of one's own shameful acts; to allow a criminal to numb the memory of his or her victims.6 Some of these scenarios are perhaps far-fetched. But although the pharmacology of memory alteration is a science still in its infancy, the significance of this potential new power-to separate the subjective experience of memory from the truth of the experience that is remembered-should not be underestimated. It surely returns us to the large ethical and anthropological questions with which we began-about memory's role in shaping personal identity and the character of human life, and about the meaning of remembering things that we would rather forget and of forgetting things that we perhaps ought to remember.

C. Memory-Blunting: Ethical Analysis

If we had the power, by promptly taking a memory-altering drug, to dull the emotional impact of what could become very painful memories, when might we be tempted to use it? And for what reasons should we yield to or resist the temptation?

At first glance, such a drug would seem ideally suited for the prevention of PTSD, the complex of debilitating symptoms that sometimes afflict those who have experienced severe trauma. These symptoms-which include persistent re-experiencing of the traumatic event and avoidance of every person, place, or thing that might stimulate the horrid memory's return7-can so burden mental life as to make normal everyday living extremely difficult, if not impossible.xv For those suffering these disturbing symptoms, a drug that could separate a painful memory from its powerful emotional component would appear very welcome indeed.

Yet the prospect of preventing (even) PTSD with beta-blockers or other memory-blunting agents seems to be, for several reasons, problematic. First of all, the drugs in question appear to be effective only when administered during or shortly after a traumatic event-and thus well before any symptoms of PTSD would be manifested. How then could we make, and make on the spot, the prospective judgment that a particular event is sufficiently terrible to warrant preemptive memory-blunting? Second, how shall we judge which participants in the event merit such treatment? After all, not everyone who suffers through painful experiences is destined to have pathological memory effects. Should the drugs in question be given to everyone or only to those with an observed susceptibility to PTSD, and, if the latter, how will we know who these are? Finally, in some cases merely witnessing a disturbing event (for example, a murder, rape, or terrorist attack) is sufficient to cause PTSD-like symptoms long afterwards. Should we then, as soon as disaster strikes, consider giving memory-altering drugs to all the witnesses, in addition to those directly involved?

These questions point to other troubling implications. Use of memory-blunters at the time of traumatic events could interfere with the normal psychic work and adaptive value of emotionally charged memory. A primary function of the brain's special way of encoding memories for emotional experiences would seem to be to make us remember important events longer and more vividly than trivial events. Thus, by blunting their emotional impact, beta-blockers or their successors would concomitantly weaken our recollection of the traumatic events we have just experienced. Yet often it is important, in the aftermath of such events, that at least someone remembers them clearly. For legal reasons, to say nothing of deeper social and personal ones, the wisdom of routinely interfering with the memories of trauma survivors and witnesses is highly questionable.

If the apparent powers of memory-blunting drugs are confirmed, some might be inclined to prescribe them liberally to all who are involved in a sufficiently terrible event. After all, even those not destined to come down with full-blown PTSD are likely to suffer painful recurrent memories of an airplane crash, an incident of terrorism, or a violent combat operation. In the aftermath of such shocking incidents, why not give everyone the chance to remember these events without the added burden of painful emotions? This line of reasoning might, in fact, tempt us to give beta-blockers liberally to soldiers on the eve of combat, to emergency workers en route to a disaster site, or even to individuals requesting prophylaxis against the shame or guilt they might incur from future misdeeds-in general, to anyone facing an experience that is likely to leave lasting intrusive memories.

Yet on further reflection it seems clear that not every intrusive memory is a suitable candidate for prospective pharmacological blunting. As Daniel Schacter has observed, "attempts to avoid traumatic memories often backfire":

Intrusive memories need to be acknowledged, confronted, and worked through, in order to set them to rest for the long term. Unwelcome memories of trauma are symptoms of a disrupted psyche that requires attention before it can resume healthy functioning. Beta-blockers might make it easier for trauma survivors to face and incorporate traumatic recollections, and in that sense could facilitate long-term adaptation. Yet it is also possible that beta-blockers would work against the normal process of recovery: traumatic memories would not spring to mind with the kind of psychological force that demands attention and perhaps intervention. Prescription of beta-blockers could bring about an effective trade-off between short-term reductions in the sting of traumatic memories and long-term increases in persistence of related symptoms of a trauma that has not been adequately confronted.8

The point can be generalized: in the immediate aftermath of a painful experience, we simply cannot know either the full meaning of the experience in question or the ultimate character and future prospects of the individual who experiences it. We cannot know how this experience will change this person at this time and over time. Will he be cursed forever by unbearable memories that, in retrospect, clearly should have been blunted medically? Or will he succeed, over time, in "redeeming" those painful memories by actively integrating them into the narrative of his life? By "rewriting" memories pharmacologically we might succeed in easing real suffering at the risk of falsifying our perception of the world and undermining our true identity.

Finally, the decision whether or not to use memory-blunting drugs must be made in the absence of clearly diagnosable disease. The drug must be taken right after a traumatic experience has occurred, and thus before the different ways that different individuals handle the same experience has become clear. In some cases, these interventions will turn out to have been preventive medicine, intervening to ward off the onset of PTSD before it arrives-though it is worth noting that we would lack even post hoc knowledge of whether any particular now-unaffected individual, in the absence of using the drug, would have become symptomatic.xvi In other cases, the interventions would not be medicine at all: altering the memory of individuals who could have lived well, even with severely painful memories, without pharmacologically dulling the pain. Worse, in still other cases, the use of such drugs would inoculate individuals in advance against the psychic pain that should accompany their commission of cruel, brutal, or shameful deeds. But in all cases, from the defensible to the dubious, the use of such powers changes the character of human memory, by intervening directly in the way individuals "encode," and thus the way they understand, the happenings of their own lives and the realities of the world around them. Sorting out how and why this matters, and especially what it means for our idea of human happiness, is the focus of the more particular-albeit brief-ethical reflections that follow.

1. Remembering Fitly and Truly.

Altering the formation of emotionally powerful memories risks severing what we remember from how we remember it and distorting the link between our perception of significant human events and the significance of the events themselves. It risks, in a word, falsifying our perception and understanding of the world. It risks making shameful acts seem less shameful, or terrible acts less terrible, than they really are.

Imagine the experience of a person who witnesses a shocking murder. Fearing that he will be haunted by images of this event, he immediately takes propranolol (or its more potent successor) to render his memory of the murder less painful and intrusive. Thanks to the drug, his memory of the murder gets encoded as a garden-variety, emotionally neutral experience. But in manipulating his memory in this way, he risks coming to think about the murder as more tolerable than it really is, as an event that should not sting those who witness it. For our opinions about the meaning of our experiences are shaped partly by the feelings evoked when we remember them. If, psychologically, the murder is transformed into an event our witness can recall without pain-or without any particular emotion-perhaps its moral significance will also fade from consciousness. If so, he would in a sense have ceased to be a genuine witness of the murder. When asked about it, he might say, "Yes, I was there. But it wasn't so terrible."

This points us to a deeper set of questions about bad memories: Would dulling our memory of terrible things make us too comfortable with the world, unmoved by suffering, wrongdoing, or cruelty? Does not the experience of hard truths-of the unchosen, the inexplicable, the tragic-remind us that we can never be fully at home in the world, especially if we are to take seriously the reality of human evil? Further, by blunting our experience and awareness of shameful, fearful, and hateful things, might we not also risk deadening our response to what is admirable, inspiring, and lovable? Can we become numb to life's sharpest sorrows without also becoming numb to its greatest joys?

These questions point to what might be the highest cost of making our memory of intolerable things more tolerable: Armed with new powers to ease the suffering of bad memories, we might come to see all psychic pain as unnecessary and in the process come to pursue a happiness that is less than human: an unmindful happiness, unchanged by time and events, unmoved by life's vicissitudes. More precisely, we might come to pursue such happiness by willingly abandoning or compromising our own truthful identities: instead of integrating, as best we can, the troubling events of our lives into a more coherent whole, we might just prefer to edit them out or make them less difficult to live with than they really are.

There seems to be little doubt that some bitter memories are so painful and intrusive as to ruin the possibility for normal experience of much of life and the world. In such cases the impulse to relieve a crushing burden and restore lost innocence is fully understandable: If there are some things that it is better never to have experienced at all-things we would avoid if we possibly could-why not erase them from the memory of those unfortunate enough to have suffered them? If there are some things it is better never to have known or seen, why not use our power over memory to restore a witness's shattered peace of mind? There is great force in this argument, perhaps especially in cases where children lose prematurely that innocence that is rightfully theirs.

And yet, there may be a great cost to acting compassionately for those who suffer bad memories, if we do so by compromising the truthfulness of how they remember. We risk having them live falsely in order simply to cope, to survive by whatever means possible. Among the larger falsehoods to which such practices could lead us, few are more problematic than the extreme beliefs regarding the possibility-and impossibility-of human control. Erring on the one side, we might come to imagine ourselves as having more control over our memories and identities than we really do, believing that we can be authors and editors of our memories while still remaining truly-and true to-ourselves. Erring on the other side, we might come to imagine that we are impotently in the grip of the past as we look to the future, believing that we can never learn to live with this particular memory or give it new meaning. And so we ease today's pain, but only by foreclosing, in a certain way, the possibility of being the kind of person who can live well with the whole truth-both chosen and unchosen-and the kind of person who can live well as himself.

2. The Obligation to Remember.

Having truthful memories is not simply a personal matter. Strange to say, our own memory is not merely our own; it is part of the fabric of the society in which we live. Consider the case of a person who has suffered or witnessed atrocities that occasion unbearable memories: for example, those with firsthand experience of the Holocaust. The life of that individual might well be served by dulling such bitter memories,xvii but such a humanitarian intervention, if widely practiced, would seem deeply troubling: Would the community as a whole-would the human race-be served by such a mass numbing of this terrible but indispensable memory? Do those who suffer evil have a duty to remember and bear witness, lest we all forget the very horrors that haunt them? (The examples of this dilemma need not be quite so stark: the memory of being embarrassed is a source of empathy for others who suffer embarrassment; the memory of losing a loved one is a source of empathy for those who experience a similar loss.) Surely, we cannot and should not force those who live through great trauma to endure its painful memory for the benefit of the rest of us. But as a community, there are certain events that we have an obligation to remember-an obligation that falls disproportionately, one might even say unfairly, on those who experience such events most directly.9 What kind of people would we be if we did not "want" to remember the Holocaust, if we sought to make the anguish it caused simply go away? And yet, what kind of people are we, especially those who face such horrors firsthand, that we can endure such awful memories?

The answer, in part, is that those who suffer terrible things cannot or should not have to endure their own bad memories alone. If, as a people, we have an obligation to remember certain terrible events truthfully, surely we ought to help those who suffered through those events to come to terms with their worst memories. Of course, one might see the new biotechnical powers, developed precisely to ease the psychic pain of bad memories, as the mark of such solidarity: perhaps it is our new way of meeting the obligation to aid those who remember the hardest things, those who bear witness to us and for us. But such solidarity may, in the end, prove false: for it exempts us from the duty to suffer-with (literally, to feel com-passion for) those who remember; it does not demand that we preserve the truth of their memories; it attempts instead to make the problem go away, and with it the truth of the experience in question.

3. Memory and Moral Responsibility.

The question of how responsible we are or should be held for our memories, especially our memory failures, is a complicated one: Are remembering and forgetting voluntary or involuntary acts? To what extent should a man who forgets his child in a car, by mistake, be held "morally accountable" for his forgetting? Is remembering "something we do" or "something that happens to us"?

Hard as these questions are, this much seems clear: Without memory, both our own and that of others, the notion of moral responsibility would largely unravel. In particular, the power to numb or eliminate the psychic sting of certain memories risks eroding the responsibility we take for our own actions-since we would never have to face the harsh judgment of our own conscience (Lady Macbeth) or the memory of others. The risk applies both to self-serving uses of such a power (for example, drugs taken after a criminal act and before the next one) and to more ambiguous "social" uses (for example, drugs taken after killing in war and before killing again). Without truthful memory, we could not hold others or ourselves to account for what we do and who we are. Without truthful memory, there could be no justice or even the possibility of justice; without memory, there could be no forgiveness or the possibility of forgiveness-all would simply be forgotten.

The desire for powers that numb our most painful memories is largely a personal desire: to have such drugs for myself, in the service of my own peace of mind and happiness. Yet we cannot be blind to the potentially coercive and immoral uses-by other individuals and by the state-of biotechnical interventions that alter how we remember and what we forget, and that indirectly affect our well-being. Just as drugs that dull the emotional sting of certain memories might be desired by the victim to ease his trauma, so they might be useful to the assailant to dull his victim's sense of being wronged. Perhaps no one has a greater interest in blocking the painful memory of evil than the evildoer. We also cannot ignore the potentially coercive nature of normalizing the use of such drugs in certain occupations: that is, by making chemically aided desensitization part of the "job description" (augmenting or replacing existing non-chemical means of desensitization). Nor can we forget the central place of manipulating memory in totalitarian societies, both real and imagined, and the way such manipulation made living truthfully-and living happily-impossible.

4. The Soul of Memory, The Remembering Soul.

Perhaps more than any other subject in this report, memory is puzzling. It is both central to who we are as individuals and as a society, yet very hard to pin down-so variable in its many meanings and many manifestations. Jane Austen may have captured this complexity best:

If any one faculty of our nature may be called more wonderful than the rest, I do think it is memory. There seems something more speakingly incomprehensible in the powers, the failures, the inequalities of memory, than in any other of our intelligences. The memory is sometimes so retentive, so serviceable, so obedient-at others, so bewildered and so weak-and at others again, so tyrannical, so beyond control!-We are to be sure a miracle every way-but our powers of recollecting and of forgetting, do seem peculiarly past finding out.10

On the one hand, when considering the meaning of human memory, we need to face the fact that there are limits to our control over who we are and what we become. We are not free to decide everything that happens to us; some experiences, both great joys and terrible misfortunes, simply befall us. These experiences become part of who we are, part of our own life as truthfully lived. And yet, we do have some measure of freedom in how we live with such memories-the meaning we assign them, the place we give them in the larger narrative of our lives. But this meaning is not simply arbitrary; it must connect the truth or significance of the events themselves, as they really were and really are, with our own continuing pursuit of a full and happy life. In doing so, we might often be tempted to sacrifice the accuracy of our memories for the sake of easing our pain or expanding our control over our own psychic lives. But doing so means, ultimately, severing ourselves from reality and leaving our own identity behind; it risks making us false, small, or capable of great illusions, and thus capable of great decadence or great evil, or perhaps simply willing to accept a phony contentment. We might be tempted to alter our memories to preserve an open future-to live the life we wanted to live before a particular experience happened to us. But in another sense, such interventions assume that our own future is not open-that we cannot and could never redeem the unwanted memory over time, that we cannot and could never integrate the remembered experience with our own truthful pursuit of happiness.

In the end, we must wonder what life would be like-and what kind of a people we would become-with only happy memories, with everything difficult, uncertain, and hard edited out of our lives as we remembered and understood them. We would suffer no loss, but perhaps only because we loved feebly and cared little for what we had. We would never shudder at life's injustices, but perhaps only because we had little interest in justice. We would little relish our own achievements, since we would achieve them without any memory of hardship along the way and with no recollection of achieving in spite of the odds. To have only happy memories would be a blessing-and a curse. Nothing would trouble us, but we would probably be shallow people, never falling to the depths of despair because we have little interest in the heights of human happiness or in the complicated lives of those around us. In the end, to have only happy memories is not to be happy in a truly human way. It is simply to be free of misery-an understandable desire given the many troubles of life, but a low aspiration for those who seek a truly human happiness.

III. MOOD AND HAPPINESS

Even more than memory, mood conditions and is conditioned by our happiness. Thoughtful reflection reveals that memory is crucial to human happiness because it links our present identity with our past deeds and experiences; but the connection between mood and happiness (and also unhappiness) is self-evident to all. Indeed, the content of our happiness seems at first glance to be largely a function of our present mood: the word "happy" is normally taken as the opposite of "sad," and the question, "Are you happy?" is typically understood as an inquiry about one's mood. Yet although many people, if asked, might say that being happy and being in a good mood are one and the same, the truth of the matter is not so simple. If happiness were nothing other than "good mood," it would seem to follow that anything that elevates one's mood automatically increases one's happiness. And if that were the case, the development of safe and effective mood-elevating drugs-not only for the clinically depressed but also for the merely sad or discontented-would seem to herald a future blessed by ever-greater numbers of ever-happier people. But, as we shall see, closer examination reveals that the connection between mood and happiness is much more subtle, and the prospects for making people happy through pharmacology are much more ambiguous.

The first complication concerns "mood" itself: what it is, and how to think about it. Narrowly understood, "mood" refers to a frame of mind or state of feeling: "I am feeling blue," "I am in a grumpy mood," or "I am in the mood for dancing." These more or less transient feeling states come and go, shifting or persisting in ways over which we have only limited control. Although they rise and fall as we prosper or fail in the things we try to do from day to day, our moods are also at the mercy of fortune. They may be soured by hunger, fatigue, or illness; they may be sweetened by a call from an old friend, a kindness shown to a stranger, or a simply beautiful day; they may soar into ecstasy at the birth of a child, they may sink into despair at the death of a spouse.

Yet beneath our shifting moods are more pervasive and persistent dispositions of feeling, commonly called "temperaments."xviii Temperament is the general orientation of "feeling," "mood," and "outlook" that we bring to all experience and on which particular experiences work to produce the various and shifting states of emotion. It is our temperament that inclines us toward being generally upbeat or gloomy, hopeful or fearful, extroverted or introverted, emotionally quick and mercurial or emotionally slow and phlegmatic. Seen through the wider lens of temperament, "mood" means more than cheerful or sad, "good mood" or "bad." It covers the ranges between-and combinations among-being confident and reticent, outgoing and shy, bold and timid, engaged and apathetic, excitable and calm, irascible and easygoing, ambitious and lazy, proud and humble. Although rooted in some combination of inborn natural gifts and altered by nurture and experience, temperament is also somewhat shapable through habituation into more or less stable traits of character: depending on how we recurrently react to fearful situations, we become more courageous, cowardly, or rash; depending on how we recurrently react to other people, we become more amiable, unfriendly, or obsequious. Although temperaments are centrally matters of feeling or emotion, they are also related to awareness and thought. They will both color and be colored by opinions and beliefs we have about the world and about ourselves. People with unduly high expectations are probably more easily disappointed and discouraged; people who believe that "selfish genes" govern behavior may be less troubled by their own moral failings; people who trust in a loving and forgiving God may be less susceptible to despair.

As these last comments indicate, mood and temperament are not only outward-looking and responsive to worldly happenings. They are also much connected with our inner sense of self. Animals no doubt experience feelings of pleasure and pain, fear and calm, frustration and satisfaction, and something that looks from the outside like spiritedness, anger, and even pride. But it is unlikely that they harbor humankind's explicitly judgmental feelings of self-love, self-esteem, self-worth, self-doubt, and self-loathing, especially as these are tied in human beings to some explicit or tacit idea of who one thinks one is, judged in relation to who one thinks one should be and (especially) in relation to others. Some of us are very hard on ourselves, filled with self-criticism and doubt about self-worth at even the smallest falling short; others of us are very self-content or even self-indulgent, able to brush aside even large failures with what looks like blithe indifference. Like the other temperaments, the self-regarding dispositions are, of course, not simply inborn and fixed; cumulative life experience, including our history of genuine successes and failures, no doubt contributes much. But self-demanding perfectionists are unlikely to turn into laid-back "accommodationists," especially from life experience alone. Accordingly, these self-regarding feelings and dispositions-no less than our basic temperaments and supervening moods-play a major role in whether we find satisfaction in life, or the opposite.

A second difficulty concerns the range and "spectral" character of moods, however narrowly or broadly defined. Human moods, temperaments, and attitudes of self-regard vary enormously in character, intensity, and persistence, as well as in their effects on the way each of us lives our lives. The possible combinations of particular dispositional traits seem virtually limitless, and they defy the capacity of ordinary language to describe them accurately and fully, even for any one individual. One feeling or mood blends into another, and all of them admit of degree. When we analytically separate out any one dimension for description-say, for example, the range from cheerful to gloomy-we notice that people distribute themselves along a full and continuous spectrum of "normal" mood states and dispositions, and this seems true across the board.

Yet it is clear that there are many individuals who are not emotionally normal, whose psyches are "taken over" for long periods of time by a dominant and debilitating mood or outlook. They live in the grip of profound sadness, hopelessness, or despair, or of panic and terror regarding social situations, or unrelieved guilt, shame, or feelings of abject unworthiness. Not liking the way they feel and are, sometimes suicidal and often desperate for help, these people bring themselves (or are brought by others) to the doctor's door, where, fortunately, in many cases real help is increasingly available. Indeed, vast numbers of people suffering persisting and disabling disorders of mood and temperament are today diagnosed and treated by psychiatrists and other physicians for numerous affective disorders, including major depression, bipolar disorder, social anxiety disorder, obsessive-compulsive disorder, oppositional disorder, and the like. Scientists increasingly believe that most of these psychic disorders are-like schizophrenia-partly the product of, or at least correlated with, certain underlying abnormalities and (partially heritable) disorders in the brain. Yet there are at present no specific diagnostic tests to prove the point. For this reason, it is often hard to determine whether any given individual suffering the symptoms that define these disorders belongs simply to the extreme end of a spectral distribution of "normal" temperaments or rather to a separate "class" of people with a specific brain disorder. What is, however, easy to recognize is the enormous misery these symptoms and conditions cause, and the further fact that such patients often respond well to so-called "mood-altering" or "mood-brightening" drugs.

The different meanings of "mood" and the wide range of their character, both negative and positive, give rise to a third complication regarding the relation of mood and happiness, this one regarding human aspiration: What mood or moods, what states of feeling, what emotional outlook on life and self do we aspire to? As one would expect, our aspirations in this realm are many and varied. Some of us, depressed or despairing, crave merely a cessation of pain, our troubles lifted. Some of us, bored or listless, would like spikes of bliss-to get "high"-and some would even want that bliss perpetually, if that were possible. Some would prefer simply peace or contentment, never to be sad again. Some would have their dispositions brightened and stabilized, inhibitions eased, optimism and resilience gained or restored. Some strive for the best experiences-falling in love, attaining some honor, performing at one's best-in order to enjoy the good feelings and self-esteem that accompany those experiences, whereas others would be satisfied by the feelings alone, without actually having to endure the work, hardship, and risk of failure. As this variety suggests, while the desire for happiness is universal, the content of happiness is elusive, opinions and wishes varying from person to person depending in part on "where we start," "who we are," and what we desire as the things most needful. Increasingly, however, both our culture's preoccupation with "how we feel about ourselves," and especially the availability of mood-altering drugs that can change those feelings, have encouraged us to treat "states of mind"-mood, feeling, disposition-as goals and targets that can be separated and pursued apart from the actions and experiences they normally accompany.

In the remainder of this discussion, and very mindful of all the ambiguities and uncertainties involved in doing so, we will use "mood" in the very broadest sense, to embrace the transient and supervening states of feeling, the basic underlying temperaments, and the emotionally charged outlooks we have on ourselves and the world. Any of them, if negative and severe enough, mars the chance for happiness. Any of them, if sufficiently enduring and disabling, deserves to be classified as illness or disease. All of them are in principle subject to pharmacological intervention, if not today, very likely sometime soon. Given the wide variety of mood-altering agents, present and projected, and given our ignorance of the precise effect any particular drug will bring about in any given person, we are somewhat at a loss about what to call these chemicals: "antidepressants" seems too narrow, "mood-altering-agents" too non-specific, "mood-elevators" or "mood-brighteners" too specialized, "euphoriants" inaccurate.xxix Moreover, no single name describes a drug that, in different people, can alleviate depression, calm panic, moderate compulsions, boost confidence, or improve self-esteem. Somewhat arbitrarily, we will use "mood-brighteners," despite the inaccuracy, so as to keep before us their ability not only to lift mood but also to improve the outlook of the person, including about himself.

A. Mood-Improvement through Drugs

Whereas drugs designed to alter memory are new, mood-altering agents are not. Alcohol and opiates have been with us for centuries. Doctors first used lithium for its mood-stabilizing effects in the early twentieth century. Since the 1950s, psychiatrists have used tricyclics and monoamine-oxidase inhibitors (or their precursors) to treat depression. The desire to use these and other technological means to take control of our mood abides and likely will abide so long as there are human beings who wish for happiness and do not have it. The desire being so strong and the technologies so familiar, we have developed a network of laws, social taboos, professional standards, and understandings of risks, both physical and moral, through which we more or less manage the technologies' use-though there continue to be many casualties along the way, and alcoholism and drug abuse remain massive social problems. Now, as rapid advances in scientific and medical research are producing new technologies of feeling-safer, more powerful, and more specific than any that came before-there is reason to suspect that our laws, knowledge, and ethical practice are lagging behind our technology. So we must ask anew what to think of the powers over mood we are in the midst of developing. The question, if more familiar, is also more pressing than any connected with powers over memory, for the technologies of mood-control are not only coming but already here.

1. Mood-Brightening Agents: An Overview.

We already have at our disposal a wide range of newer psychotropic agents useful in altering mood, some named above. But selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Paxil, Zoloft, Celexa, Lexapro, and Effexor, stand out.xx SSRIs are the newest and most advanced mood-brighteners available. There is nothing futuristic about them-a recent poll suggests one in eight adult Americans use them today, mostly as treatment for diagnosed illness11-yet they give some sense of what mood-brightening technologies are to come, at least in the near future. Their effects appear to be far-reaching, touching not only those with obvious mental illness but also those in the penumbra of depression, those with merely melancholy or inhibited temperaments, and possibly those who are emotionally or temperamentally balanced or normal.12 But their effects and the reason for their effects are not understood with any precision. They are fairly safe and non-addictive, and they are legal, yet there is no consensus in America about the limits of their appropriate use. A public conversation has begun, but only begun.13 While we will focus much of our discussion on SSRIs-with occasional turns to other mood-elevating drugs, such as MDMA (methylenedioxy-n-methylamphetamine, or "Ecstasy")-we also keep in mind the prospect of more advanced pharmacological means for altering mood in the not-too-distant future. We are interested not in the SSRIs as such, but in the insights we might gain from their current uses regarding the ethical and social implications of mood-brightening pharmacology in general, today and especially tomorrow.

As we noted at the start of this chapter, medical researchers developed SSRIs, and doctors by and large prescribe them, not to stave off ordinary unhappiness, but to treat major depression and other emotional problems so disabling as to indicate the presence of mental illness. For these conditions, the drugs are true medicines of great benefit. In efforts to help those afflicted with the worst anxieties and depressions, those sliding into similar afflictions, and those suffering psychic pain severe enough-diagnosable illness or not-to make claims on a doctor's duty to save (that is, those at risk of suicide), SSRIs are often indispensable, and patients and doctors have every reason to use them.14 As far as we know, most prescription and use of SSRIs are of this therapeutic character.

Yet some doctors are prescribing mood-brighteners for people whose troubles are not so severe and whose neurochemistry may not be abnormal. This should not be surprising or shocking, given that the boundaries between mental illness and misery or between mental health and happiness are not easily drawn. Physicians are prescribing for patients with lesser and lesser forms of depression, psychiatrist Peter Kramer has argued, precisely because Prozac and similar drugs can give them relief, a classic case in which the availability of a technology of cure drives, and expands, the definition of illness.15 But whether or not diagnostic categories are being expanded, and properly or not, two separate human enterprises-curing mental illness and pursuing happiness-appear to be converging, because of the development of medicines so effective that their use overshoots the illness for which they were developed and because they aid or seem to aid the realization of ordinary human desires for happier souls.

Also worth noting at the outset is the astonishing variety of individual situations for which people use these drugs and the diverse effects they have on users' minds and lives. No single ethical inquiry can hope to discuss, much less resolve, the questions attending every particular case of use. Moreover, much hard-to-design empirical research would be needed to verify whether the troubling consequences that ethical reflection identifies as possible are in fact coming to pass. The subject is too subtle, the emotional lives of human beings too diverse and elusively complex. Yet many of our ethical and social questions cannot on those grounds be set aside.

The millions of Americans now taking SSRIs are probably only the beginning. Epidemiologists widely consider depression to be undertreated in America: according to recent studies, between 9.5 percent and 20 percent of Americans suffer from some form of depression.16 If all were treated with mood-brighteners, one out of every five to ten people would use them. Moreover, the rate of diagnosed depression appears to be climbing in the United States, as in all developed countries-probably due not just to greater reporting, but to real increase.17 At the same time, the diagnosis of depression seems to be expanding to include lesser and lesser forms of sadness,18 while more and more conditions besides depression (social phobia, obsessive-compulsive disorder, and many others) are being treated with mood-brighteners.19 Although data is hard to come by, according to some reports as many as 20 percent of students on elite college campuses now take or have taken prescription mood-brighteners.20 As these trends dovetail with new drugs still to come, whose risk and side-effect profiles may well be increasingly gentle, use of mood-brighteners will almost certainly expand.

In light, then, of both present actualities and future possibilities, we need now to deepen our understanding of mood-brighteners, and to evaluate their human costs as well as their benefits, as we strive to reach sensible judgments about how they should be used. At stake are not only questions of private health and happiness, but also, as we shall see, questions regarding the character of American society.

2. Biological and Experiential Effects of SSRIs.

Assessment begins with trying to understand the effects of SSRIs, both on the brain and on felt human experience. In both cases, we know only a little of what we seek to know, and still less about the connection between the biological and experiential effects.

Neurologically, what SSRIs do is alter the brain's handling of serotonin. Like other neurotransmitters, serotonin is released from one neuron to bind with and thereby activate another. The brain recycles serotonin after each release, gathering it up again by means of a "reuptake system." SSRIs inhibit the serotonin reuptake system, thus increasing the concentration of serotonin available to the receiving neurons-hence the name, "serotonin reuptake inhibitor." (Since SSRIs inhibit serotonin reuptake without interfering with reuptake of other neurotransmitters, we get the full name, "selective serotonin reuptake inhibitor.") When given to patients diagnosed with mood disorders, SSRIs brighten or stabilize moods in most of them, presumably as a result of the increased availability of serotonin in certain crucial places in the brain.

Scientists do not yet know how inhibiting the reuptake of serotonin alters the mental state. What serotonin does, how it functions, and even whether it is a serotonin problem that causes depression in the first place, remain largely unknown.21 Serotonin does not alter mood directly, such that more of it produces more pleasure or confidence and less of it the opposite; that much is clear. Serotonin is not an opiate or a euphoriant. But just what does happen when more or less serotonin is available-whether mood is eventually reoriented by some plastic development in the brain, or by some other downstream effect, some subtle influence over feeling, perceiving, and thinking, or something else entirely-is at present a mystery.xxi Neuroscience is a young field; many of the powers it is yielding arrive in advance of its capacity to understand them. And even if we knew more about brain chemistry and its functional significance, it is not clear that such knowledge would be of a sort to help ethical inquiry. How to characterize and assess what someone's mood becomes when it is serotonin-enabled-whether "happy" or "calm" or "confident" or "insensible" or something else again-is outside of strictly biological inquiry. Brain science is and likely will remain silent on the nature and significance, in human terms, of the experienced changes in mood that the SSRIs produce.

One effect of SSRIs is clear: they relieve a number of disorders of mood, particularly depression. Yet the nature of these disorders is complicated and their causes remain largely unknown. In DSM-IVxxii the lengthy discussion of depression (like the discussions of other psychiatric disorders) is essentially a compendium of symptoms, with no attempt at a coherent account of the nature or causes of the illness.22 Although studies of patients' family histories suggest an important role for genetic predispositions and inherited susceptibilities, no underlying biological counterpart to major depression, let alone its specific variants, has so far been found, no broken part identified-not even a disorder in the serotonin system.23 There is as yet no genetic or blood test, brain scan, or electroencephalogram for diagnosing depression. The very term "depression" seems to refer not to one thing, but to a heterogeneous collection of conditions with different symptoms, causes, courses of illness-and responses to SSRIs.24 This last point is especially important: how serotonin affects a person appears to depend-though few studies address the matter directly-on what the person's starting point is. The mentally ill and the more-or-less-healthy-but-unhappy experience, it seems, different effects from the drugs. Those with the type of depression seen in bipolar disorder often make a full recovery, becoming steady in mood and capable of fitting emotional responses to all the highs, lows, and "middles" of life. Those with something closer to ordinary sadness or grief, or those with a melancholy or inhibited temperament, seem to have subtler responses, though ones they still welcome. And some individuals respond to one medication but not another, while others have no response at all.

Our attention here is mainly on the latter group, "normal" people who want to feel "better than normal," or at least better than they normally do. People who take SSRIs in the absence of definite mental illness, and the physicians who observe them, commonly report that negative feelings such as sadness and anger do not disappear but diminish, as does the inclination to brood over them. Loss, disappointment, and rejection still sting, but not as much or as long, and one can cope with them with less disturbance of mind. Sensitivity also declines, along with obsession, compulsion, and anxiety, while self-esteem and confidence rise. Fear, too, is reduced, and one is more easily able to experience pleasure and accept risk. Mental agility, energy, sleep, and appetite become more regular, typically increasing. And mood brightens-though not to the point of perpetual bliss or anywhere near it.25 People do indeed feel better.

Still, it is hard to know what to make of this bundle of reported effects. Speaking abstractly, one can see a certain unity to them, a reduction of various negative feelings, an increase in positive ones, a general moderation prevailing where once there was excess or deadness. Also, it seems that only the "positive/negative axis" of feeling is touched: SSRIs do not directly affect other aspects of feeling-do not impart or remove empathy, have no direct effect on moral conscience, neither increase nor lessen one's ability to appreciate beauty. Might there be some way of understanding and characterizing these effects as a whole?

One suggestion is that SSRIs alter a person's native temperament or affective disposition-an individual's tendency to respond to the circumstances and events of life in a particular emotional fashion. Temperaments vary, for example, in characteristic intensity of emotions and moods, from strong (or intense) to weak (or mild). While a severely stressful event will of course provoke a strong reaction from almost anyone, some people react more strongly (and some more mildly) to equivalent stresses, and-important for our purposes-their tendencies to react at such a pitch are long-lasting.xxiii SSRIs affect this dimension of temperament: they tend to reduce the intensity of emotional responsiveness.26 One might say that SSRIs, at base, make people calmer.xxiv

Yet "calmness" is not the only way to understand the effects of SSRIs on mood and psychic experience. For one thing, the calmness explanation stumbles on the example of MDMA (Ecstasy), which also makes more serotonin available and which induces not calm but bliss, social and sensory openness, and feelings of intense affection.xxv 27 A second view of serotonin function is that it deals with something more basic than emotion and mood: a nondescript measure of well-being. This idea takes off from findings in animal research, indicating that serotonin systems are active in brains of lower organisms, organisms that almost certainly do not experience conscious moods or emotions.xxvi One could easily imagine how it might be useful for any organism to have an internal gauge of its well-being-satisfaction of its needs and desires, its social status, and the like-that would prod it to undertake actions that foster survival and reproduction. Perhaps serotonin is part of such a gauge, a mechanism by which organisms set their background level of felt well-being.28

A variety of human observations support the "background level of felt well-being" thesis. With humans, as with primates, SSRIs do not directly introduce or block emotions and moods; one can experience a variety of emotions and moods-including negative ones-while taking them, and presumably while enjoying elevated levels of serotonin. Also, while SSRIs change a user's serotonin levels within hours, they produce no experienced psychic effect for weeks. Something subtler than direct control of emotion and mood is taking place, something that would create tendencies toward, and shape the intensity of, certain emotions and moods, but not simply implant them.

In this regard, it is striking that SSRIs are effective in relieving symptoms for so many conditions: social phobia, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, premenstrual dysphoric disorder, a variety of eating disorders and sexual compulsions, and the whole range of conditions clustered around major depression, possibly ranging all the way from melancholic dispositions to ordinary sadness. The emotions and moods, not to mention the causes, symptoms, and courses of illness of these conditions, are very different. How is it that SSRIs address them all? This broad efficacy makes sense if SSRIs establish a background sense of well-being, for in the presence of such a sense those many conditions could not persist; each disorder is an instance of feeling unwell, and so each is inconsistent with a general sense of being well. It is as if SSRIs erect the kind of healthy dispositional foundation that those blessed with fortunate genetics and favorable environments tend to have (without the need for drugs), below which, apart from the most crushing circumstances, one's despair will not fall.

A third hypothesis suggests that SSRIs can sometimes transform personality. Consider, for example, the story of "Sally," a patient of psychiatrist Peter Kramer, who describes her case in Listening to Prozac. Shy by nature, raised by depressed and inhibited parents, sexually abused by an uncle, Sally developed an "entrenched timidity and social discomfort," which led to "a sameness to her life, a terrible monotony . . . a life of intolerable bleakness."29 It had few pleasures, no lovers or close friends, little to look forward to or to relish, and-though she did not think of herself as depressed until midlife-she became then not just depressed but "openly desperate." As she wrote to Kramer before seeing him:

I am forty-one years old. I feel angry and hurt most of the time. I feel like my spirit has been shattered and fragmented with each piece having been trampled on and bruised. I am very, very anxious. I am afraid of everything, even centipedes and roaches. I keep thinking something very, very bad is going to happen to me, some great misfortune, or that I'll become handicapped and have to depend on people to take care of me. I don't know who I am, because that person stopped growing at the age of four, and it makes me very sad.30

Sally's touching story is, in outline, widely shared: a difficult environment amplifies a troubled or troublesome predisposition and sets in motion a great unhappiness. Prozac had a dramatic effect on her. She felt that the drug cleared her head, made her more calm and confident. With her new assertiveness, she negotiated a promotion at work, where she had been locked into one job for eighteen years. The changes in her social life were positively stunning. More easygoing, more cheerful, and-most of all-unafraid at last, she dated several men, came to love one, and married him: "an extraordinary achievement, a sign of victory over a crippling aspect of the self." Sally said the Prozac had let her true personality finally emerge, the personality deflected by hardship and inborn fear; it let her truly live for the first time. When her doctor expressed some concerns and suggested suspending the use of it temporarily, Sally flatly refused.

Trying to understand the nature of Sally's transformation, Kramer suggests that it was social inhibition, not depression or anxiety, that led to her unhappiness and stagnation, and concludes as follows:

The vast majority of these [naturally shy] people, including those who are outright inhibited socially, will be "normal" in psychological terms. Most of them will be highly functional in their careers and private lives. No one has ever called people with inhibited personality mentally ill. The brief conclusion to this line of reasoning is that in patients like Sally, and in many others with less dramatic stories and perhaps with no history of depression at all, what we are changing with medication is the infrastructure of personality. That is, Sally is able to marry on Prozac because she has achieved chemically the interior milieu of someone born with a different genome and exposed to a more benign world in childhood.31

Yet SSRIs do not transform personality utterly: Prozac only changed the easily measured, gross traits of Sally's temperament, Kramer explains, not the "many small and consequential features that make each person unique . . . [their] opinions, aspirations, bętes noires, mannerisms, and memories."32 Sally acquired the states of feeling not of anyone, but of Sally, had Sally been born and raised to be well.xxvii

Many psychiatrists disagree with Kramer's conclusion, arguing that people like Sally are chronically depressed or otherwise disordered, and what appears to be personality change is actually just the liberation of their true self.33 Yet, be this as it may, we may still share Kramer's wonder at "the capacity of modern medication to allow a person to experience, on a stable and continuous basis, the feelings of someone with a different temperament and history." Indeed, in response to his critics, Kramer presents a sharp challenge to the view that SSRIs cannot alter personality, in the process clearly articulating this Council's concern regarding the "beyond therapy" uses of these drugs. Arguing that SSRIs clearly can produce dramatic improvements in people who were once not considered ill, he insightfully suggests that this fact presents doctors, along with society more generally, with the choice either to expand the notion of mental illness or to see SSRIs as medicating personality.xxviii

These three accounts of what SSRIs fundamentally do-induce calmness, provide a background sense of well-being, change personality-probably ought not to be looked at as mutually exclusive competitors. Inducing a background sense of well-being could be the cause of greater calm, and greater calm in turn the cause of a transformed personality. The three could also be identical: the difference between a background sense of well-being and a greater sense of calm may be, at least in part, one of description, and each of those could be understood as personality changes. The three accounts double back, overlap, and imply one another at many points, and we can perhaps see them as three ways of making the same change, whose results can, in summary, be called a "brighter mood."

This very confusion, however-the uncertainty regarding what SSRIs do, the unclear relationship between the various accounts-is instructive for thinking about the future of mood-brighteners, and we have dwelt on it for this reason. Our technological powers often arrive far ahead of our capacity to understand them. This is only partly due to the fact that researchers often first come across a new and effective mood-altering drug by accident, and only later learn the mechanism of its action. It is also due to the enormous complexity of the brain and the still greater complexity of mental life. And it is due especially to the deep and unbridgeable divide between the language of inner experience and the language of neurochemistry, a fact that will always bedevil efforts to understand the humanly felt import of molecular events in the brain. The outcome: We acquire drugs that satisfy our aspirations, yet we know not how or why. As the example of SSRIs shows, even though we are ignorant, even though we suspect that the unknown effects of the drugs are subtle and deep, we make substantial use of them nonetheless. The generalizable lesson seems clear: in the years to come, SSRIs will in all likelihood become more effective in accomplishing what they accomplish; they will be modified to produce fewer and gentler side effects and they will be utilized more and more. When some discovery leads to an altogether new drug with even greater powers to satisfy our aspirations for a happier soul, it will also be used despite much ignorance and uncertainty. Where deep human desires are present, and where the effects of technology are so attractive, most people will prefer benefits despite ignorance to knowledge without benefits.

B. Ethical Analysis

From an ethical perspective that gives primacy to personal freedom and an individual's right to pursue happiness as he or she defines it, the use of mood-brighteners in search of a happier soul might seem at first glance to be largely unproblematic. If we have available to us a drug that induces a background sense of well-being, why shouldn't we use it when we feel unfulfilled or steadily "blue"? What could be wrong with, or even just disquieting about, wanting to feel better about ourselves and our lives, and availing ourselves of the necessary assistance in doing so? If we may embrace psychotherapy for the same purpose, why should we not embrace mood-brighteners, especially if they are not only safe but also cheaper and more effective than "talk therapy"? Only a person utterly at peace with the world and content with himself would be beyond temptation at the prospect of having his troubles effortlessly eased. And even were we to resist the temptation for ourselves, we might seek it for our unhappy children, whose sorrows are for most of us much more painful than our own.

Yet further reflection gives rise to questions-about both ends and means-that ought, at the very least, to give pause to anyone tempted by the pharmacological road to happiness. For we care that our children-and that we ourselves-have not only the sense or feeling of well-being, but well-being itself. We desire not simply to be satisfied with ourselves and the world, but to have this satisfaction as a result of deeds and loves and lives worthy of such self-satisfaction. We do not want to kill our aspiration for a better life by drowning in a self-absorbed contentment those experiences of lack and self-discontent that serve as aspiration's source, or those engagements with the world and other people that serve as aspiration's vehicle.xxxixHere, then, lie several potential grounds of our unease about-not rejection of-mood-elevating drugs: the prospect of mistaking some lesser substitute for real happiness; the danger of seeking happiness at the cost of confounding our own identity or losing our longings for the real thing; and the price to be paid-in personal aspiration, interpersonal relations, and communal character-should a large fraction of our society (successfully) pursue happier souls by this inward-turning means.

1. Living Truly.

Most people seek some form of the well-being that Sally came to experience, in her case only with the help of medication: We seek to be confident in everyday life, to form lasting and meaningful relationships with others, to pursue worthy goals and take pleasure in their achievement. But what is the significance in relying on mood-brightening drugs to achieve such happiness? To what extent is the happiness of the happy person attributable to the drug and to what extent is it "her own"? To what extent are drug-induced psychic states connected with or disconnected from life as really lived? Surely, for Sally and others who benefit greatly from mood-brightening drugs, the drugs are not the direct cause of their happiness. Sally's happiness has much to do with her new husband and new job, her new attachments and new achievements, though she would likely not have sought or found them without taking Prozac. The drug itself did not make her happy; it merely enabled her to do and experience the many things that make her happy. But now imagine being Sally's husband: Just to whom am I married? Would I love Sally if she stopped taking Prozac and relapsed into timidity and hopelessness? Would Sally love me? Would Sally be Sally?

With a drug like Ecstasy, the answers to such strange and difficult questions-about the identity of the person taking such drugs and the status of the positive feelings they induce-are more obvious, if no less disquieting. People high on Ecstasy routinely profess their love for perfect strangers. Imagine that a young party-goer, under the influence of the drug, tells a young woman that he loves her and wants to marry her. Imagine also that he means it, insofar as the feeling he now has is indistinguishable from what he might one day feel when he truly falls in love with a woman. Should the fact that his feelings are produced by the drug, rather than inspired by the woman, matter? It should of course matter to her. His drug-based professions of love cannot be taken seriously. Neither should a marriage proposal that owes everything to his being "high." But it should also matter to him, once he awakens from the "alternative reality" induced by taking Ecstasy and recovers the real identity that the drug temporarily erased.

The young man's drug-induced "love" is not just incomplete-an emotion unconnected with knowledge of and care for the beloved. It is also unfounded, not based on anything-not even visible beauty-from which such emotions normally grow. The young woman, were she to learn about his use of Ecstasy, might readily agree: "He doesn't really love me. It's just the drugs talking." She might even say that the man is not really himself: "This isn't the real him; he isn't in his right mind." Insofar as his feelings are attributable to Ecstasy, the young man's feelings and words are, to speak plainly, fake, indeed, doubly fake: they are neither true nor truly his.xxx The drugs deceive him and induce him to behave in ways that could deceive another.

In human affairs, we care a great deal about the difference between "the real" and "the merely appearing." We care about "living truly." To be sure, people for centuries have produced spurious feelings of all types with alcohol and other agents. Yet although our society is generally tolerant of the practice-alcohol, if not "harder" drugs-we do recognize the risks, limits, and costs, not to mention the heightened possibilities of wrongdoing, connected with "not being in one's own right mind." In fact, much of the disquiet often voiced about mood-brightening drugs-even when appropriately used to treat serious mental illness-clusters around this concern. Some patients fear personality change, fear losing the "real me." Some also worry about using artificial means to change their psyches, a concern that springs ultimately from their desire that feelings and personalities not be artificial and false but genuine and true. Their worry, also widely shared, about having one's experiences of the world mediated by a drug is, at least in part, a worry about having one's real experience distorted. Even the expressed concern over "taking the easy way out" may involve not so much an opposition to ease, but a concern about distortion and self-deception.

With mood-brightening drugs like SSRIs, questions of truthfulness and identity are indeed complicated. Unlike Ecstasy (a drug regarded on multiple grounds as dangerous and declared illegal), SSRIs cannot implant a groundless emotion, and they cannot instantly transform a soul. Especially for the mentally ill, these drugs, far from distorting reality, may enable patients to "get into their right mind" and to experience the richness of life more fully and truthfully, sometimes for the first time. It would thus be wrong and unfair to say that people whose lives are improved by mood-brightening drugs live falsely or untruthfully, or that people taking Prozac do not really love the husbands or wives they fell in love with while taking their medication.

But while they do not live falsely, many of them do live different lives than they would otherwise have lived, lives first made possible because of the drug and often requiring its continued use to be sustained. Though SSRIs do not instantly change the psyche, they can, gradually and over time, induce a persisting background sense of well-being, even where well-being itself is lacking. As a result, they can significantly change a person's temperament and therewith his personality, often markedly. According to the striking testimony of some users, SSRIs allow them to "become themselves" again or-strangely-to gain their true identity for the "first time." This matter of changed or transformed identity is, on its face, perplexing, with individuals living lives and doing deeds they never did or could have done before taking the drugs. And it remains for many a source of persisting disquiet.

Many people-perhaps all people, at some point-desire a happier life than the one they have now. Dissatisfied with themselves, they want to do better or feel better. In some cases, they opt for sharp and sudden highs, for a brief "holiday from reality" made possible by drugs like alcohol, heroin, or Ecstasy. In other cases, discontent spurs changed habits, new pursuits, and better ways of living and behaving. In yet other cases, people are and will be tempted to turn to mood-brightening drugs-SSRIs today, perhaps more advanced drugs in the future-that might enable them more easily to do for themselves the things they wish to do but cannot, or to feel the things they wish to feel but do not, or to feel the things they once felt but can feel no longer. While such drugs often make things better-they often help individuals achieve some measure of the happiness they desire-taking such drugs may also leave many of the same individuals wondering whether their newfound happiness is fully their own-and in this sense, fully real. This concern persists even when one becomes happy about genuinely happy things-like a new spouse or new job. It is even more pertinent, and more disquieting, should one come to feel happy for no good reason at all, or happy even when there remains much in one's life to be truly unhappy about.

2. Fitting Sensibilities and Human Attachments.

A central concern with mood-brightening drugs is that they will estrange us emotionally from life as it really is, preventing us from responding to events and experiences, whether good or bad, in a fitting way. Of course, changing the way we respond to life's happenings is a prime motive for developing such drugs in the first place: to help individuals feel more joyful about joyful things or less overwhelmed by their troubles and sorrows. And many people, their neurobiological "equipment" defective, surely need psychopharmacological assistance if they are to become able to respond fittingly to life's many ups and downs. But there is a danger that our new pharmacological remedies will keep us "bright" or impassive in the face of things that ought to trouble, sadden, outrage, or inspire us-that our medicated souls will stay flat no matter what happens to us or around us.

Writing in his Confessions about the death of his mother, St. Augustine provides a moving account of what it means to respond to real life in a fitting way:

I closed her eyes; and there flowed a great sadness into my heart, and it was passing into tears, when mine eyes at the same time, by the violent control of my mind, sucked back the fountain dry, and woe was me in such a struggle! . . . [I]n Thine ears, where none of them heard, did I blame the softness of my feelings, and restrained the flow of my grief, which yielded a little unto me; but the paroxysm returned again, though not so as to burst forth into tears, nor to a change of countenance, though I knew what I repressed in my heart. And as I was exceedingly annoyed that these human things had such power over me, which in the due order and destiny of our natural condition must of necessity come to pass, with a new sorrow I sorrowed for my sorrow, and was wasted by a twofold sadness.34

At first blush, St. Augustine's comments may strike a modern reader as strange. He regarded his own grief, at least partially, as a failing, believing that it betrayed too much concern for earthly things. But such grief was, by his own admission, a "human thing," a fitting response to the death of the mother he loved dearly. What he felt was deep sadness at a deeply sad event. If his response to his mother's death had been hysterical unremitting sorrow, we might think it excessive. And if he had been coldly indifferent, we would wonder at his lack of humanity. The sadness he actually felt was the humanly fitting response, the emotion called for and appropriate to the circumstances. And yet, his sorrow, while fitting, also troubled him greatly.

Permit a somewhat outrageous thought experiment: might St. Augustine's physician, were such a drug available, have offered him a mood-brightener? With it, St. Augustine might still have mourned, but with less misery. He might have had to struggle less to "suck back the fountain dry," or to sorrow less for his own sorrowing. He might even have been less deflected from his primary aspiration to attend to matters divine-if, that is, the drug did not also flatten his longings. Would he, should he, have accepted such pharmacological assistance?

If St. Augustine's grief bothered him for theological reasons, because of its excessive worldliness, the prospect of such grief troubles many of our contemporaries for psychological reasons, either because we want no such psychic burdens interfering with our worldly doings or because we think we cannot endure them on our own. A desire for pharmacologic relief is understandable. Some things, we fear, will simply hurt too much, if faced in their unvarnished reality without somehow dulling the pain.xxxi Yet especially in matters of love and death, such psychic relief may also estrange us from the attachments that matter most. Seeking to "make the pain go away," or simply to ease it in the moment of its greatest sting, we risk giving our departed loved one less significance than he or she deserves. Suffering "less than we should," we risk diminishing our appreciation of the depth of our love and of the one whose absence now causes our pain.

This dilemma holds not only in matters of mourning. It applies also to the pain of failing to achieve our goals or uphold our highest principles, the pain of betraying or being betrayed by a friend, the pain of no longer being able to do the things we once did with great ability and great joy. Nothing hurts only if nothing matters. And while we rightly seek to reduce the causes of gratuitous suffering, both physical and psychic, we do not want to remove the capacity to suffer when suffering is called for.xxxii

It is true that in order to function in everyday life, one needs some measure of detachment from the things that touch us most deeply. We cannot and should not be filled to the emotional brim at every moment or wear all our feelings on our sleeves. To feel things deeply and fittingly does not require living without reticence or self-restraint. Yet by seeking psychic detachment by means that pharmacologically insulate or remove us from the highs and lows of real life, we may risk coming to love feebly or to care shallowly, losing the fine texture of emotional and psychic life and weakening our appreciation for the very human attachments that make life most meaningful.

3. What Sorrow Teaches, What Discontent Provokes.

The previous reflection casts a small doubt on the unqualified goodness of the goal of a "happy soul." "Feeling good" may not always be good or good for us. Never to suffer loss may mean never to love deeply; never to feel ashamed may mean that our standards for ourselves are too low; never to be dissatisfied with ourselves may mean that we aspire to too little. Even as we seek happiness, in other words, we must not overlook what sorrow teaches and what discontent provokes-the intuitions, longings, and hunger for improvement and understanding that make for a fuller and more flourishing life.

There is, despite what the Romantics thought, no nobility in having consumption (tuberculosis)-though there may be in how one copes with it. So, too, there is no nobility in suffering from major depression or crippling despair or even protracted grief following the death of a spouse or child. In some cases, the very possibility of doing and living nobly and finely may be crushed in ways that only mood-brightening drugs, properly used, can help restore or repair. And clearly, one should not actively seek misery for the lessons it might teach us, any more than one should seek to gain a fatal disease in order to face it with courage or to relate better to those who suffer from it.

But we cannot ignore the truth that life's hardships often make us better-more attuned to the hardships of others, more appreciative of life's everyday blessings, more aware of the things and the people that matter most in our lives. Sadness in the recollection of a loss or a national tragedy (for example, September 11) keeps alive and pays tribute to the blessings we once enjoyed or still enjoy, gratuitously and vulnerably. Anxiety in the face of a crucial meeting or big decision registers the importance of the undertaking and prods us to rise to the occasion. Shame at our own irresponsible or duplicitous conduct exhibits knowledge of proper conduct and provides a spur to achieving it. These emotional stings not only reflect the truth. If they do not crush us, they may make us better.

It seems paradoxical: sane people would never choose or pray for sorrow, yet it is common to hear people say, after the fact, that their darkest times were in some respects their finest hours and the source of a better future. True, sorrows can often cripple or destroy. But sometimes, as the philosopher Nicholas Wolterstorff writes in his Lament for a Son:

there emerges a radiance which elsewhere seldom appears: a glow of courage, of love, of insight, of selflessness, of faith. In that radiance we see best what humanity was meant to be. . . . In the valley of suffering, despair and bitterness are brewed. But there also character is made.35

Sorrow, courageously confronted, can make us stronger, wiser, and more compassionate.

To what extent might SSRIs, when used to reduce our troubles and sorrows, endanger this aspect of affective life? Although they do not prevent psychic pain, SSRIs may generally dull our capacity to feel it, rendering us less capable of experiencing and learning from misfortune or tragedy or empathizing with the miseries of others. If some virtues can only be taught through very trying circumstances, those virtues might be lost or at least less developed.

But it is not only the discontent thrust upon us by external events or great misfortunes that can help to make us better. We can benefit too from the discontent with our own deeds, actions, and character that comes from honest self-examination. To be sure, many forms of self-loathing are destructive or excessive, ranging from joyless perfectionism to suicidal despair. But without some proper measure of self-discontent, there would be no spur to self-improvement. If we never felt the emotional pangs of our own shortcomings and limitations, we would never aspire to become better or wiser. Just as physical pain prods us, say, to remove our hand from the hot stove, psychic pain prods us, when it functions well, to improve those aspects of our daily life (at work, at home, in the community) that are not "working well." Just as the pangs of hunger push us to nourish the body, so the pangs of psychic hunger spur us to nourish the soul.

The motive force of passion is not confined to the negative emotions. Positive emotions, too, when they are fitting and function well, reinforce our attachment to what is good in our lives, encouraging us to continue in the activities and human relationships that are fulfilling and to preserve and enlarge the good things we seek and cherish. In a word, healthy affect, negative as well as positive, is efficacious. It guides us to overall well-being. Undermine that function-by means, say, of a drug that induces a sense of well-being-no-matter-what in a person whose ordinary emotions are functioning properly-and the cost is a life in which fitting feeling can no longer guide or spur us toward living well.

In sum, a mood-brightening drug that always made us pleased with ourselves no matter what we did-a drug that guaranteed our self-esteem, even when such esteem is not warranted-might shrink our capacity for true human flourishing.xxxiii Possessed of full self-satisfaction, why would we be spurred to seek improvement? Possessed of full peace of mind, why would we risk loss by giving our heart to another or hazard disappointment by aspiring to something difficult and noble? The example of "soma," the drug in Aldous Huxley's fictional Brave New World, illustrates the debased value of a spurious, drug-induced contentment.36 Soma-like cocaine, only without side effects or addiction-completely severs feeling from living, inner sensation from all external relations, the feeling of happiness from leading a good life. Rendered impotent in their aspirations, the denizens of Huxley's dystopia do not loathe their condition and do not yearn for another, largely because they cannot loathe and cannot yearn. They imagine themselves to be happy as they are, and thus never pursue a life that would be more fully human, with the ups and downs that come from having aspirations self-consciously chosen and ardently pursued.

SSRIs do not completely sever how one feels from how one lives. On the contrary, in many therapeutic uses, they probably re-link feeling and living, permitting passionate experience its proper role in fostering further growth. But in certain uses and in certain people, these drugs may fracture the relationship between passion and action, inducing calm, apathy, and easy self-satisfaction where energy, engagement, and the desire for self-improvement might be called for.

4. Medicalization of Self-Understanding.

Welcome though they are for those who really need them, even the proper use of mood-brighteners to treat emotional disorders is not without hazard. Precisely because of the effectiveness of the medication to alter mood and self-esteem, there may well be a tendency to redefine, in medical and biological terms, what are currently considered normal emotions, moods, and temperaments. Because the psychic pains of mental illness are akin or sufficiently similar to the psychic pains of ordinary life, there will be a natural tendency to regard ordinary affective life through the lens first polished for viewing mental disorders.xxxiv Such medicalized understanding might well make suffering easier to cope with. For example, a person who attributes his discontent or sadness to sickness may spare himself difficult self-examination and self-recrimination, as well as arduous attempts to change the way he lives. He can take mood-brighteners without guilt or without any sense that he is missing something. But this benefit, if it is that, may well come at considerable cost. For one reconceives sadness as sickness only by emptying it of psychic or spiritual significance and turning it into a mere thing of the body. Not only is the soul seen as dissolved into the body, but the body itself is seen as dissolved into genes and neurochemicals. Ardent desire is reduced to an elevated peptide concentration in the hypothalamus, righteous indignation is reduced to an elevated serotonin level in the temporal lobe. In the limit, happiness itself, along with misery, can be reconceived as a matter of neurons and neurotransmitter levels. No longer a spiritual achievement or the fruit of a life well-lived, it can come to be seen as the gift of either natural good fortune or biotechnical manipulation. The medicalization of psychic pain, however necessary as a path to providing much needed relief for the sick, indicates (whether intended or not) a great advance for biological reductionism against the citadel of mind and soul, a march that knows no natural stopping place, and that at each point along the advance threatens to reduce further the dignity of our inner life-or at least our self-understanding of it.

Our concern regarding such a transformation is not merely of theoretic or conceptual importance. It is also practical, affecting how doctors treat patients and the problems they bring to the doctor's door. Thanks to the efficacy of mood brightening agents, and of psychotropic drugs more generally, there may well be a temptation to redefine and to treat what are currently considered normal emotions, moods, and temperaments on the model of mental illness, and mental illness as a matter purely of bodily-ultimately, of molecular-character and causation. Should this occur, there will be large difficulties in assigning moral responsibility for any improper (or, for that matter, admirable) behavior, not only in matters criminal but in all interpersonal relations.

Are normal emotions or normal problems of living today being "diagnosed" or regarded in the way we regard mental illness? Is medicalization actually taking place, in practice as well as in thought? It is hard to say, and careful social science research would be needed before an answer could be hazarded with confidence. And a positive answer, in some cases, need not be cause for concern. It is possible that temperaments we once saw as typically human-habitual mild melancholy, for example, or shyness, or alienation, or inhibition-will be shown indisputably to result from definite neurochemical abnormalities. Epilepsy was once thought to show demonic possession ("The Sacred Disease"), and manic depression was thought to reveal bad character. Both diseases were stigmatized and treated ineffectively. Now, thankfully, both epilepsy and bipolar disorder have been entirely medicalized, both in idea and in practice. Medicalizing the problems of living, and using drugs to brighten a healthy mood, may have serious human costs, but so does refusing to use beneficial medication when one is sick and treating problems of health as problems of character. Good medicine and sound ethics thus have the same interest: effectively treating the sick in light of a sound conception of human health, without treating as illness every troubled state of soul.

Many psychiatrists, keenly aware of the problem, already understand their mission in these terms. A leading book in the field introduces the subject of depression by explaining that, of the patients who turn to a doctor because they are feeling downhearted, "the majority . . . will be facing a serious life situation," while some "will be suffering not from some responsive mood but from a fixed depressive state," which then "must be recognized for what it is, major depression."37 The DSM-IV requires for a diagnosis of major depression or dysthymia that "[t]he symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning."38 If doctors maintain high diagnostic standards, treating with mood-brightening drugs only those patients who have an illness, are sliding into one, or whose emotional troubles are so urgent as to make claims on the duty to save, the worst excesses of using mood-brighteners can perhaps be avoided or reduced.

Yet we should not be complacent. Many forces and incentives are pushing us in the opposite direction. As already noted, the arrival of efficacious mood-brightening (and other psychotropic) drugs invites enlargement of the domain of illness and further reductionist thinking about its cause. Doctors are the gatekeepers to drugs, drugs are prescribed (and their costs reimbursed) only for diagnosed illnesses, and the growing demand for drugs-a demand in part deliberately created by their manufacturers in direct advertising to consumers-exerts great pressure for the expansion of diagnostic categories. Even were the medical profession interested in developing a sound and limited concept of health, a workable account is hard to come by, and, truth to tell, the search for it is rarely undertaken. Especially as health comes to be regarded less as the absence of disease but as some positive state of well-being, ever open-ended and unlimited in its boundaries, the incentive increases to medicalize not only health but all human activities, psychic and social.xxxv One need not philosophically embrace the World Health Organization's notorious definition of health-as "complete physical, mental, and social well-being"-to contribute in practice to making human happiness a growing part of the doctor's business, ever more open to pharmacological assistance.

5. The Roots of Human Flourishing.

As we noted at the start of this chapter, the nature of human happiness is a contested matter, not only between different cultures but within any one culture. Western thought boasts many distinguished accounts of how emotions and feelings are, and should be, involved with human flourishing or human happiness. An important issue in dispute is the connection between "feeling pleasure" and "being happy," a question advertised in the ambiguities of the word "happiness," perched as it is between "pleasure" and "flourishing," between "feeling good" and "living well." A most prominent ethical outlook, utilitarianism, seeks the greatest happiness for the greatest number, with happiness often measured solely by self-reported pleasure or contentment. On such a view, mood-brightening technology might be regarded as an unequivocal good, a direct contribution to greater human happiness, whose only cost would be any pleasure it might prevent or obstruct, say, through side effects or addiction.

A very different picture of what it means to flourish emotionally emerges from the ethical analysis presented above. Perpetual bliss would not be the emotional ideal (at least in the world we inhabit), because emotional flourishing of human beings in this world requires that feelings jibe with the truth of things, both as effect and as cause. As response, affect is at its best when it exhibits certain cognitive and aesthetic virtues like measure and proportion; the criterion is that it be fitting. As motive, affect should lead a person to seek out a good life or to preserve the one he has; the criterion is that it be efficacious in service to the good to which the emotion points, whether positively or negatively. When affect is a healthy part of a psychic whole, it serves not the limited purpose of pleasure alone, but serves and helps constitute overall human flourishing.

Taking an additional step, we suggest that, under conditions of psychic health, the moods of the mind and the experienced pleasures, both of soul and body, are neither primary nor independent aspects of our lives. They are rather derived from and tied to the things we do and encounter: the people we meet, love, and lose, and the children we rear; the activities we pursue and the successes and failures that we encounter; the thoughts we have and the judgments we make; the beauty we admire and the evils we abhor. Moreover, because human activities and experiences differ greatly among themselves, so, too, do the attendant pleasures and pains differ in kind and in quality. Whatever we may assert in speech about the supremacy and homogeneity of pleasure or satisfaction, we care in fact primarily about activity and experience, and we care also about the quality of the pleasure and satisfaction. We do not really want the pleasure without the activity: we do not want the pleasure of playing baseball without playing baseball, the pleasure of listening to music without the music, the satisfaction of having learned something without knowing anything. Pleasure follows in the wake of the activity and, as it were, lights it up into consciousness. But without the activity there is and can be no happiness. We embrace neither suffering nor self-denial by suggesting that disconnected pleasure (or contentment or self-esteem or brightness of mood) produced from out of a bottle is but a poor substitute for happiness.

Where does this leave us regarding the relation between mood-brighteners and happy souls? We human beings share with all higher animals a predilection for feelings of comfort and pleasure. But our uniquely human capacity is to recognize that all the pokings, proddings, and temptings of feeling are like arrows that point us to lives of meaning and purpose. And recognizing the direction of our aspiration, we also find in ourselves the eminently human capacity to desire and direct its aim. There have always been those who, seeing how intense and how woven into our various enterprises is the desire for pleasure, think its satisfaction the whole point of human life. If that were true, the potential appeal of mood-brightening drugs would appear limitless.

But if, as we have suggested, it is not true, then to put mood-brightening technology to its best human use is to use it sparingly, medically, to help those who cannot do so unassisted to attain the capacity for securing fitting relationships between their feelings, their causes, and their effects. It is to help them achieve an appropriate relationship between their circumstances, inner life, and possibilities for action, so that they are able to feel joy at joyous events and sadness at sad ones, to marvel at the world's wonders, resist cruelties, and all the while strive to develop their talents, honor their obligations, and cherish their friendships and loves. For none of us lives humanly by the feeling of untroubled ease alone.

6. The Happy Self and the Good Society.

So far, we have focused largely on the meaning of using mood-brightening drugs for the individual, and the danger of gaining peace of mind at the cost of living less truly or not being oneself. But individuals do not pursue happiness alone as solitary beings, nor is the search for individual well-being, narrowly understood, the sole or even central purpose of our lives. The individual depends on others to live a full and flourishing human life-on farmers to feed him, teachers to guide him, soldiers to protect him, family and friends to stand with him. His very identity is embedded in a web of overlapping communities-family, neighborhood, institutions of work and worship, nation. And these communities often need individuals to put the good of the whole before their own inner (or inward-looking) search for happiness. If human beings were merely self-absorbed, all good and lasting things would wither.

At the same time, we also cannot ignore the great achievement of liberal society in its concern for the dignity of the individual person-for seeing individuals not simply as useful and expendable means to society's ends, but as ends in themselves. Their individual well-being must be regarded and protected, not only against oppressive government or religious authority, but also against the tyranny of the majority and the ruling opinions and conventions of society.

The availability and use of mood-brightening drugs creates (and reflects) potential dangers in these two corresponding directions. The first danger is that individuals will become so preoccupied with their own state of mind that they remove themselves increasingly from active participation in civic life, discarding those attachments without which they cannot achieve the happiness they seek and without which the community cannot survive and flourish. The second danger is that social goals or expectations-the external pressure to be productive, to gain status and recognition, to get ahead-will produce a "mood-brightened society," where pharmacological interventions in our psyches become normal or expected for students, employees, and ultimately everyone. Put simply, the first danger involves the solipsistic self, worried only about the state of his feelings, who uses psychopharmacology to ensure a flat and shallow self-regarding psychic pleasure. The second danger involves the slavish self, whose worth is measured only in the eyes of others or according to his success in the rat race, and who takes mood-brightening (or other) drugs to assert himself or to increase his chances of meeting society's demands. Neither alternative bodes well for a free society.

Needless to say, one is hesitant to fault doctors and individuals who use mood-brightening drugs in search of relief from melancholy or malaise in cases where indications of serious depression are unclear. The decision to medicate in such cases, often difficult and full of ambivalence, is usually best made by patients and physicians in private. But we also cannot ignore the potential social consequences if self-medication of the soul, freely and individually chosen, were to become the social norm. Nor can we ignore the present culture in which these individual choices are made: a culture that prizes self-esteem, self-fulfillment, and self-advancement, and that increasingly looks to modern medicine to heal the troubled self. Indeed, new drugs for the psyche, new direct-to-consumer advertisements promising greater happiness through pharmacology, an expanding number of mental illnesses with ever broader criteria of diagnosis-this potent brew may already be creating new anxieties about mental health and new desires for mood-brightening drugs where neither existed before. These newly created desires, and the self-understanding that accompanies them, can transform the souls of a society even more profoundly than the drugs themselves.

Perhaps a remedy for our psychic troubles lies in the rediscovery of obligations and purposes outside the self-a turn outward rather than inward, a turn from the healthy mind to the good society. And perhaps the most promising route to real happiness is to live a fully engaged life, as teachers and parents, soldiers and statesmen, doctors and volunteers-in short, to follow the vocations of life that involve not the self alone, but the ties that bind and that ultimately give the individual's identity its true shape. To be sure, there are many people whose deep psychic distress precludes meeting obligations and forming close relationships, and for whom the proper use of mood-brighteners is the blessed gift that can restore to them the chance for a full and flourishing life. But there is also a danger that such drugs, suitably improved and refined, may one day offer us peace of mind not only without side effects but also without exertion or interest in human attachments-a peace of mind that might rival friends, family, and country for our deepest devotion.

IV. CONCLUSION

The promise and the peril of memory-blunting and mood-brightening drugs may prove to be quite profound. The awesome powers modern science has placed in our hands to control the external world increasingly enable us to control our inner experience, indeed to sever the link between subjective experience and our actions in the world. Not only can we produce an enormous range of things that make us happy-including stronger bodies, smarter minds, and stronger and smarter children-but increasingly we can produce through drugs the subjective experience of contentment and well-being in the absence of the goods that normally engender them. In some cases-as with traumatic memories or a pervasive and crippling sense of anxiety and despair-the new drugs can help return a person to the world and enable him to take responsibility for his life. But in many other cases, the growing power to manage our mental lives pharmacologically threatens our happiness by estranging us not only from the world but also from the sentiments, passions, and qualities of mind and character that enable us to live in it well.

Living well in the world has always meant striving for physical pleasure, wealth, honor, recognition, friendship, love, understanding, and spiritual fulfillment. And no small part of the challenge has been to reconcile the conflicting demands of these abiding human goods. In responding to the challenge, it has always been advantageous to be strong of body and sound of mind, and it has always been a pleasure to move freely under one's own power and to understand accurately the ways of the world. Nearly all the goods we seek involve living well with others, so some knowledge of the human heart is indispensable to our happiness. Since friendship and love, the goods for which we often long most, indissolubly link the happiness of others to our happiness, we also have a keen interest in that sympathetic understanding that allows us to figure out both our own wants, needs, and desires and those of our friends and family members. In other words, happiness today, as always, consists in the activity of the well-functioning and self-aware soul.

Memory- and mood-altering drugs pose a fundamental danger to our pursuit of happiness. In the process of satisfying our genuine desires for peace of mind, a cheerful outlook, unclouded self-esteem, and intense pleasure, they may impair our capacity to satisfy the desires that by nature make us happiest. The fashioning of a memory that does not reflect how we have shaped and been shaped by experience threatens to bestow upon us satisfactions that are not truly our own. And the creating of calmer moods and moments of heightened pleasure or self-satisfaction that bear no relation to our actual undertakings threatens to erode our sentiments, passions, and virtues. What is to be particularly feared about the increasingly common and casual use of mind-altering drugs, then, is not that they will induce us to dwell on happiness at the expense of other human goods, but that they will seduce us into resting content with a shallow and factitious happiness.

It is no great surprise that it is our freedom-loving, technology-fancying, and happiness-chasing society that is bringing these wares to market. Yet these drugs also pose a fundamental danger to a society based on the individual's right to the pursuit of happiness. A society whose citizens can obtain tranquility on demand and enjoy no-fault ecstasy is a society whose citizens are bound to be less prepared to perform the responsibilities incident to citizenship in a free country. Wise policy is not derived from a formula. Laws are not self-enacting. Emergencies, resulting both from acts of nature and from acts of human recklessness and cruelty, will happen. But who will judge wisely, who will act honorably, who will rise to the occasion should drugs increasingly estrange us from the satisfactions connected to acting wisely and well? Who will take seriously even the everyday duties to kith and kin in a world that esteems-and uses medicine to produce-self-satisfied egos, looking out only for Number One?

The remedy for the new individual and social dangers to which our freedom exposes us must be consistent with our right to "the pursuit of happiness." And so it is. For the remedy consists in organizing our lives around happiness rightly understood, and our freedom gives us the opportunity to acquire that understanding and act upon it. In the end, it is happiness understood as complete and comprehensive well-being, or happiness of the soul, that we seek. And the happiness of the soul is inseparable from the pleasure that comes from perfecting our natures and living fruitfully with our families, friends, and fellow citizens.

No doubt the amazing new world of biotechnology has an enormous role to play in our soul's aspiration for happiness. Whether it will further or frustrate that aspiration depends in no small measure on our ability to clarify happiness's character and content. It depends especially on our willingness, both as individuals and as a society, not to settle for a shallow and shrunken imitation.


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FOOTNOTES

i. "Pursuit" is here properly ambiguous, encompassing both the quest to find happiness and the enjoyment of happiness once found (as in "my favorite pursuits").

ii. We note at the outset of this discussion that some people do not regard happiness as the supreme goal, preferring instead to place righteousness, duty, virtuous and creative activity, or holiness and serving God at the peak of human aspiration. Whether or not this remains a disagreement depends finally on whether happiness, if understood as human fulfillment, embraces these other goals as well, or whether it is distinct from them.

iii. John Locke, one source of our present views of happiness, wrote that the quest for happiness is, in fact, nothing more than an effort to alleviate "the uneasiness a man is at present under." (Essay Concerning Human Understanding [1690], Chapter XXI, "Of Power," §31.)

iv. Once again, whether we in fact accept these invitations to change our self-understanding and whether, if we do, the baneful consequences (for the fitness and truthfulness of our emotional lives) will in fact follow are empirical questions, to be investigated in future research, but not therefore to be banished from current reflection.

v. At the same time, it is important to note that "stored memories" do not remain static. Every time we recall a memory, what gets stored after such acts of recollection is a different memory, altered on account of how we, in recollecting it, have "received" and reacted to it. Once encoded, memories can be altered by recall.

vi. We also know that individuals "naturally" edit their memory of traumatic or significant events-both giving new meaning to the past in light of new experiences and in some cases distorting the past to make it more bearable. The question before us is how or whether new biotechnical interventions alter this inborn capacity to refine, reshape, and edit the way we remember the past.

vii. A few recent findings were noted in Chapter Four, "Ageless Bodies."

viii. Of course, this is not to say that the use of "memory-enhancers" would be a simple matter, ethically or socially. Such drugs, if they became available, would likely have many "beyond therapy" uses; they would raise questions about the meaning of enhancing cognitive performance pharmacologically and the meaning of "normal" memory decline that accompanies aging, both matters we discuss or at least touch on in other parts of this report.

ix. Schacter finds that our memory commits the following "seven sins": transience, absent-mindedness, blocking, misattribution, suggestibility, bias, and persistence. While each of these failings can sometimes be a nuisance, they are also, he argues, necessary for our survival. See Schacter, D., Presentation at the October 2002 meeting of the President's Council on Bioethics, Washington, D.C. Transcript available on the Council's website at www.bioethics.gov; also Schacter, D., The Seven Sins of Memory: How the Mind Forgets and Remembers, New York: Houghton Mifflin, 2001, p. 4 ff.

x. An individual with "retrograde amnesia" suffers from a sudden loss, either partial or total, of his own memory of the past. His personal past is inaccessible to him; it remains known and remembered only (and necessarily only in part) by others. Though he can learn new things, he remains a stranger to his world, thrown into a life and human relationships that he has no memory of forming. In contrast, an individual with "anterograde amnesia" suffers from the inability to remember new things, new events, or new experiences. The past remains intact as memory, but he is unable to move beyond it. Although the sufferer remains himself, he remains psychically fixed in time, with mind and body, self-consciousness and reality, alienated from one another.

xi. "The utility of all the passions consists only in their fortifying and prolonging in the soul those thoughts which it is good for it to conserve and which otherwise may be easily effaced; as also all the harm they can cause consists in their fortifying and conserving these thoughts more than is needed, or in fortifying and conserving others which ought not to be fixed there." (Descartes, The Passions of the Soul [1649], § 74.)

xii. As crucial as animal research is to providing insight about the workings of human memory, we must also keep in mind the limits of the comparison. The character of human memory is so distinct, involving experiences so foreign to other animals, that shared systems of the brain may have very different functional and experiential meanings, and crucial subtleties may be lost in seeing only the broad neurological similarities. The hazard of extrapolating too much from other animals to human beings is always present in research-but perhaps especially in the case of memory and other psychological-moral experiences that are singularly human.

xiii. Beta-blockers-more precisely, beta-adrenergic receptor antagonists-such as propranolol were originally developed in the 1960s (and today are still chiefly used) for the prevention and treatment of heart disease and hypertension.

xiv. Long-time and sizable clinical experience with beta-blockers in treatment of heart disease and hypertension has not revealed memory defects or personality change to be major side effects. Yet one might not expect to see their memory-blunting power except in the face of the huge adrenaline outpourings associated with frightening and horrifying experiences.

xv. These symptoms are observed especially among combat veterans; indeed, PTSD is the modern name for what used to be called "shell shock" or "combat neurosis." Among veterans, PTSD is frequently associated with recurrent nightmares, substance abuse, and delusional outbursts of violence. There is controversy about the prevalence of PTSD, with some studies finding that up to 8 percent of adult Americans have suffered the disorder, as well as a third of all veterans of the Vietnam War. See Kessler, R. C., et al., "Post-Traumatic Stress Disorder in the National Comorbidity Survey," Archives of General Psychiatry 52(12): 1048-1060, 1995; Kulka, R. A., et al., Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study, New York: Brunner/Mazel, 1990.

xvi. There is already ongoing controversy about excessive diagnosis of PTSD. Many psychotherapists believe that a patient's psychic troubles are generally based on some earlier (now repressed) traumatic experience which must be unearthed and dealt with if relief is to be found. True PTSD is, however, generally transient, and the search for treatment is directed against the symptoms of its initial (worst) phase-the sleeplessness, the nightmares, the excessive jitteriness.

xvii. Of course, many Holocaust survivors managed, without pharmacological assistance, to live fulfilling lives while never forgetting what they lived through. At the same time, many survivors would almost certainly have benefited from pharmacological treatment.

xviii. The term harkens back to the time when these dispositions were thought to be the result of the temper, or balance, of the body's so-called "four humors": blood, phlegm, bile, and black bile. As a result of insufficiently tempered mixtures, so the theory had it, persons with an unbalanced excess of one or another of the humors would be of sanguine, phlegmatic, choleric, or melancholic temperaments. It has been noted that current scientific efforts to tie temperaments to various imbalances in neurotransmitter levels in the brain may be regarded as a modern scientific "revival" of the idea that "humoral tempering" is central to determining our emotional outlooks.

xvix. The difficulty in describing the effects of psychotropic agents is very likely inherent in the difficulty in describing the psychic phenomena themselves. Regarding our "inner experience," we are often stuck with metaphors-"higher," "brighter," "depressed"-including the spatial metaphor of "inwardness" itself. We return to this topic when we treat the effects of some of the drugs now most commonly in use.

xx. Effexor also inhibits norepinephrine and is sometimes referred to as an SNRI (serotonin-norepinephrine reuptake inhibitor). In this chapter, for convenience, it can be assumed under the heading of SSRI. Some other agents, such as the aminoketone Wellbutrin, are used in ways similar to SSRIs; the analysis that follows may also apply or apply partially to them.

xxi. There is some evidence that major depression may be associated with reduced volume in the hippocampus, perhaps reflecting a loss of neurons in that part of the brain; furthermore, very recent studies suggest that treatment with SSRIs (as well as other antidepressants) leads to significant neurogenesis (new growth of neuron cells) in the hippocampus. It is, however, far too early to say whether hippocampal atrophy is a major cause of depression, or whether the antidepressant efficacy of SSRIs and other drugs is in fact mediated by stimulation of neurogenesis. See Sheline, Y. I., et al., "Hippocampal atrophy in recurrent major depression," Proceedings of the National Academy of Sciences, 93: 3908-3913, 1996; Santarelli, L., et al., "Requirement of Hippocampal Neurogenesis for the Behavioral Effects of Antidepressants," Science, 301: 805-809, 2003.

xxii. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is the psychiatric community's authoritative guide to diagnosis. Its chief and stated purpose is to "provide a helpful guide to clinical practice" (p. xxiii).

xxiii. This line of variation has been differently described as the neuroticism-stability dimension, the unstable-stable dimension, or the strong-weak dimension, of human temperament. But as the names suggest, part of the model's clinical importance is in explaining emotional vulnerability: the more intense one's moods and emotions, the more likely one is to fall into a variety of behaviors and states of mind that are troubling.

xxiv. A calmer disposition might then permit more fitting emotional responses to particular experiences. Arguably, SSRIs might also shrink the range of emotional responses, raising the floor but lowering the ceiling.

xxv. MDMA functions differently from SSRIs: rather than inhibiting serotonin reuptake, it increases serotonin production, causing massive dumps of serotonin into the synapses. Yet to the receiving neuron, more serotonin is available either way. Whether the difference between SSRIs and MDMA is one of degree or of kind, and what the example of one means for the other, is not clear.

xxvi. For example, lobsters show increased serotonin production when nearing food sources. Primates' levels of serotonin correlate with their position in the social hierarchy. (Peter Kramer, presentation at the September 2002 meeting of the President's Council on Bioethics, Washington, D.C. Transcript available on the Council's web site at www.bioethics.gov.) The examples are both suggestive and perplexing. Lobsters seem unlikely to have emotions or moods of a fine-grained sort. Yet primates of high social status show a wide range of emotions and moods (presumably while enjoying high serotonin levels). Perhaps serotonin is involved with something more basic than emotion and mood, something less specific yet still registering the difference between positive and negative.

xxvii. We are not unaware of the strangeness of the claim that such a hypothetical identity, previously hidden but newly released, would be identical to one that would have been formed in a life differently lived.

xxviii. "This research is pushing psychiatry toward the treatment of ever more minor levels of mood disruption; there is, in other words, an empirical rationale for expanding the range of psychiatric diagnosis. It may be appropriate to medicate patients whose level of depression is "subsyndromal"-certainly a melancholic person may be a fit candidate for that other mental health technology, psychotherapy-but I would say that an honest labeling of this use of antidepressants would deem it an attempt, through pharmacology, to replace a normal if unrewarded personality style with another normal style that is more comfortable or better socially rewarded." (Kramer, P., Listening to Prozac, Second Edition, New York: Penguin, 1997, p.322.)

xxix. Consider the analogy of "treating" the anxiety and disproportionate urgency (and associated danger) of adolescent sexuality by extinguishing it at its biochemical source (note that in some patients Prozac will diminish libido). This fundamental biological drive, and its attendant discontent, is inextricably related to the larger longings of romantic love and in turn to some of life's highest aspirations and achievements.

xxx. The subject of true love and love potions is, of course, a familiar theme of great literature, from the myth of Tristan and Isolde to Shakespeare's A Midsummer Night's Dream. These writings are interested in the degree to which eros itself is like divine, demonic, or "magical" possession. Are people who fall in love in their own "right minds"?

xxxi. Many a person has drowned his sorrows in alcohol, though it should be added that-unlike with the use of mood-brighteners-sorrow returns the morning after, often made worse by a hangover. And chronic drunkenness brings its own miseries and sorrows.

xxxii. This point about psychic pain and psychic fitness exactly parallels the situation regarding bodily pain and fitness. We try to prevent or treat gratuitous pain, but we recognize the life-saving and fitness-preserving virtues of the capacity to feel pain. Full analgesia is deadly.

xxxiii. The cultivation and corruptions of a spurious self-esteem are, of course, possible without using drugs. Examples abound in our current cultural climate.

xxxiv. The same thing happened with psychoanalysis, where a theory devised to explain neurosis became the ruling explanation of all psychic life, abnormal and normal.

xxxv. Proposals are now circulating among psychiatrists to define a new "relational disorder" to cover people with serious marital difficulties, including spousal abuse.

______________

ENDNOTES

1. Aristotle, Nicomachean Ethics, 1095a17-20.

2. Borges, J. L., "Funes the Memorious," in Ficciones, John Sturrock, ed. (original publication 1942; English transl., Grove Press, 1962; rpt. by Alfred A. Knopf/Everyman, 1993), pp. 83-91; Luria, A. R., The Mind of a Mnemonist: A little book about a vast memory (Solotaroff, L., trans.), New York: Basic Books, 1968.

3. On this research see LeDoux, J. E., "Emotion, Memory, and the Brain," Scientific American, 270: 32-39, 1994; McGaugh, J., "Emotional Activation, Neuromodulatory Systems and Memory," in Memory Distortion: How Minds, Brains, and Societies Reconstruct the Past, edited by D. Schacter, et al., pp. 255-273, 1995; and McGaugh, J., "Memory consolidation and the amygdala: a system perspective," Trends in Neuroscience, 25(9): 456-461, 2002.

4. Cahill, L., et al., "Beta-Adrenergic activation and memory for emotional events,"Nature, 371: 702-704, 1994.

5. Pitman, R. K., et al., "Pilot Study of Secondary Prevention of Posttraumatic Stress Disorder with Propranolol,"Biological Psychiatry, 51: 189-192, 2002.

6. See, for example, Goodman, E., "Matter Over Mind?," Washington Post, November 16, 2002, and Baard, E., "The Guilt-Free Soldier," Village Voice, 28 January 2003. It is interesting to note the dual appeal of such drugs to both the traumatized victim seeking escape from the horror of his or her experience and the traumatizing assailant looking to escape the inconvenience of his guilty memory.

7. There is no definitive diagnostic criterion for PTSD, but the core symptoms are thought to include persistent re-experiencing of the traumatic event, avoidance of associated stimuli, and hyperarousal. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision, Washington, D.C.: American Psychiatric Association, 2000, pp. 463-486.

8. Schacter, D., The Seven Sins of Memory: How the Mind Forgets and Remembers, New York: Houghton Mifflin, 2001, p. 183.

9. For a discussion of memory-altering drugs and the meaning of "bearing witness," see the essay by Cohen, E., "Our Psychotropic Memory," SEED, no. 8, Fall 2003, p.42.

10. Austen, Jane, Mansfield Park (1814), Ch. 22.

12. Kramer, P., Listening to Prozac, New York: Penguin, 1997, p. 66. The point is thematic throughout the book; see also, for example, pp. 46, 89, 125-127, and 320-322. See also Braun, S., The Science of Happiness: Unlocking the Mysteries of Mood, New York: John Wiley & Sons, 2000, pp. 8-9 and 161-181, and Barondes, S., Better Than Prozac: The Future of Psychiatric Drugs, Oxford: Oxford University Press, 2003. Relatively little academic research, as opposed to clinical observation, has been done on this issue. What has been done supports the idea that SSRIs affect the mood of people without severe illness, ranging from mild depression to normalcy. See Dunlop, S. R., et al., "Pattern Analysis Shows Beneficial Effect of Fluoxetine Treatment in Mild Depression," Psychopharmacology Bulletin, 26: 173-180, 1990; Knutson, B., et al., "Selective Alteration of Personality and Social Behavior by Serotonergic Intervention," American Journal of Psychiatry 155: 373-379, 1998; Liotti, M., et al., "Differential Limbic-Cortical Correlates of Sadness and Anxiety in Healthy Subjects: Implications for Affective Disorders," Biological Psychiatry, 48: 30-42, 2000.

13. Dozens of books aimed at a general audience about mood-brighteners, in particular the SSRI Prozac, have been published in the last decade alone (some are listed in endnote 12). Popular articles abound in publications ranging from the New York Times to Newsweek to Glamour (Slater, L., "Prozac Mother and Child," New York Times Magazine, 17 October 1999, pp. 15-17; Gates, D., "The Case of Dr. Strangedrug," Newsweek, 19 June 1993; Fried, S., "Addicted to Antidepressants? The Controversy Over a Pill Millions of Us Are Taking," Glamour, April 2003, pp. 178-180, 262). Television programs have also covered the matter, including "Nightline," "Geraldo," the "Today" show, "60 Minutes," "Donahue," "Larry King," "Eye on America," and "Prime Time Live." The tremendous coverage, while highly varied in quality, indicates the degree to which drugs that touch on such deep and universal human aspirations provoke interest.

14. For one, among many, moving accounts of major depressive illness and its associated risks, including risk of suicide, see Rosenberg, L., "Brainsick: A Physician's Journey to the Brink," Cerebrum, 4: 43-60, 2002.

15. Kramer, P., Listening to Prozac, pp. 15-16, 44-46, 321-322. This point is one of Kramer's principal themes. See also Barondes, S., Better Than Prozac, op. cit.

16. The National Institute of Mental Health, The Numbers Count: Mental Disorders in America, Washington, D.C.: NIH Publication No. 01-4584, 2003, p. 1; Sapolsky, R., "Will We Still Be Sad Fifty Years from Now?" in Brockman, J., The Next Fifty Years: Science in the First Half of the Twenty-First Century, New York: Vintage, 2002, p. 106; Nestler, E.J., et al., "Neurobiology of Depression," Neuron, 34: 13-25, p. 13, 2002.

17. Klerman, G., et al., "Increasing rates of depression," Journal of the American Medical Association, 261(15): 2229-2235, 1989; see also Sapolsky, R., "Will We Still Be Sad Fifty Years from Now?" op. cit., pp. 106-107.

18. See the references cited in endnotes 12 and 16.

19. The National Institute of Mental Health, Medications, Washington, DC: NIH Publication No. 02-3929, 2002, p. 20; Nestler, "Neurobiology of Depression," op. cit., p. 15.

20. Glader, P., "From the Maker of Effexor: Campus Forums on Depression," Wall Street Journal, 10 October 2002, p. B1. Very little definitive information on the prevalence of mood-brighteners among college students is available. One survey suggests that only slightly over 4 percent of students are currently taking mood-brighteners (American College Health Association, National College Health Assessment: Reference Group Executive Summary Spring 2002, Baltimore: American College Health Association, 2002). But this assessment does not speak to how many have taken them, and it contradicts the impressions of many college officials.

21. Nestler, "Neurobiology of Depression," op. cit.

22. Diagnostic and Statistical Manual of Mental Disorders, op. cit., pp. 345-428.

23. Nestler, op. cit.; Healy, D., The Antidepressant Era, Cambridge: Harvard, p. 174, 1997.

24. Nestler, "Neurobiology of Depression," op. cit., p. 13. Braun, The Science of Happiness, op. cit., pp. 17-18.

25. See Listening to Prozac, op. cit.; The Science of Happiness, op. cit., p. 12 and pp. 161-181; Better Than Prozac, op. cit.

26. For a discussion of both this aspect of temperament and the capacity of SSRIs to affect it, see McHugh, P., et al., The Perspectives of Psychiatry, Baltimore: Johns Hopkins, 1998, pp. 132-135.

27. For a report of the experience of taking MDMA, see Klam, M., "Experiencing Ecstasy," The New York Times Magazine, 21 January 2001.

28. A related line of thought has been developed by Michael McGuire. See Kramer, Listening to Prozac, 169.

29. Listening to Prozac, pp. 144-148, 162, 177, and 195.

30. Listening to Prozac, pp. 145-146.

31. Listening to Prozac, p. 177.

32. Listening to Prozac, p. 195.

33. Healy, The Antidepressant Era, op. cit., p. 173.

34. The Confessions of St. Augustine, trans. J. G. Pilkington, Norwalk: Easton Press, 1979, ch. 9, pp. 160-162.

35. Wolterstorff, N., Lament for a Son, Grand Rapids: Eerdman's, 1987, pp. 96-97.

36. Huxley, A., Brave New World, Norwalk: Easton Press, 1978.

37. McHugh, P., et al., The Perspectives of Psychiatry, p. 71.

38. Diagnostic and Statistical Manual of Mental Disorders, op. cit.

 


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