THURSDAY, June 12, 2003
Session 2: Medicalization:
Its Nature, Causes, and Consequences
Discussion of a correspondence between Paul McHugh,
and Leon R. Kass, M.D.
CHAIRMAN KASS: All right. In this session we
move from the scientific and medical to the sociological and philosophic,
the question of so-called medicalization, making medical some aspects
of human behavior not previously regarded as medical, and the question
before us is what is medicalization and why might it be important
to our enterprise as the President's Council on Bioethics.
And I'm going to make some semi-coherent, I hope, at least
semi-coherent remarks to introduce this, just to indicate why we're
talking about it.
We have touched on this topic implicitly in many of our discussions
of beyond therapy, whether using biomedical technologies to satisfy
personal desires or to achieve some form of behavior control, and
we have sometimes tried to get at that question by distinguishing
the medical from the nonmedical, say, and the distinction between
therapy and enhancement of the use of medical means for nontherapeutic
or nonmedical purposes.
The topic also came up in the last meeting in the discussion with
Steven Pinker, where the issue was not so much the uses of biomedical
technologies as the question of the assignment of guilt and responsibility
in a world in which behavior is understood largely biologically.
Some observers of the work of the council have concluded, I think
falsely, from random remarks made in these discussions that the
council has doubts about the existence of genuine mental illness,
such as schizophrenia, depression, bipolar disorder, or that it
means by raising these kinds of questions to object to the treatment
of these disorders under a medical model using psychotropic drugs.
I think that is a misreading of what we have been doing.
But rather than shy away from this subject, it seems to me that
we would do well to try to clarify this matter of medicalization
by actually treating it thematically rather than as an adjunct to
other matters, to see what it is, what causes it, and whether and
why it might be important.
And one of the reasons for doing so is it provides us with at
least one look at the larger social, cultural context that shapes
almost all of the bioethical issues that we have examined or might
examine. For example, ethical issues raised by preimplantation
genetic diagnosis or even prenatal diagnosis are really unintelligible
save when seen in the context of the fact that pregnancy and childbirth
have already been pretty much completely medicalized, or the ethical
issues that would be raised by the uses of psychotropic drugs in
children would be unintelligible except if we recognize the degree
to which behavioral problems have been medicalized and taken out
of the moral realm and brought into the therapeutic, or even any
discussion of the regulation of the use of biomedical technologies
must begin with the fact that uses of approved remedies are, by
and large, left to the practice of medicine and the standards of
Now, medicalization is a sociological concept that's been
around for some 30, 35 years, and it has been a matter of interest
and concern to sociologists for some time, and its scope is much
broader than questions just of behavior control or mental diseases.
The background paper written by Peter Conrad that we circulated
is a review essay by a person who is one of the first to write on
this subject, and he discusses the concept of medicalization and
shows how widespread is its reach, beginning with discussions of
the medicalization of deviant behavior from alcoholism to compulsive
gambling, to child abuse, to the medicalization of natural life
processes of childbirth, child development, and the end of life,
and going on to women's issues, from eating disorders, birth
control, premenstrual syndrome, menopause; children's issues
of learning disabilities, behavior problems.
And as this little clip at your place from the Wall Street
Journal from yesterday indicates, now shortness of stature is
about to become a medical problem, to old people's issues of,
alas, forgetfulness and growing kinds of weaknesses.
And I think that Conrad's essay points out, I think, quite
nicely how these are matters partly of conceptualization, partly
matters of institutional rearrangements, and also when the doctors
are actually involved of direct medical implications for the human
relations whenever people bring these matters to the physicians.
And he also points out how the development of effective technologies
to intervene in a whole range of areas also increases the tendency
to make more and more aspects of human life matters of medical concept
and medical approach. And this is meant to be said simply descriptively.
You know, there's no prejudgment, although some people talk
about medicalization with a negative connotation. We simply mean
it at least at this point to be descriptive.
Three things I would like to in my own name sort of put before
us that seem to me to be of special significance before introducing
the materials that Paul McHugh has especially prepared for us.
First, the matter of surveillance and how many, many more things
are now coming under the medical gaze, where the medical view of
this, that or the other is now kind of commonplace. The medical
view of marriage and its benefits for health, a recent bit of discussion.
And this medical surveillance, I think, now is something that
should concern us especially with the coming of the powers of genetic
screening which will, I think, soon be a major issue in which not
only will child birth be under the medical gaze, but so, too, the
necessary conditions for thinking about what are the criteria sufficient
to warrant entry into life.
So the whole question of surveillance is one of the things that's
Second, there are economic questions that I think are worthy of
our attention, and he points out very nicely, Conrad does, that
if the only way to get reimbursement for gaining help with life's
problems is through medical insurance, there is a high premium on
having all kinds of things declared medical in order to get the
help that you need.
And the corollary of that is this, of course, drives up medical
costs and places enormous burdens on the health care system as more
and more things, whether medical in the narrow sense or in the broad
sense, now come to the doors of hospitals and clinics.
Finally, in a most abstract way, this question of medicalization
bears really even on the business of bioethics because it finally
bears on what constitutes a medical or biological phenomenon and
what is an ethical one, as our friend Michael Gazzaniga will be
quick to tell us, especially if and when we come to begin to think
about ethical sensibilities in terms of their underlying biological
basis and substratum.
So that even the very activity that we're engaged in is affected
by the rise of the medical and biological model for thinking about
behavior, including even ethicizing.
Now, with this as a background and presupposing the Conrad material
as read, I want us to turn to the material especially prepared for
this meeting. Although the areas of human life that have been medicalized
are many, the area of behavior is, in fact, of special interest,
especially as behavior at least as we've always understood it
has some kind of biological or natural substrate, but also a human
and moral meaning.
And staff has asked Paul to help us think about this larger topic
by reflecting on the phenomenon of medicalization in the domain
of psychiatry, a subject that has been one of his professional interests
really for decades.
And I think before we start that one should simply declare for
the record that there should be no mistake about this. Neither
Paul nor I nor the council means in any way to cast doubts on the
existence of these mental illnesses or the urgency of caring for
the thousands who suffer from them or the families who are also
devastated by these illnesses.
There is no hidden agenda here. We're simply trying to understand
this phenomenon and what it might mean for the work of this council.
Paul chose to develop his thoughts in epistolary form, and we
decided that it was less work to synthesize his two letters as if
they were a seamless document than to allow the things to appear
actually as the conversation went between us, and we put those materials
before you for discussion.
Paul, do you want to say anything by way of start?
DR. McHUGH: No, Leon. I'm very grateful
to you for having this epistolary discussion with me. I enjoyed
I would like to — I think the stuff rather speaks for itself.
There is a subtext, I'm sure you see, that is, that Leon asked me
to do a little something about medicalization and psychiatry. I
wrote the first letter, disappointing him. He wrote—
DR. McHUGH: — a letter reminding me that
I could do better, and I tried harder the second time, and I want
you all to know that I'm aware of that subtext and want you
to be as well.
CHAIRMAN KASS: If others would like to begin,
please do so. If not, I would in a way put a question to you, Paul,
as away of continuing the conversation.
I'm very excited, as you know, by your attempt to go beyond
the merely symptomatic classification of human troubles, to provide
what you call the reference classes of diseases, of aberrant behaviors,
of what you sometimes call dispositions and sometimes you call —
I've lost the other term for it — and then finally the
sort of life experiences problems.
And the first of the three is the only class that you see as being
somehow on the model of ordinary somatic disease, but all of them
legitimately come to the healer of the soul for help.
And I guess the question is: why isn't that part and parcel,
in fact, of the growing medicalization, in fact, of all of those
other things even if our approach to them is not exactly the same?
Maybe you could elaborate on the value of these kinds of categories
for leaving the things to Caesar that are Caesar's and the things
to God that are God's.
DR. McHUGH: Well, it's a long story at one
level, and I'll try to make it brief. What it amounts to is
that psychiatry is a discipline of medicine. It is a medical discipline,
but people come into your office just like they come into any doctor's
office with complaints and with plenty of psychiatric complaints.
The conditions from which they spring don't necessarily seem
directly medical, and a psychiatrist has to decide where they belong.
Prior to DSM-III, the dominant approach to dealing with people's
complaints was to try to fit them into an ideological scheme. In
America the dominant one was, of course, Freudian thought and a
subdominant one in plenty of institutions was the Skinnerian behavioral
The great advantage that the classifications developed by DSM-III
were that patients' complaints were subgrouped according to
which complaints the patient brought forth and which symptoms could
be recognized out of an examination.
The problem with that though is that by classifying things by
symptoms and complaints, psychiatry was condemned really to stay
at the level that 19th Century medicine was when we classified people
according to the fever charts and the characteristics of their pain.
And no director of a department, such as I was, that hoped to
achieve a coherent discourse with his group, direct research, and
at the same time care for patients could be satisfied with simply
And so what I have been writing about and I have been proposing
for a long time is to see different reference classes of patients
just as medicine does. After all, medicine talks about infectious
disorders, neoplastic disorders, congenital disorders, genetic disorders,
and the time has come in psychiatry to move towards that kind of
But when you think about psychiatry, it's quite clear that
there are plenty of conditions that go beyond because of human kind
and the particular features that the human brain brings into play
that give other reference classes for disorders.
And so I was interested in my department and in my work to separate
the things which are diseases, where everyone could see that these
are a breakdown of cerebral faculties, straightforward losses of
the capacity to think, to perceive, to remember, to emote appropriately,
to have executive control from a second group of classes that are
the abnormal behaviors in which what are the rhythms of our ordinary
behaviors fall awry sometimes because of injury to the brain, sometimes
because of conditioned experiences, the behavior disorders, in other
The dimensional disorders in which our psychological characteristics
are dimensions of human variations just as our physical characteristics
are, and so some people can be in distress not because they have
anything broken like a disease would imply, but simply because they
are at some extreme along a dimension of human variation, the most
obvious one being mental retardation, but others being excessive
neuroticism, excessive extroversion or introversion.
And then finally, the conditions or the complaints people bring
me or any psychiatrist that fundamentally come out of their life
experience, what they've encountered in life and what assumptions
they're making about that.
These four reference classes, what I refer to in my books as the
four perspectives of psychiatry, obviously interrelate. They all,
of course, depend upon a brain. You can't have any of this
without a brain, but the brain, the human brain does all kinds of
interesting things, and a psychiatrist in interacting with such
people does different things.
He tries to cure diseases. He tries to interrupt behaviors, to
guide the individuals that are often some extreme in human variation.
He tries to help, essentially rescript assumptions that lead people
into encounters with life that will distress anybody.
And when you ask me about how to think about psychiatry in these
terms, those were the things; that was my natural place to go.
I think the question that you could ask is: well, by doing this
kind of an approach and, by the way, then generating — let
me just spell out briefly that this would mean that any department
of psychiatry would have in it individuals, for example, who are
skilled at brain imaging and the recognition of certain breakdowns
of faculties out of the generation of molecular abnormalities, genetic
abnormalities and physiological abnormalities.
The disease model that is clear in medicine should be found in
psychiatry departments and representatives of that would be there,
but also psychiatry departments should have people who are very
interested in the life story of individuals, the narrative and how
the narrative reveals sometimes the natural wellsprings of disorder.
And such a broad psychiatry department would be open then not
only to the medical departments that surround it in any university,
but it would also be open to the public at large that wonders and
wants to find not only help for, but some kinds of understandings
that could make sense out of current problems, current sets of assumptions
and the like.
Your question that started me off on this little preamble was,
well, does this make medical everything. Well, no. In my opinion,
although a psychiatrist is often the person that people come to
now at first with a concern, like feeling sad or feeling disrupted
in their plans of life or disappointed in what they had hoped for,
he or she might come to a psychiatrist first to make sure that the
psychiatrist in evaluating the person didn't find something
else more fundamental wrong, but the psychiatrist at the end might
well say, "Look. This complaint that you have, this demoralized
state, this state of discouragement or depression is, in fact, something
that derives from who you are and what you're thinking and lots
of people besides me can help you with that, and I want you to be
able to turn to those other people to think about what you want
In that way, you see, I feel I would like to move psychiatry where
medicine or surgery is today, namely, to the point where the patient
can be really on all fours with me in discussing the implications
of not only the symptoms that they have, but the treatment that
they might accept.
Prior to this or often with simply a categorical diagnostic system,
the patient comes to a psychiatrist and then has to say, "Well,
you're a person with all of this experience. You must know
better than I do about what counts and the way I ought to live and
all of that because you know the secrets."
And this way you'd say, "No, I don't know the secrets.
I think you belong in this kind of problem. Let's find out
who might know better and who might open you and me, by the way,
to a better understanding of what you've encountered and how
that encounter has shaped your reaction."
I can assure you right now that the problem here is not that you've
got some twisted neuron or a twisted molecule. I'm good at
that. I want to open you to the idea that maybe you have a twisted
thought that somebody else as well as me might help you with.
And that's a long answer to your brief question. I have to
say that it has been the story of my life, trying to make this clear
to as many people who will be willing to listen.
CHAIRMAN KASS: Do you want to follow up on this,
Frank? Because I had Gil and then — Gil, then go ahead.
PROF. MEILAENDER: Yeah, I mean, I am following
up on this if that's okay with you.
CHAIRMAN KASS: Well, sure. Yeah.
PROF. MEILAENDER: I just want to try to figure
out, Paul, and I have to sort of direct it to you though someone
else may have insight. What difference this really makes, the kind
of distinction that you're trying to make. All right?
And I have in mind a sentence that comes on page 9 of your now
published correspondence where you say near the top, "But the
claim that alcoholism, narcissistic personality, and stage fright
are sicknesses of the same kind as schizophrenia cannot be sustained
just because these people walk into our office and we help them."
Okay? Now, it's evidently okay with you that they continue
to walk into your office, people who have stage fright or these
obnoxious narcissists. It's okay that they come in, and you
think that on a number of occasions you are able to do something
or other that helps them. It might be pharmacological in some cases.
It might just be conversation on other occasions.
So that in terms of the points that Leon raised before, these
can still come under medical surveillance, and they can still find
ways to be reimbursed through insurance and so forth for the costs
So what difference does it make that some of these things don't
fall into the category of brain disease, but they fall into one
of the other categories?
I mean, I understand that, and it certainly makes some difference
just in the sense of conceptual clarity, but in terms of the practice
of medicine, it doesn't seem to make much difference other than,
I guess, the person with the brain disease. You wouldn't say,
"Go talk to your friends about this," but with the narcissist
you might say there are some other people, too.
But, you know, it's appropriate that they come into your office.
There are things within your armamentarium that you can use to help
them. So what's the difference finally?
DR. McHUGH: Well, let me say, first of all, Gil,
that nobody comes into any doctor's office usually with a diagnosis
attached to him. He doesn't come in and say, "Guess what
I have. An aortic aneurism, and it's causing me pain."
DR. McHUGH: He doesn't do that. He comes
in and says, "Listen. I've got belly pain, and I don't
Of course, it could be nowadays when you read the magazines that
you could do that, and occasionally I can tell you in psychiatry
people come in and tell me they've got adult ADHD and I'm
to give them Ritalin and let's get on with it.
But for the most part people don't come in to a doctor's
office with that. They come in with complaints and wonder, appropriately,
whether the doctor can help them.
And the difference that we're making here amongst them is
to say that there are different sources of these complaints, and
psychiatrists have greater or lesser capacities to help them, and
by making these differentiations and differentiating things according
to their essential differences, I think, not only do we serve that
patient well, but we ultimately serve the public well who want to
ask us appropriately who and whether the patient should get help
from you or from other people, and ask us exactly how we give them
So first of all, the differentiation is very helpful to the public,
in my opinion, by enhancing the differential, enhancing the discourse
on the differences in natures about conditions that cause people
Yes, I think that I often tell people with stage fright who come
into me and say, "Dr. McHugh, I have stage fright, and guess
what. I saw at the Super Bowl that Paxil is very good for this
and you're to give it to me."
And I tell them, "No, I'm not going to give you that.
I don't think we have to go that route. Why don't you find
another way to practice and then come back and tell me whether by
helping you practice will help you do better? Okay?"
So I will ask them to go back to their teachers. I mean, I get
this question of stage fright from high school students, you know,
who are working, and I'm telling them, "No, I'm not
going to give you a medicine now."
It may well be that when I see a person who has more difficulty,
for example, a violinist who has problems with trembling in their
hands, I might and I often do recommend, as a lot of people do,
Propanolol to help them from those trembles, help them with the
physical condition, but I will debate with all of them what they're
And by showing them the nature of what they're asking, I think
I enhance their understanding, my understanding, and the public's
understanding of my role. Okay? Which is not to be the only arbiter
of how life should be led.
CHAIRMAN KASS: Gil, do you want to follow or
PROF. MEILAENDER: Well, no one else is champing
at the bit?
CHAIRMAN KASS: No. Well, I mean, if —
PROF. MEILAENDER: I'll wait. I'll wait.
CHAIRMAN KASS: Okay. I have Frank and Robby
George and Michael.
PROF. FUKUYAMA: Well, I enjoyed the exchange
of letters between you and Leon. I think we ought to do all of
our reports henceforth in epistolary form. I have a question about
the underlying biology, which maybe you could help me with it, Michael
Gazzaniga or other scientists.
Now, in somatic medicine, as I understand it, there's a fairly
clear, you know, model for what a disease should look like. There's
a clear etiology. There's a causative agent. So we have this
thing calls SARS. We believe that there is actually something that
you've going to find, a virus or whatever that will, you know,
Now, in the world of psychiatry, I assume that there are diseases
in that somatic disease sense, but actually the vast majority of
the phenomenon that you deal with is this very large category of
things called disorders, all of which have biological correlates.
I mean even the most fleeting thought or emotion is going to have
some biological correlate, but that there are degrees of biological
causation, and there are certain disorders where the biological
determinants, you know, are relatively more important.
I guess what I'm getting at is that it seems to me within
this category of disorders what makes it so squishy is that a very
large number of them are basically, you know, normally distributed
behaviors, and that what you're classifying as a disorder is
simply something that's out in the tail of the distribution.
And so the question is: if your project is to try to move your
discipline towards a more, you know, biologically grounded categorization
of these different things, you know, your four categories, what
are the prospects of doing this in terms of the underlying biology?
For example, is it clear in all cases which of these are simply
points on a distribution as opposed to, you know, things that will
have a different kind of biological, you know, correlate?
And what are the prospects of, you know, moving the field towards
a system of classification that is grounded, you know, more firmly
in the underlying biology?
DR. McHUGH: Well, first of all, my aim was not
simply to move the field into a more biologically based classification,
although I support biologically based opinions about certain disorders.
My effort was to say which ones in which I thought a broken part
played the major role, that is, the classical disease concept in
which an etiology, a pathology lied underneath an expressed clinical
I also wanted to say, as everyone would, that you can't have
anything in mental life without a brain. We're not angels.
We all do that.
On the other hand, I also want to acknowledge that there are things
about the human brain which are at least to all of us mysterious
as to how the brain itself as mechanism causes the problems that
the patients bring.
For example, the issue of jealousy. You can find jealousy as
a symptom of a disease, that is, a disease like schizophrenia or
manic depressive disorder or Huntington's disease or Alzheimer's
disease. All of those conditions have been described in some of
its classical forms as presenting with a jealousy.
On the other hand, much jealousy comes out of dispositional characteristics
of an individual in relationship to a life circumstance that they
find themselves in, and that their assumptions coming out of their
dispositions and the interactions with that environment produce
a jealous response.
I want to be sure that people who want to talk about psychiatry
would want to differentiate those and appreciate the place of other
forms of therapy than a strictly biological form of therapy for
And, please, press on.
PROF. FUKUYAMA: I mean, if I can just follow-up.
DR. McHUGH: Yeah.
PROF. FUKUYAMA: I mean, I'm not asking
to make these distinctions so that we can then discard everything
that doesn't have a very strict biological, you know, cause.
That's not my purpose.
DR. McHUGH: No, that's right. No, that's
PROF. FUKUYAMA: I accept fully that you also
want to treat that vast realm of things where the cause is squishier.
But it does seem to me that — and in a way, this gets to
Gil's point about why these differences are important, you know.
If something is simply caused by a virus, you don't expect anybody
to do anything about that other than, you know, get treatment for
DR. McHUGH: Right.
PROF. FUKUYAMA: On the other hand, there's
a whole range of behavioral and mental phenomena where, you know,
there may be a biological component to that behavior, but the other
component is what we traditionally think of as kind of moral behavior
that is the result of self-discipline, education, you know, thinking
things through and so forth.
And I think that the thing that troubles me and probably a lot
of other people about the progressive medicalization or this expansion
of the domain of the therapeutic is that it tries to move things
that are within this traditional moral realm into a realm of, you
know, biological causation where, you know, you're basically
telling the patient, well, you can't do anything about it.
So you know, you just have to take your medicine and the like.
And so even if you can get money for being treated for that, you
know, what used to be treated by the priests and counselors and
so forth, it's still a helpful distinction to be able to say,
"Well, look. This thing is, you know, 90 percent biological.
You can't do anything about it," whereas another category
of disorders actually does have this very large component where
individual responsibility and, you know, so forth plays a large
And so I guess the question is: does the state of the science
give you any help in trying to make that distinction?
DR. McHUGH: Well, I think it does, and I think
the advantage of having separate reference classes or separate perspectives
of disorder is to see that with each separate class there is a separate
understanding of what constitutes disorder within this class, and
I think the science does help us a tremendous amount in this.
Well, let me just talk about, for example, what the science, essentially
epidemiological science, did to help us understand psychotherapy,
and in this case we're talking about the psychotherapy of people
that come to us with things like ordinary grief, demoralization,
The epidemiology showed us that in contrast to what was expected
at the time of the Freudian dominance, that all of these patients
would have similar sources of their problems, namely in their libidinal
conflicts. It turned out that these people had very different sources
of their problems.
What was common to the psychotherapy patients is that they all
felt over mastered by something in life and were discouraged about
being over mastered by that rather than that they had a common sources
for their problems.
And so that immediately opened up psychotherapy and psychotherapists
tomore individual understanding of lives rather than trying to dig
deeper for some problem in infantile or early childhood life in
relation to their libidinal problems.
But as well it said, well, since the problem here is feeling over
mastered, a psychiatrist can help you maybe, but they're going
to help you in the same way as other counselors, friends, people
of that sort, priests, and the like have previously helped people
and open the door to that.
Now, when you bring in, as you did, as Gil did and you did, this
idea that we want to be paid for it, I just want to be paid not
necessarily for my treatment. I just want to be paid, I think,
for my time like other people, and I want to be sure that I am offering
some kind of help.
Sometimes the help is not therapeutic in the sense of actually
correcting a disorder, but it is reassuring to people and things
of that sort, the same things that other professional people like
And at some level the work is of that sort. But just to come
back to the main point, to express my reference classes could from
one point of view be seen as extending medicine out beyond its boundaries.
On another way of looking at it, it could be, and the way I look
at it, it would be by defining these reference classes. People
could look at what places — the medical doctor would be primary
in the care, and in such classes lots of other people would be able
to be on equal standing in that care, and that, I think, would advance
us in all kinds of ways, including, by the way, being able to give
parity to the mentally ill for the conditions which are most like
medical conditions and not clamor for parity for individuals for
whom some aspects of their condition, their over mastery, could
be helped by others.
CHAIRMAN KASS: To this? Mary Ann Glendon.
PROF. GLENDON: I just need a little help understanding
the distinction between your Class I and Class II, and maybe I'm
just wrong in what I've read in the popular literature, but
is there not some scientific support for the idea that, say, alcoholism
— that there are some people who are more prone to that through
brain characteristics than others?
So that your boundary between one and two doesn't seem to
me to be quite clear.
DR. McHUGH: Well, the boundary only relates to
what leads to the course, not that there — by the way, again,
there are going to be brain things behind everything, including,
by the way, behind jealousy.
Your question is a frequently asked question, namely, don't
you see that certain people, perhaps because of their make-up, have
more temptations to sustain a behavior like alcoholism than others.
For example, oriental people often are sickened by alcohol because
of an Antabuse-like reaction that they have. This is very protective
for them from taking up this conditions and carrying it further.
It's also probably true that some people get more aroused
by a glass of alcohol than other people do and, therefore, find
it more rewarding.
Both of those things are true, but in contrast to a disease like
Huntington's disease, you will advance in that condition steadily
forward regardless of whether you are able to move about or not.
You cannot advance in alcoholism unless you choose to drink, and
that choice is, after all, a matter of deciding one way or the other.
That there is a vulnerability behind that choice does not change
the fact that it's still a choice, and ultimately the Alcoholics
Anonymous that wants to clamor for the concept of disease here as
though it was a broken part ultimately does say that, you know,
you have to choose to live a different life and acknowledge.
You know, it doesn't matter whether you acknowledge that Huntington's
disease has a power over you or not. It will carry itself through,
but it does make a difference if you acknowledge that you are powerless
against alcohol and, therefore, avoid it.
And since there are those elements to it, the therapies change.
The responsibilities change, and ultimately the outcome.
Just as a final thing, I might have mentioned this to you before,
Mary Ann. About once a year I get someone coming to my office and
saying to me, "Dr. McHugh, I want you to come to court with
me because I've been arrested for driving while intoxicated,
and I want you to tell the judge that, of course, I'm an alcoholic
and, therefore, should get off."
And I always tell them, "No. I want you to go and be punished
for driving while intoxicated because my friends and my children
and everybody else are driving, and I don't want that to happen.
After you are punished, I might be able to help you with this conditions,
but I might not be able to help you either, depending upon what
you're after. It seems to me today that what you're after
is some license and not the appropriate contrition."
CHAIRMAN KASS: I have Robby George.
PROF. GEORGE: Paul, I have two questions. I
think they're only remotely related, and the first one you may
have gone far toward answering, but it would just help me to get
a little firmer grip on it.
I want to sort of follow up. What I took Gil's question to
be, which is really about when are you as a psychiatrist in and
when are you out.
Now, from what you've said in response to Gil and Frank and
now Mary Ann, I take it that the situation is a little like the
separation of powers, if I can use an analogy from my own field.
There's an old line that says we don't have so much a separation
of powers in our government as having separate institutions sharing
powers, and I take it from what you're saying what we have when
it comes to treatment of certain sorts of things that are problems,
but they're not like Huntington's disease, we have a kind
of sharing of authority, sharing of roles where the psychiatrist,
the priest, the dad, all might be dealing with the same problem,
and you wouldn't want to carve things up such that you would
have strict boundaries where you say, "Ah, this counts as the
psychiatric problem. This counts as the spiritual problem. This
counts as the moral problem."
Am I right so far?
Okay. But that leaves us where I think we were left after Gil's
question. There must be some criteria by which you as a psychiatrist
and others in the field decide, look, this just isn't appropriate
for me to deal with. If I did that I would be practicing priestcraft
without a license.
Let me just try and example or two. I mean, if a corporate CEO
comes to see you and says, "Look. I've got a great career.
I'm making a ton of money. My business is going well. Everything
is great, but you know, I find myself getting involved with the
secretaries romantically, and this could wreck everything. Doc,
I want you to help me."
Would that be the kind of case in which if you didn't detect
some pathology, what you detected is a guy who's prone to this
kind of —
DR. McHUGH: Fall in sin, yeah, right.
PROF. GEORGE: Would you say, "Look. You've
got the wrong place. I mean this is not something that I as a psychiatrist
am qualified to deal with"?
DR. McHUGH: We certainly recognize incontinent
behavior and call it just that and say, "You don't have
a disease, pal. You have become incontinent in your sexual behavior,
and I can tell you what I think about it, and I can tell you some
of the things that might help you stop it, but you need lots of
other forms of help in the process."
Because they often come with this and say, you know, "I just
can't help it, Doc."
And I say, "Can't means won't, and you won't
help it," and I begin to talk about drawing in these other
people to help them.
PROF. GEORGE: Well, now he said, "Well,
Doc, look. Don't get me wrong. I'm an enlightened guy.
I don't have any moral problems about what I'm doing. I
just don't want my career — I know that the world is such
that my career and my company and my business is at risk here.
I just want a fix so I won't do this. You know, I'm not
religious. There's no clergyman I can go to. If I told my
pals that this was a particular problem I had, they wouldn't
consider that to be a problem. I need you to fix this."
Now, do you now because you're the only game in town, you're
the only person he can go to, do you now say, "Well, look.
This isn't psychiatry. I'm now functioning as some sort
of counselor to you, but I'm going to stick with you and see
if we can save your professional life"?
DR. McHUGH: Always the beginning of building
up a hypothetical case, you gradually get to the point where you
might be imagining pigs with wings, you know, and what are you going
to do with this flying pig.
But look. In my opinion, the kind of case you're drawing,
Robby, is not at all unusual for many psychiatrists to say, and
they, at least as far as I know have not given up on the idea that
this kind of behavior is destructive to the milieu in which the
person is living, as well sa the character of the person who is
Some of them will use the word "sin" and "adultery."
Others will say this is corruption and the like, and begin from
that position, not from the position that your patient that you've
imagined said, that is, "Listen, Doc. You and I are guys together,
you know. Aren't we having fun? And I just am afraid that
his having so much fun is going to get me into trouble."
If someone said that — no one has ever said such a thing
to me — but if they said that, I would say, "No, we aren't
guys together. We are people in this society, and there are certain
things not only which are against the law, but which are against
our ethical posture towards this."
Now, this is to take in some situations a judgmental stance.
Okay? And, by the way, in my opinion, because psychiatry is the
kind of discipline it is and it moves up through these reference
classes or up a hierarchy, ultimately we do make judgments and acknowledge
that those judgments are derived from the world in which we live.
DR. KRAUTHAMMER: If I could just say, Robby,
we had a recent case of that, and the attempted intervention was
not psychiatry, but impeachment.
CHAIRMAN KASS: I have Michael Sandel and then
PROF. SANDEL: The question that occurs to me
in this discussion, and, Paul, I'm constrained to more general
territory and the general question of medicalization, is why we
worry about it or if we should worry about it.
Why should we have an impulse to try to limit the scope of the
medical? But what is the source of that impulse and is it justified?
And in listening to the discussion, it seems to me there are two
different kinds of reasons to worry about the expansion of the medical.
One of them, the one we tend to focus on for the most part is a
worry that the biological will colonize the ethical and crowd it
out; that the therapeutic will displace the moral. That's the
worry that comes to the fore when we worry about diminishing the
responsibility people have for their own conditions if they come
to see those conditions as subject to remedy by a pill or by surgery
or some kind of medical intervention.
And so we wrestle with cases like narcissism or child abuse or
the drunkenness of the driver or the squirminess of the child in
the class, and realizing those kinds of things will crowd out or
diminish moral responsibility for one's conduct. So that seems
to be one set of reasons to worry about medicalization.
But it seems to me there's a different set of considerations
that have nothing to do with whit worry about the biological displacing
the ethical, but instead have to do with the range of cases, Leon,
that you mentioned at the beginning having to do with medicalizing
shortness or the kind of medicalization that accompanies more and
more cosmetic surgery.
And this worry has nothing to do with disputing the biological
character of these conditions. No one disputes that shortness is
a biological condition. No one says, "Well, if we medicalize
shortness, then people will no longer take moral responsibility
for being so short," as in the other cases.
Or if we medicalize the question of someone who has a prominent
nose and wants to have cosmetic surgery, we don't say, "No,
that's troubling because we want people to pull themselves up
by their bootstraps and deal with this themselves, not to pretend
that it's just a medical problem that needs to be taken care
So it's not that issue at all. Here it's not the worry
about the displacement of moral responsibility, and yet there is
still a worry about medicalization in this other domain, and it
comes closer to the enhancement cases we were discussing.
And then I think it has to do with another feature of the medical,
the reason we want to cabin or confine the medical, and that has
to do not with its concern with the biological, but instead with
its orientation to fixing rather than accepting.
And so because it's a feature of the medical that it attends
to disease. The telos of medicine, traditionally understood at
least, is to attend to disease, which is to say to attend to things
in need of fixing.
And so we worry here in this second domain that we will redescribe
conditions like shortness or like having a prominent nose as diseases
when they're not properly regarded as diseases, and one way
of expressing this worry is to say that medicalizing these kinds
of things will stigmatize people who are short, let's say such
that beforehand we might not have noticed it as much, but now that
it becomes something that's routinely subject to a medical cure
we notice and worry more when people are short or when they have
prominent noses or when they have teeth that aren't perfectly
white and aligned or whatever the case may be.
So it's the fixing part of medicine here that wants us to
rein in the scope of application of the medical lest we consider
more and more conditions as things to be fixed rather than as things
to be accepted or, for that matter even appreciated.
I don't know if that's a helpful distinction. The one
final thought about the second category is we could deal with that
problem, the problem of medicalizing conditions like shortness and
so on in one of two ways. We could say, "Well, all right.
We will expand, as implicitly we must, what counts as a disease
to include that, but that seems bothersome."
Anther way of dealing with it would be to say, "Well, maybe
medicine should be detached from that. Maybe we need to enlarge
the telos of the medical so that we no longer regard it as concerned
with curing disease."
What do we call the people who do cosmetic surgery for a living?
Well, they're engaged, we would say, or are they, in a medical
practice. Well, here let's talk about just purely elective,
or would we say we should detach the medical from the notion of
curing disease so that at least we don't taint all sorts of
conditions with disease and just say, "Well, maybe medicine
isn't solely about curing diseases. Maybe it can be for fixing
things that people simply want to fix, even if there is no disease."
But that seems also to carry a certain kind of cost or at least
there seemed to be reasons. I think a lot of people would resist.
So enlarging the medical by detaching it from curing or attending
to disease, but it seems to me in any case that these are two very
different reasons to worry about medicalization.
CHAIRMAN KASS: Does someone want to join in
on this before we move on?
DR. KRAUTHAMMER: Yes, I would. I would like
to add a third reason, I think, and it might actually be the reason
why society decides that it's going to have to act on it, and
that is the economic cost, that apart from the moral cost of expanding
the medical, the economic cost would be huge.
There is a sense that we have, and I think it's correct, that
if you suffer from a medical condition, society has a kind of obligation
to help you in coping, and that if you're poor, you shouldn't
have to suffer in a way that a rich person would not, and that's
why we have this idea of Medicare-Medicaid and expanding social
It's inexorable. In Europe, of course, it's universal.
Here it's expanding.
Now, as you expand what is legitimately considered medical you
will expand the realm in which society is seen as required to contribute
to your assistance, and as that area expands, it's going to
create a huge social cost, and I think that in the end may be the
reason why there are attempts to contract it.
We see the argument acutely in whether or not a psychiatric illness,
mental conditions should get the same kind of coverage as so-called
physical illnesses. That's the most obvious and acute example
of this, but I think it's going to expand as the range of the
medical expands as well.
PROF. SANDEL: Could I give a quick reply to
that? I don't think that the economic reason is a third reason
independent of these two. To the contrary, I think it's parasitic
on one or the other of these two for the following reason.
If it were just a matter — if worries about medicalization
were just a matter of society having to bear too great a financial
cost, it can't just be that because the reason — suppose
the reason that things became very expensive is simply because we
got very good at transplants, and so people in need of hearts and
kidneys on a much larger scale were able maybe because the immune
problem were overcome to have them.
We wouldn't regard that — it would be an economic challenge,
but it wouldn't be a challenge of the kind that we worry about
when we object to medicalization because it's not controversial
that a heart or a kidney transplant is a medical procedure.
DR. KRAUTHAMMER: What about orthodontics?
PROF. SANDEL: What's that?
DR. KRAUTHAMMER: What about orthodontics?
PROF. SANDEL: Well, the reason that becomes
controversial is it falls into one of the two reasons we have for
questioning the scope of the application of the medical.
So the economic issue only arises against the background assumption
that we as a society agree that genuinely properly medical needs
are covered, and so we worry about medicalization under these two
other headings — maybe there are others — because in
both of those cases we have reason for questioning whether the scope
of the medical isn't being expanded in ways that are objectionable,
whether because it crowds out the moral or whether because it tries
to fix what should be accepted.
CHAIRMAN KASS: Gil, did you want a small thing
on this, too?
PROF. MEILAENDER: Yeah. I think that finally
there's not such a large distinction between your two categories,
Michael. I mean there is an obvious on the face of it distinction
between your accepting moral responsibility and what medicine ought
But as you yourself recognize, if it turns out that there are
some things that people want and that we can do, but that don't
seem to constitute fixing in the sense that medicine traditionally
fixed things, then we have a couple alternatives.
We could expand the realm of medicine and say doctors didn't
used to do this, but now doctors do it, or we could say, "Well,
but people still want it done. So proctors should do it. Yo u
know, they've got a lot of the same skills that doctors do and
they should do it."
And if you want to resist that, whether you want to resist the
expansion of medicine or you want to resist the notion that kind
of somebody else should do this, what you're going to have to
say is this is something that should be accepted, that should not
just be fixed.
And we're beginning now to do talk that though granted it
grew out of a different issue is rather like the moral responsibility
talk. So I don't think that there is finally quite as wide
a gap between them, though I agree that the second kind of case
you raise grows out of the question of what really constitutes health
and what really constitutes disease or medicine, but it finally
drives us back to assert what we do or do not take responsibility
CHAIRMAN KASS: Briefly Michael and then .-
PROF. SANDEL: They're both normative question
I agree, but they're different normative questions. One has
to do with what should people be held morally responsible for,
and the other has to do with what do we consider should be accepted
rather than fixed.
I agree they're both normative.
PROF. MEILAENDER: Well, people perhaps should
be held morally responsible for learning to accept certain things
CHAIRMAN KASS: Jim Wilson will now make trouble.
PROF. WILSON: I think the problem that Paul
has addressed under the concept of medicalization is much broader
than the problem as he sees it in psychiatry, and my views on this
are, in part, an effort to answer Gil's question what difference
Medicalization to me as a non-real scientist, but a fake political
scientist is a synonym for causation. Now, all behavior is causes,
and there is an effort in not only our society, but most societies
around the world to extend the concept of cause so that everything
is caused in a way that crowds out the moral, as Michael said.
Let me give you the case from criminal justice, if Mary Ann Glendon
will overlook the many mistakes I will make in this brief summary.
Somebody shoots another person by firing a gun. The person is
brought to trial, and there are a variety of arguments a person
can use. One is that he is a victim of epilepsy. Admiring a gun
that is part of his collection, he had a seizure and his finger
squeezed the trigger and fired a bullet at somebody else.
The next level is he's insane or, to put it bluntly, he is
crazy. He doesn't know the difference between right and wrong
and thinks the voices of Satan are directing him to do it.
The next level is duress. Someone pressed a gun to his temple
and said, "If you don't shoot this bullet through this
window and hit this person, I will blow your brains out."
The next level up is diminished capacity, which is kind of an
adolescent version of insanity. They're kids. They're
not quite sure what they're doing. They're 14 years old.
On the next level up is prior abuse or neglect of the sort pled
by those two wealthy, young Beverly Hills men who pumped 12 rounds
of 00 buckshot into their parents and watched them die because,
as their lawyer later claimed, they had been the victim of abuse
when they were ten years younger.
And then the next level up are life experiences generally, in
which you could put alcoholism.
And then finally at the highest level — I'm skipping
several — is pure choice.
Now, defense lawyers will go into court and try to push the argument
back toward causation, and prosecutors will go into the court and
try to push the argument back towards pure choice.
Now, in this case, there is a solution to the problem. That is
to say a judge and a jury must make a decision that is either a
yes or no decision. The person is guilty or innocent or possibly
not guilty by reason of insanity.
And in making their judgments, they asked the question: to what
extent was the person able to control his behavior? And the control
judged by a contemporary social scientist may not be very large,
but though they would probably excuse epilepsy and insanity and
perhaps duress from diminished capacity all the way up to pure choice,
they tend to collapse it into the category of pure choice.
Now, what evidence do they have to back it up? I think the evidence
they have, which the judges sometime state and sometimes not, is
that we can think of people who had the same prior abuse, prior
neglect, diminished capacity, alcoholism, et cetera, who didn't
shoot anybody, and since people with these conditions can avoid
shooting other people, the fact that you chose to shoot somebody
else means that whatever your circumstances may be, you made a choice
that you didn't have to make.
Now, this is not the problem that society faces because society
does not have a judge or a jury, and society increasingly, in my
view, over the last half century has begun to say that social controls,
society's effort to judge somebody as innocent or guilty, have
been profoundly weakened because to judge somebody as guilty, society
must use such things as shame or stigma, and increasingly we are
told that shame and stigma are a bad idea.
And, indeed, the people who go to Paul and say, "I've
got stage fright," or, "I am sexually incontinent,"
or the other will hear from him a response that says, "This
isn't a medical condition. You should be ashamed of this."
And what they're going to do is drop Paul as their psychiatrist
and go to somebody else, and they will find other people who will
say, "Yes, we certainly mustn't use the word 'shame'
Society does not want to be judgmental. Being nonjudgmental is
a good thing. So I think the problem that the exchange between
Leon and Paul raises should not be limited to the definition of
what is medical in the eyes of a medical professional, but rather
should be viewed as the general social problem of how we define
personal responsibility and the fact that in my opinion, which could
be wrong, we have changed profoundly the extent to which we judge
people as acting improperly, and we are reluctant to impose social
rewards and punishments to induce them to act properly.
PROF. GEORGE: Leon, could I ask a question of
CHAIRMAN KASS: Please.
PROF. GEORGE: Jim, I followed that, I think,
completely, and it certainly sounded right to me, but I just wondered
about a statement you made very early on in the presentation and
its compatibility with what followed, and that was the statement
that all human behavior is caused, unless you mean by that simply
that there are empirical conditions of all human behavior, including
choices that constrain the options for effective choice.
PROF. WILSON: Yes.
PROF. GEORGE: Is that all that that meant?
PROF. WILSON: Yes, I probably shouldn't
have used the phrase, but behavior is caused in the sense that some
combination of biological imperatives, cultural traditions, personal
choice, and the nature of immediate circumstances leads persons
to exercise Option A rather than Option B.
I mean nothing more profound than that, and you can strike the
word "cause" if that seems to become a motive.
PROF. GEORGE: No, in philosophy there's
a big literature about the distinction between reasons and causes.
PROF. WILSON: I understand.
PROF. GEORGE: And I was just wondering whether
you were rejecting the idea that there could be reasons that are
something independent of the causes.
PROF. WILSON: No, no.
PROF. GEORGE: And I take it you —
PROF. WILSON: I am not rejecting the notion
that all behavior is caused and part of the causes are the reasons
people developed to make a point.
PROF. GEORGE: Yeah.
DR. McHUGH: And if I could just enter, too, into
this very interesting comment you've made, Jim, and it's
this issue of stigma. And it is often said that psychiatrists and
doctors and all of us should give up on stigma, and that is certainly
true for the diseases in psychiatry. We want to give up on stigma.
In epilepsy we want to give up the stigma on bipolar disorder.
But everyone knows that no one is giving up the stigma on certain
behaviors. Smoking behavior is the most stigmatized behavior right
now in our country. It's stigmatized and not tolerated.
In point of fact, your other statement that if I did stigmatize
this to a person — again, we have to remember that we made
a pig with wings here with Robby — that he would run away.
In point of fact, that's not my experience. People who come
in with the concern that, gee, my behavior is liable to get me into
trouble and hear from me that, yes, it will get you into trouble
and it should if you continue it would then ask me and do ask me
not only how they can avoid it, but how they might look at it in
a different way, stigmatizing it appropriately and thinking about
it in its relationship to its effect on others.
And, by the way, most of them stay with me and say, "You
know, I never thought of that before," when they give as their
cause that they're doing this because their feelings matter
and their feelings are driving them, and their feelings are the
cause, and they hear from me and from other psychiatrists that,
you know, when you grow up your feelings don't matter to most
people. It's just your behavior that does.
And they always say, "That's a very remarkable statement
to hear," and stay with me as their behavior gets better.
PROF. WILSON: People keep coming back to you,
Paul, because you have such an engaging personality.
PROF. WILSON: You can stigmatize them without
using the word "stigma."
DR. McHUGH: Well, that's —
PROF. WILSON: But I would be willing to bet
you that the search for non-stigmatic relief is more widespread
than your own office experience would be.
CHAIRMAN KASS: Alfonso and then Bill May and
then Janet and then Bill.
DR. GÓMEZ-LOBO: This is going to be a
very brief and perhaps minor remark. I'm just trying to think
for my own benefit about the more general context, and I tend to
think that this is a really particular case of something much deeper
and much more pervasive in Western culture and Western history.
What I have in mind is something like this. I would bet that
30 years ago most people made financial decisions on their own,
you know, whether they were going to buy stocks or bonds, et cetera.
Nowadays, I think most people would deeply hesitate to do this
before consulting an advisor, financial advisor, or I found this
out some time ago. People who are going to send their kids to college
now can go to a college choice counselor.
Now, what does this mean? It means that socially we have tended
to parcel reality and to assume that there are people that within
a domain have something close to an algorithm to make the decision.
The reason why we go to a physician is because we trust that the
physician is going to have symptoms, et cetera, in front of her
and then come to the conclusion, oh, you have pneumonia, and then
the solution is going to come.
So I'm not surprised at all about the medicalization, this
tendency to reduce things to treatment that can be controlled because
this tendency in our culture is a tendency to find areas of control,
and naturally enough to displace the prudential approach to those
fields, which I think is what Paul is alluding to, and also the
moral deliberation, the moral reasoning about those fields.
If a field is dominated by a specialist, of course, we can withdraw
and say, "Well, that's where the responsibility lies."
So what I'm just suggesting is that we really immerse in a
much broader thrust of our culture to control certain areas of behavior
by handing them over to people who would know how to decide.
CHAIRMAN KASS: Bill May.
DR. MAY: Well, it's very interesting hearing
you, Alfonso, talk like Ivan Ilyich, the broader professionalization
of life in all aspects.
DR. GÓMEZ-LOBO: My source is actually
DR. MAY: Yeah. Well, the pathology, however,
is a very large and growing, modern one. You know, professionals
hang out a shingle, and in doing that it specifies a little further
and you invite certain strangers in to deal with, but at the same
time, of course, off the streets comes an awful lot of things that
are unbidden and not asked for.
And now you end up. You've got a moral alternative there
as a professional. You can preserve the purity of your specialization
and say, "But I don't deal with that," and therefore
refrain from medicalizing everything or lawyers legalizing everything
and so forth across the board in the professionals.
But on the other hand, at the same time, you happen to be neighbor
to the problem because they've come in and you're nearest
to that problem, a little bit like 19th Century doctors who became
aware of the problem of sanitation even though they were not sanitary
Of course, in that case you saw the social remedy, and that led
to important improvements in health care that were not available
directly through the efforts of the professional, but you are neighbor
to the problem, and it may be a rather privileged moment for that
She can't talk to her husband. The relation is frozen in
all sorts of ways. They've moved at least once every five years.
Other forms of help and larger family and so forth are quite distant,
and so forth. And he or she has come to you with a problem.
Now, have you medicalized everything by not simply turning attentive
ear? It's a moment that may pass, and you have further responsibilities.
It seems to me that you may not be fully paid for if you stick simply
to treating disorders, but in your ascending scale interrupting
behaviors, guiding dispositions, and reframing life stories, you're
moving farther away from the medical, but humanly you have certain
And how can we sort this out in such a way that one does not escape
ones responsibilities as human being in order to preserve the purity
of professional identity?
High school teachers or junior high teachers maybe even more than
senior high are in a position of privileged neighbor when things
aren't working out well with mother and father and so forth,
and that's not what they teach, but they have a privileged position
close to that problem.
Now, we have — and this is where Leon's economic issue,
concern here. It's easier to get compensation for this kind
of time expended in life if one can define it as medical, and so
we end up medicalizing an awful lot through the economic pressure
here, but we don't want excessively to shrink responsibility
simply in order to avoid medicalizing problems.
DR. McHUGH: And I think, Bill, if you look at
the history of some of the great advances in psychiatry over the
last several decades, it has been just exactly this being neighbor
to a certain problem and then helping the society, the culture,
the school and the like to enhance what it's doing for the betterment
not just of this particular patient, but for people in general.
I mean, much of the advances, for example, in child psychiatry
have been in relationship to speaking to the schools, offering a
wide spectrum of opportunities for children to succeed in. Once
it was recognized that it helped children to become adults if they
had had some kind of success earlier in life that came out of first
looking at the individual patients, but ultimately it spoke to the
public at large as to how a school should have a variety of things,
from athletics out to scholarly work, to give more people a chance
And I think that the place, it is a very privileged place to be
close or neighbor to it. I think that's a wonderful metaphor
you draw there because it does speak to many of our situations to
which we become responsive by calling attention to the patient and
to the society that this is the place where they could work together.
DR. KRAUTHAMMER: Could I make just one interjection
CHAIRMAN KASS: Yes.
DR. KRAUTHAMMER: Bill, you brought up an interesting
example of the person who comes into you and you feel a responsibility
to respond humanly, even though it may not be a medical problem.
The complication here is that she came into you because you hung
a shingle and you are a doctor. She didn't go to the bartender
or the man on the street.
And I felt this acutely. I quit psychiatry exactly 25 years ago
this month, an anniversary that I celebrate every year. One of
the reasons is that I always felt that uneasiness, a sense to respond
humanly, but I was doing it because of her illusion that as a psychiatrist
or as a doctor I had a special insight or wisdom or secret, as paul
And I found that by actually using that misconception on her part,
I could actually do good, essentially produce a placebo effect,
but it was under a false premise. I knew that there wasn't
a secret, and it was in a sense a Wizard of Oz operation.
So you've got an obligation as a human to respond, but given
the context, you're doing it under the rubric of having special
medical powers, and that creates a real complication and a contradiction
in some sense.
DR. MAY: Yes, although the way Paul has described
his work as a psychiatrist, he takes advantage of that in order
to clarify instead of remain behind the vail.
DR. KRAUTHAMMER: Well, he gives it up in the
first half hour.
DR. MAY: Yes.
DR. KRAUTHAMMER: I found out if you didn't
you could actually get a real placebo effect, and that would actually
help the patient, particularly in changing behaviors like smoking
or excessive compulsive behavior.
I mean, hypnosis essentially, which is one of the things I practice,
is essentially a way of using that aura as a way to achieve the
results, and it actually does work remarkably.
CHAIRMAN KASS: Janet Rowley.
DR. ROWLEY: Well, first I have to express my
surprise when I was reading this interchange of letters to note
the comments about a lecture that I gave at Hopkins, and I certainly
want to thank Paul for his very generous comments.
I'd like to take a different track, and Paul McHugh also mentioned
the analogy of psychiatry being in the 19th Century as compared
to many aspects of medicine. One could certainly see now that we've
moved to yet another century that it's in the 20th Century and
not in the 21st.
And I think that psychiatry, as well as many areas of medicine
are both a moving target and clearly even better defined diseases
are very heterogeneous.
I guess the concern I have about this discussion is to what extent
are we mixing medicalization with increasing scientific understanding
of the biological basis for behavior, and certainly in many aspects
of understanding brain function and interneuronal connections and
the importance of that, we're only on the threshold, and this
increasing understanding of a very complex system is certainly going
to change both our understanding of behavior, but also a possibility
of modifying behavior.
Now, certainly one modification of behavior can just be learning
to take advantage of other aspects of the nervous system so you
control unwanted behavior, but again, in a heterogeneous situation
where there are tails of behavior, it may well be that some additional
form of treatment might be helpful.
But I think that it is very important that we keep understanding
that we're pretty ignorant about behavior. We just had a lecture
on the immune system and the complexity of the interaction of cells,
B cells, T cells, antigen presenting cells, and antigen. The nervous
system has been likened to the immune system in that there are these
multiple cellular interactions, which we are very, very ignorant
And just as cells communicate by releasing substances which tell
other cells to do other things, this is certainly true in the nervous
system as well, and we're early on in, say, understanding homosexuality.
Some of this is almost certainly going to be due to the lack of
receptors on critical cells or the lack of ligands so that the kind
of behavior that we accept as normal does not occur in these individuals
because of these biological differences.
And we will some time in the next several decades be able to sort
this out. So as I say, I have concerns about worrying about some
of these things.
Amongst the things that are listed as being medicalized are childbirth.
I think that it's pretty clear as you look at the statistics
for maternal deaths and fetal deaths in the black population that
their lack of health care emphasizes that childbirth is not just
something that you can go off in the corn field and everything goes
And I think we also have to recognize that very soon obesity is
going to become a very serious medical problem which will have many
complex aspects of it, genetics as well as the total change in life
style, our lack of exercise, our exposure to foods that are not
good for us. All of these things are going to be important.
But we have to then look at a very complicated response to this
major health problem, and one response may well be some aspect of
involving medicine or drugs at the same time as we also try to help
people understand how they can change other things so that we don't
have this problem, which leads to very serious, fatal medical consequences.
So this is a long winded expression of concern that we look at
this in a broader context and are sort of cautious as to coming
back to Michael Sandel, is this a problem or why is it a problem
or what problem might we as a council be able to provide advice
and guidance on?
CHAIRMAN KASS: Okay. We are late in the hour.
I have just — Frank, did you want a very quick thing? Bill
is in queue.
PROF. FUKUYAMA: I mean, Janet, it seems to me
that that doesn't really — it fails to recognize how politicized
a lot of this is, and homosexuality is a perfect example of that.
As I understand it, homosexuality used to be classified as a psychiatric
disorder, came out of the DSM at about the same time that ADHD
went in. All right? We know about both of those conditions. Actually
fairly similar. They had biological correlates. Over time there's
been growing understanding of the biological bases of both of those
disorders, but you know, the only way that you can actually understand
the actual outcome, I think, is in terms of the politics and the
sociology of the way the society, you know, constructs one as a
disease and the other as not.
So I think that is is true that we are .- I mean it would be nice
if there were this correlation between our understanding of the
biological causes and the way we classify these things, but there's
a huge element of social construction, I think, in the way we understand
these psychiatric disorders.
CHAIRMAN KASS: Bill —
DR. ROWLEY: Well, all I'm saying is I think
it's very important that we first understand that it's heterogeneous,
and that we be very cautious in how we as a council, separate from
society and politics, how we think about the broader issues.
CHAIRMAN KASS: Bill.
DR. HURLBUT: It's interesting Janet because
as I ponder the emergence of scientific knowledge as you say, I
feel what you mentioned, the possibility of interventions at various
levels and the possibility that things that we attribute to some
kind of construction of personal identity as being, in fact, driven
by underlying chemistry.
But what impresses me even more is that our notion of cause is
changing. We've talked here about how medicalization is really
a shift in the notion of causation, but what I would add to it is
also a shift in our sense of what is appropriate by way of cure,
if you will, for a given condition.
When I ponder what science is teaching me as I see the underlying
processes by which the person emerges, if anything cause is becoming
more complex and instead of labeling something biological versus
whatever you call it, moral or personal character, it's beginning
to seem more and more, as it should obviously, that the emergence
of the person within the phylogenetic process was, in fact, a biological
phenomenon with significance. In other words, if you look at all
of phylogeny, you see the steady assent from physicochemical determinism
up to an increasing sense of genuine freedom, distancing from determinism.
So that the person actually makes a difference, has a meaning,
and allows a specificity of response that you can't get with
a chemical, and I think Paul's early letter actually had a lot
of good things about this with psychiatric treatment, is that it's
often directed at symptoms. Symptoms are very broad, and the drugs
lack the specificity of actually remediating an individual person.
And Charles' comment about the placebo effect and so forth
is an interesting one because at least the placebo effect engages
the reality of the person.
The problem, it seems to me, is that a simple, materialistic cause
deletes the complexity of the cause and also the sense of solving
something with a chemical erodes the engagement of the full human
person and the manning of the human process. So that it actually
operates too low in the chain of causation. Therefore, it's
not specific enough. It doesn't operate at the real level of
what is causing things, which is both chemical and at the same time
the convergence of chemistry with ideas, attitudes, memories, beliefs,
and in other words, chemistry and the underlying chemistry and the
overarching cognition that's actually part of human existence,
and the proper approach to a real human problem, not a problem that
has a genuine underlying medical or physical cause that probably
is properly treated by medicine, but the problem is that medicalization
is delivering into the medical hand and the medical gaze and the
sense of where the cure should come from, those things which are
actually humanizing in their way of being dealt with properly.
In other words, what I'm saying is that in a sense those fullest
extensions of human nature, what you might call a mental spiritual
psyche are actually extensions of more fundamental biological agencies
so that what really makes a person a full person and a more effective
person is not just physical, but what you might call the realm of
philosophy and faith, a true integrated personal identity operating
within a cosmology, which is at once deeply humanizing. It both
upholds the person and the process of the person alike.
I mean, in the final end what's going to happen with this
medicalization is we're going to medicalize morality itself
so that we think that there isn't really any free agency. There
And this is what is the most corrosive quality of evolutionary
psychology. It essentially deletes the higher order meaning of
human consciousness. It actually converts ultimately everything
to a simplistic medical explanation, deletes human fullness, and
in the process converts everything into what you were calling earlier
a libidinal problem just driven by unconscious drives and desires
over which we have no agency.
In the final end then all of criminal behavior, all of behavior
will be simply medical problems deleting the person and the meaning
of life itself.
CHAIRMAN KASS: Thank you.
We are at 12:30. We have guests coming at two o'clock. The
hour is late. I'll spare you a summary.
Please be prompt for our guests.
(Whereupon, at 12:29 p.m., the meeting was recessed
for lunch, to reconvene at 2:00 p.m., the same day.)