Thursday, September 12, 2002
Peter D. Kramer, M.D., Ph.D.
Session 3: Enhancement 3: Happiness and Sadness:
Depression and the Pharmacological Elevation of Mood
Clinical Professor of Psychiatry & Human Behavior, Brown
CHAIRMAN KASS: All right, the two sessions
this afternoon are sessions on a particular case study under
the general heading of our inquiry into what goes by the wrong
name of "enhancement," defined for now as possibly non-therapeutic
uses of biotechnical power to alter by direct intervention
the, quote/unquote, "normal" workings of the human body and
psyche, whether by drugs or genetic engineering or other manners.
Our interest in this stems from the fact that we sense that
these uses of these powers may raise some of the weightiest
questions of bioethics, touching on the ends and goals, on
the nature and meaning of human flourishing, and, at bottom,
questions of humanization, super-humanization, de-humanization,
and the like.
It has been a rather neglected topic in public bioethics,
and yet it is, some of us think, one of the deepest sources
of the disquiet that people feel about these new capacities,
represented in remarks about man playing God or "Brave New
World" or post-human future.
While this topic is hard to get a hold of, especially if
you look at it across the board, we have decided at least
to have a go at it, because if not us, who? It has not yet
been taken up by any of the previous councils. It has been
a subject of interest in the bioethics literature. We do have
the freedom and the opportunity to step back from some of
the potboiler questions of the sort we just finished to have
a look at this field as a whole and see if we can develop
some useful means of talking about it.
Nevertheless, rather than go at this in the abstract, we
have decided to proceed case by case and look at a series
of areas where these kinds of questions might come up. Over
the next several months we will be inviting people in who
have worked in these various areas to tell us what the new
powers can do, how they are now being used, what the reasonable
and unreasonable uses might be, and what we might expect in
We have in October already lined up people to come talk about
pharmacological modifications of memory, both to enhance and
to erase. We have Francis Collins coming in December to talk
on the possible enhancement uses of new genetic technology.
We have people coming to talk about Ritalin, and we are in
the process of getting people to talk about work going on
in the biology of aging, as well as in choosing sex of children.
So looking both at the genetic and the pharmacological end,
we will over the next three months try to educate ourselves
as to what is going on and what this might mean. In the course
of doing that, staff will try to develop some of the analytical
One of the great difficulties in this area is to learn how
to talk about them, and especially when you are dealing with
things like the so-called higher human functions, it's especially
difficult. It is for that reason that we are really very fortunate
to have with us this afternoon two people who not only know
the science and the clinical practice, but who have given
a lot of careful thought precisely to this question of: How
do you really begin to talk about this topic?
We are delighted to welcome Dr. Peter Kramer, who is Clinical
Professor of Psychiatry and Human Behavior at Brown University
and the author of Listening to Prozac, and Dr. Carl
Elliott, who is Professor in Philosophy and in Pediatrics
as well as the Director of Graduate Study at the Center for
Bioethics at the University of Minnesota and author of a forthcoming
book, Better Than Well: American Medicine Meets the American
Welcome to both of you. We are delighted to have you here.
We will divide the sections up as scheduled with Dr. Kramer
going first. Dr. Elliott will speak in the second half, but
in the discussion of each other's papers we would like to
invite both of you to feel full members of the panel and join
in the discussion.
CHAIRMAN KASS: Dr. Kramer?
DR. KRAMER: I am honored by this invitation,
not a little daunted to speak before such an accomplished
group of people. I got a phone call from Dr. Kass only four
or five weeks ago about whether I would come down here, and
I thought it might be an advantage rather than a disadvantage
to prepare quickly.
I am an academic only in a marginal sense. I do sometimes
write academic papers. But it was a relief to know that I
didn't have time to prepare a full paper with footnotes, and
The call found me at a particular spot in my thinking about
issues related to enhancement in depression. I had written
about those in a book that came out in 1993, Listening
to Prozac, which then led me into a number of subsequent
discussions, including some hosted by Carl Elliott.
But really in the interim, in order not to be trapped by
the success of that book, I had written two very different
books, one about intimacy in couple relationships and the
other most recent one, a novel, which is also a novel of social
So I had just come back to this issue. While I am going to
be very comfortable reviewing with you some of the thoughts
that I raised in Listening to Prozac, the overview
of what has happened in the eight or ten years since is more
in the nature of a work-in-progress. I hope you will allow
me that, to have that sort of uncertain status.
I want, as regards to enhancement, to consider with you the
case of depression or, rather, conditions that are not depression
but resemble it and might respond to interventions developed
to treat depression. For convenience, I am going to call those
conditions, the ones that aren't illness, minor depression
or melancholy, but I mean for those words to extend to very
solid degrees of health, where people have complaints that
relate to depression but no one would consider to be ailments.
I want almost to warn you off this topic; I think that minor
depression is uniquely problematic among the indications for
enhancement that you are likely to consider. We had mentioned
ordinary muscle mass or ordinary forgetfulness, and certainly
ordinary shortness has been considered for enhancement or
ordinary states of declining sexual functioning.
I think that minor depression differs from these in a way
which I will call a problem of value. That is to say that
we can value minor depression, whereas I think no one is likely
to value forgetfulness, or one is at least less likely to
value forgetfulness than one is to value the traits that make
But before we turn to that special problem of value, I want
to begin with a question of method. This is the topic that
in Listening to Prozac I call "cosmetic psychopharmacology."
Now to step back half a second, that book is built around
a sort of core vignette that involves what I call recursion.
That is, a person who, say, had a legitimate medical problem,
was depressed, or had a serious anxiety problem, is treated
with a medication, gets better, comes off the medication,
and comes back to the physician, say, months or years later
and says, "I'm not depressed again. I don't have that legitimate
medical indication for which I first came to you, but when
I was on the medication I was a better parent" or "I negotiated
better at work" or "I had some benefit," that is the kind
of benefit that people do in fact claim to experience on medications.
"Will you put me on the medication again?"
Later, in discussing this issue at some of these ethics and
philosophy conferences, I extended this sort of thought experiment,
which actually occurs in offices, to one where somebody was
never ill at all. So that say a woman comes into the office
and says, "I have all the characteristics of the melancholic
temperament. I'm a little timid. I have low energy. I am easily
derailed from my purposes. And I have an identical twin sister.
We were raised in the same family, had very similar childhood
experiences, and where we diverged is that she had an unfortunate
love affair and fell into a deep depression, was put on medication,
and not only recovered from the depression, but had these
other benefits of appearing, feeling more sanguine and less
melancholic. Would you put me on medication? Would you prescribe
for me based on the likelihood that I might have a similar
response to the one she had?"
Now in considering dilemmas of this sort, these dilemmas
are answered often in terms of medication side effects or
long-term effects of medication. There's a general belief
as regards mood that what goes up must come down.
One of my teachers, who was also a mentor of Dr. Krauthammer,
labeled this sort of belief "pharmacological Calvinism" or
"Puritanism." It may actually be that the opposite is the
case, that depression is so damaging an ailment that what
goes down goes down, and that intervening quickly allows,
raising the level of mood, allows for future good mood.
But, in any case, there is general resistance to medication
under the belief that it will incur some kind of doom and
is morally weak or wrong in any case. To me, those are interesting
considerations. Certainly, if you think about enhancement,
you will have to think about those concerns, but they beg
the question of the inherent morality of enhancement.
To that end, I framed this definition of "cosmetic psychopharmacology"
that is also a sort of thought experiment. I defined "cosmesis"
as using medication to take a person from one normal state
to another equally normal state that is more desired or better
I stipulated that the imagined medication is not addictive
and not even directly hedonic; that is, taking the medication
is not enjoyable, though the results of medication may allow
a person better to enjoy ordinary pleasures in the manner
that other normal people already enjoy them, and that the
medication has no side effects or only such ones as a rational
person would accept in exchange for the expected benefit.
I wanted to ask, in that case, what are the moral issues
attendant on offering the medication? I think the same considerations
would inform a discussion of electronic interventions or genetic
interventions, although this is cosmetic psychopharmacology
because I began with the example of Prozac, which is a medication.
I wanted, through this definition, through this term, to
eliminate most frivolous uses of medication. So, in other
words, this is not people that want to get high or to enter
a radically-altered state of consciousness, and to eliminate
concerns of safety, matters where we would say the doctor
knows best, and even some issues of evolutionary fitness or
unfitness by the constraint of changing from normal to normal,
so both conditions have passed the test of generations, and
to clear the field for the very issue at the core of your
current considerations: What are the most basic moral considerations
attendant on enhancement?
Now I didn't frame this issue in a vacuum, but the inspiration
was, frankly and openly, the introduction of the first selective
serotonin reuptake inhibitor, or SSRI, in this country, Prozac.
Patients reported on that medication that they felt better
than they had ever before felt, that is, better than before
they had taken the medication at all, perhaps better than
before they had fallen ill. They use this expression that
Carl adopted for his book, Better Than Well, which
I take to be the same as this term "enhancement."
The manner of this improvement was different in different
instances, but a shorthand description for what patients reported
was that medication for them was like Garrison Keillor's powder
milk biscuits, that the SSRIs lent them courage. They made
patients less sensitive to rejection or loss. They occasionally
lent them energy, allowed for greater optimism and social
In those patients who had suffered psychic injuries early
in life, it seemed that they were more the way they had imagined
they might be before the injury occurred. To use a political
term, the medication was empowering, but it was worrisome
on a different level because it was empowering in precisely
the direction that the culture values.
The medication could be called conformity-inducing as regards
a favored personality style for the modern woman, in particular,
although that style includes a measure of assertiveness and
potential for rebellion. That is, it was a model of the way
we want them, a modern woman might be when she was admirable,
but wasn't conformity-inducing in the sense that her behavior,
her choices, would then be conformist or subject to influence.
This change was in response to a medication which, whatever
its substantial negatives, had a side effect profile that
was more acceptable than that of medications that had come
before. Most patients didn't feel drugged or aware that they
were on medication.
In Listening to Prozac, I detailed the reasons I had
for suspecting that such effects might occur, that is, to
give credence to these reports. In brief, at the first level
the SSRIs worked through serotonergic pathways in the brain,
and in other mammalian species serotonergic pathways appear
critical not so much in the maintenance of mood as in the
regulation of status hierarchy.
Again to simplify, alpha males have high serotonin levels,
and in times of turmoil within the troop, animals premedicated
with SSRIs are more likely to assume dominance. This is a
very antique mechanism. If you look at lobsters that are closer
to the food supply, apparently, they have a better serotonergic
transmission than lobsters not near the food supply.
It seems to be both from clinical observations and from pre-clinical
research literature that SSRIs' major effect might be in inducing
an overall sensation of social well-being. As you know, some
of these medications subsequently have gotten indications
for the treatment of social phobia.
Whether it is true that in humans these medications have
the effects I have suggested is a question that has never
been properly tested, but there is one detailed study that
appeared in 1998 that did find that normal people given Paxil
were more socially adept when confronting a test challenge.
They were given a very-difficult-to-solve problem, put in
pairs, and the observers saw who was the leader in the pair
and how they got help in solving sort of a tangram problem.
Academic articles citing the experiment said that the effects
that this experiment found were the ones that I had predicted.
Although we can imagine quite varied instances of cosmetic
psychopharmacology, the test case I considered was this one
that had to do with a movement along the personality spectrum
from self-doubt to a sense of belonging or insider status
or from melancholy to sanguinity.
I knew that observers might be troubled by such use of medication,
and the question was, why? In fact, I was troubled by it.
Was this expectable response psychopharmacologic Puritanism
or Calvinism or did it have some inherent moral justification?
In considering this question, I began with the observation
that for many years we have had an intervention that meets
all but one of these standards of cosmetic psychopharmacology,
and that intervention is psychotherapy. The standard that
it fails to meet is that it is not a medication, although
some recent research does suggest that in gross terms psychotherapy
may work through brain mechanisms similar to those of pharmacotherapy.
That is, there are these studies looking at complicated brain
imaging of people who have had either psychotherapy or medication,
and after a few doses of each, the changes in the brain in
people who successfully respond look similar.
We have no objection to a physician's conducting that intervention,
that is, to giving psychotherapy for making a melancholic
person, say, more sanguine. Indeed, part of what seems eery
or uncanny about the new medications is that they resemble
psychotherapy. This is so both as regards psychotherapy's
ends and its processes or intervening effects. That is, patients
in studies report that antidepressants can connect memory
to affect or make painful memories more bearable or accessible,
and so forth.
To make the ethical case against medication yet tougher to prosecute,
I should remind you that there are psychotherapies that work
through mechanisms other than insider memory. There's been no
ethical debate attaching to support of psychotherapies where
the therapist helps the patient to bear affect or tolerate stress
without relying on the transmission of understanding, and it
has been only the most minor ethical debate about paradoxical
therapies intended to catapult patients into more desired states
through means whose intent is kept hidden from the patient entirely.
That is to say, we have lived comfortably for 50 or 100 years
with the goal of enhancement within the medical profession.
In truth, we might say that, as a society, we have lived with
this goal much longer if we accept that people have tried
to make themselves less melancholy through a variety of means
that in Listening to Prozac I call "quest," methods
such as religion, friendship, work, self-inquiry, and so forth.
An interesting book for the Council to look at is Martha
Nussbaum's "Therapy of Desire," which frames the schools of
Hellenistic philosophy, the Stoics and Cynics and Epicureans
and Aristotelians, in terms of their efforts to create relative
invulnerability to the pain of loss. In this sense, enhancement
is at the base of the Western cultural enterprise.
By this analysis, the new issues as regards psychopharmacology
will ignore the questions of ends altogether and will cluster
around means. Although in sentiment Listening to Prozac
was on the side of those who feel unease at these potential
new uses of medication, the challenge it set was to specify
the cause of that unease on the basis of differences between
the new technology and the old.
I would venture to recommend this method to the Council in
general when framing its response to the challenges of enhancement.
In a given instant, is it the goal of enhancement that raises
ethical challenges or the means? I think the method behind
cosmetic psychopharmacology as a thought experiment is a useful
probe in this clarification.
For any given proposed enhancement, if there were a purely
harmless means of achieving it, would the ends still be ethically
troubling? If not, we're down to the issue of risk and benefit,
broadly taken, which is a manageable topic.
If I can be allowed a parenthetical digression on the risk-benefit
question, the automatic assumption might be that we would
require a lower ratio of risk-to-benefit for enhancement than
for treatment. We hesitate to put the healthy at any risk,
and the ill are already at risk. For them, the question is
not whether to play the game, but how. The paper you read
this morning made some remarks in that direction, that ill
people are in some ways more suitable for taking on certain
But if we add in the element of judgment, our perspective
may change. After all, if risk and benefit are properly calculated,
those terms of the equation include the differing starting
points of the players. What the equation lacks is an assessment
of an element we might call freedom or coercion or leisure.
The healthy actor is fully able to make an unpressured judgment.
His vantage begins with a self as it is ordinarily. His decision
is truly his own. On this basis, he might ask to be permitted
to assume a greater level of risk than he would demand were
The example of depression is illustrative. Who has the less
impaired judgment in terms of informed consent, the person
when he is free of depression or the person who is merited
or diagnosed because of impaired memory and concentration,
suicidality, low self-esteem, and the like.
To be sure, there are meta-considerations beyond the perspective
of the individual seeking enhancement or even a physician
supervising the intervention. I mean effects on the culture
and effects mediated by culture.
One difference between medication and psychotherapy might
be their differing effects on the social atmosphere. For example,
if harmless medications were available that could reliably
make people more assertive, then social coercion might come
into play. A boss might say to a salesman, "Don't come back
until your medication level is adequate," or words to that
In such an atmosphere or such a workplace, those who are
not characteristically assertive off medication would be at
a disadvantage relative to those on. The analogy to steroids
in sports is evident.
This coercion might apply all the more for medications less
benign than those imagined by the strictures of the thought
experiment I have labeled cosmetic psychopharmacology, say
addictive medications or those with insidious harmful effects.
We might fear medications because of the influences of their
manufacturers, the pharmaceutical houses.
It does seem that the risks for distortions in informed consent
differ as between medication and psychotherapy. As regards
decisionmaking, the pressures brought to bear by therapists
would tend to be more intimate but less organized and less
Regarding considerations of evolutionary psychology, I have
said the ground rules of our thought experiment, normal to
normal, make certain concerns disappear. True, melancholic
traits may have conferred fitness in the hunter/gatherer environment,
but then so did sanguine ones. At the level of the individual
nothing is lost, but at the level of the culture we might
fear the effects of too much uniformity, everyone a top banana.
The same worry could conceivably result from psychotherapy
or religion, but our experience is that quest has never so
far worked in this overly-effective way. This is the challenge
I posed with cosmetic pharmacology as a variant of enhancement.
I would like in our remaining time to update you on my thoughts
of the following eight or ten years and to say something about
progress and prospects for progress in biological psychiatry.
This may be going on too long. Are we comfortable?
The first set of thoughts have to do with my own experience.
You will recall that I had made a division between ends and
means, saying that since we accept ends of enhancement when
quite mechanical forms of psychotherapy are applied, the principal
issues must be those attached to the new technology.
But something strange happened. When medical ethicists took
up the challenge, for the most part they continued to talk
about ends. You will hear from Carl Elliott, and may have
seen his work referenced in my monograph and his own in the
Hastings Center Report in your materials. I don't intend today
to address that material in detail, as I do in my own written
reply. But I can say that Dr. Elliott makes a series of cases
for alienation as a valuable human trait.
But by way of precis, let me propose a quick thought experiment.
A patient in one of the recursive vignettes returns and says,
"I'm not depressed again, but I noticed on the medication
I felt more comfortable in conventional social groups. I had
less sense that I was an outsider. People found me less awkward.
I was less troubled by absurdities and contradictions. I was
less finicky. And I have been proposed for membership in a
conventional business leadership group. Acceptance would help
my career. For the probationary period, I would like to resume
taking the medication."
If this request sounds unlikely, I should remind you of that
study by Knutson and Wolkowitz in 1998 demonstrating that
an increased ease in affiliative behavior and leadership behavior
in response to serotonergic medication. I take this request
as invoking the sort of possible objections made by Dr. Elliott
when he writes memorably that, "To address alienation as a
psychiatric issue is like treating Holy Communion as a dietary
issue. It's a category mistake."
I think that the question of alienation is an open one. Alienation
is very much an element in some psychiatric conditions, and
even where it is not, it might legitimately engage the psychiatric
enterprise and all of its aspects, including the pharmacological.
But at the same time, I want to say that the recursive vignette
is an example of a request for enhancement, not a treatment
of an illness, and it does raise questions of value, in this
case the value of alienation, which is a trait philosophers
have valued on a variety of grounds, for example, placing
it at the core of existentialism.
I should add that, in the wake of Listening to Prozac,
ethicists have written in praise of rejection sensitivity
and self-doubt. However painful, these traits are aspects
of self-awareness and awareness of circumstance. Value can
be attached to almost any of the personality traits that are
also symptoms of depression.
And there are other problems here. I saw this article by
Stephen Braun also in the advance material, where he talks
about having these mini-storms in his life where he would
feel depressed for a short while, maybe not rising to the
level of illness, and wondered whether there was something
behind them, although apparently there was not, whether there
was some problem in the marriage, or so on.
Of course, psychoanalysis has taught us not to trust our
own testimony. So it might be that someone would think something
is random, where some adequate explanation or adequate inquiry
would show that there was some particular human value in having
that symptom. He concludes in that article that there is not,
that this is just some kind of mental glitch, and is happier
being on medication.
This circumstance makes depression and its neighboring conditions
special, if not unique, among the examples you are likely
to consider. I think I have said this.
I have come to think that the matter is yet more difficult,
that ethicists might value depression itself, not just the
neighboring conditions, call it illness though we may. One
provocative test of this assertion is this question: Would
we want to eradicate depression the way we eradicated smallpox,
so that no human being experiences depression ever again?
This question might elicit different answers, presumably a
wider range of answers than a comparable question asked of
cancer or diabetes or arthritis or some other illness.
Now think of the objection to this provocative test. It displays
and conceals verbal ambiguity packed into the word "depression."
That is to say, some people might be content to eradicate
or entirely prevent the severe condition depression if its
boundaries could be well-demarcated.
It is the minor conditions that make the question sound troubling,
but that objection is a demonstration of the problem of value
of minor depression. That is, the reason people make that
objection is that, while they are quite happy to get rid of
major depression, even those who are, they want to hold onto
minor depression. That is why they think it is a trick question.
I hope that was clear. If not, we can forget about it or discuss
I mention this possible exercise as a quick proxy for a longer
discussion of the premise that, when it comes to minor depression
as regards enhancement, some possible objection attaches to
In recent years I have come to think that the argument from
psychotherapy deals with these concerns too easily because
of unspoken beliefs about the test intervention. Ethicists
seem to think that psychotherapy does not work or does not
work thoroughly or acts only through a limited sort of means,
such as insight. It is only in the face of interventions we
imagine to be ruthlessly effective, such as medication, that
the issue of value emerges.
I want to mention a second issue that makes depression special,
although not unique, which is that it is a true spectrum disorder.
Your materials also list how psychiatrists diagnose depression.
It is based on having a depressive episode, and to have an
episode you think about nine symptoms. You need to have five
of these symptoms continuously for 14 days and they have to
rise to an adequate level of severity, and if so, you have
a depressive episode, and then from there you might have different
kinds of depression.
This is the sort of sharp-edged definition that allows for
enhancement paradoxes. Shortly after the publication of Listening
to Prozac, when colleagues challenged the assertion that
SSRIs could affect people who had never been depressed, and
I mounted variants of the identical twin challenge proposed
earlier, if the, quote, "unafflicted" twin had only experienced
four symptoms, would she, nevertheless, respond to treatment?
A similar question might serve to indicate the difficulty
of defining enhancement. If a person has never suffered more
than four symptoms, but those four are chronic and disabling,
does addressing them constitute enhancement or treatment?
What of those who have experienced only three symptoms? Will
a single symptom suffice? Is this sufficient?
In reality, in a doctor's office people do come in with just
one symptom. You know, they are only suicidal, say, or they
only have low self-esteem. We are often happy to treat those.
These questions are made more complicated because of the
results of recent research. It turns out that the accepted
definition is arbitrary on every axis: the number of symptoms,
the duration, and the severity. In other words, if you looked
at people with only four symptoms or have five symptoms for
ten days or, you know, have a lower level of severity of symptoms,
they all have a degree of risk for future bad outcomes that
is very similar to those who meet the definition. This is
a true spectrum.
The same is true if you try to raise the bar, that is, if
you try to look at really core symptoms of depression like
suicidality, you know, you start losing some people whom everyone
would say are truly depressed and you still include people
who turn out to do very well in the future.
In fact, only half of people who meet the initial definition
of depression ever have another depressive episode. I think
psychiatry is much more interested in this term of illness,
in this sort of career of depression over a lifetime.
This doesn't make the definition of depression a bad one.
It has proved very useful for research and public policy purposes,
but it limits its applicability to ethical conundrums. Clearly,
we would not consider a culture immoral that had a differing
definition of depression, slightly above or below ours in
terms of the severity demanded.
The matter is all the more problematic because of recent
research that emphasizes the physical deterioration implicit
in depression. There are studies that show brain nuclei to
be atrophied or perhaps small in the first place in patients
who have been depressed, and the size, the loss of tissue
appears to be correlated with the length, lifetime length
of depression, the number of days of depression. There are
also post-mortem studies that show cellular disorganization,
glial cell atrophy. So this looks like a condition that doctors
legitimately might want to prevent on the basis of anatomical
In addition, there is research on what is called sub-syndromal
symptomatic depression that looks as if it leads to all sorts
of bad outcomes, like worse results in heart disease, and
The result is that many of the areas that ten years ago we
would have thought about as the realm of enhancement have
probably been subsumed into the medical enterprise. I warned
about this tendency under a phrase I called "diagnostic bracket
creep," the tendency of diagnosis to expand to meet the medication
Although that designation contains a measure of sarcasm,
the movement is not necessarily for the worse. What happens
is, if you have an effective medication, you start doing research
on ever more minor conditions, and you may find legitimately
that they are as fully medical under the concerns you had
as the ones you had started treating when you needed a more
uniform population to do your research.
So I have proposed two sets of problems: Do we grant legitimacy
to the concern over enhancement based on valuation of the
target ailment, or lack of ailment, and can we define a territory
that is outside the legitimate medical enterprise? It would
be interesting to see what would happen if worlds collide.
Imagine an ethical determination, say by a commission such
as this one, that the culture values a trait related to depression
and considers its diminution to be problematic unless certain
conditions are fulfilled. So say we value alienation and say
really medication ought not to be used to treat alienation.
Then imagine that research defines a cause and set of biological
markers of a subtype of depression, and that subtype turns
out to include some of the cases where we have said it is
morally preferable for people to live with the trait. Could
we stand fast against the suasion of biological evidence?
The same argument might apply to prevention. To create an
extreme example, say that depression in offspring is caused
by maternal exposure to a pathogen. So say it is like toxoplasmosis,
where if the pregnant woman is exposed to feces of cats carrying
toxoplasmosis, the child is at risk in life for certain ailments.
And let us say that if you didn't handle cats, your child
is much less likely to be depressed. Would you sincerely —
would you take seriously the worry that your child also might
not be alienated? That is, do we so value these traits that,
if they thoroughly entered the medical enterprise, we would
continue to value them, and someone would say, "No, women
ought to go on handling cats because otherwise the human race
would lose this valuable problem of melancholy"?
One response is that we don't think depression or melancholy
personality are like that, but of course there have been surprises
in medicine before. Well, what do we think depression is like?
There are a number of speculative models now, some of them
built on a neurobiological analog of what we see in the behavioral
phenotype; namely, problems and resilience. In other words,
that the brain in depressed people does not produce reparative
chemicals. So that when there is stress, whatever damage is
done remains more in the brains of depressive people than
A fuller model, worked out in rodents, involves stress, increases
in stress hormones in the brain and then difficult-to-reverse
brain damage. A yet fuller model sees depression as maybe
35 or 40 percent based on genetic vulnerability, where that
vulnerability merely takes you further down that road of the
results, the effects on the brain of repeated stresses.
And a yet fuller model sees subtypes that may be tied to
particular stressors, such as, for example, declines in vascular
sufficiency. If this is so, and I know that was a quick runthrough
but just accept perhaps this conclusion, then prevention may
be a better strategy than treatment for depression.
Now no one objects to prevention for depression. There are
all sorts of interventions with high-risk mothers, say, to
prevent depression in children. But, again, this may be a
false counter-example because it seems so natural and because
it is not thorough.
I haven't spoken to you about developments in psychopharmacology,
and the reason I haven't done that is that I don't think there
have been ones that present dramatic new ethical problems
beyond those that I talked about ten years ago in terms of
what has come to market.
But there have been medications that haven't come to market
because they have had side effects on the liver, and so on,
that involve interrupting the effect of stress on the brain.
These include CRF inhibitors intended to block receptors for
corticotropin-releasing factor. In lower mammals these compounds
prevent even the effects of prenatal stress on offspring.
So that you can imagine someone undergoing a stress, taking
these medicines, and not suffering the deleterious anatomical
presumed effects of stress on the brain. These do, I think,
present new ethical problems.
For instance, if a child lost his or her parent, lost a mother,
would you want to give such a medication to prevent the future
liability for depression, and if you did so, would you feel
that you were preventing certain normal responses to the loss
of a parent, such as development of, say, melancholic personality
traits? Or taking away this kind of proxy problem that children
present, would you want a spouse to take it upon the death
of a pre-deceasing spouse?
And at the next level of science fiction we can consider
genetic interventions. Robert Sapolsky and colleagues have
done lower animal experiments in terms of introducing genetic
material to prevent cascades of stress hormones that follow
upon strokes, so strokes don't generalize. So that if an animal
has a stroke, it won't have the permanent elaborator effects
of that stroke on the brain.
Sapolsky has talked about the possibility that one could
in theory create genetic interventions that would have the
same effect as regards depression. That is to say, when a
person who is liable to become depressed in response to stress
would have such an intervention, that person would then be
less liable. Are we concerned that such interventions also
would prevent alienation, moodiness, sensitivity, and the
This forecast, which is also in the way of a thought experiment,
raises questions about agency. Ought we to allow or encourage
mood enhancement, perhaps under the name of resilience, as
a boon to public health or economic productivity, or would
you prohibit or discourage or attempt to minimize enhancement,
perhaps even when it occurs as a side effect of clearly legitimate
or mainstream medical projects? Is depression a special case?
Ought it to be a special case?
Our own current interest is in a topic, my own current interest
is in a topic, I'm sorry, that bears directly on this last
question. What is the origin of this sentiment for minor depressive
symptoms? Is a "faute de mieux" a result of millennia where
men and women could not prevent these traits and so had to
live with them, or did the human race develop strengths out
of handicaps, so that we entail some risk, individual or societal,
when we mitigate melancholy?
I am, frankly, suspicious of much of the sentiment in favor
of melancholy. If we accept the medical model of depression,
then we may imagine that some years hence that sentiment will
resemble the romanticization of tuberculosis in the 19th century.
Although the role of depression in the culture is yet more
substantial, it informs our very notion of romance and has
for centuries. If that is confusing, I can say more about
that as well.
I want to end, as psychiatrists often do, by showing the
other side of the coin. I have said that depression and its
lesser relations may be an unfavorable area to tackle because
of the unique medical and cultural qualities of the core disease
and the sentiment or valuation attaching to associated traits.
But I might also want to say the opposite, that these questions
are timely. It seems to me important to say what we want to
say about melancholy now before we are unduly influenced by
the facts. The valuation, say, of alienation is a cultural
question and best assessed at the end of millennia in which
it gains its status, millennia during which its causation
remained unclear. Once we know more about the causes of depression,
this debate will be that much harder to engage, so prone are
we to give biological dissections priority.
I see that I have taken an odd tact in outlining issues arising
from concerns about enhancement. In the end, any wider opinion
you issue will focus on informed consent, implicit coercion,
social conformity, the natural and unnatural, risks of addiction
or other forms of seduction, modes of balancing risk and benefit,
and the like.
My only justification for the path I have taken is to say
that it is my interest, the one that has captured my interest,
and that it serves to underscore the question that I think
should come first in considering enhancement, since it properly
informs all the others, questions of value.
So why don't I stop there? I am happy, you know, in the course
of the discussion to say more about my own opinions on this
issue, whether if we discovered tomorrow that a combination
of vitamins actually prevented minor depressive traits, people
ought to be encouraged to take those vitamins or not, but
I think I should hear from you first. Thank you.
CHAIRMAN KASS: Thank you very, very much
for a very rich and stimulating presentation.
Let me just open the floor for discussion and hold my own
PROF. MEILAENDER: This is very interesting
and very puzzling. I would like to get you to think a little
bit for me not just about kind of reporting on what people
think, but react yourself with respect to one of the kinds
of issues you raised especially near the end.
I mean, we often think, I often think at least, that to love
anyone is to make yourself vulnerable because you might be
hurt if the person is lost. I would like to think about your
case of the person being widowed, say. What would be an appropriate
reaction to losing the person to whom you had been married
for 25 years, say, or something like that? I want you just
to reflect normatively on it for me now.
If I lost my wife after 25 years, and it wasn't that I just
soldiered on kind of, you know, because there were things
that had to be done, but I just carried on kind of happily,
readjusted, and so forth, and seemed positively buoyant, in
fact, on many occasions, would you judge there to be — I
mean, am I defective as a human being in some way? Has something
gone wrong? Or if not, then maybe it would be desirable for
you to help anybody who lost his or her spouse after 25 years
to just carry on buoyantly.
Just think about the case a little bit more for me. I am
really interested in what you, yourself, want to think normatively
DR. KRAMER: I am very much within the culture.
So my answer is likely to be an answer from within the culture,
and I certainly would think you had missed some of the richness
of life if you didn't mourn or grieve to some extent.
But that is more one vote.
PROF. MEILAENDER: Are there different cultures
on that matter?
DR. KRAMER: Yes. Yes, there are. One of
the things I wrote about in Listening to Prozac was
a particular case that was initially admired of mourning in
rural Greece. In rural Greece I guess women wear black after
the death of a pre-deceasing child or husband, and they are
given a long period of mourning during which they are very
much supported by the rest of the community and allowed not
to do certain tasks that ordinarily a woman would be required
to do, and so on. And this was held up as sort of a model
for the mourning process.
But someone who looked more closely at that culture found
that some women were very antsy and grumpy about this, that
they recovered much faster than this ideal period required,
and that they were just too resilient for that culture. It
didn't fit them well.
I think there is a range of naturalistic responses to loss.
But my question is more for the philosophers, which is, forgetting
what I think is natural or normal, where does the value attach?
In other words, do we more admire the women who take a year
or the women who after a couple of months want to be back
And is the value in thinking about the person constantly
or being forced to think about the person constantly? That
is, let's say you could take a medicine that after a couple
of months would relieve you in some way. You certainly could
go on thinking about your lost loved one as much as you wanted,
but you wouldn't be forced to.
So I think ordinarily when we think about morality, something
is more admirable when it is done without coercion than when
it is done merely because there is no other choice. So I think
it is an interesting question.
More broadly, I want to say something about suffering because
I think we value suffering altogether. The question is, do
we value suffering because we learn from it and it is morally
somehow enhancing — that's probably the wrong word — or
do we value it almost because we can't avoid it in this manner
that I called "faute de mieux"?
I had an interesting — I am just going to tell a story,
which is I was in Denmark, and through various storms and
things I was forced not to go where I wanted to go and ended
up at Isak Dinesen's house, Rungstadlund, with a Danish pharmacologist.
We had been talking about these sorts of issues that we are
talking about today, about the amelioration of depression.
People always say, what if Prozac had been available in van
Gogh's time or in Denmark what if Prozac had been available
in Kierkegaard's time? So I said jokingly, "What if penicillin
had been available in Isak Dinesen's time?" because the story
on Dinesen was that she suffered from syphilis given to her
by her Baron Bror Blixen, the bad husband in this movie "Out
of Africa". And the chronic pain that she had from the syphilis
made her a darker writer, and so on.
And no one objects to treating syphilis. There is no moral
objection or richness of human experience objection to treating
syphilis in a woman infected by a feckless husband. I mean
it is just not something we consider at all.
This pharmacologist said to me, "You know, she probably did
not have late-stage syphilis. Probably she was cured of the
syphilis early by arsenicals. There was no trace of this ailment
in her later life. She was on phenothiazines and barbiturates,
and probably what she had was depression."
So why is there a Prozac question and not a penicillin question?
Just as an interesting — this is not, I know, it doesn't
have to do with mourning in particular, but why is it that
we ask questions? And I think the answer to that question,
in my mind, having thought about it, is that depression is
sort of a proxy for suffering altogether, whereas these other
illnesses are all individual forms of suffering. What we don't
want to lose is something that relates to the capacity to
suffer, although any given instance of suffering we would
be happy to free the human race of.
I know that was not a good answer to the question, but —
PROF. MEILAENDER: Just a brief followup:
I mean your distinction between any given instance of suffering
and the capacity is a good one. I was just going to say, I'm
not particularly big on suffering, but let me try to put the
question, or at least a version of the question, once more
in a way that doesn't make it a question about medicating
I don't know how you would get this information. It would
be a difficult question. But if you were to die and then you
were to find out that your wife, having given you a dignified
burial, just carried on, you know, we're not talking about
five years or anything, just carried on —
DR. KRAMER: I got the question.
PROF. MEILAENDER: — didn't seem to matter
at all, and you somehow could get this information and evaluate
it, would you think yourself to have been loved?
DR. KRAMER: Yes. Well, you know, an interesting
question is, was I loved? You know, that is, I think that
you are asking the question that anybody — I mean it is the
right question. This is the right first question.
On the other hand, imagine a science fiction future in which
someone looks back and says, "Do you remember primitive days
when attachment was guaranteed by the pain that followed upon
loss, whereas now we love because we love and we are free
to love. We would be free to withdraw our love, but we love
because we really love."
You know, it is like what parents say to adopted children,
"I had you because I wanted to have you. We had you because
we wanted to have you. We chose to have you."
So that one might say that a more noble form of love would
be one that wasn't predicated on pain of loss, although, yes,
that certainly would seem unnatural to us.
I mean, I suppose one reason it would seem unnatural to us
is that we would have further beliefs about what the nature
of that love was. The availability of a medication that erases
those assumptions, that is, you assume a fully normal, loving
person would have been able to abbreviate the mourning process
through those, whereas today we would think that wasn't love
at all, and we would be right.
CHAIRMAN KASS: Are you satisfied for now?
Michael Sandel, Mary Ann. There's going to be a queue here.
You've started us all up. Thank you.
PROF. SANDEL: Well, I found this very provocative
and suggestive. Not having thought this through fully at all
before hearing your talk, it strikes me that the issue or
the thing that troubles us isn't the medication at all, but
the mode of being that the medication induces or promotes.
Let me say why what you said suggests that to me.
You identified certain traits or dispositions associated
with cosmetic pharmacology, traits that people might want,
even if they are not clinically depressed. Then you mentioned
some other means of acquiring those traits, traits like optimism,
social assertiveness, a sense of the sanguine, ways of acquiring
those traits other than medication that we regard as acceptable
or unproblematic: psychotherapy, even religion.
Your suggestion there, as I understood it, was, well, if
we accept those ways of acquiring these traits, then why not
accept the medication, too? By the way, I would add to the
list of other means of acquiring those traits of optimism,
social assertiveness, a kind of blithe optimism, and sense
of being sanguine, maybe even a blithe vacancy — I would
add to the drugs, the psychotherapy, and the religion spending
too long in Southern California.
In fact, before I knew about Prozac or what traits it promoted,
I was struck at a party once by a woman, a friend of my wife's,
who seemed to be more than usual displaying these traits,
and I wondered about that and then later learned that she
was taking Prozac.
Now in reflecting on the traits, what struck me about them
was I can understand why someone might want them rather than
to be, say, fraught with self-doubt or something like that,
and yet there is something associated with those traits, however
desirable given the alternative, that seems shallow or a kind
of vacancy, a kind of unreflective self-possession that goes
I would say, having spent some years of my life in Southern
California, that that's true of people there in general, even
ones who aren't on Prozac. That's actually one of the reasons
that I wasn't eager to go back or to raise a family in Southern
California, and it had nothing to do with drugs.
But it did have to do with a certain way of being that I
thought was promoted or made more likely or induced by living
in Southern California that I didn't really want my kids to
grow up having, nor would I really be happy if I found that
they joined a religion, stoic or otherwise, that promoted
those kinds of qualities, even though I would want them to
be assertive in other kinds of ways.
But the package of dispositions that we are talking about
here that seem to be associated with Prozac — and I don't
know how uniformly that's the case — but it seems to me that
to possess those traits too fully is to lack, never mind alienation
and melancholy, maybe that overstates the alternative, but
it is to lack a certain kind of depth of character or a quality
of reflectiveness, even short of being plagued with kind of
clinical melancholy, if there is such a thing.
Then when we consider that there are risks and side effects
to acquiring this morally-dubious package of dispositions,
then you really wonder about the character of someone who
would aim at that mode of being, knowing that it carries certain
risks. I mean it is bad enough just to come into the possession
of that mix of traits with the superficiality and kind of
vacancy that sometimes attends it, at least around the edges,
but then —
CHAIRMAN KASS: Some of us "resemble" those
PROF. SANDEL: But then to actually undergo
risks and side effects for the sake of that really might lead
to further worries about the character of the person who would
go in for it. So that makes me think that really the issue
isn't enhancement, because here on reflection the making better
the enhancement isn't really fully an enhancement.
After all, if you take this account of the package of dispositions
— and so maybe we can accept all of the analogies that you
propose and say that any of those means to this mode of being
would be troubling and for the same sort of reasons, though
the side effects might differ in the case of religion, psychotherapy.
In Southern California, the side effects might be more or
less grave. It would depend, but the graver they are, the
more we would worry, but in any case, we worry for the same
kind of reason about all of them.
DR. KRAMER: I wish I had taken notes because
I think there are about five issues, you know, in that, and
I hope that this council doesn't end up forbidding people
to move to Southern California.
DR. KRAMER: Because I think that is almost
?- let me tell you what —
CHAIRMAN KASS: We're only advisory.
DR. KRAMER: I am raising my children in
New England for this same reason.
I think there are some problems. One has to do with what's
in the package, and it does happen that almost any psychotropic
medications we know about sometimes cause apathy, and almost
any antidepressant we know about sometimes causes mania. So
I think that part of my normal to normal requirement would
meant to get rid of what very likely are side effects or negative
effects of actual antidepressants in actual people with mood
So that, you know, I think some of what one sees actually
on antidepressants is apathy or silliness, disinhibition,
and so on, and that I would want to exclude those cases. So
it's not clear exactly what the package is.
But I think that the Southern California example, it troubles
me, and I think it contains a judgment on a lot of normal
people. That is, we admire and think to be intellectual people
who have trouble making decisions or are, you know, very reflective,
are prone toward pessimism and worry.
And the question is: to what extent are we just admiring
ourselves and to what extent do we want to sign our name to
that as a moral position.
I encountered this when I was asked to write a preface to
a new edition of a book by Carl Rogers, the Midwestern American
psychologist, who I knew largely through being considered
not to be intellectual, and I thought very seriously about
why he wasn't an intellectual, because he was someone who
had written a number of research papers at a time when people
in the mental health field rarely did, and had been innovative
in certain research methodologies and was in dialogue with
some of the great people of his era.
And I think the answer was that he was an optimist; that,
you know, a Midwestern American optimist could not be an intellectual.
And even though when his ideas were stolen by, you know, sort
of Viennese depressives, they took on a different cast.
But that is the nature of my answer, which is I'm asking
us to rethink this denigration of optimism on the assumption
that it comes with blandness and so on.
The question you point to is exactly the question that troubles
me, whether we're not too quick to value depressive traits
exactly on those grounds, and you know, what do we make of
Southern California? I think it's an interesting question.
PROF. SANDEL: Could I give just a quick
reply? Which is I entirely agree that what I've said contains
a judgment on normal people, but the whole tradition of moral
philosophy and moral reflection consists precisely in that,
containing and engaging in reflective judgments on normal
people, including ourselves.
What is moral reflection if not precisely that?
DR. KRAMER: Let me actually make a second
answer to that because I think there is another answer to
it, which is to think about William James' first and second
born religious joy. That is, some people just seem to be born,
you know, able to believe in God and to believe that the world
is good, and that we somehow consider those people less morally
worthy than people who have to struggle and go through suffering
and come to, you know, essentially what James claimed was
essentially the same state of religious optimism.
You know, the moral enterprise, it is true, values troubled
people more than untroubled people, but it's also true if
you think about these Stoics and Cynics and Aristotelians
that the apparent goal is to live a life less troubled by
loss and pain or, you know, in the case of a religious person,
to get to the state of faith.
And then the question is: why is it that just having it naturally
or having it through some automatic means is less valuable
than having it through some other means?
I mean, I think there would be an answer along those lines,
CHAIRMAN KASS: I have Mary Ann and then
Rebecca and then Paul.
PROF. GLENDON: Well, first of all, thank
you for such an interesting paper and discussion. There's
so many things one would like to ask.
I'm going to start with some little questions that a number
of us were wondering about this morning and then come back
to this discussion between you and Michael Sandel.
In something we read it was said that Prozac is the fourth
most commonly prescribed drug in the United States in the
year 2000. Would that be approximately right?
DR. KRAMER: I don't know the answer to that,
but let's say it is.
PROF. GLENDON: Okay, and so one thing we
were wondering about about the top three, would any of those
DR. KRAMER: My memory is that the top ones,
you know — that the top one or two always have to do with
high blood pressure and esophageal reflux, but certainly if
you throw together Prozac and Zoloft and so on you get pretty
high up on the list.
PROF. GLENDON: So this is the last of the
little questions. Would you want to take a stab at guessing
what proportion of the American population at any given time
is on some kind of mood altering drug?
DR. KRAMER: I don't know the answer to that,
and someone does know the answer to that. I just don't know.
But you know, an implicit question behind this is: how does
the prescribing relate to the burden of illness? And the data
I've read is that you could still double the number of antidepressants,
maybe more than double before you would reach the number of
people who at any one moment are thought to be depressed by
those criteria that I mentioned.
Now, we could discuss whether those criteria really include
some things that aren't depression, and it also is the case
that those medicines aren't only used for depression. They're
used adjunctively in other mental illnesses or directly in
some other mental illnesses and for some other purposes altogether.
But you know, also if you had gone back ten or 15 years,
there would have been much less prescribing of antidepressants.
I forget again what the numbers of it are. It certainly has
gone up by one and a half times, you know, in the short period
PROF. GLENDON: Well, one reflection is the
one that is prompted by the thought. Those of us who are learning
about this for the first time, I suppose, now the next time
we walk into any social gathering, you're going to look around
the room and say, "I wonder how many people here am I experiencing
in some kind of pharmacologically altered state."
Of course, we all go to cocktail parties. So we're sort of
DR. KRAMER: All there.
PROF. GLENDON: — to that, but more seriously,
if this is a mass phenomenon and if the effects or Prozac
are as you describe them, then how are we to think about the
effect of that on our political and civic culture? That's
And the other is whether you've changed your mind over the
years since you wrote this book about the way you feel about
Walker Percy. You seem to be, on the one hand, powerfully
attracted by him, but ultimately, am I right that you're in
disagreement with him? You think maybe — well, specifically
his idea that it's very bad to be a castaway. I think he gets
that from Heidegger, the "Geworfenheit."
It's very bad to be a castaway, but the one thing that's
worse than that is not to know you are a castaway. He's thinking
of that more in existential terms, but for those of us who
operate at a more political level, it's somewhat alarming.
There are times in the history of a country when you think
that there are things that people ought to be worried about
and not going around what may worry.
So I wonder if you think that this mass use of these mood
altering drugs has an effect on our political and civic culture.
DR. KRAMER: I think that the — I'm sort
of a clearing house for Prozac complaints and information
and crackpot schemes and so on. So that, you know, just by
monitoring my answering machine and email I have some odd
overview. And I don't mostly think these drugs are used trivially.
I guess that might be a first step towards this social —
I haven't seen these examples that people worry about.
And, of course, it may be that you run into someone and they
say they're on it to be more creative, but you know, if you
really interview them, they're not on it to be more creative.
They're on it — they were put on it for some very substantial
And there are effects. I mean, I read something twice in
The New York Times, once in the education section
and once in some other article, where the health services
at universities are complaining that they're getting sicker
children, sicker young people because the people who otherwise
would have been handicapped or hamstrung by depression in
high school are on these medications which, say, work for
them for a year, a year and a half, whatever, and they do
well enough to get into a higher level college, and then the
health service has more children who, you know, started out
more depressed to begin with.
And I think we would say that is a good thing, you know.
That is assuming that we don't have some other concerns about
the medication and their long-term effects and so on, but
merely that more depressed young people are entering into
ordinary productive behaviors more successfully we would say
is a good thing.
And I suspect that that is the major effect, and I think
one reason we're hearing about things like accommodation in
the work place for the mentally ill is that there are more
depressive people successfully in the work place, and then
they're having whatever trouble they have on top of it and,
you know, what is the right accommodation for them?
So that on the whole, I think, you know, on a public health
basis the first thing to say is recognizing depression, treating
depression is probably much more important a problem even
where we are now than worries about overuse of medication.
I think I'm very prone to ambivalence myself, and I don't
know if I'm much changed with regard to Walker Percy. I've
thought a lot about, you know, what I value in myself. You
know, do I value my ambivalence and so on?
And I think a lot of my work comes out of worry and empathy
with depression and so on, although at the same time I think
any time I've had a chance to cast some of that aside, I have
done so quite willingly.
And I think, you know, if we had the opposite, if we had
a medicine or a procedure that made people less confident
and more troubled and so on, there would be very few takers
for it, you know.
I think depression is one of the things we value very much
in others or in this "faute de mieux" way where people write
memoirs of depression and they say, you know, "But there were
all of these things I got out of the depression."
And you say, "Yeah, right." I mean, that's true. In every
life one gets things out of what it is one experienced, but
you know, they really have worked very hard and the same is
true in earlier eras. I mean, you know, what if van Gogh had
antidepressants? Well, you know, van Gogh was on, I guess
— was it arsenicals? He was on digitalis. He was on high
dose digitalis as a sort of antidepressant, anti-epileptic
on the general sense that if you slowed things down, these
people with manic depression would do better, and there's
this story about whether one of his yellow paintings is related
to medication side effect.
I mean, there hasn't really been a time where people haven't
wanted to very vigorously diminish those traits. I don't know
if that — oh, let me give the real Percy answer, which is
I think it's the same answer about freedom.
That is, yes, I want to be troubled by things that are legitimately
troublesome, and no, I don't want to solve all of my problems
by going to the Gap and buying another pair of clothes to
feel that I'm being rewarded as a consumer.
But at the same time, it doesn't seem to me that there's
a lot of inherent nobility in suffering that is mere biological
PROF. GLENDON: I have one short question
about the effects of Prozac. Does it affect people's ability
to conceive and plan long-term projects, to think about the
DR. KRAMER: I mean, I think it may, but
you know, I think it may be one of these sort of parabolic
curves, if I have the right shape, where, you know, if you're
depressed and now you're less depressed, you can certainly
plan where you couldn't before. Whereas if you're manic, you
know, you're sort of throwing off all sorts of things without
choosing well among them.
It may be that that's one of the — in terms of main effects,
I think that's the spectrum. I think in terms of the side
effects of apathy or failing to care adequately, you know,
that that is just a problem on a number of dimensions which
would include planning.
CHAIRMAN KASS: The queue is longer than
we have time for. So let me call on a few people now. We'll
take a break and we'll hear from Carl Elliott, and then we'll
I have Rebecca and then Paul McHugh. We'll see where we are
when those two are done.
PROF. DRESSER: I wonder if you think about
a different kind of group of social effects, I suppose economic.
So does it bother you if drug companies are focusing a lot
of resources on, you know, the next Prozac or after the next
whatever, the next thing in this so-called cosmetic area,
as opposed to, you know, all the many others, even if you
limited it to mental illness, the needs that are out there?
You know, its effect on priorities, either drug companies
or, say, federal funding or what's covered by health insurance,
given, you know, increasing pressure to cut cost and people
are losing insurance.
I mean in the real world, these are the questions that bother
me, sort of allocation of resources and priority questions.
DR. KRAMER: Yes, yes. I'm very worried about
that. I mean, I think we could have started the worries earlier.
I actually think that, you know, doctors who go into cosmetic
surgery where that is not plastic surgery for cleft lip and
palate and burn victims, but for taking normal people and
making them look more attractive, should have to at least
pay back the subsidized costs of medical school, to the medical
school that I went to medical school.
I mean, I think, you know, that really there is a distinction
between treatment and enhancement, you know, that we want
to be able to make, and that treatment really is the priority.
There's no doubt that treatment is a humane consideration,
and there is doubt about enhancement.
I do think that most drug companies are working on treating
mental illness, and there's an enormously long distance to
go in treating mental illness, but because of the way brain
pathways work, because you're really working on developing
things that attach to receptors or, you know, all of those
methodologies, it seems to me are going inevitably to produce
substances that are as likely to change temperament as they
are to treat mental illness.
CHAIRMAN KASS: Paul.
DR. MCHUGH: Peter, it is wonderful of you
to come and to talk with us in this way, and I wanted to begin
by telling you that, while I like you because of your gifts
and your generosity, your handsomeness, your height —
DR. MCHUGH: — what I value in you, why
I think you are a remarkable psychiatrist in America, and
I've said this to many people, is that you're one of the few
psychotherapists that really listens to his patients and drew
from what the patients said not a conclusion about their particular
insights that you delivered, but that maybe the pill that
you were giving them was doing something quite remarkable,
and it took a lot of other people a much longer time to recognize
what you did and, therefore, you advanced the field tremendously,
and I value that.
And in the questions I want to ask you now is I want to know
if I can get you to move along a little bit further along
the same directions, of course, that you went.
First of all, you are talking in DSM-IV and DSM-III terms
a bit, and you and I know, and certainly Charles knows better
than anyone else, that that's a very poor lead for us to know
what we're talking about really because DSM-IV is a nomenclature.
It's a dictionary. It's not even a classification like we
And, therefore, the terms that we get to use may be too loose
for us to carry the kind of weight that you want to carry
in ethical terms. For example, because we don't have yet a
solid foundation on the biology of depression, we cannot tell
whether we're dealing with one subject that is a spectrum
or whether we're dealing with the fact that there may be a
particular disease in which something broken, just like tabes
dorsalis is a broken thing. Epilepsy is a broken thing, and
that there are other conditions that both of them are affected
by Prozac, but they might be different.
So, for example, bipolar disorder, of which depression is
one and which you haven't talked about as specific depression,
that might be clearly a broken part, and if we could find
out what that broken part would be, we might want everybody
to get fixed up just like we did before we discovered things
We're very confused about the range of epileptic phenomena,
out to fainting and things of that sort. We're quite clear
about what epilepsy is now and how different it is from swooning.
Now, to bring that around to what we're talking about, but
just as an aside, by the way, you talk about what we want.
"We" might be a very special group, we guys that grew up in
New England and all, because there are lots of people, you
know, following Michael's view, that were not terribly pleased
with psychoanalysis not just because of the theories, but
because of the kind of being that it promoted.
I mean, the idea was that you signed out, and there were
plenty of people that said, "Well, gee, what would have happened
to van Gogh if somebody psychoanalyzed him?"
You know that. I'm telling you things that you're perfectly
aware of. So what we're coming down to and what's concerning
lots of us in this conversation and, I think, concerning you
is whether the things that we're driving for are really what
Aristotle would call, you know, "eudaimonia" or whether we're
talking about Joe Campbell's bliss. Is that really the pursuit
of happiness, is to chase a bliss, and if we get a drug for
bliss, is that really what we want?
And, secondly, are you talking about wanting to support and
find value in — value by the way that I don't share — in
issues that are common and are called depression, but really
are the state of mind of fundamentally unstable introverts?
You know, unstable introverts are okay, but they don't necessarily
DR. KRAMER: Paul, I want to go back at some
point and ask you how you ever became a psychiatrist.
DR. KRAMER: Because they only let unstable
DR. MCHUGH: Spoken like a psychotherapist.
But what do you think, Peter? Do you think — these are all
tremendously important questions that you've raised, and I've
loved listening to you, but do you think they're going to
shape up and fall out? When we start instead of using the
word "depression" and even your word "melancholia," we're
going to start using words like demoralization in a certain
situation, the common state of mind of unstable introverts,
the mode of being that is more aggressive and assertive rather
than more accepting. And in that way we might be able to get
to a point where we could agree or disagree about what we're
doing instead of bringing this medical stuff all in with it.
DR. KRAMER: All right. Well, thank you for
the lead-in. I really appreciate the lead-in, and you know,
as usual, you've gotten the exact issues, which I am probably
not going to answer well.
Right. I think it's very hard to discuss these issues without
knowing what depression is, and we really don't know very
well. A psychiatrist in the office throws away the DSM, and
as I say, if you have a patient who has one or two symptoms,
but they really look like career symptoms, you might think
this person really is depressed. This is the real thing.
Whereas if you have someone who comes in and meets every
bit of those criteria, but you see a lot of resilience behind
that, and there's not much history going in and not much family
history, you might treat that person very differently than
the first one and really assume that although it looks on
a phenotypic basis exactly like depression, you're just going
to assume this person is going to get better on his own or
on her own or with just a little support.
So that we are looking for some core ailment, and it may
be that we're going to be able to pick off pieces of it. So
let's say late life depression really is a vascular phenomenon.
Well, we would all sign on to say we'd eradicate that. No
one needs, you know, vascular problems in the brain late,
late in life.
And so that maybe we'll pick things off, but my sense is
that in the end a lot of depression is just going to look
like what goes wrong when things go wrong in a certain direction,
and some people are going to be more vulnerable to that and
some less vulnerable.
And it's true that the hints of who is more vulnerable is
going to be something like neuroticism. This might be a private
discussion. I don't know, but I mean, that we can forecast
who's going to have a lot of trouble, and the way that looks
like is going to look like emotional reactivity in general.
So that's sort of how it looks now anyway, and I think that's
what psychiatrists, you know, maybe not a lot of psychiatrists,
but I think the psychiatrists who have thought well about
this, or researchers think.
Then we are going to be stuck with problems like the ones
I've talked about because it's going to look to the Darwinists
as if those problems are really a way of getting mothers to
attach strongly to their infants, by punishing them for loss
of attachment or so. It's going to look like part of the normal
human condition to be emotionally vulnerable in certain ways.
And the question is: there's going to be, you know, a very
profound question, which is how much we want to play the hand
that's dealt us, and how much we want to be free to do something
which, yes, the medical profession could treat it as a predisposition
to depression, but being really honest about it, what we're
doing is freeing people from constraints that have been necessary
human constraints or useful for the troop.
And you know, whether we want to do that is going to be a
very serious question, and that's why at the end of that,
everybody said maybe it's better to decide these questions
now than when we know more because we're very much in touch
with the whole tradition of caring about alienation or caring
about approaching troubles with a great deal of ambivalence
and doubt and worry and so on, and that maybe we ought to
decide how we value those before it turns out, you know, that
we can sort of pick them off piece by piece, attaching them
to things that medicine calls ailments.
I may have said two opposite things there, but you know,
that might be a fuller description of what I'm imagining.
CHAIRMAN KASS: Look. I'm somewhat arbitrarily
— I've still got five of us in the queue, and there are probably
others who would like to get in. Let's take a break, and let's
make the break a little shorter, say, ten minutes instead
We'll have Carl's paper. Dr. Kramer will stay with us, and
we'll continue this discussion once again.
(Whereupon, the foregoing matter went off the record
at 3:20 p.m. and went back on the record at 3:36 p.m.)