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Thursday, September 12, 2002


Session 4: Enhancement 4: Happiness and Sadness: Depression and the Pharmacological Elevation of Mood

Carl Elliott, M.D., Ph.D., Director of Graduate Studies, Center for Bioethics, University of Minnesota

CHAIRMAN KASS: Would people please return to the table so we can start?

Let me just turn the floor over to Carl Elliott, and thank you.

DR. ELLIOTT: All right. Well, thank you. Thank you very much.

I've enjoyed this so far.

Leon Kass called me and asked if I would talk about SSRIs and our souls and if possible, in less than half an hour. I'm going to give it a try.

I should probably start by at least mentioning, if I'm going to talk about psychiatry and souls, Walker Percy, the Southern doctor-novelist, and particularly his 1971 satire Love in the Ruins. Peter talked about the Thanatos Syndrome in his book. I liked Love in the Ruins a lot better.

And those of you who know the book know that its hero, my inspiration, is an alcoholic, lapsed Catholic psychiatrist and ex-mental patient named Thomas More, a descendent of the famous Englishman who invents an instrument called the ontological lapsometer, or as he calls it "a stethoscope of the human soul."

And the lapsometer is basically a medical instrument with which More can diagnose and treat existential illnesses. So his patients are generally these lonely, alienated, well to do Southerners who play golf and bridge and mow the lawn on the weekends, and then suddenly they wake up and look in the mirror and say to themselves, "Jesus Christ, is this all there is? You know, golf on Saturdays and shopping at the mall?"

And what Tom More finds is that he can actually treat these people with his lapsometer. He gives them a sort of quick, temporal lobe massage, and in no time these alienated folks are back to their old selves. They're self-fulfilled; they're self-realized; they're happy in their work, and at home in the world. What's wrong with that?

Something, More thinks, but it's not clear exactly what it is.

So when the psychopharm boom and panic began in the early '90s, Love in the Ruins was the first thing I thought about Prozac as the ontological lapsometer. Now, of course, America has been going through these psychopharm booms and panics for at least 50 years now. In the '50s it was Miltown. In the '60s and '70s, it was Valium and Ritalin. Ritalin set off one boom and panic in the '70s, another one in the '90s.

And it seemed to me that one common thread that was running through these panics was the notion that the drugs were somehow changing people, that they were somehow turning people into something or someone other than who they really were or who they ought to be, sort of this Stepford Wives' syndrome.

And so what seemed different in the '90s though was a strand that emerged especially in Peter's book Listening to Prozac, which I thought was very smart, a very smart book and very observant, that seemed to turn that old worry on its head. With the SSRIs, people were saying things like, "I feel like myself on Prozac," or, "This is who I really am," or stop taking Prozac and, "I don't feel like myself anymore."

And that seemed like a striking difference to me, as it did to Peter. I mean, it's one thing to use drugs as a kind of emotional numbing device. That's a familiar story. But what does it mean to find ourself, find your true self on Prozac?

Now, the answer that industry has pushed, of course, is a story that's told in the language of pathology and treatment, that we are being restored to mental health. The reason we don't feel like ourselves is that we're sick. Sick people don't feel like themselves. We have a dysfunction in brain chemistry, and once our serotonin levels are fixed, we'll feel like ourselves again.

In fact, GlaxoSmithKline even uses that line. They must have taken it from your book, Peter. You know, "I feel like myself again" in their TV ads for Paxil. But the Walker Percy in me wanted to resist that explanation.

Now, about the same time, as a result of a Canadian project that I started when I was teaching at McGill, I started to look at other kinds of so-called enhancement technologies, things like plastic surgery steroids, Ritalin, Botox, extreme body modification, sort of the works.

And the more I read and the more I talked to people using those technologies, the more I started to hear that same kind of language, that language of identity and fulfillment; you know, transsexuals who talked about becoming themselves with sex change surgery; body builders saying they use steroids to make themselves look on the outside the way they feel on the inside; shy people getting ETS surgery to prevent them from blushing so that they can be the same people in public that they are in private.

Even people who wanted their healthy limbs amputated because they're convinced that they'll only feel really at home in their bodies if they're missing a leg.

And the more I heard, the more I started to believe that I ought to rethink the way I had initially approached these patients who say they feel like themselves on SSRIs, and I started to think that that language that people are using is not so much a result of anything radically different about the SSRIs, but simply because that vocabulary, that vocabulary of identity and fulfillment and authenticity, that's the vocabulary that comes naturally to us now. It's everywhere.

You know, you find it on Web sites, chat rooms, interviews, ethnographies, TV advertisements, movies. You hear it in pop music. This is just the way we talk now. This is the way we think. This is the way we picture our lives.

And it seems natural to me now that it should be the way that people talk about psychopathology and medical treatment. So that even when people describe these radical self-transformations, when they've changed things that you would think are, you know, at the very core of their identities, you know, men into women, 90 pound weaklings into Schwartzenegger look-alikes, even healthy bodied people into amputees. They find it natural and fitting to describe that as becoming who they really are.

So when I gave this book that I've been working on, the subtitle American Medicine Meets the American Dream, that's what I had in mind, the way that the tools of medicine have been enlisted in that search for self-fulfillment and psychic well-being.

And it seemed to me that there must be a reason why that's happening here and now, and part of that reason, I suspect, is that when we retreat into ourselves, when we focus solely on the self, we lose our sense of how to measure the success or the failure on the life of any yardstick other than psychic well-being, and psychic well-being, I think, is something that can easily be bought and sold in a consumer economy.

Now, that said, the more I've given these sorts of talks about Prozac and I'm starting to teach classes using Peter's book, the more I've found a kind of striking contrast between private conversation about SSRIs and the broader public discussion.

It seems like in public everybody is officially anti-Prozac. All right? Feminists want to know why doctors prescribe Prozac more often for women than for men. Undergraduates worry that Prozac is going to give their classmates a competitive edge. Philosophy professors argue that Prozac will make people shallow.

My German friends will object that Prozac is not a natural substance. Americans say Prozac is a crutch, and most people seem to feel that Prozac is creating some version of what David Rothman called, in a New Republic cover story, "shiny, happy people."

In private though, people seek me out and tell me their Prozac stories. I think they have tried Prozac and they hated it. They tried Prozac and it changed their life. They tried Prozac and can't see what the big deal is. And it's starting to seem as if everybody I know is on Prozac or has been on Prozac or is considering Prozac, and all of them want my opinion.

And most of all, they want me to try Prozac myself. They say, "How can you write about it if you've never even tried it?"

And I can see their point. They're right, but still it strikes me as a very strange way to talk about a prescription drug. I mean, these people are oddly insistent. It's like we're back in high school, and they're trying to get me to smoke a joint.

Now, back in the '60s, I quoted Richard Nixon saying back in the '60s that Americans have come to expect happiness in a handful of tablets. I don't think that's right. I don't think that's quite right. That doesn't quite get at what's going on.

I think Peter is right, that the drugs are not being prescribed in a trivial way. I think we take the tablets, but we brood about it. We try to hide them from our friends. We worry that taking them is a sign of weakness, and we try to convince our friends to take them, too.

We fret that if we don't take them, others will outshine us, and we take the tablets, but they leave a kind of bitter taste in our mouths.

Now, why do they leave that bitter taste, you might ask. That's the question that I'm interested in, and I think it's a legitimate question. What actually is wrong with a psychoactive drug that not only relieves human suffering, as the SSRIs do, but can also move us from one normal state to the other?

That's the way that Peter framed the issue in Listening to Prozac, you know, as a drug that can move people along that spectrum from shy to outgoing, from melancholy to upbeat, from obsessive to laid back, and from a clinical point of view, I think that's a perfectly adequate description.

People have a variety of different personalities, a variety of different personal styles, and if a person makes an uncoerced decision to move from one style to another, then why should anyone else have the right to get in their way. I'll concede that point.

I think what we shouldn't lose sight of, though, is what that way of framing the issue misses, and I think what it misses is any sense of a person's relationship to frameworks of meaning outside the soul. If all you pay attention to is a person's inner psychic well-being, then you can't say anything about the appropriateness of that psychic well-being, whether it's the right kind of response to a predicament.

I think that's why I appreciated Gil Meilander's thought experiment.

Now, psychiatrists know this, of course, and psychiatry tries to finesse the issue somewhat successfully, not completely, by talking about how the patient functions, you know, how they get on at work, how they get on with their families, how they perform these various social roles, and so on.

But I think that function is only going to take you so far because it's not just a matter of how well you function in your job or with your family. I think what we want to say is that some jobs are demeaning; some families are dysfunctional; and some ways of living are spiritually empty.

And if your worry is about the spiritual emptiness of life as an American consumer, then it's the happy consumers that you're going to be worried about, the people who don't feel any sense of alienation from that kind of life.

I have to say I feel a little bad that Peter was sort of put on the defensive about Prozac, and I think his actual writings show much more ambivalence, and especially his novel, which I highly recommend to you, and I think in some ways gets at some of the same worries that I have about the SSRIs.

Now, Walker Percy, I think, talks about this very same thing, The Delta Factor. Percy says given two men living in Short Hills, New Jersey, each having satisfied his needs working at rewarding jobs, participating in meaningful relationships with other people, et cetera, et cetera, et cetera, one feels good; the other feels bad. One feels at home; the other feels homeless.

Which one is sick? Which one is better off?

Now, from a clinical point of view, the answer is clear. If you're a psychiatrist measuring depression using the Beck depression inventory, there's no question which man is better off. It's better to feel good than to feel bad. It's better to feel at home than to feel homeless.

And I think it's perfectly reasonable for the man who feels bad and feels homeless to want a medication that's going to make him feel better.

For Percy though, the answer is not so clear. Percy wants to say sometimes it's not better to feel good than to feel bad. Some situations call for a kind of alienation. Some people ought to feel guilty. Some people ought to feel ashamed. Some things call for fear and trembling.

So when the psychiatrist looks at the unhappy American consumer, she sees somebody in need of treatment, somebody who could function better on Zoloft or Prozac or Paxil. When Percy looks at the same unhappy American consumer he sees something very different. He doesn't see a patient with a problem, but a person in a predicament.

And part of that person's predicament, Percy thinks, is that he's come to see himself as nothing more than a consumer of experiences the success of whose life can be measured in terms of his mental hygiene, his sexual happiness, and the state of his body and his bank account.

That's his real predicament, and that's not a patient in need of treatment. That's a wayfarer who has lost his way, a castaway.

Now, Percy is the first to say it's not great thing to be lost, of course. It's a problem. It's just not a medical problem. All right? And this is not a criticism of medicine. It's a plea to keep medicine in its proper place.

The problem, I think, is the tyranny of a world view that presents all unhappy psychological states as medical problems defined by the languages and techniques of psychiatry rather than, say, as existential problems defined by our predicament as mortal beings who will die.

Within that medical world view, suffering becomes a problem of brain chemistry. A drug that fixes the chemistry solves the problem of suffering, and so death, loss, grief, fear, anxiety, shame, all become medical problems that can be addressed by experts with prescription pads.

Now, I take it that it's an open question whether, in fact, SSRIs do, in fact, blunt people's sense of alienation. Some people have argued that they may even help Percy's alienated consumer take charge of his own life and change it.

I'll have to defer to the clinicians here for that, but there is a literature that suggests that at least in some patients, the opposite is true, that the SSRIs do take that edge off of alienation, that they do cause a kind emotional blunting, that they do cause a certain apathy, help people get rid of their shame, and that literature seems to fit with, you know, what I hear from friends and colleagues who are taking SSRIs or prescribing them.

Now, the impulse here if you're worried about what some people will call the medicalization of unhappiness is to try to draw some lines, to try to drop a few anchors, to try to come up with some hard definitions of mental illness so that we know who really has major depression and social phobia and generalized anxiety disorder, and so on.

Now, I can understand the impulse, but dropping those kind of anchors is very difficult. It's not nearly as easy as it looks. I mean, we talk about mental illness, but the fact is mental illness doesn't stand on all fours with physical illness. One of our project meetings, Peter was there. The philosopher Jim Edwards made a sort of offhand comment that he felt as if the word "depression" has a lot more in common with a word like "suffering" than it does with a word like "diabetes."

And I think that's right, and I think it gets at something important about the grammar of psychological experience, and the words that we are drawn to use when we're trying to describe those psychological states.

I have a sort of thought experiment here that I want to repeat to you. It comes from Wittgenstein. Whenever I say the word "Wittgenstein" people's eyes tend to glaze over. So I'll make it short.

PROF. SANDEL:: Here they brighten.

(Laughter.)

DR. ELLIOTT: One. I'll look at you when I — okay.

There's a famous passage in the Philosophical Investigations, the so-called beetle box game where Wittgenstein says imagine a game. Suppose everybody has a box. Something is in it. We call it a beetle, "beetle" in scare quotes here, a beetle. Nobody else can look into anyone else's box.

Everyone says he knows what a beetle is only by looking at his beetle. Right? Now, Wittgenstein says, look. It would be quite possible for each person to have something different in his box. In fact, it would even be possible for the contents of the boxes to be constantly changing. In fact, it would even be possible for all of the boxes to be empty. Yet still the players could still use that term "beetle" to refer to the contents of their boxes. There don't have to be any actual beetles in the boxes for the game to be played.

Now, what's the point, you're asking yourself. Well, the point is that the words that we use to describe our inner lives, our psychological states, words like "depression" or "anxiety" or "fulfillment," those words get their meanings not by referring and pointing to intermental states, things in our heads. They get their meaning from the rules of the game, the social context in which they're used.

They're like the word "beetle" in Wittgenstein's game. We learn how to use the words not by looking inward and naming what we see there. We learn how to use the words by playing the game. The players don't all need to be experiencing the same thing in order for the words to make sense.

I say I am fulfilled. You say you're fulfilled. We both understand what the other means. Yet that doesn't mean that our inner psychic states are the same. Right?

We can all talk about our beetles, yet still have different things in our boxes.

Now, I hasten to say none of that means that psychological suffering isn't real. I surely don't want to say anything to demean the experience of psychiatric patients.

The point is about the grammar of psychological language. Generally speaking, there are no independent, objective tests for mental disorders. There's no blood work; there's no imaging devices; there's no ontological lapsometer.

Psychiatrists usually don't listen to heart sounds and percussed chests. They can't open up the box and look at the beetle.

The diagnoses that they give to patients are determined not by what they see in the box. They're determined by the rules of the game, and psychiatrists don't write the rules. They try. That's why you have manuals like the DSM, but even if they could, the rules would still be indeterminate because of the grammar of psychological experience.

Everybody can have something different in his box and still play the game. Now, what that means is that no matter how rigidly you define psychiatric disorders, no matter how many criteria you list in the DSM, there's always going to be that kind of indeterminacy, and that indeterminacy can be exploited.

And you know, I guess in the end that is what I worry about, the way that that kind of fuzziness around the edges, what Peter called "diagnostic bracket creep," the way that can be exploited and it will be.

Antidepressants are now the most profitable class of drugs on the market. The pharmaceutical industry is now the most profitable industry in America. According to Fortune magazine, the drug industry has had the highest profit margins of any industry in America for the past ten years, over 18 percent.

The study that you referred to, Professor Glendon, it was the one I referred to. It came from the National Institutes of Health Care Management, and it said in the year 2000 Prozac was the fourth most prescribed drug in America. Zoloft was the seventh most prescribed drug, and Paxil was the eighth.

GlaxoSmithKline spent over $91 million that year in direct consumer advertising for Paxil, mostly TV ads. That's more money spent advertising Paxil than NIKE spent advertising its top shoes.

Now, that is a remarkable change over the past — really over the past five years, but especially over the last ten years.

We've been talking about antidepressants, and you've got a background paper on depression, but in fact, the term "antidepressant" is starting to sound more and more old fashioned all the time because the SSRIs are now approved by the FDA not just for depression, but for social phobia, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and premenstrual dysphoric disorder, and they're likely used off-label for a whole range of other conditions, from eating disorders to sexual compulsions.

And that expansion in use corresponds with an expansion of mental disorder. It's diagnostic bracket creep.

Now, that's not to say that drug companies are in any way making up diseases. Nobody doubts, or at least I don't, that some people genuinely do suffer from depression or social phobia or that the right medications will make them better. But around the core of those disorders is this wide zone of ambiguity that can be chiseled out and expanded.

And the industry has a very powerful financial interest in doing just that because doctors are gatekeepers to prescription drugs. It's only when a condition is recognized as a proper disorder that it can be treated with prescription drugs. The bigger the category, the more patients who fit in it and the more psychoactive drugs that will be prescribed.

Now, to me in some ways that's potentially the most dangerous part of the SSRI story. I mean, in Love in the Ruins, Walker Percy, I think, saw this coming. When Tom More is tempted by the devil, the devil looks like a drug rep, a detail man as they were called back then.

I think that's unfair to drug reps, actually, who are just doing their jobs after all, but I don't think it's unfair to psychiatrists. Since we have at least three psychiatrists around the table, I say this with some trepidation, but I don't think psychiatrists have been exactly iron-willed in resisting this particular temptation.

Here you've got the most profitable class of drugs in America being produced and marketed by the most profit industry in America. Yet psychiatrists apparently see no conflict of interest in being on that industry payroll. You have psychiatrists doing clinical trials for industry, recruiting patients for industry, clinical trials, signing patent and royalty agreements with industry, taking gifts and honoraria from industry, signing their name to ghost written articles for industry, even holding industry stock.

Two years ago, the editor of the New England Journal, Marcia Angell, who was then the editor, wrote that when the journal published an article on the antidepressants, the ties of its authors to the drug industry were so extensive that the journal didn't have sufficient space to list them all in print. They had to run them on the journal's Web site instead.

And when she tried to commission an editorial on the antidepressant, she could find very few academic psychiatrists who didn't have financial ties to the makers.

Now, that makes me very nervous. I mean, it makes me nervous about how much I can trust the drug approval process which relies on academic psychiatrists as outside experts.

It makes me worry how much I can trust psychiatrist expert witnesses in litigation. It makes me worry about how much I can trust what I read in psychiatric journals.

But mostly it makes me worry about patients. Psychiatrists, like other doctors, have this extraordinary responsibility over vulnerable patients. Yet they're assuming a position where they have financial ties to corporations with an interest in having them write more and more prescriptions.

That's not just a conflict of interest. It's a microcosm of what's happening with enhancement technologies more generally: a medicine has moved to become more and more like an industry run by large corporations, managed care forums, for profit hospitals, insurance companies, the drug industry, the biotech industry. The sale of psychic well-being has become big business, and mental health as a result is becoming just another commodity to be bought and sold in a market economy.

I think I'll stop there. It's a sort of polemical tone to stop on, but I tend to get worked up when I talk about the pharmaceutical industry. I'll stop.

DR. KRAUTHAMMER: I'd like to take up two points. One, the social construction of disease, which is what I think you were getting at, Dr. Elliott, and secondly, try to get us back to the issue of enhancement.

I have no conflict of interest in talking about these issues because I'm a psychiatrist in remission.

(Laughter.)

DR. KRAUTHAMMER: I haven't had a relapse in 25 years.

It's clear to me that when we talk about the diagnoses, psychiatric diagnoses, there is an enormous amount of arbitrariness in those definitions. I know that from personal experience because I worked in the '70s on the depression inventory with Gerry Klerman. I worked with him on DSM on the depressive illnesses in DSM-III, and I have the unique experience of having written a paper identifying a psychiatric syndrome, a depressive syndrome actually, a manic syndrome, and inventing the criteria for it and then discovering over the last quarter century that every year a dozen or 20 papers are published, discovering new cases of this illness that I had described using the criteria that I had chosen.

And I know that I chose them reasonably, but also arbitrarily. I could have chosen in my Chinese menu three from Column A instead of four.

So there's an enormous amount of arbitrariness that goes into these definitions, but I think that does not mean that the illnesses are necessarily socially constructed.

I think Paul is absolutely right that when you see a psychotically depressed patient, you know that something in his world is cracked. This is clearly something medical. It is not a question of just excessive suffering. There is something here that is not arbitrarily — Thomas Szasz is wrong. It is not something that is imposed on the patient by us.

But once you get closer to the norm, then that is where the arbitrariness kicks in. I think we would say that similarly with the question of intelligence and retardation. If we have a person with an IQ of 30, you would say that something here is cracked. If you have somebody with an IQ of 90, you would say this is just a variation off the norm, which I think brings us to the issue of enhancement, which is to go from one position, one normal state to another.

I think that's a good definition that Peter offered.

If you have a pill that would cure retardation, take a person with a 30 IQ and give them a 100, nobody here, I believe, would object. The question is: do you take people with 80 IQ, give them a pill which puts them at 90?

In this analogy of depression, I don't think anybody has a problem with giving ECT or drugs to cure a person with psychotic depression. We're always amazed and gratified when it works, as it generally does.

Our question is: do you give a person who is melancholic a pill that will bring them to a different, otherwise normal state, which they feel more comfortable with?

So in answering that, I think that we have to go to what Mary Ellen spoke about, which is what are the larger social, societal costs.

Now, I'm just throwing this out as a possible answer to this question. I'm not sure that if an individual came to me and said, "I'm melancholic. I'm not depressed. I'm not mentally ill, but I want to feel better," will I deny them Prozac?

As an individual I think my answer would be no. As a prescriber, I think I would say I would have qualms. We've discussed what are the drawbacks in terms of that person's soul, if you like, in doing that, but I wouldn't deny them.

The question is that if you have the whole society on that what happens. It's almost a question of externalities. What is the cumulative effect of having a society that does that?

I was thinking of this question that was raised earlier by Gil about grief, normal grief and loss. I was thinking of yesterday, September 11th, and how necessary, how moving, how human was that sort of tidal wave of sorry and grief that we saw, and what — and I imagined for a moment what our society would be like if we could have had a pill to eradicate that.

Yes, in the cases of one or two individuals and even ourselves, our loved ones, we might even want to have that pill and administer it. But how catastrophic would be the results if that was how we dealt with grief and loss as a society.

So I'm throwing out a very crude way to look at our question of enhancement (a) to say that there are real diseases that I don't think anybody would have a problem dealing with. They bleed into the normal. That's where we have our problem.

On the individual level I'm not that troubled, and I'm not sure as society we would be with allowing a person to go from, say, a depressive scale that was equivalent to an IQ scale of 80 to 110, but if you did that as a matter of course in society, I think it would have terrible societal effects, and that, I think, is the paradox and dilemma of enhancement.

CHAIRMAN KASS: Jim Wilson.

PROF. WILSON: Since I'm from Southern California and was raised there, I am naturally a buoyant spirit as my remarks are about to indicate.

Thirty-four years ago, in May of 1969, I sat in a room at Harvard College where a couple of people much younger than I said that corporate greed and the profit motive of industry was preventing young people from feeling authentic and was instead instilling in them a deep sense of alienation, of which Harvard University was the witting or unwitting tool.

Now, 34 years later, I sit in a room and young people tell me that corporate greed is encouraging authenticity and preventing alienation. The pendulum has swung. I'm not particularly interested at either end of the pendulum swing. I'm more interested in what is generally true.

And if you look at the human temperament, as Charles suggested, you might look at IQ. You would see that many traits are normally distributed. Some people, some men at the death of their wife immediately become suicidal and may, in fact, kill themselves. They may represent just a tiny fraction of the population.

At the other end there probably are some men who at the death of their wife go buoyantly off chasing the next skirt in town. I doubt, however, that the second group is as large as the first because unless the wife had been seriously abused, she would long since have left this husband because she would have realized he was incapable of love.

But in between are 96 percent of the population, and so the question I'm raising is: what are we talking about here? Are we moving toward some understanding of how most people ought to be treated by most physicians or rules should be set governing how patients are treated by most physicians or are we simply trying to stake out the territory at the ends of the cyclical swings?

CHAIRMAN KASS: That's a question which Dr. Elliott or Dr. Kramer could be invited to respond.

DR. ELLIOTT: I'm curious about why this council is discussing psychopharmacology. I mean, when Peter and I talk about it in our project meetings, it's fairly clear that we're not looking for any sort of policy results. We're sort of doing philosophy or literature, whatever.

And I don't think we've had any conversations in our group about regulating.

CHAIRMAN KASS: The intention here is not a regulatory one or not immediately a policy one. As I indicated in the introductory remarks, which I kept fairly short, I think that among the concerns that people have for biotechnical powers are those uses that go beyond the obviously intelligible use of treating known individuals with recognizable diseases or acknowledged disabilities or suffering, ranging from the mere satisfaction of desires, however reasonable, to the uses for social control, to the possibility of improvement bordering ultimately on making changes in what at least people who are still friendly to this notion would regard as changes in human nature, and that we have the luxury here of being able to step back from some of the burning questions to have a survey of these powers now present and on the horizon and to try to figure out what do they actually do to us. What do those actions mean? Why, if at all, should we be bothered?

Is our disquiet simply a function of their novelty or are there really questions that touch deeply the character of our humanity as individuals and as a community that we should worry about?

And one of the reasons I think we chose to begin — and we've had something on the use of genetic technology for the enhancement of athletic performance, and we will tomorrow be talking about muscling up with the aid of genetic technology. This is the first venture really into the technologies that affect the psyche.

And one of the reasons for starting with Prozac is not that anybody here is envisioning new regulatory mechanisms, but here is one of these drugs which has a whole spectrum of uses in which, as has been indicated, the indications are fuzzy. The diagnostic categories are to some extent arbitrary, where it's not really clear what the character of the moral disquiet is, and we've got an opportunity to learn from something which is here, which we've had some time to think about, maybe pick up some pointers about how we should think about the things which are on the horizon.

And I think Jim Wilson's question is — I mean, the question is what is the source of our disquiet and our concern. I don't think, Jim, you meant to say that the economic interests in this area are irrelevant to our concerns. I mean, I don't think that was —

PROF. WILSON: I'm prepared to open that up as a hypothesis to be discussed. I have no views one way or the other on it.

CHAIRMAN KASS: Right. But, I mean, partly there are the questions, it seems to me, of — well, let me have a stab at it, and maybe this will provoke some other things.

For the people who have been waiting, let me apologize. I was somewhere in the queue, in fact, just about now.

It seems to me part of the difficulty with this subject is it's not clear on whose turf, which is to say in whose universe of discourse, conversation properly belongs. If Mike Gazzaniga will get into the conversation, I suspect we would start much closer to neuroscience than to the question of the pharmacological industrial complex and its medical complicity.

When Peter Kramer starts, he starts with patients who come to see him with what to begin with looked like depression, but then who come with various other existential conditions which they would perhaps like to see altered.

One can enter this in a variety of ways. You could begin to talk really about personal self-discontent without regard to clinical definition of depression. I mean, there are people who don't like something about themselves, and one happens to have here, thanks to neuropharmacology, something that enables them to do something about it.

And the question is: is there any reason why that is somehow different than people who are in some other ways handicapped by things which are perfectly acceptable to us as a result of their being familiar?

So partly there's a question of what's the proper terminology for talking about what this is, and I think there are lots of possibilities, and all of them have a certain kind of plausibility, at least at the start.

Second, it seems to me there are the questions about the end results that are being aimed at and whether or not and the costs of their success, whether an individual or, as Charles and Mary Ann are talking about, in terms of the community. And there it's not necessarily obvious to me that what we're talking about is the virtue of melancholy and alienation rather than something else.

I mean, everyone is talking about flattening of souls or a decline of aspiration or a certain complacency or whether one's talking about freeing people from certain demons or goblins or just impediments that would enable them to pursue their human ends in the way in which people who don't feel these impediments do.

And then there is, it seems to me, also the further question about what you really mean by happiness or well-being and to what extent that is a mood or a temperament or whether that is somehow connected with human activities the realization or fulfillment of which produces a kind of flourishing, which is a different account of happiness than Paul alludes to.

And then there is, finally, the question which Peter Kramer raised in passing, but we didn't discuss so far, and that really has to do with the question of the peculiarity of pharmacology as a means and whether part of our disquiet has to do with the fact that these drugs bring about changes from the patient's point of view like magic. That is to say one can feel their result, but what has happened to oneself is unintelligible because the means of change are not the usual means of self-improvement, which are through speech or symbolic deed or things which are at least in principle intelligible to us, even if we are being coerced by people we can somehow see what they're trying to do to us.

It seems to me these are a family of questions which somehow are responsible for why there is a disquiet here. No one is talking about legislating about these things. One's trying to understand what does this mean. Is it important? What does this bode for things that might be more powerful and that affect other aspects of our being, you know, from memory and alertness to various kinds of dispositions in the world?

DR. KRAMER: I'm just trying to be quiet for a minute, but I actually think I do want to say a little, tiny something.

And I'm in agreement with all of the last number of speakers. I think Carl has done the favor of being somewhat practical where I have been impractical by bringing, you know, drug companies into the mix more openly.

And I think that I am torn two ways about what categories are and what category mistakes are. And one practical thing to say — I know this commission isn't going to do this — is that there is some risk of taking this medical model, which is built on things like there being genetic contributors and there being changes in the brain and there being standard courses of the ailment and so on. That's how we construct illnesses.

There's some risk of taking that and extending it further and further because as we get better at genetics, as we get better at brain imaging, it's going to turn out that lots of very minor things are going to turn out to have those qualities.

There's going to be genetics fighting a lot with your spouse, and there's going to be brain damage from that stress and so on if we get subtle enough.

And one question is who controls those boundaries. Are the boundaries more or less like what the boundaries of health and illness have been for a millennia, for centuries anyway, or do we allow those to be expanded in some way so that the medical enterprise takes on more and more legitimately?

And one question is a lot like the IRB question, which is: who controls the data that contribute to that decision? Who makes the decisions?

And I've said many times I would be much more comfortable, say, if drug companies were taxed based on the success of their drugs or, you know, "tax" may be a bad word, but where in some ways contributed to a pot of money where some independent agency then tested the after market risks of the drugs or even tested efficacy of the drugs.

And it would be good to take that out of commercial hands. You'd still want this vastly successful enterprise of drug development to continue, but you'd like some greater independence for this enormous amount of money so that the psychiatry professors and all do not have conflicts of interest and so on.

That would seem to me a good thing, and it relates to this question of enhancement in the sense that the boundary between illness and wellness would be somehow controlled by public discussions that weren't overly commercially influenced. So that seems to me that's one practical result.

The other thing I want to say though is back on the impractical sphere, which is that as regards these category changes and category mistakes, in the past our failures have largely been in the other direction than the one we're fearing here. That is, there was a period that Charlie referred to where people said schizophrenia was really the result of bad parenting or mixed messages within the family and so on, and where, you know, the claim was that what medicine called an illness really was an existential dilemma for a troubled soul.

And really, I think, one would have to believe just very strange things to believe that today. I think schizophrenia really looks a lot like an illness on every ground, and it may be that on quite legitimate grounds we will expand the definition of illness as regards things like minor depression because we — you know, it really just turns out that some things that have seemed like normal levels of melancholy and so on really are caused by a virus, you know, and it's clear that people that don't have that virus, you know, do much better and they make beautiful paintings and write poetry as well.

So I think that, you know, those seem to me, anyway, two aspects of it.

CHAIRMAN KASS: Let me go in the queue. I have Bill Hurlbut, Dan, Frank and Bill May, Paul and Janet.

DR. HURLBUT: The issue you just raised about expanding the borders of definition of illness, that seems to me something we could reasonably endorse. The question is: where does it get over into just normal human variation? And where does it end up relating in some way to something that shouldn't be called a disease at all?

That wasn't very insightful, but let me go on, and I'll show you where I'm circling back.

Leon said a few minutes ago that — mentioned the notion of alienating — I guess he didn't use quite this word — but alienating ourselves from our own self-understanding by taking a drug that doesn't allow the continuity of comprehensible change or intelligible change, and so in a way it alienates us from ourselves, making us not just unable to understand, but inadequate and in a sense turns us over to — turns our problems over to the matter of being understood by an expert.

And I think one of the weird things about these new drugs is that you see people saying to themselves, "Do I need this?" who never even thought they were sick in the first place. It's expanding the question in everybody's mind as to what do I need to be optimal.

And that's what I want to get back to. I want to ask each of you a question and make a comment, but premising this, when you said, Charles, that you can imagine people going from 30 to 80 and then from 80 to 110, but what about from 110 to 160 or 140 to 180? I think that's the real issue.

And so I want to ask you each a question, one, and then I want to make a comment about them because I think there's a coherence.

If we look to this whole question of enhancement that moves us off center, not just to center, then the question of values and goals comes up. Peter when you were saying — when you were speaking earlier, we pretty much all dismissed the notion of — well, there were two dimensions that were dangerous with regard to goals. One was that we might become frivolous, have frivolous, meaningless lives, what you spoke of, alienation, the Los Angeles syndrome, what Nietzsche called pitiable comfort.

But the other thing, and this is what I want to ask you, you implied earlier that serotonin was genetically and socially a drug related to hierarchy and, therefore, evolutionary competition or at least social competition and evolutionary success.

To what extent is this well-being feeling that we're getting actually just the feeling that we're winning? And is this really, in fact, a form of competition?

DR. KRAMER: I think that these serotonergic drugs give a feeling of well-being, and I'm not a great believer in evolutionary or Darwinian explanations. They seem to me so unfalsifiable and so much in accord with what just happens to be the case.

But one of the more attractive views of what depression is on a Darwinian basis is its discouragement in foraging activity at a time of scarcity. I mean, there could be a million different theories like this, but let's think about this one.

Let's say food is scarce and it makes sense on the basis of energy expenditure to sit in the cave for a while. So the body does that to you by making you depressed.

And then when things look a little more likely, you spend the energy and go out and forage for food. And now, we don't think on the basis of human good that we should necessarily be subject to those signals, except when they're adequate signals. Maybe we're far enough from the hunter-gatherer domain that we oughtn't to experience even minor versions of those feelings because they're actually not accurate signals. They're accurate only in a sort of metaphoric or analogical way, and we have other ways, less painful ways of gathering that information and making choices about action.

So I think, you know, that's sort of a partial answer. That is, I don't think that it necessarily is the case that the medications are making everybody feel like, you know, the top male or that they're winning, but taking people who sort of characteristically are prone to be the first ones to feel this sense of unlikeliness that things will succeed and, you know, bringing them probably into a more adaptive relationship with their current environment.

That was not even grammatically clear, but you know, I think that's sort of a partial answer to one way of thinking about the question you asked.

DR. HURLBUT: I mean, I don't endorse evolutionary psychology wholeheartedly either, but I think it's a reasonable premise that the mind would have been shaped just like the anatomy and the physiology for functions that had real significance of evolutionary import, and in that sense our sense of well-being ought to coordinate with that which is in our evolutionary best interest.

Does that make sense?

DR. KRAMER: Well, I think the issue is, you know, is it now a misleading signal where it once was a leading signal and is there enough other development, you know. Are we enough different from mice and so on that we could do with less of it?

I mean, I think that is one question. That is, when we talk about the natural, this is a particular area where the natural is very much related to the social environment, you know, both when we think in gloomy ways and when we think in optimistic ways about making those changes.

That is, you know, it seems to me a person might rationally say, "Yeah, this may have been a useful signal for a hunter-gatherer, you know, but I've got to punch the clock at nine in the morning."

And then we could take that statement seriously and say it's not adaptive for this person to be depressed even in a minor way, and then we could ask whether there are social distortions that then enter in, if people who otherwise are depressed are enabled or whether there are benefits to the individual, what level of analysis we want to apply.

But I think we don't necessarily have to say because it developed on some evolutionary basis we want to saddle people with it or discourage them from altering it in any fashion.

DR. KRAUTHAMMER: Leon, could I give just a quick answer to Bill's question about the extremes? You asked about the 110 and the 160.

I think the reason that we're talking about the middle range is because the extremes are easy. If you're taking either an intelligence, retardation or if you wanted some arbitrary or fictional scale of well-being or happiness, someone who's at 30 and you bring them to 100, everybody would say that's okay. If you start at 110 and you go to 160 and create a genius or someone with an excessive sense of well-being, we'd be troubled by it, and I think consensually so.

The difficult problem is the 80 to 90 to 100, and I throw out again an example from September 11th. We have a drug that treats grief, demoralization, unhappiness, disgust with oneself. It's called alcohol. The problem is it wears off.

So assume that we had one that didn't. Would we administer it? I think that that's a difficult question.

DR. HURLBUT: Well, I'm not sure I agree with you. I mean, I think I see this as intuitively more difficult as you get toward the norm, but why shouldn't the goal of enhancement or maybe put it this way.

The reason it seems to me that we find the 160 to 180 easier to say is not because it isn't better to be smarter. It's because we see the competitive motive in it. We see it as disordering society somehow.

But why shouldn't it be go for everybody to be enhanced?

DR. KRAUTHAMMER: Well, I think that is what I raised earlier about the cumulative societal effects. If you do this on a widespread basis, what would our society look like if everybody had 160, I think?

CHAIRMAN KASS: But probably that depends, Charles, on having an accurate description of what it is that these various measures do to us, and that's not altogether clear.

I mean, are we sort of turning people into things that — well, by Peter's hypothesis, it's moving the individuals who would like to from one kind of normal condition to another, and it's not absolutely obvious that if a sizable fraction of the population moved over that the world would be a worse place.

DR. KRAUTHAMMER: It would be different, and because it would be different in ways that are obscure to us, it's the difficult question. I think the other ones are a lot easier.

DR. HURLBUT: Can I follow this a little further?

CHAIRMAN KASS: Briefly because there are others.

DR. HURLBUT: That's okay.

CHAIRMAN KASS: Frank.

PROF. FUKUYAMA: I'd like to take a stab at answering Jim Wilson's question about what's really at stake here. I mean, I agree with the things that Leon said, but I think there's an easier way of describing the problem.

I regard a lot of this discussion as part of the broader discussion that's been going on way before neuropharmacology about the expansion of the domain of the therapeutic medicalization of a whole series of behaviors, and what's wrong with that? What's wrong with that is that it undercuts the notion of individual moral agency, which is a public good.

It's important that people believe that they are responsible for important domains of their lives and to the extent that you tell them that what they have is a disease that is caused by an external, that there's an external etiology for that, then you relieve them of that responsibility of taking care of themselves, and I think that's exactly what happens with a lot of these pharmacological agents.

I mean, one of the popular books written on Ritalin in the 1990s was titled It's Nobody's Fault, and you know, the authors begin by saying, well, there's something like — I don't know — 20 million people that have ADHD, and they just don't know it. And if you have trouble concentrating, it's because you've got this disease and no one has told you about it.

And there's a drug, and you shouldn't have to worry about, you know, your interior motives because it's really not your fault.

So I think the problem is really that. Everyone would agree that the popular belief in individual moral agency is an important public good that ought to be preserved, and it's threatened by this constantly expanding domain of the therapeutic, and I would say that the threats are very much as Dr. Elliott described.

I mean, the drug companies — well, okay. There's three parties really that are pushing this. The drug companies, you know, Prozac goes off patent, and so they've got to figure out new disorders that this thing treats.

The psychiatrists, you know, want the business, but it's also the patients. I mean, every participant on Oprah wants to be told that it's not their fault, you know, that they're feeling sad or that, you know, they can't get their lives together, and everybody would like to be told that, in fact, no, you got this disease. It is treatable and get your own, you know, individual moral self out of it.

And so without the cooperation of all of those groups, you know, together, I don't think you would have this problem. I do think that it is, you know, something that requires more rules.

This doesn't happen in somatic medicine nearly so much because, you know, there's fairly accepted standards for what's the pathology, and you need a pathogen and so forth.

But as Paul and Charles and we have discussed this in earlier sessions of this, I mean the DSM is a mess. I mean, it's driven by politics. There's not a clear consensus as to what's a disease, what's a disorder, which means that basically it becomes this grab bag, that anyone with an interest in putting something in there can put it in and cumulatively that has the effect of medicalizing, you know, virtually everything.

And I think that's really what's problematic about that. And so I think, you know, it is worth thinking a little bit whether there's a way. I mean, given these very powerful interests on the part of these three communities that are pushing us in this direction, whether there are ways of, you know, breaking that a little bit.

I mean, one suggestion is, you know, there are cases where something, as Paul was saying, cases where things are definitely broken, and if you could actually use better science, you know, to figure out, you know, where that point comes and where you can actually say that something is broken, then, you know, that might be a contribution to breaking this broader process.

CHAIRMAN KASS: Jim.

PROF. WILSON: I certainly agree with Frank's view about the importance of individual moral agency. I certainly agree that maintaining standards of guilt and shame and innocence and guilt are extremely important.

I wrote a slender book which three people read, two of them quite critically, about how moral agency is maintained in the court system, in the criminal court system, where you see brought out the full panoply of alleged expert opinion, much of it produced by so-called scientists who are testifiers for hire, some produced by psychiatrists and physicians who should know better.

And what's striking about it is that people reject it. There are conspicuous exceptions, and we can all name a few where people have been let off for what strikes us as absurd, over medicalized reasons.

But in general society doesn't tolerate the medicalization of deviants. They are very stern at least with respect to the criminal code regarding individual accountability.

Now, the reason I mention that is not to confront Frank with an alternative view or to dismiss the importance of what he says, but simply to highlight the following question. Before we discuss this much longer, we have to have some idea of what the problem is.

Now, when I tried to find the problem in the criminal courts, does the abuse excuse work, does chemical agents cause behavior to be modified in ways that juries will let up, I couldn't find it. Now, maybe we can find that on Oprah, though unlike Frank, I have not watched Oprah. So I will have to check it out.

But in Southern California we have more important things to do than watch television.

(Laughter.)

PROF. WILSON: But unless we get a sense of what the problem is, not at the conceptual level, that we want to be concerned about the human soul, but at the level that we can embrace in the 18 months in which this council has yet to live, it's hard for me to understand what we're talking about.

CHAIRMAN KASS: Does someone want to tell him?

DR. MCHUGH: Well, yeah. I think this is an important point that Jim is raising and it's the one that I want to come back to, and that is that whenever you start talking about the realm of psychiatry, you very often don't know what you're talking about.

That came very clear to me when I was made a chairman of a Department of Psychiatry in 1975 and had before me the task of developing the careers of people who wanted to be treaters, people who wanted to do research, how to go to the dean and speak to him about what the department needed and the like, and I looked around and I looked for a model department.

There is none or there was none. I looked at what constituted psychiatric disorders. Everybody was at that time fussing about whether it was biological or dynamic. What should be a treatment? Nobody knew. This was even before Prozac.

And I decided that the crucial thing then, and I still think the crucial thing now, is to speak about what we mean by the nature of the disorders psychiatrists take care of. And when you look at them, in point of fact, and if you define them simply as conditions that people come to you with problems in their mental life or behavior, in fact, some of them are on all fours with any physical disease.

I mean, for example, delirium is on all fours with any other neurological condition. Alzheimer's disease. You remember Alzheimer was a psychiatrist. It's hard to believe that, but Korsakoff syndrome, all of those.

The real problem for psychiatry and for our conversation here has been not the medicalization of unhappiness, but the neurologicalizing of unhappiness and the neurologicalizing of psychiatry. That's really what's happened.

I happen to be both a neurologist and a psychiatrist, and was fundamentally disappointed that there were things that the neurological system didn't take in.

Now, the person who really called this to my attention early and in some of his writings was, in fact, Walker Percy, not just in his novels, but in his interest in child psychology, and Percy wrote several interesting essays on the distinction between what he called dyadic disorders, of which the neurological ones are the kind we are talking about, that one gene, one disorder, one problem, from triadic disorders, which human beings can have as well as dyadic, namely, how they symbolize the world, what assumptions they take about the world, and how those assumptions can get them into trouble.

And I believe that psychiatry in DSM-4 has not only screwed itself up completely in this terrible nomenclature, but it has given up on the idea that we have responsibilities, both the conditions which are dyadic and other conditions which are triadic in the sense of taking responsibility for them, changing our assumptions about them, finding our way out of the troubles, out of our predicaments because of what we're in.

And I think I tried to lead a Department of Psychiatry that took all of those into account.

I was not only prompted thinking in these terms by Walker Percy, but an early person prompted me to this, Augustine when he said, "Give me chastity, but not yet," and made you realize that he thought that at some point he needed a gift to get out of the troubles that he was in.

And sometimes a doctor or psychiatrist appropriately would work in that arena. But what do you think about that, Dr. Elliott? Do you think — by the way, I also want to announce to you that I am an academic psychiatrist. I take not one nickel and never have from any drug company. I have no — the only monies I ever got outside of the Johns Hopkins was from the NIH.

And I agree with you that it has certainly poisoned the wells of our confidence in this field when we discover that there are essentially people making millions of dollars a year from drug companies and claiming to be advocates for particular disorders.

But what do you think about that? Do you think really there's a problem, the problem that's being raised by Jim and everything, is that we have forgotten the fact that psychiatrists take care of both conditions which have clear neurological issues and things which are also quite clearly of human origin and the human capacity to symbolize, to assume, to take up positions far and beyond what rats and mice and other things can do?

DR. ELLIOTT: I think I agree with virtually everything you've said actually. It seems to me that the problem is that it's so easy to neurologize ordinary life. I mean, because of the fact — I mean, you're absolutely right. Some illnesses that are taken care of by psychiatrists are on all fours with physical illnesses certainly. Schizophrenia, probably.

The problem is that even for many of those the pathophysiology is unclear, and so you rely solely on what you see the patient doing and saying for diagnosis, and once you have a diagnostic system that's built solely on that, that kind of arbitrariness is going to be built into the diagnostic categories from the start.

And then if you — yet because psychiatry is medicine, it's wedded to a medical model where you have diseases and you have treatments and you match them up and, you know, that's the way medicine works.

But you have these drugs being produced that don't quite fit into that model, and so the model has to be made to fit them. And so it seems to me that what you've had with the SSRIs, you know, has been, you know, a gradual expansion of things. You sort of look at what they do to people, and then you come up with, you know, an illness to fit it or you expand an illness that was there before.

I mean, social anxiety disorder is one, you know.

DR. MCHUGH: Well, as Charles says, we don't come up with the illness, things which alcohol can take care of when we discover that we can feel more cheerful with alcohol. We don't try to fit a disease to that.

DR. ELLIOTT: But if you had to have a prescription from a psychiatrist every time you went into a bar, you probably would.

DR. MCHUGH: Well, I don't know. Not necessarily. A psychiatrist could well say, "I mean, look" — I mean a psychiatrist really does study mental life, not simply follow a neurological point, but studies mental life.

He could well say, "Look. There is grief," Gil's point, "and panic-like grief that Jacqueline Kennedy suffered down in November 22nd, down in Dallas." She was given a drink to just calm her down. We didn't think that she had a neurological disease. We thought she was a person who had just seen and witnessed something that was, you know, devastating.

We psychiatrists, I think, do this all the time or at least I hope the psychiatrists that I train do. They might discover, and all of us might agree, that your neuroticism came down with an SSRI, and that if you are severely unstable, we could kind of help you for a little bit. But we wouldn't say that neuroticism was a disease any more than we say a low IQ necessarily is a disease.

DR. ELLIOTT: What if your a managed care organization said —

DR. MCHUGH: Oh, yeah, well —

DR. ELLIOTT: — to be reimbursed you have to have a reimbursement code?

DR. MCHUGH: Managed care would not be here without DSM-III, let me tell you. DSM-III opened the door to managed care by making it clear that we psychiatrists could only think in these categorical terms.

And that's the reason why people want to put more conditions into DSM-IV, you know, because then they're going to get reimbursed for it. I think we should go back to something else.

CHAIRMAN KASS: I've got a few people in the queue, and we're coming close to closing. I have Bill May; I have Dan Foster, Janet.

Bill.

DR. MAY: I'm not disposed to think of the conversation for this particular group a waste of time. I mean, if one is talking about the problem of medicating away something that's valuable, then that's worth our considering.

I would like to begin by offering two cheers for sadness. Dr. Kramer, you talked about the way in which we can sentimentalize the traditional society that provides structured forms of appropriating a major event like death and pointed out to us there are perky Greek widows who are restless under the discipline of this social structure, and of course, there's the modern widow who may be not permitted to grieve, not because we force her to pop Prozac, but we don't have adequately developed social forms for framing the grief that people have to go through.

And we're not talking here simply about bundles of dispositions, but we're talking about the way in which people negotiate the passages of life, and that fundamental negotiation is not simply the final event of death, but death as it besets us in the course of life over and over again, and not simply because others die, but because we're going through redefinitions of the self.

We are giving up and taking on in a variety of ways. You may recall, Jeffrey Gore in his book Death, Grief and Mourning did talk about society that maybe doesn't have adequate social forms for accommodating, condemns too many people to limitless grief.

And the prior problem may be that we haven't developed the social forms that make us excessively dependent upon the medication to solve the problem in private settings.

The stamp of grief is even there on the most celebratory of occasions, the Jewish wedding and the breaking of the glass, the traditional society puberty rights, which included the whipping, the tattooing, the pulling of a tooth.

I was very impressed by one traditional society which had a rite for parents following the rite where the child now, death to childhood, now enters adult life, and then a rite for parents called crossing the fence.

And I've often thought if I were doing a commencement address, it would be interesting to have the ceremony, commencement ceremony, and then a following rite for parents called "over the hill and crossing the fence." There's a redefinition not simply of the child, but also of those who are close to him or her who are going through redefinitions themselves.

On this whole business of alienation, which appears in the articles that we've read, and then the association of alienation with pessimism, and the unalienated with optimism, and I don't think that's what is at issue in the literature on alienation.

Alienation, as I understood it, in "Geworfenheit," the Heideggerian literature and so forth, is the whole problem of how are we thrown outside of an absorption in the world, and of course, Heidegger did, of course, identify this in the being towards death and so forth, but even Heidegger had the sense that there's a kind of cognitive significance to feelings other than the feeling of anxiety.

Boredom throws us outside of our absorption with the world. Joy can also do it, the element of ecstasy, of standing outside of our normal forms of absorption.

And that very much relates to human transcendence, a kind of openness. Now, that's very different from both pessimism and optimism. I mean, the optimist is absorbed in the world, the unimpeded flow of the shallow mind. And we've had lots of descriptions of the surfer in this afternoon's discussion.

But there's also the question of the absorption of the pessimist, choked with worry, preoccupied, anxious. And it may very well be that Prozac and other such drugs are very important in establishing a little bit of that clearing, that openness to the self and openness to others, and so forth which that person is not able to achieve on his or her own.

The last comment on healing. We have tended in this discussion to associate healing with curing us of the negative, but in Leon's earlier work when he defined health as the well working of the organism as a whole, there was the connection to the positive, which was very important and the way in which you develop that.

And of course, in traditional societies, the traditional healer, there were two different narratives for illness, one as the invasion of the negative, in which case the healer treats to overcome the negative, or the removal from the positive and the way of reconnecting with the positive.

Now, it's that latter activity that has some difficulties in establishing boundaries because shouldn't we be drawn to ever increasing possibilities for participating in the enhancement, better working of the organism of the whole? And, hey, we've got something further that will help that well working of the organism as a whole even more.

And it is this latter understanding of healing that we can't dismiss. It's important, but tends to create all of these problems of boundary that are not so obvious when healing is defined as fighting against the invasion of the negative.

CHAIRMAN KASS: Very, very nice. Let's see. Dan.

DR. FOSTER: Mr. Chairman, in view of the fact that we've gone past the time, I'm going to pass.

CHAIRMAN KASS: Janet. You don't have to follow his example.

PROF. ROWLEY: Well, I was thinking about that earlier, but there are two comments I want to make. One is sort of following on some of the discussion, and that is as an optimistic Midwesterner, I object to the equation of optimism as shallow and insubstantial.

The second is that — and partly in response to your question to us as to what are we doing here or why are we looking at this question — as you can see, we are a democratic group with very disparate views of almost all parts of the world, and there are at least some of us or I, speaking for myself, am not really very concerned about enhancement, and I think that some aspects that we're talking about do have some issues of concern, but I think that from my view, this is not one of the more major problems of ethics and bioethics that face either our society or the world.

And I will repeat what I've said before, that when we know, Charles, how to take somebody with an IQ of 100 and make them 160 or 180, the world will probably have already come to an end because this is just not something that is even within the realm of possibility, and we are spending time and effort on — we talk about etherial things and elusive things. This is just not going to come to pass.

And so I am concerned —

DR. KRAUTHAMMER: Janet, you —

PROF. ROWLEY: — that we are not spending our time and effort on consequential problems.

DR. KRAUTHAMMER: You entirely misconstrued my point on intelligence. I was using it entirely analogously.

What I'm saying is that in depression, we have the drug that can take you from 30 to 100. ECT can do it. Antidepressants can do it, and they can do it — ECT can do it in one day.

And what we have with Prozac, as Dr. Kramer has outlined, is we have another technology which can draw you from — and I use these numbers. I was using IQ only as analogous — as a way to be able to draw a scale.

Prozac will take you from, say, 80 to 100 or 110, from a normal state to another normal state. I was not talking about our ability to create a genius. I was talking about a real problem today of having a drug which can cure clinical serious depression, which we would all agree is a good thing and having drugs which at the same time can change your normal state, which is what we're discussing here. Is that a good thing for individuals and for society?

And I think that's a real issue and real problem.

CHAIRMAN KASS: Yeah, and I think the discussion has indicated that for a variety of reasons these come through the path of medicine because these are prescription drugs which we tend to think require some diagnosable indication, but the more — I mean we didn't talk about this particular very much, this selection from Stephen Braun. Kramer alluded to it ?- but the more one finds out about the workings of the brain and the more one develops various kinds of agents that can produce, by the way, not just transient relief from some acute episode of grief, but that can bring about certain transformations of the psyche.

The pressure will not be from people who say, "I have this disease," but there is an efficacious way of making me different than I am and the way that I would like to be, and it's not clear, given the fuzzy boundaries of nosology and psychiatry, that self-discontent doesn't count as a perfectly legitimate reason for coming to ask for some kind of help unless, of course, there are some kinds of arguments that can be offered either in the individual case or in a communal case for why this doesn't really make a lot of sense.

The incidence of use of these things above and beyond the treatment of clear and severe disease already is, I think, an indication of the fact that lots of us — and I'll speak for myself — reading your stuff made me wonder to what extent is my outlook simply in the Middle Ages. Melancholy was an excess of black bile. Now you guys have got new names for this stuff, and to what extent is my outlook a certain kind of funny humoral balance of these neurotransmitters rather than a correct response, a correct feeling, affective response to a correct perception of the world?

And the more and more that question comes up, the more and more it seems to me lots of people are going to be interested in experimenting with this to see if they can't get themselves to a kind of psychic condition which they like themselves better or the people around them like them better or they're going to function better.

And that's got nothing to do with clinical disease because the boundary, it seems to me is very fluid, and I think you've already eight years ago or nine years ago did an enormous service by calling attention to the fluidity of this, and it does seem to me, I mean, it's not necessarily a public policy question for us, and it may not be the most burning question, but these are now powers to do things to where we really live and fit with certain cultural understandings of what's desirable, fueled by certain kinds of economic forces and the reconception, the neurological reconception or the neurobiological reconception of who we are.

But once those concepts begin to change and you have powerful means for doing something, people are going to want this whether the drug companies are pushing it or not.

So it does seem to me whether it's the right case study for us, it seems to me something that's already here with large implications for what it means to be whole and how you go about pursuing it.


  - The President's Council on Bioethics -  
 
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