Thursday, September 12, 2002
Carl Elliott, M.D., Ph.D.,
Director of Graduate Studies, Center for Bioethics, University
Session 4: Enhancement 4: Happiness and Sadness: Depression
and the Pharmacological Elevation of Mood
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
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
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
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
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
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
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
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
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,
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
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
PROF. SANDEL:: Here they brighten.
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
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
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.
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,
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
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
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
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
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
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,
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
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
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
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
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
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
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
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
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
CHAIRMAN KASS: Briefly because there are
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
And there's a drug, and you shouldn't have to worry about,
you know, your interior motives because it's really not your
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
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
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
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
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
But in Southern California we have more important things
to do than watch television.
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
CHAIRMAN KASS: Does someone want to tell
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
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
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,
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
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
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.
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
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
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
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.
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
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.