Crossing the Medical Boundary?
On the human flourishing approach, it can be argued that psychiatrists need not confine themselves to offering treatment for the traditionally evolved psychiatric categories of illness or disorder. Psychological conditions that are not intrinsically harmful should not count as psychiatric disorders. But there are intrinsically harmful psychological conditions that do not fit the traditional disorders. The methods of psychiatry, whether psychotherapeutic or pharmacological, may also help someone escape a life-diminishing personality.
Some thoughtful psychiatrists notice a shift in their own aims when prescribing antidepressants. Peter Kramer raised this issue in the context of his treatment of his patient “Tess.” Her alcoholic father died when she was 12. Her mother went into permanent depression. Tess took over caring for her mother and the nine younger children until they grew up. At 17, partly to give her brothers and sisters a base, she married an older man, an abusive alcoholic. The marriage collapsed. Tess became a successful businesswoman and still also looked after her mother. She had a strong sense of guilt and responded, perhaps too much, to the claims of others. She thought she put off men, and she had unhappy involvements with abusive married men. She had all the symptoms of clinical depression.
Dr. Kramer prescribed medication that brought Tess out of clinical depression.1 But she was still easily upset and cried when asked about her boyfriend. Wanting a more robust return to her personality before depression, Dr. Kramer suggested Prozac: “My goal was not to transform Tess but to restore her.”
On Prozac Tess did seem transformed: relaxed, energetic, and with more self-esteem. She laughed more and had a new ease with people. She stopped crying over her old boyfriend and often dated other men. She felt less guilt about her mother and stopped living so close to her. She was less self-sacrificing. She felt relief at this “loss of seriousness.” Her illness cured, she went off Prozac and continued to do well.
Yet, no longer depressed, Tess asked to go back on Prozac. She felt it had given her stability, ease, and confidence. Without it, she said, “I’m not myself.” Dr. Kramer prescribed Prozac, and Tess recovered her ease and assurance, but he worried because that he was no longer treating an illness, but changing her underlying temperament and personality.
Psychiatrists are right to be concerned about crossing the normal medical boundary. On the Aristotelian approach, crossing the boundary could be justified in such a case. The aim was to overcome psychological obstacles to a good life. Peter Kramer’s worries suggest a degree of commitment to the medical categories, but his policy here suggests the pull of the human flourishing model. If some or all of the “personality disorders” are not considered to be medical conditions, this approach could justify offering treatment aimed at eliminating the disorders or alleviating their harmful effects.
The conditions for crossing the medical boundary should be stringent. The aim must be to benefit the person concerned, not to promote the interests of the government, or the supposed interests of society, as in the Soviet, Chinese, and other political abuses of psychiatry. Also, of course, those treated must give their reflective and voluntary consent. They must be told about any risks and the element of nonmedical “enhancement” of their psychology. Under these conditions, psychiatry directed at enriching a person’s life, not at curing illness, may sometimes be justified.
Tess, as Kramer describes her, had problems that seem to have arisen out of her childhood and family circumstances. But as thoughtful psychiatrists often notice, many of the psychological problems they are asked to treat have wider social origins.
The impact of poverty and unemployment on mental health and on suicide are well documented.2 Soldiers in huge numbers return from combat with post-traumatic stress. Of the 1.3 million soldiers who have returned from the wars in Iraq and Afghanistan, 28.2 percent have sought mental health treatment.3 In those wars, suicide has cost more American lives than death in combat.4 An intelligent version of preventative psychiatry would focus on getting politicians and the public to see clearly the heavy psychological costs both of economic policies careless of the human dimension and of wars too easily embarked on.
Those choosing these uncaring or unintelligent policies prefer to see the associated psychiatric epidemics as mainly caused by individual psychology. This may also suit pharmaceutical companies, some of whose priorities are seen in their spending. About 35 percent of their revenues go to marketing and administration, “the largest single item in big pharma’s budget, larger than manufacturing costs and much larger than R & D.”5 Peaceful foreign policies, or economic policies aimed at eliminating the stress of poverty and insecurity, could reduce the demand for their products.
Medical priorities are different. Education about smoking, carried out against the interests of the tobacco industry and the opposition of some uncaring politicians, has saved many lives. There is an obvious preventive medical case for equally vigorous public education about the social and political causes of psychiatric disorders.
Until public education succeeds, there remains a need for psychiatric help. The prime causes of suicidal thoughts in people who have lost a job or in soldiers back from war are to be found more in society than in individual psychology. But this is no help to the person who needs help for very real depression or post-traumatic stress. The dominant causes might not be medical, but the condition becomes psychiatric through being a psychological state that significantly impairs the person’s chances of a good life. If there are helpful psychiatric interventions, of course they should be offered.
It seems right for Dr. Kramer to have offered Tess help. What should be the limits of this boundary-crossing “human flourishing” version of psychiatry?
In the very conservative, ultra-orthodox Haredi community in Israel, antidepressants are said to have been given to yeshiva students, seminary girls, and married adults because these medications suppress sexual desire. An account, based on statements made by psychiatrists, patients, and family members, was given in the Israeli newspaper Haaretz.6 Requests for these prescriptions are said to come from rabbis, yeshiva supervisors, and marriage counselors. There are claims that some rabbis pressured psychiatrists to prescribe particular drugs.
In 2011 the Israeli Psychiatric Association held a conference titled “The Haredi Community as a Consumer of Mental Health Services.” Professor Omer Bonne, director of Hadassah University Hospital, Jerusalem, was reported as saying that antidepressants were sometimes prescribed to yeshiva students to dampen sexual desire. The aim was to reduce anxiety and depression. These were caused by the tension between their homosexuality, masturbation, or “compulsiveness in sex” and the religious teaching that these things were sinful.
Professor Bonne said that, when younger, he had been against prescribing the drugs: these sexual activities were not medical problems. But awareness that in that context they create terrible mental conflict changed his mind.
Professor Bonne’s earlier view, opposing the use of psychiatric medication for nonmedical problems, gains support from the history of “treating” gays. But cases like Peter Kramer’s “Tess” may support his later view, in licensing some uses of psychiatry against other obstacles to the good life, obstacles that do not fit the medical categories.
Further support for this use of antidepressants may come from the earlier discussion of whether the normal grief of a bereaved person calls for medical intervention. In grief the depression can be severe, but priority should be given to context and meaning. When the grief is meaningful to the person who is grieving, that person might not want to eliminate it. There is some parallel with the religious case. Sexual desires may have a different meaning to people when they conflict with deep religious convictions. In that context, wanting to dampen the desires could make sense. Should not context and meaning prevail here too?
Further support may seem to come from the discussion of severe and perhaps suicidal depression in people who have lost a job or who have postcombat trauma. The causes may not be medical, but the condition still calls for the offer of treatment as a severe psychological obstacle to the good life. Does not this also apply to the anxiety and depression of the yeshiva students?
This is a strong case. It would be decisive if it were the whole story. But it is not. Some religious communities may indeed see rejection of “sinful” homosexuality or masturbation as essential to the good life. Those who accept this may, in their own terms, be justified in requesting the medication. But what about the rest of us, who do not see these things as sinful and may distrust the indoctrination behind a student’s acceptance of the medication? How should we, and especially psychiatrists who do not share these religious values, respond?
There are good reasons for opposing these interventions. Apart from any bad side effects of the medication, there are real doubts about the autonomy of the request, so influenced by external pressure from people who disapprove of the sexual desires. Even without immediate outside pressure, a request shaped by community-imposed indoctrination still might not be autonomous.
These are good reasons for rejecting the request. But psychiatrists who see this may still be pulled the other way by wanting to relieve the terrible mental conflict. Accepting that the desires are not sinful and that the request is not autonomous, they may see medication as the only way to rescue the person from cruel mental distress.
This is a decent motive. But that way lies the contentment of Brave New World. And the dark side of the history of psychiatry warns against it. If changing society is impossible, changing the person may seem to be the way out. This may be through trying to “cure” gay people to spare them the distress caused by society’s prejudices. It may be through trying to help dissidents or colonial rebels escape conflict by curing their “latent schizophrenia” or the “inadequacies” of “the African mind.” It may take the form of reducing normal sexual desires to help someone escape guilt about “sin.” So, from good motives psychiatrists can become collaborators in oppression. The boundaries should be drawn to exclude this.