Is It Moral to Feel Better than Well?

In 1935, Borden, the maker of milk products, produced a famous animated cartoon called “the Sunshine Makers.” It featured one group of grumpy dwarfs who went around saying, “I’m sad” or “I feel terrible,” and another happy group that would reply, “That’s good!” The happy group, filled with sunshine, tries to get the sad group to be happy by firing guns loaded with sunshine at them, but the Grumpies resist. In the end, the Happies bombard the Grumpies with sunshine, and after being forced to be happy, the Grumpies rejoice.

Alarmists think that an alliance of pharmaceutical companies and psychiatrists push sunshine on a society of passive Grumpies, and that such techie sunshine cannot substitute for the real thing. In Beyond Therapy: Biotechnology and the Pursuit of Happiness, Leon Kass implies that such sunshine merely mimics authentic life. Yes, you can take Prozac to feel better, but it’s a drug-induced fog.

Kass’ view mimics one of the greatest works of literature about mood-altering drugs, Aldous Huxley’s Brave New World. A benevolent dictatorship runs a highly efficient society stratified by biological castes, where a daily dose of Prozac-like soma keeps citizens quiescent. If citizens take too much soma, it puts them to sleep.

The opposite of Brave New World appeared in 2007 when psychiatrist Peter Kramer published Listening to Prozac. In it, he describes Tess, a woman in her mid-thirties in public housing who, after her father died when she was twelve, cared for her depressed mother and her nine siblings, never dating and always living for others.^[1] She came to Dr. Kramer depressed and unable to socialize. On Prozac, Tess overcame her depression and fears, started to date, left her apartment, and became independent.

Critics claim that the Prozac engendered fake happiness for Tess. Tess retorted to Kramer that Prozac allowed her real self to appear.

Kramer reports that many of his patients experienced the same thing. In a chapter entitled “Makeover,” he describes how patients on Prozac lost their compulsivity or depression, became focused, and no longer avoided people.

Clinical depression, as opposed to the passing depression of temporary setbacks, has been described by some as feeling like being in a cold, dark freezer that numbs emotions. Antidepressants such as Prozac take one out of the freezer and into the sunshine.

Critics say the hard way of talking therapy is better, but why, I wonder, is the more difficult way better? Is it more effective? Traditional talking psychotherapy works well for some problems, but not for depression caused by biochemical imbalance. Because our Puritan heritage makes us think we don’t deserve to be happy, do we mistrust quick fixes?

For critics of mood enhancement, antidepressants symbolize enhancement. They represent quick, shallow change. Where natural change of mood comes slowly and arduously, change with antidepressants seems quick and easy. For critics, if we become a Prozac Nation, we’ll morph into drugged zombies who shuffle around blandly on islands of Dr. Moreau. On antidepressants, we’ll spend our days atrophying on the Internet, prisoners in Plato’s Cave, watching shadows of pixelated artifacts.

Some bioethicists, such as philosopher Carol Freedman of Williams College, philosopher Erik Parens of the Hastings Institute, and Minnesota physician Carl Elliott, argue that mood enhancers enforce dubious norms, undermine personal responsibility, and substitute a false, manufactured personality for earned character. This character only comes through effort and struggle. As such, these bioethicists favor public policy that limits such drugs.^[2]

Wake Forest English professor Eric Wilson, in Against Happiness: In Praise of Melancholy, leads this charge from the brigade of literature. He argues that Prozac simulates a living death, blocks our creativity, hinders our spiritual-growth-through-suffering, and should be avoided.^[3] Wilson believes that creativity, success, ambition, and vision conflict with a desire to be happy, and that this desire for happiness will lead us into “half-lives, to bland existences, to wastelands of mechanistic behavior.”^[4] For Wilson, to be happy at all, while people die in Africa from AIDS, is to be “inauthentic.” Sorrow is “sweet,” he says, but happiness is “self-satisfied smiles” (smugness), “treacly expressions … painted on our faces” like botoxed lips and rouge. To be happy is to have “an essential part of [our] hearts sliced away and discarded like so much waste.”

So should we go forth and suffer? Should we wish on Wilson, then, an unhappy, turbulent, chaotic life? According to Wilson’s writings, we should. Here Wilson taps into an ancient Christian trope of growth-through-suffering, itself an answer to the age-old Problem of Evil (Question: Why do we suffer so much from a kindly God? Answer: He wants us to grow in spirit.)

Perhaps the best, shortest attack on Wilson’s book comes from comedian-singer Garrison Keillor, producer of National Public Radio’s “Prairie Home Companion.” In a review of Wilson’s book, Keillor wondered why, given that Wilson embraced suffering so much, he hadn’t written a better book.^[5]

When it comes to mild depression, anxiety, and other mood disorders, philosopher Freedman argues that it’s a fact that talking therapy beats drugs.^[6] However, a review of the clinical literature does not appear to back up her claim.^[7]

Carl Elliott agrees with Wilson and argues that mild depression should not be seen as an illness but as a personal reaction to the ills of the world. “From this perspective,” he says, “treatment of the depressing state should not be covered by insurance because the condition is actually a truth about the world.”^[8]

Elliott is clear about what values may be lost using Prozac. He thinks people should ideally have a long-term project in life toward which they work and the completion of which fulfills them. Part of this quest comes from looking inward and searching for a worthy project. Elliott considers a suburban accountant who, while seeing a psychiatrist, questions his life. Elliott thinks that if the accountant gets Prozac, he will stop questioning his life because he has been contentedly medicated, so the psychiatrist should not write him a prescription.

I agree with Elliott about the ideal. Unfortunately, most people find it difficult to obtain. Even with effort, good health, secure income, and intelligence, it takes luck.

The assumption that Alarmists make is that projects performed on mood enhancers are fake. They think that the good results come from a drug, not one’s true self.

I personally believe that for many people, a biochemical disturbance lies behind their depression. So I believe that any increase in happiness they achieve on antidepressants is real, not fake.

Remember Dick Cavett and his talk show, where he sparkled with the world’s wittiest guests. Many were shocked to read in 2008 that Cavett suffers from severe depression. In his essay in the New York Times, Cavett urges people not to ask the sufferer “what he has to be depressed about,” because the illness is biochemical, not situational.^[9]

Cavett wished that his psychiatrist could once get inside him for a minute to feel what he felt. When his psychiatrist heard this, he replied, “Oh, I know. I got pretty sad when my father died.” To which Cavett angrily retorted, “Do you think grief is even close to this?” He went on to describe how bad things can get:

So would English professor Wilson urge Cavett to stay creative and eschew anti-depression drugs?

No, he and the other bioethicists say we can allow such drugs for people with severe depression. Critics fight not over genuine clinical depression but over mild depression, the kind that may be temporary, a life-stage (post-partum depression), or situational (after being fired), and which millions struggle with during part of their lives. For such mild depression, Wilson thinks people should avoid antidepressants.

Of course it makes sense that Wilson is an English professor. English, especially because of its subfield of creative writing, has become a popular, ersatz therapy for people with mental illness. Some mistaken person often encourages these vulnerable people to write about their delusions as therapy. In fact, this is only true if the writer adopts a third-person perspective, if he does not relive violent episodes, and if the professor of creative writing has been trained in supervising the writing of people with mental illnesses, all rarely the case.^[10]

After the Virginia Tech shootings in 2007, English professors across North America worried about whether students who showed potential for violence should be expelled from class. The shooter, Seung-Hui Cho, wrote about violent acts in poet Nikki Giovanni’s class.

In January 2008, the Association of Writers and Writing Programs at their annual meeting in New York City held a special session devoted to this topic. The session concluded that Wilson’s view does not help many troubled people: these people need good drugs, psychiatrists, and reality checks, not encouragement to throw away their medications.

The strangest thing about this debate is the notion of other people judging one person’s private mental states. What could it possibly be more difficult? Or more obnoxious than some know-it-all telling Martha that, although Martha has never felt more at the top of her game as a history professor, Martha teaches inauthentically because she takes antidepressants?

Here’s why Wilson is wrong. If antidepressants made thirty million Americans into zombies, wouldn’t it be obvious to the rest of us that their lives had turned into Night of the Living Dead? On the other hand, if we have the repeated testimony of many who take antidepressants that their lives improved greatly, that they couldn’t imagine going back to life without drugs, and that they now function better as mothers, editors, and teachers, then these observations do not sound like those of zombies but of awakened Rip Van Winkles.

Perhaps Wilson confuses old and new drugs. Old-time antidepressants made people zombie-like, but new ones let personality spring forth. As Emory bioethicist Paul Wolpe observes, in both cases the new person may be unrecognizable to those who once knew her.^[11]

A critic might ask me why I favor allowing people to somatize their moods with Prozac while I question Virtual Life and cosmetic surgery as fake. Well, I believe that major clinical depression is a biochemical disorder like schizophrenia and, as such, should be treated biochemically. That is, I don't believe that most depression is fake or that its cure is fake.

I view the history of psychiatry as a fight against the view that merely better attitudes can cure mental illness. Whether it is better attitudes by parents to avoid an Oedipal complex in boys, or better attitudes of depressed patients to will themselves to “snap out of it,” society has often believed that something softer than biology causes mental illness.

When biology faces free will as the cause of diseases, biology usually wins. We once thought that only the sinful got syphilis, cholera, and HIV, but now we know better. We once thought that people’s attitudes caused depression, bipolar disease, sexual orientation, and schizophrenia, but now we know better.

Popular wisdom has made many mistakes about mental illness and will likely continue to do so. Public policy about reimbursement of treatment for mental illness has fared even worse: few systems of medical coverage adequately cover such problems. This error began decades ago when some critics thought people with schizophrenia, in order to get out of work and to get benefits, faked their delusions.

Such mistakes show that we are as likely to be wrong as correct in thinking that competent adults fare better off antidepressants than on them. Given that chance of error, why shouldn’t group policies cover them?

A mean, cold-hearted worldview mistakenly substitutes a personal view of goods in one worldview with a just public policy. The personal worldview is that antidepressants for mild depression are frivolous, unworthy of being subsidized by group medical coverage.

Only a few decades ago, everyone thought that psychiatrists could use therapy to talk people out of being depressed. Of course, legions of counselors, social workers, therapists, and clergy still make a living through talk therapy. They believe it’s the only way.

But as Peter Kramer said about Tess, that view just begs the question. If competent judges—who’ve experienced both states—claim the drugs helped them, then critics are mistaken.

Critics such as Wilson do not empathize with the situational depression of a single mother who works the night shift of KFC at an interstate gas station, feeling trapped, and going nowhere. Maybe she needs antidepressants to keep putting food on the table. Until the revolution comes and its workers' paradise, maybe she could use some “inauthentic” happiness? Would it be so terrible for her physician to help her? Or should she take Wilson’s advice and, for the good of her soul, suffer?

The reality is that she will be lucky to have any medical coverage, much less for mental illness, much less for antidepressants. Employers out to maximize profit don’t offer employees coverage for mental illness or coverage for the drugs such people need to function.

Many people’s lives fare less-than-ideal, as they try to cope with deaths of pets, children, spouses, and aging parents, and also endure job stress, personal illness, and poverty. Some were laid off or never found good, profitable careers. Still others remain in bad relationships for the sake of children or finances.

In the end, does it matter whether a lousy life changed Gene’s biochemistry or whether Gene’s lousy biochemistry caused Gene’s unhappy life? In either case, improving the biochemistry may change the way Gene feels about this life.

I am rarely depressed and I don't take anti-depressants, but perhaps my biochemistry will change in ten years and I will need them. I certainly might need them if situational trauma, such as the death of someone I love, changed my biochemistry.

In conclusion, our method of analyzing different kinds of cases has paid off in this chapter. We shouldn’t lump all enhancement-physicians together. Psychiatrists prescribing antidepressants to depressed people differ ethically from sleazy physicians prescribing growth hormone to every client who enters their office with a roll of $100 bills. Ideally, it’s best not to need any enhancement, but life is not always ideal, and for many people—and perhaps each of us one day—it’s nice to have such tools around when we need them.

Notes

Peter D. Kramer, Listening to Prozac (New York: Viking, 1993), 1ff.

Ronald Bailey, Liberation Biology: The Scientific and Moral Case for the Biotech Revolution (Amherst, NY: Prometheus, 2005), 234.

Eric Wilson, Against Happiness: In Praise of Melancholy (New York: Farrar, Straus and Giroux, 2009).

Eric Wilson, Against Happiness, 6.

Garrison Keillor, “'Against Happiness': What Goes Up Should Come Down,” review of Against Happiness, International Herald Tribune, March 14, 2008. http://www.iht.com/articles/2008/03/11/arts/IDSIDE15.php

Carol Freedman, in Erik Parens (ed), Enhancing Human Traits: Ethical and Social Implications, (Washington, D.C.: Georgetown University Press, 1998).

See the National Institutes for Mental Health web page on “Depression” and notes 21–27: http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml

James Sabin, review of Enhancing Humans, ed. Erik Parens, Journal of Health Politics, Policy and Law, 26:4, August 2001, 809.

Dick Cavett, “Smiling Through,” New York Times, June 27, 2008.

10.

“Teaching the Troubled: Writing Workshops after Virginia Tech,” Association of Writers and Writing Programs (meeting), New York City, February 2, 2008.

11.

Quoted by Ronald Bailey in Liberation Biology, 234.