Wednesday, June 15, 2005

Listening to Prozac? How about Listening to Women?

I started this blog to work on my book and today, by gum, I am going to write a post that is dedicated to this end. So, here it is:

"Imagine that we have to hand a medication that can move a person from a normal
psychological state to another normal psychological state that is more desired
or better socially rewarded." --Peter Kramer

In 1993, Peter Kramer published Listening to Prozac, a book intended to draw ethicists into debating the ethical implications of Selective Serotonin Re-Uptake Inhibitors (SSRIs), which were the new generation of antidepressants gaining recognition among psychopharmacologists. Kramer's most provocative thesis is to defend "cosmetic psychopharmacology" as an ethically permissible psychiatric practice. Prozac, according to Kramer, is no mere antidepressant; rather, what we have here is a powerful drug that patients who are not afflicted with depression can use to make themselves "better than well." Prozac promises to transform brooding, socially awkward persons into peppy and popular ones. More importantly, prescribing this drug to the non-afflicted does not transgress the proper boundaries of psychiatric practice.

As Kramer hoped, ethicists and psychiatrists responded to his challenge with both applause and horror. In bioethics circles, which is the arena I am mostly concerned with, the Prozac debate has evolved into a debate over the line between "treatment" and "enhancement," and how new technologies radically rewrite the cultural narrative on depression. While a fringe of anti-psychiatrists will always linger who will question the very legitimacy of the profession in general and specifically any therapeutic intervention, for the most part no one involved in this debate has any serious qualms about the emergence of drug therapy for treating mental illness. Instead, the debate centers on what constitutes clinical depression, that is drawing the line between the kind of "depression" that warrants medical treatment and the kind that is a by-product of our all-too-human nature.

Arguing against Kramer's defense of cosmetic psychopharmacology are the "psychopharmacological Calvinists," who generally find some cultural and personal value in experiences of depression. Prozac, they argue, robs depression sufferers of important insights. Or, it interrupts processes crucial to our moral development--an experience which the first-rate thinker John Stuart Mill credited as transforming his ideas about pleasure, which benefitted all humankind.

On the other hand, the "psychopharmacological Hedoninsts,"--Kramer prominent among them--consistently point out the old-fashioned and romantic ideas to which these Calvinists cling. To still believe that bouts of depression offer us a "special perspective" belies another uncritical belief: that moods are more than neurochemical patterns that color our perceptions of the world. We are each born with a given temperament, a neurochemical profile, that may or may not be valued by the larger culture. Kramer writes
"certain dispositions now considered awkward or endearing, depending on taste,
might be seen as ailments to be pitied and, where possible, corrected. Tastes
and judgments regarding personality styles do change. The romantic, decadent
stance of Goethe's young Werther or Chateaubriand's Rene we now see as merely
immature, overly depressive, perhaps in need of treatment. Might we not, in a
culture where overseriousness is a medically correctable flaw, lose our taste
for the melancholic or brooding artists--Schubert, or even Mozart in many of his
moods?" (Kramer 1993, 20).

Hence the Prozac debate pits the rather romantic ethicists and psychiatrists, who want to preserve a long standing view that depression can be culturally valuable, against the rather unromantic ethicists and psychiatrists, who decode the mysteries of mood into neurochemistry.

And, I think these ethicists have the debate all wrong. The Prozac debate is primarily a debate over which gender traits our culture prefers: competitive, productive, and energetic "masculinity" over self-effacing, unassuming, and irritating "femininity." Both of these camps of the Prozac debate fail to take seriously how cultural preferences for idealized masculinity play out in both the diagnosis and treatment of depression. While the calvinists and hedonists debate the importance of depressive temperaments to art and philosophy, the majority of Prozac prescriptions are written to anxious and overwhelmed women, who have been bombarded by a marketing campaign that trains women to see themselves as ill. Our cultural burden of worshiping wise melancholic men is once again directing our cultural energies toward eradicating the problem of mad depressed women.