Thursday, June 23, 2005

This is No Mother's Little Helper

This is No Mother's Little Helper
Posted by: aspazia.

This is No Mother’s Little Helper: Or, How Did the Bioethicists Lose Sight of Gender in the Cosmetic Psychopharmacology Debate?

The naïve view of the players in this Prozac bioethics debate is that they are simply white, middle-class men for whom the question of gender never arises. This is simply not true. Back in 1993, when Kramer introduced the question of the ethical permissibility of Prozac, he wasn’t wholly blind to the gender implications of this drug. Kramer embraced the ways that Prozac helped make women less sensitive to rejection, more assertive, and energetic. Anticipating the feminist criticism that his exhuberance for Prozac—particularly for subclinical obsessive and neurotic women overwhelmed with the competing responsibilties of mothering and work—might recall an earlier exhuberance for “mother’s little helper,” Kramer takes pains to distinguish Prozac from Valium or Miltown. There are at least two important differences between the current era of Prozac and the era of “mother’s little helpers.”

First of all, mainstream, American Psychiatry has traded in psychoanalysis and its particular conceptual language of intrapsychic conflicts for a more biological paradigm (read: objective and observable). The development and success of antidepressants—beginning in the 50’s—spurred psychiatrists to consider the neurochemical basis of mood regulation, rather than exhort patients to explore their early childhood attachments (see also Healy 1997). Secondly, the guiding mission of psychiatrists treating neurotic housewives with Valium or Miltown was “to keep women in their place, to make them comfortable in a setting that should have been uncomfortable in a setting that should have been uncomfortable, to encourage them to focus on tasks that did not matter” (Kramer 1993, 39). Women have certainly come a long way, baby, and Prozac is just the drug for the anxious, post-women’s movement, woman.

In discussing the case of Julia—a woman plagued by an obsession with keeping her house ordered—Kramer begins to consider why Prozac is a “feminist” drug. Once Julia is on the drug, she is able to more easily let go of her need to control the household. She can handle messy dogs and a less-than-perfect husband and children. Before Prozac, she was unable to leave the home and enter back into the workplace, stymied by her fear of losing control. After Prozac, she returns to a career in nursing, with a desire to specialize in pediatric nursing—certain she will no longer be irritated by the unruly children. Kramer uses this case study to illustrate why Prozac is no “mother’s little helper”; “it was the opposite of a mother’s little helper: it got Julia out of her house and into the workplace, where she was able to grow in competence and confidence . . . There is a sense in which antidepressants are feminist drugs, liberating and empowering” (Kramer 1993, 40). The measures Kramer uses for the liberatory power of Prozac is: do women become more breezy and fun-loving in their romantic life (rather than needy and draining), are they more assertive and risk-taking at work, and, how resilient are they to criticisms at work or in their private life?

By labelling Prozac a feminist drug, Kramer makes plain to us what he understands feminism to be: making woman act and think more like we expect men to act and think. Kramer’s notion of feminism is not informed by the writings and actions of feminists, but rather current market demands for 21st century femininity:

A certain sort of woman, socially favored in other eras, does poorly today. Victorian culture valued women who were emotionally sensitive, socially retiring, loyally devoted to one man, languorous and melancholic, fastidious in dress and sensibility, and historionic in response to perceived neglect. We are less likely to reward such women today . . . We admire a quite different sort of femininity which . . . contains attributes traditionally considered masculine: resilience, energy, assertiveness, and enjoyment of give-and-take . . .(270).

Since temperament, or personality, has a biology, which can be altered by pills, then why not utilize these pills to help women better conform with current societal expectations? Remember, that in the background music of all of Kramer’s musings on the permissibility of cosmetic psychopharmacology is a simple, repeated theme: mood and temperament are ultimately biological. Kramer does not offer up a crass reductionism, he does acknowledge that environment has a significant impact on a person’s life; real traumas—namely, the fact that Tess’ alcoholic father sexually and physically abused her or Lucy’s discovery of the mother’s murder at the hands of their manservant—biologically encode themselves in such a way as to make these women more vulnerable, more sensitive, and perhaps more needy (Kramer 1993, 112). Biography, nonetheless, ultimately becomes biology—some rerouting of neurochemistry in a way that is maladaptive to these women in a society that now expects them to be peppy, energetic, and resilient. Enter Prozac with its powerful, fast, and economically efficient restorative powers for brain chemisty gone awry. Hence, biology might have used to be destiny—even if that biology was a product of a sexist culture—but now we have a pill to undo that damage. Furthermore, this helps women become what Kramer, perhaps understandingly, misinterprets the second-wave women’s movement for total equality wish to be: help women act and think like men.

In an abrasive review of Listening to Prozac appearing in The New Republic, David Rothman, articulates a very good reason why feminists might not share Kramer’s belief that Prozac is a feminist drug:

A feminist criticism of Kramer would rightly see Prozac as enforcing the values of aggression and self-seeking ambition . . .Indeed, there is no subtly to Kramer’s rebuttal of the indictment that ‘we are suing medication in the service of conformity to social values.’ In his stories, Prozac emerges not only a male-gendered drug, but also as a quintessentially American drug. It does not enhance pleasure or bring happiness, but promotes adroit competitiveness. It is not a street drug that brings a quick high, it is an office drug that enhances the social skills necessary in a postindustrial, service-oriented economy (1994, 36)

While Kramer does respond, in his “Letter to the Editor” to Rothman’s review, and rightfully points out that Rothman has oversimplified both his views and dismissed his qualms about Prozac, he doesn’t address this particular criticism that Rothman makes. However, Kramer has already anticipated Rothman’s criticism in Listening to Prozac. In last chapter, “The Message in the Bottle, which is the meatiest section of the book—at least for bioethicists and feminists—Kramer articulates both criticisms of cosmetic psychopharmacology and counterarguments to those criticisms. Sometimes he lets certain criticisms simply remain unchallenged, offering two ways to look at the same situation, but not necessarily committing himself to one position over the other. A perfect example of such as criticism is to consider that Prozac’s impact on the high stakes workplace of post-industrial capitalism will resemble the impact of steriods on sports. At issue here is the undermining of autonomy—the ability to make uncoerced choices.

If one or two athletes take steroids, and thereby enhance their athletic performance, then they gain a distinct advantage over the others. One could also argue in those cases, that the athletes freely chose to take steroids for enhancement purposes. However, the situation dramatically changes when everyone “freely chooses” to take steroids, and therefore, if you want any hope of competing you will have to take them too. Do steroids in sports constitute coercion? Yes and no. Technically, the athletes can still choose to not take steriods, however, the result of that choice will be that they will most likely be unable to compete. Likewise, one can view the taking Prozac as a "free choice" to enhance “masculine traits” that are more competitive in the marketplace as eventually leading to a similar scenario as steroids in sports: unfortunate women and men with irritating and ineffectual feminine traits lining up to take their Prozac so as to have any hope of competing in the market place.

In two places in this chapter, Kramer leave us with two interpretations of this possible Prozac scenario. First, while addressing directly that Prozac can become like steroids, he forsees the first outcome: “a myriad of private decisions, each appropriate for the individual making them, will result in our becoming a tribe in which each member has a serotonin level consonant with dominance”(274). On the other hand, he reconsiders:

But the pressure to engage in hyperthymic, high-serotonin behavior precedes the availabilty of the relevant drugs. The business world already favors the quick over the fastidious. In the social realm, an excess of timidity can lead to isolation. Those environmental pressures leave certain people difficult options: they can suffer, or they can change. Seen from this perspective, thymoleptics [drugs that can transform personalities] offer people an additional avenue of response to social imperatives whose origins have nothing to do with progress in pharmacology (274-5)

So, either we can surmise that liberal prescribing of Prozac will result in all of us electing to take the drug to model ourselves after the most socially rewarded ideal, or we can simply embrace Prozac as a pharmacological solution to a social dilemma it is not responsible for creating. Neither of these interpretations, however, is very satisfying, particularly for a feminist interested in Rothman’s question.

The second time Kramer leaves us with competing interpretations on how to view the possibility that Prozac will result in social engineering (whether that be the result of private decisions or a totalitarian government), he offers an even sunnier second interpretation. Discussing the advantages of rethinking temperament as biological, and moreover, as technologically malleable, he suggests our first option: “Emphasis on temperament can be divisive or oppressive, if a culture too strongly favors one temperament over another—traditionally masculine over feminine traits, for example” (298). However, he quickly follows with option two: “Or, awareness of temperament can be inspiring, leading perhaps to efforts to minimize psychological harm to children, or to foster a social environment welcoming to constitutionally diverse adults” (298). This second option sounds more promising, however, it strikes the reader as a non-sequitor. How is it that discovering that temperament is pharmaceutically alterable—even if it is the result of horrific traumatic experiences—may lead us to a more just, and safe world? Let’s backtrack in the text and see if we can follow his reasoning here. A few pages before this suggestion, Kramer proposes that with the updated, biological psychiatric view all biography eventually becomes biology—we might see mild depressions as akin to carcinogens. “An unreliable lover enrages us—he is doing not just psychic but physical harm . .” (296). Hence, within the conceptual framework of the post-Prozac era, we can view traumas to the self as causing physical damage (since really there is not difference between physical and psychic for Kramer) tha not only can be mended with Prozac, but Prozac can also act as a prophylactic protecing us from future damage (perhaps like sunscreen or vitamins?) If we take this statement above (“an unreliable lover”) together with the suggestion that Prozac might be healing (and remember, here is going beyond the more benign statement that Prozac is a least a solution to a problem it didn’t create), then we might conclude that Kramer is proposing that Prozac will make the world safer and more just, because it can “erase” the damage done by trauma. This can play out several ways: we can restore women’s broken self-esteem from abusive relationships, or we can intervene early in the life cycle of a potential abuser.

Now let’s add another level of nuance to our interpretation of Kramer’s option two. Remember that Kramer has assured us that Prozac is no mother’s little helper because it gives women vitality and energy to “leave abusive relationships or stand up to overbearing bosses”(272) rather than deaden them to a bad situation. He also says that they are feminist drugs because “they free women from the inhibiting consequences of trauma” (271). What this means then, is that Prozac treats the symptoms (broken, inhibited women) of culture that violently devalues women, by restoring their biological self to a pre-trauma state. Moreover, it gives extra zest and vitality to women, who might have been cursed with an shy and socially retiring inborn temperament. However, if this is true, then what you really have here is damage control for a misogynistic culture. If the culture devalues what is feminine and violently takes it out on women, then one solution is to cure the wounds of misogyny and then repackage the victims as more masculine, so as to make them less vulnerable to that same violence again.

While Kramer is always dancing around the question of whether or not Prozac puts more pressure on women to conform or not, what emerges in his argumentative strategy is a classical libertarian line of argument. This, I wager, is the reason why the gender implications of Prozac drops out, for the most part, from the bioethics debates over cosmetic psychopharmacology that follows the publication of Listening to Prozac. Libertarianism, as a political and philosophical theory, focuses on maximizing personal freedom to make decisions, and minimizing any state or communal regulation over that freedom. Moreover, libertarianism is a metaphysical theory of the self (something that Kramer’s writings suggest is outdated), because it asserts, rather than proves through evidence, that individuals are the best agents to make good decisions for themselves and that any state interference in peoples’ ability to make their own choices is a violation of liberty. Hence, what becomes the focus of moral debates that are issued forward in the language of libertarianism—free choice, autonomy, preferences—is a shift away from the concrete reality of the impact of Prozac, specifically Prozac's impact on women in a misogynistic culture. What follows instead, are debates about the compatibilty of cosmetic psychopharmacology with the exercise of personal freedom, if one must rely on a prescription from an expert. Or, the debate shifts to considerations of equitable distribution of enhancement technologies. Thirdly, a lively debate over how to properly diagnose mental illness emerges—should listening to drugs be the method for mapping mental illness? And, lastly, you see those arguing for the importance of conserving some our communal ties to each other, which are, perhaps, strenghtened in times of personal crisis. So, old debates between radical individualism and community become a primary lens through which bioethicists consider whether or not cosmetic psychopharmacology—or any enhancement biotechnology for that matter—is ethically permissible in a liberal society. And, old debates over the rigor of psychiatry as a medicine discipline draw a great deal of attention. What doesn’t emerge is a sustained engagement with the impact of cosmetic psychopharmacology on how our culture values traits and behavior that is different from idealized masculinity.

Moreover, it appears that while Kramer is well aware that cosmetic psychopharmacology can disproportionately affect women, he or his supporters can always dismiss this worry by stressing that Prozac gives a sufferer more, rather than less, autonomy. Since autonomy is so crucial to traditional bioethics debates, then giving women more autonomy should ward off suggestions that it is socially engineering women to become like men. After all, by taking Prozac, women are giving themselves more of a choice in what sort of person they want to become, and what preferences they hold. So, once given Prozac, women can choose between their earlier, socially irritating self, or their socially rewarded Prozac self. The choice is ultimately theirs to make, so it would seem odd—to anyone subscribing to this reasoning—that Prozac disproportionately harms women.

The final reason why the bioethics debates on Prozac do not put gender at the center, is because of a very successful and powerful red herring that Kramer puts forward again and again in his writings: that our distaste for Prozac and its capacity to wipe out melancholic traits comes from a deeply rooted psychopharmacological Calvinism that sees values in those traits. Psychiatry--as it strives toward a biological and scientific approach—should take any opportunity to disabuse people of the pseudo-scientific thinking that melancholic traits are what makes its sufferers deep, artistic, or likely to go on a self-discovery search for authenticity. Melancholy is simply passé. We created a cult of melancholy—praising the usefulness of depressed or anxious moods in the quest for authentic existence—in an era of bad science. Modern science has opened our eyes to how debilitating these ailments (even personality traits) are, and to how depression is, in fact, a disease treatable like diabetes. Hence, we have to let go of this 19th century romanticization. While Kramer is making a rather reasonable and compelling point, it certainly does not address Rothman’s concern that Prozac is remaking women into men—that Prozac is a powerful new tool for making women fit into institutions built around concerning masculine values and ideals. But it is a successful red herring because it preoccupies many of the ethicists that take up his invitation to debate cosmetic psychopharmacolgy.