Friday, June 17, 2005

Why the Citizenry of the Prozac Nation are Women

The reason why bioethicists do not consistently confront the serious gender matters tied up with the debates over “cosmetic psychopharmacology”—namely, prescribing pills for a personality makeovers—is because they often separate moral questions from political questions. However, the reality of our current Prozac Nation is that women by far comprise its citizenry. Women make SSRI visits to their physicians at 2.4 times the rate that men do, a disparity that Center for Disease Control (CDC) researchers point out is far greater than the disparity in the rates of overall health visits between men and women (NCHS 2004, 60-61).

When the psychopharmacological Calvinists and Hedonists discuss the permissibility of “cosmetic psychopharmacology,” they tend to create thought experiments in different worlds, which admittedly can clarify the core ethical concepts, but then miss that those who are asking their physicians if Prozac is right for them are women living in a misogynistic culture.

At the end of Listening to Prozac, for example, Kramer tweaks a thought experiment entitled
“The Message in the Bottle” first presented by the Christian existentialist novelist, Walker Percy. In Percy’s version, you have an island castaway who discovers in his beach strolls at least 22 messages stuffed in bottles, which have drifted from far away shores. What the messages say, argues Percy, matters less than that they signify “transcendence,” the human quest to travel away from our safe well-trodden islands to distant, and uncertain shores. Now, consider Kramer’s version:

. . . imagine a woman—one who finds herself a castaway, always feeling like an outsider, somewhat sad, compulsive in her ways that seem alien to her, quirky in ways that are only partly comfortable, oversensitive to slights, limited in her capacity to enjoy the fruits of the island, a bit vague in her thought, listless, doubtful of her worth. She has struggled to ascertain the roots of her unease and perhaps has come a certain distance toward that goal, having made herself aware of the difficult experiences of her childhood. But her mood and social circumstances remain unchanged, and so her search continues. Now let us imagine that as she walks along the beach she finds a bottle containing not a slip of paper but a number of green-and-off-white capsules filled with a white powder. Questioning and desperate, she decides to take the capsules, one each day, and in time she feels bolder and less troubled, more at ease with herself, keener of thought, energized, more open to ordinary pleasure. Is there a message after all, a message in the capsule? (1993, 281).

The point of a thought experiments is to strip away all the contingent and therefore non-essential factors from a particular ethical dilemma in order to discover the essential problem. Many philosophers, to that end, model their thought experiments on science fiction to prevent the reader from getting too mired in details that might muddy their view of the situation, e.g. the particular people involved or places involved. Kramer aiming for the “universal” problem in his thought experiment—contrary to Percy’s contention that we quest after “transcendence” that humans are questing after—our questing is a in fact a symptom of a malfunctioning mind, which is easily corrected by the technological solution of tiny green-and-off-white capsules. However, the his choice of a female, with classic and predictable details of her self-effacing, anxious feminine nature is curious, especially since it is clearly modeled on the women patients that make up the heart of his book on the significance of Prozac to our conceptions of self and identity.

The impact of feminism on philosophy is to challenge the “neutral” or “universal” examples that philosophers tend to use and expose them as more often that not to be representing idealizations of masculinity. Rather than ecompass the breadth of human experience, the assumptions that philosophers make only reflect what men have traditionally valued. Moreover, men have the social and economic power to pursue those ideals aand fashion our social institutions by them. Hence, feminists ask questions about the historical and cultural context in which certain concepts as well as moral values come into existence. In case of Prozac and the cosmetic psychopharmacology debate, my job is to point out to the ethicists some important facts about who is both asking and receiving Prozac from their doctors. The fact that Kramer’s “message in a capsule” thought experiment features a distraught woman seeking to transform herself from a brooder to a pleasure seeker is no coincidence.

Consider a proponent of Kramer’s, the ethicist David DeGrazia, who writes an article defending patients’ rights to demand and physicians’ rights to prescribe Prozac as an enhancement drug. DeGrazia’s abstract summarizes his ethical judgement in universal, gender-neutral language: “A person can be true to oneself even while transforming and even creating the person one is. One’s self is not something merely waiting to be discovered, after all. To some extent, part of the human endeavor is deciding and trying to become who we want to be” (2000, 34). From this statement, we would all surmise that De Grazia advocates the use of Prozac for anyone who wishes to have a more powerful tool to aid in the lifelong process of self-creation. This suggests that the ethical question over the permissibility of cosmetic psychopharmacology transcends gender; it isn’t framed as an ethical question confronting women, akin to the permissibility of breast implants or silicone injections.

Yet, when DeGrazia presents us with his first case study it is Marina, a patient who resembles in many ways the most famous patient in Kramer’s book, Tess. Both Marina and Tess grew up in alcoholic homes with distant or abusive fathers and depressed and inefficacious mothers. Both women assume the parent role and take care of their sibilings. Lastly, Tess and Marina succeed in their careers, while failing socially and romantically. With Tess, Kramer first discovers how effective Prozac can be. What is most remarkable about Tess’s turnaround to Kramer, is her romantic successes: “She became socially capable, no longer a wallflower but a social butterfly. Where she once focused on obligations to others, now she was vivacious and fun-loving. Before, she had pined after men; now she dated them, enjoyed them . . .”(Kramer 1993, 11). Now, through DeGrazia, we meet Marina who resolves on her 30th birthday that she no longer wants to be pensive, self-loathing and socially awkward. She approaches a psychiatrist, who after 4 sessions decides she has no diagnosable disorder. He recommends therapy, but her HMO won’t cover it and so the prohibitive cost leads her to reject that suggestion.
Still, she wants changes. At work, she feels overly tentative, unsure, too prone to worry about possible errors. In her social life, she hates how she endlessly interprets the latest transactions with friends and the way she is attracted to men who are bad for her. She feels alienated by her obsessional thoughts, considering them ridiculous and bothersome even if not very harmful. After extended periods of introspection . . . Marina decides that she wants to become more outgoing, confident, and decisive professionally; less prone to feelings of being socially excluded, slighted, or unworthy if a good partner . . .She calls the psychiatrist who provided the consultation, whom she likes, and explains that she has heard that Prozac sometimes produces transformations like the ones she seeks—and more quickly and less expensive than could be expected from therapy. Marina requests a prescription for Prozac (DeGrazia 2000, 35).

It is Marina’s request for Prozac that forms the basis of DeGrazia’s entire argument that self-creation projects through biotechnologies like Prozac, are not only ethically permissible, but authentic means to becoming what we desire to become. And yet, not once does he highlight that women are more likely to ask for Prozac than men are. The fact that women ask for Prozac more simply does not figure into the Prozac enhancement debate.