The Market for Medicalization: Enhancing Evolution?
posted by Frank Pasquale
Many recent books are questioning the expansive trend toward “medicalizing” emotional responses that were once considered acceptable. I greatly enjoyed Christopher Lane’s Shyness: How a Normal Behavior Became a Sickness, and I’ve just started in on Peter Conrad’s The Medicalization of Society: On the Transformation of Human Conditions Into Treatable Disorders. Metapsychology has given a positive review to Horwitz and Wakefield’s The Loss of Sadness: How Psychiatry Transformed Normal Sorrrow into Depressive Disorder. The authors argue that “instances of what Freud called ‘ordinary human misery’ should not be confused with real mental disorder”–but there are many pressures toward treating them as such.
As the realm of “mental optimization” expands, I predict more employers will request (or demand) employees take certain drugs. For example, someone grieved by a loss might become much more productive if they can nip misery in the bud with the right intervention. Will such pill-taking ever become a bona fide occupational qualification? Are there cases where it might make sense?
I think it is helpful to think about two “ideal types” here. First, imagine some pill that makes pilots particularly acute during their flights, or gives them better vision, with no side effects. Second, imagine a personality “brightener” that a company believes makes its sales force far more fun and personable. Is one intervention less objectionable than the other?
I think the first is far more understandable, because flying has some objective standards (most notably, don’t crash). By contrast, the sales force is engaged in what is essentially a positional competition for more revenue–there’s no way to define “good performance” that is not relative to how well other employees are doing. (For an example, consider Jack Welch’s famous policy of knocking out the bottom 10% of employees each year–or the struggle for a partnership at a law firm.) Moreover, the first intervention is unlikely to affect the personality of the pilots, while the latter may go to the heart of personality.
A few parting thoughts. First, thanks to Patrick at the Medical Humanities Blog for pointing out Christian Perring’s superb article on clarifying the concept of mental illness. I have worried that greater pressure to perform will lead to an endless expansion of this category.
Second, the pressures to take chemical enhancements should lead us to question any sanguine characterization of the ethics of enhancement as a purely personal and individual matter. In his Enhancing Evolution, John Harris argues that “citizens should be free to make their own choices in the light of their own values, whether or not these choices and values are acceptable to the majority.” As Jonathan Franzen suggested in The Corrections, a positional rat race may be driving personality optimization far more concretely than “individual values.” Harris briefly mentions positional competitions in his book before throwing up his hands at solving them. Thankfully theorists like Jonathan Wolff and Avner de-Shalit are taking the issue more seriously. Where Harris sees the “enhancement” of evolution, many others may more justifiably predict its derailment.
October 29, 2007 at 11:14 am
Posted in: Health Law
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Responses (5)
Patrick S. O'Donnell - October 29, 2007 at 11:46 am
Frank,
Thanks for the acknowledgment and link. In addition, the following titles should help readers unfamiliar with recent literature on some of the subects you raise here:
Bolton, Derek and Jonathan Hill. Mind, Meaning, and Mental Disorder: The Nature of Causal Explanation in Psychology and Psychiatry (New York: Oxford University Press, 2003)
Brody, Howard. Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry (Lanham, MD: Rowman & Littlefield, 2007)
Buchanan, David R. An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being (New York: Oxford University Press, 2000)
Healy, David. The Creation of Psychopharmacology (Cambridge, MA: Harvard University Press, 2002)
Ghaemi, S. Nassir. The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness (Baltimore, MD: Johns Hopkins University Press, 2003)
Sadler, John Z., ed. Descriptions and Prescriptions: Values, Mental Disorders, and the DSMs (Baltimore, MD: Johns Hopkins University Press, 2002)
Patrick S. O'Donnell - October 29, 2007 at 11:48 am
Oops! Not in alphabetical order.
Daniel Goldberg - October 29, 2007 at 12:52 pm
Richard DeGrandpre’s work on behavioral pharmacologism is also worth reading on this point: The Cult of Pharmacology.
Also, Frank, we’ve discussed this before, but I continue to think it is necessary to engage the epistemic problem of distinguishing enhancement from therapy.
Frank - October 29, 2007 at 1:14 pm
Patrick, thanks for that list!
Daniel, I think my next post on this will be “How I Learned to Stop Worrying and Loathe the Therapy/Enhancement Distinction.” I’m beginning to think that there’s no way for theorists to convincingly draw a theoretical line between the two, and I’m beginning to doubt the utility of such a line. Aren’t the real questions here normative inquiries, such as “What is the good life” and “Does a particular intervention help or hinder our attaining it?”
If the term “good life” seems to normatively loaded, I urge readers to substitute for it their own preferred formulations–”right conduct in light of natural reason,” “maximum utility,” “functionings,” “capabilities,” etc.
Daniel Goldberg - October 29, 2007 at 1:34 pm
Hey Frank,
Oh, I completely agree there’s no such line, and given that I am a dedicated non-essentialist, I have no attachment to the necessity of drawing any such line.
But if there’s no such line, I do think it means we need to think carefully about what “enhancement” actually means. In some sense, I think the term as a referent for a constellation of ethical problems is unhelpful and obscurantist, partly because it is unclear what is problematic about “enhancement” if in fact what constitutes enhancement might well be therapeutic for any given person or persons.
So, I completely agree that the Platonic question is (as always) the important one. I just think scholars who work in these areas might generally find it more fruitful to engage what seems problematic about, e.g., medicalization of social problems without invoking the notion of enhancement (this is not intended as a not-so-veiled jab at you, BTW).
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