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16thApril2002

Galileo LoLeggloCandidateNumber: 981272503

PROZAC:EXPLORINGTHE MYTH

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TABLE OF CONTENTS

INTRODUCTION.................. Page12

CFIAPTER1GENESIS FA WONDERDRUG...................... Page 4

Serotonin........ Page 4TheBirthof Prolzac................. Page 5Prozac How does t work?.. Page07Prozac ptakeUninhibited.... ........................Page8Prozac nd heMedia ............ .,......................age 0

CHAPTER2LISTENING O DR.KRAMER .....................age 5

Functional utonomy............. ........................age 6Kindling......... Page .8InbomTemperament.............. Page2}Further Points Page?

C}IAPTER3PROZAC ND THEETHICSOFENHANCEMENT.................. Page26

Enhancements.Treatment..... ......................Page26DoMeansMatter?.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Page30TheBusiness lympics........... ........................age 3

CHAPTER4PROZAC,ALIENATION AND SOCIETY ....Page 6

Alienation . Page39

Conformity..... Page4

CONCLUSION Page48

BIBLIOGRAPHY ......................... Page 1

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INTRODUCTION

The subject surrounding 'mental illness' hasalways been of great interest to me.

IAIhen I came to think about my dissertation, I knew that I wanted to writesomething within this area.I first heard about Prozac through some friends, who

were either taking the medication or whose parents were. I then read Elizabeth

Wurtzel's bookr Prozac Natíon. The book really got me thinking about

antidepressants in general. I wanted to understand, firstly the biological

underpinnings which validated the prescription of medication for mental

conditions; secondly I wanted to get to grips with some of the problems that

come about when our culture applies biological methods to something that is as

intangible as the human mind. For these reasons decided that the subject of

Prozacwould be interesting for my project.

In my first chapter I decided that it would be_important to outline how Prozac

was discovered and how it is believed to work. Thesewould give me a basis or

further discussion with regard to,theories of depression. also wanted to

highlight the widespread usage of the drug and the way it was portrayed in the

media, because wanted to place Prozac n a cultural context. I wanted to show

that Prozac's successwas controversial from its very beginning. During my

research discovered a popularsciencebook,

which had receivedhigh media

coverage/written by Peter D. Kramer. When I read it I knew it would be central

to my own work. The book was entitled Llsú ning to Proza|.

' See .12'See .10ff

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My second chapter discusses some of the theories around depression and Prozac

that are found in the above-mentioned book. This is done in the hope of creating

a base from which my argument can develop. In this chapter I also begin to

highlight some of the problems that arise from the prescription of such a

medication.

The third chapter is a much more detailed exploration of the ethics that surround

human enhancement hrough biology in general,and of Prozac as a personality

enhancer n specific.Here I will explore the distinction between enhancement

and treatment. There will also be a section that discusseswhether the means

used to enhanceoneselfare of importance. I will conclude the chapter with an

investigation of fairness and social coercionwhen using Prozac as a personality

enhancer.

In my final chapter I will be arguing that depressionand other forms of minor

'mental' conditions are in fact reasonable esponses o our current culture and

society,and that curing these diseases'is to misunderstand the causesof these

problems. I will do this by discussing the concept of alienation, by looking at

Karl Marx, Erich Fromm, R.D. Laing and an ethicist called Carl Elliot. I will also

discusshow modern society can be seen o pressure people into conforming to

an ideal personalify style.

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l

CHAPTER1

GENESIS FAWONDERDRUG

In this first chapter I will be exploring the birth of Ptozac from its discovery to

the subsequentmedia explosion. will begin by looking briefly at how serotonin

and neurotransmitters are affected by Prozac. I will continue by a brief

historiography of Prozac's discovery. Once I have placed Prozac into context I

will look at the media's iniuence in its popularisation and the backlash that

consequential ly appeared. This is will provide a good place where to begin a

proper analysis of Prozac in the context of culture, society and ethics.

Serotonin

The Prozac story can be said to have.begun with the discovery of serotonin.

Serotonin or 5HT, its chemical name, was first identified in the 1940's. ts role of

regulating the tone of blood vessels nterested scientists and for this reason it was

named sero-tonin, 'sero' refers to blood and 'tonin' to its toning effects.However,

it was not unfil the mid 1950's hat Serotonin was discovered in the brain. The

first hint of serotonin's usefulness n psychopharmacology came about when

fohn Gaddum, a scientist at Edinburglu speculated o a group of researchers hat

"It is possible that the S-HT [serotonin] in our brains plays an essential ole in

keeping us sane."3This suggested to psychopharmacologists that if serotonin

kept us sane, ncreasingserotonin in the brain might help in countering mental

illiesses.-It was not until the end of the 1.950'shat a Swedish scientist began to

I Gaddum,J.H.;DrugsAntagonistic o 5Hydroxytry?tomin';Wolstenholme,G.E.W.et al (eds,)Ciba

Foundation wnposium n H!'Dertension;Churchiu, ondon.1954\.177: uotedn Shorter. .:A Historvof Psvchiatrv;[ohnWilev& Sons, hich ster.199V:o.320-321.

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map out the brain pathways containing serotonin. In the early 1960's t was

accidentally discovered that drugs which raised serotonin easeddepression.

Serotonin is just one of thousands of chemicals found in the brain. What isspecial about this chemical s that it was found to be a neurotransmitter. 5HT is

not unique as scientists have discovered "l00 or more substances that] have

been identified that control neurotransmission, and many of them are

neurotransmitters."a Neurotransmitters are found in the synapse, this is the gap

between neurones down which electrical impulses pass. Neurotransmitters -

which have been compared to messengersof the brain - are released in the

synapses,passing on a seriesof 'messages'to next neurone which fires off the

next impulse, and so on and so forth.5 Neurotransmitters can be viewed as the

most basic necessityfor the brain to function, different neurotransmitters are

secretedand thereforedifferent kinds of messages re passedon for all brain and

ultimatelyhuman

functions.6

The Birth of Prozac

In the 60's amongst the walls of Eli Lilly?, the main stage for our drama. One

researcher,Dr. Fuller, had been testing drugs, using a very new and effective

method, to see how these drugs affected the serotonin pathways.s Fuller

suggested to a colleague, Brian Molloy, that because of this method the time was

right to research brain chemistry. Molloy began a series of tests on possible

a Breggio P.R. & Breggin G.R.;Talking Back To Prozac; (St.Martin's Paperbacks,New York, 1995);p.2O-U' see Dra.pp. zt-u6SeeWolpert,L.;MaligrnntSadness-theanatomyofdePression:(faberandfaber,Londo,2001);P106-707TProzacwas discovered, slmthesized and paienied by Eli Lilly. It is one of the big pharrnaceuticalcomDarues.8Thèse are the neurones affected by serotonin.

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antidepressants hat did not have as many side effects as previous medicatione,

making them quite undesirable for patientslo.

1971- anbe said to be the next big event in the making oÎ Prozac. Firstly, Fuller,

by now Eli Lilly's senior pharmacologist, had started to push the idea that

serotonin could be useful in combating depression.DesPitesome reservations

the company gave in to Fuller's proposal, and as Shorter suggests:"Fuller, in

alliance with Lilly biochemist David Wong, carried the day inside the company.

Lilly organised a serotonin depression eam."rl The last piece in the jigsaw of

Prozac came at a lecture in the sameyear, in which Molloy and Wong met and

began a collaboration as part of the serotonin depression eam. The lecture was

given by Nobel Prize winner Solomon Snyder, perhaps one of the greatestminds

in biological psychiatry. The subject was neurotransmission. Snyder had

developed a method that could test how much of a neurotransmitter nerve

endings would absorb after having been treatedwith a potential antidepressant,

this he called the synaptosome test.

This method caught Wong's interept, and he went about in testing Molloy's

compormds, using the synaptosometest.Wong discovered that thesewere in fact

potent norepinephrine blockers, ust like the majority of antidepressantson the

market. Wong also noticed that Snyder's synaptosome reacted differently to

compounds that had a very similar structure. So, Wong decided to test those

compounds which he thought might block the uptake of serotonin. Wong tested

over two hundred and fifty compounds and one of them, "LilIy 8281'6" seemed

to be the most selective in the inhibition of the re-uptake of serotonin, this

eHeart palpitations,, urine letention, and drymessof mouth.roseesection on how Prozac worksI'Shorter,E.; op. cit.;p.322

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compound is chemicallyknown as luoxetine oxalate.Compound 82816was then

tried out on Fuller's test and once again it appeared to block the up take of

serotonin and little else. It later appeared easier to work with a different

compound "Lilly 110140".In L974 Wong and Molloy publicly announced

compound LL0140 o be a selectiveserotoninre-uptake inhibitor in rats'brains.

I^ \975 it was given its chemical name fluoxetine hydrochloride, which was later

given the trade name of PROZAC.

Prozac How does t work?

A widely believedbiologically based heory about the causeof depression s that

depressedpeople lack a sufficient amount of neurotransmitters,especially hat ol

serotonin and norepinephrine, in the brain. When a neurotransmitter is fired

from a pre synaptic nerve cell it remains in the cleft between that cell and the

adjacent one, for a very short time'. Someof it binds to the receptor of the post-

synapticcell, whilst the rest s eitherbroken down in various ways or takenbackup to the pre-synaptic nerve cell for future use. This Process s generally known

as re-uptake. ntidepressants (except or the classknown as MAOIs) generally

work on the principle that they block the re-uptake of certain neurotransmitters.

staying in the cleft longer and therefore allowing them to stimulate the post-

synaptic cell more strongly.

Previous to the discovery of 55RIs (selectivel3 erotonin re-uptake inhibitors), a

c_lass f drugs called tricyclics (named after their chemical structure being

composed of three rings) were the main kind of treatment against depression.

DIf it were to stat it would continue to stimulate the Post-synaPticnerve cell.13Or specific

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Both these types of antidepressants block the re-uptake of neurotransmifters. The

main difference between the two classess that tricyclics not only effect serotonin

and norepinephrine pathways, but also the re-uptake of other neurotransmitters,

giving the patient a so-called " dirty drug"la. The word dirty refers to the sense

that it effects the pathways of more neurotransmitters than are needed. This

excessgives the patient a higher quantify of side effects. These side effects range

from drowsiness to heart palpitations, from urine retention to dryness of mouth

and confusion.They are also ethal in the caseof overdose.sWhilst SSRI,mainly

blocks the re-uptake of serotonin, with a slight effect on the norepinephrinepathways, giving these drugs fewer side effects and on the whole overdosing on

them is not lethal.

These new drugs [SSRIs]are not more potent in terms of their abilify to

reducedepressivesymptoms,but their advantage ies in reduced side effects

and so an improved quality of life... In severalstudiesthe failure to continue

taking the drug was lessthan 10per cent for fluoxetine and around 30 per

cent for the tricyclics.ró

ProzacUptake Uninhibited

Since ts discovery, Prozac had to be approved by government agenciesaround

the globe. This took over ten years n America and was done through the Food

and Drug Administration (FDA). In 1986 Prozac was approved in Belgium

t' I(ramer,P.D.; op. cit.; p.5715Giving a suicidal patient a drug with which they could overdose,would require constant supervision ofthat patient either by doctors in psychiahic hospital or by ihe patient's relations.ìó Wolpert L.; op. cit.; p.133

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shortly followed by America in 1987.Sincethen, Prozac has been approved in

more than 90 countries.lT

By 1989annual sales of.Prozacreached$350Min America, making up more thanone tenth of Eli Lilly's total revenues. This amounts to more than the total spent

by Americanson all other antidepressantsn the previous year. In both 1.991 nd

1992Eli Lilly's revenue tfuough Prozac rose to $1 billion for eachyear, out of a

total of $8 billion antidepressantmarketl reaching a staggering $2.6billion in

the 1997-1998evenue. By then, Prozac had become the fourth most profitable

drug of all times.le

Since ts approval, Prozac has been prescribed to more than 40 million people

around the globe of which around 22 million Americans.2o n Britain, it is

estimated that in 5 years(1994-1999) t least one million people have taken it.zr

This meansthat around 85% oÍ the American population and almost 2"/" oÎ the

UK population have taken Prozac.zAntidepressants, n other words, have, in a

relatively short time, becomebig business;and Eli Lilly have had a major share

of the profits. In just a decade, heir yearly revenue from Prozac has multiplied

seven-fold.

r?This data has beentaken frorn Eli-Lilly's web site www.prozac.com; url:h.f'cp / :www.pr ozac.com/i0/k1-1 jsp13This data has beentaken from Bteggin, P,R et al.; oP.cit.;P.2-3reData talen from Finctt J.;

Iast of the Million dollar drugs'; Ggaguatu G7 1/1998); p.28'0Data taken from www,prozac.com; oP cit..2!Data talen from Bossely,S.; They said it was safe';Sgar[lggt; Q0 10 /1999) P10" This data has beenworked out using the previous data and Collins Atlas of the World; (Harper CollinsPublisher, Londory 1999),p.6 and p. 105

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Prozacand the media

How does a prescription drug become so popular, to the extent that there are

now over 30 books available to buy with its name in the title? What does it meanwhen you can buy Prozac Capsule earrings or even wear a T-shirt with its

barcode on the front? To understand this, we have to start by looking at the

media.

The first hint of Prozac'sgrowing popularity camewhen in March 1990 a floating

Prozaccapsule appeared on the cover oÎ Newsweekwith the caption:

PROZAC

A Breakthroughrug or Depression23

The article entitled The Promíseof Prozacdiscusses he benefits of SSRI'sover the

old tricyclics,raising the issue of side effects. n this article PeterD. Kramer was

quoted, then an unknown psychiatrist, saying that "there may even be a drug

that can "changepeople in ways they want to be changed- not just away from

illness but toward some desirable psychological state.""2a

Kramer, a clinical professor of psychiatry at Brown, beganwriting about Prozac

in a column of a trade magazine for psychiatrists at the end of the 1980's.He

famously coined the phrase"cosmeticpsychopharmacology" which appeared n

an essaypublished by ThePsychintricTimes'% ramer's popularity really began

when his secondessaywas published as a cover story of NEW YORK Magazine n

March L990(where the Newsweek uotation comesfrom). Further, Kramer was

'3Newsweek; (Ma1ch26 1990);cover page'4Cowlet G. et al; 'The Promise of Prozac'; in Newsweelc (March26,1990)t p,4l25seeKramel, P.D.; The New You'; Psvchiatric Times: March 1990;PP.45-46

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referenced in "a definitive contemporary article for physicians on the use of

antidepressants, in The New England ournal of Medicine."% n 1993 Kramer

published Listening to Prozac. The book detailed the personality enhancing

properties of the drug and its cure-all possibilities. The book was a hit and it

spent 21 weeks on the New York times Best seller list. As Rothman suggests,

"Prozac and Listening to Prozac have both become best-sellers. Indeed the

fortunes of the book and the drug are so intertwined (the book made the lists

before it was so much as advertised or reviewed) that it is impossible to discuss

one without the other."27Or as the editor of The ancet notesz

Listening to Prozacby psychiatristPeterKramer-400 or sopagesof anecdote nd

folksy psychobanter is an American best seller that has almost certainly

contributed o thestaggeringUS salesof thedrug...4

By 1994thenotion of Prozacas a personality enhancerhad becomewidespread.

An article entitled The Culture of Prozac suggested hat "[t]he antidepressant drug

Prozac has gained tremendous popularity among people with no mental illness

who simply wish to changeor enha,nceheir personalities".aEli Lilly was now

showing concerns around the hype of Prozac's wonder properties. And in a

reply ad/article they argue that "much of this attention has trivialized the very

serious nature of the diseaseProzac was specifically created to treat - clinical

depression" s

e Kramer; P.D LigEli4glqBqzaE (Fourth Estate;London; 1994);p. xvi'?Rothman, D.J.; Listening to Prozac'i \19!dlBepgb!!E (Feb14,1994, 27o n7); p342 Editorial ; ?rtificial Paradise Encapsulated'i Lancet: (APril 9,7994, v343 ú9O2)i P.865'eCowlep G. et a!.'The Culture of Prozac',@k; $ebÍrary 7,1994),P.41,30Quoted from Wurtzell, E.; Plozac Nation - Young ard Depressed n America - a memoir; (Qualtet Books,London, 1996);p.304

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In 1994 Prozac'sentry into popular culture was kicked off with Prozac Nation

by Elizabeth W:uriizel"3l, memoir of a depressed young woman who was

'saved' by Prozac. It was an instant hit, especially within the youth culture in the

midst of 'grunge' music like Niruann.The purpose of the book in Wurtzel's eyes

was to "come out and say that clinical depression s a problem, that it ruins lives,

that it ends lives... that it afflicts many, many people, many very bright and

worthy and thoughtful and caring people..."32.However, the title of the book is

deceiving asProzac s not really such a central ssue,"ProzacNation is lessabout

Prozac than it is about another contemPoraryphenomenon: divorce."s And what

she does say about Prozac s extremely subjectiveand largely unsupported by

any evidence, theories or references,what it does offer are Wurtzel's highly-

strung opinions. As Dawn Marlan of the ChicagoReaiewsuggests:"Prozac Nation

is ft.rndamentally compromised by Wurtzel's inflated and unargued assumption

that her story immediately explains he story of others."s

In the same year, what might be described as the antithesis to Listening to Prozac

was published. Peter R. Breggin wrote the book, and it was appropriately

entitled TalkingBack o Prozac.Itscentral argument is about the lack of proper

testing of Prozac and the part that pharmaceutical comPaniesplay in tests which

should be done independently by the FDA, "Breggin..' seesProzac as fitting

today's values... by creating tranquilized consumers duped by capitalist

3rHoe,L.; 'Prozac Nation(Featue)'; Sg4!bJl!!!oca; (SePt23, 2001);P.43'Wurtzel,E.; op.cit.;pp.315-31613Klinghoffer, D.; 'Prozac Nation: A Memoir. (book reviews)'; National Review; (Nov 7 1994v46 rAD) P753rMarlan, D,; 'ProzacNation: Young and Depressed n America.' (book reviews); Chicago Review; (Winter1996v42 ttl), p.93

t2

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companies more concerned about their profits than their Patients' health."s It

also highlights the ctnical arg:umentsagainst Prozac's wonder status, suggesting

that there is little difference between Prozac and other psychotropic drugs, such

as amphetamine or cocaine.Unfortunately Breggin'sbook is throughout far too

medical for any seriousphilosophical debatearound Prozacas "[h]is arguments

are essbalanced han Kramer's, and his sourcesappear ess eliable."36

The backlash againstProzaehad begun in February 1990.The Americaournal of

Psychiatry suggested that "this drug be used cautiously and that the practitioner

should be attentive to the... emergenceof suicidal ideation..."37 y Septemberof

the same year, after an article about Prozac suicides had appeared in the

PhiladelphiaEnquirer, the first 'Prozac Survivor' group was formed.s In addition,

in L990 the NezuYork Times confirms that most law suits against Eli Lilly had to

do with violent behaviour and thoughts, suicidal obsessionsand acts, and self-

mutilation.3en 1991,, ti Lilly was compelled - by these and many other media

and medical reports - to hold a hearing on the suicidal feelingsallegedly caused

by Prozac. These were dismissed as inconclusive and no label apart from the

German label of Prozac mention this possible side effect.4 By 1992, Eli Lilly

reported that around L70 egal actions had been filed against them to recover

Having dismissed Wurtzel's and Breggin's books as inadequate for a serious

philosophical discussionabout the use of Prozac, do believe that Kramer's book

35KeganGardiner, J.iCan Ms. Prozac talk back? Feminism, drugs, and social constructionism'; &4i4b!

Snrdies;(F4ll 1995v21 n3); p.50516ibid;. D.50237Teich;r, M.H. et a! Emergenceof bltense Suicidal Preoccupation During Fluoxetine Treatment; A!!c!@foumal of Pslrchiatry; (147:2Feb 1990);p-6833SeeBreggiryP.R; op.cit.;p.8! See bid.; p.94 More about the C€rman label in Boseley,S.; op- c.;t.;p10

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is. The vast majority of literature points to the importance of Kramer's book in

exploring the philosophical implications of Prozac.Julie Wheelwright writing a

review in New Statesrnan Society,notes that "Kramer is careful to debunk

Prozac's growing mystique as a wonder drug and instead explores its ethical

conundrums." She adds that " whatever its future - and Prozac is relatively new-

Kramer shedsmuch-needed ight on a potentially explosive ethical dilemma."al

The mportance of the book is noted by critics of Kramer also. Carl Elliot writes:

Yet, while Kramer ultimately defendswhat he half ironically calls "cosmetic

psychopharmacology,"e is no evangelistor the drug. His aim is rather to

explore what the effects of hozac mean or largerphilosophicalquestionsabout

the self and how we come o bewho we are.€

For all these reasons believe that it ìs necessary o analyse Kramer's book in

some detail, which is what I will do in the next chapter.

" Wheelwright, J.;Happy Pills'; New Statesmandóocietv; (18March 1993);p.54

" Elliot, C.; 'Listening to ProzacOook reviews)'; Britísh Medical loumal; (June25,1994v308 n6945);p.1724

1 ^

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CHAPTER2

LISTENTNGTO DR. KRAMER

This chapter, for the reasons have given at the end of my previous chapter,

conceff$ a discussion of Kramer's influential text. My analysis, I beteve, will set

a basis from which to uncover the ethical, social and cultural implications of the

use of Prozac allowing me to discuss hese ssues urther in later chapters' will

begin by looking at the reasonsKramer gives for writing his book. I will then

offer an outline of his biologically basedtheories on mood disorders, followed by

an analysis of Kramer's own conclusions. will address the implications of his

highly speculative, (he would admit this himself), theories on psychiatric

treatmen| self, identity and personality; and on society and culture more

generally. .

Kramer statesthat "[b]y now... eight million people have taken Prozac... My

concem has been with a subsetof thesemiltons: fairly healthy people who show

dramatic responses o Ptozac,people who are not so much cured of illness as

transformed."€ This begs the question: "[H]ow is it that taking a capsule for

depression can so alter a person's sense of seli?"4 Kramer also appears

preoccupied with a simplistic biological materialism that is in revival in our

modern culture. He worries about it in two ways. Firstly, he is uncertain that a

simple biology-as-destiny theory can explain much about the self, or humans.

Sècondly,he is appalled to find himself falling into biological determinist traps,

a3Kramer, P.D.; op.ciq p, xix-- rDrd,;P.xlx

1J

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both in everyday life and in his practice.6For this reasonhe wants to construct a

biologically based, but not deterministic, theory of the self and personality,

trying to merge together psychology and biology, mind and brain, character and

temperament. His theory can be divided into three parts that can be

encompassed nto a broader theory: 'functional autonomy', the 'kindling' model

and'inbom temperament'.

Functional Autonomv

Kramer begins to tell us about functional autonomy with regard to sensitivity.

He describes a patien! Lucy, who had an obsessive streak when it came to

boyfriends. Through psychotherapy she discovered that due to her mother's

murder and her father's lack of attention in her formative years, she had now

become very sensifive to rejection. "Lucy understands this sensitivity, too, as

originating in the apprehension that she will lose anyone she loves."6 Kramer

then hypothesises about the reason of her continued 'rejection-sensitivity' - a

term coined by psychopharmacologist Donald Klein - even though she has

gained nsight of the reason or her behaviour:

We all reactto disappointments,venminor ones.Always there s a visceral

response...t will pass... ut or themomentwe aredeeplyaffected.

For some, his pain is worse han othersare...They arenot depressed, ut they are

vulnerable...The idea underlying this diagnosis s that certain people are

physiologicallywired to be deeply sensitive o rejection...According o this

theory,a varietyof personality tyles... ndevenmental llnesses anbe traced o

'5see bid.; Introduction - pp. ix-xix46ibíd..;p.69

t6

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the complexadaptations versensitive eoplemake o the abnormalityn their

emotional hermostat.aT

Rejection-sensitivityaccording to Klein could be seen n some hysteric patients.

Up until then it was believed that hystericswould not resPond to medication.

But Klein, in his research,found that MAOIs did in fact help some of these

hysteric patients. Klein deèided to descriptively categorise these medication

respondent hysterics with the term 'hysteroid dysphoric''s Klein described these

women as attention ht gty, who are deeply affected by rejection" and whose

symptoms arise from their "abnormally painful experience to loss".aeKlein used

the phrase 'functional autonomy' to describe the cause of rejection-sensitivity.

In Klein's words. "A causeengenders n adaptive esponse function) that

persistsafterthe terminationof the causeautonomy). Regardless f its origins,

thevulnerabilityo losshada ife of its own n adulthood.s0

Kramer follows by describing a psychiatric 'disease' in which functional

autonomy had found widespread accePtance panic anxiety. This, according to

Kramer, was due to the discovery of a very effective medication against anxiety,

Xanax.He believes that the reasonwhy functional autonomy found acceptance

in respect with panic anxiety, but not in respect with rejection-sensitivity, is

)ecauseXanax actedas a populariser for the disease.Becausedoctors 'listened'

11bid.i pp.70-714 For a fuller descrjption of hysteroid dysphorics see bid.; p.7475f ibid.; p.75n ibid.; pp.7516

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to the drug, they let medication tell them how humans work. Up until now there

has not been a drug to do the same thing for rejection-sensitivity. He believes

Prozac s that drug.

Following his theoretical frame, Kramer speculates that functional autonomy of

rejection-sensitivity can be expressed n different ways by different Patients:

Surelyfor every rejection-sensitiveersonwho evolves nto a caricatureof

femininity heremustbea dozenwho adapt ndcope n otherways.5r

So what does functional autonomy tell us about mood disorders. Well, it

suggests hat in certain casesa mood disorder which has a psychological reason

behind it may become detached from those reasons and come to have a

biological life of its own. No amount of insight through psychoanalysis,

therefore, can remove the symptoms: only a biological cure can. Here, Prozac can

be seen as"["]set[ting]

a floor["] under emotionally brittle patients"s2, husenabling such patients to escape Patterns of behaviour which have been

intensified by functionally autono'moussymptoms. So, Prozac can be quite

happily be prescribed "in the hope of "breaking the back" of a more comPlex

problem of behavior and self-image."s

Kindling

Kramer looks at what is called the 'kindling' model in order to understand how

psychological symptoms can becomedetached rom their original psychological

5ribid.; p.91e ibid., p.89" lDlO.; .óv

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causes.He begins by looking at the research of Robert Post into a particular

mood condition: manic depression n general, and rapid-cycling in particular.

Manic depression is a condition in which a person goes from depression to

mania in what is called cycles or mood swings. Rapid-cycling is when these

mood swings happen more and more frequently and often may be entirely

autonomous. The rapid-cyclist does not need any stimuli, like provocation or

disturbance of sleep, to be induced into either a state of mania or depression.

The above pattem had been discoveredby Post, he then looked for a biological

model that worked in a similar fashion. He found that it functioned analogously

to epilepsy. Post put his analogy to the test, and put desperatepatients with

rapid-cycling on a drug used for conkolling epileptic seizures that chemically

resembledantidepressants.The drug. n many casesworked. So the analogy is

not a simple theoretical analogy but isi in fact, a working analogy. To understand

this process further,Kramer looks at researih into the cellular effect of kindling.

He discovers that neurones put through electrical currents change anatomically

all the way to its DNA structure,' further, he found that these changes start

happening even before any seizuresbecome apparent.

What Kramer is trying to demonstrate is that psychological traumas are very

likelyto

damage our biology too. Furthermore he demonstrates hat biological

changesmay happen even before any serious psychological symptoms become

apparent. People who show less obvious mental problems could be at risk

becausè hey may be at the early stagesof a kindled kind of depression.As he

notes:

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If minor depression s an early stage of kindled disorder... hen continued

depression, ot to mention urther stressor loss, will be dangerouso mental

health....Living with the sortof personality tyle that leads o repeated ocial

failuresmay,beyond hepaincausedo self andothers, ntailhealth isks.5a

If we now put together functional autonomy and kindled depressionwe seehow

Kramer's theory is building up. Depressioncan be causedby trauma. Trauma, n

turn, causes biological chànges in the brain. When these changes become

widespread, through further trauma, the psychologicalsymptoms, which are in

fact are biological symptoms, becomedetachedfrom their Psychologicalcauses

and therefore a biological cure may be required. Kramer does not rule out the

usefulness of psychoanalysis. n fact he wonders whether psychoanalysis can

affect the neurones, n a way similar to trauma. He notes, however, that this is

pure speculationas here s virtually nd reseatch o backhis statement.s

Inborn Temperament

Kramer begins to tell us about the importance of inborn temperament or risk

factor by distinguishing between temPerament, character and personality. He

suggests hat, traditionally, ternperamenthas been used to describe the part of

human personality that is genetically determined, given to us at birth, whilst

character s the part of personality that that comes rom life experiencesand has

the possibility to evolve and change.Personality s a mixture of botNó' Kramet,

il ibid.; pp.l2+125 ." se rDlo.iPP, z/-tzv16see bid.; pp.148-149

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however, thinks this distinction is inappropriate, and offers a different

distinction.He notes,

I will use"temperament"to refer to the biologicalunderpinning f personality,

even f biologyhasbeenshaped r altered y circumstancer chemicals.n this

sense,an adult's medicated emperament ill differ from his or her "inborn

temperament."t must- the neuralchemistrywith which we arrive n the world is

inevitably modified by development, nvironment, ife events,and now by

discretemedicine.5T

This provides a lessdeterministic theory of temperament.

Kramer is interested in the question of whether we are all bom with the same

inborn temperament,and whether our'experiencesshape our biology, henceour

temperament or whether we are, in fact, born with different temPeraments some

of which may be more at risk to mood disorders than others.Kramer disregards

the first option. He believes that the idea of a variety of inborn temperaments has

been a taboo for years becauseof the way these heorieshave been used in the

past. He also points out that the ideas behind inborn temperamentsare alien to a

liberal democracy.s8Kramer does want to use biology, but not in a simple

deterministic way. He wants to create a more sophisticated theory in which

biology plays a role, but where it is not the only factor.

Kramer points to researchdone by |erome Kagan on inhibited children' Kagan

shows in his research that a small percentage of children who show signs of

inhibition will remain inhibited through their entire childhood and adolescence,

n ibíd.;p.749s Seebid.;pp.16G161

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and he speculates that some will remain inhibited as adults.5eAccording to

Kramer this is not such a special discovery in itself. What he finds interesting

about Kagan's research is the physiological inquiry done on these inhibited

children, alongside the psychological one. What Kagan discovered was that

neurotransmitters and stresshormones levels in thesechildren were analogous

to that of animals under stress.Kagan tried to explain the fact that not all

children who are born inhibited do not always remain "true to type"o by coming

up with what is now known as the stress/risk model. Children who have an

inhibited temperament will remain true to t)?e only if they are stressedby

environmental trauma.

[I]t is possible o come o dysthymia hroughstress, emperament, l both in

combination... child born with depressiveemperament ay havea parentwho

sufferedsimilarly.The child at risk will therefore e a stressed hild as well'..

The stresses he child suffers'are encodedphysiologically, as altered

neuotransmitterystems.heyarealsoencoded sychologically, scharacteristic

defenses,ór

For Kramer the stress/risk model has its advantages over either a purely

biologicalmodel, or a purely psychologicalone/becauset "admits complexity.It

attends to the mind, and the broader social setting, as well as to the neurons. It

illuminates the stories of the patients we have met. And it correspondsto the

commonsensebelief that there should be biological as well as environmental

seKagan suggests hat between 1.5 and 3 percent of the adult population will be bom inhibited and remainso as heyreachadulthood.See bid.; pp.151-15260ibid.;p.1516t ibid.; pp.192-193

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components o personalityand that they should interact n intricate ways"Q

Kramer acknowledgeshe fact that Kagan's esearchs very flimsy indeed.But

Kramer ikes he dea of the stress/riskmodel,partly becauset fits in quitewell

with therest of his theory.

When we put functional autonomp kindling of depressionand stress/risk

together to form a coherent theory of mental illness and personality, the

following becomesapparent.A person can be born with neurotransmitter evels

that put such a person at risk, because f her biology she may be rejection-

sensitive o slight stresses nd traumas.Thesestresses repsychological,but they

cause urther biological changes o her neural pathway. As more and more

stresses, nd more and more changeshappen to her biology (kindling), her

symptoms now become functionally autonomous to the causes.The

psychological tresses,nd her depressioryavenow takena life of their own.

Psychotherapymay help in understanding he original causesof her depression,

but ultimately may be inefficient in dealing with the functionally autonomous

symptoms hat havebeencausedby her changinganatomy,and medicationmay

becomenecessary.Because tressmay causeour anatomyto change,what may

appear o be near normal behaviourand personalitymay, in fact, be an early

stage of kindled depressionand thereforemay require early intervention,

perhapseven hrough medication.

@ibid.; p.194

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Further Points

There are two further points that come out of this theory, which I would like to

highlight. The first is that if mental disorders,personality and neurotransmittersare so closely interlinked, a medication that can help depression should also be

able to transform personahfy. Kramer notes that:

What the differentmodelshave n common s an understandinghat not only

depression ut also temperamentests on[,] and is sustained y[,] levels of

neurotransmitters nd stresshormones.One conclusionwe might draw from this

understandings that medication hatalter evels of, or transmission y, these

substancesught to affect temperament.ndeed,we shouldbe surprised f a

medicine hatresets he norepinephrinend serotonin ystems oesnor directly

alter temoerament.6s

But what are the ímplications that come at us when we have a drug that allows

for the enhancement of human personality? Kramer raises this point by

describing Prozac as a possible "steroid[s] for the business Olympics"*, raising

all of the issues that surround human enhancement in general.

The secondpoint raised by Kramer with regard to the way that personality,

psychologyand biology interact,concerns he possibility that when a society

rewards a particular personality style, thosewho do not fit in that categorymay

find themselves t risk for trauma,. ecauseheir personality styleand behaviours

are not rewarded.What this may mean s that, in fact, a society hat doesnot

- 1D1O.; .r /Cv ibid,-;p.244

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reward certain temperaments may be Part of the cause of people's mental

distresses and that to cure such temperaments may be nothing better than

creating conformity. Kramer rightly points out:

[S]houldapersonwith apersonality tyle hatmight succeedn a differentsocial

settinghave o changeher personality by meansof drugs!) n order to find

fulfilment?... Perhapsmedication ow risksplayinga role that psychotherapy

was accusedof playing in the past: t allows a person o achievehappiness

through onformityo contemporaryorms.ut

These ast two points, are central for an understanding of Ptozac'splace in our

society. In the next chapter, I will concentrateon the ethics that surround the

issue of human enhancement,specifically Prozac as a personality enhancer. n

my final chapter, I will look at the arguments that surround the idea that Prozac

creates onformity.

6 ibid.; p.40

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CHAPTER 3

PROZAC AND THE ETHICS OF ENHANCEMENT

Ir this chapter I will discuss in particular the ethical problems that surround the

use of Prozac as a form of self-enhancement,and, more generally, of human

enhancement through biology. To begin with, I will look at what counts as

enhancement and what dops not. I will then explore the distinction between

treatment and enhancement. I will also give an account about whether different

means of enhancement are important for an evaluation of the ethics behind the

use of Prozac. This will be followed by an examination of what Kramer terms

enhancement or "the businessOlrrmpics".tr

Enhancementvs. Treafinent

What should be considered as enhanceme-ntand what should not? Kramer,

himsell frequently points to this distinction with regard to depression and other

affective disorders. He also alludes to the issueof categorisation when discussing

mental diseases:

I wonderedwhetherwe were eady or "cosmeticpsychopharmacology".t was

my musing about whether t was kosher o medicatea patient in the absence f

depressionhat ed me to coin thephrase...We may mask he ssueby defining

lessand essseveremood states spathology,n effect saying, If it respondso

n Kramer,P.D.;Liglcgi!&OllgzaE (London,1994, ourthEstate);p.246

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an antidepressant,t's depression."...ow largea sphere f humanproblemswe

chooseo defineasmedicals an mportant ocialdecision.6?

Kramer highlights a very interesting point: the medicalisation of normal or near-

normal human traits. He highlights this concem by imagining a future "culture

in which this biologically driven sort of self-understandingbecomeswidespread.

Certain dispositions... might be seen as ailments to be pitied and, where

possible,corrected."6Kramer arrivesat two possibleoutcomes:

One s to stretchhe scopeof mental llness10encompassher)characterraits.

Another s to say hat we have ound a medication hat canaffectpersonality,

perhaps ven n the absence f illness...Either way,we areedging owardwhat

might becalled he"medicalizationof personality".6e

Here, Kramer implies that the distinction between enhancement and health is a

matter of disease. f there s a diagnosabledisease hat can be identified, it should

be categorisedas treatmen| otherwise it has to be enhancement.Unfortunately

this category distinction has one major problem - one that Kramer has already

nailed on the head - it is very easy to expand our conception of disease to

include the effects of medication. If the distinction drawn from a conceptionof

disease s unhelpful, we need to find one that is at least lessproblematic.

One such alternative could be the model createdby Norman Daniels and James

Sabin. They call this model 'normal function' and according to this theory the

n ibid.; pp.1F1663ibid.; p.20" rDLO.)p.JO-ó/

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role of medicine is "to maintain, restore, or compensate for the restricted

opportunity and loss of function caused by diseaseand disability' Successful

health care restorespeople to the range of opportunities they would have had

without the pathological condition or prevents further deterioration"'ro

According to this definition of health all humans do not have the same innate

capabilities, that would be naive. Instead, they suggest that all humans have their

own specific natural capabilities, possibly determined by genetic factors. The

purpose of medicine therefore, is to Prevent, or treat, situations where those

biologically based capabilities have been, or could be, stifled. The 'normal

function' model of medicine tells us what constitutes a fair health care system: it

would entail treatment but exclude enhancement' It allows us to make the

distinction between enhancementand treatment by identifying the proper role of

medicine. The normal function model also helps to keep the medicalisation of

normal human traits at bay by acceptiirg that "people are tfuown into the world

with different endowments, it can be a tool to fight medicalization; it can help us

remember that there are nafural differences and characteristics hat medicine

ought not to be used to erase."71

So, in summary, a treatment/enhancement distinction based on whether a

recognisablediagnosis can be identified is too simplistic' It does not take into

account the fact that diagnosescan be created, repealed or expanded and when it

comes to diseasesof the mind we do not, yet, have a sophisticatedand thorough

understanding of them. Daniels' model tells us what the proper role of medicine

should be, that is, keeping the natural capabilities of any given person from

6eing stifled. This in tum allows us to createa distinction between enhancement

?SabiruJ.E.& Daniels, N.; 'Determining 'Medical Necessity' ir Mental Health Practíce'; HastingsCe erREort (24, J.6,1994)t.10r Éarens. E.; Is BetteiAlwavs Good?The EnhancementProject'; in Parens'E.(ed.);Enlrnacing Human Traits- Ethical and SocialImplicaÍions; (Georgetown University Press,Washington D.C,1998); p.5

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and treatment. Treatment is what medicine should be preoccupied with,

anything else should be consideredas superfluous and therefore categorisedas

enhancement. But this model has at least one major problem. Where does

preventative medicine (like vaccines) fall? Can we Put it in the category of

treatment or should we call it enhancement?Perhaps the only solution is to

create a category unto itself, so that we have "treatment (of disease) and

enhancement" and a third "prevention (of disease)".z n this sense, reatment

and prevention of disease'are part of the role of medicine. Anything else is

enhancement.

Let us now apply this version of the category distinction back onto my

discussionabout Prozac. f we are to takeKramer's theory, that many personality

traits are in fact s1'mptomsof a biologically based kindled depression, then, a

great deal of the symptoms for which Prozac s prescribed can, n fact, be viewed

asprevention. Your neural pathways may deteriorate unlessyou take Prozac or

any other SSRI.Then there are thosewho tate Prozac or treatment. In this case

your neural pathways are deterioratin& you needProzac to Prevent any further

problems and perhaps restore the frathways to their former selves.As we can

see, f we are to acceptboth Kramer's theory of affectivedisordersand the above

distinction between treatment and enhancement,Prozac's use, in most cases,

does not fall in to enhancement. But we can imagine occasions where an

individual is not really at risk from deteriorating pathways'ts f this person uses

Prozache is neither treating a diseasenor preventing it' According to our theory

what he is doing is enhancing his personality.

'- lDrO.; p.Cu Unlesswe decide that any life experience s risky and could causeneurones to deteriorate. In that casewewould need to medicateeveryone from birth as a forrn of prevention.

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Do means matter?

This leads us to the issue of enhancement. Enhancement in our culture is

generally viewed as a good thing, something that we should all be striving for.So, why is there a problem of enhancing our personality with medication? It

appears that it must have something to do with means.

ln Listening to ProzacKramer raises the point that one mean of enhancement

(psychotherapy) can be viewed as better, morally and ethically, then another

(psychopharmacology).He explores this avenueby looking at pharmacologicalCalvinism. This is "[a] general distrust of drugs used for non therapeutic

purposes and a conviction that if a drug 'makesyou feel good, t must be morally

bad."''n He continues by pointing out that with regard to mental conditions

"[d]octors tend to underprescribe... and patients tend to take lessmedicine than

the doctors prescribe."%However, he is not satisfied that this form of Calvinism

may stop people from taking Ptozac,as t is not rational:

Pastexperience uggestshat we'cancounton ourpharmacological alvinism o

saveus from coercion.On the other hand,pharmacological alvinismmay be

flimsy protection rom the allure of medication.Do we feel secure n counting on

our irrationality our antiscientific rejudice to saveus from the ubiquitous

cultural oressuresor enhancement?76

?aKlermary G.; 'Psychotropic Hedonism Vs Pharmacological Calvinism'; Hasting Center RePort;(1972,Vol.2 n.4);p.375Knmer, P.D.; op.cit.; p.27416ibid.;p274

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Kramer adds to this argument in his essay The Valorization of Sadness'where

he suggests hat psychotherapy, and a drug like Prozac for example, may achieve

the sameend:

[P]sychotherapyasbeen hetechnology pplied o melancholy.n thisaccount,

psychotherapyncludesapproaches,uchas supportive r strategic herapies...

where hegoal s changen affective tate .. And thosewho hopepsychotherapy

succeedsmust be comfortablewith the diminutionof rnelancholy.For these

reasons, I came to believe that a critical objection to cosmetic

psychopharmacology ust nvolve the methodof change, amely,medication,

more han hegoalsof intervention.TT

Kramer, aswe have seen, doesraise the point about means,however, he suggests

that perhaps our worry is that technology is unnatural, and that is why we object

to it. He therefore dismisses t quite readily as some silly technophobia.

Kramer's dismissal is challenged by Dan- Brock. He argues that there is a

mistaken understanding about means.He suggests hat means matter becauseon

many occasionswhat is valued is the hard work needed o arrive at a Particular

end. For example, in sport we appreciate sPortsPersonsbecause of their

discipline and becauseof all of the training they have endured. If the same end, a

great sportsperson, were to be achieved by biological, quick fix means, then what

we value about sport has been erased.78lence, means do matter:

In manyvaluedhumanactivities, hemeansof acquiring he capacitiesequired

for theactivity are asmuch valuedandadmiredas heperformance f theactivity.

t?Knmer, P.D.; "TheValorization of Sadness';Hastings Center RePort; (March 2000,v30, i2); P.1373Brock D.W.; 'Enhancementof Human Function: SomeDistinctions for Policymakers'; in Palens, E.(editor);op.cit.;p.58

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They arepart of the definition of the activity, and transforming hem transforms,

andcandevalue.he activitv tself.Te

A second argument about means is, as Parens suggests,"that different means

sometimeswork on... different " objects."w He highlights this by giving an

exampleusing the classroomas the location. In this example the end is to raise

students' performance, and the means are, firstly reduction of class size, or

secondly Ritalin - a medication. So, the means are different but the end is the

same.Parens here argues that the two different means are not affecting the same

object at all. Reduction of classsize "changes the child's environment", whilst

Ritalin "changesthe child's bíology."81Sohe ends are really not the sameafter all.

They are the same in respect of only one measure. An example to clarify this

point can be viewed as follows: Both Prozacand prayer may raise serotonin in

the brain. But the ends of using Prozaeand of praying are not the sameat all; all

that is the same s the level of serotonin.e

This demonstrates that psychotherapy and pharmacology may aPPear o achieve

the sameend enhancement of personality, but the end is not the sameat all. The

former affects self-understanding and the latter affects biology. Prozac may

diminish the value of the new personality. You achieved t but you really have

not understood how or why you have this new personality, except that you have

changed your biology. From what we have seen above, I think that Kramer is

mistaken in thinking that our distrust of Prozac is simply an irrational

technophobia. There are real issues suggesting that the means used to achieve

something have a real impact on the value that we humans give to that

8 ibid.; p.58e Parens,E.;op.cit.;p.128ribid.;pp.12-133'seeParens,E,;op.cit. p.14

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something. I would see he role of medication with regard to mental conditions

to be a last resort to be tried only when psychotherapy fails.

The BusinessOlympics

Even though Kramer does not fully understand the importance of means when it

comes to enhancement, he is aware of the problems surrounding the uses of

Prozac for enhancement with regard to its uses in our competitive business

world. He asks:

How shall we respond o the complaint that a particular executive acks

decisivenessndvigor?By prescribing rozac?83

Later Kramer argues:

This nightmare iew of the useof àredicationo increasementalagility...helped

form the basis or my coining the term-"cosmeticpsychopharmacology"nd

speculatingabout the use of antidepressants s "steroids for the business

Olympics."&

\ Ihat he appears o be worried about are the same ssues hat surround the use

of steroids n sporting events,namely, the idea of social coercion.Should steroids

be allowed in competitions?Those who take steroidshave an unfair advantage

over other sportspersons who for whatever reason, money or ethical choices for

example,choosenot to use steroids.The steroid free competitorswould neverbe

a6le to achieve the same level of comDetition as those who do. As the amount of

3rKramer;P.D.;Listening o Prozac; p.cit,;pp.1Gl7u ibid., pp.245-246

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people who use steroids n competition increases,more sportspersonswould feel

compelled to take them, otherwise they would never have a chance o achieve

their goal. This is what Kramer calls "free choice under pressure"s in which free

choice is diminished. He suggests that the same could happen with Prozac:

In the science-fictionhorror-storyversion of interplay of drug and culture, a boss

says, Why sucha long face?Can'tyou takea Moodstim beforework?"...Only

slightly essnightmarishs theprospect f free choiceunderpressure. here s

alwaysa Prozac-taking yperthymicwaiting to do your ob, so, f you want to

compete, ou had better ake Prozac, oo. Either way, a sociallydesirable rug

tums from boonto banebecauset subjectshealthypeople o demands hat they

chemically alter their temperament.s6

According to Erik Parens enhancement technologies could widen the gap

between the rich and the poor. He sug$ests hat in our capitalist and competitive

society these technologieswould not be available to everyone (becauseof costreasons).Furthermore, universal usage of these technologies would be a self-

defeating act. So, enhancement technologies "have the potential to widen the gap

between the have and the have nots."87

Here, I tend to agree with Parens. Il Prozac were to be available to anyone who

askedand payed, without any seriousregulations from the govemment, people

who cannot afford it, may be at risk of being left behind in our competitive

business world. Because of all the issues highlighted in this chapter, I feel

85ibid.; p.27336ibid.; p.27387Parens,E.;op.cit.ip.25

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inclined to say that Prozac should reallnremain a medication which is prescribed

to peoplewho need it, not sold to peoplewho want it.

As we have seen there are many ethical issuessurrounding the use of Prozac forenhancement. However, I think there is another issue which is even more

important when discussing cures for minor mental conditions. Are these

conditions, which are becoming more widespread, really a deviation from the

norm? Alternatively, are they just reasonableresponses o a society in which

normal human activities have become alienated from what it is to be human? Is

Prozac really tending to the causesof this widespread malaise?Or, is it only

curing the symptoms? I shall be examining thesequestions in my final chapter.

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CHAPTER4

PROZAC.ALIENATION AND SOCIETY

In this final chapter, I would like to explore the idea that minor forms of 'mental

illness', such as anxiety and minor depression, are in fact quite reasonable

responses o the human situation in our present culture. As in the previous

chapter, I will explore the kinds of issues hat Kramer raises on this subjectand

use the conceptof 'alienation' to illustrate this. Subsequently will suggest hat

Prozac forces the 'user' to conform to a personality style that is considered

desirable and normal in our society. I will follow this by arguing that alienation

(and minor forms of mental illnes) is a reasorrable esPonse to our contemporary

society. I will conclude the chapter by exploring the idea that 'curing' the

individual is, in fact, an unreasonable response and that the reasonable one

would be to 'cure' societyand our culture.

Kramer is aware that cultural norru.are important when defining mental illness.

Even his biologically based heory doesnot excludethe impact of culture, in fact,

he attempts to incorporate it:

To be neat n a culture hat prizesneatnessmay bespeak very different, ess

aberrantbiological state hanmaintenance f the samebehavior n a culture that

has adopted different values... whether a particular behavioral style like

pgrfectionism s deviant s verymuch amatterof cultural expectations..88

33KramerP.D.;LillcEb&lqPlgzag; ftondon, FourthEstate, 994,P.39

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Kramer looks at the work of Richard Schwartz, a psychiatrist at Mclean hospital

in Harvard. Schwartz calls Prozaca mood brightener. Schwartz"fears that mood

brighteners have the capacity o reinforce oppressivecultural expectations."se e

uses an example about prolonged bereavement. Psychiatrists have reported

successwhen prescribing medication to patientsone year after a death. Schwartz

contrasts one year of mourning to the five years of formal grieving that takes

place in rural Greece. He suggests that "[w]hen doctors pharmacologically

mitigate the pain of bereavement after one year/ they may be using medication to

reinforce cultural norms and encourage conformity. The medication seems ojustify the standard that is in place by labelling those who deviate from a cultural

norm as ill and then "curing" them."{

Kramer does not argue against Schwartz on this point, but objects to the term

'mood brighteners' as a correct description Îor Prozac.Prozacdoesnot brighten

moods in a direct manner/as t doesnot conferhappinessor pleasure n itself, in

the taking of it, unlike let's say marijuana or cocaine.What Prozac does is change

personality in such a way that a person is able to experience pleasurable

activifies. So for Kramer a drug that is able to change personalities is even more

worrying in respect of cultural expectation. According to Kramer Prozac

"highlights our cultwe's preference or certain personality types."elHe takes, as

an example, the traits that are valued in women today and suggests that they arenot the same as the personality styles that were seen as morally appropriate in

the Victorian period. In fact, many of Victorian character raits are now seenas

'deviant' and problematic for a woman's mental wellbeing. He continues by

3'Kramer,P.D.;op.cit.ip,254q ibid.; p.254e1ibid.p.277

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suggesting hat Prozac helps in sustaining the social conformity that attends to

""masculine" capitalistsvalues".e2He appears to be torn between two sides of

the debate.One which seesdrugs like Prozac as a "feminist drugs, in that they

free women from inhibiting consequencesof trauma." On the other hand,

Kramer seesProzacas " curing women of traditional, passive eminine traits... []

reinforc[ing] the cultural expectationsof a particular exigent form of economic

organization."e3

Kramer continues to investigate this side of Prozac by putting forward Marx's

analogy about opium. He suggests hat opium can be seenas an instrument of

conformity, by deadening mind and bodp thus removing any willingness to

rebel.qHe continues by saying t}:rat Prozac suPPortssocial stasisby allowing

people to move toward a cultural ideal - the flexible, contented, energetic,

pleasure-driven consumer. In the popular imagination, Prozac can serve as a

modern opiate, seducing the citizenry into political conformity."esHe concludes

by saying that psychotherapy really is not any different from Prozac in this

matter:

Early this century,psychotherapy as criticized or inducing adaptationo the

dominant culture; even if it containeda radical critique of that culture,

psychotherapy as ultimatelyan agentof stasis.This argument pplieswell to

Prozac,%

n if",ìA n )71et i } . À.n171q Seebid.;p.271esibid', pp.27l-2:n%ibid.; pp.27l-272

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The conceptof alienation suPPorts his idea of cultural expectation.Feelings of

anxiety, melancholy and other minor forms of 'mental illness' are normal

symptoms of an alienated self in an alienating society.Kramer is aware of this

argument and he usesthe writings of Walker Percy to higtrlight them:

Percy avorsErich Fromm's formulationthat anxietyamong he affluent... s the

sign and symptomof alienation rom the self, an appropriateeaction o the

accurateeeling hat ife runs hroughhandsike sand.'.Anxiety s "a summon o

authentic xistence,obe heeded t anycost."e?

Kramer dismisses Percy's claims quite readily by suggesting that, in Íact, Îor

users of Prozac who are not mentally ill "the drug seems to aid rather than

inhibit the struggle to locate the self"es

Alienation

Originally, alienation was a term that related directly to mental health. The word

has its origins in the Latin languages where it denoted psychosis, "the

thoroughly alienated person."e However, the term was given a different

meaning by Hegel and then later by Marx. For both Marx and Hegel "the concept

of alienation is based on the distinction between existenceand essence, n the

fact that man's existence s alienated from his essence,hat in reality he is not

qbid.; pp.277-278

%ibid.;p.278t Fromm, E.; The SaneSociew; (London, Routledge & Kegan Paul LTD, 1956);p.121'

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what he potentially is.. . that he s not what heought to be,and that he ought to be hat

whichhecouldbe."lú

According to Marx the nature of alienation is connected to the way we, humans,relate to our work. The unhappy consciousnessarises when production and

consumption become sePatateProcesses/as in our own consumer culture. Under

capitalist social relations, people do not produce directly for their own needs.

Having been deprived, by .various social developments, of ownership of, or

control over, the means of production, they must submit to wage-labour in order

to gain the money to purchase consumption goods on market'

[T]he worker s related o theproduct of his labor as o an alíen object...The

alienationof the worker n hisproductmeans ot onlythat his aborbecomes n

object,assumes î externalexisteirce, ut that it standsopposedo him as an

autonomousower.The ife whichhe hasgiven o the objectsets tself against

him as an alienhostile orce.1o1

Marx believes that the processesof labour in capitalist society dehumanises

(wo)man and brings her back down to her animal self:

[Man (theworker)feelshimself to be freely active only in his animalfunctions

eating,drinking andprocreating, r at most also n his dwellingand n personal

r@Fromm,E.;ù[ag3..]eqleeplgl!!a4; (FrederickUngarPublishingCo.,NY, 1969); .47totMarx,K.;Economic nd philosoPh hanslatedby Bottomore, .B.; VariousEdition.); nbrd.; pp.95-96

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adomment while in his human unctionsheis reduced o ananimal' The animal

becomes umanand he humanbecomes nimal.1o2

This idea of man as alienated from his labour and his consumptiory leads to

(wo)man being alienated from herself and from other (wo)men, she has no

control over her future and her acfions in the sense hat the need for subsistence

rules her and forces her into a kind of work that is uncreative and unrewarding'

Fromm expanded Marx's concept of alienation and related it back on to the

concept of sanity. In The SaneSociety,he explores the way that alienation works

in modern capitalism. Fromm suggests that contracted labour demeans man

becauseman is for sale,as a prostitute would be.

The senseof self stems rom the experience f myself as the subjectof rry

experiences,zy thought,my feehng,my_decision. y judgement,my action. l

presupposeshatmy experiences my own, andnot an alienatedone Thingshave

no self andmenwho havebecomehingscanhaveno self.r03

His only value comes from the external, man-rÉde economic marke! and he has

no control over it. He is a success f his traits and skills are valued; he is a failure

if his traits and skill are of no use to the 'market'. As Fromm suggests,however,

the market is 'fickle', and those values are ever changing. Therefore:

tú ibîd..;p.99t@Fromm, E.; The SaneSocietv;oP.cit.;P.143

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[t]he alienatedpersonalitywho is for salemust ose agooddeal of the sense f

dignity which s socharacteristicf maneven n hisprimitivecultures.He must

losealmostall sense f self,of himselfasa uniqueand nduplicable ntity.lo4

Fromm continues by suggesting that for the alienated man remaining sane can

only occur by external validation by "fitting into one of the current pattems"10s r

conformity. Man loses himself in his routine, in his need for survival, in his

alienated work and alienated labour, and by doing so, he rePresses the awareness

of the basic roblems f humanexistence."lMy doing so, he doesnot fulfil himself.

Becausehe does not fulfil himself he is not sanebecausehe is not true to his

nature. "[M]an can fulfill himself only if he remains in touch with the

fundamental facts of his existence... f he is completely enmeshed n the routine

and in the artefactsof life... he looses. ouch with the grasp of himself and the

world."lv Therefore, capitalist culture iobs man of his humanity if he conforms

to the conceptof man as an object,a living machine, hat canbe bought and sold,

that works to live and lives to work.

Carl Elliot, a critic of Prozacand of Kramer, takes a more subtle approach.He

creates distinctions between different forms of alienation; personal alienation,

cultural alienation and existential alienation.Personal alienation is describedas

"a sense hat you don't conform with social expectationsof someone n your

particular circumstances."loshis kind of alienation happens when "a person's

tu ibid.;p.142'05ibid.; ;.143'tr ibid.; ;.144tù1ibid;í.lMtoeElit, C.; 'Pursued by Happiness and Beaten Senseless';úEl[lSlgcdlcLBePpIU (March 2000v30 i2 ); P.7

ll'l

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identity is in question or under reevaluation."tt It does not Pose too many

problems, you are unhappy with your life, your circle of friends, your job, so you

make a change.

Cultural alienation involves much deeper emotions.A person can feel alienated

from his own culture. "You stepoutside of your own socialiazation' and look at

your own culfure from a stand point of detachment./l1o This kind of alienation in

western society shows itself mainly in the form of a person's discovery that what

he has been told all of his life - that he is an individual, that he is unique - is in

fact false. "[T]here is something terrifying about looking deep inside and

discovering that you're no different from the guy next door. That your life is just

an average ife, and your story so ordinary it is not evenworth telling. [This] is

enough to make you think about an antidepressant."llt

The last form of alienation that Elliot describess existentialalienation.This takes

the form of questioning the point of life in itself. "The result is not just the feeling

that you are ill-suited for your own particular form of life" ' rather, it is a calling

into question of the foundations of any form of life...It is a sense hat there is no

rh)rme and reason to your form of life other than the exigencies of biology and

history, that the big picture is really nothing more than a big pictute."llz

'w ibid;p.7tto ibid.;p.7ttt ibid.; p.7ttz ibid..; p.7

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Conformity

With regard to Kramer, Fromm and Elliot, there is a real concern about the way

that society tries to make people conform into the cultural norms of a given

society. This concern stretchesfrom the meansemployed to achieve it tfuough to

the idea of normailisation altogether.Here, I will need to look, albeit briefln at

the idea that we have to be aware that what is called 'mental illness' could iust be

a simple deviation from the norm.

R.D. Laing, famous for his books on schizophrenia and madness, would agreewith Fromm and Marx about the idea that we are all alienated. He points out in

t}nePolitics of Experiencehat "The condition of alienation, of being asleep, of

being unconscious, of being out of one's mind, is the condition of the normal

nìan./'113e later suggests hat in fact madness s just one of many expressionsof

alienation. And that those who express heir alienation in a way that is apart

from the rest are to be viewed as deviant, by societyat large, and perhaps made

to conform:

Thereare orms of alienationhat are elativelystrangeo statisticallynormal'

fomrs of alienation.The 'normally' alienatedperson,by reasonof the fact that he

actsmore or less ike everyoneelse, s taken o be sane.Other forms of alienation

that are out of step with the prevailingstateof alienationare those hat are

labelled y the"normal"majorityasbador mad.lra

tt3Laing R. Di The Politics of Experience and the Bird of Paradise:(Penguin, Middlesex, L967);p.24\taibid;p.24

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In the samevein, Fromm raises he point that just becausesomething is normal

in a given society, it does not really imply that something should be sane or

reasonable on this merit alone:

Consensualalidationas suchhasno bearingwhatsoevet n reasonor mental

health. ustas heres a"follie à deux" theres a "follie à millions."The act hat

millions of peoplesharehe samevices doesnot make hesevicesvifues, thefact

that they sharesomany errorsdoesnot make he errorsto be truths, andthe fact

that millions of peopleshare he same orms of mentalpathology doesnot make

these eople ane.115

Here we can start to understand mental illness in a new way. If you think that

our way of living is incompatible with how humans should be, then you may be

prepared to remove the 'mad' or 'mentally ill' labet, from people who are

considered to be mad or mentally ill. The label, in fac! may now apply to those

who conform to that way of living. This point is well highlighted by Laing once

more:

From the alienated tartingpoint of our pseudo-sanity,verythings equivocal.

Our sanity s not 'true' sanity.Theirmadnesss not 'true' madness..I,et no one

supposehat wemeettrue'

madness nymorehan we are ruly sane'116

Fromm suggestshat sadness nd feelingsof insecurity, ike those eelings hat

someof Kramer'spatientsreported, are, n fact, normal feelingsnatural to man.

Man has no reason to feel secure "[b]ecause of the very conditions of our

rr5Fromm, E.; The SaneSocielv:oP.cit.,PP.14-15"ó Laing,R.D.;op.cit.;p.118

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existence,we cannot feel secure about anythin9."117Ottr lives are rarely fully

controlled by us, as the possibility of accidentor death remains prevalen! there

is never any certainty about the decisions that we make, and we hardly make

such decisions with all the information necessary.For Fromm, and I tend to

agreehere, alienated man attemPts to feel secureby conforrning, by not standing

out. úrstead of curing it, this insecurify should be accepted:

The psychic ask which a personcan and must set for himself, is not to .feel

secure,but to be able to tolerate nsecurity,withoutpanic and undueear.rr8

Anxiety and feeling of insecurity, aswell as sadness,are reasonable resPorìseso

our capitalist society and therefore such statesshould be valued as part of our

humanity. What Prozac does is to remove such insecurities.Prozac, therefore,

could be the new opiate of the masses,giving men and women a false senseof

security, that leads to conformity of personalities and to a static society.

I-r conclusionI would argue that 'alienation' shows us what we are really doing

when we prescribeProzac for these minor conditions.Taking Prozacattendsto

the symptoms and the symptoms alone. Therefore/ we are really missing the

point, and at least part of the causes,of these conditions. We are not curing these

conditions at all, we are just transforming people to fit into a society that creates

the conditions of alienation.I suggest hat this situation is deeply problematic.It

is humans who create society and culture. But when this culture seems o fail us

--and the figures for minor depression and other minor conditions are on the rise

- what we do not do is changeour society,which is maladjusted to our human

r17Fromm, E.;The SaneSocielv;oP.cit.;PP'196t13ibid.; p.196

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needs. Instead we suggest that it is us humans that should change to fit in with a

unreasonablesociefy. This appears to be higtùy illogical.

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CONCLUSION

In my first chapter I investigated the rise of Prozac by looking at the basics of

neurochemistry, and by looking at how it was discovered. I followed this by

looking at some of the statistics on Prozac. I found that a large amount of people

have been prescribed this medication' To understand the reason behind the

widespread usage of this medication I decided look at how the media had

portrayed it in the years following its licence. An immediate hype was created of

which Kramer was deemed of the main culprits. Here I also discussed the

backlash against Prozac.I decided that the best courseof action was to outline

some of Kramer's theories in the second chapter, ashis book was deemed useful

in engendering philosophical debate.Here I discuss the three main parts of his

book: 'functional autonomy', the 'kindling' model, and the idea of inborn'

temperaments. When analysing these points, I discovered that Kramer had

created a theory of depressionand personality that was based in biology-

Kramer's theory, though, was not a simplistic biological determinist theory. :'

Instead, it was a sophisticated one in which he weaved together biology and

psychiatry, mind and body, nature and nurture. In this chapter I also began to

highlight some of the problems that surround the use olPtozac, which I discuss

in more detail in the following chapters.

Chapter 3 is an exploration of the ethical issues hat come up when suggesting

that Prozac be used as a personality enhancer.Here I begin by defining what

constitutes as enhancement. found that we have to make a clear distinction

between treatrnent and prevention of disease,and enhancement.IL this chapter I

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also discuss the importance of means when we decide to enhance ourselves.

Here I found that what we value in a lot of human activities is not simply the

goal, but also the process used to arrive at the goal. Quick fix methods and

shortcuts can devalue an activity, as they change the activity itself. I continue the

chapter by highlighting ethical problems with regard to social coercion and

unfairness. n my final chapter I continue to look at social coercion.Here I point

out that perhaps minor 'mental' conditions are in fact a result of alienation.

Alienation is a widespread condition caused by the way the western world

defines the self in relation to worlg profit and competition. I then go on to saythat our culture alienates us in such a way that we feel compelled to conform and

to make others conform by adjusting our personalities to one that is simply more

coÍunon. Here I take the view that perhaps these mental conditions are iust

variations of personalities.Thesepersonality styles are at the least as normal as

any other and at the most much more reasonable.They take into account the

realities of human life.

In my opinion Kramer creates a théory of affective disorders that takes into

account all aspects.He usesnature and nurture together. His theory may not yet

be accurate enough, but I think he is 'on to something'. I would argue that his

book is good in raising someof the issues hat are problematic,when we accept

this theory. Unfortunately, Kramer far too often dismisses his own concerns far

too readily, especiallywith regards to means.When it comesto enhancement

believe that we should avoid at all costs shortcuts to happiness. That happiness

would not be worth too much.

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Here I want to point out that I do think that Prozac should be available to people

who need t, people in desperatecases hat really need help. I do alsobelieve that

other methods should be employed first, like psychotherapy. However, I do

think that we as a society, should be looking in much more detail to the real

causes f this widespread malaise,our ozun ulture.

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Internet

Eli-Lilly - url: http/ /www.prozac.com

National Mental Health Institute - url: http: / /www.nmhi.com