Milinda’s Questions

Sometimes I wonder how all those who do not write, compose or paint can manage to escape the madness, the melancholia, the panic fear which is inherent in the human situation.

Mad Melancholic Feminista is the blog of a philosophy professor at Gettysburg College who posts under the nom de plume Aspazia. Which is how I’ll refer to her, unless she prefers otherwise, although her identity is pretty easy to discern if you go to her departmental website. By her own account, Aspazia started her blog a couple of years ago at least partially as a sandbox for a work-in-progress examining the ongoing debate among bioethicists concerning the ethical ramifications of the widespread use of SSRIs (the category of antidepressant to which Prozac, Paxil and Zoloft belong.) She posted frequently on this and related topics for about a year, but recently the Prozac project seems to have largely disappeared from MMF (whether due to lack of interest from readers, or to potential objections from publishers as the book nears completion, I don’t know.) For a while, she was also doing a weekly feature called “Notes from the Prozac Nation,” which had a lot of interesting links, but that seems to have disappeared too. It must be noted that Aspazia is expecting a baby very soon (congrats!), which I imagine keeps her pretty busy. In fact, I would have said that psychopharmacologicoethical concerns appear to be entirely off Aspazia’s radar these days, were it not for today’s post on Propanolol. She has wise things to say:

When I first started writing and thinking about the ethics of enhancement drugs, I found myself . . . concerned that this technological approach to tweaking our personality and making us more socially acceptable was bad, bad, bad. . . . But, alas, enough reading and thinking about this issue has challenged this view for me.
. . .
Surely many of the opponents to enhancement drugs think that what is wrong with contemporary American culture is its rampant consumerism, its ultimate faith in technology to “fix” all perceived problems, and the pervasive and perhaps, shallow view, that we all deserve to be happy.
. . .
I don’t think [they are] totally wrong about this, but over the years, my intuition about the typical patient seeking out enhancement drugs has transformed. I no longer envision snivelly, whiny, and weak willed Americans looking for a quick fix. Rather, I envision people battling real tragedies and real stresses seeking for relief.

My sentiments exactly. (BTW, the body of the present post was composed before I saw this most recent one from Aspazia. The above remarks do somewhat change my general impression of “where she’s coming from”, but I don’t think any of the particular things I say here need revision. I could be wrong, though.)

Anyway: the bioethical discussion on SSRIs and other psychotropic medications is a topic I’m intensely interested in, and I’m grateful to Aspazia for offering a means of rapidly getting up to speed on some of the main participants and positions in the debate. At the same time, though, I’m going to be somewhat critical of the feminist analysis she brings to the issue.

Aspazia’s central claim is that the Prozac debate has largely ignored the gender implications of the widespread use of SSRIs. In response, I will offer two points. First, I think that Aspazia’s intentions would be better served if she framed her project as one of starting a new conversation, as opposed to expanding the terms and perspectives in an existing discussion through criticism of the texts it’s generated. Second, to me Aspazia’s argument is weakened by inconsistent accounts of what the contents of “the existing debates” are. I’ll develop the two points in order.

I. A New Conversation?

In principle, when a nonparticipant says of some discussion or discourse, “This discussion misses the point,” she may be saying one of two things:

1. There’s a related topic that I think is more interesting or important than the question under discussion.
   or
2. There are concerns relevant to the issues as formulated in this discussion which are being ignored by all participants.

A possible response to (1) is always, “You may be right, but we happen to like talking about just what we’re talking about now.” (Analytic philosophers give versions of this response very frequently.) Let’s call this the exclusionary response for short; I’m not going to define it more formally, because for the present audience I think it’s clear enough what I’m talking about. I am enough of an anal.p. that I sympathize with this response, and would claim that in general the burden is on the objector to show that the excluded factors are relevant to the discussion as defined by the participants.

Outside of academic journals and seminars, though, the issue isn’t nearly so cut-and-dried. A partial and one-sided perspective can dominate the public discourse on an issue, such that other perspectives are excluded. Which way should we look at the “Prozac debate”? Here I’m going to defend the “exclusionary response”, for the following reasons.

First, I don’t think there is a single “Prozac debate” in contemporary culture. Rather, a wide range of issues are being discussed in various communities and forums. My not-very-well-informed impression is that the most media attention has been drawn to the implication of Prozac in suicides and other violent behavior. Let’s take a look at this issue for a moment. I believe that the following claims have been adequately established in the public record:

• In a relatively small percentage of cases, Prozac and other SSRIs induce suicidal ideation, usually in conjunction with intense physical restlessness, and usually within a few days of the initial prescribing. Some of those so afflicted attempt suicide, sometimes successfully.
• Eli Lilly, and other large pharmaceutical companies, suppressed the evidence of the link to suicide as that evidence was emerging in the professional literature.
• Prozac was insufficiently tested before it was released, and its development, including its foreseen uses, were overwhelmingly market-driven.
• SSRIs are aggressively overmarketed as universal panaceas, and are overprescribed by physicians who do not adequately monitor their patients (or didn’t before the publicity about suicide finally emerged.)

(I am relying on David Healy’s Let Them Eat Prozac for these points. Healy’s book was on my To Read list before I discovered Aspazia’s blog, but I am indebted to her for pushing it up to the top of the list.)

It’s unfortunate, but as I see it the discourse being conducted in professional ethics journals will have almost no impact on any of the institutions and practices that brought this situation about. There are things that can be done about the collusion between Big Pharma, academia and the medical profession; Healey suggests a number of these in his book. But none of these measures will hinder Big Pharma from its massive marketing campaigns, or discourage overworked primary care physicians prescribing medications which might provide a solution to complaints for which GPs themselves cannot provide an alternate remedy (even if insurors would pay for such an alternative.)

Second, I don’t see that the “engendered” perspective Aspazia wants to bring to the debate will have much impact on any of these issues. I can’t see any way, for example, to prevent Big Pharma from using gender stereotypes to target women in its advertising campaigns for SSRIs.

For these reasons, I respectfully suggest that Aspazia’s project of expanding the existing “Prozac debate” to include a feminist perspective. It would be more straightforward to start a new discussion on a different issue. Aspazia’s case would be stronger if she argued directly for her thesis that the widespread use SSRIs differentially affects women, rather than letting that thesis emerge from her analysis of the debate so far.

As I see it, Aspazia has 3 planks in her argument that the bioethical debate as currently constituted illegitimately ignores gender concerns:

1. Most SSRI prescriptions are written for women.
2. SSRIs are claimed to enhance psychological traits that are traditionally thought of as “feminine.”
3. The case studies cited by Peter Kramer in Listening to Prozac, and by other writers, overwhelmingly feature female protagonists.

Claim (3) strikes me as the strongest point by far, at least as Aspazia presents it, largely because all the evidence need to make the argument is right there on the page. Its “engenderedness” is a striking feature of LtP, and cries out for the kind of close reading which feminist critics have given to Freud’s texts. The leap from that kind of analysis to claims about large-scale social phenomena strikes me as problematic, though.

As for Claim(1), it would require some more statistical evidence to make this a compelling line of argumentation, and I can’t see that Aspazia has provided it in the portions of her work currently online.

Of course, Claim (2) is really the core of what’s at issue here.

Therefore, I intend to put off dealing with it until later.

:>)

II. What is “the existing debate?”

Another part of my problem in evaluating Aspazia’s claim that the mainstream debate ignores gender concerns is that she offers changing accounts of what the mainstream debate is. (This is quite understandable in a work in progress, and I expect it won’t be a problem when her book is published.) Initially, Aspazia says characterizes the mainstream debate in two ways: she says it concerns the line between treatment and enhancement, and she calls it a debate between “psychopharmocological hedonists” and “psychopharmacological Calvinists.”

The question of treatment vs. enhancement is relevant to, but not identical with, the discussion of the permissibility of the use of SSRIs in general. I would think that the default assumption here is: Treatment is permissible. Enhancement is not. This would seem to lead to operative definitions of “The measures you approve of are treatment; those you don’t approve of are enhancement.” However, it’s also open to the hedonist to acknowledge that certain things are by any reasonable definition “enhancements”, and are nonetheless permissible. It’s also open to the Calvinist to argue, not only that enhancement is impermissible, but certain forms of treatment are as well. In other words, the relationship between the treatment vs. enhancement issue and the Calvinist vs. hedonist issue is complex, and I don’t see that Aspazia has adequately trace out the connections (at least online.)

Aspazia’s discussion of the “Prozac debate” does get increasingly complex in subsequent posts; I’m afraid I don’t quite see how all the pieces of it fit together, though. Considering only the portions that are online, the argumentative heart of her work is in 3 sections (which I notice now were posted in an astonishingly productive three-day period in June 2005):

• the rewrite of This is No Mother’s Little Helper on 06/27/2005 (together with a few additional paragraphs from the original version of MLH, written a couple of days earlier.)
• The Psychopharmacological Hedonist’s Orthodoxy: Part I on 06/28/2005.)
• The Autonomy Enhancer on 06/29/2005 (an expansion of part of the argument of PHO.

And, in the time-honored tradition of writers for serial publication, I’m going to break things off right after introducing this brand-new topic, hoping, if not to entice readers to check back here for the sequel, at least to try to motivate myself to get around to writing it. In the meantime, readers can prepare for class by reading the posts just listed.