Monday, February 20, 2006

It Has Been Bugging Me All Day

Yesterday, ambling around the Internet, I read an article, and a blog post, that seemed to call for some kind of response.  The article is on The Nation's website: Brave Neuro World: The Ethics of the New Brain Science, by Kathryn Schulz; the blog post is Prozac Feminism?, by Aspazia.  What was bugging me, is that my intuition was telling me that there is some kind of important connection between the themes of the two pieces, but I could not quite put my finger on it.

Tonight, I am going to try to clarify for myself what the connection is.  This is not a post that was thought out before writing it.  Rather, I let my unconscious mind wrestle with it, and now I am going to sit down and start typing and see what comes out.  Ah, the joy of blogging!  

I will refer to the Schulz' article as BNW, and Aspazia's as PF, just as a kind of shorthand.

In BWN, Schulz poses a number of questions that are created by advances in neuroscience, and in our ability to control what the brain does.  Essentially, she points out that the prospect of enhancement technologies will pose ethical quandaries.  If enhancement is possible, to what extent will humans be free to make use of those enhancements?  Will it be possible, or proper, for anyone to coerce another to make use of such enhancements?  What are we to do about the inevitable unequal access to enhancement technologies?  

Schulz can no more answer these questions that anyone else.  Admittedly, I was sort of hoping that she would venture some answers, no matter how speculative or premature.  

Aspazia takes a different approach.  Not surprisingly, she ends up with different questions.  Rather than viewing Prozac as an enhancement technology, she views it as a means of promoting conformity to social expectations.  In that way, Prozac becomes a metaphor for the social pressures that promote conformity and compliance in women.Viewed in that way, Prozac is only an "enhancement" technology to the extent that conformity and subservience are improvements over the original.

I will leave aside the question of whether Prozac actually does that, or can do that.

What occurs to me first, is sort of an odd parallel.  I realize that understanding this requires some specialized knowledge, and that I am too impatient to expand on all of the prerequisites in sufficient detail, so I may loose some readers by not explaining things sufficiently.

In the 1950's, three particular new molecular entities were developed for the treatment of depression: phenelzine, isocarboxazid, and tranylcypramine.  These were marketed successfully as Nardil, Marplan, and Parnate, respectively.  All three are monoamine oxidase inhibitors (MAOIs).  Although there are highly effective, they were supplanted rather quickly by the tricyclic antidepressants (TCAs).  The reason is that all of them required that the patient follow a special diet, in order to avoid an interaction with a chemical found in certain foods.  (See the Wikipedia article for details.)  MAOIs also tended to cause weight gain, sexual dysfunction, and various other adverse effects.  

Although the MAOIs were supplanted by the TCAs, and the TCAs were supplanted by Prozac, they continue to excel in one respect.  MAOIs have particular efficacy for the treatment of atypical depression.  Atypical depression is characterized by a cluster of four symptoms: overeating, oversleeping, leaden fatigue, and rejection sensitivity.  Ordinary depression, in contrast, tends to involve loss of appetite, insomnia, intentional social isolation, and fatigue that does not have a peculiar somatic sensation associated with it.  MAOIs are particularly effective at reducing the symptom of rejection sensitivity, and thus are the preferred agents for treatment of Social Phobia.

As an historical aside, there is a disused term lurking in the dustbin of psychiatry: hysteroid dysphoria.  The term hysteroid was used in reference to an ancient (but not ancient enough) belief that certain emotional symptoms were caused by a wandering uterus.  (Really.  People actually believed that.)  It was thought that certain emotional symptoms tended to cluster together, along with rejection sensitivity.  That cluster was given the name hysteroid dysphoria.  In the 1980s, someone got around to analyzing the statistics, and it was found that the proposed symptom cluster had no validity.  The term has been abandoned since then.  In retrospect, it seems that it was merely a term of disparagement that was applied to women who had emotions that were inconvenient to men.  (As a part of the process of discarding pejorative terminology, the symptom of rejection sensitivity now is often referred to as mood reactivity.  The two are not exactly synonymous, but close enough for some purposes.)

Anyway, in the 1950's, the treatment of mood reactivity was hard: the patient had to memorize a list of foods to avoid, learn new recipes, get the family to accept a new menu, and scrupulously avoid dietary indiscretions.  Likewise, in the 1950's, housework was hard.  

Prozac changed the treatment of mood reactivity, sort of like the way the microwave oven changed housework.  Just push a button, and you're done.  Nothing hard about it.   That is the odd parallel that I referred to earlier in this insufferable stream of consciousness.

Both BNW and PF pose questions about bioethics.  Specifically, they ask how society should deal with the fact that we are developing new ways to alter brain function.  Both essays point out that there is a potential for coercion.  

BNW concludes with this:
If we fail to have that discussion, we risk winding up with a social policy for neuroscience based on tactical decisions, not ethical ones; benefiting the few, not the many; and obscuring the complex relationship between personal decisions about our minds and public decisions about our culture. That is a social policy we need like a hole in the head.
PF concludes with this:
What sort of culture do we become when we can gender engineer ourselves right into the sort of personality types that kick ass in business, that make us less sentimental about sex, and less overly sensitive to the needs of others?

Are we ready for this medically enhanced post-modern Feminism?
I think these issues are important.  What is important to note, though, is that society does not put people on medication.  Doctors put people on medication.  Society may exert unarticulated pressure on companies to develop products, on doctors to prescribe those products, and on people to go to their doctors to get those products, but ultimately it is the responsibility of the physician to be aware of those pressures, counteract them, and to make the prescribing decisions based on clinical grounds, with the patient's interest and value system in mind.  

I have mixed feelings about this.  On the one hand, many medical decisions are complex.  With that in mind, it seems that the need for a physician to sort out sociological and gender issues and consider them in the prescribing decision is no more complex than the decision about who should get bypass surgery.  On the other hand, the medical profession has a spotty record when it comes to that kind of thing.  It has been reported that women with heart disease have not gotten treated as aggressively, or as appropriately, as men.  There are other examples of bias in medical decision-making, such as racial or class biases.  I don't think the problem of potential biases is intractable, but I do think it requires some attention.

It is not something that worries me, really, because I do think that the medical profession is responsive when such biases are documented.  If we are paying attention, we should be able to avoid such biases, so hopefully they will not occur in the first place.  The authors are correct to point out the potential for such biases.

(Note: The Rest of the Story/Corpus Callosum has moved. Visit the new site here.)
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Thank you for this post. This is really excellent and thoughtful. I also am grateful to get your perspective as a Psychiatrist. I read a lot about hysteroid dysphoria in Kramer's book (it was a diagnoses named by Donald Klein, is that right?) Kramer argues that fluoxetine is far better at treating rejection sensitivity than MAOIs, mainly because the side effects are much more tolerable than MAOIs are.

But, you get to the point that doctors are the ones prescribing. However, to let doctors a tad bit off the hook here, it seems that more than ever patients can pressure docs to give them the prescriptions they want, or threaten to leave and find another physician who will. David Healy argues, btw, that we should just make SSRIs over-the-counter. What do you think?
Thanks for a well thought-out post. Although MAOIs have a lot of food restrictions, the other side effects are usually temporary or controllable. I have taken Marplan and Nardil for agoraphobia and other anxieties for quite a while now.

However, I gradually realized that no drug will completely "fix" you, no matter how much you want to believe so. I never considered myself well - or whatever you want to call it - until I went through about six months of cognitive therapy. It took me a long time to get here, but I'm glad I managed to stay the course.
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