J Med Ethics. 2006 February; 32(2): 100–105.
doi: 10.1136/jme.2005.013540
Medicating the mind: a Kantian analysis of overprescribing psychoactive drugs
B A Manninen
Correspondence to: Bertha Alvarez Manninen
Department of Philosophy, Purdue University, 100 N University Street, Beering Hall 7137, West Lafayette, IN 47907, USA; balvarez@purdue.edu
Received July 8, 2005; Revised September 7, 2005; Accepted September 8, 2005.
Abstract
Psychoactive drugs are being prescribed to millions of Americans at an increasing rate. In many cases these drugs are necessary in order to overcome debilitating emotional problems. Yet in other instances, these drugs are used to supplant, not supplement, interpersonal therapy. The process of overcoming emotional obstacles by introspection and the attainment of self knowledge is gradually being eroded via the gratuitous use of psychoactive medication in order to rapidly attain a release from the common problems that life inevitably presents us with. In this paper, I argue that Kant's formula of humanity, which maintains that persons ought never to treat others or themselves soley as a means to an end, proscribes this. Moreover, Kant argues that we have an imperfect duty of self development, and I argue that we fail to adhere to such a duty whenever we seek to evade the process of introspection and self knowledge in favour of the expedient results that drugs may provide us with as we attempt to overcome the emotional hurdles in our lives.
Keywords: Kant, abuse, interpersonal therapy, prescription drugs
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In the USA today adults and children are prescribed antidepressants and other mood altering drugs at an increasing rate. Last year alone, 15 million prescriptions for antidepressants were written for children and teenagers, although the number has decreased since the Food and Drug Administration (FDA) sanctioned the new “black box” warning labels, cautioning that antidepressants can increase suicidal thoughts and behaviour among children. For some people these antidepressants can function as a blessing, allowing them to regain control and functionality in their lives. While psychiatric drugs, along with interpersonal therapy, can play an essential role in getting some people back on their feet after a severe bout with some sort of mental illness, there seems to be a rising number of people who seek to supplant interpersonal therapy altogether with mood altering drugs. As a result, there is the danger that the self knowledge and self insight that may result from using interpersonal therapy is being sacrificed in favour of attaining the end goal of feeling better sooner. As medicine advances, almost all psychological afflictions will be able to be alleviated with the use of drugs, and there is reason to believe that many are taking advantage of this by using them gratuitously. While this is certainly not the case for all instances of psychiatric drug use, I hope to show that this danger does exist, and that this way of relating to ourselves is in violation of what is arguably Immanuel Kant's most important version of the categorical imperative: the formula of humanity, where Kant implores that persons must treat others and themselves with inherent dignity, rather than soley as means toward some end.
Revealing the problem
Depression is a psychological affliction that is being diagnosed more frequently among children and adults (and more so in women than in men1), so much so that it has become “the common cold of mental illness”.2 Each year, twenty million Americans take antidepressants, and each year there is a ten per cent increase in such use.2 Many individuals who suffer from depression discover relief in medication that they have been unable to find using other means. In her response to Tom Cruise's categorical condemnation of psychiatric drug use, actress Brooke Shields defended her use of the drug Paxil while battling postpartum depression, revealing that at one point while suffering from the potentially debilitating affliction, she contemplated driving her car into a wall with her infant daughter in the backseat. She attributes her recovery to taking Paxil and to weekly therapy sessions. There are millions of women who can relate to her story, and millions who have been successfully treated with the use of antidepressants. Indeed, depression can at times be so incapacitating that medication is needed in order to render it controllable so that therapy can even begin to be beneficial for the patient.
Thus, there is no debating that medication can be a successful means for treating severely debilitating mental diseases. A recent study appearing on the website of the Archives of
General Psychiatry illustrated that after 16 weeks of treatment:
patients in both the medication and cognitive therapy groups showed improvement at about the same rate…by the 16 week post‐treatment assessment, response rates were identical (57 per cent) for both pharmacotherapy and cognitive therapy…cognitive behaviour therapy and antidepressants are about equally effective in treating mild, moderate and even severe depression.3
It seems to me that the controversy surrounding mood altering drugs focuses explicitly on whether they achieve desirable results; that is, whether they are effective, as effective as therapy, or whether they are safe to use in the first place. While these are all worthwhile concerns, there is another worry that has not been given due attention. It seems to me that there is a growing trend to use these medications unnecessarily; to treat not only severe cases of psychological dysfunction, but also to “treat” any instance of emotional unhappiness. The result being that previous instances of struggle and challenge that used to facilitate emotional growth and self insight are now being diagnosed as medical conditions that necessitate the use of drugs. The following are examples of this troubling and growing trend.
A recent cover of Newsweek reads: “Kids: Moving Beyond Ritalin”. Instead of finding an article that discusses possible ways of dealing with childhood and teenage angst that may not necessarily entail the use of drugs, the article detailed all the different types of drugs, other than Ritalin, that can be used to help a child deal with emotional issues. According to this article, 15 per cent of parents with children between the ages of five and 18 administered some sort of psychoactive medication daily to their children.4 One child in the article was prescribed Prozac at the age of five in order to combat hyperactivity, resulting in a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and an “extreme phobia about bugs”.4 In response to the child's disruptive behaviour in the classroom, she was prescribed Dexadrine in addition to Prozac. No mention was ever made in the article that the child's behaviour was first attended to in an interpersonal manner; drugs were represented as the obvious and quick solution to what may have been common childhood afflictions. (I too was terrified of roaches as a child—I still am.)
Current advertisements geared toward medical practitioners reveal a rather disconcerting trend to relabel as psychiatric problems what once were common childhood experiences. One advertisement in the American Journal of Disease of Children espoused prescribing a drug called Vistaril for childhood “anxieties” such as “school, the dark, separation, dental visits, [and] ‘monsters'”.5 Another journal recommended prescribing a drug called Librium to a young college student who was possibly experiencing “anxieties” over her exposure to new friends and other occurrences in her new college life away from home that “may force her to re‐evaluate herself and her goals”.5 This common college experience of having one's worldview challenged, a once pivotal aspect of growing up and “finding yourself,” is now being relabelled as a medical affliction that can only be “cured” by using psychoactive medication.
Some medical professionals seem to espouse using medication to circumvent the process of self development that can come through dealing with emotional issues in an interpersonal manner—for example, by engaging in cognitive therapy. In his book Listening to Prozac, Dr Peter Kramer touts the positive effect that Prozac has had on many of his psychiatric patients diagnosed with depression. Kramer does express some concerns about medicating patients for what are essentially personal problems. He initially wishes to avoid medicating a patient, Julia, for what simply seems to be a challenging marriage.6 Kramer ends up prescribing Prozac for Julia, however, resulting in positive changes in her personality, marital life, and her relationship with her children. The issue, then, is not whether drugs are effective in dealing with emotional problems; both therapy and drugs seem to have comparable effective results. Indeed, in some cases, therapy may take longer than drugs to achieve the end goal of a functional life. Some people may spend years in therapy, and spend thousands of dollars, in order to undo depression or rectify low self esteem.
What primarily concerns me about Kramer's account of Julia's experience with Prozac is reflected in the exchange between him and her former social worker.
I asked the social worker why she felt guilty. The medication had done what she would have wished to accomplish with her psychotherapy: it had facilitated an improvement in the family dynamics. The problem, for the social worker, was that this change came about without an increased self knowledge on Julia's part. I said that evidently insight had not been necessary… once the drug kicked in, [Julia] had visited the social worker only infrequently, and then with skepticism. “If I had been on Prozac,” she said, “I would not have needed to see the marriage counselor either” [my emphasis] (Kramer,6 pp 31–2).
It is this substitution of self knowledge or self development with medication that primarily concerns me about the increasing trend to view mood altering drugs not just as treatment for serious mental and emotional issues, but as a quick fix to challenging situations in life that could otherwise be addressed in a manner conducive to some sort of personal or spiritual growth. Drugs are meant to aid in the recovery of a patient alongside of interpersonal psychological therapy if the latter is deemed insufficient treatment; it is not meant to supplant this process. These kinds of drugs, when used alone without the aid of interpersonal therapy, “diminish the capacity for self insight”.7 Julia did not fix her marriage or her relationship with her children via insight into herself or into the hearts and minds of her loved ones. She completely bypassed this process and opted, instead, to solve her problems with artificial chemicals.
Thus, there is reason to think that people are becoming increasingly eager to fix any instance of emotional challenge or distress quickly with the use of drugs, rather than dealing with these challenges in an interpersonal manner that may result in self development, self knowledge, and personal growth. Drugs will undoubtedly aid anyone dealing with emotional challenges to cease feeling badly, and indeed may even do so in a fraction of the time that it would have taken by engaging in interpersonal therapy. As recounted above, medication seemed to help Julia achieve peace with her husband and children much more rapidly than therapy had; indeed, she had been going to a marriage counsellor for some time, apparently to no avail. Given this, the obvious challenge one may raise against someone who wishes to argue for the importance of interpersonal therapy in the treatment of some emotional issues is the following. If medication alone can parallel the results of interpersonal therapy—for example, a rise in self esteem or an improvement in marital or family dynamics, in a fraction of the time, why shouldn't a patient opt for using medication exclusively?
If all that a patient cares to achieve is the above mentioned behavioural and emotional results, and so approaches the issue with some sort of utilitarian calculus in mind—that is, how can I achieve my desired results in the shortest amount of time—then I would be hard pressed to convince her that she should engage in the longer and more arduous process of self insight and self discovery that interpersonal therapy can provide rather than just ingesting a pill once a day that can significantly curb the time it takes for her to achieve self esteem or to rectify any other emotional problems. However, for those who actually care about the process of self discovery, for those who feel that there is something intrinsically worthwhile about such a process, and that the appropriate response to dealing with difficult situations in life is not just about feeling better sooner, but feeling better in the right way, supplanting interpersonal therapy with drugs leaves much to be desired. For example, an individual teased in school and verbally abused at home will, most likely, grow up to possess very low self esteem. Drugs may aid her in no longer experiencing these negative feelings, indeed drugs may produce in her a euphoric feeling of self worth that eradicates any low self esteem from which she may have suffered. Yet, choosing to rely solely on medication, she has made no effort to understand herself, to work on her self esteem by achieving personal goals, or to come to terms with the fact that she is a genuinely good person worthy of respect and dignity. By choosing to rely solely on medication she has shown that all she cares about is achieving a certain state of mind: one that is free of emotional burdens and which thus allows her to experience the pleasure common to that relief, as rapidly as possible, even if that means forgoing an opportunity to achieve self knowledge or any type of personal growth.
Thus, my chief concern is not with the fact that antidepressant medication is being used to treat those who really need it. Rather, my concern is that such medication is being used to “treat” people who really do not need it—people who simply wish to feel better quickly when faced with the commonplace problems that are bound to ensue as we all go through life. I am concerned that we are progressively substituting a “drug modality for an interpersonal one” (Lennard,5 p 441). It seems that psychoactive medication is increasingly serving the role of realising the “experience machine” of Robert Nozick's thought experiment8: individuals who opt to take these drugs instead of undergoing the effort necessary to overcome emotional obstacles in life are sacrificing personal growth and self development in exchange for alleviating any emotional burdens and feeling better sooner rather than later. It seems to me that this is a rising danger, and I want to show why there are Kantian reasons for being resistant to this type of psychoactive drug use.
A Kantian criticism of drug modality
This phenomenon of supplanting interpersonal methods of dealing with emotional issues with psychiatric drugs ought to particularly concern bioethicists, who have remained largely silent on the issue. Interestingly enough, a criticism of such a practice can be offered by appealing to Immanuel Kant's moral philosophy. I proffer that such a practice violates Kant's formula of humanity as invoked in the Grounding for the Metaphysics of Morals, which maintains that individual dignity ought never to be compromised, not even in the face of overall utility. Kant writes:
[R]ational nature exists as an end in itself. In this way man necessarily thinks of his own existence; thus far is it a subjective principle of human actions…[t]he practical imperative will therefore be the following: act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means.9
Kant utilises this version of the categorical imperative to argue in favour of two duties to the self: the perfect duty to refrain from suicide and the imperfect duty to cultivate one's talents. Following the logic of his arguments in support of these duties has much to offer in understanding how the drug modality discussed above also violates Kant's imperative.
When discussing how the formula of humanity entails the perfect duty to refrain from suicide, Kant writes:
[T]he man who contemplates suicide will ask himself whether his action can be consistent with the idea of humanity as an end in itself. If he destroys himself in order to escape from a difficult situation, then he is making use of his person merely as a means so as to maintain a tolerable condition in life. Man, however, is not a thing and hence is not something to be used merely as a means; he must in all his actions always be regarded as an end in himself. Therefore, I cannot dispose of a man in my own person by mutilating, damaging, or killing him.9
When this particular maxim is motivating an individual, he is willing to relinquish his life in order to “escape from a difficult situation”. He is destroying his own life as a means to achieving the (perceived) end of peace. Thus he violates the formula of humanity by not according proper respect to his life as a rational agent; he views his life as dispensable rather than as intrinsically valuable. What Kant is trying to establish by using this example is critical for understanding the crux of his philosophy and how it can be applied to the issue in this paper: according to Kant, we ought not to disrespect or sacrifice our rational agency in order to alleviate pain, whether it be to “escape from a difficult situation” or to “achieve a tolerable condition in life”.
It seems to me that Kant's argument can be applied not only to proscribe suicide in the way that he espouses, but also to proscribe the unnecessary use of psychoactive drugs in the way I have described. When drugs are used as a quick fix, we are choosing to circumvent the process of self discovery and emotional maturation in order to rapidly alleviate the pain that we experience when faced with the inevitable obstacles of life. This is what occurs, for example, when one chooses medication in order to alleviate the anxieties that may result from having one's worldview challenged while in college, rather than using the exposure to facilitate personal growth and expand one's mind to encompass other cultures and other ways of life. It is because of our rationality that we are moral and genuinely free agents (which for Kant is the source of our intrinsic worth). It is also because of our rationality that we have the ability for self development, self insight, and self knowledge, and we are choosing to sacrifice this integral aspect of our nature as rational beings when we use drugs in the way I am describing here. The current trend seems to be, as exemplified by Kramer, that self knowledge is too time consuming and ultimately unnecessary if we can achieve the desired results through medication instead. Now that the FDA has released the “black box” warnings concerning prescribing antidepressants to children, “fewer parents want a quick fix…they're willing to stay in family counseling longer to avoid drugs for their child”.10 What is troublesome is that parents wanted this quick fix to begin with. That prolonged family counselling, which may have served the role of facilitating self insight for the child, in addition to cultivating family intimacy through communication and a sharing of emotions, had taken a backseat to convenience.
Therefore, just as the suicidal man disrespects his rational agency and intrinsic worth by killing himself in order to alleviate himself of the pains of life, individuals who decide that they would rather circumvent the process of self discovery and self knowledge that only interpersonal methods of coping can provide, in the interest of alleviating their pain and feeling better sooner, also disrespect their rational agency. This is because they are sacrificing an integral part of their humanity, their ability to engage in introspection, achieve self knowledge, and engage in personal development, in the interest of alleviating themselves of emotional pain through drugs. Thus, they too are “making use of [their] person merely as a means so as to maintain a tolerable condition in life”.
A further study of Kant's arguments sheds more light on why it is good to cultivate our capacity for self insight rather than letting it fall victim to the end of rapidly achieving a life as free from emotional burdens as possible. Consider Kant's argument that the formula of humanity entails the imperfect duty of self development; that is, to cultivate our talents or capacities.
Now there are in humanity capacities for greater perfection which belong to the end that nature has in view as regards humanity in our own person. To neglect these capacities might perhaps be consistent with the maintenance of humanity as an end in itself, but would not be consistent with the advancements of this end (Kant,9 p 37).
Although failing to nurture one's talents is consistent with regarding humanity as an end in itself (that is, there is no resulting contradiction as there is when you universalise the maxim), failing to cultivate personal talents does not promote the goal of treating yourself as an intrinsically valuable being. We cannot will a state of affairs that is at odds with our advancement as rational agents and that stifles our happiness. Proper respect for ourselves as rational and dignified beings entails that we cultivate those talents special to us in order to achieve the “greater perfection” of our human nature.
Kant emphasis this in the Metaphysics of Morals:
A human being has a duty to himself to cultivate his natural powers (powers of the spirit, mind, and body), as a means to all sorts of possible ends. He owes it to himself (as a rational being) not to leave idle and, as it were, rusting away the natural predispositions and capacities that his reason can some day use.11
It is important to note that Kant is not just arguing that we ought to cultivate our talents because a life with such cultivation is better or more pleasurable than a life without it (this would be an inherently utilitarian argument). Rather, developing one's talents is a way of properly respecting one's rational agency. What Kant thinks is so valuable about human beings is that, due to our rationality, we humans have the ability to set ends for ourselves and pursue them. We cannot do this, according to Kant, if we neglect the cultivation of our talents, and in doing so we treat our rational agency with contempt rather than respect. Human beings, then, have an obligation to themselves to engage in self development, not because cultivating talents is valuable and adds pleasure to our lives (although this may be true, it is not why Kant is primarily concerned with cultivating capacities), but because failing to cultivate our capacities is also failing to respect our humanity, our intrinsic worth as rational beings. Even though it may be easier to choose to disregard our talents, be it because we are lazy and uninterested in cultivating them or because the complexities of life often preclude the time necessary in order to do so, to let them waste away is to make it progressively more difficult to be able to set goals for ourselves and realise them, and this means we are not according our rational agency proper respect. Thus, according to Kant, we owe it to ourselves not to let our capacities waste away: “it is a command of morally practical reason and a duty of a human being to himself to cultivate his capacities”.11
The duty of self development is imperfect in so far as there is no specific talent that we must develop or no specific way in which we must develop them; we have the choice as to which talents we think are worthy of cultivation and how we choose to cultivate them. This is primarily because, given our individuality, we each have different talents to cultivate and we each have different ends and goals for our lives that we set for ourselves. Nevertheless, I will deviate from Kant slightly on this point and suggest that there are some talents, some natural gifts, that as human beings we all share due to our rational nature: in addition to being moral agents and free beings, we share the capacity to be introspective, to achieve self knowledge, and to engage in self insight, and this seems to me to be an integral aspect of self development. Proper respect for ourselves as rational creatures seems to demand that we cultivate these talents, that we indeed follow the Socratic imperative to “know thyself,” and this is precisely what we fail to do when we seek to bypass interpersonal methods of dealing with our emotional issues and opt solely for medication to relieve ourselves of their painful symptoms and achieve a pleasurable state of affairs in life. Indeed, “patients who are prescribed drugs frequently tend to give up trying to understand themselves, including the sources of their problems and their potential for psychological or spiritual growth” [my emphasis] (Breggin et al,7 p 190). The capacity for self knowledge and self development is fundamental to living an examined life and it is an essentially human capacity that we all share due to our rational nature. As mentioned above, Kant argues in favour of the duty to cultivate talents because he is interested in preserving our ability to set ends for ourselves and pursue those ends. There is reason to believe that the exclusive use of psychiatric drugs without interpersonal therapy to resolve emotional distress thwarts this ability as well. Individuals who opt for this type of drug use become “skeptical and despairing about the possibilities of overcoming depression through self insight, improved principles of living, a better family life, a more inspiring occupation, and all of the other transformations that often lead to spiritual triumph” (Breggin et al,7 p 190). That is, these individuals often give up setting goals for themselves—for example, the goal of achieving a more fulfilling career—and pursuing them. The Kantian duty of cultivating one's capacities, therefore, entails cultivating the important universal human capacity for self knowledge or self insight. If the exclusive and frequent use of prescription drugs results in a tendency to ignore this capacity, or to give up trying to cultivate it or other possible self imposed ends, then this makes it difficult to fulfil what seems to me to be an integral aspect of properly satisfying the Kantian duty of self development.
Kant also argues that failing to cultivate our talents in exchange for living a life devoted to pleasure cannot be universally willed because doing so results in a contradiction.
Any individual who opts to devote his life to indulging his desires rather than nurturing his talents “cannot possibly will that this should become a universal law of nature… for as a rational being he necessarily wills that all his faculties should be developed, in as much as they are given to him for all sorts of possible purposes” (Kant,9 p 31). Therefore, we must reject the maxim that we may fail to cultivate our talents in exchange for enjoying a life of leisure or pleasure.
Kant's argument for condemning this maxim applies to the discussion at hand. When someone chooses to take drugs instead of engaging in interpersonal therapy to resolve emotional distress, what she essentially wishes to do is to relieve herself as quickly as possible of any emotional or psychological burdens she may be experiencing. In the end, the desire is to achieve some sort of pleasure in her life; not necessarily some crass or hedonistic pleasure, but the pleasure that naturally comes from not feeling depressed, anxious, or irritable. As understandable as this desire is, this action can nevertheless fall within the scope of Kant's criticism. The maxim that this individual is acting upon may look something like this: “Whenever my emotional issues are getting the best of me, I will relieve my psychological burdens as rapidly as possible through drugs and forgo this opportunity to cultivate self knowledge or self insight”. Keeping true to Kant's analysis, we cannot universally will that we compromise our capacity for self knowledge or self insight in order to achieve a pleasurable end result, even if that result is the pleasure of no longer feeling emotional distress. This is not to say that wanting to rid oneself of emotional distress is not a good or important goal, and Kant is not against cultivating certain talents that will lead to the achievement of certain ends. Kant argues that the reason why we should cultivate our talents lies not in what ends we wish to achieve, but rather it lies in the fact that cultivating our talents is a duty that we owe to ourselves for the reasons cited above.
[T]he basis on which [a person] should develop his capacities (for all sorts of ends) is not regard for the advantages that their cultivation can provide….it is a command of morally practical reason and a duty of a human being to himself to cultivate his capacities…11
But, of course, Kant is not against using these talents “as means to all sorts of possible ends”. What he is against is sacrificing the cultivation of our talents in order to achieve a certain end: the end of pleasure or enjoyment. Interpersonal therapy allows one to cultivate the capacity for self knowledge and self insight, and this cultivation will aid in the goal of attaining a functional, pleasurable, and healthy life. Supplanting that development with the exclusive use of drugs will lead to the same end result (for no one is denying that drugs can be effective at solving emotional problems) at the expense of sacrificing the duty that we owe to ourselves to cultivate this important capacity. Allegiance to Kant's imperative to engage in self development and to cultivate our capacities, therefore, requires that we take the former route, even if doing so is more time consuming and more arduous.
I want to reiterate that this critique is not meant to target all instances of psychoactive drug use. There are some cases of mental illness and severe depression that are so debilitating that they require the use of such drugs, and indeed their use may even facilitate the fulfilment of Kant's duty for self development, given that such drugs can provide the crucial first step in helping people regain control over, and functionality in, their lives. This in turn can lead them to achieving self development. My criticism is meant to target what I fear is a growing trend not just among patients, but among physicians as well, to use these drugs for treating people for essentially commonplace challenges in everyday life that can be overcome via interpersonal therapy and the inner struggle that can ultimately result in cultivating the self knowledge and self development that Kant's imperative seems to demand. I once heard a physician tell another at a conference that he knows of a woman who was prescribed antidepressants just one week after being raped because she had not yet gotten over the traumatic experience. This seems to be jumping the gun, and while being raped can certainly result in a clinical depression so severe that it necessitates such medication, it is this type of eagerness on behalf of patients and physicians to solve emotional problems with medication rather than first attempting interpersonal methods of coping that primarily concerns me.
This brings me to the last topic I want to discuss concerning this issue: the responsibility that others have to emotionally afflicted individuals to help them further their capacity for self knowledge rather than subjecting them to medication prematurely. This applies not only to physicians, but to parents as well, given that increasing numbers of children are being prescribed psychoactive medication. Recall that Kant argues that we are to use neither ourselves nor others soley as a means to an end. He also maintains that we have a duty of beneficence “to promote according to one's means the happiness of others in need” (Kant,11 p 262). Although physicians and parents may well be genuinely trying to help an afflicted individual, exposing a troubled person to medication without first giving them an opportunity to deal with their troubles in a manner that may facilitate self knowledge disrespects their humanity. Granted, a physician such as Dr Kramer may well be genuinely trying to help his patients, and he may not be using them as a means to achieving a selfish end or personal gain. Nevertheless, by encouraging the circumvention of self discovery for the ease of a quick fix, and/or by maintaining that self knowledge is unnecessary or dispensable in the face of more expedient results, a physician is encouraging his patient to treat herself as a means to an end. He is no doubt trying to help his patient, but he is doing so in a manner that fails to respect her humanity.
This applies to parents as well, many of whom, as mentioned above, were opting for medication over therapy before the FDA revealed that antidepressants might cause suicidal thoughts in their children. Although the duty to cultivate talents is a duty to the self, children, especially depressed ones, often need their parents' help to fulfil all sorts of moral challenges. Indeed, until children are old enough to be moral agents, we have a duty to help them achieve such agency. In raising children, we are not just respecting and encouraging the development of rational agents, we are, in effect, creating rational agents, and so we must take special care in helping them fulfil their duties to others and to themselves. Thus, I propose that parents not only have a duty of beneficence toward their children (as they do to all other human beings, albeit perhaps to a greater extent), they also have a duty to help their children cultivate their talents and capacities, and this includes the capacity for self knowledge. This entails that parents open the lines of communication with their children when they are afraid, depressed, or experiencing anxieties that are typical aspects of growing up. It entails that parents teach their children how overcoming emotional distress can lead to the attainment of personal and spiritual growth; and it entails that parents do not convey the message that expedient end results matter more than the self development that may come via interpersonal methods of coping with emotional issues. This, of course, entails parents exposing children to counselling and perhaps engaging in cognitive therapy before they resort to the exclusive use of drugs to help them resolve their children's emotional pains. It ought not to have taken an FDA “black box” label to make parents rethink their eagerness to help their children cope with their emotional problems by using medication rather than therapy, or with a proper combination of the two if therapy alone is deemed insufficient. Proper respect for the humanity of children, and the rational agents that are being created, seems to have always demanded this.
However, parents, physicians, and patients alone are not to blame for this eagerness, and this brings me to my last point. Opting for the exclusive use of medication over interpersonal therapy is more economical, given that insurance companies are less willing to pay for the services of specialists necessary to dispense interpersonal therapy:
The growing preference for pills reflects the push by insurers to have patients treated by primary care physicians rather than specialists. Primary care doctors can write prescriptions but are seldom trained in psychotherapy. The cost of psychotherapy varies by region of the country, but the national average for cognitive behaviour therapy is $100 per session for the standard course of 15–20 sessions, or about $1,500 to $2,000 for the full course of treatment. (In some cities, the price could be as much as twice that.) Branded antidepressants generally cost about $1,000 per year plus the bill for the doctor's appointments needed to continue the prescription.3
This means that if an individual opts for interpersonal therapy, she may face having to pay for most of it from her own pocket, leaving less money for necessities and also, admittedly, for some luxuries. That is, our current medical system is set up in such a way as to encourage drugs as a solution to our emotional problems, regardless of whether an individual really needs them or whether therapy may suffice to aid her in her road to recovery. We live in a society that is progressively prizing expediency and financial savings over the personal growth of its members, and so Kant's imperative is being violated on a much grander scale. The best I can hope for in writing this paper is to make individuals aware that respect for themselves, and their children, demands that they treat themselves and others as intrinsically valuable beings. We have a duty to cultivate our talents, including our talent for self knowledge and self insight, which is a gift that we all possess by virtue of our rational nature. The goal of life should not just be a release from emotional burdens in favour of a pleasurable state of existence, but the achievement of this in the proper way; in a way that respects our humanity and the humanity of others.
Conclusion
I too have family members who take prescription drugs and as such I have first hand knowledge as to how they may be necessary in helping people cope with severe emotional problems. Teenage depression in particular is a prevalent issue which could result in suicide if not diagnosed and treated: “one in every 33 children and one in eight adolescents may be suffering from depression…suicide is a risk, and so is homicide”.12 Depression is caused primarily by sociological factors, but there are times when chemical imbalances may be to blame. I am not maintaining that drugs ought to be eradicated as a possible cure for depression or as an aid when dealing with other emotional issues, since they can indeed be very effective. What I am maintaining is that they need to retain their roles as supplements and ought to be used in conjunction with interpersonal therapy if the latter is deemed insufficient to aid in recovery. Artificial chemicals ought not to replace the personal or spiritual growth that comes from battling our emotional problems and coming to a sense of triumph and self worth. While we can achieve functionality with drugs, as Julia did, in doing so we fail to fulfil our duties to ourselves. Using drugs exclusively as substitutes for interpersonal help and self knowledge violates Kant's formula of humanity in a variety of ways. Like the suicidal man, we compromise an integral part of our humanity in order to achieve a cessation of pain. We also fail to follow Kant's duty of self development by evading the cultivation of our capacity for self knowledge and personal growth, and we induce our children to do the same when we stifle their personal growth and self development in the interest of attaining a quick fix.
We are rational beings worthy of dignity and respect. Our minds are not things to be medicated when life gets difficult. Our minds, rather, should be developed and strengthened through self knowledge, self insight, and self development, even if doing so may take longer and cost more. This is a small price to pay for properly respecting ourselves, and our children, as inherently valuable beings. If Kant were writing in today's world, I am sure he would argue the same.
Acknowledgements
Many thanks to my husband Tuomas William Manninen, to Dr James Stacey Taylor, and Dr Sarah Buss for their help and comments on earlier drafts of this paper. I would also like to thank the Journal of Medical Ethics reviewers and editorial staff for their helpful comments, which greatly contributed to the improvement of this paper.
Abbreviations
FDA - Food and Drug Administration
Footnotes
i The study did show, however, that when dealing with the long term consequences of both therapy and psychiatric drugs, the patients who were treated with the former had fewer relapses two years after their treatment than those treated with drugs alone.
i The contradiction that arises would be something like the following. According to Kant, nature has given all persons talents that require development. Therefore it cannot be the case that a law of nature exists that commands that we not cultivate the talents given to us by nature in the first place; nature would have simultaneously given us talents to cultivate and made it impossible to cultivate them. Thus, forgoing developing our talents in order to have more time to seek pleasure cannot be universally willed.
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3. Does therapy work? www.warwick‐associates.com/does_therapy_work.htm (accessed 25 Sept 2005)
4. Tyre P. Finding what works. Newsweek . 2005 Apr 2554–56.56.
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6. Kramer P. Listening to Prozac. New York: Penguin Books, 1993. 23.
7. Breggin P, Breggin G R. Talking back to Prozac: what doctors won't tell you about today's most controversial drug. New York: St Martin's Press, 1994. 189.
8. Nozick R. Anarchy, state and Utopia. New York: Basic Books, 1974. 42–43.43.
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10. Elias M. Suicide alert has parents rethinking antidepressants. USA Today. 2005 Feb 1, news:01a .
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doi: 10.1136/jme.2005.013540
Medicating the mind: a Kantian analysis of overprescribing psychoactive drugs
B A Manninen
Correspondence to: Bertha Alvarez Manninen
Department of Philosophy, Purdue University, 100 N University Street, Beering Hall 7137, West Lafayette, IN 47907, USA; balvarez@purdue.edu
Received July 8, 2005; Revised September 7, 2005; Accepted September 8, 2005.
Abstract
Psychoactive drugs are being prescribed to millions of Americans at an increasing rate. In many cases these drugs are necessary in order to overcome debilitating emotional problems. Yet in other instances, these drugs are used to supplant, not supplement, interpersonal therapy. The process of overcoming emotional obstacles by introspection and the attainment of self knowledge is gradually being eroded via the gratuitous use of psychoactive medication in order to rapidly attain a release from the common problems that life inevitably presents us with. In this paper, I argue that Kant's formula of humanity, which maintains that persons ought never to treat others or themselves soley as a means to an end, proscribes this. Moreover, Kant argues that we have an imperfect duty of self development, and I argue that we fail to adhere to such a duty whenever we seek to evade the process of introspection and self knowledge in favour of the expedient results that drugs may provide us with as we attempt to overcome the emotional hurdles in our lives.
Keywords: Kant, abuse, interpersonal therapy, prescription drugs
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In the USA today adults and children are prescribed antidepressants and other mood altering drugs at an increasing rate. Last year alone, 15 million prescriptions for antidepressants were written for children and teenagers, although the number has decreased since the Food and Drug Administration (FDA) sanctioned the new “black box” warning labels, cautioning that antidepressants can increase suicidal thoughts and behaviour among children. For some people these antidepressants can function as a blessing, allowing them to regain control and functionality in their lives. While psychiatric drugs, along with interpersonal therapy, can play an essential role in getting some people back on their feet after a severe bout with some sort of mental illness, there seems to be a rising number of people who seek to supplant interpersonal therapy altogether with mood altering drugs. As a result, there is the danger that the self knowledge and self insight that may result from using interpersonal therapy is being sacrificed in favour of attaining the end goal of feeling better sooner. As medicine advances, almost all psychological afflictions will be able to be alleviated with the use of drugs, and there is reason to believe that many are taking advantage of this by using them gratuitously. While this is certainly not the case for all instances of psychiatric drug use, I hope to show that this danger does exist, and that this way of relating to ourselves is in violation of what is arguably Immanuel Kant's most important version of the categorical imperative: the formula of humanity, where Kant implores that persons must treat others and themselves with inherent dignity, rather than soley as means toward some end.
Revealing the problem
Depression is a psychological affliction that is being diagnosed more frequently among children and adults (and more so in women than in men1), so much so that it has become “the common cold of mental illness”.2 Each year, twenty million Americans take antidepressants, and each year there is a ten per cent increase in such use.2 Many individuals who suffer from depression discover relief in medication that they have been unable to find using other means. In her response to Tom Cruise's categorical condemnation of psychiatric drug use, actress Brooke Shields defended her use of the drug Paxil while battling postpartum depression, revealing that at one point while suffering from the potentially debilitating affliction, she contemplated driving her car into a wall with her infant daughter in the backseat. She attributes her recovery to taking Paxil and to weekly therapy sessions. There are millions of women who can relate to her story, and millions who have been successfully treated with the use of antidepressants. Indeed, depression can at times be so incapacitating that medication is needed in order to render it controllable so that therapy can even begin to be beneficial for the patient.
Thus, there is no debating that medication can be a successful means for treating severely debilitating mental diseases. A recent study appearing on the website of the Archives of
General Psychiatry illustrated that after 16 weeks of treatment:
patients in both the medication and cognitive therapy groups showed improvement at about the same rate…by the 16 week post‐treatment assessment, response rates were identical (57 per cent) for both pharmacotherapy and cognitive therapy…cognitive behaviour therapy and antidepressants are about equally effective in treating mild, moderate and even severe depression.3
It seems to me that the controversy surrounding mood altering drugs focuses explicitly on whether they achieve desirable results; that is, whether they are effective, as effective as therapy, or whether they are safe to use in the first place. While these are all worthwhile concerns, there is another worry that has not been given due attention. It seems to me that there is a growing trend to use these medications unnecessarily; to treat not only severe cases of psychological dysfunction, but also to “treat” any instance of emotional unhappiness. The result being that previous instances of struggle and challenge that used to facilitate emotional growth and self insight are now being diagnosed as medical conditions that necessitate the use of drugs. The following are examples of this troubling and growing trend.
A recent cover of Newsweek reads: “Kids: Moving Beyond Ritalin”. Instead of finding an article that discusses possible ways of dealing with childhood and teenage angst that may not necessarily entail the use of drugs, the article detailed all the different types of drugs, other than Ritalin, that can be used to help a child deal with emotional issues. According to this article, 15 per cent of parents with children between the ages of five and 18 administered some sort of psychoactive medication daily to their children.4 One child in the article was prescribed Prozac at the age of five in order to combat hyperactivity, resulting in a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and an “extreme phobia about bugs”.4 In response to the child's disruptive behaviour in the classroom, she was prescribed Dexadrine in addition to Prozac. No mention was ever made in the article that the child's behaviour was first attended to in an interpersonal manner; drugs were represented as the obvious and quick solution to what may have been common childhood afflictions. (I too was terrified of roaches as a child—I still am.)
Current advertisements geared toward medical practitioners reveal a rather disconcerting trend to relabel as psychiatric problems what once were common childhood experiences. One advertisement in the American Journal of Disease of Children espoused prescribing a drug called Vistaril for childhood “anxieties” such as “school, the dark, separation, dental visits, [and] ‘monsters'”.5 Another journal recommended prescribing a drug called Librium to a young college student who was possibly experiencing “anxieties” over her exposure to new friends and other occurrences in her new college life away from home that “may force her to re‐evaluate herself and her goals”.5 This common college experience of having one's worldview challenged, a once pivotal aspect of growing up and “finding yourself,” is now being relabelled as a medical affliction that can only be “cured” by using psychoactive medication.
Some medical professionals seem to espouse using medication to circumvent the process of self development that can come through dealing with emotional issues in an interpersonal manner—for example, by engaging in cognitive therapy. In his book Listening to Prozac, Dr Peter Kramer touts the positive effect that Prozac has had on many of his psychiatric patients diagnosed with depression. Kramer does express some concerns about medicating patients for what are essentially personal problems. He initially wishes to avoid medicating a patient, Julia, for what simply seems to be a challenging marriage.6 Kramer ends up prescribing Prozac for Julia, however, resulting in positive changes in her personality, marital life, and her relationship with her children. The issue, then, is not whether drugs are effective in dealing with emotional problems; both therapy and drugs seem to have comparable effective results. Indeed, in some cases, therapy may take longer than drugs to achieve the end goal of a functional life. Some people may spend years in therapy, and spend thousands of dollars, in order to undo depression or rectify low self esteem.
What primarily concerns me about Kramer's account of Julia's experience with Prozac is reflected in the exchange between him and her former social worker.
I asked the social worker why she felt guilty. The medication had done what she would have wished to accomplish with her psychotherapy: it had facilitated an improvement in the family dynamics. The problem, for the social worker, was that this change came about without an increased self knowledge on Julia's part. I said that evidently insight had not been necessary… once the drug kicked in, [Julia] had visited the social worker only infrequently, and then with skepticism. “If I had been on Prozac,” she said, “I would not have needed to see the marriage counselor either” [my emphasis] (Kramer,6 pp 31–2).
It is this substitution of self knowledge or self development with medication that primarily concerns me about the increasing trend to view mood altering drugs not just as treatment for serious mental and emotional issues, but as a quick fix to challenging situations in life that could otherwise be addressed in a manner conducive to some sort of personal or spiritual growth. Drugs are meant to aid in the recovery of a patient alongside of interpersonal psychological therapy if the latter is deemed insufficient treatment; it is not meant to supplant this process. These kinds of drugs, when used alone without the aid of interpersonal therapy, “diminish the capacity for self insight”.7 Julia did not fix her marriage or her relationship with her children via insight into herself or into the hearts and minds of her loved ones. She completely bypassed this process and opted, instead, to solve her problems with artificial chemicals.
Thus, there is reason to think that people are becoming increasingly eager to fix any instance of emotional challenge or distress quickly with the use of drugs, rather than dealing with these challenges in an interpersonal manner that may result in self development, self knowledge, and personal growth. Drugs will undoubtedly aid anyone dealing with emotional challenges to cease feeling badly, and indeed may even do so in a fraction of the time that it would have taken by engaging in interpersonal therapy. As recounted above, medication seemed to help Julia achieve peace with her husband and children much more rapidly than therapy had; indeed, she had been going to a marriage counsellor for some time, apparently to no avail. Given this, the obvious challenge one may raise against someone who wishes to argue for the importance of interpersonal therapy in the treatment of some emotional issues is the following. If medication alone can parallel the results of interpersonal therapy—for example, a rise in self esteem or an improvement in marital or family dynamics, in a fraction of the time, why shouldn't a patient opt for using medication exclusively?
If all that a patient cares to achieve is the above mentioned behavioural and emotional results, and so approaches the issue with some sort of utilitarian calculus in mind—that is, how can I achieve my desired results in the shortest amount of time—then I would be hard pressed to convince her that she should engage in the longer and more arduous process of self insight and self discovery that interpersonal therapy can provide rather than just ingesting a pill once a day that can significantly curb the time it takes for her to achieve self esteem or to rectify any other emotional problems. However, for those who actually care about the process of self discovery, for those who feel that there is something intrinsically worthwhile about such a process, and that the appropriate response to dealing with difficult situations in life is not just about feeling better sooner, but feeling better in the right way, supplanting interpersonal therapy with drugs leaves much to be desired. For example, an individual teased in school and verbally abused at home will, most likely, grow up to possess very low self esteem. Drugs may aid her in no longer experiencing these negative feelings, indeed drugs may produce in her a euphoric feeling of self worth that eradicates any low self esteem from which she may have suffered. Yet, choosing to rely solely on medication, she has made no effort to understand herself, to work on her self esteem by achieving personal goals, or to come to terms with the fact that she is a genuinely good person worthy of respect and dignity. By choosing to rely solely on medication she has shown that all she cares about is achieving a certain state of mind: one that is free of emotional burdens and which thus allows her to experience the pleasure common to that relief, as rapidly as possible, even if that means forgoing an opportunity to achieve self knowledge or any type of personal growth.
Thus, my chief concern is not with the fact that antidepressant medication is being used to treat those who really need it. Rather, my concern is that such medication is being used to “treat” people who really do not need it—people who simply wish to feel better quickly when faced with the commonplace problems that are bound to ensue as we all go through life. I am concerned that we are progressively substituting a “drug modality for an interpersonal one” (Lennard,5 p 441). It seems that psychoactive medication is increasingly serving the role of realising the “experience machine” of Robert Nozick's thought experiment8: individuals who opt to take these drugs instead of undergoing the effort necessary to overcome emotional obstacles in life are sacrificing personal growth and self development in exchange for alleviating any emotional burdens and feeling better sooner rather than later. It seems to me that this is a rising danger, and I want to show why there are Kantian reasons for being resistant to this type of psychoactive drug use.
A Kantian criticism of drug modality
This phenomenon of supplanting interpersonal methods of dealing with emotional issues with psychiatric drugs ought to particularly concern bioethicists, who have remained largely silent on the issue. Interestingly enough, a criticism of such a practice can be offered by appealing to Immanuel Kant's moral philosophy. I proffer that such a practice violates Kant's formula of humanity as invoked in the Grounding for the Metaphysics of Morals, which maintains that individual dignity ought never to be compromised, not even in the face of overall utility. Kant writes:
[R]ational nature exists as an end in itself. In this way man necessarily thinks of his own existence; thus far is it a subjective principle of human actions…[t]he practical imperative will therefore be the following: act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means.9
Kant utilises this version of the categorical imperative to argue in favour of two duties to the self: the perfect duty to refrain from suicide and the imperfect duty to cultivate one's talents. Following the logic of his arguments in support of these duties has much to offer in understanding how the drug modality discussed above also violates Kant's imperative.
When discussing how the formula of humanity entails the perfect duty to refrain from suicide, Kant writes:
[T]he man who contemplates suicide will ask himself whether his action can be consistent with the idea of humanity as an end in itself. If he destroys himself in order to escape from a difficult situation, then he is making use of his person merely as a means so as to maintain a tolerable condition in life. Man, however, is not a thing and hence is not something to be used merely as a means; he must in all his actions always be regarded as an end in himself. Therefore, I cannot dispose of a man in my own person by mutilating, damaging, or killing him.9
When this particular maxim is motivating an individual, he is willing to relinquish his life in order to “escape from a difficult situation”. He is destroying his own life as a means to achieving the (perceived) end of peace. Thus he violates the formula of humanity by not according proper respect to his life as a rational agent; he views his life as dispensable rather than as intrinsically valuable. What Kant is trying to establish by using this example is critical for understanding the crux of his philosophy and how it can be applied to the issue in this paper: according to Kant, we ought not to disrespect or sacrifice our rational agency in order to alleviate pain, whether it be to “escape from a difficult situation” or to “achieve a tolerable condition in life”.
It seems to me that Kant's argument can be applied not only to proscribe suicide in the way that he espouses, but also to proscribe the unnecessary use of psychoactive drugs in the way I have described. When drugs are used as a quick fix, we are choosing to circumvent the process of self discovery and emotional maturation in order to rapidly alleviate the pain that we experience when faced with the inevitable obstacles of life. This is what occurs, for example, when one chooses medication in order to alleviate the anxieties that may result from having one's worldview challenged while in college, rather than using the exposure to facilitate personal growth and expand one's mind to encompass other cultures and other ways of life. It is because of our rationality that we are moral and genuinely free agents (which for Kant is the source of our intrinsic worth). It is also because of our rationality that we have the ability for self development, self insight, and self knowledge, and we are choosing to sacrifice this integral aspect of our nature as rational beings when we use drugs in the way I am describing here. The current trend seems to be, as exemplified by Kramer, that self knowledge is too time consuming and ultimately unnecessary if we can achieve the desired results through medication instead. Now that the FDA has released the “black box” warnings concerning prescribing antidepressants to children, “fewer parents want a quick fix…they're willing to stay in family counseling longer to avoid drugs for their child”.10 What is troublesome is that parents wanted this quick fix to begin with. That prolonged family counselling, which may have served the role of facilitating self insight for the child, in addition to cultivating family intimacy through communication and a sharing of emotions, had taken a backseat to convenience.
Therefore, just as the suicidal man disrespects his rational agency and intrinsic worth by killing himself in order to alleviate himself of the pains of life, individuals who decide that they would rather circumvent the process of self discovery and self knowledge that only interpersonal methods of coping can provide, in the interest of alleviating their pain and feeling better sooner, also disrespect their rational agency. This is because they are sacrificing an integral part of their humanity, their ability to engage in introspection, achieve self knowledge, and engage in personal development, in the interest of alleviating themselves of emotional pain through drugs. Thus, they too are “making use of [their] person merely as a means so as to maintain a tolerable condition in life”.
A further study of Kant's arguments sheds more light on why it is good to cultivate our capacity for self insight rather than letting it fall victim to the end of rapidly achieving a life as free from emotional burdens as possible. Consider Kant's argument that the formula of humanity entails the imperfect duty of self development; that is, to cultivate our talents or capacities.
Now there are in humanity capacities for greater perfection which belong to the end that nature has in view as regards humanity in our own person. To neglect these capacities might perhaps be consistent with the maintenance of humanity as an end in itself, but would not be consistent with the advancements of this end (Kant,9 p 37).
Although failing to nurture one's talents is consistent with regarding humanity as an end in itself (that is, there is no resulting contradiction as there is when you universalise the maxim), failing to cultivate personal talents does not promote the goal of treating yourself as an intrinsically valuable being. We cannot will a state of affairs that is at odds with our advancement as rational agents and that stifles our happiness. Proper respect for ourselves as rational and dignified beings entails that we cultivate those talents special to us in order to achieve the “greater perfection” of our human nature.
Kant emphasis this in the Metaphysics of Morals:
A human being has a duty to himself to cultivate his natural powers (powers of the spirit, mind, and body), as a means to all sorts of possible ends. He owes it to himself (as a rational being) not to leave idle and, as it were, rusting away the natural predispositions and capacities that his reason can some day use.11
It is important to note that Kant is not just arguing that we ought to cultivate our talents because a life with such cultivation is better or more pleasurable than a life without it (this would be an inherently utilitarian argument). Rather, developing one's talents is a way of properly respecting one's rational agency. What Kant thinks is so valuable about human beings is that, due to our rationality, we humans have the ability to set ends for ourselves and pursue them. We cannot do this, according to Kant, if we neglect the cultivation of our talents, and in doing so we treat our rational agency with contempt rather than respect. Human beings, then, have an obligation to themselves to engage in self development, not because cultivating talents is valuable and adds pleasure to our lives (although this may be true, it is not why Kant is primarily concerned with cultivating capacities), but because failing to cultivate our capacities is also failing to respect our humanity, our intrinsic worth as rational beings. Even though it may be easier to choose to disregard our talents, be it because we are lazy and uninterested in cultivating them or because the complexities of life often preclude the time necessary in order to do so, to let them waste away is to make it progressively more difficult to be able to set goals for ourselves and realise them, and this means we are not according our rational agency proper respect. Thus, according to Kant, we owe it to ourselves not to let our capacities waste away: “it is a command of morally practical reason and a duty of a human being to himself to cultivate his capacities”.11
The duty of self development is imperfect in so far as there is no specific talent that we must develop or no specific way in which we must develop them; we have the choice as to which talents we think are worthy of cultivation and how we choose to cultivate them. This is primarily because, given our individuality, we each have different talents to cultivate and we each have different ends and goals for our lives that we set for ourselves. Nevertheless, I will deviate from Kant slightly on this point and suggest that there are some talents, some natural gifts, that as human beings we all share due to our rational nature: in addition to being moral agents and free beings, we share the capacity to be introspective, to achieve self knowledge, and to engage in self insight, and this seems to me to be an integral aspect of self development. Proper respect for ourselves as rational creatures seems to demand that we cultivate these talents, that we indeed follow the Socratic imperative to “know thyself,” and this is precisely what we fail to do when we seek to bypass interpersonal methods of dealing with our emotional issues and opt solely for medication to relieve ourselves of their painful symptoms and achieve a pleasurable state of affairs in life. Indeed, “patients who are prescribed drugs frequently tend to give up trying to understand themselves, including the sources of their problems and their potential for psychological or spiritual growth” [my emphasis] (Breggin et al,7 p 190). The capacity for self knowledge and self development is fundamental to living an examined life and it is an essentially human capacity that we all share due to our rational nature. As mentioned above, Kant argues in favour of the duty to cultivate talents because he is interested in preserving our ability to set ends for ourselves and pursue those ends. There is reason to believe that the exclusive use of psychiatric drugs without interpersonal therapy to resolve emotional distress thwarts this ability as well. Individuals who opt for this type of drug use become “skeptical and despairing about the possibilities of overcoming depression through self insight, improved principles of living, a better family life, a more inspiring occupation, and all of the other transformations that often lead to spiritual triumph” (Breggin et al,7 p 190). That is, these individuals often give up setting goals for themselves—for example, the goal of achieving a more fulfilling career—and pursuing them. The Kantian duty of cultivating one's capacities, therefore, entails cultivating the important universal human capacity for self knowledge or self insight. If the exclusive and frequent use of prescription drugs results in a tendency to ignore this capacity, or to give up trying to cultivate it or other possible self imposed ends, then this makes it difficult to fulfil what seems to me to be an integral aspect of properly satisfying the Kantian duty of self development.
Kant also argues that failing to cultivate our talents in exchange for living a life devoted to pleasure cannot be universally willed because doing so results in a contradiction.
Any individual who opts to devote his life to indulging his desires rather than nurturing his talents “cannot possibly will that this should become a universal law of nature… for as a rational being he necessarily wills that all his faculties should be developed, in as much as they are given to him for all sorts of possible purposes” (Kant,9 p 31). Therefore, we must reject the maxim that we may fail to cultivate our talents in exchange for enjoying a life of leisure or pleasure.
Kant's argument for condemning this maxim applies to the discussion at hand. When someone chooses to take drugs instead of engaging in interpersonal therapy to resolve emotional distress, what she essentially wishes to do is to relieve herself as quickly as possible of any emotional or psychological burdens she may be experiencing. In the end, the desire is to achieve some sort of pleasure in her life; not necessarily some crass or hedonistic pleasure, but the pleasure that naturally comes from not feeling depressed, anxious, or irritable. As understandable as this desire is, this action can nevertheless fall within the scope of Kant's criticism. The maxim that this individual is acting upon may look something like this: “Whenever my emotional issues are getting the best of me, I will relieve my psychological burdens as rapidly as possible through drugs and forgo this opportunity to cultivate self knowledge or self insight”. Keeping true to Kant's analysis, we cannot universally will that we compromise our capacity for self knowledge or self insight in order to achieve a pleasurable end result, even if that result is the pleasure of no longer feeling emotional distress. This is not to say that wanting to rid oneself of emotional distress is not a good or important goal, and Kant is not against cultivating certain talents that will lead to the achievement of certain ends. Kant argues that the reason why we should cultivate our talents lies not in what ends we wish to achieve, but rather it lies in the fact that cultivating our talents is a duty that we owe to ourselves for the reasons cited above.
[T]he basis on which [a person] should develop his capacities (for all sorts of ends) is not regard for the advantages that their cultivation can provide….it is a command of morally practical reason and a duty of a human being to himself to cultivate his capacities…11
But, of course, Kant is not against using these talents “as means to all sorts of possible ends”. What he is against is sacrificing the cultivation of our talents in order to achieve a certain end: the end of pleasure or enjoyment. Interpersonal therapy allows one to cultivate the capacity for self knowledge and self insight, and this cultivation will aid in the goal of attaining a functional, pleasurable, and healthy life. Supplanting that development with the exclusive use of drugs will lead to the same end result (for no one is denying that drugs can be effective at solving emotional problems) at the expense of sacrificing the duty that we owe to ourselves to cultivate this important capacity. Allegiance to Kant's imperative to engage in self development and to cultivate our capacities, therefore, requires that we take the former route, even if doing so is more time consuming and more arduous.
I want to reiterate that this critique is not meant to target all instances of psychoactive drug use. There are some cases of mental illness and severe depression that are so debilitating that they require the use of such drugs, and indeed their use may even facilitate the fulfilment of Kant's duty for self development, given that such drugs can provide the crucial first step in helping people regain control over, and functionality in, their lives. This in turn can lead them to achieving self development. My criticism is meant to target what I fear is a growing trend not just among patients, but among physicians as well, to use these drugs for treating people for essentially commonplace challenges in everyday life that can be overcome via interpersonal therapy and the inner struggle that can ultimately result in cultivating the self knowledge and self development that Kant's imperative seems to demand. I once heard a physician tell another at a conference that he knows of a woman who was prescribed antidepressants just one week after being raped because she had not yet gotten over the traumatic experience. This seems to be jumping the gun, and while being raped can certainly result in a clinical depression so severe that it necessitates such medication, it is this type of eagerness on behalf of patients and physicians to solve emotional problems with medication rather than first attempting interpersonal methods of coping that primarily concerns me.
This brings me to the last topic I want to discuss concerning this issue: the responsibility that others have to emotionally afflicted individuals to help them further their capacity for self knowledge rather than subjecting them to medication prematurely. This applies not only to physicians, but to parents as well, given that increasing numbers of children are being prescribed psychoactive medication. Recall that Kant argues that we are to use neither ourselves nor others soley as a means to an end. He also maintains that we have a duty of beneficence “to promote according to one's means the happiness of others in need” (Kant,11 p 262). Although physicians and parents may well be genuinely trying to help an afflicted individual, exposing a troubled person to medication without first giving them an opportunity to deal with their troubles in a manner that may facilitate self knowledge disrespects their humanity. Granted, a physician such as Dr Kramer may well be genuinely trying to help his patients, and he may not be using them as a means to achieving a selfish end or personal gain. Nevertheless, by encouraging the circumvention of self discovery for the ease of a quick fix, and/or by maintaining that self knowledge is unnecessary or dispensable in the face of more expedient results, a physician is encouraging his patient to treat herself as a means to an end. He is no doubt trying to help his patient, but he is doing so in a manner that fails to respect her humanity.
This applies to parents as well, many of whom, as mentioned above, were opting for medication over therapy before the FDA revealed that antidepressants might cause suicidal thoughts in their children. Although the duty to cultivate talents is a duty to the self, children, especially depressed ones, often need their parents' help to fulfil all sorts of moral challenges. Indeed, until children are old enough to be moral agents, we have a duty to help them achieve such agency. In raising children, we are not just respecting and encouraging the development of rational agents, we are, in effect, creating rational agents, and so we must take special care in helping them fulfil their duties to others and to themselves. Thus, I propose that parents not only have a duty of beneficence toward their children (as they do to all other human beings, albeit perhaps to a greater extent), they also have a duty to help their children cultivate their talents and capacities, and this includes the capacity for self knowledge. This entails that parents open the lines of communication with their children when they are afraid, depressed, or experiencing anxieties that are typical aspects of growing up. It entails that parents teach their children how overcoming emotional distress can lead to the attainment of personal and spiritual growth; and it entails that parents do not convey the message that expedient end results matter more than the self development that may come via interpersonal methods of coping with emotional issues. This, of course, entails parents exposing children to counselling and perhaps engaging in cognitive therapy before they resort to the exclusive use of drugs to help them resolve their children's emotional pains. It ought not to have taken an FDA “black box” label to make parents rethink their eagerness to help their children cope with their emotional problems by using medication rather than therapy, or with a proper combination of the two if therapy alone is deemed insufficient. Proper respect for the humanity of children, and the rational agents that are being created, seems to have always demanded this.
However, parents, physicians, and patients alone are not to blame for this eagerness, and this brings me to my last point. Opting for the exclusive use of medication over interpersonal therapy is more economical, given that insurance companies are less willing to pay for the services of specialists necessary to dispense interpersonal therapy:
The growing preference for pills reflects the push by insurers to have patients treated by primary care physicians rather than specialists. Primary care doctors can write prescriptions but are seldom trained in psychotherapy. The cost of psychotherapy varies by region of the country, but the national average for cognitive behaviour therapy is $100 per session for the standard course of 15–20 sessions, or about $1,500 to $2,000 for the full course of treatment. (In some cities, the price could be as much as twice that.) Branded antidepressants generally cost about $1,000 per year plus the bill for the doctor's appointments needed to continue the prescription.3
This means that if an individual opts for interpersonal therapy, she may face having to pay for most of it from her own pocket, leaving less money for necessities and also, admittedly, for some luxuries. That is, our current medical system is set up in such a way as to encourage drugs as a solution to our emotional problems, regardless of whether an individual really needs them or whether therapy may suffice to aid her in her road to recovery. We live in a society that is progressively prizing expediency and financial savings over the personal growth of its members, and so Kant's imperative is being violated on a much grander scale. The best I can hope for in writing this paper is to make individuals aware that respect for themselves, and their children, demands that they treat themselves and others as intrinsically valuable beings. We have a duty to cultivate our talents, including our talent for self knowledge and self insight, which is a gift that we all possess by virtue of our rational nature. The goal of life should not just be a release from emotional burdens in favour of a pleasurable state of existence, but the achievement of this in the proper way; in a way that respects our humanity and the humanity of others.
Conclusion
I too have family members who take prescription drugs and as such I have first hand knowledge as to how they may be necessary in helping people cope with severe emotional problems. Teenage depression in particular is a prevalent issue which could result in suicide if not diagnosed and treated: “one in every 33 children and one in eight adolescents may be suffering from depression…suicide is a risk, and so is homicide”.12 Depression is caused primarily by sociological factors, but there are times when chemical imbalances may be to blame. I am not maintaining that drugs ought to be eradicated as a possible cure for depression or as an aid when dealing with other emotional issues, since they can indeed be very effective. What I am maintaining is that they need to retain their roles as supplements and ought to be used in conjunction with interpersonal therapy if the latter is deemed insufficient to aid in recovery. Artificial chemicals ought not to replace the personal or spiritual growth that comes from battling our emotional problems and coming to a sense of triumph and self worth. While we can achieve functionality with drugs, as Julia did, in doing so we fail to fulfil our duties to ourselves. Using drugs exclusively as substitutes for interpersonal help and self knowledge violates Kant's formula of humanity in a variety of ways. Like the suicidal man, we compromise an integral part of our humanity in order to achieve a cessation of pain. We also fail to follow Kant's duty of self development by evading the cultivation of our capacity for self knowledge and personal growth, and we induce our children to do the same when we stifle their personal growth and self development in the interest of attaining a quick fix.
We are rational beings worthy of dignity and respect. Our minds are not things to be medicated when life gets difficult. Our minds, rather, should be developed and strengthened through self knowledge, self insight, and self development, even if doing so may take longer and cost more. This is a small price to pay for properly respecting ourselves, and our children, as inherently valuable beings. If Kant were writing in today's world, I am sure he would argue the same.
Acknowledgements
Many thanks to my husband Tuomas William Manninen, to Dr James Stacey Taylor, and Dr Sarah Buss for their help and comments on earlier drafts of this paper. I would also like to thank the Journal of Medical Ethics reviewers and editorial staff for their helpful comments, which greatly contributed to the improvement of this paper.
Abbreviations
FDA - Food and Drug Administration
Footnotes
i The study did show, however, that when dealing with the long term consequences of both therapy and psychiatric drugs, the patients who were treated with the former had fewer relapses two years after their treatment than those treated with drugs alone.
i The contradiction that arises would be something like the following. According to Kant, nature has given all persons talents that require development. Therefore it cannot be the case that a law of nature exists that commands that we not cultivate the talents given to us by nature in the first place; nature would have simultaneously given us talents to cultivate and made it impossible to cultivate them. Thus, forgoing developing our talents in order to have more time to seek pleasure cannot be universally willed.
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References
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