Broadly speaking, we can say that modern expert opinion has replaced the mutual exclusion of medical and judicial discourses by a game that could be called the game of dual, medical and judicial, qualification. This practice, this technique of dual qualification, organizes the realm of that very strange notion, "perversity," that begins to emerge in the second half of the nineteenth century and that will dominate the entire field of this double determination and authorize the appearance of a range of manifestly obsolete, laughable, and puerile terms or elements in the discourse of experts who are justified as scientists. When you go through these expert medico-legal opinions ... you are struck by terms like laziness, pride, stubbornness, and nastiness. You are given biographical elements that do not in any way explain the action in question but are kinds of miniature warning signs, little scenes of childhood, little childish scenes that are presented as already analogous to the crime. It is a kind of scaled-down criminality for children characterized by the language used by parents or by the morality of children's books. In fact, the puerility of the terms, notions, and analysis at the heart of modern expert medico-legal opinion has a very precise function: it makes possible an exchange between juridical categories defined by the penal code, which stipulates that one can only punish when there is malice or a real intention to harm, and medical notions like "immaturity," "weak ego," "undeveloped superego," "character structure," and so on. You can see how notions like those of perversity make it possible to stitch together the series of categories defining malice and intentional harm and categories constituted within a more or less medical, or at any rate, psychiatric, psychopathological, or psychological discourse. The whole field of notions of perversity, converted into their puerile vocabulary, enables medical notions to function in the field of judicial power and, conversely, juridical notions to function in medicine's sphere of competence. This set of notions functions, then, as a switch point, and the weaker it is epistemologically, the better in functions.
Michel Foucault, Abnormal: Lectures at the College de France 1974-1975 (2003: 32-33)
Showing posts with label psychiatry. Show all posts
Showing posts with label psychiatry. Show all posts
13 February 2010
01 July 2009
the throne of the mind
What determines the question a scientist pursues? One side in the so-called science wars holds that the investigation of nature is a purely objective pursuit, walled off from the influence of the surrounding society and culture by built-in safeguards, such as the demand that scientific results be replicable and the requirement that scientific theories accord with nature. The gravitational force of a Marxist, in other words, is identical to the gravitational force of a fascist. Or, more starkly, if you're looking for proof that science is not a social construct, as so-called science critics contend, just step out the window and see whether the theory of gravity is a mere figment of a scientist's imagination.
That the findings of science are firmly grounded in empiricism is clear. But the questions of science are another matter. For the questions one might ask of nature are, for all intents and purposes, without end. Although the methods of science today may be largely objective, the choice of what question to ask is not. This is not a shortcoming, much less a fault, of science. It is, rather, a reflection of the necessary fact that science is, at bottom, a human endeavor. Running through both psychiatry and neuroscience is a theme that seemed deeply disturbing to me almost from the moment I began reading in the field ... when my conviction that the inner working of the mind was the only mystery worth pursuing made me vow to become a psychiatrist. What disturbed me was the idea that free will died with Freud—or even earlier, with the materialism of the triumphant scientific revolution. Freud elevated unconscious processes to the throne of the mind, imbuing them with the power to guide our every thought and deed, and to a significant extent writing free will out of the picture. Decades later, neuroscience has linked genetic mechanisms to neuronal circuits coursing with a multiplicity of neurotransmitters to argue that the brain is a machine whose behavior is predestined, or at least determined, in such a way as seemingly to leave no room for the will. It is not merely that the will is not free, in the modern scientific view; not merely that it is constrained, a captive of material forces. It is, more radically, that the will, a manifestation of mind, does not even exist, because a mind independent of the brain does not exist.
Jeffrey Schwartz, The Mind & The Brain (2003: 7-8)
That the findings of science are firmly grounded in empiricism is clear. But the questions of science are another matter. For the questions one might ask of nature are, for all intents and purposes, without end. Although the methods of science today may be largely objective, the choice of what question to ask is not. This is not a shortcoming, much less a fault, of science. It is, rather, a reflection of the necessary fact that science is, at bottom, a human endeavor. Running through both psychiatry and neuroscience is a theme that seemed deeply disturbing to me almost from the moment I began reading in the field ... when my conviction that the inner working of the mind was the only mystery worth pursuing made me vow to become a psychiatrist. What disturbed me was the idea that free will died with Freud—or even earlier, with the materialism of the triumphant scientific revolution. Freud elevated unconscious processes to the throne of the mind, imbuing them with the power to guide our every thought and deed, and to a significant extent writing free will out of the picture. Decades later, neuroscience has linked genetic mechanisms to neuronal circuits coursing with a multiplicity of neurotransmitters to argue that the brain is a machine whose behavior is predestined, or at least determined, in such a way as seemingly to leave no room for the will. It is not merely that the will is not free, in the modern scientific view; not merely that it is constrained, a captive of material forces. It is, more radically, that the will, a manifestation of mind, does not even exist, because a mind independent of the brain does not exist.
Jeffrey Schwartz, The Mind & The Brain (2003: 7-8)
the elasticity of psychiatric diagnosis
Whatever the merits of the SSRIs, they have been among the most heavily promoted drugs of the past decade. The manufacturers of anti-depressants have taken full advantage of the relaxation of U.S. FDA restrictions on prescription drug advertising in 1997. In 2000 Paxil was the fourth most heavily promoted prescription drug in America, with $91.8 million in direct-to-consumer spending. Eli Lilly spent $37.7 million that same year advertising fluoxetine—$23.3 million as Prozac and $14.4 million as Sarafem. To put these figures in context: GlaxoSmithKline spent more money advertising Paxil than Nike spent advertising its top shoes. Direct-to-consumer advertising clearly works. From 1999 to 2000, antidepressants saw a 20.9 percent increase in sales to a figure of $10.4 billion, maintaining their position as the best-selling category of drugs in the United States. In 2000 Prozac was America's fourth most prescribed drug: Zoloft was number seven, and Paxil was number eight.
Of course, the SSRIs could not have achieved such spectacular success if they did not work for some patients. Yet an equally important reason behind the success of psychoactive drugs in general, and the SSRIs in particular, is the elasticity of psychiatric diagnosis. Categories of "mental disorders" are in constant flux, and they often expand dramatically once a new treatment is marketed. For example, social anxiety disorder—the fear of being embarrassed or humiliated in public—was considered a rare disorder until physicians began treating it with Nardil (phenelzine) in the mid-1980s and then, later, with SSRIs such as Paxil. Today social phobia is often described as the third most common mental disorder in the United States. Similar stories can be told for obsessive-compulsive disorder and panic disorder... As David Healy has pointed out, the key to selling psychoactive drugs is to sell mental disorders.
But to sell a mental disorder, you must first capture it and make it your own. A drug manufacturer is not allowed to promote a product for a specific disorder until that product has FDA approval. As a result, SSRI manufacturers jockey aggressively among themselves to claim new pieces of the mental disorder market. While the FDA has approved all six SSRIs on the market for depression, Paxil was until recently the only drug approved for social anxiety disorder. (In 2003 it was joined by Zoloft and Effexor.) All of the SSRIs except Celexa and Effexor have been approved for obsessive-compulsive disorder, but only Effexor and Paxil have been approved for generalized anxiety disorder. Zoloft and Paxil have claimed panic disorder and posttraumatic stress disorder, but only Prozac has been approved for bulimia. Eli Lilly's patent on Prozac expired in 2001, but Lilly has begun marketing the same drug under a different name, Sarafem, as a treatment for "premenstrual dysphoric disorder".
Conventional wisdom attributes the spectacular success of the SSRIs to their relative absence of side effects. For instance, monoamine oxidase inhibitors, an alternative type of antidepressant, can be dangerous without strict dietary restrictions, and people taking the longer established tricyclic antidepressants often complain of drowsiness, dizziness, dry mouth, or constipation. Prozac and the other SSRIs initially appeared much less burdensome. Another significant reason for the success of the SSRIs lies in their ease of use. "One pill a day forever," says Jonathan Cole. "Fluoxetine at one pill a day is the ideal primary care physician's drug." Today, in fact, it is no longer even one pill a day. Prozac Weekly is a once-a-week version of Prozac that Lilly has marketed using coupons in newspapers and magazines. The one-pill strategy has clearly worked, whether the one pill is taken daily or weekly. It has been estimated that as much as 70 percent of the SSRIs is prescribed not by psychiatrists but by primary care physicians.
... In bioethics the conventional response to the phenomenon that Kramer called cosmetic psychopharmacology" has been to classify it as enhancement technology. The distinction between enhancement and treatment had gained currency during the ethical debate over gene therapy in the late 1980s and early 1990s. Many people were eager to press a research agenda into the therapeutic uses of genetic technology for conditions such as adenosine deficiency or cystic fibrosis but worried about the use of such technologies for eugenic purposes. Since then, bioethicists have used the term "enhancement technology" as a shorthand for all sorts of technologies whose uses go beyond the strictly medical, from synthetic growth hormone for short boys to Botox injections for aging women. The unstated assumption behind the term has been that there is a morally important distinction between enhancement and treatment. Treating illness, it has been argued, is an essential part of medical practice. Doctors have an obligation to treat sick people. Enhancements, in contrast, are seen as extras—ethically acceptable, perhaps, but not something that a doctor has any particular obligation to provide or that a liberal society has an obligation to fund.
Yet the distinction between treatment and enhancement turns out to be much more elusive than it first appears, especially in psychiatry. Where is the line between psychopathology and social deviance, perversion, or eccentricity? When does shyness turn into social phobia, or melancholy into depression? The problem is complicated still further by the fact that so little is known about the causes or pathophysiology of mental disorders, or even about how chemical treatments for these mental disorders work. Philosophers have traditionally argued that illness is a departure from species-typical human functioning, but that definition offers us little guidance when the subject turns to the human mind and human behavior. What kind of behavior is typical of Homo sapiens?
It might be better to ask, What should we make of the social place that the SSRIs have come to occupy? Every culture has its own socially prescribed psychoactive substances, from peyote, kava, and betel nuts to alcohol, caffeine, and nicotine. But with the SSRIs, the gate to the drug is guarded by doctors, and the passport for access is the diagnosis of mental disorder. Unlike alcohol, which is dispensed in bars and liquor stores, or caffeine, which is dispensed at Starbucks and Unitarian churches, SSRIs are dispensed at doctor's offices and pharmacies. It is the social place occupied by SSRIs that has produced the ambivalence that many of us feel about their popularity. Unlike bartenders and espresso baristas, doctors have not generally thought of their job as making well people feel better than well. But that might change.
Carl Elliott, Prozac as a Way of Life (2004: 4-7)
Of course, the SSRIs could not have achieved such spectacular success if they did not work for some patients. Yet an equally important reason behind the success of psychoactive drugs in general, and the SSRIs in particular, is the elasticity of psychiatric diagnosis. Categories of "mental disorders" are in constant flux, and they often expand dramatically once a new treatment is marketed. For example, social anxiety disorder—the fear of being embarrassed or humiliated in public—was considered a rare disorder until physicians began treating it with Nardil (phenelzine) in the mid-1980s and then, later, with SSRIs such as Paxil. Today social phobia is often described as the third most common mental disorder in the United States. Similar stories can be told for obsessive-compulsive disorder and panic disorder... As David Healy has pointed out, the key to selling psychoactive drugs is to sell mental disorders.
But to sell a mental disorder, you must first capture it and make it your own. A drug manufacturer is not allowed to promote a product for a specific disorder until that product has FDA approval. As a result, SSRI manufacturers jockey aggressively among themselves to claim new pieces of the mental disorder market. While the FDA has approved all six SSRIs on the market for depression, Paxil was until recently the only drug approved for social anxiety disorder. (In 2003 it was joined by Zoloft and Effexor.) All of the SSRIs except Celexa and Effexor have been approved for obsessive-compulsive disorder, but only Effexor and Paxil have been approved for generalized anxiety disorder. Zoloft and Paxil have claimed panic disorder and posttraumatic stress disorder, but only Prozac has been approved for bulimia. Eli Lilly's patent on Prozac expired in 2001, but Lilly has begun marketing the same drug under a different name, Sarafem, as a treatment for "premenstrual dysphoric disorder".
Conventional wisdom attributes the spectacular success of the SSRIs to their relative absence of side effects. For instance, monoamine oxidase inhibitors, an alternative type of antidepressant, can be dangerous without strict dietary restrictions, and people taking the longer established tricyclic antidepressants often complain of drowsiness, dizziness, dry mouth, or constipation. Prozac and the other SSRIs initially appeared much less burdensome. Another significant reason for the success of the SSRIs lies in their ease of use. "One pill a day forever," says Jonathan Cole. "Fluoxetine at one pill a day is the ideal primary care physician's drug." Today, in fact, it is no longer even one pill a day. Prozac Weekly is a once-a-week version of Prozac that Lilly has marketed using coupons in newspapers and magazines. The one-pill strategy has clearly worked, whether the one pill is taken daily or weekly. It has been estimated that as much as 70 percent of the SSRIs is prescribed not by psychiatrists but by primary care physicians.
... In bioethics the conventional response to the phenomenon that Kramer called cosmetic psychopharmacology" has been to classify it as enhancement technology. The distinction between enhancement and treatment had gained currency during the ethical debate over gene therapy in the late 1980s and early 1990s. Many people were eager to press a research agenda into the therapeutic uses of genetic technology for conditions such as adenosine deficiency or cystic fibrosis but worried about the use of such technologies for eugenic purposes. Since then, bioethicists have used the term "enhancement technology" as a shorthand for all sorts of technologies whose uses go beyond the strictly medical, from synthetic growth hormone for short boys to Botox injections for aging women. The unstated assumption behind the term has been that there is a morally important distinction between enhancement and treatment. Treating illness, it has been argued, is an essential part of medical practice. Doctors have an obligation to treat sick people. Enhancements, in contrast, are seen as extras—ethically acceptable, perhaps, but not something that a doctor has any particular obligation to provide or that a liberal society has an obligation to fund.
Yet the distinction between treatment and enhancement turns out to be much more elusive than it first appears, especially in psychiatry. Where is the line between psychopathology and social deviance, perversion, or eccentricity? When does shyness turn into social phobia, or melancholy into depression? The problem is complicated still further by the fact that so little is known about the causes or pathophysiology of mental disorders, or even about how chemical treatments for these mental disorders work. Philosophers have traditionally argued that illness is a departure from species-typical human functioning, but that definition offers us little guidance when the subject turns to the human mind and human behavior. What kind of behavior is typical of Homo sapiens?
It might be better to ask, What should we make of the social place that the SSRIs have come to occupy? Every culture has its own socially prescribed psychoactive substances, from peyote, kava, and betel nuts to alcohol, caffeine, and nicotine. But with the SSRIs, the gate to the drug is guarded by doctors, and the passport for access is the diagnosis of mental disorder. Unlike alcohol, which is dispensed in bars and liquor stores, or caffeine, which is dispensed at Starbucks and Unitarian churches, SSRIs are dispensed at doctor's offices and pharmacies. It is the social place occupied by SSRIs that has produced the ambivalence that many of us feel about their popularity. Unlike bartenders and espresso baristas, doctors have not generally thought of their job as making well people feel better than well. But that might change.
Carl Elliott, Prozac as a Way of Life (2004: 4-7)
Subscribe to:
Posts (Atom)