16th April2002 Galileo LoLegglo CandidateNumber: 981272503

PROZAC: EXPLORINGTHE MYTH

TABLE OF CONTENTS INTRODUCTION.................. Page12

CFIAPTER 1 GENESIS A WONDER OF DRUG...................... Page 04 Serotonin........ Page 04 TheBirthof Prolzac................. Page 05 Prozac How doesit work?.. Page07 Prozac Uptake Uninhibited.... ........................Page 08 Prozac theMedia............. and .,...................... 10 Page CHAPTER2 LISTENING DR.KRAMER TO Functional Autonomy............. Kindling......... InbomTemperament.............. Further Points ..................... 15 Page ........................ 16 Page Page 1.8 Page2} Page?

C}IAPTER3 PROZAC AND THEETHICS ENHANCEMENT.................. OF Page26 Enhancement Treatment..... vs. ......................Page26 DoMeansMatter?.................... .......................Page30 TheBusiness Olympics........... ........................ 33 Page CHAPTER4 PROZAC, ALIENATION AND SOCIETY ....Page 36 Alienation .;............................. Page39 Conformity..... Page4 CONCLUSION BIBLIOGRAPHY ......................... Page48 Page 51

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INTRODUCTION The subject surrounding 'mental illness' has always been of great interest to me. IAIhen I came to think about my dissertation, I knew that I wanted to write something within this area. I first heard about Prozac through some friends, who were either taking the medication or whose parents were. I then read Elizabeth Wurtzel's bookr Prozac Naton. The book really got me thinking about

antidepressants in general. I wanted to understand, firstly the biological underpinnings which validated the prescription of medication for mental conditions; secondly I wanted to get to grips with some of the problems that come about when our culture applies biological methods to something that is as intangible as the human mind. For these reasons I decided that the subject of Prozacwould be interesting for my project. In my first chapter I decided that it would be_important to outline how Prozac was discovered and how it is believed to work. Thesewould give me a basis for further discussion with regard to,theories of depression. I also wanted to

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highlight the widespread usage of the drug and the way it was portrayed in the media, becauseI wanted to place Prozac in a cultural context. I wanted to show that Prozac's successwas controversial from its very beginning. During my research I discovered a popular sciencebook, which had received high media coverage/written by Peter D. Kramer. When I read it I knew it would be central to my own work. The book was entitled Lls ening to Proza|.

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' See p.12 ' See p.10ff

My second chapter discussessome of the theories around depression and Prozac that are found in the above-mentioned book. This is done in the hope of creating a base from which my argument can develop. In this chapter I also begin to highlight some of the problems that arise from the prescription of such a medication. The third chapter is a much more detailed exploration of the ethics that surround human enhancementthrough biology in general,and of Prozac as a personality enhancer in specific. Here I will explore the distinction between enhancement and treatment. There will also be a section that discusseswhether the means used to enhance oneself are of importance. I will conclude the chapter with an investigation of fairness and social coercion when using Prozac as a personality enhancer. In my final chapter I will be arguing that depression and other forms of minor 'mental' conditions are in fact reasonableresponsesto our current culture and 'diseases'is to misunderstand the causesof these society, and that curing these problems. I will do this by discussing the concept of alienation, by looking at Karl Marx, Erich Fromm, R.D. Laing and an ethicist called Carl Elliot. I will also discuss how modern society can be seen to pressure people into conforming to an ideal personalify style.

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CHAPTER1 GENESIS OFAWONDERDRUG

In this first chapter I will be exploring the birth of Ptozac from its discovery to the subsequentmedia explosion. I will begin by looking briefly at how serotonin and neurotransmitters are affected by Prozac. I will continue by a brief historiography of Prozac's discovery. Once I have placed Prozac into context I will look at the media's iniuence in its popularisation and the backlash that consequentially appeared. This is will provide a good place where to begin a proper analysis of Prozac in the context of culture, society and ethics. Serotonin The Prozac story can be said to have.begun with the discovery of serotonin. Serotonin or 5HT, its chemical name, was first identified in the 1940's.Its role of regulating the tone of blood vesselsinterested scientists and for this reason it was named sero-tonin, 'sero' refers to blood and 'tonin' to its toning effects. However, it was not unfil the mid 1950'sthat Serotonin was discovered in the brain. The first hint of serotonin's usefulness in psychopharmacology came about when that fohn Gaddum, a scientist at Edinburglu speculatedto a group of researchers "It is possible that the S-HT [serotonin] in our brains plays an essentialrole in keeping us sane."3This suggested to psychopharmacologists that if serotonin kept us sane,increasing serotonin in the brain might help in countering mental illiesses.-It was not until the end of the 1.950's that a Swedish scientist began to
'Drugs Antagonisticto 5Hydroxytry?tomin';Wolstenholme, I Gaddum, G.E.W.et al (eds,) Ciba J.H.; Foundation London.1954\ Swnposium H!'Dertension; on lChurchiu, o.177: ouoted Shorter. A Historv in E.: ([ohnWilev& Sons, of Psvchiatrv; Chich ester.199V: oo.320-321.

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map out the brain pathways containing serotonin. In the early 1960's it was accidentally discovered that drugs which raised serotonin eased depression. Serotonin is just one of thousands of chemicals found in the brain. What is special about this chemical is that it was found to be a neurotransmitter. 5HT is "l00 or more substances not unique as scientists have discovered [that] have been identified that control neurotransmission, and many of them are

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neurotransmitters."a Neurotransmitters are found in the synapse, this is the gap between neurones down which electrical impulses pass. Neurotransmitters which have been compared to messengersof the brain - are released in the 'messages'to next neurone which fires off the synapses,passing on a series of next impulse, and so on and so forth.5 Neurotransmitters can be viewed as the most basic necessity for the brain to function, different neurotransmitters are are secretedand therefore different kinds of messages passedon for all brain and ultimately human functions.6

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The Birth of Prozac In the 60's amongst the walls of Eli Lilly?, the main stage for our drama. One researcher,Dr. Fuller, had been testing drugs, using a very new and effective method, to see how these drugs affected the serotonin pathways.s Fuller suggested to a colleague, Brian Molloy, that becauseof this method the time was right to research brain chemistry. Molloy began a series of tests on possible
a Breggio P.R. & Breggin G.R.; Talking Back To Prozac; (St. Martin's Paperbacks,New York, 1995);p.2O-U ' seerDra.pp. zt-u 6SeeWolpert,L.;MaligrnntSadness-theanatomyofdePression:(faberandfaber,Londo,2001);P106-707 TProzac was discovered, slmthesized and paienied by Eli Lilly. It is one of the big pharrnaceutical comDarues. 8Thse are the neurones affected by serotonin.

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antidepressantsthat did not have as many side effects as previous medicatione, making them quite undesirable for patientslo.

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1971-canbe said to be the next big event in the making o Prozac. Firstly, Fuller, by now Eli Lilly's senior pharmacologist, had started to push the idea that serotonin could be useful in combating depression. DesPite some reservations "Fuller, in the company gave in to Fuller's proposal, and as Shorter suggests: alliance with Lilly biochemist David Wong, carried the day inside the company. Lilly organised a serotonin depression team."rl The last piece in the jigsaw of Prozac came at a lecture in the same year, in which Molloy and Wong met and began a collaboration as part of the serotonin depression team. The lecture was given by Nobel Prize winner Solomon Snyder, perhaps one of the greatest minds in biological psychiatry. The subject was neurotransmission. Snyder had developed a method that could test how much of a neurotransmitter nerve endings would absorb after having been treated with a potential antidepressant, this he called the synaptosome test. This method caught Wong's interept, and he went about in testing Molloy's compormds, using the synaptosome test. Wong discovered that these were in fact potent norepinephrine blockers, just like the majority of antidepressantson the market. Wong also noticed that Snyder's synaptosome reacted differently to compounds that had a very similar structure. So, Wong decided to test those compounds which he thought might block the uptake of serotonin. Wong tested "LilIy 8281'6" seemed over two hundred and fifty compounds and one of them, , to be the most selective in the inhibition of the re-uptake of serotonin, this

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

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compound is chemically known as fluoxetine oxalate.Compound 82816was then tried out on Fuller's test and once again it appeared to block the up take of serotonin and little else. It later appeared easier to work with a different compound "Lilly 110140".In L974 Wong and Molloy publicly announced

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compound LL0140to be a selective serotonin re-uptake inhibitor in rats'brains. I^ \975 it was given its chemical name fluoxetine hydrochloride, which was later given the trade name of PROZAC. Prozac- How does it work? A widely believed biologically basedtheory about the causeof depressionis that depressedpeople lack a sufficient amount of neurotransmitters,especiallythat ol serotonin and norepinephrine, in the brain. When a neurotransmitter is fired from a pre synaptic nerve cell it remains in the cleft between that cell and the adjacent one, for a very short time'. Some of it binds to the receptor of the postsynaptic cell, whilst the rest is either broken down in various ways or taken back up to the pre-synaptic nerve cell for future use. This Process is generally known Antidepressants (except for the class known as MAOIs) generally as re-uptake. work on the principle that they block the re-uptake of certain neurotransmitters. staying in the cleft longer and therefore allowing them to stimulate the postsynaptic cell more strongly. serotonin re-uptake inhibitors), a Previous to the discovery of 55RIs (selectivel3 of c_lass drugs called tricyclics (named after their chemical structure being composed of three rings) were the main kind of treatment against depression.
D If it were to stat it would continue to stimulate the Post-synaPticnerve cell. 13 specific Or

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Both these types of antidepressants block the re-uptake of neurotransmifters. The main difference between the two classesis that tricyclics not only effect serotonin and norepinephrine pathways, but also the re-uptake of other neurotransmitters, giving the patient a so-called " dirty drug"la. The word dirty refers to the sense that it effects the pathways of more neurotransmitters than are needed. This excessgives the patient a higher quantify of side effects. These side effects range from drowsiness to heart palpitations, from urine retention to dryness of mouth and confusion. They are also lethal in the caseof overdose.sWhilst SSRI,mainly blocks the re-uptake of serotonin, with a slight effect on the norepinephrine pathways, giving these drugs fewer side effects and on the whole overdosing on them is not lethal. These new drugs [SSRIs]are not more potent in terms of their abilify to reduce depressivesymptoms, but their advantagelies in reduced side effects and so an improved quality of life... In severalstudies the failure to continue taking the drug was less than 10 per cent for fluoxetine and around 30 per cent for the tricyclics.r ProzacUptake Uninhibited Since its discovery, Prozac had to be approved by government agenciesaround the globe. This took over ten years in America and was done through the Food and Drug Administration (FDA). In 1986 Prozac was approved in Belgium

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t' I(ramer,P.D.; op. cit.; p.57 15Giving a suicidal patient a drug with which they could overdose, would require constant supervision of that patient either by doctors in psychiahic hospital or by ihe patient's relations. Wolpert L.; op. cit.; p.133

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shortly followed by America in 1987.Since then, Prozac has been approved in more than 90 countries.lT By 1989annual sales of.Prozac reached $350M in America, making up more than one tenth of Eli Lilly's total revenues. This amounts to more than the total spent and in by Americans on all other antidepressants the previous year. In both 1.991 1992Eli Lilly's revenue tfuough Prozac rose to $1 billion for each year, out of a total of $8 billion antidepressant marketl reaching a staggering $2.6 billion in revenue. By then, Prozac had become the fourth most profitable the 1997-1998 drug of all times.le Since its approval, Prozac has been prescribed to more than 40 million people around the globe of which around 22 million Americans.2oIn Britain, it is at estimated that in 5 years (1994-1999) least one million people have taken it.zr This means that around 85% o the American population and almost 2"/" o the UK population have taken Prozac.zAntidepressants,in other words, have, in a relatively short time, become big business;and Eli Lilly have had a major share of the profits. In just a decade,their yearly revenue from Prozac has multiplied seven-fold.

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r?This data has been taken frorn Eli-Lilly's web site www.prozac.com; url: h.f'cp / :www.pr ozac.com/i0 /k1-1 jsp / 13 This data has been taken from Bteggin, P,R et al.; oP.cit.; P.2-3 'Iast of the Million dollar drugs'; re Data talen from Finctt Ggaguatu G7/1/1998); p.28 J.; '0 Data taken from www,prozac.com; oP cit.. 2!Data talen from Bossely,S.; 'They said it was safe'; Sgar[lggt; Q0/10 /1999) P10 " This data has been worked out using the previous data and Collins Atlas of the World; (Harper Collins Publisher, Londory 1999),p.6 and p. 105

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Prozacand the media How does a prescription drug become so popular, to the extent that there are now over 30 books available to buy with its name in the title? What does it mean when you can buy Prozac Capsule earrings or even wear a T-shirt with its barcode on the front? To understand this, we have to start by looking at the media. The first hint of Prozac's growing popularity came when in March 1990a floating with the caption: Prozac capsule appeared on the cover o Newsweek

PROZAC Drug A Breakthrough for Depression23

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The article entitled The Promseof Prozacdiscusses the benefits of SSRI's over the old tricyclics, raising the issue of side effects.In this article Peter D. Kramer was "there may even be a drug quoted, then an unknown psychiatrist, saying that "change people in ways they want to be changed - not just away from that can illness but toward some desirable psychological state.""2a Kramer, a clinical professor of psychiatry at Brown, began writing about Prozac in a column of a trade magazine for psychiatrists at the end of the 1980's.He "cosmetic psychopharmacology" which appeared in famously coined the phrase Kramer's popularity really began an essaypublished by The PsychintricTimes'% when his second essaywas published as a cover story of NEW YORK Magazinein quotation comes from). Further, Kramer was March L990 (where the Newsweek
'3 Newsweek; (Ma1ch 26 1990);cover page '4 Cowlet G. et al; 'The Promise of Prozac'; in Newsweelc (March26,1990)t p,4l 25 Kramel, P.D.; 'The New You'; Psvchiatric Times: March 1990; see PP.45-46

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referenced in "a definitive contemporary article for physicians on the use of antidepressants, in The New England lournal of Medicine."% In 1993 Kramer published Listening to Prozac. The book detailed the personality enhancing properties of the drug and its cure-all possibilities. The book was a hit and it spent 21 weeks on the New York times Best seller list. As Rothman suggests, "Prozac and Listening to Prozac have both become best-sellers. Indeed the fortunes of the book and the drug are so intertwined (the book made the lists before it was so much as advertised or reviewed) that it is impossible to discuss one without the other."27Or as the editor of Thelancet notesz and Listening to Prozacby psychiatristPeterKramer-400 or so pagesof anecdote folksy psychobanter is an American best seller that has almost certainly US contributedto the staggering salesof the drug...4 By 1994thenotion of Prozacas a personality enhancerhad become widespread. An article entitled The Culture of Prozacsuggested that "[t]he antidepressant drug

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Prozac has gained tremendous popularity among people with no mental illness their personalities".a Eli Lilly was now who simply wish to change or enha,nce showing concerns around the hype of Prozac's wonder properties. And in a reply ad/article they argue that "much of this attention has trivialized the very

serious nature of the diseaseProzac was specifically created to treat - clinical depression".s

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e Kramer; P.D (Fourth Estate;London; 1994);p. xvi LigEli4glqBqzaE '? Rothman, D.J.; 'Listening to Prozac'i \19!dlBepgb!!E (Feb 14,1994, v27o n7); p34 2 Editorial ?rtificial Paradise Encapsulated'i Lancet: (APril 9,7994, v343 9O2)i ; P.865 'e Cowlep G. et a!.'The Culture of Prozac', @k; $ebrary 7,1994), P.41, 30 Quoted from Wurtzell, E.; Plozac Nation - Young ard Depressed in America a memoir; (Qualtet Books, London, 1996);p.304

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In 1994"Prozac's entry into popular culture was kicked off with Prozac Nation a by Elizabeth W:uriizel"3l, memoir of a depressed young woman who was 'saved' by Prozac. It was an instant hit, especially within the youth culture in the midst of 'grunge' music like Niruann. The purpose of the book in Wurtzel's eyes was to "come out and say that clinical depressionis a problem, that it ruins lives, that it ends lives... that it afflicts many, many people, many very bright and worthy and thoughtful and caring people... "32. However, the title of the book is "Prozac Nation is lessabout

deceiving as Prozacis not really such a central issue,

Prozac than it is about another contemPorary phenomenon: divorce."s And what she does say about Prozac is extremely subjective and largely unsupported by any evidence, theories or references,what it does offer are Wurtzel's highlyReaiewsuggests: strung opinions. As Dawn Marlan of the Chicago "Prozac Nation

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is ft.rndamentally compromised by Wurtzel's inflated and unargued assumption that her story immediately explains the story of others."s In the same year, what might be described as the antithesis to Listening to Prozac was published. Peter R. Breggin wrote the book, and it was appropriately entitled Talking Backto Prozac.Its central argument is about the lack of proper testing of Prozac and the part that pharmaceutical comPanies play in tests which "Breggin..' sees Prozac as fitting should be done independently by the FDA, today's values... by creating tranquilized consumers duped by capitalist

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3rHoe,L.; 'Prozac Nation(Featue)'; Sg4!bJl!!!oca; (SePt23, 2001); P.4 3'Wurtzel, E.; op.cit.;pp.315-316 'Prozac Nation: A Memoir. (book reviews)'; National Review; (Nov 7, 1994v46 rAD) 13 Klinghoffer, D.; P75 'Prozac Nation: Young and Depressed in America.' (book reviews); Chicago Review; (Winter 3rMarlan, D,; 1996v42 ttl), p.93

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companies more concerned about their profits than their Patients' health."s It also highlights the ctnical arg:uments against Prozac's wonder status, suggesting that there is little difference between Prozac and other psychotropic drugs, such as amphetamine or cocaine.Unfortunately Breggin's book is throughout far too "[h]is arguments medical for any serious philosophical debate around Prozac as are lessbalancedthan Kramer's, and his sourcesappear lessreliable."36 The backlash against Prozaehad begun in February 1990.The Americalournal of Psychiatry suggested that "this drug be used cautiously and that the practitioner

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By should be attentive to the... emergenceof suicidal ideation..."37 Septemberof the same year, after an article about Prozac suicides had appeared in the PhiladelphiaEnquirer, the first 'Prozac Survivor' group was formed.s In addition, in L990 the NezuYork Times confirms that most law suits against Eli Lilly had to do with violent behaviour and thoughts, suicidal obsessionsand acts, and selfln Eti mutilation.3e 1991,, Lilly was compelled - by these and many other media and medical reports - to hold a hearing on the suicidal feelings allegedly caused by Prozac. These were dismissed as inconclusive and no label apart from the German label of Prozac mention this possible side effect.4 By 1992, Eli Lilly reported that around L70 legal actions had been filed against them to recover Having dismissed Wurtzel's and Breggin's books as inadequate for a serious philosophical discussionabout the use of Prozac,I do believe that Kramer's book

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35 Kegan Gardiner, J.i 'Can Ms. Prozac talk back? Feminism, drugs, and social constructionism'; &4i4b! Snrdies; (F4ll 1995v21 n3); p.505 16 ibid;. D.502 37 Teich;r, M.H. et a! Emergenceof bltense Suicidal Preoccupation During Fluoxetine Treatment; A!!c!@ foumal of Pslrchiatry; (147:2 Feb 1990);p-68 33 BreggiryP.R; op.cit.;p.8 See ! Seeibid.; p.9 4 More about the Crman label in Boseley,S.; op- c.;t.;p10

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is. The vast majority of literature points to the importance of Kramer's book in exploring the philosophical implications of Prozac.Julie Wheelwright writing a review in New Statesrnan Society,notes that "Kramer is careful to debunk I Prozac's growing mystique as a wonder drug and instead explores its ethical " conundrums." She adds that whatever its future - and Prozac is relatively newKramer sheds much-needed light on a potentially explosive ethical dilemma."al The importance of the book is noted by critics of Kramer also. Carl Elliot writes: Yet, while Kramer ultimately defendswhat he half ironically calls "cosmetic psychopharmacology," is no evangelistfor the drug. His aim is rather to he explore what the effects of hozac meanfor larger philosophicalquestionsabout the self andhow we cometo be who we are.

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For all these reasons I believe that it s necessaryto analyse Kramer's book in some detail, which is what I will do in the next chapter.

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'Happy Pills'; New Statesmandocietv; (18 March 1993);p.54 " Wheelwright, J.; " Elliot, C.; 'Listening to Prozac Oook reviews)'; Britsh Medical loumal; (June 25,1994v308 n6945);p.1724

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CHAPTER2 TO LISTENTNG DR. KRAMER

This chapter, for the reasons I have given at the end of my previous chapter, conceff$ a discussion of Kramer's influential text. My analysis, I beteve, will set a basis from which to uncover the ethical, social and cultural implications of the use of Prozac allowing me to discussthese issuesfurther in later chapters' I will begin by looking at the reasons Kramer gives for writing his book. I will then offer an outline of his biologically based theories on mood disorders, followed by an analysis of Kramer's own conclusions.I will address the implications of his highly speculative, (he would admit this himself), theories on psychiatric treatmen| self, identity and personality; and on society and culture more generally. Kramer states that . "[b]y now... eight million people have taken Prozac... My

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concem has been with a subset of these miltons: fairly healthy people who show dramatic responsesto Ptozac, people who are not so much cured of illness as "[H]ow is it that taking a capsule for transformed." This begs the question: depression can so alter a person's sense of seli?"4 Kramer also appears preoccupied with a simplistic biological materialism that is in revival in our modern culture. He worries about it in two ways. Firstly, he is uncertain that a simple biology-as-destiny theory can explain much about the self, or humans. Scondly,he is appalled to find himself falling into biological determinist traps,

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a3 Kramer, P.D.; op.ciq p, xix -- rDrd,; xlx P.

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both in everyday life and in his practice.6For this reasonhe wants to construct a biologically based, but not deterministic, theory of the self and personality, trying to merge together psychology and biology, mind and brain, character and temperament. His theory can be divided into three parts that can be encompassed into a broader theory: 'functional autonomy', the 'kindling' model and'inbom temperament'. Functional Autonomv

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Kramer begins to tell us about functional autonomy with regard to sensitivity. He describes a patien! Lucy, who had an obsessive streak when it came to boyfriends. Through psychotherapy she discovered that due to her mother's murder and her father's lack of attention in her formative years, she had now become very sensifive to rejection. "Lucy understands this sensitivity, too, as originating in the apprehension that she will lose anyone she loves."6 Kramer then hypothesises about the reason of her continued 'rejection-sensitivity' - a term coined by psychopharmacologist Donald Klein - even though she has gained insight of the reasonfor her behaviour: We all react to disappointments, even minor ones.Always there is a visceral response... will pass... for themoment aredeeplyaffected. It but we For some,this pain is worsethan othersare...They arenot depressed, they are but vulnerable...The idea underlying this diagnosis is that certain people are physiologicallywired to be deeply sensitiveto rejection...According to this theory,a varietyof personality styles... evenmentalillnesses be tracedto and can
'5 seeibid.; Introduction - pp. ix-xix 46ibd..;p.69

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peoplemake to the abnormalityin their oversensitive the complexadaptations emotionalthermostat.aT

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Rejection-sensitivityaccording to Klein could be seenin some hysteric patients. Up until then it was believed that hysterics would not resPond to medication. But Klein, in his research, found that MAOIs did in fact help some of these hysteric patients. Klein deided to descriptively categorise these medication 'hysteroid dysphoric''s Klein described these respondent hysterics with the term women as attention ht gty, who are deeply affected by rejection" and whose "abnormally painful experience to loss".aeKlein used symptoms arise from their the phrase 'functional autonomy' to describe the cause of rejection-sensitivity.

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"A causeengenders adaptiveresponse(function) that an In Klein's words. (autonomy)." Regardless its origins, of persistsafter the terminationof the cause to the vulnerability losshada life of its own in adulthood.s0 'disease' in which functional Kramer follows by describing a psychiatric autonomy had found widespread accePtance panic anxiety. This, according to Kramer, was due to the discovery of a very effective medication against anxiety, Xanax. He believes that the reason why functional autonomy found acceptance in respect with panic anxiety, but not in respect with rejection-sensitivity, is )ecause Xanax acted as a populariser for the disease.Becausedoctors 'listened'

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11bid.i pp.70-71 4 For a fuller descrjption of hysteroid dysphorics seeibid.; p.7475 f ibid.; p.75 n ibid.; pp.7516

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to the drug, they let medication tell them how humans work. Up until now there has not been a drug to do the same thing for rejection-sensitivity. He believes Prozacis that drug. Following his theoretical frame, Kramer speculates that functional autonomy of rejection-sensitivity can be expressed in different ways by different Patients: personwho evolves into a caricatureof Surely for every rejection-sensitive and who adapt copein otherways.5r femininitytheremustbe a dozen So what does functional autonomy tell us about mood disorders. Well, it suggeststhat in certain casesa mood disorder which has a psychological reason behind it may become detached from those reasons and come to have a biological life of its own. No amount of insight through psychoanalysis, therefore, can remove the symptoms: only a biological cure can. Here, Prozac can be seen as "["]set[ting] a floor["] under emotionally brittle patients"s2,thus

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enabling such patients to escape Patterns of behaviour which have been intensified by functionally autono'mous symptoms. So, Prozac can be quite happily be prescribed "in the hope of "breaking the back" of a more comPlex

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problem of behavior and self-image."s Kindling Kramer looks at what is called the 'kindling' model in order to understand how

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psychological symptoms can become detachedfrom their original psychological

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

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causes.He begins by looking at the research of Robert Post into a particular mood condition: manic depression in general, and rapid-cycling in particular. Manic depression is a condition in which a person goes from depression to mania in what is called cycles or mood swings. Rapid-cycling is when these mood swings happen more and more frequently and often may be entirely autonomous. The rapid-cyclist does not need any stimuli, like provocation or disturbance of sleep, to be induced into either a state of mania or depression. The above pattem had been discovered by Post, he then looked for a biological model that worked in a similar fashion. He found that it functioned analogously to epilepsy. Post put his analogy to the test, and put desperate patients with rapid-cycling on a drug used for conkolling epileptic seizures that chemically resembled antidepressants.The drug. in many casesworked. So the analogy is not a simple theoretical analogy but isi in fact, a working analogy. To understand this process further, Kramer looks at researih into the cellular effect of kindling. He discovers that neurones put through electrical currents change anatomically all the way to its DNA structure,' further, he found that these changes start happening even before any seizures become apparent. What Kramer is trying to demonstrate is that psychological traumas are very likely to damage our biology too. Furthermore he demonstrates that biological changesmay happen even before any serious psychological symptoms become apparent. People who show less obvious mental problems could be at risk becausthey may be at the early stagesof a kindled kind of depression. As he notes:

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is If minor depression an early stage of kindled disorder...then continued to depression, to mentionfurther stressor loss, will be dangerous mental not social health....Living with the sort of personalitystyle that leadsto repeated entailhealthrisks.5a to the failuresmay,beyond paincaused self andothers, If we now put together functional autonomy and kindled depressionwe seehow

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Kramer's theory is building up. Depressioncan be causedby trauma. Trauma, in turn, causes biological chnges in the brain. When these changes become widespread, through further trauma, the psychological symptoms, which are in fact are biological symptoms, become detached from their Psychological causes and therefore a biological cure may be required. Kramer does not rule out the usefulness of psychoanalysis. In fact he wonders whether psychoanalysis can affect the neurones, in a way similar to trauma. He notes, however, that this is pure speculationas there is virtually nd reseatchto back his statement.s Inborn Temperament Kramer begins to tell us about the importance of inborn temperament or risk factor by distinguishing between temPerament, character and personality. He suggeststhat, traditionally, ternperament has been used to describe the part of human personality that is genetically determined, given to us at birth, whilst characteris the part of personality that that comesfrom life experiencesand has the possibility to evolve and change.Personality is a mixture of botN' Kramet,

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however, thinks this distinction is inappropriate, and offers a different distinction. He notes, of to I will use "temperament" refer to the biologicalunderpinning personality, In or by or evenif biology hasbeenshaped altered circumstance chemicals. this will differ from his or her "inborn temperament sense,an adult's medicated It temperament." must - the neuralchemistrywith which we arrive in the world is environment,life events,and now by inevitably modified by development, medicine.5T discrete This provides a less deterministic theory of temperament.

Kramer is interested in the question of whether we are all bom with the same inborn temperament, and whether our'experiencesshape our biology, hence our temperament or whether we are, in fact, born with different temPeraments some of which may be more at risk to mood disorders than others. Kramer disregards the first option. He believes that the idea of a variety of inborn temperaments has been a taboo for years becauseof the way these theories have been used in the past. He also points out that the ideas behind inborn temperamentsare alien to a liberal democracy.s8Kramer does want to use biology, but not in a simple deterministic way. He wants to create a more sophisticated theory in which biology plays a role, but where it is not the only factor. Kramer points to researchdone by |erome Kagan on inhibited children' Kagan shows in his research that a small percentage of children who show signs of inhibition will remain inhibited through their entire childhood and adolescence,
n ibd.;p.749 s See ibid.;pp.16G161

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and he speculates that some will remain inhibited as adults.5eAccording to Kramer this is not such a special discovery in itself. What he finds interesting about Kagan's research is the physiological inquiry done on these inhibited children, alongside the psychological one. What Kagan discovered was that neurotransmitters and stresshormones levels in these children were analogous to that of animals under stress. Kagan tried to explain the fact that not all "true to type"o by coming children who are born inhibited do not always remain up with what is now known as the stress/risk model. Children who have an inhibited temperament will remain true to t)?e only if they are stressed by environmental trauma. ol [I]t is possibleto come to dysthymiathroughstress,temperament, both in may temperament havea parentwho A combination... child born with depressive child as well'.. be sufferedsimilarly. The child at risk will therefore a stressed The stressesthe child suffers'are encoded physiologically, as altered psychologically, characteristic as Theyarealsoencoded systems. neuotransmitter defenses,r For Kramer the stress/risk model has its advantages over either a purely biological model, or a purely psychologicalone/ becauseit "admits complexity. It

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attends to the mind, and the broader social setting, as well as to the neurons. It illuminates the stories of the patients we have met. And it corresponds to the commonsensebelief that there should be biological as well as environmental

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se Kagan suggests that between 1.5and 3 percent of the adult population will be bom inhibited and remain so as they reachadulthood.Seeibid.; pp.151-152 60 ibid.; p.151 6t ibid.; pp.192-193

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componentsto personality and that they should interact in intricate ways"Q is the Kramer acknowledges fact that Kagan'sresearch very flimsy indeed.But it Kramerlikes the idea of the stress/riskmodel,partly because fits in quite well with the rest of his theory. When we put functional autonomp kindling of depressionand stress/risk together to form a coherent theory of mental illness and personality, the following becomesapparent.A person canbe born with neurotransmitter levels of that put such a person at risk, because her biology she may be rejectionare and sensitiveto slight stresses traumas.Thesestresses psychological,but they causefurther biological changesto her neural pathway. As more and more stresses, and more and more changeshappen to her biology (kindling), her symptoms now become functionally autonomous to the causes. The have now taken a life of their own. and psychological stresses, her depressiory of may help in understandingthe original causes her depression, Psychotherapy but ultimately may be inefficient in dealing with the functionally autonomous symptomsthat have beencausedby her changinganatomy,and medicationmay Because stressmay causeour anatomy to change,what may becomenecessary. appearto be near normal behaviourand personalitymay, in fact, be an early stage of kindled depressionand therefore may require early intervention, perhapseventhrough medication.

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Further Points There are two further points that come out of this theory, which I would like to highlight. The first is that if mental disorders, personality and neurotransmitters are so closely interlinked, a medication that can help depression should also be able to transform personahfy. Kramer notes that: that What the different modelshave in commonis an understanding not only rests on[,] and is sustainedby[,] levels of depression but also temperament and neurotransmitters stresshormones.One conclusionwe might draw from this by, is understanding that medicationthat alter levels of, or transmission these Indeed,we should be surprisedif a ought to affect temperament. substances systems doesnor directly and the medicinethat resets norepinephrine serotonin alter temoerament.6s But what are the mplications that come at us when we have a drug that allows for the enhancement of human personality? Kramer raises this point by describing Prozac as a possible "steroid[s] for the business Olympics"*, raising

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all of the issues that surround human enhancement in general.

The secondpoint raised by Kramer with regard to the way that personality, the psychologyand biology interact,concerns possibility that when a society rewards a particular personality style, thosewho do not fit in that categorymay their personality style and behaviours because find themselves risk for trauma,. at are not rewarded.What this may meanis that, in fact, a societythat doesnot
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reward certain temperaments may be Part of the cause of people's mental distresses and that to cure such temperaments may be nothing better than creating conformity. Kramer rightly points out: in stylethatmight succeed a differentsocial with a personality [S]houlda person settinghave to changeher personality(by meansof drugs!) in order to find medication now risks playing a role that psychotherapy fulfilment?... Perhaps was accusedof playing in the past: it allows a personto achievehappiness norms.ut through conformityto contemporary These last two points, are central for an understanding of Ptozac's place in our society. In the next chapter, I will concentrate on the ethics that surround the issue of human enhancement,specifically Prozac as a personality enhancer.In my final chapter, I will look at the arguments that surround the idea that Prozac createsconformity.

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CHAPTER 3 PROZAC AND THE ETHICS OF ENHANCEMENT

Ir this chapter I will discuss in particular the ethical problems that surround the use of Prozac as a form of self-enhancement,and, more generally, of human enhancement through biology. To begin with, I will look at what counts as enhancement and what dops not. I will then explore the distinction between treatment and enhancement. I will also give an account about whether different means of enhancement are important for an evaluation of the ethics behind the use of Prozac. This will be followed by an examination of what Kramer terms enhancementfor "the businessOlrrmpics".tr Enhancementvs. Treafinent What should be considered as enhanceme-ntand what should not? Kramer, himsell frequently points to this distinction with regard to depression and other affective disorders. He also alludes to the issue of categorisation when discussing mental diseases: "cosmetic psychopharmacology".was It

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I wondered whetherwe werereadyfor

of my musing about whetherit was kosherto medicatea patient in the absence We depression led me to coin the phrase... may maskthe issueby defining that "If to in mood states pathology, effect saying, it responds as lessandlesssevere

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

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we of How largea sphere humanproblems it's an antidepressant, depression."... socialdecision.6? is choose defineasmedical animportant to Kramer highlights a very interesting point: the medicalisation of normal or near"culture normal human traits. He highlights this concem by imagining a future in which this biologically driven sort of self-understandingbecomeswidespread. Certain dispositions... might be seen as ailments to be pitied and, where possible,corrected."6Kramer arrives at two possibleoutcomes: (her) character traits. One is to stretchthe scopeof mentalillness10encompass Another is to say that we havefound a medicationthat can affect personality, perhaps of evenin the absence illness...Either way, we areedgingtowardwhat might be calledthe "medicalizationof personality".6e

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Here, Kramer implies that the distinction between enhancement and health is a If matter of disease. there is a diagnosablediseasethat can be identified, it should be categorisedas treatmen| otherwise it has to be enhancement.Unfortunately this category distinction has one major problem - one that Kramer has already nailed on the head - it is very easy to expand our conception of disease to include the effects of medication. If the distinction drawn from a conception of diseaseis unhelpful, we need to find one that is at least less problematic.

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One such alternative could be the model createdby Norman Daniels and James 'normal function' and according to this theory the Sabin. They call this model
n ibid.; pp.1F16 63 ibid.; p.20 " rDLO.) pp.JO-/

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role of medicine is "to maintain, restore, or compensate for the restricted opportunity and loss of function caused by disease and disability' Successful health care restores people to the range of opportunities they would have had without the pathological condition or prevents further deterioration"'ro

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According to this definition of health all humans do not have the same innate capabilities, that would be naive. Instead, they suggest that all humans have their own specific natural capabilities, possibly determined by genetic factors. The purpose of medicine therefore, is to Prevent, or treat, situations where those 'normal biologically based capabilities have been, or could be, stifled. The function' model of medicine tells us what constitutes a fair health care system: it would entail treatment but exclude enhancement' It allows us to make the distinction between enhancement and treatment by identifying the proper role of medicine. The normal function model also helps to keep the medicalisation of "people are tfuown into the world normal human traits at bay by acceptiirg that with different endowments, it can be a tool to fight medicalization; it can help us remember that there are nafural differences and characteristics that medicine ought not to be used to erase."71 So, in summary, a treatment/enhancement distinction based on whether a recognisable diagnosis can be identified is too simplistic' It does not take into account the fact that diagnoses can be created, repealed or expanded and when it comes to diseasesof the mind we do not, yet, have a sophisticated and thorough understanding of them. Daniels' model tells us what the proper role of medicine should be, that is, keeping the natural capabilities of any given person from 6eing stifled. This in tum allows us to create a distinction between enhancement
'Determining 'Medical Necessity' ir Mental Health Practce'; HastingsCe er ?Sabiru J.E.& Daniels, N.; p.10 REort (24,IJ.6,1994)t r arens. E.; 'Is BetteiAlwavs Good? The Enhancement Project'; in Parens'E. (ed.); Enlrnacing Human Traits - Ethical and Social Implicaions; (Georgetown University Press,Washington D.C,1998); p.5

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and treatment. Treatment is what medicine should be preoccupied with, anything else should be considered as superfluous and therefore categorisedas enhancement. But this model has at least one major problem. Where does preventative medicine (like vaccines) fall? Can we Put it in the category of treatment or should we call it enhancement?Perhaps the only solution is to "treatment (of disease) and create a category unto itself, so that we have enhancement" and a third "prevention (of disease)".z In this sense,treatment

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and prevention of disease'are part of the role of medicine. Anything else is enhancement. Let us now apply this version of the category distinction back onto my discussionabout Prozac.If we are to take Kramer's theory, that many personality traits are in fact s1'mptoms of a biologically based kindled depression, then, a great deal of the symptoms for which Prozacis prescribed can, in fact, be viewed as prevention. Your neural pathways may deteriorate unless you take Prozac or any other SSRI.Then there are those who tate Prozac for treatment. In this case your neural pathways are deterioratin& you needProzac to Prevent any further problems and perhaps restore the frathways to their former selves. As we can see,if we are to acceptboth Kramer's theory of affective disorders and the above distinction between treatment and enhancement, Prozac's use, in most cases, does not fall in to enhancement. But we can imagine occasions where an individual is not really at risk from deteriorating pathways'ts If this person uses Prozache is neither treating a diseasenor preventing it' According to our theory what he is doing is enhancing his personality.

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u Unless we decide that any life experienceis risky and could causeneurones to deteriorate. In that casewe would need to medicate everyone from birth as a forrn of prevention.

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Do means matter? This leads us to the issue of enhancement. Enhancement in our culture is generally viewed as a good thing, something that we should all be striving for. So, why is there a problem of enhancing our personality with medication? It appears that it must have something to do with means. ln Listening to ProzacKramer raises the point that one mean of enhancement (psychotherapy) can be viewed as better, morally and ethically, then another (psychopharmacology).He explores this avenue by looking at pharmacological Calvinism. This is "[a] general distrust of drugs used for non therapeutic 'makes you feel good, it must be morally purposes and a conviction that if a drug bad."''n He continues by pointing out that with regard to mental conditions "[d]octors tend to underprescribe... and patients tend to take less medicine than However, he is not satisfied that this form of Calvinism the doctors prescribe."% may stop people from taking Ptozac,as it is not rational: Calvinismto suggests we'cancounton our pharmacological that Pastexperience Calvinismmay be saveus from coercion.On the other hand,pharmacological flimsy protectionfrom the allure of medication.Do we feel securein countingon our irrationality- our antiscientificprejudice- to saveus from the ubiquitous for cultural oressures enhancement?76

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'The Valorization of Sadness'where Kramer adds to this argument in his essay he suggests that psychotherapy, and a drug like Prozac for example, may achieve the sameend:

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In appliedto melancholy. this account, has [P]sychotherapy beenthe technology therapies... or psychotherapy includesapproaches, suchas supportive strategic in wherethe goalis change affectivestate... And thosewho hopepsychotherapy must be comfortablewith the diminution of rnelancholy.For these succeeds reasons, I came to believe that a critical objection to cosmetic namely,medication, psychopharmacology must involve the methodof change, more than the goalsof intervention.TT Kramer, as we have seen, does raise the point about means, however, he suggests that perhaps our worry is that technology is unnatural, and that is why we object to it. He therefore dismisses it quite readily as some silly technophobia. Kramer's dismissal is challenged by Dan- Brock. He argues that there is a mistaken understanding about means. He suggests that means matter becauseon many occasionswhat is valued is the hard work needed to arrive at a Particular end. For example, in sport we appreciate sPortsPersons because of their discipline and because of all of the training they have endured. If the same end, a great sportsperson, were to be achieved by biological, quick fix means, then what llence, means do matter: we value about sport has been erased.78 required In manyvaluedhumanactivities,the meansof acquiringthe capacities of for the activity areasmuchvaluedand admiredasthe performance the activity.
t? Knmer, P.D.; "The Valorization of Sadness';Hastings Center RePort; (March 2000,v30, i2); P.13 73 Brock D.W.; 'Enhancement of Human Function: SomeDistinctions for Policymakers'; in Palens, E. (editor);op.cit.;p.58

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They are part of the definition of the activity, and transformingthem transforms, andcandevalue. activitvitself.Te the

"that different means A second argument about means is, as Parens suggests, " "w sometimes work on... different objects." He highlights this by giving an example using the classroom as the location. In this example the end is to raise students' performance, and the means are, firstly reduction of class size, or secondly Ritalin - a medication. So, the means are different but the end is the same. Parens here argues that the two different means are not affecting the same object at all. Reduction of class size "changes the child's environment", whilst

the Ritalin "changesthe child's bology."81So ends are really not the sameafter all. They are the same in respect of only one measure. An example to clarify this point can be viewed as follows: Both Prozac and prayer may raise serotonin in the brain. But the ends of using Prozaeand of praying are not the same at all; all that is the same is the level of serotonin.e This demonstrates that psychotherapy and pharmacology may aPPearto achieve the same end enhancement of personality, but the end is not the same at all. The former affects self-understanding and the latter affects biology. Prozac may diminish the value of the new personality. You achieved it but you really have not understood how or why you have this new personality, except that you have changed your biology. From what we have seen above, I think that Kramer is mistaken in thinking that our distrust of Prozac is simply an irrational technophobia. There are real issues suggesting that the means used to achieve something have a real impact on the value that we humans give to that
8 ibid.; p.58 e Parens, op.cit.;p.12 E.; 8ribid.; pp.12-13 3' seeParens,E,;op.cit. p.14

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something. I would see the role of medication with regard to mental conditions to be a last resort to be tried only when psychotherapy fails. The Business Olympics Even though Kramer does not fully understand the importance of means when it comes to enhancement, he is aware of the problems surrounding the uses of Prozac for enhancement with regard to its uses in our competitive business world. He asks:

How shall we respond to the complaint that a particular executive lacks decisiveness vigor?By prescribing and Prozac?83 Later Kramer argues: view of the useof redication increase to mentalagility...helped This nightmare form the basis for my coining the term-"cosmeticpsychopharmacology" and speculatingabout the use of antidepressants "steroids for the business as Olympics."&

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\ Ihat he appears to be worried about are the same issues that surround the use of steroids in sporting events,namely, the idea of social coercion.Should steroids be allowed in competitions? Those who take steroids have an unfair advantage over other sportspersons who for whatever reason, money or ethical choices for example,choosenot to use steroids.The steroid free competitors would never be a6le to achieve the same level of comDetition as those who do. As the amount of

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more sportspersonswould feel people who use steroids in competition increases, compelled to take them, otherwise they would never have a chance to achieve "free choice under pressure"s in which free their goal. This is what Kramer calls choice is diminished. He suggests that the same could happen with Prozac:

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In the science-fictionhorror-storyversionof interplay of drug and culture, a boss says,"Why sucha long face?Can't you take a Moodstim beforework?"...Only Thereis is of slightly lessnightmarish the prospect free choiceunderpressure. hyperthymicwaiting to do your job, so, if you want to alwaysa Prozac-taking you had bettertake Prozac,too. Either way, a sociallydesirable drug compete, that they it tums from boon to banebecause subjectshealthy peopleto demands chemicallyalter their temperament.s6 According to Erik Parens enhancement technologies could widen the gap between the rich and the poor. He sug$ests that in our capitalist and competitive society these technologies would not be available to everyone (becauseof cost reasons).Furthermore, universal usage of these technologies would be a selfdefeating act. So, enhancement technologies between the have and the have nots."87 Here, I tend to agree with Parens. Il Prozac were to be available to anyone who asked and payed, without any serious regulations from the govemment, people who cannot afford it, may be at risk of being left behind in our competitive business world. Because of all the issues highlighted in this chapter, I feel "have the potential to widen the gap

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inclined to say that Prozac should reallnremain a medication which is prescribed to people who need it, not sold to people who want it. As we have seen there are many ethical issues surrounding the use of Prozac for enhancement. However, I think there is another issue which is even more important when discussing cures for minor mental conditions. Are these conditions, which are becoming more widespread, really a deviation from the norm? Alternatively, are they just reasonable responses to a society in which normal human activities have become alienated from what it is to be human? Is Prozac really tending to the causesof this widespread malaise? Or, is it only curing the symptoms? I shall be examining these questions in my final chapter.

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CHAPTER4 PROZAC.ALIENATION AND SOCIETY

'mental In this final chapter, I would like to explore the idea that minor forms of illness', such as anxiety and minor depression, are in fact quite reasonable responses to the human situation in our present culture. As in the previous chapter, I will explore the kinds of issuesthat Kramer raises on this subject and use the concept of Prozac forces the 'alienation' to illustrate this. SubsequentlyI will suggest that 'user' to conform to a personality style that is considered

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desirable and normal in our society. I will follow this by arguing that alienation (and minor forms of mental illnes) is a reasorrableresPonse to our contemporary society. I will conclude the chapter by exploring the idea that 'curing' the

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individual is, in fact, an unreasonable response and that the reasonable one would be to 'cure' society and our culture. Kramer is aware that cultural norru.are important when defining mental illness. Even his biologically based theory doesnot exclude the impact of culture, in fact, he attempts to incorporate it: may bespeak very different,less a To be neat in a culturethat prizesneatness of aberrantbiological statethan maintenance the samebehavior in a culture that has adopted different values... whether a particular behavioral style like '88 pgrfectionismis deviantis very much a matterof cultural expectations..

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33 1994,P.39 KramerP.D.;LillcEb&lqPlgzag; ftondon, FourthEstate,

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Kramer looks at the work of Richard Schwartz, a psychiatrist at Mclean hospital in Harvard. Schwartz calls Prozaca mood brightener. Schwartz "fears that mood brighteners have the capacity to reinforce oppressivecultural expectations."se He uses an example about prolonged bereavement. Psychiatrists have reported when prescribing medication to patients one year after a death. Schwartz success contrasts one year of mourning to the five years of formal grieving that takes place in rural Greece. He suggests that "[w]hen doctors pharmacologically mitigate the pain of bereavement after one year/ they may be using medication to reinforce cultural norms and encourage conformity. The medication seems to justify the standard that is in place by labelling those who deviate from a cultural norm as ill and then "curing" them."{

Kramer does not argue against Schwartz on this point, but objects to the term 'mood brighteners' as a correct description or Prozac.Prozacdoes not brighten moods in a direct manner/ as it does not confer happiness or pleasure in itself, in the taking of it, unlike let's say marijuana or cocaine. What Prozac does is change personality in such a way that a person is able to experience pleasurable activifies. So for Kramer a drug that is able to change personalities is even more worrying in respect of cultural expectation. According to Kramer Prozac "highlights our cultwe's preferencefor certain personality types."elHe takes, as an example, the traits that are valued in women today and suggests that they are not the same as the personality styles that were seen as morally appropriate in the Victorian period. In fact, many of Victorian character traits are now seenas 'deviant' and problematic for a woman's mental wellbeing. He continues by
3' Kramer, P.D.;op.cit.ip,254 q ibid.; p.254 e1ibid.p.277

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suggesting that Prozac helps in sustaining the social conformity that attends to ""masculine" capitalists values".e2 appears to be torn between two sides of He "feminist drugs, in that they the debate. One which seesdrugs like Prozac as a free women from inhibiting consequencesof trauma." On the other hand, " Kramer seesProzacas curing women of traditional, passivefeminine traits... [] reinforc[ing] the cultural expectationsof a particular exigent form of economic organization."e3 Kramer continues to investigate this side of Prozac by putting forward Marx's analogy about opium. He suggeststhat opium can be seen as an instrument of conformity, by deadening mind and bodp thus removing any willingness to "Prozac suPPorts social stasis by allowing rebel.q He continues by saying t}:rat people to move toward a cultural ideal - the flexible, contented, energetic, pleasure-driven consumer. In the popular imagination, Prozac can serve as a modern opiate, seducing the citizenry into political conformity."esHe concludes by saying that psychotherapy really is not any different from Prozac in this matter: to was Early this century,psychotherapy criticizedfor inducing adaptation the dominant culture; even if it contained a radical critique of that culture, applieswell to psychotherapy ultimatelyan agentof stasis.This argument was Prozac,%

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The concept of alienation suPPortsthis idea of cultural expectation. Feelings of anxiety, melancholy and other minor forms of 'mental illness' are normal

symptoms of an alienated self in an alienating society. Kramer is aware of this argument and he uses the writings of Walker Percy to higtrlight them: Percy favors Erich Fromm's formulation that anxiety amongthe affluent... is the reactionto the sign and symptomof alienationfrom the self, an appropriate to Anxiety is "a summon like sand.'. feelingthat life runsthroughhands accurate at existence, be heeded anycost."e? to authentic Kramer dismisses Percy's claims quite readily by suggesting that, in act, or "the drug seems to aid rather than users of Prozac who are not mentally ill inhibit the struggle to locate the self"es Alienation Originally, alienation was a term that related directly to mental health. The word has its origins in the Latin languages where it denoted psychosis, "the

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thoroughly alienated person."e However, the term was given a different meaning by Hegel and then later by Marx. For both Marx and Hegel "the concept

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on of alienation is based on the distinction between existenceand essence, the that in reality he is not fact that man's existenceis alienated from his essence,

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q bid.; pp.277-278. % ibid.;p.278 t Fromm, E.; The SaneSociew; (London, Routledge & Kegan Paul LTD, 1956);p.121'

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what he potentially is.. . that he is not what he ought to be,and that he ought to bethat whichhecouldbe."l According to Marx the nature of alienation is connected to the way we, humans, relate to our work. The unhappy consciousnessarises when production and consumption become sePatateProcesses/as in our own consumer culture. Under capitalist social relations, people do not produce directly for their own needs. Having been deprived, by .various social developments, of ownership of, or control over, the means of production, they must submit to wage-labour in order to gain the money to purchase consumption goods on market' [T]he worker is relatedfo theproduct of his labor as to an alen object... The an not alienationof the workerin his productmeans only that his laborbecomes to but a object,assumes external existeirce, that it standsopposed him as an power.The life which he has given to the object setsitself against autonomous him as an alien hostile force.1o1 Marx believes that the processes of labour in capitalist society dehumanises (wo)man and brings her back down to her animal self: [Man (the worker) feels himself to be freely active only in his animal functions or eating,drinking and procreating, at most alsoin his dwelling and in personal

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r@ p.47 UngarPublishingCo.,NY, 1969); Fromm,E.;[ag3..]eqleeplgl!!a4; (Frederick totMarx,K.; Economic philosoPh T.B.;(VariousEdition.);in hanslatedby Bottomore, and brd.; pp.95-96

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adomment- while in his humanfunctionshe is reducedto an animal' The animal animal.1o2 becomes humanandthe humanbecomes This idea of man as alienated from his labour and his consumptiory leads to (wo)man being alienated from herself and from other (wo)men, she has no control over her future and her acfions in the sense that the need for subsistence rules her and forces her into a kind of work that is uncreative and unrewarding' Fromm expanded Marx's concept of alienation and related it back on to the concept of sanity. In The SaneSociety,he explores the way that alienation works in modern capitalism. Fromm suggests that contracted labour demeans man becauseman is for sale,as a prostitute would be. of The senseof self stemsfrom the experience myself as the subjectof rry my lzy experiences, thought,my feehng,my_decision. judgement,my action.Il is presupposes my experience my own, andnot an alienatedone. Thingshave that thingscanhaveno self.r03 no self andmenwho havebecome His only value comes from the external, man-rde economic marke! and he has no control over it. He is a successif his traits and skills are valued; he is a failure if his traits and skill are of no use to the 'market'. As Fromm suggests,however,

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

t ibd..;p.99 t@ Fromm, E.; The SaneSocietv; oP.cit.;

P.143

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personalitywho is for salemustlose a gooddeal of the sense of [t]he alienated He of dignity which is so characteristic manevenin his primitive cultures. must entity.lo4 of losealmostall sense self,of himselfasa uniqueandinduplicable Fromm continues by suggesting that for the alienated man remaining sane can "fitting into one of the current pattems"10s or only occur by external validation by conformity. Man loses himself in his routine, in his need for survival, in his " alienated work and alienated labour, and by doing so, he rePresses the awareness By problems humanexistence."lM doing so, he does not fulfil himself. of the basic of Becausehe does not fulfil himself he is not sane becausehe is not true to his nature. "[M]an can fulfill himself only if he remains in touch with the

fundamental facts of his existence...If he is completely enmeshedin the routine touch with the grasp of himself and the and in the artefacts of life... he looses. world."lv Therefore, capitalist culture iobs man of his humanity if he conforms to the conceptof man as an object,a living machine,that can be bought and sold, that works to live and lives to work. Carl Elliot, a critic of Prozac and of Kramer, takes a more subtle approach. He creates distinctions between different forms of alienation; personal alienation, cultural alienation and existential alienation. Personal alienation is described as "a sense that you don't conform with social expectations of someone in your This kind of alienation happens when particular circumstances."los "a person's

tu ibid.; p.142 '05 ibid.; ;.143 'tr ibid.; ;.144 t1 ibid;.lM toe Elit, C.; 'Pursued by Happiness and Beaten Senseless'; IEl[lSlgcdlcLBePpIU

(March 2000v30 i2 ); P.7

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identity is in question or under reevaluation."tt It does not Pose too many problems, you are unhappy with your life, your circle of friends, your job, so you make a change. Cultural alienation involves much deeper emotions. A person can feel alienated "You step outside of your own socialiazation'' ' and look at from his own culture. your own culfure from a stand point of detachment./l1o This kind of alienation in western society shows itself mainly in the form of a person's discovery that what he has been told all of his life - that he is an individual, that he is unique - is in fact false. "[T]here is something terrifying about looking deep inside and discovering that you're no different from the guy next door. That your life is just an averagelife, and your story so ordinary it is not even worth telling. ' ' [This] is enough to make you think about an antidepressant."llt The last form of alienation that Elliot describesis existential alienation. This takes "The result is not just the feeling the form of questioning the point of life in itself. that you are ill-suited for your own particular form of life" ' rather, it is a calling into question of the foundations of any form of life...It is a sensethat there is no rh)rme and reason to your form of life other than the exigencies of biology and history, that the big picture is really nothing more than a big pictute."llz

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

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Conformity With regard to Kramer, Fromm and Elliot, there is a real concern about the way that society tries to make people conform into the cultural norms of a given society. This concern stretches from the means employed to achieve it tfuough to the idea of normailisation altogether. Here, I will need to look, albeit briefln at 'mental illness' could the idea that we have to be aware that what is called iust be a simple deviation from the norm. R.D. Laing, famous for his books on schizophrenia and madness, would agree with Fromm and Marx about the idea that we are all alienated. He points out in that "The condition of alienation, of being asleep, of t}nePolitics of Experience being unconscious, of being out of one's mind, is the condition of the normal nan./'113 later suggeststhat in fact madnessis just one of many expressionsof He alienation. And that those who express their alienation in a way that is apart from the rest are to be viewed as deviant, by society at large, and perhaps made to conform: to that arerelativelystrange statistically'normal' Thereare forms of alienation fomrs of alienation.The 'normally' alienatedperson,by reasonof the fact that he actsmore or lesslike everyoneelse,is takento be sane.Other forms of alienation that are out of step with the prevailing stateof alienationare those that are labelled the "normal"majorityasbador mad.lra by

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In the same vein, Fromm raises the point that just becausesomething is normal in a given society, it does not really imply that something should be sane or reasonable on this merit alone: on validationas suchhas no bearingwhatsoevet reasonor mental Consensual "follie deux" thereis a health.Justasthereis a "follie millions."The fact that

millions of peoplesharethe samevices doesnot makethesevices vifues, the fact that they shareso many errors doesnot make the errors to be truths, and the fact that millions of peoplesharethe sameforms of mental pathology doesnot make peoplesane.115 these Here we can start to understand mental illness in a new way. If you think that our way of living is incompatible with how humans should be, then you may be prepared to remove the 'mad' or 'mentally ill' labet, from people who are

considered to be mad or mentally ill. The label, in fac! may now apply to those who conform to that way of living. This point is well highlighted by Laing once more:

everythingis equivocal. startingpoint of our pseudo-sanity, From the alienated 'true' madness..I,et no one ' is Our sanityis not 'true' sanity.Their madness not 'true' madness anymorethan we aretruly sane'116 that suppose we meet

and that sadness feelingsof insecurity,like thosefeelingsthat Fromm suggests someof Kramer's patients reported, are, in fact, normal feelings natural to man.
"[b]ecause of the very conditions of our Man has no reason to feel secure
rr5Fromm, E.; The SaneSocielv: oP.cit.,PP.14-15 " Laing, R.D.;op.cit.;p.118

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Ottr lives are rarely fully existence,we cannot feel secure about anythin 9."117 controlled by us, as the possibility of accident or death remains prevalen! there is never any certainty about the decisions that we make, and we hardly make such decisions with all the information necessary.For Fromm, and I tend to agree here, alienated man attemPts to feel secure by conforrning, by not standing out. rstead of curing it, this insecurify should be accepted: The psychic task which a personcan and must set for himself, is not to .feel secure,but to be able to tolerateinsecurity,withoutpanic and undue fear.rr8 Anxiety and feeling of insecurity, as well as sadness,are reasonable resPorsesto our capitalist society and therefore such states should be valued as part of our humanity. What Prozac does is to remove such insecurities. Prozac, therefore, could be the new opiate of the masses,giving men and women a false senseof security, that leads to conformity of personalities and to a static society. I-r conclusion I would argue that 'alienation' shows us what we are really doing

when we prescribe Prozac for these,minor conditions. Taking Prozac attends to the symptoms and the symptoms alone. Therefore/ we are really missing the point, and at least part of the causes,of these conditions. We are not curing these conditions at all, we are just transforming people to fit into a society that creates the conditions of alienation. I suggestthat this situation is deeply problematic. It is humans who create society and culture. But when this culture seemsto fail us --and the figures for minor depression and other minor conditions are on the rise - what we do not do is change our society, which is maladjusted to our human
r17 Fromm, E.; The SaneSocielv; oP.cit.;PP'196 t13 ibid.; p.196

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needs. Instead we suggest that it is us humans that should change to fit in with a unreasonable sociefy. This appears to be higty illogical.

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CONCLUSION
In my first chapter I investigated the rise of Prozac by looking at the basics of neurochemistry, and by looking at how it was discovered. I followed this by looking at some of the statistics on Prozac. I found that a large amount of people have been prescribed this medication' To understand the reason behind the widespread usage of this medication I decided look at how the media had portrayed it in the years following its licence. An immediate hype was created of which Kramer was deemed of the main culprits. Here I also discussed the backlash against Prozac.I decided that the best course of action was to outline some of Kramer's theories in the second chapter, as his book was deemed useful in engendering philosophical debate.Here I discuss the three main parts of his book: 'functional autonomy', the 'kindling' model, and the idea of inborn'

temperaments. When analysing these points, I discovered that Kramer had created a theory of depression and personality that was based in biologyKramer's theory, though, was not a simplistic biological determinist theory. Instead, it was a sophisticated one in which he weaved together biology and psychiatry, mind and body, nature and nurture. In this chapter I also began to highlight some of the problems that surround the use olPtozac, which I discuss in more detail in the following chapters. Chapter 3 is an exploration of the ethical issues that come up when suggesting that Prozac be used as a personality enhancer. Here I begin by defining what constitutes as enhancement. I found that we have to make a clear distinction between treatrnent and prevention of disease,and enhancement. IL this chapter I :'

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also discuss the importance of means when we decide to enhance ourselves. Here I found that what we value in a lot of human activities is not simply the goal, but also the process used to arrive at the goal. Quick fix methods and shortcuts can devalue an activity, as they change the activity itself. I continue the chapter by highlighting ethical problems with regard to social coercion and unfairness.In my final chapter I continue to look at social coercion.Here I point 'mental' conditions are in fact a result of alienation. out that perhaps minor Alienation is a widespread condition caused by the way the western world defines the self in relation to worlg profit and competition. I then go on to say that our culture alienates us in such a way that we feel compelled to conform and to make others conform by adjusting our personalities to one that is simply more counon. Here I take the view that perhaps these mental conditions are iust variations of personalities.Thesepersonality styles are at the least as normal as any other and at the most much more reasonable.They take into account the realities of human life. In my opinion Kramer creates a thory of affective disorders that takes into account all aspects.He uses nature and nurture together. His theory may not yet 'on to something'. I would argue that his be accurate enough, but I think he is book is good in raising some of the issuesthat are problematic, when we accept this theory. Unfortunately, Kramer far too often dismisses his own concerns far too readily, especially with regards to means.When it comes to enhancementI believe that we should avoid at all costs shortcuts to happiness. That happiness would not be worth too much.

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Here I want to point out that I do think that Prozac should be available to people that really need help. I do also believe that who need it, people in desperatecases other methods should be employed first, like psychotherapy. However, I do think that we as a society, should be looking in much more detail to the real

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culture. causesof this widespread malaise,our ozun

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BIBLOGRAPHY
Books No Know Author; Collins Atlas of the World; (Harper Collins Publisher, London, \999) Breggin P.R. & Breggin G.R.;Talking Back to Prozac;(St Martin's paperbacks, New York 1995) Callinicos,A.; The RevolutionarlzIdeas of Karl Marx; (Bookmarks,Londoru 1996) Eagleton,T.; Marx and Freedom;(Phoenil London, 1998) Fieve,R.; Prozag (Thorsons,London, 1995) Fromm, E.; The SaneSociety;(Routledge& Kegan Paul LTD., London, 1956) Fromm, E.; Marx's Concept of Man; (FrederickUngar Publishling Co., NY, 1969) Healy, D.; fu.Antidepressaa!-E&t (Harvard University Press, London, 1999) Kramer, P.D.;Listening to Prozac;(Fourth Estate,London, 1994) Laing, R.D.; The Politics of Experienceand the Bird of Paradise;(Penguin, Middlesex, 1967) Marx, K.; Economic and PilosophicalManuscriPts;translatedby Bottomore,T.B.i (various editions) McKenzie, K.; The British Medical Assoeiation- Understanding Depression; (Family Doctor Publications,Banbury, 1.990) (ed.); Parens.E. (GeorgetownUniversity Press,Washington D .C.,1998)

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(John Chichester,t99T) Wiley & Sons, E.; Shorter, A History of Psychia4v; 1998) Cambridge, D.; Cultureand Modemitv; (PolityPress, Slater, Consumer

srahl, s.M.;
(CUP,Cambridge,2000 Storey,J.;Cultural Theory and PoPularCulture - An Introduction; (EUP, Edinburgh, 1996) Londoru1980) and Culture;(Verso, with Materialism Williams,R.;Problems and faber, ;(faber the Wolpert,L.; MalignantSadness- anatomyof dePression 2001.) Londoru memoir;(Quartet in and Nation-)roung dePressed america-a Wurtzell,E.;Prozac Books, London,1996)

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(editorial); Encapsulated' Lancet; No Known Author; 'Artifical Paradise (9/ 4/ 199 343n89 ; p.865f 4v f 02) 'Theysaidit was safe';Guardian;(30/10/1999);p.L0 Bossely, S.; A.; American: Depression, Identity and Selfhood'; Twentieth Cheever, 'Prozac (Fall2000. v.46.i.l3\ o.346f CenturvLiterature; f 'TheCultureof Prozac'; (2/7 /I99a);p.36 Cowley,G et al; Newsweek; (26/3/1990);p.aLff Newsweek; Cowley,G et al; 'ThePromise Prozac'; of R.; Nation;(08/11./1993;voL257,n.15) p.536 Cushman, 'ListeningTo Prozac'; Desrazia,D.:'Prozac, Enhancement SelfCreation'; and HastineCenterReport; (March2000, v.30,i.2);p.34ff 'Passion, Edwards, Activity and the Careof the Self';HastingCenterReport; J.C.; (March2000, .30,i.2);p.3If v 'Listeningto Prozac (reviews)'; Elliot,C.; BritishMedicalTournal; p.1724r . Q5/ 6/ 1994v308n6945); 'Pursued Happiness Beaten Elliot, C.; and Senseless'; HastinssCenterReport, bv (March2000v30; p.7f i2) (12/10/1996, BritishMedicalTournal; Elliot, C.; 'TheElvis of Pharmaceuticals'; v.313, n.7062); p.950 Findr,J.;'Lastof the million dollar drugs';Guardian;(31./1/1998);p.28 (02 Heller,Z.;'Health:Blunderor Wonderbru g?'; Guardan: / 01/ 1996); p.8 'GoodScience GoodBusiness?'; HastingCenterReport;(March2000 HealyD.; or v30i2),p.Dr. Healy,D.; 'HaveDrug Companies Hyped Social Anxiety Disorderto Increase 2001., vL75,6);p.364f Sales?'; Westemloumal of Medicine;(December (23 Hoe,L.; 'Prozac Nation (feature)'; SundayTimes; /9 /200L);p.a (15 O.;'The Happiness Gap';Guardian; / 0L/ I99D; p.2 James, (02/02/1997);p.5 O.;'Serotonin, Chemical a FeelGoodFactor'; Observer; James, 'Can Ms Prozactalk back?- Feminism,drugs and social KeganGardiner,J.; (Fall1995v21n3); FeministStudies; p.505ff constructionism'; HedonismVs Pharmacological Klerman,G.;'Psychotropic Calvinism';Hasting (7972,Yo1.2 o.7ff Report; n.4\: Center Klinghoffer, D.;'Prozac Nation - A Memoir (bookreviews)'; Ndonel-Rsyieur (Nov Z 199 46n21)p.75ff 4v ; Kramer,P.D.;'TheNew You'; Psychiatric Times;(March1990); pp.45-a6 Kramer,P.D.;'TheValorizationof Sadness'; HastinsCenterReport;(March2000 v30 2);p.L3ff (I4/03/I994;vo1.210 Kramer,P.D.;et al;'Is EverybodyHappy?';New Republic; n.Ll);p.4

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Marlan, D.; 'ProzacNation: Young and Depressedin America.(book review)'; p.93 Chicargo Review; (Winter 1996v42n1\; 'The Discovery of Fluoxetine'; PharmaceuticalNews; (1994, Molloy, B.B.et al; v.l,n.2);p.6tf Rothman, DJ.; Listening to Prozac',New Republic; (14/2/1994,v210n7);p.34ff Rundle, G.; 'This is the Night, Rememberedif Outlived. (Depression)';Arcna ll4asazirre: (April 2000);p.28ff 'Determining 'Medical Necessity' in Mental Health SabiruJ.E. & Daniels,N.; Practice'; The Hastings Center Report, (3/ 2000v30r2);p.10 TeicherM.H.et al; 'Emergance of Intense Suicidal Preoccupation During FloxetineTreatrnent';American Toumalof Psychiatry,(February1990;L47:2); p.65 (18/ 3/ 1993);p.I72a Wheelwright, f .;'Happy Pills', @ Internet Eli-Lilly - url: http/ /www.prozac.com National Mental Health Institute - url: http: / /www.nmhi.com

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