These letters, between two Members of the President's
Council on Bioethics, were discussed at the Council's June
2003 meeting. They were made public to aid discussion, and do
not represent the official views of the Council or of the United States
I. Paul McHugh to Leon Kass—May 27, 2003
You asked me to summarize my thoughts about the progressive medicalization
of human mental life—an issue that the Council has considered
in discussing “therapeutics” versus “enhancements”
at several of its meetings, and about which both you and Michael
Sandel have written enlighteningly.
The prime concern from my point of view is the insidious transition
of pharmacological and other bio-scientific discoveries for treating
mental disorders such as depression, attention deficit, chronic
fatigue into means of enhancing personal skills and faculties on
demand. We are witnessing a kind of “off-label” usage
of medications for cosmetic, commercially driven, even fashionable
purposes, rather than for disorder-directed, reparative ones.
This is a vexed problem with regard to psychotropic agents in particular
because psychotropic medications lack the biological specificities
that inform most medical treatments—say in cardiology or infectious
disease—and for the most part keep those treatments within
At the risk of being simple-minded, let me develop that point—placing
it into a historic perspective. The major advance in modern medicine—occurring
in the late 19th century—was the abandonment of “symptomatic”
therapeutics (treating symptoms such as fever, rash and the like
directly) for “rational” therapeutics (treating the
causes of symptoms such as infections or vascular insufficiencies).
The treatment of gangrene exemplifies the issue. In mid-19th century,
gangrene was separated into “wet” and “dry”
forms. If wet, you dried it; if dry, you wet it. With both, you
prayed. Now we differentiate gangrene into that due to infection,
infarction, neoplasia and the like, and, accordingly, direct a rational
treatment against it (antibiotics for infections, re-vascularization
for infarction, chemotherapy/radiation for neoplasia).
We have not abandoned symptomatic treatments. We use aspirin for
pain and fever relief today. But the rule does hold that symptomatic
treatments are problematic if they are the mainstay of therapeutics.
Their effects are unpredictable, and they tend to be overused.
Most psychotropic medicines are “symptomatic”—discovered
by accident, indefinite in their mechanisms of action, and indeed
titled by the symptoms they target as with antidepressants, anxiolytics,
mood-stabilizers and the like. We psychiatrists are pleased to have
these medications available as they have brought us great power.
But an expanding usage against new targets was almost predictable
because of their symptomatic character and because the present day
classificatory approach to psychiatry—the DSM III and IV method—is
a symptom-based nomenclature. Symptomatic treatments for symptom-defined
conditions will expand and tend to push other treatment approaches
and ways of looking at mental travails aside. Hence the medicalization
of human mental life that is the concern for us today.
What's the answer? Obviously, if we could identify at their roots
in the brain all aspects of mental travail, we might know just where
a rational practice might find its targets and its limits as we
do in other organ-based specialties in medicine such as cardiology.
But we cannot translate mind events into brain events in either
health or disease. Many psychiatrists hold that the symptom-criteria
definitions of mental disorder employed by DSM-IV is the best we
can expect until the mind/brain problem is solved and are prepared
to accept the expansion of treatments without much limit, given
that we need to learn more about what we can do for people.
I have been long dissatisfied with this stance because similar mental
symptoms are not the same in either nature or cause and deserve
careful thought over their therapies. Mourning and melancholia are
not the same, although both are forms of depression. Youthful high
spirits and attention deficit disorder are not the same, even though
both bring about distraction from schoolwork. Stage fright and panic
disorder are not the same, although both are anxieties and lead
to conduct diffidence. Borderline personality and bipolar affective
disorder are not the same, even though both display wide ranges
of emotional expression and provoke interpersonal difficulties.
The efforts to distinguish these conditions from one another in
DSM-IV have not held back the expansion of psychotropic treatment
of their common symptoms.
I always struggle against psychiatry's imperialist tendencies to
bring more and more of ordinary human living under its jurisdiction
and its control. Previously I fought against the assumptions about
human nature that drove Freudians. Now I argue against the imperialism
of psychopharmacology that would promote a pill for every vexation
and justify the practice by calling the vexation a “mental
Essentially my concerns over the Freudians and the psychopharmacologists
are the same. I do not deny that with some patients a Freudian conflict
might be the problem or that with some patients psychotropic medication
is effective. I use both forms of therapy every day. What I object
to is the assumption that, at root, all mental disorders are the
same—either some sexual conflict open to psychoanalysis or
some twisted neuron suitable for psychopharmacologic correction.
With neither do I see a way of keeping practices within bounds once
their assumptive premises are accepted.
I have been arguing that recognizing a structure of psychiatry that
divides patients and their problems into four distinct “reference
classes” will help limit the medicalization of mental life.
Each class is made up of several different mental disorders that
share a common identifiable basic nature. These reference classes
are (1) the class of conditions encompassing the diseases of the
brain such as dementia, manic-depression, schizophrenia; (2) the
class of conditions encompassing destructive behaviors where choices
play a role such as sexual paraphilias and drug addictions; (3)
the class of conditions encompassing the problematic dispositions
such as the mentally subnormal, the histrionic, and the immature
who face emotional problems because of their dispositional vulnerabilities;
and (4) the class of conditions derived from troubled life experiences,
social maladjustments, and disruptive assumptions such as grief,
jealousy, homesickness and demoralization.
These four reference classes (Diseases, Behaviors, Dimensions, and
Life Stories) embrace all the conditions psychiatrists encounter
and are described by symptoms alone in DSM-IV. These classes define
how psychiatrists develop their opinions and identify what they
can say with confidence.
But the concept of reference classes (along with their natural distinctions
from one another) keeps us from floundering over symptoms and complaints
that all psychiatric patients share. With each reference class the
assumptions about appropriate treatments can be analyzed and the
expansion of treatments beyond the class identified and debated.
This permits an honest conversation with patients as to what are
truly beneficial treatments and what may cheat them. The aim is
to identify both the place and the limits of psychiatric expertise
and restrict the medical treatment of human mental life to those
Psychiatrists, after all, work with a selected sample of mankind—patients.
Therefore, they are not expert on every aspect of human nature.
And, they should be the first to make that clear by defining just
what they mean by disorders and do so in ways that are more explicit
than simply composing a dictionary that lists symptoms and complaints.
Treatments that act on people without disorders, but with distinctions
in their nature, may well impoverish our world and distract us from
appreciating the diversities in it.
Leon, as I said, though, this is just a beginning of a conversation
that needs to continue.
To be continued,
II. Leon Kass to Paul McHugh—May 29, 2003
I have read your letter several times. I appreciate its contents
and the effort that produced it. Here is my not fully considered
response, to keep the ball rolling.
First, let me set down the context for this exchange and discussion.
The “beyond therapy” project has several times touched
on the matter of the creeping “medicalization” of life—not
only of mental life through the offices of psychiatry, but also
of procreation in screening of fetuses and embryos, of the life
cycle in dealing with aging or memory, or of athletic and other
performances through enhancement technologies. We have so far not
made this subject thematic. To do so, we should ask: what IS medicalization—as
an idea, as a practice, as social/institutional attitudes and arrangements?
Is it really on the rise? If so, what is responsible for it? What
are its consequences? Why should we care? What, if anything, could/should
be done about it—or some aspects of it? Formulated this way,
it is a very big topic, certainly too big for the Council right
now, and certainly too big for one session at one meeting. But it
is one of the big themes of what ought to concern us.
Second, your letter stays (both for better and for worse) narrowly
within the confines of psychiatry and its contributions to the medicalization
of mental life. And within that delimited domain, the main emphasis
is on diagnostic uncertainty and confusion. Given the overall and
somewhat grandiose view of the topic, I find what you have done
good and useful, but limited. Even keeping within the context you
choose, you do not indicate what the consequences of medicalization
are or why we should be bothered by it (not that you had to take
More important—and some substantive points now—you
treat the drugs as the driving force in the new medicalization of
mental life, rather than the reconceptualization of all behavior
on the biological model (a change of thinking about the mind that,
to be sure, the drugs contribute to, but so does it contribute to
the turn to drugs). As my next point will try to make clear, a fuller
look at what medicalization IS might fruitfully enrich your presentation,
even staying within the confines of psychiatry (which after all
helped—or tried—to medicalize alcoholism, stress, anxiety,
guilt, narcissism, sexual orientation, etc., even in the absence
of psychotropic drugs). Moreover, and more serious, it is not YET
clear to me from what you have said how your wonderful new scheme
with reference classes (which, as I have told you, I like greatly)
will address the problem at hand. After all, people in all four
classes will still come to the DOCTOR rather than to their priest,
and they will expect cures— not absolution or encouragement
for reform or education. One might even suggest that your vastly
improved scheme could even encourage more people to look to medical
psychiatry for remedies, given that behaviors, dispositions, and
life experiences are now put in DIAGNOSTIC (i.e., medical) categories.
Now I suspect that I am missing something here, and that it is I
and not you who is confused. But the letter as written does not
give help on this point.
Third, turning from your letter back to the broader subject, a
few words on medicalization itself, written now off the top of my
head, and done mainly to force me to clarify my own mind here. What
do I think I mean when I use this bit of unfortunate jargon? Something
like this: Medicalization is, in the first instance, a way of thinking
and conceiving, that then guides ways of acting and organizing social
institutions. Medicalization is the tendency to CONCEIVE an activity,
phenomenon, condition, behavior, etc., as a disease or disorder
or an affliction that should be regarded as a disease or disorder,
to wit: (1) people SUFFER it (the essence of patient-hood) or it
befalls them; they are victims of it, not causes, neither are they
responsible for it; (2) the causes are PHYSICAL or SOMATIC, not
“mental” or “spiritual” or “psychic”;
(3) it requires (needs) and demands (has a claim to) TREATMENT,
aimed at CURE or at least relief and abatement of symptoms; (4)
at the hands of persons trained in the healing arts and licensed
as HEALERS; and (5) this conception of the condition will be supported
by the society, which will also support efforts at treatment out
of its interest in the HEALTH (as opposed to the morals or the education)
of its people.
Fourth, look at the many aspects of human life that have increasingly
been brought under the medical gaze and paradigm: ordinary childbirth,
infertility, sexual mores and “perversion,” certain
aspects of criminal behavior, alcoholism, anxiety, stress, dementia
and old age more generally, grief and mourning. This is meant to
be said without passing judgment; I intend a descriptive account,
not a moralizing one.
Fifth, the push toward medicalization is thus only partly driven
by new technologies, though the availability of effective drugs
and other instruments lends much support to a medical conception
of the problem, and contributes to creating demand for medical services
as treatment. It is also driven by deep cultural and intellectual
currents: for example, to see more and more things in life not as
natural givens to be coped with, but as objects rightly subject
to our mastery and control; to have compassion for victims more
than to blame perpetrators, even when the victims are victimized
by their own perpetrations; to see the human person in non-spiritual
and non-moral terms, but as a highly complex and successful product
of blind evolutionary forces (which still perturb him through no
fault of his own). It is also driven by commerce and the love of
technique, the inflation of human desires to remove all obstacles
to our happiness, etc.
Finally, to return to your letter, here are some suggestions for
how it could be developed to be somewhat broader as a jumping-off
point for Council conversation, and without taxing you too much
in a short space of time. The following thoughts occur to me, all
of them merely suggestive.
First, we should make explicit what we of course implicitly agree
upon: that we are NOT trying to cast doubt on the existence, blamelessness,
and need for treatment of people with mental illness.
Second, perhaps some initial material could indicate that you do
indeed understand that the matter of medicalization is more than
a problem of off-label uses of these drugs or of a faulty symptom-based
system of diagnosis. Having presented the broader context, your
own reflections on a part of the problem will be taken for exactly
Third, you could spell out in brief why it might matter that this
medicalization takes place, and why it may be worrisome in its consequences
and outcomes. Finally, and perhaps most important from the point
of view of what it is that you are emphasizing, you could expand
the last part on the new and better classification, to show how
it might indeed help to improve the medical treatments of medical
problems and avoid medicalizing those which should not be. This
means showing, as you did for the staff, the differences in the
types of interventions that the four categories call for.
As you told us, there is no way to keep all four types of conditions
from being brought to the doctor's door—people present with their
own troubles, and where the shingle is out, one takes them in. But
the additional and perhaps pernicious medicalization of their travails
could be prevented if physicians themselves were better versed in
the distinctions among the kinds of sufferings and their cause,
and better able to sort out what is pathological and what is just
part of the pain and sorrow of life.
Time does not allow for refinements or improvements in what I have
only hastily put together here. But I hope that this will serve
as the basis of a conversation, and, if you are willing, for a response
and an enlargement of your letter so that we could send it to Council
members in the briefing book.
III. Paul McHugh to Leon Kass—June 3, 2003
As always in our exchanges you raise the level of discourse from
the mundane level of my practice to the implications hidden within
it. I noted the ethical incoherence of some psychiatric matters,
and then you replied by noting the more deeply problematic issue
of the contemporary “medicalization” of all human travails.
You define “medicalization” as that view reducing
all forms of human distress and disorder to aspects of “sickness”,
expressions of “patient-hood” and thus expressly open
to technical, mostly bio-medical, correction at the hands of experts
for whom ideas of good and evil, freedom and responsibility, sanctity
and sin, approval and reprobation are meaningless. Medicalization
is a materialist ethos with roots in both biological sciences and
contemporary medicine. You want us to think about its emergence,
its authority, its hubristic potential, and how to speak to it.
I'm certainly happy to try.
We must, though, begin with an emphatic assertion. You and I celebrate
the technical and conceptual advances of medicine (including psychiatry)
that have occurred in the last century. Antibiotics, antihypertensives,
antiarhythmics in medicine and antidepressants, antipsychotics,
anxiolytics in psychiatry have been life-preserving, life-enhancing,
welcome. These achievements rest upon knowledge of the body and
brain that is continuing happily to advance with even better treatments
(more specific, less disruptive etc.) in the offing.
I recently had the pleasure of listening to an eponymous lecture
at Hopkins given by our Council colleague and friend Janet Rowley.
She described her discoveries of the fundamental, molecule-based
mechanism of one of the leukemias, along with the cure to which
this mechanism succumbs. Like some Champollion at the Rosetta Stone,
she transformed the hieroglyphs of genes, molecules, and protein
structures into the coherent language of pathogenesis, pathophysiology,
and rational therapeutics. It was breathtaking.
I have also witnessed over the last decades great advances in conception
and treatment in psychiatry. We can celebrate together the progress
in knowledge and understanding of Alzheimer's disease, Huntington's
disease, schizophrenia, bipolar disorder etc. These mental disorders
are diseases in every sense of the word and the patients who suffer
from them deserve all the supports—protective, fiscal, empathic—we
offer the sick everywhere.
I should remind you that the discovery of specific treatments often
confirmed the idea that these conditions are diseases and the patients
victims. The most telling of such discoveries was that of lithium
for manic-depression. Here was an ELEMENT that relieved a complex
and persistent affective condition indicating that the problem was
not derived from personal mismanagement of life's conflicts, but
a brain dysfunction affecting a vital psychological faculty. The
idea that manic-depression, schizophrenia, and several other psychiatric
conditions were brain diseases—in that sense like epilepsy—is
now secure, and investigations to study them at the genetic, molecular,
and structural level of the brain are advancing apace.
If we can agree about all this, then what are our concerns? I think
I can speak for both of us in saying that one of the concerns is
how to keep the power of these new techniques from spreading out
in unintended ways. If we can cure manic-depression, should we then
eliminate grief? If we can treat attention-deficit disorder, should
we then scrub boyish high jinks from the classrooms?
In these dubious proposals one senses the medicalizing assumption
that is our main concern here. They follow from the idea that all
our vexations are due to some twisted molecule or protein that may,
for better or worse, be fixable in time.
Since these two concerns intertwine, let's untangle them at first
with nomenclature calling the first concern (keeping a treatment
or practice within professionally befitting bounds) the ETHICAL
PROBLEM and the second concern (the disposition or viewpoint about
humankind that spurs thoughts, customs, and practices which you
have called medicalization) the ETHOS PROBLEM. For all that they
are entangled, they do have slightly different sources and implications
and are addressed in slightly different ways.
Both have been around for as long as there have been doctors thinking
about what they are doing. Doctors with powers to act on the body
quickly realize that these powers can be misused. Much of the Hippocratic
canon revolves around the injunction “first do no harm”
and the Hippocratic Oath around the expressed intention “I
come for the benefit of the sick.” The Oath demonstrates how
professional ethics emerges from a coherent ethos. What you are
specifically striving for (the professional ethos you support) determines
what you will and won’t do (the professional ethics).
Within the Oath one finds several explicit ethical injunctions
on treatment: “I will neither give a deadly drug to anybody
if asked for it nor will I make a suggestion to this effect. Similarly
I will not give to a woman an abortive remedy.” Although these
ethical injunctions against physician-assisted suicide and abortion
are still debated, they at least derive from the expressed intention
to “benefit the sick.” Likewise, matters of ethical
decorum—keeping secrets, and refraining from sexual relations
with patients—are spelled out in the Oath as further expressions
of doctoring as a humane practice.
You expand usefully on the passage about “the benefit of
the sick” in your chapter on the Hippocratic Oath in Toward
a More Natural Science. Here you point out that in the Hippocratic
conception, people qualify for a physician's services “because
they are sick, not because they have claims, desires, wishes, demands
or rights. The healer works with and for those...who are not whole.”
(p.232) This important idea challenges the “medicalization”
ethos because it demands that we describe what we mean by “sick”
and think about whether we are expanding our treatments too far.
We offer some medical/surgical treatments to people who are “whole”
but would like help to “fit in.” We see no ethical concern
in such practices as orthodontia because both dental function and
appearance are enhanced. Face-lifts and “tummy-tucks”
begin to provoke concern that we are going beyond the sick, but
we accept them—sometimes with an embarrassed laugh over our
vanities. Finally, sex change operations and limb amputations for
sexual desirability we sometimes see as abominations.
Where are we in psychiatry, though? People come to us because they
are troubled or are troubling others. We recognize the ones with
diseases and treat them. But the claim that alcoholism, narcissistic
personality, and stage-fright are “sicknesses” of the
same kind as schizophrenia cannot be sustained just because these
people walk into our office and we help them. I hold that such a
medicalized claim is foolish at its root and disruptive to any coherent
view of the way we help these patients.
Hence my call for reference classes that specify the nature of
the disorders that psychiatrists manage, the therapeutic approaches
these natures imply, and the distinctive character of our success
with these patients. Without such a structure we can neither decide
on the ethical sense in psychiatric practice nor explain why we
are not succumbing to a medicalizing ethos where it is most pernicious—in
its appreciation of human mental life—when we are working
to help these folk.
I have spelled these reference classes out in my first letter and
will not repeat them here. Rather I want to draw from them their
distinct principles of treatment and what ethical matters they imply.
With those mental disorders that we mentioned above as brain diseases,
the prime responsibility for care lies with the doctor in both discovering
and applying the proper treatments. Doctors here are healers and
are dominant and irreplaceable. The ethical principles that apply
encompass the expectations of the patient that the treatments offered
are truly beneficial and that they are treatments with which the
physician is fully familiar. Standard medical ethics is in order
in the treatment of such medical conditions.
With the other reference classes that we psychiatrists manage and
help (patients with behaviors that we strive to interrupt, patients
with problematic dimensional characteristics such as subnormal IQ
or neuroticism whom we try to guide, patients with difficult life
stories that we try to reframe) we act less as medical healers and
more as thoughtful counselors and coaches bringing mastery of situations
to demoralized people, rather than “cures” for diseases.
With these patients, our treatments are not aimed at interrupting
an autonomous biologic process playing itself out along some fixed
and determined course. They are efforts to help a person choose
to live more successfully in the present and confront the future
more effectively. Some biological measures help in these matters—methadone
for heroin dependence, etc. But primarily one combats these mental
conditions by promoting other attitudes and modes of life—persuading
the patient that they are better than the ones in which the patient
is embedded—activities that go beyond traditional medical
matters. DSM-IV with its categorical diagnostic approach, however,
defines itself as a “medical nomenclature” (p xviii)
and thus may promote the medicalization of mental life.
I should, though, stop and say that the medicalized ethos embedded
in psychiatry with DSM-IV is not the first—or the worst—problematic
conception I have witnessed in psychiatry. Freudianism and Skinnerian
Behaviorism are both conceptions of the human mind that have justified
very strange practices. DSM-III was, in fact, an attempt to free
psychiatrists from these earlier theories of human mental life and
get them to concentrate on patient presentations—hence its
oft-noted and self-proclaimed “a-theoretical” stance.
In combating these original conceptions and moving the psychiatric
conversation in a more pragmatic and empirical direction, we can
all be grateful to the authors of DSM -III.
But DSM-III was composed 25 years ago and psychiatrists are now
stuck in a medicalized stance that provides a gravely limited view
of human assets and vulnerabilities. The oft-expressed view that
such issues as crime, marital disruptions, poverty, discrimination,
terrorism and the like will succumb to medical thought and practice
misunderstands both what people are and doctors can do.
I hold that we need to promote a much more complete description
of humankind than that promoted either by DSM-III, IV, or by evolutionary
psychologists like Stephen Pinker. They both promote far too mechanical
and deterministic a view of people—a view that not only flies
in the face of psychiatrists’ experience helping patients,but
represents an ideology derived from special pleadings about biological
science and human mental life. No one—not even the Pope of
Rome—is denying that human beings are biological creatures
who have evolved from lower forms of animal life. But this is not
all they are nor does this information grasp the most proximal formative
factors affecting people.
We have evolved into a unique and special form of life where matters
of our personal developmental history, our families of origin, the
socio-cultural world with its authoritative “metanarratives”
into which we emerged, and the technico-industrial capacities now
available to us have as much and often far more influence on our
mental life—its happiness and distress—than our biological
nature and evolutionary history. Indeed the major achievement of
our evolutionary history (regardless of how it came about) has been
that we are free to bring new meanings into life in ways that make
our futures—as individuals and as builders of societies—radically
unpredictable. Our nature is one that permits us to create our world—for
good or ill, for better or for worse.
From that position, one can reconsider our medical and psychiatric
powers and reach far better conclusions about what we are doing
to help people and why. That we are biological creatures with all
the frailties of a material foundation means that we can break down
and need repair. But that we are these special biological creatures
called humans means that we are free and can build for good or for
ill depending upon how we think, feel, and behave and occasionally
need help in these matters to succeed.
How to deal with the medicalization ethos then devolves into a
form of reply to the biblical question of whether we should “give
tribute unto Caesar.” Because we are biological creatures
carrying as it were the stamp of the biological imperium we must
“render unto Caesar the things that are Caesar's.” That
is: knowing that our bodies have dominion over us,we call for medical
treatment for their preservation and medical research to relax the
tyranny of their expression in disease (an enterprise our friend,
Janet, has so nobly advanced). But we also must and should “render
unto God the things that are God's.” That is: knowing our
human capacity to build the life we have inherited in a meaningful
way within a society that we help make more worthy, but also our
capacity to go awry in these enterprises and suffer accordingly,
we need help from others who see our confusions, judge them appropriately,
and act with us to relieve them. Because today (for reasons we might
discuss), so many of these others are doctors, we may have forgotten
that this help is not strictly medical in character.
To be continued,