Clarifying Cosmetic Psychopharmacology Part 5

This is the third of a multiple part series exploring Cosmetic Psychopharmacology. It includes the text of Joe's thesis and will culminate in a reanalysis and break down of the piece. Read Part One Here  Part Two Here,.Part Three Here Part Four Here      

By
Joe Chiarenzelli

Mill, Society, and the Harm principle

                Due to the social nature of cosmetic psychopharmaceuticals (i.e., their procurement must be through a doctor or through illegal means), those who seek to use them naturally must approach others in order to obtain them. It is the social nature of this procurement, which requires us to engage Mill's asserted principle in On Liberty:

The object of this Essay is to assert one very simple principle, as entitled to govern absolutely the dealings of society with the individual in the way of compulsion and control, whether the means used be physical force in the form of legal penalties, or the moral coercion of public opinion. That principle is, that the sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection. That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right... The only part of the conduct of anyone, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign. (133 emphasis added)

            This is the cornerstone on which a utilitarian ethic of cosmetic psychopharmacology rests. While an individual can judge his own enhancement, provided his behavior is of no harm to others, due to the social nature of the procurement of pharmaceuticals we must put in the hands of the doctor the judgment of whether or not his prescribing a certain drug to an individual will cause that individual undue harm. This is in agreement with the Hippocratic oath with its oath of "do no harm". Using this principle, along with the Hippocratic oath, will allow a doctor to prescribe a patient cosmetic pharmaceuticals in accordance with their opinion of the risk/benefit ratio along with the patient’s own valuation. This will allow individuals to have a dialogue with their doctor that is open and honest on both ends, providing an opportunity to maximize the benefit and minimize the harm of psychopharmaceutical use. So the doctor would only ethically be able to prescribe a drug if he did not violate the harm principle.

Utilitarianism and Customization

                Accepting the utilitarian view in regards to cosmetic psychopharmaceuticals, I contend, will have beneficial ramifications in several different areas. The utilitarian view will allow for four areas of improvement in current medical care and cosmetic psychopharmaceutical use: (1) a greater ability for customization of a psychopharmaceutical regimen in terms of drug type and amount, (2) a combination between personal and interpersonal evaluations which allows for an individual to garner information from his doctor and reflect on his motives while allowing the doctor to ultimately make the decision keeping the patient’s wishes in mind, (3) a reduction in the current "cat and mouse" game patients seeking psychopharmaceuticals play with physicians, and (4) reducing danger to users through reducing illicit procurement which leads to questionable quality and doses.

            In regards to the first point, currently when an individual goes to the doctor he/she are treated for the ills they have. Not for Health, rather for health. But given the utilitarian framework we have developed this does not have to be the case. A doctor and patient should be able to work constructively to provide an individual with Health. For instance, though an individual may receive methylphenidate or Adderall for a case of ADD, they cannot receive these drugs for their self-betterment. Taking the utilitarian view we can clearly see that this is not maximizing the potential of these pharmaceuticals to improve individual's performance; to do this a patient would need to be able to speak with his doctor and request these substances in a clinical setting.

            Within this clinical setting, a doctor and his/her patient can go about conceiving the best way for a patient to use pharmaceutical enhancement to reach their goals. However this is not justifying a doctor handing over a prescription to a patient for whatever he requests. This is because he is honor bound, via the harm principle and the Hippocratic Oath, to protect the patient both bodily and mentally. So while a doctor may not use his station to blindly hand out drugs to anyone who requests them, he may work constructively with the patient to maximize the benefits and minimize the harms attendant to the use of pharmaceutical enhancement. While this greatly expands the role of a doctor this approach is a normative one not a descriptive one. Due to this there would have to be structural and educational changes in order to follow this system, because the current system could not implement this ethic.

            The virtue of utilitarianism in this situation is thus: Using the ideal of maximizing benefit while minimizing harm, a doctor may prescribe a patient with prescriptions that he can confidently assume will not harm the individual and may benefit him. S/He can look at the medical literature and scientific studies and parse out the details of how his prescription may affect the individual. Acting on this information he can prescribe substances that he deems safe and effective for the inquiring individual. However, this is not the point at which the doctor's involvement ends. In accordance with doing no harm to the individual the doctor must have continual checkups and run diagnostic tests on the individual. The reasons for this are fairly straightforward; a doctor cannot know he is not doing harm unless he can consistently monitor the patient.  He must make sure that a patient is not becoming addicted (i.e., he must check the rate at which they are using their medication), he must make sure that he is not harming the individual bodily (i.e., running diagnostic tests), and he must not disregard the affective effects the doctor can see (i.e., through mental health tests). To avoid doing any of this the doctor would be violating the harm principle out of willful ignorance, an indefensible position.

            An added benefit of these conditions is that the doctor can also suggest other ways in which the individual can achieve their goal of Health. He may suggest that a patient quit smoking when he sees diagnostic information that shows the patient is damaging themselves. He can also suggest other routes such as meditation or physical and mental training that can help the patient improve themselves. All of these things are helping the doctor achieve his goal of maximizing benefit to the patient while simultaneously reducing deleterious effects.

            However, we must have a way in which a doctor can evaluate what exactly the individual hopes to gain (what he sees as a benefit) and what an individual can't stand to lose (deleterious effects). It is within the purview of utilitarianism that this question can be answered. A patient coming to a doctor for enhancement will most likely have considered the purpose for which he seeks pharmaceutical aid. This represents his personal evaluation of what he would like to achieve in regards to his Health. Yet, at this stage he must go through a medical care professional (someone trained in the medical sciences). This provides room for an interpersonal evaluation of the patient’s motives and a correction of misconceptions he may have about the effects themselves. Using the training and knowledge a doctor has received through years of practice and training, he can provide a sounding board for the patient’s motivation. He can also inform the patient of what he stands to lose if something goes wrong with the medication while suggesting to him the most safe and suitable substance for his request. These two types of evaluation prevent an individual from wantonly pursuing pharmaceutical aid for themselves with no consideration or knowledge of the aid they are pursuing. Ultimately, the doctor himself stands in a position to hear the thought process of the patient and deny or help them develop a plan for achieving their Health.

            An important ancillary effect of this open system of evaluation and communication is that patients and doctors no longer need to play what I have dubbed the "cat and mouse" game. When the use of pharmaceutical aids is denied without question a patient who wishes to use a pharmaceutical aid is put in an unfortunate position. For instance, say if a patient would like to use Modafinil in order to make themselves more competent with their short term memory because they work in a field that requires great usage of this skill. If this patient knows that it is impossible to get this aid because laws do not allow it, then he has an incentive to fake a disease that could get him a prescription to Modafinil. When the patient goes to see the doctor he will deceive them such that he can get the aid he wanted. The doctor, knowing that this pharmaceutical is thought to aid in certain tasks, is prepared for this deception either through experience or through recognizing the problem himself. This situation escalates such that the patient must more convincingly portray himself as a sufferer of the disease or the doctor must catch the patient in a lie and reject the patient. Either solution is unsatisfactory. If the patient (mouse) successfully evades the doctor (cat) then the doctor will be operating under false assumptions about the individual’s health and this could lead to horrible life threatening consequences. If the reverse happens then the patient, if he truly desires the use of the aid, will either turn to illegal channels of distribution or move on to another doctor. For this reason a patient and doctor must be able to talk candidly about pharmaceutical aid so that the doctor has the pertinent information about the patient and so that the patient himself is not harmed.

            This leads naturally into a discussion of the beneficial effects this openness will have in regards to illegal distribution. Due to the illicit nature of drug dealing, an individual who is seeking aid for their Health benefit runs a high risk of receiving a substance that is either not what he is told it is, adulterated by a harmful substance, or not understand the dosing that can confer the benefit he seeks. By having to go through a doctor these risks are mitigated and a patient will not be blindsided by adverse reactions and subject to jail time if they seek help and the substance they have purchased is found.

Objections

            As in any ethical pursuit there are objections to using the utilitarian system that I have laid out in the context of cosmetic psychopharmacology. The three main objections are as follows: (1) By using pharmaceutical enhancement we are fundamentally altering the self/soul, (2) the use of pharmaceuticals eliminates the effort which plays a key role in self-development, and (3) this system would make drugs too easy to abuse.

            In regards to the fundamental alteration of the self there are several reasons this is not grounds to reject the my utilitarian system. But first it is necessary to look at exactly what the objection is. This objection has its roots in theological considerations. Essentially we are imbued with a self/soul that itself has intrinsic value. By adulterating this soul we are polluting and harming our spiritual selves. This is not to say that there cannot be an idea of the soul as something without restrictions on adulteration, but the objection itself rests on the immutability of the soul.

            This objection is very problematic for several reasons. If we consider the self to be immutable and unchangeable in a way that is connected with our cognitive lives then we encounter natural problems in things that are well regarded as good and important. The first is that if the self is immutable and changing it is impermissible, then this implies we must not attempt to reform prisoners because they have intrinsic worth in the way they currently are. This leads to a situation in which we must allow prisoners to stay the same way they are. Also, if our self is connected to our cognitive states then we must also not allow the use of corrective brain surgery in order to cure illnesses, because the cognitive generation of these states has an intrinsic worth. A reply to this may be that the soul is not connected to cognitive states, it transcends them. But, if this is true, then the self/soul has no bearing on the issue in the first place because the brain states that are being changed by cosmetic psychopharmaceuticals are not effecting the soul at all.

            Another important objection is the one based on effort. This generally takes the form of asserting that a natural and key human experience is that of suffering and putting forth effort to overcome this suffering. This is problematic for several reasons. The first and most important is that this stance leads us through reductio ad absurdum to seemingly untenable positions. For instance, I can say, by using pharmaceutical enhancement we are removing the need for people to put forth their maximal effort to solve intellectual or social tasks. This at first seems like a very reasonable objection. It is generally recognized that we need to exert effort in order to better ourselves and achieve our goals. But we, as human beings, are constantly trying to make the things we do easier so that we can move on to more difficult tasks. Would we deny a man driving to his job rather than walking because the act of driving reduces the time and effort it takes to get to his job? Further, would we deny the man the use of shoes on his walk because it reduces his effort of walking? We can see where this line of reasoning leads us; we must at all times put ourselves in situations that require us to exert the most effort in order to develop ourselves. While this argument seems to be a slippery slope fallacy it does have reasoning behind it that validates its assertion.

            As a tool using species it is natural for us to develop techniques which allow us to better ourselves outside of our natural biology. But we can see through the course of human existence making certain tasks easier does not mean that we stop pursuing and exerting effort on challenges. Einstein did not sit and rest on Newton’s conception of physics, Descartes did not accept Aristotle’s views and no longer pursue his own, and the individuals who developed our newest psychopharmaceuticals did not rest on the simple basis that caffeine or nicotine can induce more productive states. The fundamental presupposition of this position is that by making tasks easier will rest on our laurels and not trek further into intellectual or material pursuits. This however is empirically false. By making our current tasks easier we are allowing ourselves to pursue more difficult tasks. So the preceding argument does not commit a slippery slope fallacy because it is just highlighting the way that humans interact with their world. When we can find an easier way to do things, we naturally move on to other tasks. So prior to shoes individuals had to walk around in their bare feet, prior to cars we had to walk everywhere, and prior to cosmetic psychopharmaceuticals we could not garner benefits from the enhancement these substances can confer.

            An ancillary argument is the use of cosmetic surgery (not the strongest objection but still an argument from analogy about what we think is right to do and how we would be hypocritical to use surgery and not mental augmentation). If we cannot alter our own mental state in order to make our lives easier then we should have a moratorium on individual’s pursuing surgery to look better, because this allows them to achieve their interpersonal goals with less effort. A man who hopes to reduce the size of his noses to have better success in his love life should not be able to do so because he is reducing the effort he has to exert to attract a partner. To go even further, a woman should not be able to use make-up to cover up a blemish because this reduces the effort she has to exert in attracting a partner. Again we can see that this leads to quite absurd conclusions.

            At this point it can be said that there is a fundamental difference between mental augmentation and physical augmentation. But if we reject Cartesian dualism then this cannot be the case. The body and mind are one and the same, thus a change to one is the same as a change to the other. Calculators are a simple example of this phenomenon. The use of calculators takes place in a physical context, typing in the numbers and doing calculations. But the end result is that we can use this tool to reduce the exertion of calculating the numbers by hand, freeing our mind to perform other tasks. Thus a physical interaction has the ramification of inducing a cognitive change.

            The final objection has already been addressed by the “cat and mouse” discussion, the difficulty of controlling and deterring substance abuse. If an individual is constantly being monitored by his doctor his abuse would be obvious. This means that by legitimizing the use of psychopharmaceuticals there would actually be a reduction in the likelihood of abuse. If an individual can communicate and have a continuing dynamic dialogue with his doctor then signs of abuse will be evident. Also, if the individual is seeking to better himself through pharmaceutical means he will wish not to abuse the drug. Instead he would be looking to avoid abuse in order to maximize his benefits from pharmaceutical aid.

Coercion

            Another round of objections comes not from a concern about the individual, but rather it arises from the effects that one’s use may have on others. Remember, that the harm principle does not allow an individual to abuse or misuse the pharmaceutical; instead they must use it responsibly in order to maximize their enhancement. This leaves one main objection: coercion, and this has two parts. 1) Indirect coercion occurs within a competitive environment where an individual is competing with their peers and is using a psychopharmaceutical to aid this effort. 2) Direct coercion occurs when an individual in a position of power mandates that individual have to use a certain pharmaceutical or risk negative repercussions.

Indirect Coercion

            The best way to think of indirect coercion is to imagine a competitive work environment. Within this environment there are two individuals competing for the same promotion. Jim, in an effort to make himself more mentally capable, starts to use Ritalin in an effort to out compete his competitor, Dwight. Dwight however does not wish to use Ritalin because he does not wish to alter his mental state in this way.

            Due to the fact that Jim is using this pharmaceutical and gaining a competitive edge on his colleague, he is indirectly exerting coercive pressure on Dwight. So if Dwight wants to be on level playing ground with Jim, he must find a pharmaceutical that will give him the same boost. Thus we can see that by using a pharmaceutical, Jim promotes Dwight’s use of pharmaceutical aid. It is this coercive force that can be pointed to as a deleterious consequence of pharmaceuticals in a competitive environment.

            However there are certain biological reasons why this problem is not as severe as it first looks. Firstly, it may very well be impossible for Dwight, with his biochemistry, to obtain the same benefits as Jim. Secondly, because these pharmaceuticals act via extant biochemical pathways drugs, therefore these drugs cannot be piled on ad infinitum with positive effects. So any visions of an escalating drug arms race can be assuaged by the harm principle placing restrictions on harm to the patient. Lastly, Dwight does not need to change his biochemistry if he does not want to, he can individually evaluate the risk/benefit ratio to be in the negative.

            If Jim gets a positive effect from using Ritalin, this does not entail that Dwight will also receive the same benefit. In fact, Dwight can try a whole host of drugs to boost his performance but they may in fact all fail. This means that in certain cases, indirect coercion cannot have any actual effect on the coerced individual, because there is no way for the individual to act on this coercion. This can be illustrated in a simple baseball analogy. Even if Barry Bonds uses steroids and gets a great boost to his overall homerun record, if another player cannot gain benefits from steroid use, then the player has no means by which to act on this coercion. This raises the concern that patients could be harmed in an effort to better themselves, but the fact that the individual would have to go through a physician would mitigate this risk.

            Suppose however that Dwight does get a benefit from a pharmaceutical that matches that of Jim. If this is the case then the two individuals are back to square one and neither of them has a competitive advantage. You would think that this would result in an escalating battle of pharmaceutical enhancement, where Jim uses another drug or more of the same drug to regain his advantage and Dwight responds by doing the same. However there are two reasons this cannot happen. Firstly, neither Dwight nor Jim can continue just piling on pharmaceuticals in an effort to better themselves, because these drugs have therapeutic windows and interactions that will result in a loss of ability rather than a gain. Thus an arms-race between the two cannot continue indefinitely. Secondly, these two individuals would still be going through their doctors to get these drugs and thus their doctors would deny them these avenues because it would result in deleterious biological effects that would not justify the gain in ability (especially since this gain would quickly turn into a loss). Again we can look to baseball to illustrate the point. When we watch baseball we watch it for the competition itself, thus there is an incentive to keep the playing field "fair" to keep the competition high and therefore entertaining. However, when we are doing work or a task our goal is not to make the process entertaining rather we are attempting to get the work or task done in a timely and competent manner. So, in the case of baseball there is a reason to keep the playing field level while outside the realm of competition we do not need to keep the playing field level, assuming we are not doing it for entertainment purposes.

            Most importantly, both the previous cases suppose that Dwight will respond to coercion in the first place. Dwight may very well judge the risks of using a pharmaceutical aid to be unworthy of the biological risks it entails. Due to his judgment about the risk/benefit ration, he would never approach the doctor in the first place to ask for this enhancement. This means that Dwight can actively deny to be coerced, the same way when I see someone going 55 on the highway I can still go 50. They are at the limit of what they can do, but I myself do not need to advance on this limit if I do not want to. If Dwight loses out on a promotion then it is because he is not working as efficiently as Jim, which is the end goal of the work in the first place.

Direct Coercion

                Direct coercion is the more dangerous of the two types. Essentially, if someone is running a company he can mandate that everyone must use psychopharmaceuticals or risk losing their jobs. In this situation Dwight is at a great disadvantage because it is no longer his decision whether he uses psychopharmaceuticals or not, rather it is the decision of a higher up that is forcing him to do so. Jim, on the other hand, has no problem because he has decided that he would like to use them anyway.

            In this situation, the harm principle truly demonstrates why it is of the utmost importance to a system of cosmetic psychopharmaceuticals that is safe and moral. There are two safe-guards in this situation if the utilitarian model is to be used. Firstly, it is a violation of the harm principle for an outside party to force an individual into a decision through the threat of termination. Secondly, it is in violation of the harm principle for the doctor himself to prescribe this drug with the knowledge that the patient is requesting it for this reason and/or because the drug may have unwanted deleterious effects that the patient is not themselves evaluating for the risk/benefit ratio.

            If the utilitarian model of psychopharmaceutical enhancement is to be accepted then we can see that any directive of this sort is a violation of the ethical principle at work. This would provide grounds on which to sue the company itself for improper directives, providing that this system informs law. For instance, if for the business it would better for every individual to vote for a Republican this does not mean that the company itself can mandate this. Any jury in their right minds’ would quickly recognize this fact and decide in favor of the plaintiff.

            Also, we have already discussed the need for open and direct communication between a doctor and their patient. If this is the case then a doctor will easily be able to recognize that Dwight does not want to take the drugs because he is not in favor of the risk/benefit ratio. So, he could persuade Dwight to take some sort of action in response to the directive or, if Dwight insists against his own judgment, deny him the pharmaceutical in the first place. This expands the role of the doctor and because of this the medical establishment would have to be altered in accordance with this system to better educate doctors.

            It is clear from these situations that the harm principle provides multiple safeguards against direct coercion in the utilitarian system. By creating a reason by which an individual can deny the forced use of a psychopharmaceutical, the system creates ways in which the coercion itself can be fought against and stopped. Thus this system protects against the prospect of direct coercion.

What needs to change?

            If we are going to use the utilitarian system to judge and understand the morality of psychopharmaceutical use, the system as we have it cannot remain the way it is currently. This is for three main reasons: psychopharmaceuticals need to be legalized and placed at the discretion of physicians in order to prevent ill health effects due to black market trade and a lack of medical knowledge, the pharmaceutical industry has to design drugs that are not easy to abuse, and the pharmaceutical industry must not be allowed to coerce doctors with the intention of having them prescribe their own products.

            As we have discussed the illegal nature of psychopharmaceuticals typically results in either a “cat and mouse” game in which individuals lie to their doctors or individuals turn to the black market for drugs that are not regulated and can be adulterated. If a patient and their doctor are able to discuss the patient’s wishes and motivations along with their personal evaluation of the risk/benefit ratio behind their choices without the need to worry about possible legal consequences for either of them, then the doctor can truly operate in accordance with the patient’s best interest and supply pharmaceutical aids in correspondence with this. Also, when a patient is forced to go to a doctor for their pharmaceuticals, if they are using the pharmaceuticals in order to better themselves, they will be willing to allow the doctor to monitor their various biochemical markers and their rate of intake of the drug. This cuts down on the need for individuals with the honest intention of making themselves better from attaining the drug illegally and thus being subject to criminal prosecution, adulteration and the harm that comes from it, and finally being unawares of the actual effects the drug is having on their biology.

            Another problem is that the pharmaceutical industry needs to design drugs that are not easy to abuse. For instance, it is very easy for a company to design pills that can only be taken by route of the stomach, rather than being meant to be taken by stomach yet also capable of being taken either sub lingually (dissolved under the tongue) or intranasally (inhaled through the nose). Even though a doctor can make sure a patient is not going through the prescription at too quick a rate, he cannot make sure that the individual is not in fact using the drug via an improper and abusable route of administration. Thus by creating pills that can only be taken in one way a doctor’s job of monitoring the patients use becomes more straightforward and can be assumed to be an accurate measure of the patients actual use.

            Lastly, the pharmaceutical industry sends out pharmaceutical representatives to doctors in order to up their brand recognition and convince them to use their products. This is problematic for one main and incontrovertible reason. By doing this, pharmaceutical companies are providing the doctor with a motivation to supply a prescription to their patients that is not dependent on the patients’ wishes. While there are obviously cases in which there is a pharmaceutical that has been lobbied for and it is the appropriate prescription, this is not always the case. So when a doctor is leaning slightly for another drug that he thinks may be better for the patient’s goals, he can be convinced (on a nonmedical principle)  by the pharmaceutical companies to decide against the favored method.  Thus we need to change the way pharmaceutical companies do business with doctors in order to protect against economic interests impeding on people's health in violation of the harm principle.

Conclusion

            Overall we can see that the utilitarian method is the best method for dealing with the moral aspect of cosmetic psychopharmacology. Neither Kantian nor Aristotelian models can account for the unique nature of cosmetic psychopharmacology. Due to utilitarianism’s adjustability and implementation of the harm principle we can promote a better dialogue between doctor and patient that allows the doctor to truly help the patient achieve their goals within a safe system. The safety that the harm principle lends this system will prevent issues of coercion from becoming a problem by allowing individuals to self-evaluate and craft moral cases for why they should not have to take a psychopharmaceutical unless they so choose. Finally, if we were to implement these changes we would have to adjust our view of the legality of psychopharmaceuticals, pharmaceutical companies would have to change how they do business, and pharmaceutical companies would need to stop advertising directly to doctors.

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