Dr. Peter B. Reiner speaking at the Peter Wall Institute of Advanced Studies International Roundtable We are our brains, October 2013.
In Madness and Civilization, French philosopher and activist Michel Foucault wrote that, “from the fifteenth century on, the face of madness has haunted the imagination of Western man.” Foucault argues that the concept of ‘madness’, at least in the 1800s, was characterized as a loss of ‘reason’ – the essential mental faculty which made human beings distinct from other animals. Those who lacked reason (which all rational beings possessed) were perceived as a threat to humanity. Eventually barriers were raised – both literally and figuratively – which separated these ‘irrational’ individuals from the rest of humanity.
Such stigmatizing and social-distancing attitudes towards those living with mental illness are still deeply enmeshed in the social and cultural norms of many industrialized nations. In the 1960s, sociologist Erving Goffman spoke of stigma as a “spoiled identity;” more closer to us Bruce Link and Jo Phelan conceptualize stigma as occurring when “elements of labeling, stereotyping, separation, status loss, and discrimination occur in a power situation that allows them.” A related concept, social distance, is defined as the degree of proximity an individual is comfortable with in relation to an individual who is living with mental illness, particularly as it relates to the perceived dangerousness or unpredictability of that individual. Prevailing views amongst the public see the behaviour of individuals living with mental illness as volitional; at times these individuals might be considered ‘lazy’ (in the case of major depression and the ethical values tied to participation in the workforce), and so, intuitions about mental illness are believed to be justified blaming these individuals, or perhaps even punishing them.
Over at The New Republic, Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute, recently reviewed the controversial book Addiction: A Disorder of Choice by psychologist Gene Heyman. Heyman’s thesis is that conventional wisdom about addiction being a ‘disease’, or perhaps a ‘brain disease’, is incorrect. Satel quotes Heyman by saying, “that the idea [of] addiction [as] a disease has been based on a limited view of voluntary behavior.” Accordingly, addiction is not an “irresistible act”, as he claims the term ‘addiction’ implies, and is in fact a “disorder of choice”. [Note: I have not read Heyman’s book, so I will not comment on the book directly]. Indeed, Satel conveys Heyman’s position as one that is in opposition to perspectives from powerful public figures that support the view that “Addiction is a Brain Disease, and it Matters.” Satel agrees with Heyman’s position, namely that if addiction is a disease, it is a disease the person chose for herself.
Satel’s review of Addiction prompted a response from writer Sascha Z. Scolbic and Peter Scolbic (TNR’s executive editor), who argued that Satel was puting up a “straw man” argument. [See Satel’s reply to the Scolbic’s here].
So many sessions, so little time. It really is a shame. The quality of sessions this year was truly remarkable, so it was difficult to decide on what to see. On Saturday morning I sat down with my breakfast of coffee, muffins and fruit and took a good long look at the program. After Bernard Keating‘s plenary lecture entitled, Squaring the circle: reconciling evidence and equity (which the majority of the audience was plugged into headphones with a direct line to an English translation, as the lecture was presented mainly en français), I made my way over to two fantastic sessions.
The first session by Cynthia Forlini of the Neuroethics Research Unit at the Institut de recherches cliniques de Montreal (IRCM), reported on a qualitative study on stakeholder perspectives on the use of cognitive enhancing drugs, particularly methylphenidate (I do not have the title of the presentation – it was unfortunately absent from the conference program and I lazily didn’t bother to write it down). The presentation was based upon a paper Forlini co-authored with supervisor Eric Racine in press for Neuroethics entitled, Autonomy and Coercion in Academic “Cognitive Enhancement” Using Methylphenidate: Perspectives of Key Stakeholders. Forlini focused on the perspectives of University students using methylphenidate (MPH) to improve alertness and academic performance. She argued that the social context wherein these drugs are taken and obtained is of crucial importance, as many students reported feeling ‘coerced’ to take MPH in these settings to improve their academic performance. Moreover, the impact of social pressures to take cognitive enhancing drugs significantly impact the individual’s autonomy, such that it may cause a “funnel phenomenon” (see both the article and the figure in this post) leading to social acceptance of this type of enhancement despite beliefs in an individuals autonomous choice. During the discussion period, Forlini was hesitant to call for regulation of cognitive enhancers for use in ‘healthy’ populations, in spite of a recent high-profile commentary in Nature by Greely, Sahakian, Harris, et al. who advocate for responsible use and regulation. Forlini stated that she believes it may be too premature to call for regulation on the use of cognitive enhancing drugs in healthy individuals, as more integration of stakeholder perspectives is needed to inform future public health policy discussion.
Up next was Jennifer Bell from UBC. The title of her presentation, Rights, Risks and Smoking: how ‘denormalisation’ mediates patient-provider interactions in primary case settings, was in many ways a response to Bayer (2008) who justified the use of stigma campaigns to “effectively reduce the prevalence of behaivors linked to disease and death” (actually, volume 67 issue 3 of Social Science and Medicine is devoted to the notion of stigma, including a nifty little back-and-forth between Burris and Bayer). Bell and her co-authors argued that the success of smoking denormalisation campaigns can be witnessed in the stigma attached to smoking, and smokers. However, can stigmatising a group ever be justified as Bayer suggests? Bell and her co-authors disagree. In their analysis, they explore some of the ethical and policy implications of denormalisation strategies which construct health care as a privilege that smokers have forgone the ‘right’ to access. Moreover, Bell reminded us that the more severe health consequences of smoking tend to be greater associated with lower socio-economic status (SES) and that smoking denormalisation efforts further marginalise low SES individuals.
During the lunch hour, UBC’s own Michael McDonald was the recipient of the CBS Lifetime Achievement Award. Dr. McDonald has had a distinguished career in the area of research ethics and other areas of applied ethics. He is the founding director of the Centre for Applied Ethics at UBC and continues to significantly contribute to the ethics literature and actively participates in many ongoing projects. A well deserved honour.
Instead of attending more concurrent sessions in the afternoon, I attended a workshop entitled, Qualitative Ethics Research: Evidentiary Needs and Directions. This session was extremely useful, as we outlined various methods and methodological approaches to qualitative ethics research (not to be confused with qualitative research ethics), and discussed amongst the group some of the challenges that people have encountered in their own work. Although worthwhile, I was tempted by another session titled Conceiving the Post-Prozac Self which was occurring at the same time. Oh well. Can’t win ‘em all.