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Prozac and its chemical cousins, Paxil, Celexa, and Zoloft, are some of the most profitable and most widely used drugs in America. Their use in the treatment of a multitude of disordersfrom generalized anxiety disorder and premenstrual syndrome to eating disorders and sexual compulsionshas provoked a whirlwind of public debate. Talk shows ask, Why is Prozac so popular? What, exactly, do these drugs treat? But sustained critical discussion among bioethicists and medical humanists has been surprisingly absent.
The eleven essays in Prozac as a Way of Life provide the groundwork for a much-needed philosophical discussion of the ethical and cultural dimensions of the popularity of SSRI antidepressants. Focusing on the increasing use of medication as a means of self-enhancement, contributors from the fields of psychiatry, psychology, bioethics, and the medical humanities address issues of identity enhancement, the elasticity of psychiatric diagnosis, and the aggressive marketing campaigns of pharmaceutical companies. They do not question the fact that these antidepressants can, in some cases, provide great benefit to alleviate real suffering. What they do question is the abundant popularity of these drugs and that popularity's relationship to American culture and ideas of selfhood.
Tod Chambers, Northwestern University Feinberg School of Medicine, Chicago
David DeGrazia, George Washington University
James C. Edwards, Furman University
Carl Elliott, University of Minnesota Center for Bioethics
David Healy, University of Wales College of Medicine
Laurence J. Kirmayer, McGill University
Peter D. Kramer, Brown University
Erik Parens, The Hastings Center
Lauren Slater, AfterCare Services, Boston
Susan Squier, Pennsylvania State University
Laurie Zoloth, Northwestern University Center for Genetic Medicine, Chicago
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Prozac as a Way of Life
The University of North Carolina PressCopyright © 2004 The University of North Carolina Press
All right reserved.
Chapter OneKramer's Anxiety
In the very first paragraph of Listening to Prozac, Peter Kramer presents the case of Sam, a melancholic and proudly unconventional architect. Kramer explains that a central conflict in Sam's marriage was his interest in pornographic videos. Despite his wife's distaste, Sam insisted that she watch hard-core sex films with him.
We learn that after a reversal in his business and the death of his parents, Sam became depressed. He came to understand his depression in terms of those unhappy events, but that did not make him feel better. Eventually Kramer prescribed Prozac, and Sam underwent a remarkable transformation. Suddenly he could complete projects in one draft; he could remember more and concentrate better. He was more poised. He could speak at professional meetings without notes.
Though Sam now reported feeling "better than well," one part of his transformation troubled him. He no longer was interested in pornography, and that change felt like a loss. According to Kramer, "The style he had nurtured and defended for years now seemed not part of him but an illness." A part of his self that once seemed essential now seemed alien. Kramer continues: "Although he was grateful for the relief Prozac gave him from his mental anguish, this one aspect of his recovery was disconcerting, because the medication redefined what was essential and what contingent about his own personality-and the drug agreed with his wife when she was being critical" (11, my emphasis).
The part of that sentence before the dash telegraphs the book's central questions: What are we doing when we "listen to drugs," when we allow them to tell us which "parts" of our self are essential and which are not? What are we doing when we allow drugs to teach us that this aspect of our self is authentic and that one alien? Which conceptions of authenticity inform those discriminations? That is, are we allowing drugs to teach us oppressive-or liberatory-conceptions of what it is to be and become an authentic self? Most specifically, are we allowing drugs like Prozac to teach us oppressive or liberatory views of what it is for women to be and become "authentic"?
Those questions about authenticity in general and of women in particular are the source of what I will call Kramer's anxiety. Kramer is, after all, a physician, who has to decide what drugs to prescribe, to whom, and when. As a thinker, he is keenly aware of medicine's history of pathologizing behaviors that subsequently came to be seen as healthy but different (e.g., homosexuality) or as healthy responses to unjust situations (e.g., anomie in the face of domestic purgatory). As a physician and a thinker, Kramer is anxious about the possibility that in prescribing Prozac, he is sometimes being complicit with unjust or arbitrary conceptions of persons in general and women in particular. (Please note: Kramer is not anxious about using Prozac to treat clinical depression, nor am I.)
The part of that sentence after the dash ("and the drug agreed with [Sam's] wife when she was being critical") foreshadows Kramer's response to those questions regarding Prozac and authenticity. It foreshadows the line of argument he hopes will cure his anxiety. That argument suggests that Prozac does not necessarily promote oppressive views of the self. More specifically, if anything, Prozac promotes liberatory views, even what Kramer calls "feminist" views. Prozac agrees with Sam's wife-and presumably "feminists": watching pornography is not only hurtful to women, but it is not an essential part of a healthy man; it is something alien, something inauthentic. So if we are listening to Prozac, we need not be anxious. If anything, according to Kramer's anxiolytic argument, Prozac promotes a "feminist" conception of the authentic self.
My point here is not to suggest that Kramer and Prozac are wrong about pornography. I am not saying that Prozac hurt Sam in depriving him of his authentic desire to watch pornography. I am as New Age and sensitive a guy as you are likely to meet. My point is not about pornography at all. It is that from the very beginning of his book, Kramer goes to great pains to suggest that we-and he-need not be anxious about what Prozac will teach us regarding the authenticity of persons in general and women in particular.
Kramer does indeed speak throughout the book about Prozac in terms like the ones he uses to describe Sam: Prozac can help to discover the authentic self, which lies just beneath the surface of environmental assault and genetic bad luck. Like many of us, however, Kramer thinks and speaks at different times in different terms about the self. In fact, when he makes his most concerted attempt to assuage his anxiety about what we are doing when we listen to Prozac, he does not rely on the notion of the self as that which we discover. For the sorts of good reasons suggested by David DeGrazia in his essay in this book, Kramer does not stand solely by the view that there is an authentic self to discover. Ultimately, what assuages Kramer's anxiety is the view that Prozac facilitates an authentic process of self creation. Prozac, he argues, does not promote or teach any dominant view of what the authentic self is. Prozac does not, to borrow from the language of his subtitle, "remake the self." We, Kramer argues, use Prozac to remake ourselves according to our own lights.
In this essay I explore in more detail the two conceptions of the self that Kramer appeals to when he makes his case that Prozac promotes the authenticity of people in general and women in particular. I explore the assumptions he makes and the questions he downplays on the way to assuaging his anxiety. In the end, I suggest why Kramer's cure will not work.
Discovering the Self with Prozac
The first (right-hand) page of a recent three-page ad for Prozac's chemical cousin, Paxil, presents the image of a huge rock, in which the reader sees a not-yet-finished sculpture. Already visible are the torso, arms, and face of a man whose longing for liberation from the rock is palpable. From what is already visible, the reader can easily imagine how the whole man will look. On the ad's next two glossy pages we see the man fully emerged and exultant. Paxil is the chisel that allowed him to spring free and whole from his prison.
That conception of authenticity-there is a self that just needs to be discovered or freed from life's inessential encrustations-is a great hook for selling drugs. That way of thinking about the self and about what Prozac can do to uncover it (remember Sam's inauthentic fondness for porn) does not only appeal to Kramer. It also often appeals to his patients.
Tess is the first character Kramer introduces in detail. Though her life was strewn with trauma and sorrow, she managed to learn to nurture others, including her employees, siblings, and mother. She made remarkable adjustments and adaptations in the face of horrendous odds, but her unhappiness eventually brought her to Kramer's office. When Kramer first diagnosed her depression and prescribed imipramine, her response was great. Once on imipramine, Tess reported, "I am myself again" (4).
According to Kramer, while she was on imipramine, Tess no longer met the criteria for depression. But as he puts it, he was not yet satisfied, because he thought he picked up "a soft sign or two of depression," and he worried that Tess was at risk for relapse. Further, subtle concerns about Tess's difficulty in both her work and romantic worlds moved Kramer to increase the imipramine. But due to unpleasant side effects, he decided to prescribe Prozac. Kramer explains that his purpose was to "restore" Tess to her "premorbid self."
Much to his astonishment, however, she was not restored but "transformed." Whereas before she snuck around with abusive, married men, now she had three dates a weekend with the kinds of guys any gal would love to bring home to meet Mom and Dad. Whereas before she tended to evade confrontation at work, now she took the bull by the horns. Not only did her company's troubles settle down, but she got a big raise. She lost weight, her humor improved, and she even was freed up to attempt a rapprochement with her mother. After Tess's extraordinary response, in keeping with the usual protocol, Kramer tried to wean her off the medication.
Eight months after she stopped the Prozac, Tess phoned Kramer and reported, "I am not myself" (18). As the drug companies would have her, Tess speaks as if the drug helped to uncover her true self. She asks for more of the drug so she can restore that recently discovered self. Kramer, however, acknowledges-again, the whole book attempts to come to terms with the fact-that Tess learned the contours of her "authentic self" from the drug. As Kramer tells us at length, the drug's power to affect the self worried him: "I was torn simultaneously by a sense that the medication was too far-reaching ... and a sense that my discomfort was arbitrary and aesthetic rather than doctorly. I wondered how the drug might influence my profession's definition of illness and its understanding of ordinary suffering. I wondered how Prozac's success would interact with certain unfortunate tendencies of the broader culture" (20). To assuage those worries Kramer adopts a complementary-and perhaps more compelling-conception of authenticity than the one suggested by the Paxil ad and Tess's words.
Creating the Self with Prozac
Instead of asking, Does a drug like Prozac help one to discover her authentic self? the complementary strategy asks, Does Prozac promote an authentic process by which one can shape her self? What the two strategies share is the aim of showing that Prozac is the friend of authenticity and liberation in general-and women in particular.
Kramer's second major case involves Julia, a married registered nurse with children. Julia does part-time paid work so she can be home at the end of the school day to do the unpaid work of caring for her children. She suffers from perfectionism, which was "so pronounced that she was continually angry at her children and husband and, given the impossibility of instilling her standards in them, [she was] stalemated in her career." Though Kramer initially was reluctant to prescribe a drug to someone he saw as struggling with a combination of context-dependent psychosocial issues and with symptoms that perhaps fell in the penumbra of obsessive-compulsive disorder, he prescribed Prozac.
Like Tess, Julia felt that her life was transformed when on Prozac; when off it, she reported, "I don't feel myself" (29). When off the drug, she did not feel as assertive, resilient, and confident as when on it. At this juncture in the book Kramer worries at length about whether he is using Prozac to do for Julia what doctors did in the 1960s when they prescribed Valium. In retrospect we see that those 1960s physicians prescribed Valium to help women endure patently unjust social arrangements and attitudes. Kramer wonders whether fifty years from now the same charge might be leveled against doctors such as himself.
He worries that he and other doctors are prescribing a drug to help people live up to dominant ideals that are, if not patently unjust, then surely arbitrary. He recognizes that, for example, when he was a child, his German-born female relatives prized the very sort of "perfectionism" that now makes Julia's life so difficult. He appreciates John Updike's observation that "masochism [in women] is as unfashionable now as aggressiveness was twenty years ago" (40). Later in the book, when he returns to this same worry, he recognizes that bereavement considered pathological in the United States would be considered quite healthy in a country like Greece, where normal grieving takes five years. As well as anybody, Kramer understands the concern about using Prozac to promote culturally specific, currently fashionable conceptions of the self.
One of his responses to that worry is to point out that physicians and persons who suffer do not have the luxury of speculating about whether the values they measure themselves against are just or not, arbitrary or not. They do not have the luxury of speculating about the extent to which cultural values are relative. "In the everyday practice of medicine, and in the everyday valuation of human success and suffering, it is fruitless to try to maintain the viewpoint of cultural relativism" (41). If somebody is suffering as a result of not living up to current norms, then those with the means to do so are obliged to respond. On that view, it is at best silly to worry that giving a patient a drug to better approximate current cultural norms is a problem. People who suffer want and deserve relief, not finger wagging about the need for cultural change.
The second and far more developed-and more powerful-response to that worry is that this particular drug, Prozac, could be used in any time to help any person to create her own self. This drug is different from drugs that produce particular ways of being. It can help anybody create her own life projects, whatever they may be, in whatever way she sees fit. Prozac is "the opposite of mother's little helper [i.e., Valium]: it got Julia out of the house and into the workplace." Kramer avers, "There is a sense in which antidepressants are feminist drugs, liberating and empowering" (40).
Those who worry that Prozac makes assertive and sunny selves of a particular "virile," American variety are, Kramer suggests, confused. They think Prozac is a "mood brightener." But it is not. Prozac does not make or mask moods; it does not keep people from seeing life the way it really is. It does not "rob life of the edifying potential for tragedy." Rather, he argues, "it catalyzes the precondition for tragedy, namely participation." Nor does Prozac promote self-absorption (like marijuana or LSD). It promotes other-directed, social activities. As Kramer puts it, Prozac "generally increases personal autonomy" (265).
At this crucial juncture in his argument, Kramer suggests that Prozac does not transform selves. Instead, Prozac frees persons so that they can transform themselves. Indeed, at the end of the book Kramer suggests that the ideal psychiatrist of the future is embodied by Dr. Yang in Woody Allen's movie Alice. In that movie, the sage Dr. Yang uses a combination of drugs and words to help Alice transform herself. "His drugs potentiate change; ultimately, it is Alice's quest that transforms" (290).
Is Prozac a Morally Neutral Technology?
Thus, to relieve his anxiety about whether in prescribing Prozac he inadvertently complies with patently unjust or simply arbitrary conceptions of the self, Kramer makes a familiar move. (I surely have made it.)
Excerpted from Prozac as a Way of Life Copyright © 2004 by The University of North Carolina Press. Excerpted by permission.
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What People are Saying About This
Elliott and Chambers deserve great credit for helping keep this very necessary conversation aliveand for reminding us of the enormous stakes.Bill McKibben, author of Enough: Staying Human in an Engineered Age