THURSDAY, June 12, 2003

Discussion of a correspondence between Paul McHugh, M.D.
and Leon R. Kass, M.D.

CHAIRMAN KASS:  All right.  In this session we move from the scientific and medical to the sociological and philosophic, the question of so-called medicalization, making medical some aspects of human behavior not previously regarded as medical, and the question before us is what is medicalization and why might it be important to our enterprise as the President's Council on Bioethics.

And I'm going to make some semi-coherent, I hope, at least semi-coherent remarks to introduce this, just to indicate why we're talking about it.

We have touched on this topic implicitly in many of our discussions of beyond therapy, whether using biomedical technologies to satisfy personal desires or to achieve some form of behavior control, and we have sometimes tried to get at that question by distinguishing the medical from the nonmedical, say, and the distinction between therapy and enhancement of the use of medical means for nontherapeutic or nonmedical purposes.

The topic also came up in the last meeting in the discussion with Steven Pinker, where the issue was not so much the uses of biomedical technologies as the question of the assignment of guilt and responsibility in a world in which behavior is understood largely biologically.

Some observers of the work of the council have concluded, I think falsely, from random remarks made in these discussions that the council has doubts about the existence of genuine mental illness, such as schizophrenia, depression, bipolar disorder, or that it means by raising these kinds of questions to object to the treatment of these disorders under a medical model using psychotropic drugs.

I think that is a misreading of what we have been doing.

But rather than shy away from this subject, it seems to me that we would do well to try to clarify this matter of medicalization by actually treating it thematically rather than as an adjunct to other matters, to see what it is, what causes it, and whether and why it might be important.

And one of the reasons for doing so is it provides us with at least one look at the larger social, cultural context that shapes almost all of the bioethical issues that we have examined or might examine.  For example, ethical issues raised by preimplantation genetic diagnosis or even prenatal diagnosis are really unintelligible save when seen in the context of the fact that pregnancy and childbirth have already been pretty much completely medicalized, or the ethical issues that would be raised by the uses of psychotropic drugs in children would be unintelligible except if we recognize the degree to which behavioral problems have been medicalized and taken out of the moral realm and brought into the therapeutic, or even any discussion of the regulation of the use of biomedical technologies must begin with the fact that uses of approved remedies are, by and large, left to the practice of medicine and the standards of care.

Now, medicalization is a sociological concept that's been around for some 30, 35 years, and it has been a matter of interest and concern to sociologists for some time, and its scope is much broader than questions just of behavior control or mental diseases.

The background paper written by Peter Conrad that we circulated is a review essay by a person who is one of the first to write on this subject, and he discusses the concept of medicalization and shows how widespread is its reach, beginning with discussions of the medicalization of deviant behavior from alcoholism to compulsive gambling, to child abuse, to the medicalization of natural life processes  of childbirth, child development, and the end of life, and going on to women's issues, from eating disorders, birth control, premenstrual syndrome, menopause; children's issues of learning disabilities, behavior problems.

And as this little clip at your place from the Wall Street Journal from yesterday indicates, now shortness of stature is about to become a medical problem, to old people's issues of, alas, forgetfulness and growing kinds of weaknesses.

And I think that Conrad's essay points out, I think, quite nicely how these are matters partly of conceptualization, partly matters of institutional rearrangements, and also when the doctors are actually involved of direct medical implications for the human relations whenever people bring these matters to the physicians.

And he also points out how the development of effective technologies to intervene in a whole range of areas also increases the tendency to make more and more aspects of human life matters of medical concept and medical approach.  And this is meant to be said simply descriptively.  You know, there's no prejudgment, although some people talk about medicalization with a negative connotation.  We simply mean it at least at this point to be descriptive.

Three things I would like to in my own name sort of put before us that seem to me to be of special significance before introducing the materials that Paul McHugh has especially prepared for us.

First, the matter of surveillance and how many, many more things are now coming under the medical gaze, where the medical view of this, that or the other is now kind of commonplace.  The medical view of marriage and its benefits for health, a recent bit of discussion.

And this medical surveillance, I think, now is something that should concern us especially with the coming of the powers of genetic screening which will, I think, soon be a major issue in which not only will child birth be under the medical gaze, but so, too, the necessary conditions for thinking about what are the criteria sufficient to warrant entry into life.

So the whole question of surveillance is one of the things that's important.

Second, there are economic questions that I think are worthy of our attention, and he points out very nicely, Conrad does, that if the only way to get reimbursement for gaining help with life's problems is through medical insurance, there is a high premium on having all kinds of things declared medical in order to get the help that you need.

And the corollary of that is this, of course, drives up medical costs and places enormous burdens on the health care system as more and more things, whether medical in the narrow sense or in the broad sense, now come to the doors of hospitals and clinics.

Finally, in a most abstract way, this question of medicalization bears really even on the business of bioethics because it finally bears on what constitutes a medical or biological phenomenon and what is an ethical one, as our friend Michael Gazzaniga will be quick to tell us, especially if and when we come to begin to think about ethical sensibilities in terms of their underlying biological basis and substratum.

So that even the very activity that we're engaged in is affected by the rise of the medical and biological model for thinking about behavior, including even ethicizing.

Now, with this as a background and presupposing the Conrad material as read, I want us to turn to the material especially prepared for this meeting.  Although the areas of human life that have been medicalized are many, the area of behavior is, in fact, of special interest, especially as behavior at least as we've always understood it has some kind of biological or natural substrate, but also a human and moral meaning.

And staff has asked Paul to help us think about this larger topic by reflecting on the phenomenon of medicalization in the domain of psychiatry, a subject that has been one of his professional interests really for decades.

And I think before we start that one should simply declare for the record that there should be no mistake about this.  Neither Paul nor I nor the council means in any way to cast doubts on the existence of these mental illnesses or the urgency of caring for the thousands who suffer from them or the families who are also devastated by these illnesses.

There is no hidden agenda here.  We're simply trying to understand this phenomenon and what it might mean for the work of this council.

Paul chose to develop his thoughts in epistolary form, and we decided that it was less work to synthesize his two letters as if they were a seamless document than to allow the things to appear actually as the conversation went between us, and we put those materials before you for discussion.

Paul, do you want to say anything by way of start?

DR. McHUGH:  No, Leon.  I'm very grateful to you for having this epistolary discussion with me.  I enjoyed it.

I would like to — I think the stuff rather speaks for itself.  There is a subtext, I'm sure you see, that is, that Leon asked me to do a little something about medicalization and psychiatry.  I wrote the first letter, disappointing him.  He wrote—

(Laughter.)

DR. McHUGH: — a letter reminding me that I could do better, and I tried harder the second time, and I want you all to know that I'm aware of that subtext and want you to be as well.

(Laughter.)

CHAIRMAN KASS:  If others would like to begin, please do so.  If not, I would in a way put a question to you, Paul, as  away of continuing the conversation.

I'm very excited, as you know, by your attempt to go beyond the merely symptomatic classification of human troubles, to provide what you call the reference classes of diseases, of aberrant behaviors, of what you sometimes call dispositions and sometimes you call — I've lost the other term for it — and then finally the sort of life experiences problems.

And the first of the three is the only class that you see as being somehow on the model of ordinary somatic disease, but all of them legitimately come to the healer of the soul for help.

And I guess the question is:  why isn't that part and parcel, in fact, of the growing medicalization, in fact, of all of those other things even if our approach to them is not exactly the same?

Maybe you could elaborate on the value of these kinds of categories for leaving the things to Caesar that are Caesar's and the things to God that are God's.

DR. McHUGH: Well, it's a long story at one level, and I'll try to make it brief.  What it amounts to is that psychiatry is a discipline of medicine.  It is a medical discipline, but people come into your office just like they come into any doctor's office with complaints and with plenty of psychiatric complaints.  The conditions from which they spring don't necessarily seem directly medical, and a psychiatrist has to decide where they belong.

Prior to DSM-III, the dominant approach to dealing with people's complaints was to try to fit them into an ideological scheme.  In America the dominant one was, of course, Freudian thought and a subdominant one in plenty of institutions was the Skinnerian behavioral one.

The great advantage that the classifications developed by DSM-III were that patients' complaints were subgrouped according to which complaints the patient brought forth and which symptoms could be recognized out of an examination.

The problem with that though is that by classifying things by symptoms and complaints, psychiatry was condemned really to stay at the level that 19th Century medicine was when we classified people according to the fever charts and the characteristics of their pain.

And no director of a department, such as I was, that hoped to achieve a coherent discourse with his group, direct research, and at the same time care for patients could be satisfied with simply that classification.

And so what I have been writing about and I have been proposing for a long time is to see different reference classes of patients just as medicine does.  After all, medicine talks about infectious disorders, neoplastic disorders, congenital disorders, genetic disorders, and the time has come in psychiatry to move towards that kind of classification.

But when you think about psychiatry, it's quite clear that there are plenty of conditions that go beyond because of human kind and the particular features that the human brain brings into play that give other reference classes for disorders.

And so I was interested in my department and in my work to separate the things which are diseases, where everyone could see that these are a breakdown of cerebral faculties, straightforward losses of the capacity to think, to perceive, to remember, to emote appropriately, to have executive control from a second group of classes that are the abnormal behaviors in which what are the rhythms of our ordinary behaviors fall awry sometimes because of injury to the brain, sometimes because of conditioned experiences, the behavior disorders, in other words.

The dimensional disorders in which our psychological characteristics are dimensions of human variations just as our physical characteristics are, and so some people can be in distress not because they have anything broken like a disease would imply, but simply because they are at some extreme along a dimension of human variation, the most obvious one being mental retardation, but others being excessive neuroticism, excessive extroversion or introversion.

And then finally, the conditions or the complaints people bring me or any psychiatrist that fundamentally come out of their life experience, what they've encountered in life and what assumptions they're making about that.

These four reference classes, what I refer to in my books as the four perspectives of psychiatry, obviously interrelate.  They all, of course, depend upon a brain.  You can't have any of this without a brain, but the brain, the human brain does all kinds of interesting things, and a psychiatrist in interacting with such people does different things.

He tries to cure diseases.  He tries to interrupt behaviors, to guide the individuals that are often some extreme in human variation.  He tries to help, essentially rescript assumptions that lead people into encounters with life that will distress anybody.

And when you ask me about how to think about psychiatry in these terms, those were the things; that was my natural place to go.

I think the question that you could ask is:  well, by doing this kind of an approach and, by the way, then generating — let me just spell out briefly that this would mean that any department of psychiatry would have in it individuals, for example, who are skilled at brain imaging and the recognition of certain breakdowns of faculties out of the generation of molecular abnormalities, genetic abnormalities and physiological abnormalities.

The disease model that is clear in medicine should be found in psychiatry departments and representatives of that would be there, but also psychiatry departments should have people who are very interested in the life story of individuals, the narrative and how the narrative reveals sometimes the natural wellsprings of disorder.

And such a broad psychiatry department would be open then not only to the medical departments that surround it in any university, but it would also be open to the public at large that wonders and wants to find not only help for, but some kinds of understandings that could make sense out of current problems, current sets of assumptions and the like.

Your question that started me off on this little preamble was, well, does this make medical everything.  Well, no.  In my opinion, although a psychiatrist is often the person that people come to now at first with a concern, like feeling sad or feeling disrupted in their plans of life or disappointed in what they had hoped for, he or she might come to a psychiatrist first to make sure that the psychiatrist in evaluating the person didn't find something else more fundamental wrong, but the psychiatrist at the end might well say, "Look.  This complaint that you have, this demoralized state, this state of discouragement or depression is, in fact, something that derives from who you are and what you're thinking and lots of people besides me can help you with that, and I want you to be able to turn to those other people to think about what you want to do."

In that way, you see, I feel I would like to move psychiatry where medicine or surgery is today, namely, to the point where the patient can be really on all fours with me in discussing the implications of not only the symptoms that they have, but the treatment that they might accept.

Prior to this or often with simply a categorical diagnostic system, the patient comes to a psychiatrist and then has to say, "Well, you're a person with all of this experience.  You must know better than I do about what counts and the way I ought to live and all of that because you know the secrets."

And this way you'd say, "No, I don't know the secrets.  I think you belong in this kind of problem.  Let's find out who might know better and who might open you and me, by the way, to a better understanding of what you've encountered and how that encounter has shaped your reaction."

I can assure you right now that the problem here is not that you've got some twisted neuron or a twisted molecule.  I'm good at that.  I want to open you to the idea that maybe you have a twisted thought that somebody else as well as me might help you with.

And that's a long answer to your brief question.  I have to say that it has been the story of my life, trying to make this clear to as many people who will be willing to listen.

CHAIRMAN KASS:  Do you want to follow up on this, Frank?  Because I had Gil and then — Gil, then go ahead.  Sorry.

PROF. MEILAENDER:  Yeah, I mean, I am following up on this if that's okay with you.

CHAIRMAN KASS:  Well, sure.  Yeah.

PROF. MEILAENDER:  I just want to try to figure out, Paul, and I have to sort of direct it to you though someone else may have insight.  What difference this really makes, the kind of distinction that you're trying to make.  All right?

And I have in mind a sentence that comes on page 9 of your now published correspondence where you say near the top, "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."

Okay?  Now, it's evidently okay with you that they continue to walk into your office, people who have stage fright or these obnoxious narcissists.  It's okay that they come in, and you think that on a number of occasions you are able to do something or other that helps them.  It might be pharmacological in some cases.  It might just be conversation on other occasions.

So that in terms of the points that Leon raised before, these can still come under medical surveillance, and they can still find ways to be reimbursed through insurance and so forth for the costs of this.

So what difference does it make that some of these things don't fall into the category of brain disease, but they fall into one of the other categories?

I mean, I understand that, and it certainly makes some difference just in the sense of conceptual clarity, but in terms of the practice of medicine, it doesn't seem to make much difference other than, I guess, the person with the brain disease.  You wouldn't say, "Go talk to your friends about this," but with the narcissist you might say there are some other people, too.

But, you know, it's appropriate that they come into your office.  There are things within your armamentarium that you can use to help them.  So what's the difference finally?

DR. McHUGH: Well, let me say, first of all, Gil, that nobody comes into any doctor's office usually with a diagnosis attached to him.  He doesn't come in and say, "Guess what I have.  An aortic aneurism, and it's causing me pain."

(Laughter.)

DR. McHUGH: He doesn't do that.  He comes in and says, "Listen.  I've got belly pain, and I don't know."

Of course, it could be nowadays when you read the magazines that you could do that, and occasionally I can tell you in psychiatry people come in and tell me they've got adult ADHD and I'm to give them Ritalin and let's get on with it.

But for the most part people don't come in to a doctor's office with that.  They come in with complaints and wonder, appropriately, whether the doctor can help them.

And the difference that we're making here amongst them is to say that there are different sources of these complaints, and psychiatrists have greater or lesser capacities to help them, and by making these differentiations and differentiating things according to their essential differences, I think, not only do we serve that patient well, but we ultimately serve the public well who want to ask us appropriately who and whether the patient should get help from you or from other people, and ask us exactly how we give them help.

So first of all, the differentiation is very helpful to the public, in my opinion, by enhancing the differential, enhancing the discourse on the differences in natures about conditions that cause people to suffer.

Yes, I think that I often tell people with stage fright who come into me and say, "Dr. McHugh, I have stage fright, and guess what.  I saw at the Super Bowl that Paxil is very good for this and you're to give it to me."

And I tell them, "No, I'm not going to give you that.  I don't think we have to go that route.  Why don't you find another way to practice and then come back and tell me whether by helping you practice will help you do better?  Okay?"

So I will ask them to go back to their teachers.  I mean, I get this question of stage fright from high school students, you know, who are working, and I'm telling them, "No, I'm not going to give you a medicine now."

It may well be that when I see a person who has more difficulty, for example, a violinist who has problems with trembling in their hands, I  might and I often do recommend, as a lot of people do, Propanolol to help them from those trembles, help them with the physical condition, but I will debate with all of them what they're doing.

And by showing them the nature of what they're asking, I think I enhance their understanding, my understanding, and the public's understanding of my role.  Okay?  Which is not to be the only arbiter of how life should be led.

CHAIRMAN KASS:  Gil, do you want to follow or not?

PROF. MEILAENDER:  Well, no one else is champing at the bit?

CHAIRMAN KASS:  No.  Well, I mean, if —

PROF. MEILAENDER:  I'll wait.  I'll wait.

CHAIRMAN KASS:  Okay.  I have Frank and Robby George and Michael.

PROF. FUKUYAMA:  Well, I enjoyed the exchange of letters between you and Leon.  I think we ought to do all of our reports henceforth in epistolary form.  I have a question about the underlying biology, which maybe you could help me with it, Michael Gazzaniga or other scientists.

Now, in somatic medicine, as I understand it, there's a fairly clear, you know, model for what a disease should look like.  There's a clear etiology.  There's a causative agent.  So we have this thing calls SARS.  We believe that there is actually something that you've going to find, a virus or whatever that will, you know, cause it.

Now, in the world of psychiatry, I assume that there are diseases in that somatic disease sense, but actually the vast majority of the phenomenon that you deal with is this very large category of things called disorders, all of which have biological correlates.  I mean even the most fleeting thought or emotion is going to have some biological correlate, but that there are degrees of biological causation, and there are certain disorders where the biological determinants, you know, are relatively more important.

I guess what I'm getting at is that it seems to me within this category of disorders what makes it so squishy is that a very large number of them are basically, you know, normally distributed behaviors, and that what you're classifying as a disorder is simply something that's out in the tail of the distribution.

And so the question is:  if your project is to try to move your discipline towards a more, you know, biologically grounded categorization of these different things, you know, your four categories, what are the prospects of doing this in terms of the underlying biology?

For example, is it clear in all cases which of these are simply points on a distribution as opposed to, you know, things that will have a different kind of biological, you know, correlate?

And what are the prospects of, you know, moving the field towards a system of classification that is grounded, you know, more firmly in the underlying biology?

DR. McHUGH: Well, first of all, my aim was not simply to move the field into a more biologically based classification, although I support biologically based opinions about certain disorders.

My effort was to say which ones in which I thought a broken part played the major role, that is, the classical disease concept in which an etiology, a pathology lied underneath an expressed clinical syndrome.

I also wanted to say, as everyone would, that you can't have anything in mental life without a brain.  We're not angels.  We all do that.

On the other hand, I also want to acknowledge that there are things about the human brain which are at least to all of us mysterious as to how the brain itself as mechanism causes the problems that the patients bring.

For example, the issue of jealousy.  You can find jealousy as a symptom of a disease, that is, a disease like schizophrenia or manic depressive disorder or Huntington's disease or Alzheimer's disease.  All of those conditions have been described in some of its classical forms as presenting with a jealousy.

On the other hand, much jealousy comes out of dispositional characteristics of an individual in relationship to a life circumstance that they find themselves in, and that their assumptions coming out of their dispositions and the interactions with that environment produce a jealous response.

I want to be sure that people who want to talk about psychiatry would want to differentiate those and appreciate the place of other forms of therapy than a strictly biological form of therapy for that.  Okay?

And, please, press on.

PROF. FUKUYAMA:  I mean, if I can just follow-up.

DR. McHUGH: Yeah.

PROF. FUKUYAMA:  I mean, I'm not  asking to make these distinctions so that we can then discard everything that doesn't have a very strict biological, you know, cause.  That's not my purpose.

DR. McHUGH: No, that's right.  No, that's right.

PROF. FUKUYAMA:  I accept fully that you also want to treat that vast realm of things where the cause is squishier.

But it does seem to me that — and in a way, this gets to Gil's point about why these differences are important, you know.  If something is simply caused by a virus, you don't expect anybody to do anything about that other than, you know, get treatment for it, right?

DR. McHUGH: Right.

PROF. FUKUYAMA:  On the other hand, there's a whole range of behavioral and mental phenomena where, you know, there may be a biological component to that behavior, but the other component is what we traditionally think of as kind of moral behavior that is the result of self-discipline, education, you know, thinking things through and so forth.

And I think that the thing that troubles me and probably a lot of other people about the progressive medicalization or this expansion of the domain of the therapeutic is that it tries to move things that are within this traditional moral realm into a realm of, you know, biological causation where, you know, you're basically telling the patient, well, you can't do anything about it.  So you know, you just have to take your medicine and the like.

And so even if you can get money for being treated for that, you know, what used to be treated by the priests and counselors and so forth, it's still a helpful distinction to be able to say, "Well, look.  This thing is, you know, 90 percent biological.  You can't do anything about it," whereas another category of disorders actually does have this very large component where individual responsibility and, you know, so forth plays a large role.

And so I guess the question is:  does the state of the science give you any help in trying to make that distinction?

DR. McHUGH: Well, I think it does, and I think the advantage of having separate reference classes or separate perspectives of disorder is to see that with each separate class there is a separate understanding of what constitutes disorder within this class, and I think the science does help us a tremendous amount in this.

Well, let me just talk about, for example, what the science, essentially epidemiological science, did to help us understand psychotherapy, and in this case we're talking about the psychotherapy of people that come to us with things like ordinary grief, demoralization, jealousy.

The epidemiology showed us that in contrast to what was expected at the time of the Freudian dominance, that all of these patients would have similar sources of their problems, namely in their libidinal conflicts.  It turned out that these people had very different sources of their problems.

What was common to the psychotherapy patients is that they all felt over mastered by something in life and were discouraged about being over mastered by that rather than that they had a common sources for their problems.

And so that immediately opened up psychotherapy and psychotherapists tomore individual understanding of lives rather than trying to dig deeper for some problem in infantile or early childhood life in relation to their libidinal problems.

But as well it said, well, since the problem here is feeling over mastered, a psychiatrist can help you maybe, but they're going to help you in the same way as other counselors, friends, people of that sort, priests, and the like have previously helped people and open the door to that.

Now, when you bring in, as you did, as Gil did and you did, this idea that we want to be paid for it, I just want to be paid not necessarily for my treatment.  I just want to be paid, I think, for my time like other people, and I want to be sure that I am offering some kind of help.

Sometimes the help is not therapeutic in the sense of actually correcting a disorder, but it is reassuring to people and things of that sort, the same things that other professional people like lawyers do.

And at some level the work is of that sort.  But just to come back to the main point, to express my reference classes could from one point of view be seen as extending medicine out beyond its boundaries.   On another way of looking at it, it could be, and the way I look at it, it would be by defining these reference classes.  People could look at what places — the medical doctor would be primary in the care, and in such classes lots of other people would be able to be on equal standing in that care, and that, I think, would advance us in all kinds of ways, including, by the way, being able to give parity to the mentally ill for the conditions which are most like medical conditions and not clamor for parity for individuals for whom some aspects of their condition, their over mastery, could be helped by others.

CHAIRMAN KASS:  To this?  Mary Ann  Glendon.

PROF. GLENDON:  I just need a little help understanding the distinction between your Class I and Class II, and maybe I'm just wrong in what I've read in the popular literature, but is there not some scientific support for the idea that, say, alcoholism — that there are some people who are more prone to that through brain characteristics than others?

So that your boundary between one and two doesn't seem to me to be quite clear.

DR. McHUGH: Well, the boundary only relates to what leads to the course, not that there — by the way, again, there are going to be brain things behind everything, including, by the way, behind jealousy.

Your question is a frequently asked question, namely, don't you see that certain people, perhaps because of their make-up, have more temptations to sustain a behavior like alcoholism than others.

For example, oriental people often are sickened by alcohol because of an Antabuse-like reaction that they have.  This is very protective for them from taking up this conditions and carrying it further.

It's also probably true that some people get more aroused by a glass of alcohol than other people do and, therefore, find it more rewarding.

Both of those things are true, but in contrast to a disease like Huntington's disease, you will advance in that condition steadily forward regardless of whether you are able to move about or not.  You cannot advance in alcoholism unless you choose to drink, and that choice is, after all, a matter of deciding one way or the other.

That there is a vulnerability behind that choice does not change the fact that it's still a choice, and ultimately the Alcoholics Anonymous that wants to clamor for the concept of disease here as though it was a broken part ultimately does say that, you know, you have to choose to live a different life and acknowledge.

You know, it doesn't matter whether you acknowledge that Huntington's disease has a power over you or not.  It will carry itself through, but it does make a difference if you acknowledge that you are powerless against alcohol and, therefore, avoid it.

And since there are those elements to it, the therapies change.  The responsibilities change, and ultimately the outcome.

Just as a final thing, I might have mentioned this to you before, Mary Ann.  About once a year I get someone coming to my office and saying to me, "Dr. McHugh, I want you to come to court with me because I've been arrested for driving while intoxicated, and I want you to tell the judge that, of course, I'm an alcoholic and, therefore, should get off."

And I always tell them, "No.  I want you to go and be punished for driving while intoxicated because my friends and my children and everybody else are driving, and I don't want that to happen.  After you are punished, I might be able to help you with this conditions, but I might not be able to help you either, depending upon what you're after.  It seems to me today that what you're after is some license and not the appropriate contrition."

CHAIRMAN KASS:  I have Robby George.

PROF. GEORGE:  Paul, I have two questions.  I think they're only remotely related, and the first one you may have gone far toward answering, but it would just help me to get a little firmer grip on it.

I want to sort of follow up.  What I took Gil's question to be, which is really about when are you as a psychiatrist in and when are you out.

Now, from what you've said in response to Gil and Frank and now Mary Ann, I take it that the situation is a little like the separation of powers, if I can use an analogy from my own field.  There's an old line that says we don't have so much a separation of powers in our government as having separate institutions sharing powers, and I take it from what you're saying what we have when it comes to treatment of certain sorts of things that are problems, but they're not like Huntington's disease, we have a kind of sharing of authority, sharing of roles where the psychiatrist, the priest, the dad, all might be dealing with the same problem, and you wouldn't want to carve things up such that you would have strict boundaries where you say, "Ah, this counts as the psychiatric problem.  This counts as the spiritual problem.  This counts as the moral problem."

Am I right so far?

Okay.  But that leaves us where I think we were left after Gil's question.  There must be some criteria by which you as a psychiatrist and others in the field decide, look, this just isn't appropriate for me to deal with.  If I did that I would be practicing priestcraft without a license.

Let me just try and example or two.  I mean, if a corporate CEO comes to see you and says, "Look.  I've got a great career.  I'm making a ton of money.  My business is going well.  Everything is great, but you know, I find myself getting involved with the secretaries romantically, and this could wreck everything.  Doc, I want you to help me."

Would that be the kind of case in which if you didn't detect some pathology, what you detected is a guy who's prone to this kind of —

DR. McHUGH: Fall in sin, yeah, right.

PROF. GEORGE:  Would you say, "Look.  You've got the wrong place.  I mean this is not something that I as a psychiatrist am qualified to deal with"?

DR. McHUGH: We certainly recognize incontinent behavior and call it just that and say, "You don't have a disease, pal.  You have become incontinent in your sexual behavior, and I can tell you what I think about it, and I can tell you some of the things that might help you stop it, but you need lots of other forms of help in the process."

Because they often come with this and say, you know, "I just can't help it, Doc."

And I say, "Can't means won't, and you won't help it," and I begin to talk about drawing in these other people to help  them.

PROF. GEORGE:  Well, now he said, "Well, Doc, look.  Don't get me wrong.  I'm an enlightened guy.  I don't have any moral problems about what I'm doing.  I just don't want my career — I know that the world is such that my career and my company and my business is at risk here.  I just want a fix so I won't do this.  You know, I'm not religious.  There's no clergyman I can go to.  If I told my pals that this was a particular problem I had, they wouldn't consider that to be a problem.  I need you to fix this."

Now, do you now because you're the only game in town, you're the only person he can go to, do you now say, "Well, look.  This isn't psychiatry.  I'm now functioning as some sort of counselor to you, but I'm going to stick with you and see if we can save your professional life"?

DR. McHUGH: Always the beginning of building up a hypothetical case, you gradually get to the point where you might be imagining pigs with wings, you know, and what are you going to do with this flying pig.

But look.  In my opinion, the kind of case you're drawing, Robby, is not at all unusual for many psychiatrists to say, and they, at least as far as I know have not given up on the idea that this kind of behavior is destructive to the milieu in which the person is living, as well sa the character of the person who is involved.

Some of them will use the word "sin" and "adultery."  Others will say this is corruption and the like, and begin from that position, not from the position that your patient that you've imagined said, that is, "Listen, Doc.  You and I are guys together, you know.  Aren't we having fun?  And I just am afraid that his having so much fun is going to get me into trouble."

If someone said that — no one has ever said such a thing to me — but if they said that, I would say, "No, we aren't guys together.  We are people in this society, and there are certain things not only which are against the law, but which are against our ethical posture towards this."

Now, this is to take in some situations a judgmental stance.  Okay?  And, by the way, in my opinion, because psychiatry is the kind of discipline it is and it moves up through these reference classes or up a hierarchy, ultimately we do make judgments and acknowledge that those judgments are derived from the world in which we live.

DR. KRAUTHAMMER:  If I could just say, Robby, we had a recent case of that, and the attempted intervention was not psychiatry, but impeachment.

CHAIRMAN KASS:  I have Michael Sandel and then Jim Wilson.

PROF. SANDEL:  The question that occurs to me in this discussion, and, Paul, I'm constrained to more general territory and the general question of medicalization, is why we worry about it or if we should worry about it.

Why should we have an impulse to try to limit the scope of the medical?  But what is the source of that impulse and is it justified?

And in listening to the discussion, it seems to me there are two different kinds of reasons to worry about the expansion of the medical.  One of them, the one we tend to focus on for the most part is a worry that the biological will colonize the ethical and crowd it out; that the therapeutic will displace the moral.  That's the worry that comes to the fore when we worry about diminishing the responsibility people have for their own conditions if they come to see those conditions as subject to remedy by a pill or by surgery or some kind of medical intervention.

And so we wrestle with cases like narcissism or child abuse or the drunkenness of the driver or the squirminess of the child in the class, and realizing those kinds of things will crowd out or diminish moral responsibility for one's conduct.  So that seems to be one set of reasons to worry about medicalization.

But it seems to me there's a different set of considerations that have nothing to do with whit worry about the biological displacing the ethical, but instead have to do with the range of cases, Leon, that you mentioned at the beginning having to do with medicalizing shortness or the kind of medicalization that accompanies more and more cosmetic surgery.

And this worry has nothing to do with disputing the biological character of these conditions.  No one disputes that shortness is a biological condition.  No one says, "Well, if we medicalize shortness, then people will no longer take moral responsibility for being so short," as in the other cases.

Or if we medicalize the question of someone who has a prominent nose and wants to have cosmetic surgery, we don't say, "No, that's troubling because we want people to pull themselves up by their bootstraps and deal with this themselves, not to pretend that it's just a medical problem that needs to be taken care of."

So it's not that issue at all.  Here it's not the worry about the displacement of moral responsibility, and yet there is still a worry about medicalization in this other domain, and it comes closer to the enhancement cases we were discussing.

And then I think it has to do with another feature of the medical, the reason we want to cabin or confine the medical, and that has to do not with its concern with the biological, but instead with its orientation to fixing rather than accepting.

And so because it's a feature of the medical that it attends to disease.  The telos of medicine, traditionally understood at least, is to attend to disease, which is to say to attend to things in need of fixing.

And so we worry here in this second domain that we will redescribe conditions like shortness or like having a prominent nose as diseases when they're not properly regarded as diseases, and one way of expressing this worry is to say that medicalizing these kinds of things will stigmatize people who are short, let's say such that beforehand we might not have noticed it as much, but now that it becomes something that's routinely subject to a medical cure we notice and worry more when people are short or when they have prominent noses or when they have teeth that aren't perfectly white and aligned or whatever the case may be.

So it's the fixing part of medicine here that wants us to rein in the scope of application of the medical lest we consider more and more conditions as things to be fixed rather than as things to be accepted or, for that matter even appreciated.

I don't know if that's a helpful distinction.  The one final thought about the second category is we could deal with that problem, the problem of medicalizing conditions like shortness and so on in one of two ways.  We could say, "Well, all right.  We will expand, as implicitly we must, what counts as a disease to include that, but that seems bothersome."

Anther way of dealing with it would be to say, "Well, maybe medicine should be detached from that.  Maybe we need to enlarge the telos of the medical so that we no longer regard it as concerned with curing disease."

What do we call the people who do cosmetic surgery for a living?  Well, they're engaged, we would say, or are they, in a medical practice.  Well, here let's talk about just purely elective, or would we say we should detach the medical from the notion of curing disease so that at least we don't taint all sorts of conditions with disease and just say, "Well, maybe medicine isn't solely about curing diseases.  Maybe it can be for fixing things that people simply want to fix, even if there is no disease."

But that seems also to carry a certain kind of cost or at least there seemed to be reasons.  I think a lot of people would resist.  So enlarging the medical by detaching it from curing or attending to disease, but it seems to me in any case that these are two very different reasons to worry about medicalization.

CHAIRMAN KASS:  Does someone want to join in on this before we move on?

DR. KRAUTHAMMER:  Yes, I would.  I would  like to add a third reason, I think, and it might actually be the reason why society decides that it's going to have to act on it, and that is the economic cost, that apart from the moral cost of expanding the medical, the economic cost would be huge.

There is a sense that we have, and I think it's correct, that if you suffer from a medical condition, society has a kind of obligation to help you in coping, and that if you're poor, you shouldn't have to suffer in a way that a rich person would not, and that's why we have this idea of Medicare-Medicaid and expanding social help.

It's inexorable.  In Europe, of course, it's universal.  Here it's expanding.

Now, as you expand what is legitimately considered medical you will expand the realm in which society is seen as required to contribute to your assistance, and as that area expands, it's going to create a huge social cost, and I think that in the end may be the reason why there are attempts to contract it.

We see the argument acutely in whether or not a psychiatric illness, mental conditions should get the same kind of coverage as so-called physical illnesses.  That's the most obvious and acute example of this, but I think it's going to expand as the range of the medical expands as well.

PROF. SANDEL:  Could I give a quick reply to that?  I don't think that the economic reason is a third reason independent of these two.  To the contrary, I think it's parasitic on one or the other of these two for the following reason.

If it were just a matter — if worries about medicalization were just a matter of society having to bear too great a financial cost, it can't just be that because the reason — suppose the reason that things became very expensive is simply because we got very good at transplants, and so people in need of hearts and kidneys on a much larger scale were able maybe because the immune problem were overcome to have them. 

We wouldn't regard that — it would be an economic challenge, but it wouldn't be a challenge of the kind that we worry about when we object to medicalization because it's not controversial that a heart or a kidney transplant is a medical procedure.

DR. KRAUTHAMMER:  What about orthodontics?

PROF. SANDEL:  What's that?

DR. KRAUTHAMMER:  What about orthodontics?

PROF. SANDEL:  Well, the reason that becomes controversial is it falls into one of the two reasons we have for questioning the scope of the application of the medical.

So the economic issue only arises against the background assumption that we as a society agree that genuinely properly medical needs are covered, and so we worry about medicalization under these two other headings — maybe there are others — because in both of those cases we have reason for questioning whether the scope of the medical isn't being expanded in ways that are objectionable, whether because it crowds out the moral or whether because it tries to fix what should be accepted.

CHAIRMAN KASS:  Gil, did you want a small thing on this, too?

PROF. MEILAENDER:  Yeah.  I think that finally there's not such a large distinction between your two categories, Michael.  I mean there is an obvious on the face of it distinction between your accepting moral responsibility and what medicine ought to do.

But as you yourself recognize, if it turns out that there are some things that people want and that we can do, but that don't seem to constitute fixing in the sense that medicine traditionally fixed things, then we have a couple alternatives.

We could expand the realm of medicine and say doctors didn't used to do this, but now doctors do it, or we could say, "Well, but people still want it done.  So proctors should do it.  Yo u know, they've got a lot of the same skills that doctors do and they should do it."

And if you want to resist that, whether you want to resist the expansion of medicine or you want to resist the notion that kind of somebody else should do this, what you're going to have to say is this is something that should be accepted, that should not just be fixed.

And we're beginning now to do talk that though granted it grew out of a different issue is rather like the moral responsibility talk.  So I don't think that there is finally quite as wide a gap between them, though I agree that the second kind of case you raise grows out of the question of what really constitutes health and what really constitutes disease or medicine, but it finally drives us back to assert what we do or do not take responsibility for.

CHAIRMAN KASS:  Briefly Michael and then .-

PROF. SANDEL:  They're both normative question I agree, but they're different normative questions.  One has to do with what should people be held  morally responsible for, and the other has to do with what do we consider should be accepted rather than fixed.

I agree they're both normative.

PROF. MEILAENDER:  Well, people perhaps should be held morally responsible for learning to accept certain things about life.

CHAIRMAN KASS:  Jim Wilson will now make trouble.

PROF. WILSON:  I think the problem that Paul has addressed under the concept of medicalization is much broader than the problem as he sees it in psychiatry, and my views on this are, in part, an effort to answer Gil's question what difference it makes.

Medicalization to me as a non-real scientist, but a fake political scientist is a synonym for causation.  Now, all behavior is causes, and there is an effort in not only our society, but most societies around the world to extend the concept of cause so that everything is caused in a way that crowds out the moral, as Michael said.

Let me give you the case from criminal justice, if Mary Ann Glendon will overlook the many mistakes I will make in this brief summary.

Somebody shoots another person by firing a gun.  The person is brought to trial, and there are a variety of arguments a person can use.  One is that he is a victim of epilepsy.  Admiring a gun that is part of his collection, he had a seizure and his finger squeezed the trigger and fired a bullet at somebody else.

The next level is he's insane or, to put it bluntly, he is crazy.  He doesn't know the difference between right and wrong and thinks the voices of Satan are directing him to do it.

The next level is duress.  Someone pressed a gun to his temple and said, "If you don't shoot this bullet through this window and hit this person, I will blow your brains out."

The next level up is diminished capacity, which is kind of an adolescent version of insanity.  They're kids.  They're not quite sure what they're doing.  They're 14 years old.

On the next level up is prior abuse or neglect of the sort pled by those two wealthy, young Beverly Hills men who pumped 12 rounds of 00 buckshot into their parents and watched them die because, as their lawyer later claimed, they had been the victim of abuse when they were ten years younger.

And then the next level up are life experiences generally, in which you could put alcoholism.

And then finally at the highest level — I'm skipping several — is pure choice.

Now, defense lawyers will go into court and try to  push the argument back toward causation, and prosecutors will go into the court and try to push the argument back towards pure choice.

Now, in this case, there is a solution to the problem.  That is to say a judge and a jury must make a decision that is either a yes or no decision.  The person is guilty or innocent or possibly not guilty by reason of insanity.

And in making their judgments, they asked the question:  to what extent was the person able to control his behavior?  And the control judged by a contemporary social scientist may not be very large, but though they would probably excuse epilepsy and insanity and perhaps duress from diminished capacity all the way up to pure choice, they tend to collapse it into the category of pure choice.

Now, what evidence do they have to back it up?  I think the evidence they have, which the judges sometime state and sometimes not, is that we can think of people who had the same prior abuse, prior neglect, diminished capacity, alcoholism, et cetera, who didn't shoot anybody, and since people with these conditions can avoid shooting other people, the fact that you chose to shoot somebody else means that whatever your circumstances may be, you made a choice that you didn't have to make.

Now, this is not the problem that society faces because society does not have a judge or a jury, and society increasingly, in my view, over the last half century has begun to say that social controls, society's effort to judge somebody as innocent or guilty, have been profoundly weakened because to judge somebody as guilty, society must use such things as shame or stigma, and increasingly we are told that shame and stigma are a bad idea.

And, indeed, the people who go to Paul and say, "I've got stage fright," or, "I am sexually incontinent," or the other will hear from him a response that says, "This isn't a medical condition. You should be ashamed of this."

And what they're going to do is drop Paul as their psychiatrist and go to somebody else, and they will find other people who will say, "Yes, we certainly mustn't use the word 'shame' and 'stigma.'"

Society does not want to be judgmental.  Being nonjudgmental is a good thing.  So I think the problem that the exchange between Leon and Paul raises should not be limited to the definition of what is medical in the eyes of a medical professional, but rather should be viewed as the general social problem of how we define personal responsibility and the fact that in my opinion, which could be wrong, we have changed profoundly the extent to which we judge people as acting improperly, and we are reluctant to impose social rewards and punishments to induce them to act properly.

PROF. GEORGE:  Leon, could I ask a question of Jim?

CHAIRMAN KASS:  Please.

PROF. GEORGE:  Jim, I followed that, I think, completely, and it certainly sounded right to me, but I just wondered about a statement you made very early on in the presentation and its compatibility with what followed, and that was the statement that all human behavior is caused, unless you mean by that simply that there are empirical conditions of all human behavior, including choices that constrain the options for effective choice.

PROF. WILSON:  Yes.

PROF. GEORGE:  Is that all that that meant?

PROF. WILSON:  Yes, I probably shouldn't have used the phrase, but behavior is caused in the sense that some combination of biological imperatives, cultural traditions, personal choice, and the nature of immediate circumstances leads persons to exercise Option A rather than Option B.

I mean nothing more profound than that, and you can strike the word "cause" if that seems to become a motive.

PROF. GEORGE:  No, in philosophy there's a big literature about the distinction between reasons and causes.

PROF. WILSON:  I understand.

PROF. GEORGE:  And I was just wondering whether you were rejecting the idea that there could be reasons that are something independent of the causes.

PROF. WILSON:  No, no.

PROF. GEORGE:  And I take it you —

PROF. WILSON:  I am not rejecting the notion that all behavior is caused and part of the causes are the reasons people developed to make a point.

PROF. GEORGE:  Yeah.

DR. McHUGH: And if I could just enter, too, into this very interesting comment you've made, Jim, and it's this issue of stigma.  And it is often said that psychiatrists and doctors and all of us should give up on stigma, and that is certainly true for the diseases in psychiatry.  We want to give up on stigma.  In epilepsy we want to give up the stigma on bipolar disorder.

But everyone knows that no one is giving up the stigma on certain behaviors.  Smoking behavior is the most stigmatized behavior right now in our country.  It's stigmatized and not tolerated.

In point of fact, your other statement that if I did stigmatize this to a person — again, we have to remember that we made a pig with wings here with Robby — that he would run away.

In point of fact, that's not my experience.  People who come in with the concern that, gee, my behavior is liable to get me into trouble and hear from me that, yes, it will get you into trouble and it should if you continue it would then ask me and do ask me not only how they can avoid it, but how they might look at it in a different way, stigmatizing it appropriately and thinking about it in its relationship to its effect on others.

And, by the way, most of them stay with me and say, "You know, I never thought of that before," when they give as their cause that they're doing this because their feelings matter and their feelings are driving them, and their feelings are the cause, and they hear from me and from other psychiatrists that, you know, when you grow up your feelings don't matter to most people.  It's just your behavior that does.

And they always say, "That's a very remarkable statement to hear," and stay with me as their behavior gets better.

PROF. WILSON:  People keep coming back to you, Paul, because you have such an engaging personality.

(Laughter.)

PROF. WILSON:  You can stigmatize them without using the word "stigma."

(Laughter.)

DR. McHUGH: Well, that's —

PROF. WILSON:  But I would be willing to bet you that the search for non-stigmatic relief is more widespread than your own office experience would be.

CHAIRMAN KASS:  Alfonso and then Bill May and then Janet and then Bill.

DR. GÓMEZ-LOBO:  This is going to be a very brief and perhaps minor remark.  I'm just trying to think for my own benefit about the more general context, and I tend to think that this is a really particular case of something much deeper and much more pervasive in Western culture and Western history. 

What I have in mind is something like this.  I would bet that 30 years ago most people made financial decisions on their own, you know, whether they were going to buy stocks or bonds, et cetera.

Nowadays, I think most people would deeply hesitate to do this before consulting an advisor, financial advisor, or I found this out some time ago.  People who are going to send their kids to college now can go to a college choice counselor.

Now, what does this mean?  It means that socially we have tended to parcel reality and to assume that there are people that within a domain have something close to an algorithm to make the decision.

The reason why we go to a physician is because we trust that the physician is going to have symptoms, et cetera, in front of her and then come to the conclusion, oh, you have pneumonia, and then the solution is going to come.

So I'm not surprised at all about the medicalization, this tendency to reduce things to treatment that can be controlled because this tendency in our culture is a tendency to find areas of control, and naturally enough to displace the prudential approach to those fields, which I think is what Paul is alluding to, and also the moral deliberation, the moral reasoning about those fields.

If a field is dominated by a specialist, of course, we can withdraw and say, "Well, that's where the responsibility lies."

So what I'm just suggesting is that we really immerse in a much broader thrust of our culture to control certain areas of behavior by handing them over to people  who would know how to decide.

CHAIRMAN KASS:  Bill May.

DR. MAY:  Well, it's very interesting hearing you, Alfonso, talk like Ivan Ilyich, the broader professionalization of life in all aspects.

DR. GÓMEZ-LOBO:  My source is actually Aristotle.

DR. MAY:  Yeah.  Well, the pathology, however, is a very large and growing, modern one.  You know, professionals hang out a shingle, and in doing that it specifies a little further and you invite certain strangers in to deal with, but at the same time, of course, off the streets comes an awful lot of things that are unbidden and not asked for.

And now you end up.  You've got a moral alternative there as a professional.  You can preserve the purity of your specialization and say, "But I don't deal with that," and therefore refrain from medicalizing everything or lawyers legalizing everything and so forth across the board in the professionals.

But on the other hand, at the same time, you happen to be neighbor to the problem because they've come in and you're nearest to that problem, a little bit like 19th Century doctors who became aware of the problem of sanitation even though they were not sanitary engineers.

Of course, in that case you saw the social remedy, and that led to important improvements in health care that were not available directly through the efforts  of the professional, but you are neighbor to the problem, and it may be a rather privileged moment for that individual.

She can't talk to her husband.  The relation is frozen in all sorts of ways.  They've moved at least once every five years.  Other forms of help and larger family and so forth are quite distant, and so forth.  And he or she has come to you with a problem.

Now, have you medicalized everything by not simply turning attentive ear?  It's a moment that may pass, and you have further responsibilities.  It seems to me that you may not be fully paid for if you stick simply to treating disorders, but in your ascending scale interrupting behaviors, guiding dispositions, and reframing life stories, you're moving farther away from the medical, but humanly you have certain responsibilities.

And how can we sort this out in such a way that one does not escape ones responsibilities as human being in order to preserve the purity of professional identity?

High school teachers or junior high teachers maybe even more than senior high are in a position of privileged neighbor when things aren't working out well with mother and father and so forth, and that's not what they teach, but they have a privileged position close to that problem.

Now, we have — and this is where Leon's economic issue, concern here.  It's easier to get compensation for this kind of time expended in life if one can define it as medical, and so we end up medicalizing an awful lot through the economic pressure here, but we don't want excessively to shrink responsibility simply in order to avoid medicalizing problems.

DR. McHUGH: And I think, Bill, if you look at the history of some of the great advances in psychiatry over the last several decades, it has been just exactly this being neighbor to a certain problem and then helping the society, the culture, the school and the like to enhance what it's doing for the betterment not just of this particular patient, but for people in general.

I mean, much of the advances, for example, in child psychiatry have been in relationship to speaking to the schools, offering a wide spectrum of opportunities for children to succeed in.  Once it was recognized that it helped children to become adults if they had had some kind of success earlier in life that came out of first looking at the individual patients, but ultimately it spoke to the public at large as to how a school should have a variety of things, from athletics out to scholarly work, to give more people a chance to succeed.

And I think that the place, it is a very privileged place to be close or neighbor to it.  I think that's a wonderful metaphor you draw there because it does speak to many of our situations to which we become responsive by calling attention to the patient and to the society that this is the place where they could work together.

DR. KRAUTHAMMER:  Could I make just one interjection on this?

CHAIRMAN KASS:  Yes.

DR. KRAUTHAMMER:  Bill, you brought up an interesting example of the person who comes into you and you feel a responsibility to respond humanly, even though it may not be a medical problem.

The complication here is that she came into you because you hung a shingle and you are a doctor.  She didn't go to the bartender or the man on the street.

And I felt this acutely.  I quit psychiatry exactly 25 years ago this month, an anniversary that I celebrate every year.  One of the reasons is that I always felt that uneasiness, a sense to respond humanly, but I was doing it because of her illusion that as a psychiatrist or as a doctor I had a special insight or wisdom or secret, as paul phrased it.

And I found that by actually using that misconception on her part, I could actually do good, essentially produce a placebo effect, but it was under a false premise.  I knew that there wasn't a secret, and it was in a sense a Wizard of Oz operation.

So you've got an obligation as a human to respond, but given the context, you're doing it under the rubric of having special medical powers, and that creates a real complication and a contradiction in some sense.

DR. MAY:  Yes, although the way Paul has described his work as a psychiatrist, he takes advantage of that in order to clarify instead of remain behind the vail.

DR. KRAUTHAMMER:  Well, he gives it up in the first half hour.

DR. MAY: Yes.

DR. KRAUTHAMMER:  I found out if you didn't you could actually get a real placebo effect, and that would actually help the patient, particularly in changing behaviors like smoking or excessive compulsive behavior.

I mean, hypnosis essentially, which is one of the things I practice, is essentially a way of using that aura as a way to achieve the results, and it actually does work remarkably.

CHAIRMAN KASS:  Janet Rowley.

DR. ROWLEY:  Well, first I have to express my surprise when I was reading this interchange of letters to note the comments about a lecture that I gave at Hopkins, and I certainly want to thank Paul for his very generous comments. 

I'd like to take a different track, and Paul McHugh also mentioned the analogy of psychiatry being in the 19th Century as compared to many aspects of medicine.  One could certainly see now that we've moved to yet another century that it's in the 20th Century and not in the 21st.

And I think that psychiatry, as well as many areas of medicine are  both a moving target and clearly even better defined diseases are very heterogeneous.

I guess the concern I have about this discussion is to what extent are we mixing medicalization with increasing scientific understanding of the biological basis for behavior, and certainly in many aspects of understanding brain function and interneuronal connections and the importance of that, we're only on the threshold, and this increasing understanding of a very complex system is certainly going to  change both our understanding of behavior, but also a possibility of modifying behavior.

Now, certainly one modification of behavior can just be learning to take advantage of other aspects of the nervous system so you control unwanted behavior, but again, in a heterogeneous situation where there are tails of behavior, it may well be that some additional form of treatment might be helpful.

But I think that it is very important that we keep understanding that we're pretty ignorant about behavior.  We just had a lecture on the immune system and the complexity of the interaction of cells, B cells, T cells, antigen presenting cells, and antigen.  The nervous system has been likened to the immune system in that there are these multiple cellular interactions, which we are very, very ignorant of.

And just as cells communicate by releasing substances which tell other cells to do other things, this is certainly true in the nervous system as well, and we're early on in, say, understanding homosexuality.  Some of this is almost certainly going to be due to the lack of receptors on critical cells or the lack of ligands so that the kind of behavior that we accept as normal does not occur in these individuals because of these biological differences.

And we will some time in the next several decades be able to sort this out.  So as I say, I have concerns about worrying about some of these things.

Amongst the things that are listed as being medicalized are childbirth.  I think that it's pretty clear as you look at the statistics for maternal deaths and fetal deaths in the black population that their lack of health care emphasizes that childbirth is not just something that you can go off in the corn field and everything goes well.

And I think we also have to recognize that very soon obesity is going to become a very serious medical problem which will have many complex aspects of it, genetics as well as the total change in life style, our lack of exercise, our exposure to foods that are not good for us.  All of these things are going to be important.

But we have to then look at a very complicated response to this major health problem, and one response may well be some aspect of involving medicine or drugs at the same time as we also try to help people understand how they can change other things so that we don't have this problem, which leads to very serious, fatal medical consequences.

So this is a long winded expression of concern that we look at this in a broader context and are sort of cautious as to coming back to Michael Sandel, is this a problem or why is it a problem or what problem might we as a council be able to provide advice and guidance on?

CHAIRMAN KASS:  Okay.  We are late in the hour.  I have just — Frank, did you want a very quick thing?  Bill is in queue.

PROF. FUKUYAMA:  I mean, Janet, it seems to me that that doesn't really — it fails to recognize how politicized a lot of this is, and homosexuality is a perfect example of that.

As I understand it, homosexuality used to be classified as a psychiatric disorder, came out of the DSM at about the same time  that ADHD went in.  All right?  We know about both of those conditions.  Actually fairly similar.  They had biological correlates.  Over time there's been growing understanding of the biological bases of both of those disorders, but you know, the only way that you can actually understand the actual outcome, I think, is in terms of the politics and the sociology of the way the society, you know, constructs one as a disease and the other as not.

So I think that is is true that we are .- I mean it would be nice if there were this correlation between our understanding of the biological causes and the way we classify these things, but there's a huge element of social construction, I think, in the way we understand these psychiatric disorders.

CHAIRMAN KASS:  Bill —

DR. ROWLEY:  Well, all I'm saying is I think it's very important that we first understand that it's heterogeneous, and that we be very cautious in how we as a council, separate from society and politics, how we think about the broader issues.

CHAIRMAN KASS:  Bill.

DR. HURLBUT:  It's interesting Janet because as I ponder the emergence of scientific knowledge as you say, I feel what you mentioned, the possibility of interventions at various levels and the possibility that things that we attribute to some kind of construction of personal identity as being, in fact, driven by underlying chemistry.

But what impresses me even more is that our notion of cause is changing.  We've talked here about how medicalization is really a shift in the notion of causation, but what I would add to it is also a shift in our sense of what is appropriate by way of cure, if you will, for a given condition.

When I ponder what science is teaching me as I see the underlying processes by which the person emerges, if anything cause is becoming more complex and instead of labeling something biological versus whatever you call it, moral or personal character, it's beginning to seem more and more, as it should obviously, that the emergence of the person within the phylogenetic process was, in fact, a biological phenomenon with significance.  In other words, if you look at all of phylogeny, you see the steady assent from physicochemical determinism up to an increasing sense of genuine freedom, distancing from determinism.

So that the person actually makes a difference, has a meaning, and allows a specificity of response that you can't get with a chemical, and I think Paul's early letter actually had a lot of good things about this with psychiatric treatment, is that it's often directed at symptoms.  Symptoms are very broad, and the drugs lack the specificity of actually remediating an individual person.

And Charles' comment about the placebo effect and so forth is an interesting one because at least the placebo effect engages the reality of the person.

The problem, it seems to me, is that a simple, materialistic cause deletes the complexity of the cause and also the sense of solving something with a chemical erodes the engagement of the full human person and the manning of the human process.  So that it actually operates too low in the chain of causation.  Therefore, it's not specific enough.  It doesn't operate at the real level of what is causing things, which is both chemical and at the same time the convergence of chemistry with ideas, attitudes, memories, beliefs, and in other words, chemistry and the underlying chemistry and the overarching cognition that's actually part of human existence, and the proper approach to a real human problem, not a problem that has a genuine underlying medical or physical cause that probably is properly treated by medicine, but the problem is that medicalization is delivering into the medical hand and the medical gaze and the sense of where the cure should come from, those things which are actually humanizing in their way of being dealt with properly.

In other words, what I'm saying is that in a sense those fullest extensions of human nature, what you might call a mental spiritual psyche are actually extensions of more fundamental biological agencies so that what really makes a person a full person and a more effective person is not just physical, but what you might call the realm of philosophy and faith, a true integrated personal identity operating within a cosmology, which is at once deeply humanizing.  It both upholds the person and the process of the person alike.

I mean, in the final end what's going to happen with this medicalization is we're going to medicalize morality itself so that we think that there isn't really any free agency.  There is victimhood.

And this is what is the most corrosive quality of evolutionary psychology.  It essentially deletes the higher order meaning of human consciousness.  It actually converts ultimately everything to a simplistic medical explanation, deletes human fullness, and in the process converts everything into what you were calling earlier a libidinal problem just driven by unconscious drives and desires over which we have no agency.

In the final end then all of criminal behavior, all of behavior will be simply medical problems deleting the person and the meaning of life itself.

CHAIRMAN KASS:  Thank you.

We are at 12:30.  We have guests coming at two o'clock.  The hour is late.  I'll spare you a summary.

Please be prompt for our guests.

(Whereupon, at 12:29 p.m., the meeting was recessed for lunch, to reconvene at 2:00 p.m., the same day.)