The use of placebos in medicine raises a large number of serious ethical issues. Do they involve deceiving patients, or violating their autonomy in some way? Are they harmful to certain patients, in research trials where the actual treatment being trialled is thought likely to be successful? Can placebos – if medically warranted – be funded through a health care budget? All these questions require us to be able to say what a placebo is, and that is more tricky than one might think. Continue reading
Among close friends, or even within the family, the use of SSRI’s (selective serotonin reuptake inhibitors) can be a delicate topic, it may come with connotations of depression, suicidal behaviour, and can be emotionally marginalizing. A new scientific review may further entangle this already vexing situation, in the study (Isacsson, G. & Alhner, J. 2013) it was found that the presence of suicide warnings in SSRI’s may have indirectly increased suicide rates due to an intricate form of cultural Information Hazard.
Despite being a review, the study only faintly points toward a certain interpretational direction, but it doesn’t clearly guarantee it. With that prior caveat in mind, Isacsson and Alhner gesture that the warnings mentioning suicide risk have caused a plateau in SSRI consumption in Sweden, and that during this period, the rate of suicides among those who didn’t take SSRI’s increased, and more so than among those who did. Once the label was in place, it made the decision not to take SSRI’s worse than it was before. This is a complicated process, and it is worth analysing it further.
In both the no-warning, and the yes-warning situations, you had three populations, A, who wouldn’t take the prescription regardless of anything else, B, who would take it as long as no suicide warnings were inscribed, and C, who would take them anyway. A comparison was made between C plus B and, separately, A, in the no-warning case, factoring out of course as many irrelevant variables as possible, and it was concluded that warning the C plus B population would be a good move to avoid suicides. Yet, in the yes-warning situation, it turns out that group B (those who would actually shift from taking to not taking) ended up more likely to commit suicide, contrary to prior expectation.
In this case, the warning itself can be considered an Information Hazard, and can be qualified as belonging to the following categories developed in the linked paper above by Nick Bostrom:
Temptation hazard: The warning tempts group B, who should not make the shift, to make the shift from accepting to denying prescription.
Knowing-too-much hazard: Knowing that SSRI’s can downstream into suicidal behaviour, despite true prima facie, is an undesirable piece of knowledge to have, making one more vulnerable to the very problem the knowledge should help with.
Although unusual, this is not an unheard of situation, its reverse even has a popular name: self-fulfilling prophecy. This is a case where a prophecy is self defeating. Not very frequently Medical Ethics intersects the field of logic and philosophy of language in relevant ways, but in this case, a comparison with the liar’s paradox is worth a note. In the same vein as “this sentence is false” is false when it is true, and true when it is false, so a suicide warning appears to be ethically desirable when absent, and ethically undesirable when present. Unfortunately, in this case, what results is not a beautiful paradox like Newcomb’s, but the worst of possible worlds.
As the quantifiable data on human cultural transmission increases, we are likely to find more and more “ethical conundrums” of this kind, and it would be well advised to educate ourselves with a vocabulary and intuitions to deal with these preventively, because sometimes, it is better to find ways to deal with what’s inside the box before finding out it belongs to Pandora.
Bostrom, N. (2011). Information hazards: A typology of potential harms from knowledge. Review of Contemporary Philosophy, (10), 44-79.
Isacsson, G. & Alhner, J. (2013). Antidepressants and the risk of suicide in young persons – prescription trends and toxicological analyses. Acta Psychiatric Scandinavia, 1-7.
Love drugs and science reporting in the media: Setting the record straight
Love. It makes the world go round. It is the reason we have survived as a species. It is the subject of our art, literature, and music—and it is largely the product of chemical reactions within the brain.
No wonder science is starting to unravel the ways in which we can influence it, and perhaps even control it.
Just as Darwin’s finding that we are descended from apes shocked people in the nineteenth century, so people will be shocked to find that our most lofty social ideal is something we share with our mammalian cousins and which is the subject of scientific scrutiny and even chemistry-book manipulation.
In 2008, two of us (Julian Savulescu and Anders Sandberg) published an article in the journal Neuroethics on the topic of “love drugs” – a term we use to refer to pharmacological interventions based on existing and future bio-technologies that could work to strengthen the bond between romantic partners. All three of us have an article just published in the journal Philosophy & Technology in which we build upon that earlier work. Interested readers will take the time to study those papers in full, but we have a feeling that much of the population will stop at a handful of media reports that have recently summarized our ideas, including at least one article that we think has the potential to mislead. Let us set the record straight.
By Brian Earp
Love and other drugs, or why parents should chemically enhance their marriages
Valentine’s day has passed, and along with it the usual rush of articles on “the neuroscience of love” – such as this one from Parade magazine. The penner of this particular piece, Judith Newman, sums up the relevant research like this:
It turns out that love truly is a chemical reaction. Researchers using MRIs to look at the brain activity of the smitten have found that an interplay of hormones and neurotransmitters create the state we call love.
My humble reckoning is that there’s more to “the state we call love” than hormones and neurotransmitters, but it’s true that brain chemistry is heavily involved in shaping our experience of amour. In fact, we’re beginning to understand quite a bit about the cerebral circuitry involved in love, lust, and human attachment—so much so that a couple of Oxford philosophers have been inspired to suggest something pretty radical.
They think that it’s time we shifted from merely describing this circuitry, and actually intervened in it directly—by altering our brains pharmacologically, through the use of what they call “love drugs.”
In book 4 of Homer’s Odyssey, Odysseus’s son Telemachos arrives in Sparta to quiz Menelaos on whether Odysseus is still alive and if so where he might be. Menelaos reduces everyone (including himself) to tears by telling everyone how sad he is that Odysseus hasn’t made it home. He then says it’s time for them to pull themselves together and have dinner. His wife Helen, however, also wants to talk about Odysseus, and has a bright idea:
Into the wine of which they were drinking she cast a medicine
of heartsease, free of gall, to make one forget all sorrows,
and whoever had drunk it down once it had been mixed in the wine bowl,
for the day that he drank it would have no tear roll down his face,
not if his mother died and his father died, not if men
murdered a brother or beloved son in his presence
with the bronze, and he with his own eyes saw it. Such were
the subtle medicines Zeus’ daughter had in her possessions,
good things … (4.220-28, trans. Lattimore)
What would it be to ‘forget all sorrows’? And would it be rational voluntarily to take such a drug if it became available? Thinking about these questions raises further issues about the nature of well-being and the value of the emotions, and is particularly appropriate at a time when it is being widely claimed that there may be therapeutic benefits in memory modification or other interventions.
Some people claim that suffering pain is good in itself. It usually turns out, however, that they mean that suffering is good in so far as it enables one to acquire some other good, such as understanding what others are going or have gone through, or certain profound truths about human life. It’s also common for people to suggest that suffering, though it may be bad in itself, is required as a background against which certain good things in life – in particular, of course, pleasure – can stand out. These and other such claims, however, seem especially dubious in the case of someone who has already experienced quite a lot of suffering and can remember it – as will be true of nearly all adult human beings.
Other kinds of suffering, however, are more tricky. Telemachos fears his father may be dead, and one of Helen’s aims is to avoid arousing grief in him. Grief is usually unpleasant, sometimes extremely so. What if some medication could permanently remove any tendency to grief, with no damaging side-effects? It might be thought that if Telemachos were to remain unmoved by the notion of his beloved father’s death, this would somehow undermine the depth of their relationship. But perhaps Helen’s aim is not to remove the cognitive and more positive conative aspects of the experience of grief, but merely the unpleasant feeling. So Telemachus can still think fondly of his father’s patient heart, kindness, bravery, nobility and so on, and of how bad it would be were he to have been killed on his way home from Troy. And perhaps he can still be said to love his father, still being strongly motivated to search for him, spend time with him, and so on.
But even if this is right, it’s not clear that it would be rational to eradicate the capacity for grief in oneself entirely. For indulging in the feeling of grief as a response to fictional events – including many of those depicted in Homer, of course — can be a positively enjoyable experience. Helen might be able to provide a medicine that distinguishes between ‘real’ and ‘fictional’ grief; but it’s hard to imagine that, even in the medium-term future, human beings are going be able to do that.
Last week it was reported that police in Bangladesh had made a major bust at a factory that was producing counterfeit homeopathic drugs. The counterfeiters were attaching the labels of other drug producers to the remedies they were producing in their own factory. Dhaka's Daily Star reported the bust with the rather ironic headline "Fake Medicine Factory Busted".
Of course, even homeopathic remedies need to be guaranteed safe if they are sold in stores, and counterfeiters are not bound by the same safety controls as other more reputable sources. There are also 'intellectual property' issues concerning the use of other company's labels and trademarks. So I am not here to tell you that this drug bust was unnecessary or ridiculous. In fact I want to challenge The Star's implicit suggestion that homeopathic remedies are by their nature counterfeit therapies.
Is it true that “everyone’s a winner”, as Julian Savulescu suggested recently on this blog , if we price life and body parts? Let’s accept that if there is a valid objection to buying and selling body parts, it must be grounded in the recognition of a harm that would come to some person or group of people. Consider, then, Savulescu’s suggestion that we should price body parts, and engage in buying and selling of them. We could categorize the potential harms that it might generate under the following headings:
(1) Harm to the participants in the transactions: donors, recipients, or facilitators
(2) Harm to specific third parties
(3) Harm to society at large
In a recent article, “Sure, It’s Treatable. But Is It a Disorder?” the New York Times warns its readers to “brace yourselves for P.E. – shorthand for premature ejaculation”. If the pharmaceutical industry is to be believed, that may not be bad advice, since according them, “One in three men actually have the condition.” But the advice is not meant to be taken literally. What the reporter really meant was, “brace yourselves for ‘P.E.’ – shorthand for ‘premature ejaculation’”. According to the article, just as the makers of Viagra have in recent years introduced into the popular lexicon the name of a “modern man’s malady” and it’s acronym – ‘erectile dysfunction’, or ‘E.D.’, we can expect a similar effect as a result of the development and marketing of Priligy: a new pill for “men who ejaculate before copulating or within seconds of beginning.” Continue reading
The drug and human rights charity *Release* recently launched an advertising campaign in which the slogan ‘Nice People Take Drugs’ was displayed on the sides of London buses. Their aim was to encourage society to face up to the reality that a huge proportion of the population does at least experiment with drugs and to combat the popular assumption, which underlies a good deal of political rhetoric and media coverage, that since drugs are simply ‘evil’ there is no point in seriously debating drug policy. Those ads are now being withdrawn by the company that booked the space, after advice from the Committee of Advertising Practice: http://www.guardian.co.uk/media/2009/jun/09/nice-people-drugs-ads-pulled
Apparently, Release has been told that their strap-line would be more acceptable if it included the word ‘too’. This suggests that the CAP may have felt that the public would read the original claim as equivalent to ‘All those who take drugs are nice people’. But even adding the word ‘too’ may not be enough. For the new sentence might be read as: ‘All nice people take drugs, along with other things (such as holidays when they can, advice when they need it, offence when people are rude to them, etc.).’ Of course, no one would have understood either the new or the old sentence in these ways. But in fact, though it should be up to Release how they word their strap-line (the censorship charge they have made doesn’t seem far-fetched), adding ‘too’ does bring out more clearly what they want to say: that we should stop demonizing drug-takers and have an open, impartial, and well-informed debate.
Ben Goldacre, in the Guardian this weekend, noticed the range of headlines on health and health risks that are to be found in the media. He mentions, among others, the rise of ‘manorexia’, the failure of water to induce weight loss and the dangers of antibiotics to prevent premature birth. I found a couple more: It turns out that dark chocolate can reduce the risk of heart attacks, vegetable rich diets and in particular vegetables like broccoli reduce the chance of heart disease and stroke and turmeric, the spice that makes curries yellow, can reduce the size of hemorrhagic stroke.
It’s quite striking what research is done!