An article in the Israeli newspaper Haaretz reports on the (alleged) frequent use of psychiatric drugs within the Haredi community, at the request of the religious leaders, in order to help members conform with religious norms. Haredi Judaism is the most conservative form of Orthodox Judaism. It is sometimes referred to by outsiders as ultra-Orthodox. Haredim typically live in communities that have limited contact with the outside world. Their lives revolve around Torah study, prayer and family.
In December 2011, the Israel Psychiatric Association held a symposium entitled “The Haredi Community as a Consumer of Mental-Health Services”. One of the speakers was Professor Omer Bonne, director of the psychiatry department at Hadassah University Hospital. Professor Bonne is claimed to have said that sometimes yeshiva students (yeshiva is a religious school) and married men should be given antidepressants even if they do not suffer from depression, because these drugs also suppress sex drive.
Homosexuality and masturbation (referred to by Haredim as ‘compulsiveness in sex’) is not accepted by Haredim. Sex is not something that is to be enjoyed. (In the Gur sect within Haredi Judaism it is strictly prohibited to enjoy sex.)
Professor Bonne’s justification for providing the antidepressants to Haredim is that this helps to avoid “destructive conflicts that would make students depressed”. The medication “enables them to preserve their place, image and dignity within the system, to continue to maintain proper family and social relations, and to find a match and raise a family.
A first question that arises is whether, from a religious point of view, medication is an acceptable, or the best means for complying with religious norms. One may think that what matters most from a religious perspective is one’s strength to resist temptation rather than living in accordance with religious norms without there being anything to resist. If this is so, then this counts against using drugs as a means to conform. However, religious people already use ‘tricks’ to resist temptation, such as seeking distraction whenever ‘inappropriate’ sexual urges arise or having members of the opposite sex wear unrevealing dress. One question then is whether the use of a pill is morally different from these non-biomedical tricks. It seems not. Also, it may be that some people can only conform to religious norms by using medication; if one doesn’t have the strength to resist temptation, maybe taking the pill is the next best option.
A second question that arises is whether psychiatrists should provide such ‘treatments’ if requested by the patient. The answer will depend on what role one ascribes to psychiatrists, and medical doctors in general. One view is that medical doctors should provide any medical services the patient demands, as long as these are legal and beneficial. Providing Haredim with antidepressants is legal. Is it beneficial for the ‘patient’? This is controversial. Perhaps the drugs could indirectly reduce depression by enabling the patient to think, feel and act in accordance with the expected norms in his community. However, antidepressants have serious side-effects and it is not clear that these are outweighed by the advantages of the drug (if there are any advantages at all). Also, perhaps having a good sex life is good for you, and the Haredim are mistaken to think otherwise.
But suppose there were safe drugs that reduced sexual desire. Should psychiatrists offer them to Haredim (or other religious groups with similar values) upon request? Since such treatment would be legal, and would potentially be beneficial to the individual ‘patient’, it seems that the psychiatrist should provide the drugs.
Perhaps one could say that helping people adhere to religious norms falls outside of the psychiatrist’s sphere of duty, and that, as a consequence, psychiatrists do not have to provide such ‘treatment’ even if requested by the patient. However, the aim of the drug could be described in several ways: to help maintain the Haredi community, or to increase people’s wellbeing, for example, by increasing their authenticity, or by reducing anxiety and depression. The latter clearly falls within the professional responsibility of psychiatrists.
So should a psychiatrist then provide such treatment? Many psychiatrists may feel uncomfortable at this thought.
Could the psychiatrist refuse to provide the treatment as a form of conscientious objection? Is it permissible for a psychiatrist to refuse providing a legal treatment that may be beneficial for the patient on the ground that she strongly objects to the values she would thereby promote? According to Savulescu (2006), “values and conscience … should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patient. The door to “value-driven medicine” is a door to a Pandora’s box of idiosyncratic, bigoted, discriminatory medicine.” (p. 297).Following this reasoning, it seems that a psychiatrist has no ground for conscientious objection and should provide the treatment to Haredim. But this seems intuitively incorrect. Intuitively, it seems that individual psychiatrists should be able refuse treatment because they do not want to be complicit in maintaining religious norms that they profoundly disagree with.
Does this mean that psychiatrists work should be value driven after all?
Conscientious objection is typically discussed in a context of objections to provide abortion services, contraceptives, terminal sedation to dying patients, or pediatricians who object to providing the HPV vaccine to young female patients in the belief that it will encourage underage and unmarried sex. It is, however, interesting to think about conscientious objection where intuitively we feel the practice, though legal and possibly in the interest of the individual patient, is nevertheless morally objectionable because it sustains morally objectionable religious values.
Sources
Ettinger, Y. Rabbi’s little helper. Haaretz (6 April 2012). Available at: http://www.haaretz.com/weekend/week-s-end/rabbi-s-little-helper-1.422985
Savulescu, J. (2006). Conscientious objection in medicine. BMJ, 332(7536), 294–297. doi:10.1136/bmj.332.7536.294
Could this case be compared to the use of ADHD medication to enhance academic performance among university students or classroom behaviour in elementary schools? Legal, possibly beneficial, but morally dubious? Every pharmacological intervention carries with it the possibility that things are better left alone.
Agreed: drug intervention as you describe is objectionable because it is about controlling behaviours so they can be corrected enough to fit within whatever norm has been defined by a community/society/the powerful. So in other words, while it can be seen as prorecting ‘society’, it is restricting dversity. But use of drugs for such purposes are just another tool in restricting freedoms (prisons and the state monopoly on violence are others…so it is a fraught issue). Voluntary use of drugs is probably okay, though, even if it is to enhance performance.
I’m not sure it necessarily follows that using drugs for, e.g. chilren with ADHD is necessarily the same as ‘restricting freedoms’.
In the long-term, would children with ADHD have more possibilities in life if they were able to successfully complete their education? Presumably, yes. In which case giving them drugs to help them study will enhance their freedoms.
Thanks for your comment Melissa. Yes, I think the case could be compared to the widespread use of Ritalin in school children. Actually, I had a passage on this in an earlier version of my blogpost. It seems to me that psychiatrists should be able to refuse providing ritalin for such purposes solely on the ground that they strongly object to the use of ritalin for that purpose.
Once the acute anxiety, caused by one or more neurotic parental units is removed from the child’s environment and replaced by anyone with the equanimity of a decent dog trainer the issue usually evaporates. Of course parents rarely if ever can summon the courage and honesty to confront their destructive behavior, in fact the idea never occurs.
Controversial? Holy mackerel, none of us has the slightest idea what the long term consequences of many of these drugs will be. Conscientious objection is valid, actually required for a number of reasons not least is the question of mind control of the recalcitrant to the hegemony being superimposed. Does anyone really have any idea what will become of our drugged children as the years tick by or the massive number of people taking so called anti depressants?
I have to wonder if this was published April first? It sounds like science fiction, Orwellian, coo-coo for Coco Puffs. On the other hand if true, that anyone would consider psychiatric drugs in these contexts is reason enough to mount a public information crusade and call in the government asap.
That the subject is discussed as it is in the post is difficult to except from any ethical point of view. I know most would view the subject under discussion as outside the norms of a modicum of mental health. Hopefully the goal in publishing was to alert wider communities.
Psychiatry is a medical pseudoscience that has always been used by authority to make people conform to social ‘norms’. Forcing children to take toxic stimulants (why are these illegal and possession of them a criminal offence?) to get them fit in to a ‘sick’ school environment for the benefit of teachers and administrators is child abuse pure and simple. It is a scientific fact that psychiatric drugs cause brain damage. Read Robert Whitaker, Anatomy of an Epidemic for more information.
The fundamental difference between taking Ritalin as an enhancer and as a way of conforming is whether the benefit is assumed to accrue to the user or the group. Kids with ADHD can be disruptive, so there might be a real benefit to fellow students if they are medicated. The ADHD kids might also get a benefit, both as an enhancement but perhaps more likely just by being able to get a better education experience. However, medicating Haredi students seems to be almost completely for the benefit of the group (or rather, compliance with group norms) and relatively little for their individual benefit. Lowering libido can sometimes be a perfectly OK “enhancement” within relationships ( see https://blog.practicalethics.ox.ac.uk/2012/03/is-it-ok-to-have-an-affair-if-your-partner-is-asexual/ ) since it on the whole benefits both parts. It is less obvious to me that lowering libido for the sake of belonging to a social group produces reciprocal benefits.
I would imagine that most psychiatrists aim at improving the life of their patients rather than the state of their communities. One can certainly imagine a communitarian view of psychiatry that thinks it is more important to improve the overall social relations than the life of an individual (that is, not seeing improving social relations as a way of helping the individual), but that view seems rather alien to most Western psychiatric ethics. Informed consent becomes odd if it is about communities accepting certain activities even if members are not informed or understand what is done to them.
Thanks very much for your comment Anders (and for the comment on my earlier blogpost!). I was just wondering whether someone could argue that many psychiatrists now are prepared to proscribe Ritalin for children in cases where it is not clear that this is to the benefit of the child (or where it is to the benefit of the child but only because it then fits in better within existing societal norms). Proscribing Ritalin for a child with severe ADHD is plausibly in the interest of the child. However, it seems that Ritalin is often proscribed when the child simply has some problems paying attention and sitting still all day in class. Perhaps someone could argue that it is wrong to ‘force’ these children into the normal school system. Perhaps they would be perfectly fine in a different school system. However, we prefer to change the children, instead of the system. Perhaps someone could then say this is rather similar to psychiatrists proscribing libido-reducing drugs to Haredim, as they prefer not to change their cultural practices regarding family and sex. They’d rather change themselves.
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