An elegant example of biopsychosocial (BPS) impacts on our health has been reported today.
It has long been reported that chronic stress reduces fertility: it reduces libidos, reduces the likelihood of a pregnancy, and increases the risk of miscarriage.
Scientists from the University of Berkeley have shown that blocking the gene for a hormone – called gonadotropin inhibitory hormone (GnIH) removes the impact of the stress on fertility levels in rats, and restored a normal rate of pregnancy.
If this translates to humans, it could have major impact. According to the University of Berkeley press release:
“Stress is thought to be a major contributor to today’s high levels of infertility: Approximately three-quarters of healthy couples under 30 have trouble conceiving within three months of first trying, while 15 percent are unable to conceive after a year.”
The BPS model explores causal interaction between the biological, psychological, and social factors in illness (usually in the context of understanding mental illness). This might be one of the more simple biopsychosocial interactions. Kenneth Kendler’s fascinating Loebel Lecture series unpicked some complex interactions (video and audio available on the Oxford Loebel Lectures and Research Programme website).
But it raises an interesting ethical question, and one that frequently arises in the enhancement debate. Should we take a biological solution, when an environmental solution is available?
In the case of stress and fertility, if this discovery makes the leap from bench to bedside, we would then have two options to address stress related infertility: 1) reduce our stressful lifestyles or 2) knock out the biological response that causes the infertility. Many people would prefer the former.
Likewise, many feel uneasy about the prospect of moral enhancement by biological means (if it becomes possible), when we could enhance morality via education. Or, in a twist on the same theme, argue that instead of using genetic testing (eg PGD) to select against traits such as deafness, we should enhance our environment so that deaf people are not disadvantaged.
The BPS model is in fact incomplete. It should be BEPS: biological, environmental, psychological and social. There are 4 potential causes of any disadvantageous human condition:
- Biological
- Environmental
- Psychological
- Social
And there are 4 potential ways of alleviating that disadvantage: BEPS. It is a mistake to think that because one of these factors is the predominant cause, then the cure must be of that kind. For example, because the cause is biological, then a biological intervention is necessarily the most appropriate. Of course, usually the best way to treat the symptoms is to treat the disease. Typically, if some cause is biological, a biological intervention will be the most effective. But not necessarily.
Consider a person who is stressed because a tornado destroyed his home. The cause is environmental. The correction could be environmental – restore the environment, including the home, to a pretornado state. Or one could adopt a social solution – pay the person a lot of money in compensation. The person may prefer the social rather than environmental solution. Perhaps he wants a house in sunny Florida.
It is useful to know the predominant or network of causes of the BEPS family. But it is really only useful in deciding what we are going to do – which intervention there is most reason to choose. All options should be open. Whether a biological, psychological, social or environmental solution is adopted should be determined by benefits, costs, requirements of justice, etc.
Thus effectiveness may speak in favour of providing biological cures for deafness but justice may speak in favour of correcting prejudice causing disadvantage. These reasons can pull in different directions.
Should we reduce stress or give drugs to promote fertility? There is no straightforward answer – it depends on the benefits, health risks, monetary costs, side effects and so on. Often these trade offs are difficult and controversial to make. In the absence of a clear weight of reason, people should be encouraged to exercise their freedom and make their own decision about what is right for their lives, weighing short and long term, narrow and wide consequences.
Should you take the pill or meditate? It is up to you.
Further Reading
Kahane, G. and Savulescu, J. (2009) ‘The Welfarist Account of Disability’. In Cureton, A. and Brownlee, K. (eds.) Disability and Disadvantage. Oxford: Oxford University Press. pp 14 – 53.
Savulescu, J. (2007) ‘Genetic Interventions and the Ethics of Enhancement of Human Beings’. In Steinbock, B. (ed). The Oxford Handbook of Bioethics. Oxford: Oxford University Press. pp. 516 – 535.
As a physician who began his training in Rochester in the 1970s and learned about the BPS from Dr. George Engel, I was very taken aback by the suggestion in this discussion that ‘social’ and ‘environmental’ were separate entities. We were taught that social included the wide range of social contexts: economic, educational, workplace, environmental, family, and cultural.
That quibble aside, I agree that the best (most effective) treatment of a malady that stems from social (including environmental) causes is to treat the cause. This is no different from treating illnesses with a primarily medical etiology.
But, just as with the medical model, it is not always possible, let alone practical, to treat the root cause. We treat hypertension, pain, cancer and many other illnesses by treating the manifestations of illness, not the causes.
I am very much in sympathy with your appeal to adopt a distributed approach “…it depends…” to the issue of whether to pop a pill or meditate in order to address the problem of infertility i.e. to consider each situation as an end in itself, with all contributory factors taken into account and the resultant approach emerging from an utilitarian viewpoint (what works best for this person in this situation at this time etc.)
But your considerations imply the view that BPS, or BEPS, are separate domains that each separately influence the matter you are considering, in this case infertility. The Oxford Lectures to which you refer are intended to shed light on the fairly recent findings that in many (all?) cases each of these domains in fact affect the others. In those cases we do not have a choice between them, as to which to address. We are required to take note of the interactive mechanisms at work. Kendler’s “dappled” concept is one way to think about that.
And I agree with Dr. Elias remark, appealing to Occam’s Razor, that “social” includes a “wide range of social contexts including environmental…”
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