Every day doctors have to make difficult decisions, often when on the run and under great pressure, that have serious repercussions for their patients; and no one seems grateful when the messy process is all over. So the profession understandably rolls its collective eyeballs skywards when philosophers start pontificating about medicine. It's all very well to wallow in the niceties of philosophical analysis—but what is the practical help to us, doctors will demand impatiently, when yet another book on philosophy and medicine thumps onto the ever growing (dusty?) pile in this category.
Figure 1.
Ed Jennifer Radden
Oxford University Press, £45, pp 447 ISBN 0 19 514953 X
Rating: ★★★
Philosophy attracts intense suspicion from those who are deeply impressed by medicine's apparent progress, driven by conventional science, because philosophy has a nasty tendency to show that we doctors are not forging forward quite as quickly as we like to imagine.
For example, this collection of philosophical contributions asks some uncomfortable questions that are usually too quickly glossed over in modern medical practice. But perhaps the reason this volume is better than conventional philosophical analyses of psychiatry is that most of the contributors seem to have pragmatic experience of both philosophy and clinical practice and focus on areas where philosophy will actually aid the clinician's daily exertions.
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In the chapter called “Desire” one issue is how homosexuality got removed from official diagnostic manuals, once doctors had “decided” that it should no longer be regarded a disease. However, when this medical decision is exposed to the hard edged precision of philosophical analysis, some rather painful politically incorrect problems begin to surface.
Whatever the reason brought to bear for not classing homosexuals as diseased and in need of medical attention, there are difficult implications, because exactly the same set of arguments could be used for removing a host of paraphilias or perversions from the diagnostic manuals as well. Perversions and paraphilias range from the familiar, such as sexual masochism and fetishism, to the more exotic, such as klismaphilia, sexual enjoyment derived from enemas. Many of these do not cause distress to other people, and any upset caused to the “patient” often seems to be largely exogenous—in other words, if wider society accepted the behaviour and didn't condemn or discriminate against it then personal suffering supposedly engendered by the condition might disappear altogether.
Another flaw with the medical definition and diagnosis of perversions lies in the words “Usually the fetish is required or strongly preferred for sexual excitement, and in its absence there may be erectile dysfunction,” which comes from the definition in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, the bible of North American psychiatry. But the stubbornly flaccid husband who no longer finds his wife arousing is not necessarily impaired. The stimulus is inadequate; or a stimulus that would work for him—another woman—is missing.
The chapter on emotion raises another uncomfortable question: that there could be innumerable other common states of being that we doctors mess with in the cause of pure consistency that might better be left alone, in particular mood problems such as depression. Some forms of depression may be understandable reactions to genuine quandaries, a form of “existential alienation”—a reasonable and even desirable response to calling into question one's own values. This isn't a new idea. Aristotle asked, “Why is it that all men who have become outstanding in philosophy, statesmanship, poetry, or the arts are melancholic, and some to such an extent that they are infected by the diseases arising from black bile?”
It might be that the reduction of depression to faulty wiring in the brain or chemical imbalance is actually an impoverished understanding of the breadth and depth of the human predicament. The New Yorker magazine, in a tongue-in-cheek take on the medicalisation of life, began publishing a series of cartoons entitled, “If they had Prozac in the Nineteenth Century,” featuring figures such as Karl Marx remarking, “Sure! Capitalism can work out its kinks!” and Friedrich Nietzsche saying to his mother after church, “Me, too, Mom. I really liked what the priest said about the little people.”
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Friedrich Nietzsche and (below) Karl Marx: how might Prozac have changed their outlook?
The implication is clear: if stress and dysfunction are “natural” reactions to difficulties, and if Immanuel Kant is even partly right that melancholia is a result of the mind's imagination run riot, then what might we have lost as a culture if psychopharmacology had prevailed in earlier times?
The boundary between suffering that requires the ministrations of the medical profession and distress that should be coped with without professional intervention has become blurred, with massive implications in terms of cost and stress on the profession.
It is in the attempt to bring some focus in this area that philosophy is desperately needed. Indeed, with the remorseless advance of medical technology it is likely that our ability to interfere with states of being that are statistically extremely common is always going to be on the increase, meaning that philosophy will become ever more relevant.
This erudite volume, with its numerous practical examples, reminds us that philosophy and its tools of pitiless precision and brutal clarity are as vital a weapon against disease as brain scanners and multidisciplinary teams in the armament of modern medicine—perhaps even more so.
What might we have lost as a culture if psychopharmacology had prevailed in earlier times?