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This article was downloaded by: [Ingenta Content Distribution - Routledge]On: 11 March 2009Access details: Access Details: [subscription number 791963552]Publisher RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK The American Journal of BioethicsPublication details, including instructions for authors and subscription information: Propranolol and the Prevention of Post-Traumatic Stress Disorder: Is it Wrongto Erase the “Sting” of Bad Memories?Michael Henry a; Jennifer R. Fishman a; Stuart J. Youngner a To cite this Article Henry, Michael, Fishman, Jennifer R. and Youngner, Stuart J.(2007)'Propranolol and the Prevention of Post-Traumatic Stress Disorder: Is it Wrong to Erase the “Sting” of Bad Memories?',The American Journal of Bioethics,7:9,12 — 20 To link to this Article: DOI: 10.1080/15265160701518474 This article may be used for research, teaching and private study purposes. Any substantial orsystematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply ordistribution in any form to anyone is expressly forbidden.
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The American Journal of Bioethics, 7(9): 12–20, 2007Copyright c Taylor & Francis Group, LLCISSN: 1526-5161 print / 1536-0075 onlineDOI: 10.1080/15265160701518474 Target Article
Michael Henry, Case Western Reserve University Jennifer R. Fishman, Case Western Reserve University Stuart J. Youngner, Case Western Reserve University The National Institute of Mental Health (Bethesda, MD) reports that approximately 5.2 million Americans experience post-traumatic stress disorder (PTSD) each year.
PTSD can be severely debilitating and diminish quality of life for patients and those who care for them. Studies have indicated that propranolol, a beta-blocker, reduces consolidation of emotional memory. When administered immediately after a psychic trauma, it is efficacious as a prophylactic for PTSD. Use of such memory-altering drugs raises important ethical concerns, including some futuristic dystopias put forth by the President’s Council on Bioethics. We think that adequate informed consent should facilitate ethical research using propranolol and, if it proves efficacious, routine treatment. Clinical evidence from studies should certainly continue to evaluate realistic concerns about possible ill effects of diminishing memory. If memory-attenuating drugs prove effective, we believe that the most immediate social concern is the over-medicalization of bad memories, and its subsequent exploitation by the pharmaceutical industry.
Keywords: propranolol, post-traumatic stress disorder, memory, president’s council
INTRODUCTION
lion adults in the United States suffer from PTSD through- Neuroethics has emerged as a new frontier in bioethics.
out the course of any given year. According to an unpub- Technological advances in neuroscience, such as imaging, lished NIMH report by Narrow et al. in 1998, PTSD affects a neurological implants, and psychopharmacology, have wide range of individuals, from students and homemakers enabled us not only to better understand the brain, but to soldiers and individuals involved in attacks and accidents also to manipulate its functional capabilities. As Farah (Narrow et al. 1998). One recent study indicates that 17% of and Wolpe (2004, 36) have written, because “the brain soldiers returning from Iraq display symptoms of PTSD or is the organ of mind and consciousness,” interventions other psychological disorders (Hoge et al. 2006).
in the brain have “different ethical implications than To date, most research on the disorder has been con- interventions in other organs.” In addition to the usual cerned with treatment to reduce its symptoms. More re- issues of safety, efficacy, informed consent, and access, cently, researchers have studied ways to prevent PTSD in new developments in neuroscience raise issues of privacy, individuals who have been exposed to traumatic events but confidentiality, enhancement, assuagement and social have not yet developed symptoms. Experimental prophy- Downloaded By: [Ingenta Content Distribution - Routledge] At: 15:47 11 March 2009 control. While advances in the new genetics have raised lactics include drugs such as propranolol (a beta-blocker), many of these same issues, as Farah and Wolpe (2004, which attenuate the memory and emotions associated with 35) point out, “ethical questions of neuroscience are more urgent, as neural interventions are currently more easily In this article, we will consider the potential ethical prob- accomplished than genetic interventions.” lems of using propranolol to prevent PTSD. First, we will In this essay, we will examine the use of drugs to blunt examine issues of safety, efficacy, informed consent, and ac- and even avoid the debilitating effects of post-traumatic cess. Next, we will examine the potential long-term nega- stress disorder (PTSD). According to the National Institute tive social consequences, concerns that are inevitable with of Mental Health (Bethesda, MD), approximately 5.2 mil- a drug that could alter personality and medicalize what Received September 26, 2006; accepted April 17, 2007.
Acknowledgement: The authors would like to thank Heath Demaree and Eric Juengst for their helpful comments and suggestions on earlierdrafts.
Address correspondence to Stuart J. Youngner, Department of Bioethics School of Medicine, Case Western Reserve University, 11100 EuclidAvenue, Cleveland, OH 44106-4976. E-mail: sxy2@po.cwru.edu 12 ajob
have previously been considered “normal” human adap- routinely effective, and all of them may take months or even tation and coping. To date, there has been little exploration years to work (Bryant et al. 1999; Kent et al. 1998; Leichsen- of these potential problems. We will consider two such ef- ring et al. 2004). It is claimed that PTSD costs the government forts. The first, by Adam Kolber (2006), gives serious con- approximately $4 billion annually (Marchionne 2005).
sideration to how the use of drugs to attenuate traumaticmemory could potentially interfere with legal proceedings USE FOR PREVENTION OF POST-TRAUMATIC STRESS
that rely on just such memories. Kolber gives a strong argu- DISORDER
ment for protecting what he calls “freedom of memory”—inthis case, the right to choose to maximize mental health by Studies have shown that shortly after a trauma there is a attenuating memory at the expense of being a better wit- period in which the memory of the event is encoded and ness. The second is the President’s Council on Bioethics 2003 consolidated in the brain. The strength of the memory, as publication, Beyond Therapy: Biotechnology in the Pursuit of well as its emotional content, is directly correlated to the Happiness (President’s Council on Bioethics 2003). Whereas release of endogenous stress hormones such as adrenaline.
pharmacologic memory suppression could be problematic When the psychic stimulus is particularly strong, over- in a theoretical future, we argue that the prophylactic use of release of adrenaline causes elevated levels of noradrenaline propranolol for potential PTSD victims appears to have min- (norepinephrine). Increased levels of noradrenaline result imal risks and potentially high benefits, and deserves fur- in overconsolidation of the memory’s trace. The presence ther study through clinical trials. We are critical of the Pres- of this overconsolidated memory trace is what specifically ident’s Council’s approach, which has the potential to en- generates symptoms of PTSD (Glannon 2006; Pitman & courage irrational opposition to such medical innovations.
Delahanty 2005; President’s Council on Bioethics 2003; Reist When it comes to weighing the risks and benefits of cutting et al. 2001). If beta-adrenergic antagonists (beta-blockers) edge medical research, reasoned debate and careful data col- such as propranolol are administered for a very short period lection must shape the discussion. If memory-attenuating of time either before or after the trauma, the consolidation drugs prove effective, we argue that the most immediate of the memory and the emotions that cause PTSD can be social concern is the over-medicalization of bad memories significantly reduced by blocking the effect of noradrenaline and its subsequent exploitation by the pharmaceutical in- (Cahill et al. 2002; Grillon et al. 2004; Maheu et al. 2005; Pit- dustry. There is evidence to support this concern.
man & Delahanty 2005; Reist et al. 2001; van Stegeren et al.
2005).
In several studies (Cahill et al. 2002; Maheu et al. 2005; WHAT IS POST-TRAUMATIC STRESS DISORDER?
Reist et al. 2001; van Stegeren et al. 2005), subjects were The Diagnostic and Statistical Manual of Mental Disorders, randomly given propranolol or placebo before exposure to Fourth Edition Text Revision (DSM-IV-TR) characterizes PTSD a tragic and emotional story and to a mundane and neu- as “the re-experiencing of an extremely traumatic event tral story. When the subjects’ recollection of the stories was accompanied by symptoms of increased arousal and by tested, the placebo subjects recalled significantly more of avoidance of stimuli associated with the trauma” (American the emotional story than the propranolol subjects. Further- Psychiatric Association 2000, 424). Events that cause PTSD more, there was no difference between the propranolol and include witnessing death or injury to another individual, placebo groups in recall of the emotionally neutral story.
injury to the patient in question, the threat of such death or Reist et al. (2001) studied 37 subjects who received oral injury, or even learning of a traumatic event that befell an- doses of either 40 mg of propranolol or placebo 60–90 min- other individual, such as death or injury. Examples include utes prior to stimulus exposure. The stimulus consisted of terrorist attacks, rape, robbery, incarceration, abduction or 11 slides that told a short story. In the non-arousal version, any other type of assault or threat to the person. These events a young boy witnessed a car accident on his way to the can be experienced or witnessed. Symptoms include, but hospital to visit his father. On arrival, the hospital staff was Downloaded By: [Ingenta Content Distribution - Routledge] At: 15:47 11 March 2009 are not limited to, avoidance, anxiety, nightmares, irritabil- practicing an emergency drill. In the arousal version, the boy ity and detachment. Furthermore, the presence of PTSD in himself was injured in the car accident and sent to the hospi- a patient puts him or her at higher risk of developing other tal, where physicians attempted to reattach his severed legs.
related problems (American Psychiatric Association 2000), Seven days after stimulus exposure, subjects were asked including suicide and attempted suicide (Ferrada-Noli et al., whether they had any recollections of the slides during the 1998; Kotler et al. 2001; Tarrier & Gregg 2004). Clearly, PTSD seven-day period. They were asked to recall the slides they poses a serious threat to quality of life.
had seen, as well as the specific details. Lastly, the subjects Current available treatments include various methods each took a 76–question, multiple-choice test that examined of psychotherapy, such as cognitive behavioral therapy (Bryant et al. 1999; Chemtob et al. 1997), group therapy The Reist et al. (2001) study concluded that propranolol (Lubin et al. 1998), and psychodynamic psychotherapy had a significant effect on attenuating memory in subjects (Leichsenring 2005; Leichsenring et al. 2004). In some cases, who viewed the arousal story. Additionally, the heart rates drugs such as benzodiazepines, anti-adrenergic agents, and of subjects who took propranolol were significantly lower selective serotonin reuptake inhibitors are used (Kent et al.
than those of subjects who received the placebo. If heart rate 1998; Marks et al. 1998). None of these methods is considered is considered a proxy for adrenergic activation, these results ajob 13
raise the likelihood that this excess activation contributes to strated enough of a benefit to justify large-scale clinical trials PTSD development via augmented memory consolidation.
of propranolol’s ability to prevent symptoms of PTSD.
It is important to note that no difference was observed be- The potential side effects of propranolol are well known tween the PTSD and control subjects in terms of the effect as tens of millions of people have taken the drug chroni- of the drug on the story. If this were accurate, it would indi- cally for hypertension, arrhythmia, migraines, and angina cate that there is no altered relationship between emotional pectoris. The usual initial dosage is 40 mg Inderal twice memory and arousal in PTSD patients. Reist et al. (2001) daily, whether used alone or added to a diuretic. Dosage note, however, that 13 of 17 patients were on other psy- may be increased gradually until adequate blood pressure chotropic medications that may have modified the observed control is achieved. The usual maintenance dosage is 120 response. These researchers believe that further investiga- mg to 240 mg per day. So we need to change the text to read “from 120 to 240” instead of 80–240 (Anonymous 2006).
Studies such as these indicate that individuals in the Common side effects include fatigue, dizziness, constipa- fire, law enforcement, military and rescue fields might ben- tion, nausea, and impotence (Walgreens Pharmacy 2004).
efit from receiving propranolol prior to a traumatic stimulus Short-term memory loss is also noted in the Physicians’ Desk (Marmar et al. 1994; Marmar et al. 1996). Such individuals Reference (2007, 3430). More serious side effects have been might be treated with short-term memory repressors prior reported for patients with serious heart problems. Because to entering a situation that could put them at risk for later research subjects or patients offered propranolol to prevent developing PTSD—for example, a plane crash in which res- PTSD would only have to take the drug for a finite period cue workers must enter the site to look for survivors, treat (e.g., six weeks), the side effects would likely be more toler- the wounded, or remove the deceased (Fullerton et al. 2004).
able. Nonetheless, patients or research subjects could make It is more likely, however, that propranolol will be used their own risk/benefit assessments. They could refuse study in emergency room settings to treat patients who seek med- participation for prophylaxis, or could stop taking the drug ical attention shortly after having been attacked, abused, if side effects developed. Because the potential benefits far raped, molested or involved in any sort of accident that outweigh the risks, we believe that it is ethical to conduct may cause psychological trauma. There have been prelim- research in which informed consent is obtained.
inary empirical studies in actual emergency situations that The President’s Council on Bioethics (2003) has argued demonstrate the efficacy of propranolol in reducing PTSD that one risk of taking propranolol may be the loss of symptoms. Pitman et al. (2001) used 41 emergency depart- episodic memory—the memory of actual events and po- ment patients who had experienced a trauma likely to pre- tentially the loss of emotionally positive memory. We agree cipitate PTSD (based on DSM-IV-TR requirements). Within with the Council that these concerns must be taken seri- six hours of the occurrence of the traumatic event, subjects ously. Memory and its relationship to emotion clearly are were treated orally with 40 mg of propranolol; the dose was vital to human functioning and flourishing and are very repeated four times daily for 10 days, with a nine-day taper complex (Evers 2007). Our understanding of memory is period. After one month, symptoms of the disorder were only in its infancy. Although the ideal goal of propranolol detected in 30% of subjects given the placebo, and 18% of therapy for PTSD would be to attenuate the emotional im- pact of the memory, it is reasonable to be concerned about Another clinical study of 19 subjects (Vaiva et al. 2003) its (or future memory-altering drugs’) potential effect on demonstrated that 37.5% of those who refused propranolol episodic memory—the memory of actual events. Many of had PTSD symptoms, in contrast to 9% of those who ac- the studies previously cited indicate that there is attenu- cepted it. Subjects received 40 mg of propranolol orally, three ation of memory beyond emotion; the degree of loss and times daily for seven days, with an eight- to 12-day taper pe- its implications are unclear. It is worth noting that no severe riod. Although these two studies suggest that post-trauma memory problems have surfaced among the tens of millions use of propranolol may be useful in preventing or diminish- of individuals who have taken propranolol for heart condi- Downloaded By: [Ingenta Content Distribution - Routledge] At: 15:47 11 March 2009 ing PTSD, they also raise important ethical questions about tions and high blood pressure. There are other United States the risks and benefits of such a pharmacologic intervention.
Food and Drug Administration (FDA)-approved drugs that Further National Institute of Mental Health (NIMH)- have been shown to interfere with memory; in some cases, sponsored clinical trials are currently underway (available this side effect did not emerge until after the drug was ap- online at http://clinicaltrials.gov, accessed March 11, 2006).
proved for marketing. Ambien (zolpidem tartrate) (SanofiAventis, Bridgemeter, NJ) is the best-selling prescriptionsleeping pill in the United States. As the number of pre- BASIC ETHICAL ISSUES
scriptions increased after its release on the market, reports We will discuss the ethics of using propranolol as both an in- began surfacing about its amnesiac effects—for example, vestigational drug and, if it is found safe and effective, as an people driving their cars without any recollection of hav- accepted therapy. For the most part, these issues are straight- ing done so (Saul 2006) and binge-eating (Morgenthaler forward. During the informed consent process for any re- & Silber 2002) while under the influence of the drug. Al- search or treatment, the investigator/treating clinician must though this side effect of the drug was considered rare reveal the risks and benefits of the proposed intervention before its approval (referred to as confusional arousals), it (Appelbaum et al. 2001). Preliminary studies have demon- now seems to be more common than previously thought.
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Propranolol has the advantage of having been prescribed for Distributive Justice
many years for other uses. Any significant problems with at- The introduction of new therapies sometimes raises ques- tenuated memory would most likely have been reported by tions of social justice. Will they be affordable to everyone? Will they be in such short supply and/or so expensive that Although memory loss is listed in the Physicians’ Desk only the very wealthy will have access to them? Because pro- Reference (2007) as a potential side effect, its incidence in pa- pranolol is an extremely cheap and widely available drug, tients taking propranolol for high blood pressure have not issues of distributive justice are negligible. Walgreens’ on- been systematically studied; we rely on anecdotal reports line pharmacy (Walgreens Pharmacy 2004) sells propranolol to the cardiologists, internists and family physicians who in various forms and doses. Based on the reported doses have prescribed it. A large prospective or retrospective epi- used in the Pitman et al. (2001) and Vaiva et al. (2003) trials, demiological study of persons who take or have taken pro- prophylaxis would cost approximately $13.99 (no author pranolol for high blood pressure would help answer some 2005c). When compared with the potential costs of hours of of the questions about types and degrees of memory loss psychotherapy and chronic treatment with pharmacologi- (e.g., emotional, episodic, positive) that might occur. Such a cal agents such as antidepressants, the financial benefit of study might even shed light on the effectiveness of unrec- prophylaxis with this drug is clear.
ognized and unwitting treatment of PTSD symptoms (e.g.,a person taking propranolol who is in a bad car accident THE LEGAL IMPLICATIONS OF FORGETTING
and simply continues taking the propranolol for high bloodpressure). Unfortunately, such systematic data are not avail- Adam Kolber (2006) suggests that the use of drugs that af- able. Careful attention to memory-related side effects is pos- fect traumatic memory could pose a thorny ethical conflict sible in prospective studies about propranolol’s effects on between the right of society to protect itself from criminals memory conducted by psychiatrists and psychologists. Fu- (by not allowing the altering of valuable evidence) and the ture studies of propranolol and other drugs developed to rights of individuals to control their own minds (in this case, treat emotional memory could and should provide just this their memories) (Kolber 2006, 1560). In addition to reducing the emotional impact of memory for the victims of crime, Another potential concern about propranolol research he notes that drugs such as propranolol might “reduce the is the competence of research subjects or patients to give socially-valuable information that may be vitally important informed consent in the immediate aftermath of a severe to prosecuting the perpetrator and protecting others from psychic trauma. However, victims of rape and witnesses to harm” (Kolber 2006, 1579). For example, should a physi- murder, for example, are generally considered competent to cian who effectively prescribes propranolol to a rape vic- accept diagnostic and forensic tests, as well as psychother- tim be prosecuted for tampering with evidence or obstruct- apeutic and psychopharmacologic intervention (e.g., tran- ing justice? Would victims of “tortiously-caused physical quillizers). Considering the potential benefits of propranolol and emotional trauma” hesitate to reduce their own suf- far outweigh its risks, it is likely that health professionals fering through the use of propranolol in order to create a will accept a lower threshold for competence (Roth et al.
stronger case in court (Kolber 2006, 1584)? Kolber argues that, although memory dampening might require regula- Researchers or clinicians using this intervention to pre- tion at some point, any such regulation should be thoughtful vent PTSD must take decision-making capacity seriously. If and based on research and reasoned public debate about the a person is judged to be incompetent, we do not believe that proper boundary between “an individual’s right to modify he or she should participate in PTSD research, even with sur- his memories and society’s right to stop him from altering rogate consent. No risk, however small, should be imposed, valuable evidence” (Kolber 2006, 1560).
even by a surrogate until benefits have been demonstratedby careful research. If and when the efficacy and small risk of THE PRESIDENT’S COUNCIL ON BIOETHICS
Downloaded By: [Ingenta Content Distribution - Routledge] At: 15:47 11 March 2009 the intervention are borne out by research trials, we believe In its monograph, Beyond Therapy: Biotechnology and the that proper surrogates could agree to intervention if patients Pursuit of Happiness (President’s Council on Bioethics 2003), agree to take the oral medications. We do not believe that the President’s Council on Bioethics (the Council) raises prevention of PTSD with propranolol constitutes a medical questions about how memory loss could affect personal emergency, defined by Meisel (1979, 436) when “the con- identity and responsibility. After briefly acknowledging sequence of withholding treatment is that death will ensue that “in certain cases, traumatic memories grossly distort or the patient’s health will be substantially compromised.” and disfigure the individual’s psyche . . . [and] can cast a Therefore, patients who competently refuse propranolol, or shadow over one’s whole life, making the pursuit of hap- whose surrogates consent for them when the patients are not piness impossible” (2003, 220), the Council launches into competent, should never be physically forced or psycholog- a series of slippery-slope arguments about the dangers of ically coerced into taking the drug. In addition to being an using drugs to blunt the “sting” of bad memories. Although unacceptable form of paternalism, such heavy-handed be- many of these arguments are rhetorically interesting, the havior would likely place an additional psychic burden on Council acknowledges that they are “speculative, at least for now” (2003, 209). However, some of the Council’s ajob 15
dystopic scenarios are a bit exaggerated and distract from there is no evidence that a six-week course of beta-blockers is more realistic concerns about the use of beta-blockers that or would be harmful, these concerns seem overblown. They could and should be addressed by clinical research and certainly do not present a compelling argument for stop- policy analysis. The Council’s report too often demonstrates ping research or denying someone a potentially effective an approach characterized by Macklin (2006, 38) as the treatment for a potentially crippling illness. Results should use of “metaphors and slogans as substitutes for empirical be carefully monitored in all study participants to determine evidence and reasoned arguments,” and an epistemology who benefits most, who benefits least, and why.
that presents its intuitions as “immutable truths.” While The Council also worries that blunting traumatic mem- never actually calling for restrictive policy, the document ories with drugs could thwart “normal psychic work and hints at a deeply conservative moral agenda—one that adaptive value of emotionally charged memory” (2003, 226).
is demonstrated more candidly by Leon Kass, the head In other words, drugs might interfere with what therapists of the Council, and other Council members in their own call “working things through.” Normal grief, for example, publications (Kass 1991; Kass 1997; Krauthammer 2004; is a condition that is clearly helped by talking and think- Meilander 2003). Kolber characterizes the tone and content ing about painful memories over time, often with social and of Beyond Therapy as a form of “invasive” and “hard professional assistance. Pathological grief, however, can re- paternalism” that “imposes” values. He calls the Council’s semble major depression and often responds to pharma- concerns “suspect” (Kolber 2006, 1611–1612).
cotherapy. In PTSD sufferers, the memories and associatedemotions are often too powerful to work through. More-over, there is no existing evidence that memory and emo- Unsubstantiated Premises
tions will be blunted to such an extent that psychotherapy The Council bases most of its arguments on hypothetical will not be possible. In the early 1970s, one of the authors premises. It very briefly addresses the issue of “memory- (Youngner) remembers that rigid psychoanalysts moralized numbing drugs” given preemptively, before traumatic events against the use of antidepressants in severely depressed pa- and in non-clinical situations. There are many individuals tients. While acknowledging that the medication might re- who are in danger of exposure to a traumatic event—e.g., move the unbearable symptoms, they argued that it would firefighters, rescue workers, and civilians under bombing also prevent patients from working through their “underly- attack. The Council discusses the possibility of preparing ing” problems. With experience, however, clinicians learned soldiers for battle “to kill (or kill again); to dull the sting of that psychotherapy is almost impossible in a severely de- ones’ own shameful acts; to allow a criminal to numb his or pressed patient; when antidepressant therapy lifts the crip- her victims” (2003, 224). Although this morally wrought area pling effects of depression, it often frees people up to “work” may be worthy of more careful consideration, the Council on their problems. Is it different with PTSD? Studies and ex- raises an alarm but fails to elaborate the moral complexi- perience should answer this question—just as they should ties. Is the Council implying that it is morally wrong to help with any new therapeutic intervention.
soldiers to kill? Is this part of a general pacifist stance by The Council (2003) fears that beta-blockers will be the Council? Alternatively, is the Council suggesting that abused by people who do not really need or deserve them— memory-dulling drugs should simply be treated like other for example, persons who are not suffering from PTSD but chemical weapons and banned by international convention? who are simply seeking to escape bad feelings attached to Or, are there only some situations in which military killing bad memories. Yet, there is no evidence that any of the tens should not be facilitated? If so, which ones? Kolber (2006, of millions of people who have taken beta-blockers for years 1621–1622) wonders whether the Council has the same con- at a higher dosage for hypertension and cardiovascular dis- cerns about advanced medical technologies for treating sol- ease have discovered or abused such an “off-label” use. Pol- diers’ physical wounds so they may return to battle sooner.
icy and practice should address the possibility of abuse on Furthermore, the Council fails to raise more realistic con- Downloaded By: [Ingenta Content Distribution - Routledge] At: 15:47 11 March 2009 cerns. Would taking propranolol before battle put soldiers As a result of the use and abuse of memory suppressors, in greater danger by lessening or removing their evolution- Council warns that “the notion of moral responsibility arily evolved “fight or flight” mechanism? And, might the would largely unravel” and that “there could be no justice military be concerned that warning soldiers about PTSD or even the possibility of justice. . . and no forgiveness or the before battle might make them less anxious to enter into it? possibility of forgiveness” (2003, 232). It conjectures that Could this problem also put solders and rescue workers in memory dulling would allow victims of traumas to forget even greater danger? These are empirical questions that can the horrors they have experienced, creating a scenario in which victims would not demand apologies or retribution.
The Council spends most of its effort discussing the use The Council considers a hypothetical intervention in which of memory-dulling drugs after traumatic events. Here, its Holocaust survivors are treated with memory-blunting first concern is that preventing PTSD would necessarily en- drugs, and finds the intervention “deeply troubling” tail a prospective and quick judgment about “whether a because the “human race” would be ill-served by such a particular event is sufficiently terrible to warrant preemp- “mass numbing of this terrible but indispensable memory” tive memory blunting,” and which patients are “destined (2003, 231). In our opinion, the idea that such a horrific to have pathological memory effects” (2003, 226). Because event could be easily erased by a drug is insulting to those 16 ajob
who experienced it. This is an all too common example of Biomedicalization and the Codification of New Diseases
the trivialization of the Holocaust.
In the final chapter of Beyond Therapy, the Council briefly The Council (2003) also examines the idea of giving indicates that one of the lingering effects of new biomedical perpetrators of crimes memory-dulling drugs. It says that technologies is that they medicalize what were heretofore memory and its associated emotions make us feel the considered “normal” states of being (2003, 305). We think “sting” of conscience, and that “evildoers” can and should this phenomenon is worth exploring in greater depth. We feel the psychic pain that accompanies their “cruel, brutal, also wish to take the Council’s position one step further by or shameful deeds.” The Council implies that the use of linking medicalization to the politico-economic landscape propranolol would eliminate individual conscience of of contemporary American biomedicine and the role of the immoral acts, specifically those of “evildoers.” In other words, people would be able to commit heinous crimes Medicalization, as defined by sociologists in the 1970s without feeling enough guilt afterwards. It is by no means and 1980s, describes at least two processes: 1) placing what certain that most “evildoers” feel the sting of conscience had previously been conceived of as a “normal” aspect of at all. Did Hitler and Stalin (who did not have access to the human condition under the medical gaze; and 2) tak- propranolol) lie in bed awake at night worrying about what ing something that was deemed by society to be deviant they had done? Does the average psychopath who does and placing it under the jurisdiction of medicine (Conrad not have propranolol suffer the pangs of guilty memories? and Schneider 1980; Parsons 1979). Examples of the first The evidence suggests that the sting of conscience is not process include phenomena such as childbirth, menopause likely in these individuals, whom most persons would be and death (Conrad 1982; Zola 1972). The second process is willing to label as “evil” (Arendt 1963; Lifton 1986; Stout exemplified by alcoholism, gambling, hyperactivity in chil- dren, and even political dissent. In each of these latter cases,the condition was originally under the jurisdiction of an-other social institution (e.g., religion, law, education), and Moralizing and a Hidden Agenda
was then placed within the realm of biomedicine.
Presidential bioethics commissions or councils are, in- In recent years, new processes of biomedicalization have evitably, political; in this respect, the President’s Council appeared that are particularly germane to this argument. We on Bioethics is no different (except for its politics) than the have witnessed the expansion of the diagnostic conditions National Bioethics Advisory Commission of the Clinton ad- of an illness to include more symptoms and include greater ministration. The conservative social and political views of numbers of people (Clarke et al. 2003; Moynihan and Henry President Bush, Leon Kass, and a majority of the Council are 2006; Zita 1998). This expansion has been documented in not a secret. These views are not specified in Beyond Therapy cases of clinical depression (Healy 1997) and bipolar dis- (President’s Council on Bioethics 2003). While one could order (Healy 2006); it is particularly evident in the expan- argue, as the Council does, that the report simply raises sion of attention deficit hyperactivity disorder to include far interesting questions, the premises about evil and evildo- greater numbers of children (Lakoff 2000) and a burgeoning ers (without a definition of evil) are hardly examples of the adult population (Conrad & Potter 2000). Biomedicalization Socratic method. The Council never disavows its conser- occurs as the result of a conglomeration of societal forces, in- vative agenda, but also never delivers the punch line—i.e., cluding: medical professionals who diagnose the diseases; identifying what is evil and shameful, how that is decided, advocacy groups who fight to have their suffering recog- and by whom. For example, the Council warns about drugs nized by biomedicine in the form of a diagnosis; and chang- such as propranolol making it easier for people who per- ing societal norms that expand or contract with changing form shameful deeds. But who decides which deeds are mores. The pharmaceutical industry is a primary actor in shameful or cruel and which are noble and heroic? Politi- cians? Judges? Priests? Bioethicists? President’s Councils? The expansion of the diagnosis, and sometimes the cod- Downloaded By: [Ingenta Content Distribution - Routledge] At: 15:47 11 March 2009 Would it be wrong for a fundamentalist Christian psychia- ification of the disease category itself, is encouraged and trist to give propranolol to a teenager who is ashamed about promoted by pharmaceutical companies that manufacture masturbation or homosexual fantasies, but permissible for drugs prescribed to treat the disorders—e.g., depression a liberal secular psychiatrist to do so? Is one of those two (Healy 1997); bipolar disorder (Healy 2006); attention deficit moral viewpoints the right one? The Council completely hyperactivity disorder (Phillips 2006); erectile dysfunction fails to address or even acknowledge the profoundly impor- (Lexchin 2006); female sexual dysfunction (Fishman 2004); tant questions of who should make such decisions. Such an and premenstrual dysphoric disorder (Greenslit 2002). Phar- approach is troubling in a liberal democracy—particularly maceutical companies sponsor disease awareness cam- at a time when reason, science and open public debate are paigns, advertise prescription drugs directly to consumers, threatened by a religious fundamentalism that claims di- and target physicians at continuing medical education con- vine knowledge of right and wrong, and would like to ferences and in their offices to encourage them to prescribe use the state as its enforcer. If this were not the Council’s their drugs. Sometimes referred to as “disease mongering” intent, it surely would have reassured the reader to the (Moynihan & Henry 2006), this newer process of medicaliza- tion gives pharmaceutical companies the ability to capitalize ajob 17
on human suffering and exploit insecurities and unhappi- to consumers who may be exposed to a trauma in the near ness in order to increase drug sales. Indeed, pharmaceutical future. Perhaps everyone should have ProBenz on hand to companies seem poised to reconfigure the landscape of dis- take either before or after exposure to a trauma. Falling in ease and illness categories within biomedicine.
line with the previous cases of methylphenidate for atten- Propranolol may be ripe for pharmaceutical “re- tion deficit hyperactivity disorder and selective serotonin branding.” An enterprising pharmaceutical company reuptake inhibitors for depression diagnoses, propranolol that wishes to manufacture and market a newer version may be positioned as another catalyst of “diagnostic of propranolol for the treatment of PTSD need only bracket creep” (Kramer 1993, 15), in which the availability slightly alter its chemical composition to obtain a new of a new drug encourages the expansion of a diagnostic patent and market the drug under a new prescription category. This is made all the more complicated in this case name. It might, for example, promise fewer side effects or with the added nebulous category of “prevention” rather longer-lasting effects than the generic propranolol. Or, like than treatment where the potential for expansion is even NitroMed’s (Lexington, MA) patent on BiDil (isosorbide dinitrate/hydralazine) (BiDil-Nitromed, Lexington, MD), We believe the President’s Council on Bioethics (2003) the “new” drug to treat heart failure in African-Americans, is right to raise forward-looking concerns about the intro- which combined two already available generic prescription duction of a new medical technology. If anything, modern drugs into a single drug, we can imagine a new combination history has taught us that scientific breakthroughs are al- pill of propranolol and, perhaps, benzodiazepine marketed most always double-edged swords (Evers 2007). However, and repackaged to prevent PTSD. The pharmaceutical while the language of “evildoers” and “pain” that is “de- company responsible would then be able to brand the served” has resonance these days in high political circles, “new” and now more expensive drug and market it under it has little utility in the scientific and sober evaluation of a a new name, let us call it “ProBenz” with a new patent for new medical technology and its potential dangers.
the “new” ability to prevent PTSD. A marketing campaign Research about the use of beta-blockers to dull memory to consumers and clinicians alike is sure to follow.
is in its infancy. Propranolol might well turn out to be Various scenarios become possible. Patients would be ineffective for the treatment of PTSD. Some people may made aware of and offered of ProBenz in the aftermath of even be harmed by it. Good clinical data and reasoned a traumatic event. To sell more drugs, the pharmaceutical public debate should determine the balance between harms company would want to delineate the range of traumatic and goods. We do not believe the President’s Council on events for which its drug should be prescribed —e.g., rape, Bioethics (2003) raised concerns that would justify ending violent crimes, death of a loved one. This is where medical- research into the use of beta-blockers for prevention of ization processes come into play. Trauma—our conception PTSD, nor discouraging the clinical use of these drugs of it, its parameters, what “counts” as trauma—is necessar- if research proves them effective. One of the benefits of ily culturally and socially defined, not medically. Yet, the propranolol research may indeed be the rehabilitation of definitions of trauma would become codified by the FDA an older, widely available, and affordable drug for a new through its indications for use of ProBenz and the pharma- and important use. We do, however, see the need to keep a ceutical company that makes it would continually attempt careful eye on the potential exploitation of the research on to push the boundaries of trauma outward in order to sell propranolol and PTSD by pharmaceutical companies.
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