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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
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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-
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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
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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-
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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.
14 ajob
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
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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-
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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-
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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.
more drugs. For example, a drug advertisement in whichsomeone is encouraged to take propranolol after an embar-rassing or humiliating experience at the office. Here we have
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20 ajob
BOY SCOUTS OF AMERICA - TROOP 805 Kiwanis Service Project – Saturday, March 1, 2014 Helping the Kiwanis, our troop sponsor, with putting on a breakfast for counselors for the annual middle school Youth 2 Youth conference 6:30 a.m. – 8:30 a.m., Saturday, March 1, 2014. Logistics: Scouts should be dropped off and picked up at Dougherty Valley HS Uniforms: Wear Class A uniforms
VIDAL en ligne (eVIDAL) Présentation : Base en ligne correspondant au Dictionnaire Vidal imprimé (accès sur abonnement). Médicaments : pour chaque médicament, une fiche du produit appelée « monographie » indique toutes ses caractéristiques. Parapharmacie (accessoires et matériel médical, désinfection et lavage, hygiène et cosmétologie, etc.) : certai