The Ethics of the Mental Pursuit of Perfection
Keeley Roles
The number of individuals diagnosed for one or more mental disorders and consequently treated with a corresponding drug has significantly increased the past several years. The following statistics displaying this are shocking:
These alarming figures call us to question the causes behind this influx of diagnosed mental disorders as well as the consequential drug prescription as a solution. When asked to discuss the ethics of the mental pursuit of perfection, there are several different aspects to consider. The main ethical issues raised lie in the prescription of drugs to children and the over prescription of drugs. In addition, I will discuss who and what are responsible for our culture’s desire to “quick fix” every definable problem with some type of drug, be it prescribed, non-prescribed, or self-prescribed.
When one thinks about mental disorders in respect to children, Attention Deficit Hyperactivity Disorder (ADHD) immediately comes to mind. Defined now as “children who are excessively active, are unable to sustain their attention, and are deficient in their impulse control to a degree that is deviant for their developmental level” (Loewenton, 2002), ADHD now affects up to 5% of schoolchildren and continues in roughly 60% of those youths as they age (Henderson, 2004). There are many different opinions regarding the validity of ADHD as a psychological disorder, but according to the National Institutes of Health (NIH) back in November of 1998, ADHD was defined as a real disorder that responds positively to stimulants even though no clear neurological or physiological correlates of the disorder have been identified. Since then, research has continued and more children have been diagnosed with ADHD and treated with drugs such as Ritalin. Today, the number of children diagnosed for ADHD stands at about 5 million and the United States consumes approximately 90% of the world’s Ritalin production (Loewenton, 2002).
Ethical Issues in Prescription of Drugs to Children
One of the big ethical issues raised is that the addictive qualities of these drugs could lead to substance abuse later in these children’s lives. Ritalin, Adderall, and Metadate CD, all drugs used to treat children with ADHD, are what are known as Schedule II controlled substances, the most addictive substances that are still legal (Zernike and Petersen, 2004). Methylphenidate and Ritalin are nearly identical to amphetamine, commonly known as “speed.” The Drug Enforcement Administration puts methylphenidate in the same class of drugs as morphine and codeine: drugs with legitimate medical application but a high potential for abuse. Also according to the Drug Enforcement Administration, Ritalin and other similar stimulants are among the most frequently stolen prescription drugs. Students are crushing and snorting pills for a speed-like high and Ritalin has even been referred to as a “gateway drug” (Merrow, 1995).
The concern that giving a Schedule II substance to a child will result in future substance abuse is an ethical issue for all drugs prescribed to children, especially drugs prescriped for depression. The US Surgeon General reported on mental health in 1999 that about one of five Americans younger than 18 has a diagnosable mental disorder and more than one million children and teenagers are taking drugs for some form of a mental disorder (Elias, 2004). In addition to the fear of later substance abuse, the taking of these drugs by children has also been thought to increase suicidal thoughts and attempts in these children. In 2003, the Food and Drug Administration (FDA) found that the risk of suicidal thoughts and suicide attempts was three times greater among Paxil, an antidepressant, users than children given a placebo, the equivalent to a sugar pill (USA Today, 2003). Biological psychiatrist Dr. David Healy served as an expert witness in two American court cases involving suicide and SSRIs where he discovered information in support of this claim. Healy saw unpublished data on trials done by drug companies that found that 25% of healthy volunteers given the drug had some sort of unpleasant psychological reaction suggesting “that the likelihood of someone committing suicide during their first month of treatment with Prozac is ten times greater than if they were untreated” (Burne, 2002).
Another ethical issue raised for both children and adult patients is the doctors’ failure to explain the withdrawal symptoms that will occur when a patient wants to discontinue their use of a drug. Patients have expressed serious disdain against the many doctors that inadequately portray the side effects, withdrawal symptoms, and addictive qualities of the drugs they are taking (Harris, 2004). The side effects alone in drugs like Prozac are painful. Prozac causes rashes or hives in 7% of the people who take it, insomnia in 20%, sedation in 13%, tremors in 10%, and 10% to 70% find their sex lives diminished ( Moore 1999). James McGough, a member of the FDA pediatric drug advisory panel, astutely states that drugs are over-prescribed: “It’s a reflex. If someone’s unhappy in school, put them on antidepressants” (Elias, 2004).
Many questions remain. Are these drugs really working? Are the benefits offsetting the noticeable side effects? Is it possible that some of these children are being incorrectly diagnosed and improperly medicated? A study done by FDA showed that the benefits for taking a prescribed drug are very similar to the effects of a placebo. After conducting clinical trials in which some patients received a placebo and others the active drug, they found that for the most part, no measurable difference could be found between Prozac and the placebo. 90% of all the improvements reported by patients taking Prozac were also reported by the patients taking placebos suggesting that something other than the drug was at work in these patients. Failure to produce measurable effects was found in other drugs besides Prozac. Serzone and Paxil were also tested with similar protocols and also failed to produce measurable effects ( Moore, 1999).
These drugs are not helping patients get better, but are rather increasing the likelihood of drug dependence, propensity for suicide, and are difficult to stop taking because withdrawal symptoms are so bad. A deeper question remains: how have we been persuaded that these drugs are the answer?
$$$Money$$$ and our consumer-driven, fast-paced mentality that doesn’t allow the time to stop and fully assess the psychological causes for a child or an adult’s mental disorder is the root of the problem. The American Medical Association estimates that only 22% of those who suffer from depression receive proper medical treatment. The average consultation time between a US doctor and a patient is 7-8 minutes, not nearly enough time to make a reliable diagnosis and determine an appropriate method of treatment. And as much as we’d like to blindly trust that the doctors who prescribe us medicine know the full extent of the drugs’ costs and benefits, the fact is that they don’t. There has been a shift in the relationship between the pharmaceutical companies and the doctors. If you’ve flipped through a magazine or watched a television program recently, you’ve undoubtedly noticed an influx of drug advertisements. Whereas pharmaceutical companies once promoted prescribed drugs to physicians directly, they now advertise direct-to-consumer. In addition to more intrusive advertising, pharmaceutical companies are using the tactic of “getting in early” to prevent patients from using other drugs from different companies by giving samples of their drug to the doctor to distribute. Once on the drug, the patient’s intake slowly increases until the maximum dosage is reached to determine whether the drug is appropriate. By this point, discontinuing the use of the drug immediately would result in a series of intense withdrawal symptoms successfully “hooking” patients for at least six months (Harris, 2004). Can drug companies be trusted? We can’t forget that the goal of the pharmaceutical companies is to make money. In 2003 alone, US sales for anxiety and depression drugs was 2.5 billion dollars making the annual cost per patient $850 (Langreth, 2004).
Because of the pharmaceutical companies’ desire to increase their profit, there is a gap between what the drug companies say publicly and what their data shows. For one, as in Dr. David Healy’s case, drug companies do not always publicize data that hinders their ability to effectively market their product. Drug companies have also been caught making controversial statements. Healy pointed to a story from the Boston Globe in May 2000 where Eli Lilly, the maker of Prozac, was discussing R-fluoxetine’s, a new form of Prozac, benefits which included that it will not produced the side effects such as agitation, suicidal thoughts and self-mutilation common to Prozac, the very side effects the company had been denying for a decade (Burne, 2002). Healy’s argument is that there has been a deliberate campaign by drug companies to change our image of depression in order to increase the sales of anti-depressant drugs. Fifteen years ago, depression was viewed as a severe mental condition worthy of hospitalization where as conditions such as anxiety, sadness, feeling tired all the time, and worries about social situations were treated with tranquillizers such as Valium. However, tranquillizers fell out of favor when they were shown to be addictive, paving the way for the advertisement of SSRIs as safe, non-addictive, and effective. Everyone was familiar with the fact that serotonin is the brain’s “feel-good” chemical where too little of it causes you to be depressed, so the fact that SSRIs increase the amount of serotonin available in the brain sold well. The only problem with this story is that only very recently have there been studies that show how SSRIs work to counter depression [link to the section in Jenny Sanders’ page that discusses this recent study]. And even though scientific studies are beginning to show SSRIs’ function, the problem still remains that years of advertising has been misleading by trying to distinguish anti-depressants from the addictive tranquillizers when they aren’t much if any better and are equally addictive (Burne, 2002).
When you visit the websites of pharmaceutical companies and look at the ads promoting their products, you see the ways in which the drugs are idealized and promoted as the only answer. For example, GlaxoSmithKline, a leading pharmaceutical company’s, mission statement is: “Our global quest is to improve the quality of human life by enabling people to do more, feel better, and live longer.” The Antidepressant Drugs Database instructs the patient to “take your medications religiously ever day regardless of how your feel. It is essential that depressed people who are on medication do not discontinue taking their medication even when they feel great.” In the back-to-school section of August’s Ladies’ Home Journal, there are three full-page advertisements for ADHD treatments. Zernike and Petersen claim that these ads “evoke a sense of a Rockwellian calm. Children chat happily next to a school bus. A child’s hand gently touches the hand of an adult. In one ad for the new drug Metadate CD, an approving mother embraces her beaming son as the drug itself is named and promoted.” Celltech has created a Superman-like character with “CD” written on his chest. “A new hero for ADHD patients is here!” The new marketing message from Eli Lilly regarding adult attention deficit disorder is “Feeling distracted, disorganized? Trouble waiting your turn in line? Fidgety? Maybe you have adult attention deficit disorder, or adult ADD, and need to see a doctor” (Cohen and Goldschmidt, 2004). “The danger of the ads,” says Evelyn Green, teacher in Chicago and president of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), “is that parents could get the message that medication is all there is” (Zernike and Petersen, 2004).
Pharmaceutical companies’ quest for profit has also resulted in misleading statistics and selective publication of trial results. Many scientific reports and medical textbooks cite statistics that are inflated in one way or another. In most studies, a “responder” is someone whom the investigator judged to be much improved during one weekly visit. However, people who improved in one visit but later dropped out either because of adverse effects, lack of efficacy, or both, were also included in the data. Another way scientific reports falsely boost statistics is by ignoring those who drop out of the clinical trials. One published trial of Effexor proclaimed that 90 percent of "completers" had responded even though 36 percent abandoned the drug for adverse reactions, lack of effect or other problems before the trial ended. Also, drug companies selectively publish their clinical trials. Though FDA requires companies to submit failed trials, reports of drugs with no effect seldom make it to the medical journals. Because really, how many drug companies are going to publish a study that hinders the promotion of their drug by making it look bad? ( Moore, 1999).
But before we point the finger entirely at the pharmaceutical companies, we must also see the role insurance companies play. Budget cuts are “hacking away” at mental health services for poor children insured through public programs. About 12% of children (8.5 million) have no insurance (Elias, 2004) and if children or adults have insurance, companies are more likely to cover the money spent for “quick-fix” drugs rather than the time and money it would take to get to the psychological root of the patient’s mental disorder. Most insurance companies only have a few therapy visits on their plan, but all plans pay for pills. Even if insurance companies began to cover therapy visits, because we’re a consumer-driven society, there is a shortage of trained therapists and unless insurance companies agree to pay, this won’t change.
In conclusion, we see that the fundamental ethical issue raised by the mental pursuit of perfection is the medical and business world’s propensity to treat an acute symptom with a drug whose future and even present complications aren’t fully known in order to make the “quick buck.” “We medicalize people’s everyday unhappiness and people’s personal psychological troubles that could be better treated through a more social approach” (Horwitz, 2002). By treating symptoms rather than taking the time and money to get to the root of the patient’s problem and accurately treat it, the patient will ultimately pay more money on drugs that are only slightly improving their condition. It’s a catch 22. The drugs do show some positive effect causing the patient to continue taking them, and the more drugs the patients take, the more money both the doctors and the pharmaceutical companies are making. But at what cost are we medically advancing? The question falls on us as a society as well. Why are we too “busy” and too consumer driven to stop and fully take care of ourselves and our children. Would our money not be better spent on the growth of therapies such as cognitive-behavioral therapies which are structured and goal-oriented in teaching kids to change self-defeating attitudes and behaviors? Insurance companies, pharmaceutical companies, and doctors need to work together to financially support the kinds of treatment that will correctly diagnosis a patient’s disorder, and we as a society need to take the time to take care of ourselves physically, mentally, socially, and spiritually. All of these components are essential to our overall health as human being, and one or all have been compromised in our fast-paced, “quick-fix” society.
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