. . . .” How can we, who have (some)
of these advantages—advantages in
the games we indeed play—moralize
carelessly about the others who want
them? When that moralizing starts to
happen, one looks around for some
reasons for it, reasons having to do
with cui bono; and usually they are
not far to seek. I’m just as vulnerable
to such self-serving moralizing as
anyone else, but here I want to try to
resist it.
The point is not to insist on one
of these lives in preference to the
other; still less is it to evangelize—for
others—a life that none of us actually lead. The point is first of all to realize that there are at least two sorts
of lives there to be lived, to realize
that our common conceptions, and
common life, is a historical construction, not the plain sense of things.
This, I think, is Heidegger’s great
virtue: he reminds us that the life of
technological ordering is not the only
life there has ever been. Even if we are
not yet in position to take its measure, and to measure it against the life
we ordinarily live, such measuring
will come only when the alternatives
are clear to us. Thus the philosophical work we need to do is not, as we
might think, to find within our ordinary ethical lives the wherewithal to
say yea or nay about Prozac or other
“enhancement technologies,” and it’s
not even to deprecate those lives in
favor of some other, radically altered
version of them. Both those reactions, the complacent and the eschatological, strike me as too easy, and
too easily seductive. I think we need
to do something slower, more difficult, and probably less attractive. We
need to explore, sensibly and carefully and critically, the possibility that
we—some of us—can and should
live differently than we do. Until we
have done that, and until we have
ourselves experimented with what
we’ve discovered, I suspect we will
stay pretty much on the surface of
the problems we would like to resolve.
References
1. M. Foucault, The Care of the Self, tr.
R. Hurley (New York: Vintage Books,
1988), p. 54.
2. Think, in this connection, of what
Christians call the Passion of Jesus, the pain
and death he had to undergo, to suffer: passion is “pathos.”
3. P. Kramer, Listening to Prozac (New
York: Penguin Books, 1994), pp.1-21.
4. For the best short account see M. Heidegger, “The Question Concerning Technology,” in The Question Concerning Technology, tr. W. Lovitt (New York: Harper and
Row, 1977), pp. 3-35.
5. M. Heidegger, “What Are Poets For,”
in Poetry, Language, Truth, tr. A. Hofstadter
(New York: Harper and Row, 1971), pp.
91-142.
6. See J. C. Edwards, The Plain Sense of
Things: The Fate of Religion in an Age of
Normal Nihilism (University Park, Penn.:
Penn State Press, 1997), Chapter 5.
Prozac, Enhancement,
and Self-Creation
b y DAV I D D E G R A Z I A
A person can be true to oneself even while
transforming and even creating the person one is.
One’s self is not something merely waiting to be
discovered, after all. To some extent, part of the
human endeavor is deciding and trying to become
who we want to be.
David DeGrazia, “Prozac, Enhancement, and Self-Creation,” Hastings Center Report 30, no. 2 (2000): 34-40.
34 H A S T I N G S C E N T E R R E P O R T
M
arina’s history is notable for significant childhood neglect. After her parents split up when
she was four, her father became distant and
mostly uninvolved and her mother suffered from depression and a borderline case of alcoholism. Although involved in Marina’s day-to-day life, she was inconsistently
available on an emotional level. Because Marina was the
oldest child and apparently “had her shit together,” she was
often called on to help out with her younger sister and two
brothers, who had a variety of problems ranging from depression to juvenile delinquency to significant obsessivecompulsiveness. Due to the distraction of other family
members’ more dramatic struggles, many of Marina’s own
needs were never met. However nurturing this “parentified” child was, she never felt nurtured.
March-April 2000
Although by her own account she
had a troubled adolescence—doing
less well than she wanted in school,
flirting with drug use and reckless
sexual encounters—she managed to
get accepted to a good university. Settling down considerably, she excelled
in college and got into a top business
school, where she continued her academic success. Throughout this period, her primary source of emotional
sustenance came from several close
friendships. Although these relationships were generally strong, Marina
sometimes bristled from perceived
putdowns and betrayals by those she
held dear. Her family’s demands for
advice and assistance persisted, but
coming to understand how her overreaching family oppressed her, she established some reasonable boundaries
with her mother and siblings, an
achievement made easier by living in
a different city. Her romantic life she
considered a failure. Her intense
work ethic afforded little time for
dating, and the men she wound up
with tended to be distant, rejecting,
and sometimes emotionally abusive.
Marina has also always been somewhat obsessional. She has been disturbed by thoughts about death since
adolescence and overly concerned
with the possibility of tragedy befalling her or her family, although
these thoughts occur fleetingly and
do not disrupt her functioning. For
many years, her recurring sexual fantasies have featured powerful older
men. She is troubled and disgusted
with herself when these fantasies
drive her to consume late-night hours
pursuing the half-hearted titillation
of sex-oriented internet chat rooms.
As she approaches age thirty, Marina is rather successful in nearly
everyone’s estimation: She is a wellpaid manager for a large computer
company, she has close friends, and
she has several pastimes that she genuinely enjoys (especially bicycling
and guitar). Yet Marina finds herself
brooding and pensive, wondering
about her life and its direction. She
seeks out a psychiatric consultation,
which takes place over four sessions,
March-April 2000
and accepts the psychiatrist’s conclusion that she has no diagnosable disorder. When he suggests that psychotherapy might nevertheless be of
help to her, she is inhibited by the
prospect of paying for many sessions
out of pocket (since her HMO will
not cover them). Still, she wants
changes. At work, she feels overly
tentative, unsure, too prone to worry
about possible errors. In her social
life, she hates how she endlessly interprets the latest transactions with
friends and the way she is attracted to
men who are bad for her. She feels
alienated by her obsessional thoughts,
considering them ridiculous and
bothersome even if not very harmful.
After extended periods of introspection, fueled by her impending
birthday and the discussions that
took place in the psychiatric consul-
means of using a prescription drug
morally problematic? If so, why?
In a highly insightful set of reflections on Prozac, Carl Elliott makes
the provocative claim that deliberately changing one’s personality through
use of Prozac is inauthentic because it
results in a personality and life that
are not really one’s own. Thus he
states that it “would be worrying if
Prozac altered my personality, even if
it gave me a better personality, simply
because it isn’t my personality”; and
he asks, “What could seem less authentic, at least on the surface, than
changing your personality with an
antidepressant?”1 Elliott’s thesis suggests that it would be inauthentic,
and therefore morally problematic,
for Marina to use Prozac for the purpose of changing her personality; indeed, if the drug had its intended ef-
There is a misleading image of the self as “given,”
static, something there to be discovered. In fact, a
transformation can be an authentic
piece of self-creation.
tation, Marina decides that she wants
to become more outgoing, confident,
and decisive professionally; less prone
to feelings of being socially excluded,
slighted, or unworthy of a good partner; and less obsessional generally.
She calls the psychiatrist who provided the consultation, whom she likes,
and explains that she has heard that
Prozac sometimes produces transformations like the ones she seeks—and
more quickly and less expensively
than could be expected from therapy.
Marina requests a prescription for
Prozac.
Is Marina’s request morally problematic? Should a psychiatrist refuse
to prescribe Prozac in a situation like
this one? What may give us greatest
pause about her request is that she
wants to use a medication to change
her personality and become a different sort of person. Is either the goal
of major self-transformation or the
fect, the resulting personality would
not really be hers.
But however intuitively appealing
this reasoning may be, it is undermined by its misleading image of the
self as “given,” static, something there
to be discovered. One can be true to
oneself even as one deliberately transforms and to some extent creates oneself. In fact, a transformation such as
Marina proposes can be a perfectly
authentic piece of what I will call selfcreation.
What is at issue here is clearest in
cases of personality change that, like
Marina’s, are uncontroversially cases
of enhancement, that is, of “interventions designed to improve human
form or functioning beyond what is
necessary to sustain or restore good
health.”2 Often, enhancements are
understood as interventions to produce improvements in human form
or function that do not respond to
genuine medical needs, where the latHASTINGS CENTER REPORT
35
ter are defined in terms of disease,
normal functioning, or prevailing
medical ideology, but sometimes enhancements are picked out by the nature of their means rather than their
goals. Some means of self-improvement, such as exercise or education,
are considered natural, virtuous, or
otherwise admirable. By contrast,
means that are perceived as artificial,
as involving corrosive shortcuts, or as
perverting medicine are often
thought to render the intended selfimprovement morally suspect (as
with steroid use to improve athletic
performance).
Marina’s intended use of Prozac
implicates the concept of enhancement both because she is not mentally ill and because many would see her
use of Prozac as an artificial shortcut
that perverts the medical enterprise.
Her case, and those at issue in this
paper, are cases of what Peter Kramer
calls “cosmetic psychopharmacology”
in his landmark book, Listening to
Prozac.3 Kramer uses the term to describe Prozac’s effect on patients who
are not really ill and who become
“better than well”: more energetic,
confident, and socially attractive. It is
worth noting that to varying degrees,
certain other drugs—such as Ritalin
and other “smart drugs,” Propranolol
for reducing normal anxiety and enhancing musical performance, and
the “happy pill” ginseng—raise at
least some of the issues associated
with cosmetic psychopharmacology.4
But this paper will concentrate on
Prozac, which apparently produces
the most extensive transformations of
personality and therefore presents the
issues of enhancement and self-creation in the clearest light.
Projects of Self-Creation
E
lliott’s remarks about Prozac and
authenticity occur within a
broader discussion of the values pervading contemporary American culture. I do not dispute Elliott’s claim
that having a sense of spiritual emptiness (reflecting our culture’s hollowness) can be preferable to Prozac-
36 H A S T I N G S C E N T E R R E P O R T
induced complacency.5 What interests me here is his description of the
ethics of authenticity, to which he ascribes two leading ideas, and the possible implications of this approach for
people like Marina (pp. 181-82).
The first idea Elliott identifies is
that life is a project whose meaning
depends on how we live and for
which we are largely responsible. I
agree with this claim. The second
idea may be broken into two parts.
First, figuring out how one should
live requires introspection, because
there is no unique external standard
for living meaningfully. Here again I
agree (while noting the role introspection plays in Marina’s growth).
Second, one has to discover and be
true to oneself in order to live an authentic life. To the extent that this assertion suggests that the self is
“given,” a pre-existing reality that
might be discovered and to which
one’s actions should conform or “be
true,” it strikes me as highly problematic. And it seems fair to read this assertion as depending on the image of
a static self, since Elliott uses the assertion to argue that Prozac-driven
changes of personality are inauthentic
and lead to a personality that isn’t really one’s own. (I don’t mean to suggest that he fully embraces the image
of a static self, just that his remarks
on Prozac appear to promote this
image to a degree that I consider disturbing.)
The ideas of authenticity, of being
true to oneself, and of self-creation
provoke issues pertaining to personal
identity. But what sense of identity is
at issue? One sense of the term, analyzed by Locke, Parfit, and kindred
philosophers, is that of numerical
identity over time: a thing at one
time is numerically identical with
something at another time if and
only if they are one and the same object, even if that object undergoes
qualitative change. In this sense of
identity, the problem of personal
identity is to specify the conditions
that must be satisfied for a person to
continue to exist through time.
While this sense of personal identity
raises interesting practical issues concerning, for example, the definition
of death and the authority of advance
directives, it is not central to this discussion.
The sense of personal identity at
the heart of the concepts of authenticity and self-creation is connected
with our self-conceptions—with
what we consider most important to
who we are, our self-told narratives
about our own lives. Your inner story
allows you to get your bearings when
you act, especially when confronting
difficult or momentous decisions.6 It
is what comes apart when a person
has an identity crisis, when she is left
wondering, in an important sense,
who she is.7 In this sense of identity,
one could become a different person
by undergoing a major change of
outlook and values. And this is the
notion Kramer has in mind when he
describes the transforming effects of
Prozac: Someone on Prozac might acquire a new sense of self—or identity—and strike others as having become “a new person.”
All of this suggests that the self, in
the second sense of the identity, can
change over time. Indeed, the feeling
that a self might undergo too much
change may underlie some of the
common discomfort with cosmetic
psychopharmacology. But how malleable is the self, and to what extent
can one actively change oneself? It is
important to have a tenable view on
these issues before considering
whether self-creation via Prozac can
be authentic.
One possible view envisions the
self as completely “given,” although
to discover its shape and true colors
one may have to dig (with reflection,
therapy, or the like). One can find the
self but not change it; any change is
due to forces outside one’s agency.
One version of this view takes a person’s “inner core,” the values that define the individual, to be entirely
constructed by society.8
In another possible position, essentially the opposite of the first, the
self is as amorphous and malleable as
Silly Putty. In Sartre’s view, we
March-April 2000
human beings are thrown into the
world without any determinate nature. What we choose determines
what we are, so we are completely responsible for what we become. With
nothing except ourselves determining
our actions and identity, we shoulder
the burden of “radical freedom.”
Thus we may shape ourselves into
one form one day without limiting
what we can shape ourselves into the
next day. In this view, we are entirely
self-creating, leaving no room for discovering anything about oneself except perhaps what one freely chooses
to be.9
These two extreme views about
self-malleability strike me as highly
implausible. A little reflection suggests that we can reshape ourselves to
some extent. We may try with some
success to become more disciplined—or less disciplined, for the
workaholics and perfectionists
among us. We may work at being
more generous or more patient or
more willing to stand up to authority,
and sometimes we may succeed. We
may aspire to orient ourselves more
toward a relationship—or less. And
when we accomplish change in ourselves, it does not seem that this
change is entirely independent of our
agency (as it would be if the impetus
were simply social forces, human nature, or one’s genetic makeup).
But if human phenomenology
suggests a capacity for self-change
through our agency, it does not suggest an unlimited capacity. Persons
with addictions and obsessive-compulsive disorders, for example, know
that their will is not the only force
driving their actions. And all of us are
frequently reminded that there are
limits to what we can accomplish in
changing our characters and behavior
just as there are limits to what our
bodies can achieve in sports.
If such self-shaping is possible, it is
only one crucial process that determines what we and our lives become.
The possibilities for self-creation are
limited by its enmeshment with other
crucial processes and factors (p. 138).
One of these is the genetically deterMarch-April 2000
mined cycle of life, which we are not
free to escape: the neediness of infancy and childhood, the relative turbulence of adolescence, the gradual loss
of physical powers in advanced age,
and so on. Other crucial factors concern the tools we are given to work
with, especially our particular genetic
endowment and the quality of our
early environment. A final crucial influence derives from the unexpected,
random, yet momentous consequences of the things we choose. I
once decided somewhat reluctantly
to attend a Halloween party where I
happened to meet the woman who
later became my wife and the mother
of my child. While self-creation is
possible, the range of possibilities
available to an individual is at once
opened up and limited by other
major processes and factors that
shape our lives.
na loses these characteristics, will the
resulting person really be Marina?11
Elliott’s remarks about Prozac suggest not, but I think a negative answer here is profoundly mistaken—
and not just because of the associated
image of a static self. For, again, what
is identity in the relevant sense all
about? It is about one’s self-conception, what a person considers most
important to who she is, her self-told
inner story. That means that it is ultimately up to Marina to determine
what counts as Marina and what
counts as not-Marina; the story is
hers to write (within the constraints
set by the various factors beyond her
control). And she wants to get rid of
the traits in question, if she can. In
general, whether certain personality
traits are definitive of someone depends on whether she identifies with
them—that is, whether she owns
It is ultimately up to Marina to
determine what counts as Marina and what counts as
not-Marina; the story is hers to write.
In this moderate view, self-creation is conceived of in the way suggested by Jonathan Glover, for whom
it is a process in which we are “consciously shaping our own characteristics.”10 I understand Glover to mean
specifically the conscious and deliberate shaping of one’s own personality,
character, or life direction. Glover
captures the interplay of self-directed
shaping as well as its limits by comparing the self to wood that can be
sculpted, “respecting the constraints
of natural shape and grain” (p. 136).
People who are engaged in selfcreation seek to change themselves.
Marina, for example, wants to change
her personality. While she has been
tentative, socially a bit mistrustful,
and somewhat obsessive for as long as
she can remember, she would like to
be free of these personality traits. But
this raises a conceptual issue: If Mari-
them (pun intended!) autonomously.
An example will help make the point.
Imagine two people, Nina and
Xena, both of whom are inveterate,
addicted cigarette smokers. Both
spend a lot of money on the habit,
both find it very inconvenient at
times, and both are unsure they could
muster the willpower to quit if they
tried. Is being a smoker part of their
respective identities? In my view, that
depends on further detail.
Suppose that they have different
attitudes toward their addiction.
Nina finds it alien and out-of-character and wishes she never smoked that
first cigarette. Xena, meanwhile, delights in being contrarian and knows
that smoking and addiction generally
are contrary to what most people
consider good sense. While in a way
her addiction deprives her of the freedom not to smoke—she just has to
light up periodically—Xena is auHASTINGS CENTER REPORT
37
tonomously a smoker, precisely because she identifies with smoking
along with its delightfully contrarian
associations. So while both women
are smokers, being a smoker is part of
Xena’s identity but not part of Nina’s,
and the difference lies in their distinct
value systems.
This consequence should not be
surprising, since who we are has
everything to do with what we value.
Further, what we value largely determines our projects of self-creation.
Thus if Marina is able to rid herself of
traits with which she doesn’t identify,
and decides that the “real Marina”
does not have those traits, no one is
in a position to correct her.
What legitimate basis might there
be, then, for the idea that it would be
inauthentic for Marina to change her
personality? Do the means of making
a personality change—in this case,
using Prozac—matter here? Some
would answer affirmatively, contending that these means represent an unnatural or artificial shortcut to selfimprovement. But consider a path to
desired self-change that would be regarded as natural, admirably laborious, and clearly within the bounds of
accepted psychiatric practice: psychotherapy. Successful psychotherapy
sometimes produces a shift in personality that the patient considers an improvement.12 Now suppose Marina
wanted to change her personality
through the long, hard work of therapy. If she were willing to pay for it, I
can imagine no reasonable objection
to her enhancement project (“cosmetic psychotherapy,” we might call
it, keeping in mind that she is not
genuinely ill). So I take it that therapy is an authentic and otherwise legitimate way of facilitating self-creation, even where enhancement is the
goal.
The question is, why should the
supposedly unnatural shortcut of
Prozac use make any significant difference to the authenticity of Marina’s self-creation project? That it is
“unnatural”—that it works directly
on her biochemistry rather than indirectly, as therapy does—simply seems
38 H A S T I N G S C E N T E R R E P O R T
irrelevant; the shortcut would still be
authentic because Marina’s values and
self-conception are the basis for the
chosen means. That it involves a
shortcut might even, in some ways,
make it admirable from a prudential
standpoint. After all, it is her time
and money that will be consumed
here. While therapy may offer a patient some advantages that Prozac
does not, if Marina believes those advantages do not offset the efficiency
she hopes to find in Prozac, it is hard
to see the justification for paternalistically judging that her values and
self-conception are not authoritative
for her own life. If they are admitted
to be authoritative for judging what
is good in her life (her best interests),
then they should be authoritative for
determining what constitutes her life,
thus what is authentic for her. If this
is right, then Prozac, no less than psychotherapy, can be an authentic part
of a project of self-creation.
Some Remaining Worries
I
f the preceding arguments have
been sound, they show that using
Prozac can be an authentic part of a
self-creation project, even in cases
that involve enhancement. This conclusion of possible authenticity
seems generalizable to other cases of
cosmetic psychopharmacology—at
least assuming that an adult with decisionmaking capacity is deciding
only for herself, since decisions for
children and incapacitated adults
raise special issues.13 But even if the
charge of inauthenticity is wrongheaded, it does not follow that cosmetic psychopharmacology is ethically justified or wise. There remain
some substantial ethical concerns
about cosmetic psychopharmacology
for capable adults like Marina. In the
end, I do not think these concerns
demonstrate that Marina’s psychiatrist should refrain from prescribing
Prozac for her, or that Marina should
exclude Prozac from her project of
self-creation. But I will only gesture
in the direction of an adequate reply
to each concern.
One concern is that Prozac, and
other pharmaceuticals that could be
used for enhancement purposes, are
not available to all who might want
and stand to benefit from them.14
Forty million or so Americans lack
health insurance, and many others
are insured by plans that do not cover
prescriptions for psychiatric medications or that provide coverage only
when one has a diagnosible illness.
Of course, the relatively wealthy can
still opt to pay out of pocket. But the
overall picture is one in which cosmetic psychopharmacology is likely
to benefit mainly those who are relatively well off and otherwise advantaged. Thus by exacerbating existing
gaps between the haves and have-nots
in our society, cosmetic psychopharmacology raises issues of social and
economic fairness.
These concerns about unfairness
are legitimate. But the unfairness derives from our economic system—including our system of health care finance, which promotes the interests
of the private insurance industry at
nearly everyone’s expense—rather
than from Marina’s or her psychiatrist’s choices. In my view, they and
everyone else should fight for greater
justice in the distribution of income,
wealth, and health care access, but
doing so is compatible with Marina’s
use of Prozac. In fact, if Marina is
right that taking Prozac would cost
less than psychotherapy, her project
raises a milder problem about justice
than does therapy, since the more expensive approach would be available
to even fewer people.
Another worry is that cosmetic
psychopharmacology tends to promote some very troubling cultural
values. Part of what drives Marina’s
interest, for example, is her desire to
be more efficient at work and her
longing for a more attractive personality. Since she is already professionally successful and has good friendships, one might think her desire for
self-improvement reflects our culture’s disturbing tendency to valorize
hyper-competitiveness and “designer”
personalities. Thus her plan and her
March-April 2000
psychiatrist’s involvement (if he goes
along) raise the issue of complicity
with suspect social norms.15
I agree that our society overvalues
competitiveness and other yuppie
qualities. But it seems to me that reasonable people could disagree with
this judgment, and that in any case,
responsibility for this problem too
should be located in our broader culture, not placed in the laps of Marina
and her psychiatrist. If there is a responsibility to change the culture, it
is everyone’s, and it should not be arbitrarily imposed on particular individuals in ways that interfere with
their self-regarding projects.
Some critics also feel that widespread use of Prozac and similar
drugs, unlike psychotherapy, promotes biopsychiatry’s agenda of reducing emotional and personal struggles to mechanistic terms—as if these
struggles were just another form of
pain to be treated with a new pill.16
According to critics, this agenda
threatens our self-conceptions as reasonable agents. But people might not
be equally troubled by the possibility
that using Prozac supports biopsychiatry’s agendas. In any event, Marina
and her psychiatrist have no obligation to promote the image of human
beings as reasonable agents. We are
such agents, but we are also feeling
creatures; self-esteem problems, suspiciousness, and compulsiveness are
connected with our agency, but they
are also closely connected to unpleasant feelings, which Prozac may help
to alleviate. Besides, even if Prozac
lends itself to a mechanistic view of
the self in some ways, Marina’s plan
for changing herself and her life direction is a powerful expression of her
own agency.
Another concern is that cosmetic
psychopharmacology can encourage
social quietism because patients may
favor drug-induced complacency
over active struggle to change the social conditions that contribute to
their discontent, with the result that
these social problems are left untouched.17 But while there may be
some risk of social quietism, the risk
March-April 2000
attaches to all uses of mood-improving drugs, not just to cases of cosmetic psychopharmacology, as well as to
mainstream religions and many other
clearly acceptable practices and institutions that can brighten our outlooks.
Critics have also pointed to problems that may arise if people pursue
cosmetic psychopharmacology for
competitive reasons, such as Marina’s
desire to become a more confident
businessperson. If nearly everyone in
a particular competitive environment
makes the same choice, the result will
be self-defeating: there will be the expense and other personal costs of taking the drug but no advantage acquired over others (just as most law
school applicants take an LSAT prep
course without gaining a competitive
advantage).18 Meanwhile, those who
cern highlights the importance of an
informed consent process that includes a responsible, balanced, and
thorough discussion of risks; it does
not justify paternalistically preventing
use of the drugs in question.
Permissibility and Prudence
A
s the tone of this essay may have
revealed, I believe the kind of
self-transformation Marina proposes
can be quite admirable. At the very
least, transformation via cosmetic
psychopharmacology can be a perfectly authentic piece of self-creation,
in that the resulting personality and
life are very much one’s own. One
can identify with certain traits, authentically pursue them, and change
oneself—while maintaining one’s
identity—within a project of self-creation.
Transformation via cosmetic psychopharmacology
can be perfectly authentic,
in that the resulting personality and life are
very much one’s own.
would prefer not to take the drug
may feel social pressure and possibly
coercion to do so; they may fear
falling too far behind.19 At least with
respect to Prozac, however, concerns
about self-defeating drug enhancements and excessive social pressure to
take it are rather speculative. We are
still far from such a scenario.20 What
to do if and when it arrives is not at
all obvious (just as there is no obvious
solution to the problem concerning
the LSAT prep course), but the mere
possibility of such a scenario does not
cast significant moral doubt on Marina’s enhancement project.
Finally, we should not ignore
whatever risks are associated with the
drug in question, especially since
some risks may remain unknown
while others may be hard to discern
accurately amid the glitter of the
drug’s celebrated benefits. This con-
At the same time, the wisest path
toward desired self-creation may
often include the slow, arduous road
of psychotherapy, despite its considerable costs. For those who are willing to work and confront some unpleasantness about themselves or
their lives, and who possess at least
ordinary introspective capacities, psychotherapy offers insights that are
generally not available from other
sources or activities. Moreover, the
changes in personality, character, or
life plans that result from this vigorous work stand a decent chance of
enduring, while people who go the
route of cosmetic psychopharmacology may need to take the drugs indefinitely to maintain the desired
changes. In effect, it may turn out
that therapy is the less expensive option after all, at least in the long run.
If Marina were my friend or famiHASTINGS CENTER REPORT
39
ly member, I would urge her to consider extended therapy very seriously.
I might even try to make the case that
its likely benefits more than offset its
added costs. But the values that ultimately count here, the ones that must
be translated into benefits and costs
of various weights, are Marina’s. If she
assesses her options with her eyes
wide open, she should be allowed to
select that which she believes is best
for her. It is, after all, her identity.
References
1. C. Elliott, “The Tyranny of Happiness: Ethics and Cosmetic Psychopharmacology,” in Enhancing Human Traits: Ethical
and Social Implications, ed. E. Parens
(Washington, D.C.: Georgetown University Press, 1998), pp. 177-188, at 182, 186.
Erik Parens, who edited the excellent anthology that contains Elliott’s article, seems
to concur with him. Thus Parens speaks of
“appreciating that drugs like Prozac are
good at promoting self-fulfillment as opposed to authenticity” (E. Parens, “Is Better
Always Good? The Enhancement Project,”
in Enhancing Human Traits, pp. 1-28, at
23).
2. E. T. Juengst, “What Does Enhancement Mean?” in Enhancing Human Traits,
pp. 29-47, at 29.
3. P. D. Kramer, Listening to Prozac (New
York: Viking Press, 1993).
4. See L. H. Diller, “The Run on Ritalin:
Attention Deficit Disorder and Stimulant
Treatment in the 1990s,” Hastings Center
Report 26, no. 2 (1996): 12-18; C. Mills,
“One Pill Makes You Smarter: An Ethical
Appraisal of the Rise of Ritalin,” Report
from the Institute for Philosophy and Public
40 H A S T I N G S C E N T E R R E P O R T
Policy 18, no. 4 (1998): 13-17; P. J. Whitehouse et al., “Enhancing Cognition in the
Intellectually Intact,” Hastings Center Report
27, no. 3 (1997): 14-22; J. Slomka, “Playing with Propranolol,” Hastings Center Report 22, no. 4 (1992): 13-17; and J. Glover,
What Sort of People Should There Be? (London: Penguin, 1984), pp. 71-72 (on ginseng).
5. See ref. 1, Elliott, “The Tyranny of
Happiness,” pp. 178, 186.
6. J. Glover, I: The Philosophy and Psychology of Personal Identity (London: Penguin, 1988), p. 152.
7. Marya Schechtman emphasizes this
point in what may be the strongest theoretical exploration of this sense of personal
identity (The Constitution of Selves [Ithaca,
N.Y.: Cornell University Press, 1996], esp.
Part II).
8. This position is helpfully explored and
criticized in ref. 6, Glover, I, ch. 17.
9. J. P. Sartre, Being and Nothingness, tr.
H. E. Barnes (New York: Philosophical Library, 1943).
10. See ref. 6, Glover, I, p. 131.
11. Kramer raises this conceptual issue in
the case of his own patients (ref. 3, Listening
to Prozac, pp. 18-19).
12. Sometimes a personality change may
result from the patient’s rewriting her inner
story, since this story is about who she is.
Cf. ref. 6, Glover, I, p. 153. For a classic
background work, see Sigmund Freud, Introductory Lectures on Psychoanalysis (New
York: Norton, 1960 [1920]).
13. Much of the concern about Ritalin,
for example, focuses on parental consent on
behalf of children, sometimes in apparent
conflict with their best interests. See ref. 4,
Diller, “The Run on Ritalin” and Mills,
“One Pill Makes You Smarter.”
14. D. W. Brock, “Enhancements of
Human Function: Some Distinctions for
Policymakers,” in ref. 1, Enhancing Human
Traits, pp. 48-69, at p. 59. .
15. Cf. ref. 1, Elliott, “The Tyranny of
Happiness.” Regarding this problem in
connection with Ritalin, see ref. 4, Diller,
“The Run on Ritalin,” p. 17; and regarding
the more frightening case of prescribing for
children, see ref. 4, Mills, “One Pill Makes
You Smarter,” pp. 16-17. For an insightful
discussion of complicity with suspect cultural norms, see Margaret Olivia Little,
“Cosmetic Surgery, Suspect Norms, and the
Ethics of Complicity,” in ref. 1, Enhancing
Human Traits, pp. 162-76.
16. This viewpoint is powerfully developed in Carol Freedman, “Aspirin for the
Mind? Some Ethical Worries about Psychopharmacology,” in ref. 1, Enhancing
Human Traits, pp. 135-50.
17. See ref. 1, Elliott, “The Tyranny of
Happiness,” p. 180; ref. 4, Glover, What
Sort of People Should There Be?, pp. 72-73
and ref. 4, Diller, “The Run on Ritalin,” pp.
14-15.
18. See ref. 14, Brock, “Enhancements of
Human Function,” p. 60.
19. See ref. 4, Diller, “The Run on Ritalin,” p. 16 and Slomka, “Playing with Propranolol,” p. 15.
20. We are probably closer in the cases of
Ritalin for schoolchildren and Propranolol
for professional musicians (see cites in previous note). My sense is that the associated
difficulties are so closely tied to the features
of a particular drug and the social context
in which it is used, that we cannot profitably generalize from a viable solution for
one drug to cosmetic psychopharmacology
in general.
March-April 2000
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