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Normal Syndrome

According to Julian Savulescu: “We could halve the rate of mental illness tomorrow by redefinition. And we could continue to enhance the lives of normal people with the drugs developed in psychiatry.”

According to Julian Savulescu: “We could halve the rate of mental illness tomorrow by redefinition. And we could continue to enhance the lives of normal people with the drugs developed in psychiatry.”

By Stephen Luntz

What was once considered normal is becoming medicalised due to broader diagnostic criteria and the concoction of new disorders, but Julian Savulescu argues that this is merely biological enhancement by another name.

Professor Julian Savulescu, the controversial Australian bioethicist at Oxford University, says there has been a trend to medicalise many conditions that were once considered part of the normal range of humanity, and argues that this is occurring in large part to justify treatment. In September he told a Menzies Foundation lecture that we should instead become more comfortable with the idea that treatment should be available to those who have no disease, making these broader definitions unnecessary.

Treatment of those who are well is something that happens already, with the most obvious cases relating to fertility – either to assist during pregnancy or to prevent conception. “Pregnancy is not a disease. In fact it is the opposite of a disease,” argues Savulescu, pointing to a definition of disease as something that hinders an individual’s chance of living a full life and having offspring.

Yet while society takes medical involvement in such cases for granted, there is much less comfort with the idea of giving drugs to people who are considered well. As a result we are witnessing what Savulescu calls “an explosion of mental illness. Depression is the fourth leading cause of disability and disease worldwide. The World Health Organization projects that it will be the leading cause in developed countries by 2020. Are we unfit for the compressed, high paced, alienating, competitive world we now live in?”

Savulescu accepts this might indeed be part of the explanation, but believes that the definition of depression is being expanded to people who are experiencing periods of sadness or stress in order to remove concerns about administering drugs that will give them relief. Similarly, a diagnosis of disease may be necessary to get expensive therapy paid for by government or private insurance, providing a temptation for ongoing relaxation of diagnostic criteria.

Along with wider definitions of genuine diseases Savulescu takes aim at the creation of new conditions he considers nonsensical. “PMT is now an official health disorder,” he scoffs.

“DSM-5 [the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders] has called it ‘premenstrual dysphoric disorder’. At least one doctor has proposed ‘hypoactive sexual desire disorder’ to describe low libido.”

Such an approach is not entirely new. “My favourite psychiatric disease is ‘drapetomania’, described by American physician Samuel A. Cartwright in 1851, that caused black slaves to flee captivity.” Nevertheless, recent decades have seen unprecedented growth in new conditions.

“Worse, this epidemic is spreading to our children,” Savulescu adds. “ Around 12% of New Zealand children are medicated for Attention Deficit Hyperactivity Disorder (ADHD). Doctors in Australia will soon be screening 3-year-olds for early signs of mental health illness, including anxiety manifested, amongst other things, by sleeping with the light on, temper tantrums or extreme shyness.”

Savulescu is not against the widespread use of drugs like Ritalin to treat such conditions. “It is important to realise that just because something is normal is not a reason to stick to it. Much of this explosion of diagnosis of mental disorder, perhaps like ADHD, is a part of a legitimate concern about the well-being of people and now having the tools to improve that.”

Rather than feeling the need to define parts of the normal spectrum as diseased, Savulescu advocates accepting that there is a place for enhancement of the well. “It is time for an honest and open discussion about the proper role of enhancement in society,” he argues. “We can have our cake and eat it too. We could halve the rate of mental illness tomorrow by redefinition. And we could continue to enhance the lives of normal people with the drugs developed in psychiatry.”

Does Definition Matter?

If the most important thing is that those who will benefit from medical intervention get it, there is room for debate as to whether it matters where we set the boundaries of disease. However, Savulescu lists several costs of pathologising those who exist at one end of the spectrum of humanity. For a start there remains a stigma attached to certain illnesses, particularly mental ones. Moreover, diagnosis can lower responsibility. People come to “look on oneself as sick, ill,” Savulescu says. “It can become an excuse and create a sense of powerlessness.” Savulescu also worries about the inappropriate use of public resources and unjustified claims for compensation.

Sometimes diagnosis can help. “People with marginal Asperger’s Syndrome sometimes find the diagnosis helpful, feeling that the disorder, rather than themselves, is responsible for communication problems.” Nevertheless, he thinks that more often than not over-diagnosis causes more harm than good.

However, acceptance of enhancement would have far more profound consequences. Savulescu has long advocated the use of techniques such as gene therapy to create what others call “designer babies” in the right circumstances, and says that other examples of personal enhancement such as cosmetic surgery – including for children – are topics deserving discussion.

Critics who argue that Savulescu’s suggestions would lead to a “slippery slope” will certainly have plenty to work with in this debate. According to the editor of the bioethics newsletter Bioedge, Michael Cook, “Julian Savulescu is a stimulating polemicist with a keen eye for inconsistencies in the conventional wisdom. It’s quite clever of him to use the controversy over increasing medicalisation in the DSM-5 as a way of promoting his own ideas about human enhancement,” he says.

“What has always struck me is his naive faith in the power of doctors and scientists to enhance our lives with drugs and genetic engineering. Intelligence is an incredibly complex interaction of nature and nurture. To predict that the power to enhance it is around the corner is utterly unrealistic. He has even proposed using drugs to promote love and altruism, which seems quite daft.”

Savulescu expects that the most controversial idea will be the treatment of normal people for the sake of others rather than for their own benefit. At what point does society have the right, for example, to administer drugs to an aggressive individual in the hope of preventing violence to others?

Tricky as these arguments will be, Savulescu believes they are better confronted rationally than by hiding behind invented diseases like drapetomania, which was a convenient fig leaf covering the abuse of slaves under the guise of treating their illness. Likewise opponents of the Soviet government were routinely diagnosed as mentally ill so they could be locked up and silenced.

“Homosexuality was shamefully defined as a disease by the American Psychiatric Association until 1973,” Savulescu recalls. “Homosexuals were subjected to painful aversion therapy in the 1950s and 60s to cure them.” While these treatments would sometimes have been justified through supposed benefits to the individual, concerns about the alleged impact on the wider social fabric were always more prominent.

Treatments that harm the subject but have wider benefits are already accepted, such as donating bone marrow. A more galling example is the separation of conjoined twins even if it will be fatal to one twin. “This was justified on the basis that one twin was a ‘growth’ on the other. This was not true, but it was a story that was told to make ourselves feel better about an operation that was necessary if both twins were not to die in a matter of weeks.”

The more powerful medical technology becomes, the more such issues we will have to face, and Savulescu is keen for clear principles to be laid down. “Incursion of freedom should be as small as possible. We should try to promote autonomy. However, there are cases where the harm to the individual is small and the harm prevented to others is great.”

Here Savulescu cites churches in Cyprus that insisted that couples getting married within them should be tested for genes for thalassaemia, a recessive disease of red blood cells that is so common on the island that the cost of treatment was threatening to bankrupt the economy. By simply forcing a blood test on prospective couples, churches ensured that anyone getting married knew the risks if they had children. Most carriers opted not to have children with another carrier, and the disease has almost disappeared from the island.

However, Savulescu says that many other examples are not so clear-cut, offering either more limited social benefit or requiring greater restrictions on the liberty of those being treated.

The Cost of Normal

For all Savulescu’s enthusiasm for narrowing the definition of disease there can be costs to being defined as normal. Savulescu gives the example of a woman in Virginia who was executed for plotting to kill her husband. American law forbids the capital punishment of people with an IQ below 70, but this individual was assessed as having an intelligence quotient of 72, thus falling within the normal range. Three IQ points cost her her life.

Leaving aside the challenges of measuring intelligence to such a fine degree, Savulescu maintains that “their very definition of disease and disability is completely ill-suited to this application. It is a statistical concept, where a line has been drawn arbitrarily at 70, two standard deviations from the mean.”

Irrational as this division may be, it works to the advantage of those placed outside it. While Savulescu agrees that expanding the definition of normality carries risk, he says it is “even more desirable to have accurate tests that assess people’s functionality in the relevant domain. We want to be able to assess the extent to which someone understands the consequences of their actions, which is much more complex than measuring their IQ.”

Challenged that acceptance of treatment for the well may open up a free-for-all where pharmaceutical companies get access to wider markets for whom their products may be counter­productive Savulescu acknowledged: “We could end up with people experiencing more side-effects than benefits. The way to stop that is proper ecological studies. People are already buying these drugs on the black or grey market. There are many drugs that are already widely used that have not been studied in a rigorous way – for example caffeine. We would be much better off studying all the things we take to influence our lives.”

Such an approach sounds expensive, but Savulescu believes social media opens up opportunities for cheaper studies. “In the case of motor neuron disease, a new drug was being tested. Patients started reporting side-effects on their blogs. When these were collected it was quickly realised that the drug was not working and the clinical trial was terminated.”

Savulescu’s proposals run counter to many entrenched interests with an investment in the current system. However, this does not disturb him. “I think it will happen inevitably. It is not just health that matters but other aspects of well-being, and people vote with their feet. The question is not whether treatments will become more widely available but how this will happen. Will people take drugs on the black or gray market, or will we guide the direction, taking control and properly evaluating these treatments? Prohibition always fails. It is much better to focus on harm reduction.”

Savulescu’s approach has been criticised on the grounds that it will lead to a sort of treatment arms race. If those who fall slightly below the medium on some criteria – be it height, intelligence or impulse control – experience a boost from some treatment the average will rise, putting pressure on others to follow the same path. This may not matter where side-effects are small or non-existent, but become a serious issue where the treatment has a real cost.

“A virtually unregulated free-market world of enhancement would be appallingly undemocratic,” Cook says. “Enhancement is an expensive process which the poor will not be able to afford. The world of enhancement is, in my view, a geekish fantasy, but if ever it came about it would divide humanity into gated communities for the gene-rich and slums for the gene-poor.”

Savulescu’s response is that “we need to make a distinction between positional goods, like height, that are only beneficial if you have it and others don’t, and non-positional goods that are beneficial to everyone”. He thinks those who object to his ideas see every good as positional. “Many things are a combination of positional and non-positional benefits. Good memory for example. If we increased everyone’s IQ by three points it has been estimated this would add $150 billion to the US economy, reduce poverty by 20% and the number of men in jail by even more. So there are positive externalities as well as negative. We need to monitor each on a case by case basis.”