Philosophy, Psychiatry, & Psychology

We are grateful to Crockett and Craigie for their interesting remarks on our paper. We accept Crockett’s claim that there is a need for caution in drawing inferences about patient groups from work on healthy volunteers in the laboratory. However, we believe that the evidence we cited established a strong presumption that many of the patients who are routinely taking a medication, including many people properly prescribed the medication for a medical condition, have morally significant aspects of their cognition and behavior modified in a way that is unintended and may sometimes be unwelcome. Crockett notes that in some cases the effects of long-term drug use may differ, sometimes markedly, from the effects of short-term use. However, if acute use of a drug affects a neural system involved in mediating moral cognition or behavior, this nevertheless provides some evidence that chronic use of the drug may affect that same system and thus have morally significant effects. It is also plausible, in some cases, that an acute moral effect would give rise to a chronic moral effect via cognitive mechanisms. For example, a drug that acutely diminished anxiety in encounters with members of a different racial group might result in one or two such encounters being experienced more positively. This might in turn lead to longer term changes in racial attitudes, and/or in self-fulfilling prophecies based on expectations about what future interactions with members of that group would be like, even if the initial anxiety-reducing effect of the drug did not persist. Notice that the ethical issues we raise do not require that the morally significant effects of chronic use be exactly the same as those of acute use—it is enough that there are such effects.

Crockett also points out that a pharmaceutical may compensate for a deficit in patients: whereas normal controls may have their level of, say, serotonin raised above baseline by a drug, a depressed patient may instead have normal levels restored. Any effects on their behavior would therefore also consist in altering it from abnormal to normal. However, some of the drugs that we discussed are frequently used in normal, healthy individuals—for example, to control reproduction or normal anxiety. In addition, although we agree that where these drugs are used to treat disorders they could simply alter behavior from abnormal to normal, this cannot simply be assumed. First, [End Page 135] many people who currently use antidepressants may have depressive symptoms unrelated to serotonin abnormalities; selective serotonin reuptake inhibitors might act on them in a similar way to non-depressed people. Second, a great deal depends both on the mode of action of the drug, which may bind to receptors in areas of the brain that are not pathological, and on the etiology of the disorder. It remains controversial how selective serotonin reuptake inhibitors work; for that reason alone, we cannot assume that they merely restore patients to normal functioning across the board. Indeed, it would be surprising if they affected only those dimensions of neural functioning that are disordered in depression.

Moreover, as Crockett implicitly acknowledges, even if the effect of selective serotonin reuptake inhibitors on depressed individuals would merely be to align their moral dispositions with those of healthy people, this would still be a significant effect. Notice that although virtually everyone agrees that severe depression is undesirable, there is far less agreement about many questions in the moral domain—it is not clear, for example, when it is appropriate to accept or reject unfair offers. So it cannot be simply assumed that the moral dispositions of more healthy individuals are necessarily ideal or optimal.

However, as Crockett says, the effects on patients may be different from those on healthy controls, and the effects of chronic ingestion different from those of acute ingestion. We concur wholeheartedly and believe that such potential differences make further investigations of possible effects in...