Medication Moralists




  • The following article has been published with kind permission from Lew Mills, PhD, MFT, a Bay Area psychotherapist working with Attention Deficit in Adults.

    There is always reason for caution in prescribing pharmacological remedies. Effective treatments almost universally entail some “side-effectiveness” too. Because of the stakes, particularly in the treatment of children, it is all the more important that treatment decisions be driven by an assessment of the measurable benefits and the scientifically evidenced risks.

    A Scientific Question or a Moral Dilemma?

    Unfortunately, the debate over medical treatments for ADHD frequently evokes a disproportionately emotional reaction. The arguments seem to overflow, far beyond the medical decision involved, and inundate a broad territory of social issues. Decay of the nuclear family, under-funded schools, ineffective discipline, social entitlement, over-competitiveness, a loss of the value put on character, and many others issues stream into the discourse.

    Rather than address the technical argument about whether the positive effects of a medication are worth the risks, we are pulled into a maelstrom of social criticism. Instead of compassionately treating a disabling condition, we get caught up in “medication moralizing”

    Access to Care, not just Appeals to “Character”

    Most of us might endorse one or more of the moral agendas that are advanced by “medication moralists.” The call for “character” is a program that I would readily support. But we desperately need to separate the “moral” and the “medical” issues in order to act more intelligently and responsibly on both.

    Particularly, the appeal to “relying on character” as an alternative to treatment inhibits access to care. When treatment is considered as evidence that a person has not tried having more “character”, then treatment becomes less attractive to anyone who takes some pride in the strength of their character.

    This debate has not saved our children from sin, but rather kept many of them from success. Those who would benefit from treatment have another obstacle to overcome, where there were many already. Those who truly seek to improve their character have also been led astray with simple but empty answers.

    So long as the moral and medical issues are confounded in this way, we cannot be fully intelligent about either. Hiding a moral agenda under the surface of feigned concern about treatment cannot shed any light on moral or medical decisions.

    The Message in the Pill

    As evidence that a covert moral question persists as an undercurrent in the treatment debate, I would point to the recent FDA advisory panel decision. The panel recommended that prescriptions for stimulant medications should be slowed down. The phrases “runaway train” and “out of control” were invoked. The concern is not that medication is being prescribed to the wrong children. More accurate diagnosis is not being called for. Rarely have the benefits and efficacy of these medications been brought into this discussion. The objection is that there is just too much prescribing. Even though the scientific evidence did not support a reconsideration of the risk/benefit balance, a dire “black box” warning about health risks was advised simply in order to “slow down” the “epidemic” amount of treatment.

    Dr. Nissen, the FDA panel member championing the black box warning, admitted unapologetically that “Some of this is policy driven, as well as evidence driven”, (lack of evidence notwithstanding). If medical treatment of ADHD represents a moral “policy” question, what is it? If there is “a message in the pill”, what does it make us question?

    Personal Responsibility

    Ever since discovering that pharmacology can treat behavioral disorders, we have wondered whether chemicals can change “who we are.” Does the use of a medication represent a crutch for those who would take a shortcut on exercising their own self-control? Just because there is a chemical that increases the ability of a person with ADHD to be responsible, does that mean that those who aren’t treated are not responsible for their actions?

    The existence of these medications might seem to undermine our sense of personal agency, responsibility, and character. If a chemical supports self-control, does that mean that self-control is actually illusory? The message in the pill does seem to threaten to undermine our traditional conceptualization of autonomy and responsibility.

    So if a scientific discovery triggers anxiety about moral drift, what are we to do about it?

    When Science and Morality Collide, Both Get Cratered

    When Galileo produced scientific evidence that the earth is not at the center of the universe, it threatened to change man’s relationship with God and the Church. Of course, the evidence was of little persuasive power. Much later, Darwin’s revolution removed the human species from its place above and beyond the world of animals. Although scientific method can never be definitive, the evidence proves fairly persuasive on this matter. But the evidence will always remain muddled to those who hang a moral metric on a scientific question. And what is worse, real moral introspection is derailed in the false battles with science’s dissenters.

    Does dogmatically clinging to traditional views help forestall scientific discovery? Apparently not much. And moral rigor does not seem to collapse in the wake of our expanding scientific understanding. In the long run, the “moral” concerns about the efficacy of medications are not likely to change the actual scientific findings. Instead, medication moralists are likely to merely impede access to appropriate health care, with no discernable benefit to anyone.

    Don’t Shoot the Messenger

    Blaming the pill for the message it seems to carry is a tragic mistake. Whether it is from a concern about children’s character, the erosion of concepts about responsibility, questions about effective parenting or whatever, reducing the appropriate use of an effective treatment for a disabling disorder is not going to solve any problems.

    Shooting the messenger is not a strategy. The questions brought up by the availability of medical treatments for behavior problems will not go away. Just as Jupiter’s moons will continue to circle around Jupiter, and not the earth, wishing it were different changes nothing.

    Let Science Be Scientific. Let Medicine Treat.

    Moral judgments can’t resolve medical questions. Recognizing that we need to make changes in the social sphere does not excuse us from our more immediate responsibilities. We still need to help people with ADHD by maximizing access to proven effective treatments. We are still shamefully short of helping all the people that could be helped. Where treatment questions arise, we need to use science to learn what works. Trying to distort treatment decisions in order to support our personal models of a moral universe can only distract us, …at best.

    The side effect of making a moral issue out of a medical decision is that treatment is compromised. There is collateral damage in this culture war debate: It is our children and adults with ADHD. The inevitable effect of medication moralizing is to reduce access to some of our best treatment options.

    When we cry wolf about medications, doctors are more hesitant to treat. They will be inclined to prescribe less effective treatments or give less accurate diagnoses. Parents are an easily frightened group, because they really do care about their children’s treatment. Adults will be more reluctant to seek treatment. And even children themselves will pick up on the “black box” attitude and resist their own treatment.

    Aside from being bad medicine, moralizing about medications is not solving any social problems either. In fact it steals energy from our discussions of very real issues in families, schools and our society. We end up sounding glib as we suggest replacing medications with more attentive parenting, better-funded schools and so on. If those are real goals, which they should be, let’s really address them. Let’s not simply agitate about medication and then smugly retreat as if we have accomplished something.

    Our Moral Test

    Let’s look at the real moral question before us. But before you pick up your #2 pencils, listen to these instructions. If God is testing our moral clarity with this dilemma, we should be reminded that She often infuses Her quizzes with ample irony. Given a multiple-choice question, the simple answer is usually a trick. And if we are lucky, Her test helps us to think through to the truth, where we least expect it.

    Here is how I read the quiz: If I were to boil down the objection to the “message in the pill”, it would be that medical treatments might undermine our notions of “character.” A more recent incarnation of the traditional concept of character is now circulating as “emotional intelligence.” Science confirms the critical role of character, or emotional intelligence, in our children’s and in adults’ lives. Surprisingly, emotional intelligence is very closely related to a similar concept “executive function” which is precisely where people with ADHD are challenged.

    We may not be ready to say that medical treatments can “build character.” But treatment clearly makes it easier for people with ADHD to access the strength of their character. That would be the primary goal of an effective treatment: When confronting a character-challenging situation, wouldn’t it be better to exercise restraint, to be able to solve problems thoughtfully, to pay attention to salient information, to see priorities in perspective, to consider consequences? Aren’t these the markers of good character?

    Providing people with ADHD treatments that support their being their best selves is not pandering to a weakness. Nor is it corrosive of moral character. Rather than undermine self-determination, treatment gives people a tool to help them make their own best decisions. When we make treatments available, we support the character of those who choose to improve themselves.

    Let’s be careful to not jump to the simple answer, confounding science and moral issues. Let’s take the time to see how treatments are a compassionate, moral response to the problems faced by people with ADHD. And when we come to the real test, let’s keep our eye on what makes all of us better people.