Should We Use Medicine for Morality?

Lessons from psychiatry

Before you get to today’s article, to celebrate last month’s publication of new Clinical Practice Guidelines on the definition of death in Canada, I’m re-upping Brain Death is Death, my second-ever Value Judgments article. I describe some of the problems with non-brain-death definitions.

“Love is the most important thing.” Photo by Raimond Klavins

Medicine can do lots of stuff. Bioethics is partly about figuring out which stuff is okay and which stuff isn’t. According to one popular view, medicine is just about healing. But as I’ve previously argued, this view struggles to explain some uncontroversial interventions, such as vasectomy, tubal ligation (having your ‘tubes tied’), and other forms of birth control. Vasectomy and tubal ligation both involve damaging perfectly good reproductive systems, so they’re obviously incompatible with the healing view. Nevertheless, these days, no one says they aren’t medicine.

The healing view is false, but that doesn’t mean everything is fair game. We still need to figure out what is medicine good for. One way we could use medicine is to increase moral behaviour, but it’s unclear if we should use medicine for morality, and, if so, how we would go about doing it.

A recent BBC article offers a test case. Brendan was a leader in the white nationalist movement in the U.S. before his identity was made public by an antifascist activist. He was fired from his job and lost many of his friends who weren’t white supremacists. A couple months later, needing some money and something to do, he enrolled in a drug trial at the University of Chicago.

It was a fun study. Participants were given MDMA, then stroked with a brush at different speeds on their forearms, then asked how much they liked the feeling of each speed. Scientists have long known that people like slow strokes, but now we also know that people on MDMA like slow strokes a lot more than people not on MDMA. 

Brendan was one of the lucky participants who got the MDMA instead of the placebo. He didn’t even have to wait for the actual study to begin:

About 30 minutes after taking the pill, he started to feel peculiar. “Wait a second—why am I doing this? Why am I thinking this way?” he began to wonder. “Why did I ever think it was okay to jeopardise relationships with just about everyone in my life?”

Then the stroking began.

“I noticed it was making me happier—the experience of the touch,” Brendan recalled. “I started progressively rating it higher and higher.” As he relished in the pleasurable feeling, a single, powerful word popped into his mind: connection.

Proponents of psychedelics have long used the concepts of set (mindset) and setting (one’s environment), which can have a big impact on one’s drug experience. Giving MDMA to white supremacists isn’t going to immediately rid them of their prejudice, but Brendan took the right amount under the right conditions to prompt a moral breakthrough. Harriet de Wit, the lead researcher of the study, says in the BBC article that “It’s what everyone says about this damn drug, that it makes people feel love. To think that a drug could change somebody's beliefs and thoughts without any expectations—it’s mind-boggling.”

Brendan’s outcome was an accident, but the natural question is, could therapists use MDMA and other psychedelics more purposely for this goal? One of my undergraduate students, Patrick Alexan, wrote his honours thesis on psychedelics and moral therapy. Since psychedelics aren’t risk-free, more research is needed to determine the best approach, but he argues that there are cases where using psychedelics for moral therapy would be ethical so long as the patient consents. 

I agree. Medicine can help in lots of ways, including by helping us be more moral. In addition to studying how MDMA makes people feel good, researchers should also see if it works on prejudice and racism.

The problem for psychedelic therapy is that, as Brendan’s case shows, the people who need it most aren’t likely to sign up. Most people, especially prejudiced ones, aren’t seeking ways to change their beliefs, so there’s a recruitment problem. But other examples show that it’s possible.

Castration is sometimes offered or mandated for sex offenders. California and Florida mandate compulsory castration in some cases, while judges in Montana and Louisiana are allowed to order it. In other places, like Texas, the United Kingdom, and some European countries, only voluntary chemical castration is legal. In Canada, it’s sometimes used as a condition for parole.

Surgical castration, which in men involves removing the testicles, is effective: one European study found that recidivism rates go from 70 percent without castration to five percent with it. Although it largely eliminates sexual desire, 20 percent of castrated people were able to maintain sexual relationships. A study of 900 sex offenders in Denmark found a recidivism rate of one percent. The World Federation of Societies of Biological Psychiatry guidelines for the pharmacological treatment of paraphilic disorders notes that “post-castration recidivism rates are among the lowest rates among all forms of treatments.”

There are, however, some serious ethical problems. Surgical castration is irreversible and can have substantial downsides in addition to eliminating interest in sex. The European study found that 50 percent of subjects were satisfied with castration, but around 30 percent were often depressed and many experienced bone demineralization. Ethically, forcibly removing someone’s testicles is wrong, especially when a reversible option exists.

The better alternative is chemical castration, especially Gonadotropin-releasing hormone (GnRH). Per the World Federation guidelines, GnRH reduces testosterone within a month, thereby inhibiting

sexual fantasies, desire, and interest in sexual activities, resulting in either a dramatic decrease or an abolishment of the sexually paraphilic behaviour in more than 95 percent of patients with severe paraphilic behaviours.

The tradeoff is that many men who receive chemical castration no longer have any sex drive, but this means they also don’t have sexual desires that lead to harm. For many sex offenders, that’s a tradeoff they’re willing to make, especially if their prison sentence will be reduced.

MDMA and GnRH both change how people think and, in so doing, can prevent them from harming others. These therapies make people more moral.

Using drugs to limit sex drive has other uses. A Vice article from 2016 describes the work of Scott Woodside, a psychiatrist at the Centre for Addiction and Mental Health (CAMH) in Toronto:

He currently has about 40 patients undergoing the treatment and another 20 to 30 taking antidepressants to curb their sex drive; 25 to 30 percent of his caseload at any given time is comprised of people who are addicted to porn or struggle with chronic infidelity, while the rest are convicted sex offenders.

Treating chronic infidelity is definitely a moral therapy, but the existence of a way for medicine to increase morality doesn’t, on its own, justify its use. Again, consent is a key component of the ethical use of these interventions. There are risks and downsides, but the patient can decide what’s worthwhile. 

This also raises a bigger question: who’s deciding what’s moral? Sex offenders are an easy case, but others get more complicated or are downright unethical. The most famous castration case shows this.

Alan Mathison Turing was offered a choice between prison or chemical castration using estrogen after being convicted of having consensual sex with other men. He chose the estrogen, the effects of which led to his probable suicide. Castration was clearly unethical, but prison would have been too: they’re both wrong because gay sex isn’t unethical and shouldn’t be against the law. And unlike in many voluntary cases, castration caused Turing nothing but suffering.

We shouldn’t miss that medicine played a role in Turing’s mistreatment. As I’ve written, identifying and categorizing psychiatric disorders is notoriously controversial, especially using the healing view, which will be more likely to medicalize behaviours by appealing to value judgments:

This is represented most infamously by the categorization of homosexuality as a mental disorder. After years of pushback from the gay rights community, the American Psychiatric Association dropped homosexuality from the DSM, not because of any empirical or scientific change, but because the normative landscape shifted. 

We can’t lose sight of these mistakes, but we shouldn’t conclude that moral therapy is always unethical. Doing so would miss its positive aspects: it can prevent sexual abuse and infidelity, help people live better lives by making them less obsessed with sex, and turn a white supremacist into someone who says that “Love is the most important thing.”