On 13th December Professor Anna Greenwood (Professor of Health History) gave an excellent talk on the history of psychoactive drugs. In a follow-up blog, ‘Moral Health and Pharmacy’, Dr Luca Settimo (Department of Theology and Religious Studies), joins Anna and Professor Paul Crawford, in examining the often-overlooked impacts on moral behaviour in taking everyday medications.
Authors: Luca Settimo,[1] Anna Greenwood,[2] Paul Crawford.[3]
A number of medications commonly prescribed to patients for different conditions exert an affect on moral behaviour.[4] This often represents an under-recognised issue for patients and clinicians. It is in fact not well known that everyday medications not only affect somatic and psychological health, but can also impact moral behaviour, and in some cases can even lead patients to commit crimes.[5] This presents a fascinating additional conceptual lens through which to analyse the impact of everyday medications on patients. The fact that commonly prescribed medications can affect moral behaviour also raises broader socio-ethical issues and complexifies the understanding of criminal responsibility in terms of the medical management of patients, who, often, have no choice in taking their prescribed medications (given their illnesses).
The most striking example of drugs altering moral behaviour can be seen in pramipexole and other dopaminergic medications used to treat Parkinson’s disease (PD). Dopaminergic medications have been used not only to treat PD but have also been proposed in the treatment of other disorders including “restless legs syndrome, prolactinoma, fibromyalgia, ovarian hyperstimulation syndrome, psychostimulant addiction, disorders of consciousness (e.g. persistent vegetative, minimally conscious states) and traumatic brain injury, and erectile dysfunction. DRT [dopamine replacement therapy] has also been suggested as a possible treatment of depression and bipolar disorder.”[6] It has been demonstrated that dopaminergic medications can encourage pathological gambling and hypersexuality. In particular, there have been instances in which some patients taking pramipexole have displayed hypersexual behaviour or have even committed criminal offences, such as being involved in the use of child pornography or child sexual exploitation.[7]
A further example can be illustrated through an examination of the use of beta-blockers such as propranolol (a medication commonly prescribed for hypertension and anxiety with symptoms such as palpitation, tachycardia, sweating and tremor, migraine prophylaxis and arrhythmias). This medication can affect memory consolidation which explains why it is used to prevent and treat post-traumatic stress-disorder, as it blocks adrenergic receptors in the limbic region (the seat of human emotions) and also helps individuals to ‘forget’ traumatic memories. However, there are potential moral implications too. If a patient taking propranolol is called as a witness in a court of law, for example, the effect of this medication should be taken into account. This is because beta-blockers (such as propranolol) risk removing natural emotional responses, such as aversion towards immoral behaviours. In a court trial situation, arguably, emotional responses might be useful for establishing the psychological damage which has been inferred to a victim of a crime. Neutrality or distance might be misunderstood as tacit sympathy or, worse, might serve to help in the absolution of a perpetrator, even if the witness was called for precisely the opposite reason. For example, a person (who was a victim of a crime) taking propranolol might not be reliable in the identification of a possible perpetrator of a crime given the negative effect of this medication on the consolidation of emotional memory for a traumatic effect.[8] Moreover, feeling an emotional response such as a sense of disgust or sadness in relation to the witness and/or performance of immoral actions is arguably important for shaping and developing a sense of morality in human beings;[9] and it should be noted there are different prescribed medications which are known to affect human emotions (in addition to propranolol).[10] If, however, beta-blockers (such as propranolol) risk removing these natural emotional responses and aversion towards immoral behaviours, it is possible that these frequently prescribed medications could impact the moral health of a patient.
This short introduction has discussed the moral implications inherent in taking two types of drugs (dopaminergic medications and beta blockers), but many more everyday medications could be similarly discussed in an analysis of moral health. In fact, Levy et al (2014) have identified at least sixteen different types of drugs as possessing the potential to impact the moral behaviour of those who take them.[11] The issue is an urgent one. Clinicians and patients are often not fully aware of these effects and thus it is clear that both should be informed not only on the effects of the prescribed medications on physical and/or mental health, but also on the potential consequences for moral health. Moreover, there are important ethical issues that will need to be closely investigated such as the need to inform both the clinicians and the patients about the possible effects of the medications on a patient’s legal and moral responsibility. We need a greater contextual understanding of how this situation has arisen over time and what its far-reaching implications might be. This exercise will involve the inter-disciplinary work of clinicians, pharmacists, ethicists, historians, philosophers, theologians as well as scholars working in both the law, sociology and public health.
[1] Honorary Post-doctoral Fellow, Department of Theology and Religious Studies, University of Nottingham, NG7 2RD.
[2] Professor of Health History, Department of History, University of Nottingham, NG7 2RD.
[3] Professor of Health Humanities, Faculty of Medicine & Health Sciences, NG8 1BB.
[4] Neil Levy et al., "Are You Morally Modified? The Moral Effects of Widely Used Pharmaceuticals," Philosophy, Psychiatry & Psychology 21, 2 (2014), 111-125.
[5] For example, the legal case of a patient who committed a crime after having been prescribed a drug for the treatment of Parkinson’s disease has been discussed by Francesca Bartlett, Wayne D. Hall, and Adrian Carter, "Case and Comment. Tasmania V Martin (No 2): Voluntariness and Causation for Criminal Offending Associated with Treatment of Parkinson's Disease," Criminal Law Journal 37, 5 (2013), 330–341.
[6] Adrian Carter, Polly Ambermoon, and Wayne D. Hall, "Drug-Induced Impulse Control Disorders: A Prospectus for Neuroethical Analysis," Neuroethics 4 (2011), 94 and references therein.
[7] Levy et al., "Are You Morally Modified?" 112 and references therein;
[8] Levy et al., "Are You Morally Modified?" 114.
[9] Many scholars have argued for the importance of emotions (such as empathy, guilt, anger, shame, disgust, awe, contempt, embarrassment, gratitude and elevation) on morality. Cf. Jonathan Haidt, “The moral emotions” in Davidson, R. J., et al. (2003). Handbook of affective sciences. Oxford; New York, Oxford University Press, 866 and references therein.
[10] For example, virtually all psychotropic medications (e.g. prescribed drugs for depression, psychosis or bipolar disorders) can affect some human emotions. It has been demonstrated that even women taking the contraceptive pill (a commonly prescribed medication) could alter their definition of the ‘suitability’ or ‘goodness’ of a partner, and could even lead them to make a choice which contradicts their natural instincts (since the emotional response that lead to their choice of a partner could be different if they were not taking the pill). In other words, the contraceptive pill seems to alter a woman’s emotional response (as exemplified by her behaviour towards males). Cf. Alexandra Alvergne and Virpi Lummaa, "Does the Contraceptive Pill Alter Mate Choice in Humans?" Trends in Ecology & Evolution 25, 3 (2010); Jillian Craigie, "Moral Modification and the Social Environment," Philosophy, Psychiatry & Psychology 21, 2 (2014), 128. Also in the case of contraceptive pill (similarly to propranolol), often prescribers and women taking this medication ignore the fact that it can have an affect on human emotions and behaviour. Craigie comments this fact: “What is striking is that, despite having been known for many years, this side effect [of the contraceptive pill] seemingly has not gained the interest of drug regulators, and is not included in the information about the pill given to patients. It might be that the science has bounded ahead of public policy, and that in time drug companies will be required to make this information readily available for patients... Taking this broader perspective also seems important in considering how we should respond to the proposal that prescription drugs might be altering the moral fabric of society via effects on moral agency.” Craigie, "Moral Modification,” 128.
[11] Levy et al., "Are You Morally Modified?" 111-125.