SSRIs as Moral Enhancement Interventions: A Practical Dead End

Abstract

Selective serotonin reuptake inhibitors (SSRIs) have gained a degree of prominence across recent moral enhancement literature as a possible intervention for dealing with antisocial and aggressive impulses. This is due to serotonin's purported capacity to modulate persons’ averseness to harm. The aim of this article is to argue that the use of SSRIs is not something worth getting particularly excited about as a practicable intervention for moral enhancement purposes, and that the generally uncritical enthusiasm over serotonin's potential as a moral enhancer is a consequence of the paucity of viable options for envisaging practicable moral enhancement interventions. While there are many conceptual issues raised by the idea of moral enhancement generally, and by the idea of serotonin as a morally affective agent, the aim here is to look at practical concerns. It is argued that SSRIs do not, nor cannot in the reasonably foreseeable future, be made to work as a reliably safe or reliably effective means for moral enhancement, even within the very limited remit of treating “reactive” aggression. SSRIs might be effective as a limited and partial mental health intervention (even this is questionable), but not as a generally effective moral enhancement technology.

Keywords:

• enhancement
• morality/ethics
• neurobiology
• neuromodulation
• psychopharmacology

ACKNOWLEDGMENTS

I thank all three anonymous reviewers for their serious engagement with the original article and helpful reflections. All three sets of comments led to extensive positive refinement of the original text.

Notes

To be clear, commentators such as Rakić (2013) and Chan and Harris (2011) have indeed offered interesting conceptual reflecti-ons on Crockett's research, however the present concern is to do with matters of practical viability.

Incidentally, precisely the same remarks can be made about oxytocin and dopamine as potential psychopharmaceutically based moral enhancement interventions.

Though it is not too great a surprise to find serotonin implicated in moral judgment, serotonin has a vast array of functions in the body.

So much so that the use simultaneous use of serotonin agonists for multiple conditions (e.g., monoamine oxidase inhibitors [MAOIs], antimigraine agents, opiate analgesics, cough medicines, antibiotics, antiemetics, etc.; Boyer and Shannon 2005, 1113) is highly contraindicated in prescriptive practice as particularly dangerous to health. Note that this is not just a problem with SSRIs (i.e., something to be fixed by developing better pharmaceuticals); rather, this is an issue with the way in which excess serotonin is metabolized into hydroxyindoleacetic acid in the cytoplasm of the presynaptic neuron (Boyer and Shannon 2005, 1116).

Akathisia has known to be associated with irritability, aggression, or suicide attempts and can lead to “worsening of psychotic symptoms or behavioural dyscontrol … and loss of impulse control” (Breggin 2008, 15, emphasis added). A survey of the related research suggests that “Prozac-induced akathisia” is found in 9.7–25% of the population (Lipinski et al. 1989); the Public Citizen Health Research Group found the figure to be 15–25%. With respect to suicidality, both Rothschild and Locke (1991) and Wirshing et al. (1992), using a “challenge–dechallenge–rechallenge” (CDR) method, “clearly confirmed a cause-effect relationship between the drug and the adverse effect of suicidal impulses” (Wirshing et al. 1992 16).

For supporting studies and articles, see Wong et al. 1985; Lipinski et al. 1989; Worshing et al. 1992; Dorevich et al. 1993; Frankenfield et al. 1994; Christen 1995; Troisi et al. 1995; Howland 1996; Constantino, Liberman, and Kincaid 1997; Ebert et al. 1997; Wilkinson 1999; Healy 2000; Sim 2000; Okada and Okajima 2001; Preda et al. 2001; Breggin 2002; Wilens et al. 2003; Moncrieff et al. 2006; Shelton 2006; Stone et al. 2006.

Luvox (SSRI) is now recognized by the Food and Drug Administration (FDA) as causing manic symptoms in 4% of children who take it, and is known to increase the risk of suicidal thinking and behavior in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) (Mosholder 2004).

Worse still, such psychopharmaceuticals result in what Breggin calls a “spellbinding” effect, wherein a deterioration of the person's condition occurs without the patient recognizing it, or without recognizing that the medication is the cause of the deterioration (Breggin 2008, 11). A temporary euphoria is often created, a deceptive state of elevated subjective well-being, while by objective standards, these persons’ lives often begin to take a serious downward trajectories (often manifesting in the sudden appearance of destructive, compulsive and addictive behaviors [Breggin 2008, 11]—thus simply replacing one morally related problem [reactive aggression] with another [addictions, and other disinhibited behaviors associated with mania]).

FDA SSRI inserts (including Citalopram) were amended to contain a “black box” message reading: ‘“WARNING: Clinical Worsening and Suicide Risk.” The label warning specifically refers not only to children but also to adults. It warns about “anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania” (Breggin 2008; 46)—i.e. much the same problems they are presented by moral enhancement enthusiasts as offering the potential to solve.

Breggin, who was given access to the investigatory findings, observes that Harris's hateful and destructive attitudes were formed while taking this SSRI (Breggin 2008; 2).

Standing alone such anecdotal evidence might seem dubious. Against the background of the clinical trials and controlled experimentation cited already, these cases seem all the more compelling.

“The urgent imperative to enhance the moral character of humanity” (Persson and Savulescu 2008, 162).

It is true, in principle, an overlap between these two terms is possible. As I shall argue, this particular case is not an instance of such overlap—SSRIs have a mental health rather than a moral enhancing function.

Though this may entail as a counterpart a lowered “thrombotic risk” (De Abajo 2011, 345); also, there is some initial evidence that SSRIs may have a protective function against certain forms of heart failure (see Bhuiyan, Tagashira, and Fukunaga 2013; Chittaranjan, Chethan, and Sandarsh 2013).

Perhaps it is because SSRIs are currently handed out so freely that it is so easy to underestimate the seriousness of SSRIs as a psychopharmacological intervention—in the United Kingdom alone, 46.7 million prescriptions for antidepressants were issued in 2011 (based on Prescription Cost Analysis of the Health and Social Care Information Centre data: see http://www.hscic.gov.uk).

I think the authors cited earlier—Douglas, Hughes, De Grazia, Savulescu, Persson—and their respective statements there quoted give a representative flavor of how such an enthusiasm can overlook the practical reality that these potential technologies entail. However, one last example is justified here. The suggestion by Persson and Savulescu (2008), De Grazia (2012), and Hughes (2013) of glucose as moral enhancement technology, for purposes of boosting willpower and self-control, is the clearest illustration of how comically desperate, indeed, farcical, the contributions of certain prominent thinkers in this discourse can get at times. According to Hughes, for example, “Therapies that increase the brain's supply of glucose would therefore boost self-discipline” (Hughes 2013, emphasis added). De Grazia writes on “current and prospective means” for moral enhancement technology, a little more tongue in cheek, of the potential of “Glucose as a means of increasing resistance to temptation to do something wrong or to stop trying to do what one should” (De Grazia 2012, 8). Finally, Persson and Savulescu, again, regarding Baumeister's studies on self-control, write—in all seriousness—that “If these results hold it appears likely that pharmacological or physiological interventions (to improve glucose regulation) may be used to improve self-control abilities” (Persson and Savulescu 2008, 166, emphasis added). One can only shake one's head in wonder when reading such statements (sugar as a moral enhancement technology? Pharmacological interventions to improve glucose regulation?). Note that all of these claims stem only from Baumeister's very simple observation that persons who are fatigued display less powers of self-control. At this point, it becomes very hard to dispute that, among these extremely prominent thinkers in the discourse, there is just so much enthusiasm, so little self-critical awareness, that they have been willing to jump upon literally any claim, no matter how absurd.