David Healy’s article demonstrates how pharmaceutical companies have changed the landscape of the conversation about medicine and the self-understanding of patients. Healy begins with publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III.) The DSM-III had a major impact on psychiatry by medicalizing mental disorders which previously did not exist. This changed the way psychiatrists, doctors, and patients understood the symptoms described. Healy provides several comparisons of how patients used to describe their symptoms and how they did after the DSM-III. For example, patients before the mid 1980s would describe periods of “feeling tense and stressed…that would last from 30 minutes to 2 or 3 hours” (Healy, 220) but by the late 1980s these same periods became labelled as “panic attacks” even though a panic attack by definition should not last over 2 minutes.
What underpinned this change in diagnosis and self-understanding was marketing by pharmaceutical firms. This also contributed to more people getting diagnosed with mental disorders in general which led to in increased sales of anti-depressants and Selective Serotonin Reuptake Inhibitors (SSRIs.) Drugs (for example alprazolam), were created as perceived forms of treatment for newly created diseases (treating panic attacks.) Pharmaceutical firms were able to “strategically fund” the conversations that emerged from these new conditions and drugs which allowed them to “leverage a much wider change in consciousness in society generally (221.) Psychiatrists, patients, and news outlets all began to buy into the conversation that was being sold which led to a new paradigm for conceiving of mental diseases and their treatment(s.)
Healy describes many of tactics companies used to ensure that their drugs had a positive public perception. Companies commissioned scientific papers and handled the academic discussion on their drugs so that they were seemingly validated by “scientific knowledge.” This included “ghost-writing” of articles so that respected psychiatrists could lend their name (in place of funding company) to the promotion of certain drugs. They silenced dissent by withdrawing funding (eg. Eli Lilly’s withdrawal of funding of the Hastings Center for publishing a negative paper on Prozac.) By controlling the conversation and marketing drugs in certain lights, Healy argues that pharmaceutical companies have been able to effectively create a new paradigm of psychiatry in which people understand mental disorders.
Andrew Lakoff picks up on Healy’s notion that pharmaceutical firms play a key role in shaping the consumption and knowledge about anti-depressants. He focuses on the dramatic and sudden increase in sales in the midst of a financial crisis and economic downturn in Argentina. Many people argued that the economic crisis had created a general state of ‘depression’ in the country. The increase in anti-depressant sales was in due to the new need for “treatments for socially induced stress” (Lakoff, 249.) This was the line that pharmaceutical firms marketed and attributed their increased sales to. What Lakoff interestingly points out is how the new need for anti-depressants has nothing to do with biochemistry or neuropsychology or newly constructed definitions of diseases like in did in the United States (like in Healy’s example.) Pharmaceutical companies were open to this and attributed the increase in sales not too some physiological necessity but because of a drastic change in social contingencies. Lakoff also points out how the climate of psychiatric discussion was very different from that of the US. While the US was wedded to neuropsychology as a way of understanding mental disorders Argentina was much more akin to psychoanalytic explanations (making social features more salient than neural processes in identifying the need for drugs.)
Lakoff points out that the increase in anti-depressant sales was not due an increase in consumption (or that more people were buying them) but because of the increase in the average price of anti-depressants. The increase in revenue was due to the use of “newer [and] more expensive drugs” (252.) Lakoff argues that the increase in sales was because pharmaceutical firms became involved with the local doctors and influenced their prescribing habits. Since there was not much of a strong and prominent academic climate on pharmaceuticals as in the United States, the tactics of pharmaceutical companies were different than those implemented there. Instead of ghost-writing in scientific journals, pharmaceutical companies ended up exploited the nature of the “gift economy” that already existed to get doctors to prescribe more of their drugs. Lakoff argues that many of these doctors were not simply bribed to endorse one drug over another but instead were subtly enticed by the giving of gifts (such as paid-for trips and attendance at international conferences.)
This form of gift-giving was very different from bribing doctors since it acted more as a form of indoctrination. Pharmaceutical companies would provide doctors with gifts so that they could be in contact with other “experts” and lead doctors into specific conversations which would then form their relevant knowledge to prescribe drugs. Lakoff addresses the point that could be made that this is unethical behaviour on the part of the doctors (and the firms) since it is a “conflict of interest” between the well-being of their patients and their personal and professional profit. However, gift-giving in this example was not a conflict on interests in this sense because “marketing and expertise cannot be so easily disentangled: pharmaceutical companies are producers not only of pills, but also of knowledge of their safety and efficacy, and their gifts to doctors provide access to the latest expertise” (255.) The doctors were prescribing drugs on the basis of what they thought was best for their patients but the knowledge that informed the doctor’s behaviour was shaped and introduced to them by pharmaceutical companies.
Both Healy and Lakoff fall (broadly) under the category of “social constructivism” which Ian Hacking discusses in its prima facie opposition with realism (in the traditional philosophical sense.) In Hacking’s article, he distinguishes between “human kinds” and “natural kinds.” Human kinds are categorical ways of understanding people or “classifications that could be used to formulate general truths about people; generalizations sufficiently strong that they seem like laws about people, their actions, or their sentiments” (Hacking, 352.) Human kinds are created out of a specific interest (often a moral interest) that we have in a specific human kind. He provides the example of child abuse as a human kind that wish to gain knowledge about so that we may prevent and better understand it. Like Healy and Lakoff, Hacking argues that these human kinds are not things that are “discovered” but invented. While child abuse has existed in numerous social settings throughout history, our categorical understanding of it was created and developed within a social setting of specific contingencies and moral concerns. Hacking writes that “a body of knowledge about suicide changed beliefs about what kind of deed it was” (355); this is because “science has made suicide into a human kind” (ibid.) Human kinds, like definitions of disease, happen out of a social concern.
This is contrast to “natural kinds” which exist as divisions that exist about what there is in nature. Like Healy and Lakoff, these divisions are socially constructed as well. This brings Hacking to his interesting reconciliation of realism and social constructivism. While Hacking agrees with the social constructivists that all our categories of understanding are historical and cultural inventions, there is a strong sense in which Hacking claims that these kinds are ‘real.’ He argues that “multiple personality disorder and adolescence are just as real as electricity and sulphuric acid” (365.) This is because they are all constructs which makes them all equally ‘real.’
These kinds are not timeless and do bend along with social changes and historical movements. A major difference between natural kinds and human kinds here is that the object of a natural kind does not change along with a new paradigmatic understanding of it (only our understanding and emphasis of it changes.) Mud is mud. Calling mud anything different does not affect mud. However, when we label a human kind with a certain type of understanding it does affect the subject. We socially treat the subject differently but it also makes a moral difference to the subject what way they are identified. Because the subject changes as a result of the kind, the kind then changes again in response. This creates new questions and new knowledge to be gained about the kind which then moves back to the subject. This reciprocal relationship is what Hacking calls “the looping of human kinds.” This looping becomes an integral part in the way knowledge moves forward and how this development is socially and morally guided.
All three articles, essentially, emphasize different sides of the same coin. Knowledge is a human invention and is inextricably social and moral. Whether it’s defining a disease or securing a basis for its treatment, science has its roots in society. Corporations, activists, doctors, and lay people all play their role in the construction of the knowledge we live with.