Medical aspects of the repression of deviating behaviour


Journal: International Journal of Bioethics 6 (1995), 38-40.
Author: Darryl R. J. Macer
This topic, the medical repression of deviating behaviour is challenging because there are several ambiguities. Namely: What is deviating behaviour? When is such behaviour a medical matter? What is the medical goal of repression of such behaviour?

The aim of medicine is to cure disease, to return a person to normal. Disease is a deviation from normal that impairs the function of a person. Mental disease is a deviation of normal mental function. What is normal mental function? Is this individually defined, or a social construct? Deviating behaviour means behaviour different to the norm. We could trace the range of many characters in terms of extremes of opposites. For example, depression versus optimism. Both extremes are deviant, normalcy is to have the intermediate of both, in certain given circumstances. We would not think it was normal to be over-joyed to learn we had terminal cancer. However, we normally attempt to repress depression more than joy. "Deviant" behaviour is also a social construct, that is defined by the concept of disease that society has (Collier, 1994).

One of the ways we can study the social construction of the concept of disease is in surveys. In 1993 I conducted the International Bioethics Survey with collaborators in a total of ten countries (Macer, 1994). It was conducted in ten countries including: Australia, Hong Kong, India, Israel, Japan, New Zealand, Philippines, Russia, Singapore and Thailand. Random nation-wide samples of the public were surveyed using mail response, plus medical student samples. The results, including open comments people made, are in the book "Bioethics for the People by the People" (Macer, 1994).

Attitudes to disease are central to how much people will want to "treat" someone, or return to "normal". People were asked whether they knew someone with a genetic disease or mental disease. Except for India, more people said that they knew someone with a mental disease than a genetic disease. The most commonly cited genetic diseases were Down's syndrome, and muscular dystrophy. The most common mental diseases cited were schizophrenia and depression. The list of diseases is interesting for what diseases are included and what are not (Macer, 1994).

There were a further six open questions asking people "how do you feel towards people who had the following diseases": hemophilia, muscular dystrophy, AIDS, depression, schizophrenia and neurosis. In all samples the most common response was sympathy and compassion. Other responses included people are the same, understanding, or saying "they would help them". In general there was more expression that the diseases were "their own fault" for mental diseases than genetic ones, as well as less understanding. People were more afraid of people with neurosis, and schizophrenia was seen as most scary of the mental diseases (Table 1). The highest level of rejection of all six disease was seen for persons with HIV, another common comment being that it depends on how they got it. This is a rather judgemental attitude, as all people make mistakes and AIDS is generally a fatal disease. Singapore and Hong Kong students showed the highest degree of rejection, with many thinking it was there own fault (Table 1). The disease AIDS is regarded as almost a criminal offence by many Singapore students, a sign of deviance.
Table 1: Attitudes to disease.

Responses to the question, "How do you feel towards people with the following diseases?"*
Schizophrenia
Public
Students
Open comments: % of respondents NZ AJ IN TR IS NZA J INT P SHK
N 329201 352 419685 446 5096 110 435183 230 161235 104
Not stated 11.0 11.232.1 29.8 19.918.8 44 10.421.8 35.1 38.813.9 32.3 26.833.7
Don't know 7.2 7.67.4 8.6 3.75.3 4 5.214.6 10.1 13.71.7 3.2 11.116.4
Sad-Compassion 32.4 32.015.6 21.7 31.357.7 18 25.022.7 10.4 17.534.3 23.9 37.46.7
Want to help 12.0 7.15.9 17.2 17.52.1 8 9.45.5 8.3 15.313.9 13.6 3.09.6
Happy for therapy 6.3 7.114.1 10.6 5.71.1 6 5.23.6 8.3 5.55.2 9.0 2.60
People are same 8.5 9.65.0 1.4 2.84.0 2 11.55.5 6.8 1.13.5 5.2 10.69.6
Unlucky 1.3 2.02.1 1.0 1.62.4 0 3.10 0.2 0.60.4 1.3 01.0
Admire 0 00 0 0.30.5 0 00 0 00.4 0 00
Helpless 2.2 2.51.8 1.9 0.20.8 0 00.9 0.7 2.71.3 0 2.62.9
Other 0.91.0 1.8 2.90.6 6.9 01.0 0 1.72.2 0 0.70.4 0
Rejection 1.9 2.02.4 1.0 3.55.6 4 1.00.9 3.8 0.68.3 2.6 5.11.9
Can't understand 4.7 3.10.9 1.4 0.90.3 2 8.31.8 2.8 1.10.4 0.7 1.71.9
Own fault/depends 2.2 3.13.2 0 1.30.5 0 3.11.8 2.1 03.0 1.3 01.9
Afraid & Risk 9.1 11.78.0 1.4 9.010.9 12 16.720.9 9.2 1.111.7 6.5 4.714.4
AIDSAIDS
Public
Students
Open comments: % of respondents NZ AJ IN TR IS NZA J INT P SHK
N 329201 352 535682 446 5096 110 435314 230 161235 104
Not stated 6.3 5.622.8 18.7 7.624.0 40 5.23.6 22.4 15.64.4 18.5 11.19.6
Don't know 2.8 0.53.5 1.3 2.66.0 2 03.6 3.1 3.21.7 0.6 1.70
Sad-Compassion 34.1 30.822.4 19.8 36.158.5 20 27.119.1 17.9 25.231.3 31.2 24.315.4
Want to help 4.1 5.16.3 5.6 16.61.7 0 2.13.6 9.9 8.317.4 12.7 3.43.9
Happy for therapy 1.3 1.57.5 6.5 1.50.6 6 00.9 3.3 5.71.3 3.2 2.10
People are same 8.8 9.111.2 3.6 9.34.3 4 19.88.2 20.3 5.413.5 10.2 8.15.8
Unlucky 2.5 5.61.7 2.4 1.51.4 0 3.10.9 0.2 1.93.5 1.9 2.11.0
Admire 0.6 00.3 0 1.00 0 00.9 0.2 01.3 0.6 00
Helpless 1.6 2.51.7 5.0 0.70.9 4 4.24.6 1.7 4.80.4 3.2 2.66.7
Other 0.60.5 2.0 3.41.3 10.2 00 1.8 0.72.6 0.4 00 1.0
Rejection 3.8 2.01.7 8.6 3.84.6 8 2.13.6 2.1 3.53.0 2.6 5.18.9
Can't understand 0.3 00.9 0.9 1.00 0 00 0 0.60 0 0.90
Own fault/depends 18.8 25.213.6 13.8 11.04.3 8 12.515.5 15.1 14.317.4 10.8 38.723.1
Afraid & Risk 14.1 11.64.3 9.9 5.06.5 8 22.933.6 3.2 8.93.9 3.8 6.025.0

* Data from International Bioethics Survey conducted in 1993 (Macer, 1994). Abbreviations: Australia (A), Hong Kong (HK), India (IN), Israel (IS), Japan (J), New Zealand (NZ), Philippines, (P) Russia (R), Singapore (S) and Thailand (T).


These results illustrate that the range of attitudes that people have to disease is diverse, and that the full range is expressed in different cultures, but with some differences. The attitude is also time dependent, and we can expect to see changes in the future, the same as we have differences with the past (Trent, 1994). Some of the past definitions of mental disease have been associated with major abuses of large groups of persons, including social eugenics (Macer, 1990). The next issue is what do we do with those who have deviant behaviour. How can it be treated, if the deviance is greater than can be tolerated.

The goal of medicine is therapy. Medically we must decide on treatment options for those with deviant behaviour. The worst class of deviant behaviour is those which are socially intolerable, e.g. crime. The behaviour which prevents others from following a normal life. One method of "social treatment" is isolation. The worst cases are isolated for life, this being the only social method of repression. Hospitals offer some hope, and psychoactive drugs can help some. It may be an alternative to prison. As an illustration of social diversity, in Washington D.C. there are 27 times more cases of criminal acquittal for reasons of insanity than in the USA on average (Bloom & Williams, 1994). Are the people in Washington so deviant? At least not so much we would hope. It may be a sign of better understanding of crime. Whatever the method of repression, a problem is that even after treatment, or whole still on treatment, about one third or half of those people re-offend.

There are questions about the limits of some medical treatment, such as voluntary castration for repeated sex offenders. In the future more subtle hormone control or gene treatment could be made. Another one of the questions in the International Bioethics Survey (Macer, 1994) is relevant: "Q28. How do you feel about scientists changing the genetic make-up of human cells to: g. Make people more ethical". We find some agreement with the concept of making people more ethical (Table 2) in Asian countries, especially in India and Thailand.

This phenomenon is not always considered an individual disease, although there are numerous references to it as a social disease. Whether therapy to make oneself "more ethical", or "less deviant" should be the personal choice of the person is a question for further thought. Some people already accept it as a possible target for gene treatment, and this could increase in the future as gene treatment becomes more familiar. In much of medicine, treatment is to return a person to a healthy state, but by repressing deviating behaviour we are taking a person into a new self.

A much more common deviant behaviour is depression. Depression can be manic, which is strongly genetically linked, and may be life long, or temporary. One of the modern drugs is Prozac (fluoxetine). Prozac is an antidepressant drug that some users have found returns their behaviour to normal. It may work quickly much more effectively than psychotherapy. The users feel they are new people (Kramer, 1994). There are many therapies that have been developed for psychological and hormonal treatment of persons with deviant behaviour (Linehan, 1993).

However, this makes us ask whether depression, alienation or guilt are symptoms to be treated or something to live with. It again brings us back to the question how much deviance from normal, is normal? The medical goal must be to have people who can function as normal. The first goal of medicine is to help the individual, and their family. A second goal is to help society. The goal of criminal justice is to protect individuals, and also society. We can protect individuals from harm to themselves from the criminal punishment that will be given if they commit a crime. Is this "criminal medicine" - a new type of "preventive medicine"? If we think these preventive remedies are an option of choice by a convicted criminal, to lessen the risk of re-offence, they could be accepted as appropriate and ethical choices.

Let me close with the question. As convicted sex offenders, do you chose castration or extended jail, as a preventive measure to avoid harming society? The freedom of life in society can be far greater dignity for a human being, than a life in jail. This would counter the argument that such repression of "self" that personality change involves, destroys our human dignity. The medical goal to suppress deviant behaviour can allow the person to be free of a mental disease, and in the case of treating criminals, medicine may actually mean their freedom in society.

References
Bloom, J.D. & Williams, M.H. Management and Treatment of Insanity Acquittees: A Model for the 1990s. Washington, D.C. : American Psychiatric Press, 1994.
Collier, G. Social Origins of Mental Ability. New York: John Wiley, 1994.
Kramer, P.D. Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. London: Fourth Estate, 1994.
Linehan, M.M. Cognitive-behavioural Treatment of Borderline Personality Disorder. London: Guilford Press, 1993.
Macer, D.R.J. Shaping Genes: Ethics, Law and Science of Using Genetic Technology in Medicine and Agriculture. Christchurch, N.Z.: Eubios Ethics Institute, 1990.
Macer, D.R.J. Bioethics for the People by the People. Eubios Ethics Institute, 1994.
Trent, J.W., Jr., Inventing the Feeble Mind: A History of Mental Retardation in the United States. Christchurch, N.Z.: University of California Press, 1994.


Table 2: Acceptance of genetic treatment to make people more ethical

Public
Medical or biology students
(From Macer, 1994) NZ AJ IN TR IS NZA J INT P SHK
N 329201 352 568689 446 5096 110 435325 232 164250 104
Female (%) 59 5548 39 5264 62 5950 33 4758 54 7755
Urban (%) 77 7173 78 4690+ 80 8589 49 8558 87 9688
Married (%) 59 6266 45 5954 62 30 1 20.4 1 0.40
No child (%) 33 3940 55 2241 48 97100 100 9896 100 99100
Very religious (%) 27 2310 40 4610 38 2819 5 3654 89 3221
Mean age (Years) 47.4 45.241.7 30.6 37.236.3 33.4 20.818.1 21.1 21.821.3 21.1 19.321.0

Q28. How do you feel about scientists changing the genetic makeup of human cells to:

a. Cure a usually fatal disease, such as cancercancer

Strongly Approve 58 6042 54 7872 58 6763 41 6286 67 7054
Somewhat Approve 30 2941 31 1811 30 2633 47 2713 26 2844
SomewhatDisapprove 4 53 5 12 10 11 3 20 5 0.42
Strongly Disapprove 4 32 4 17 0 11 0.2 20 1 10
Don't know 4 212 6 28 2 52 9 71 1 0.40

c. Prevent children from inheriting a usually fatal disease
Strongly Approve 59 6337 63 7568 52 6258 33 6886 57 6157
Somewhat Approve 26 2443 24 2117 30 2531 48 2012 34 3430
SomewhatDisapprove 5 53 6 25 16 34 5 21 7 18
Strongly Disapprove 5 21 2 15 0 23 0.5 21 1 11
Don't know 5 616 5 15 2 84 13 80.4 1 34

g. Make people more ethical
Strongly Approve 14 1814 31 6819 10 33 3 2465 37 178
Somewhat Approve 13 1610 25 1812 22 1113 5 2817 21 2563
SomewhatDisapprove 12 1032 12 117 24 1023 38 129 19 2734
Strongly Disapprove 43 3421 16 644 32 6241 36 166 15 1614
Don't know 18 2223 16 718 12 1420 18 203 8 1523


To Papers list
To Eubios Ethics Institute book list
To Eubios Ethics Institute home page

Please send comments to Email < Macer@sakura.cc.tsukuba.ac.jp >.