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 A J IN T R IS NZ A J IN T P S HK

N 329 201 352 419 685 446 50 96 110 435 183 230 161 235 104

Not stated 11.0 11.2 32.1 29.8 19.9 18.8 44 10.4 21.8 35.1 38.8 13.9 32.3 26.8 33.7

Don't know 7.2 7.6 7.4 8.6 3.7 5.3 4 5.2 14.6 10.1 13.7 1.7 3.2 11.1 16.4

Sad-Compassion 32.4 32.0 15.6 21.7 31.3 57.7 18 25.0 22.7 10.4 17.5 34.3 23.9 37.4 6.7

Want to help 12.0 7.1 5.9 17.2 17.5 2.1 8 9.4 5.5 8.3 15.3 13.9 13.6 3.0 9.6

Happy for therapy 6.3 7.1 14.1 10.6 5.7 1.1 6 5.2 3.6 8.3 5.5 5.2 9.0 2.6 0

People are same 8.5 9.6 5.0 1.4 2.8 4.0 2 11.5 5.5 6.8 1.1 3.5 5.2 10.6 9.6

Unlucky 1.3 2.0 2.1 1.0 1.6 2.4 0 3.1 0 0.2 0.6 0.4 1.3 0 1.0

Admire 0 0 0 0 0.3 0.5 0 0 0 0 0 0.4 0 0 0

Helpless 2.2 2.5 1.8 1.9 0.2 0.8 0 0 0.9 0.7 2.7 1.3 0 2.6 2.9

Other 0.9 1.0 1.8 2.9 0.6 6.9 0 1.0 0 1.7 2.2 0 0.7 0.4 0

Rejection 1.9 2.0 2.4 1.0 3.5 5.6 4 1.0 0.9 3.8 0.6 8.3 2.6 5.1 1.9

Can't understand 4.7 3.1 0.9 1.4 0.9 0.3 2 8.3 1.8 2.8 1.1 0.4 0.7 1.7 1.9

Own fault/depends 2.2 3.1 3.2 0 1.3 0.5 0 3.1 1.8 2.1 0 3.0 1.3 0 1.9

Afraid & Risk 9.1 11.7 8.0 1.4 9.0 10.9 12 16.7 20.9 9.2 1.1 11.7 6.5 4.7 14.4

AIDSAIDS Public Students

Open comments: % of respondents NZ A J IN T R IS NZ A J IN T P S HK

N 329 201 352 535 682 446 50 96 110 435 314 230 161 235 104

Not stated 6.3 5.6 22.8 18.7 7.6 24.0 40 5.2 3.6 22.4 15.6 4.4 18.5 11.1 9.6

Don't know 2.8 0.5 3.5 1.3 2.6 6.0 2 0 3.6 3.1 3.2 1.7 0.6 1.7 0

Sad-Compassion 34.1 30.8 22.4 19.8 36.1 58.5 20 27.1 19.1 17.9 25.2 31.3 31.2 24.3 15.4

Want to help 4.1 5.1 6.3 5.6 16.6 1.7 0 2.1 3.6 9.9 8.3 17.4 12.7 3.4 3.9

Happy for therapy 1.3 1.5 7.5 6.5 1.5 0.6 6 0 0.9 3.3 5.7 1.3 3.2 2.1 0

People are same 8.8 9.1 11.2 3.6 9.3 4.3 4 19.8 8.2 20.3 5.4 13.5 10.2 8.1 5.8

Unlucky 2.5 5.6 1.7 2.4 1.5 1.4 0 3.1 0.9 0.2 1.9 3.5 1.9 2.1 1.0

Admire 0.6 0 0.3 0 1.0 0 0 0 0.9 0.2 0 1.3 0.6 0 0

Helpless 1.6 2.5 1.7 5.0 0.7 0.9 4 4.2 4.6 1.7 4.8 0.4 3.2 2.6 6.7

Other 0.6 0.5 2.0 3.4 1.3 10.2 0 0 1.8 0.7 2.6 0.4 0 0 1.0

Rejection 3.8 2.0 1.7 8.6 3.8 4.6 8 2.1 3.6 2.1 3.5 3.0 2.6 5.1 8.9

Can't understand 0.3 0 0.9 0.9 1.0 0 0 0 0 0 0.6 0 0 0.9 0

Own fault/depends 18.8 25.2 13.6 13.8 11.0 4.3 8 12.5 15.5 15.1 14.3 17.4 10.8 38.7 23.1

Afraid & Risk 14.1 11.6 4.3 9.9 5.0 6.5 8 22.9 33.6 3.2 8.9 3.9 3.8 6.0 25.0

* 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 A J IN T R IS NZ A J IN T P S HK

N 329 201 352 568 689 446 50 96 110 435 325 232 164 250 104

Female (%) 59 55 48 39 52 64 62 59 50 33 47 58 54 77 55

Urban (%) 77 71 73 78 46 90+ 80 85 89 49 85 58 87 96 88

Married (%) 59 62 66 45 59 54 62 3 0 1 2 0.4 1 0.4 0

No child (%) 33 39 40 55 22 41 48 97 100 100 98 96 100 99 100

Very religious (%) 27 23 10 40 46 10 38 28 19 5 36 54 89 32 21

Mean age (Years) 47.4 45.2 41.7 30.6 37.2 36.3 33.4 20.8 18.1 21.1 21.8 21.3 21.1 19.3 21.0

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 60 42 54 78 72 58 67 63 41 62 86 67 70 54

Somewhat Approve 30 29 41 31 18 11 30 26 33 47 27 13 26 28 44

SomewhatDisapprove 4 5 3 5 1 2 10 1 1 3 2 0 5 0.4 2

Strongly Disapprove 4 3 2 4 1 7 0 1 1 0.2 2 0 1 1 0

Don't know 4 2 12 6 2 8 2 5 2 9 7 1 1 0.4 0

c. Prevent children from inheriting a usually fatal disease

Strongly Approve 59 63 37 63 75 68 52 62 58 33 68 86 57 61 57

Somewhat Approve 26 24 43 24 21 17 30 25 31 48 20 12 34 34 30

SomewhatDisapprove 5 5 3 6 2 5 16 3 4 5 2 1 7 1 8

Strongly Disapprove 5 2 1 2 1 5 0 2 3 0.5 2 1 1 1 1

Don't know 5 6 16 5 1 5 2 8 4 13 8 0.4 1 3 4

g. Make people more ethical

Strongly Approve 14 18 14 31 68 19 10 3 3 3 24 65 37 17 8

Somewhat Approve 13 16 10 25 18 12 22 11 13 5 28 17 21 25 63

SomewhatDisapprove 12 10 32 12 11 7 24 10 23 38 12 9 19 27 34

Strongly Disapprove 43 34 21 16 6 44 32 62 41 36 16 6 15 16 14

Don't know 18 22 23 16 7 18 12 14 20 18 20 3 8 15 23

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Schizophrenia	Public							Students
Open comments: % of respondents	NZ	A	J	IN	T	R	IS	NZ	A	J	IN	T	P	S	HK
N	329	201	352	419	685	446	50	96	110	435	183	230	161	235	104
Not stated	11.0	11.2	32.1	29.8	19.9	18.8	44	10.4	21.8	35.1	38.8	13.9	32.3	26.8	33.7
Don't know	7.2	7.6	7.4	8.6	3.7	5.3	4	5.2	14.6	10.1	13.7	1.7	3.2	11.1	16.4
Sad-Compassion	32.4	32.0	15.6	21.7	31.3	57.7	18	25.0	22.7	10.4	17.5	34.3	23.9	37.4	6.7
Want to help	12.0	7.1	5.9	17.2	17.5	2.1	8	9.4	5.5	8.3	15.3	13.9	13.6	3.0	9.6
Happy for therapy	6.3	7.1	14.1	10.6	5.7	1.1	6	5.2	3.6	8.3	5.5	5.2	9.0	2.6	0
People are same	8.5	9.6	5.0	1.4	2.8	4.0	2	11.5	5.5	6.8	1.1	3.5	5.2	10.6	9.6
Unlucky	1.3	2.0	2.1	1.0	1.6	2.4	0	3.1	0	0.2	0.6	0.4	1.3	0	1.0
Admire	0	0	0	0	0.3	0.5	0	0	0	0	0	0.4	0	0	0
Helpless	2.2	2.5	1.8	1.9	0.2	0.8	0	0	0.9	0.7	2.7	1.3	0	2.6	2.9
Other	0.9	1.0	1.8	2.9	0.6	6.9	0	1.0	0	1.7	2.2	0	0.7	0.4	0
Rejection	1.9	2.0	2.4	1.0	3.5	5.6	4	1.0	0.9	3.8	0.6	8.3	2.6	5.1	1.9
Can't understand	4.7	3.1	0.9	1.4	0.9	0.3	2	8.3	1.8	2.8	1.1	0.4	0.7	1.7	1.9
Own fault/depends	2.2	3.1	3.2	0	1.3	0.5	0	3.1	1.8	2.1	0	3.0	1.3	0	1.9
Afraid & Risk	9.1	11.7	8.0	1.4	9.0	10.9	12	16.7	20.9	9.2	1.1	11.7	6.5	4.7	14.4

AIDSAIDS	Public							Students
Open comments: % of respondents	NZ	A	J	IN	T	R	IS	NZ	A	J	IN	T	P	S	HK
N	329	201	352	535	682	446	50	96	110	435	314	230	161	235	104
Not stated	6.3	5.6	22.8	18.7	7.6	24.0	40	5.2	3.6	22.4	15.6	4.4	18.5	11.1	9.6
Don't know	2.8	0.5	3.5	1.3	2.6	6.0	2	0	3.6	3.1	3.2	1.7	0.6	1.7	0
Sad-Compassion	34.1	30.8	22.4	19.8	36.1	58.5	20	27.1	19.1	17.9	25.2	31.3	31.2	24.3	15.4
Want to help	4.1	5.1	6.3	5.6	16.6	1.7	0	2.1	3.6	9.9	8.3	17.4	12.7	3.4	3.9
Happy for therapy	1.3	1.5	7.5	6.5	1.5	0.6	6	0	0.9	3.3	5.7	1.3	3.2	2.1	0
People are same	8.8	9.1	11.2	3.6	9.3	4.3	4	19.8	8.2	20.3	5.4	13.5	10.2	8.1	5.8
Unlucky	2.5	5.6	1.7	2.4	1.5	1.4	0	3.1	0.9	0.2	1.9	3.5	1.9	2.1	1.0
Admire	0.6	0	0.3	0	1.0	0	0	0	0.9	0.2	0	1.3	0.6	0	0
Helpless	1.6	2.5	1.7	5.0	0.7	0.9	4	4.2	4.6	1.7	4.8	0.4	3.2	2.6	6.7
Other	0.6	0.5	2.0	3.4	1.3	10.2	0	0	1.8	0.7	2.6	0.4	0	0	1.0
Rejection	3.8	2.0	1.7	8.6	3.8	4.6	8	2.1	3.6	2.1	3.5	3.0	2.6	5.1	8.9
Can't understand	0.3	0	0.9	0.9	1.0	0	0	0	0	0	0.6	0	0	0.9	0
Own fault/depends	18.8	25.2	13.6	13.8	11.0	4.3	8	12.5	15.5	15.1	14.3	17.4	10.8	38.7	23.1
Afraid & Risk	14.1	11.6	4.3	9.9	5.0	6.5	8	22.9	33.6	3.2	8.9	3.9	3.8	6.0	25.0

	Public							Medical or biology students
(From Macer, 1994)	NZ	A	J	IN	T	R	IS	NZ	A	J	IN	T	P	S	HK
N	329	201	352	568	689	446	50	96	110	435	325	232	164	250	104
Female (%)	59	55	48	39	52	64	62	59	50	33	47	58	54	77	55
Urban (%)	77	71	73	78	46	90+	80	85	89	49	85	58	87	96	88
Married (%)	59	62	66	45	59	54	62	3	0	1	2	0.4	1	0.4	0
No child (%)	33	39	40	55	22	41	48	97	100	100	98	96	100	99	100
Very religious (%)	27	23	10	40	46	10	38	28	19	5	36	54	89	32	21
Mean age (Years)	47.4	45.2	41.7	30.6	37.2	36.3	33.4	20.8	18.1	21.1	21.8	21.3	21.1	19.3	21.0
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	60	42	54	78	72	58	67	63	41	62	86	67	70	54
Somewhat Approve	30	29	41	31	18	11	30	26	33	47	27	13	26	28	44
SomewhatDisapprove	4	5	3	5	1	2	10	1	1	3	2	0	5	0.4	2
Strongly Disapprove	4	3	2	4	1	7	0	1	1	0.2	2	0	1	1	0
Don't know	4	2	12	6	2	8	2	5	2	9	7	1	1	0.4	0
c. Prevent children from inheriting a usually fatal disease
Strongly Approve	59	63	37	63	75	68	52	62	58	33	68	86	57	61	57
Somewhat Approve	26	24	43	24	21	17	30	25	31	48	20	12	34	34	30
SomewhatDisapprove	5	5	3	6	2	5	16	3	4	5	2	1	7	1	8
Strongly Disapprove	5	2	1	2	1	5	0	2	3	0.5	2	1	1	1	1
Don't know	5	6	16	5	1	5	2	8	4	13	8	0.4	1	3	4
g. Make people more ethical
Strongly Approve	14	18	14	31	68	19	10	3	3	3	24	65	37	17	8
Somewhat Approve	13	16	10	25	18	12	22	11	13	5	28	17	21	25	63
SomewhatDisapprove	12	10	32	12	11	7	24	10	23	38	12	9	19	27	34
Strongly Disapprove	43	34	21	16	6	44	32	62	41	36	16	6	15	16	14
Don't know	18	22	23	16	7	18	12	14	20	18	20	3	8	15	23