The word unhappy has almost been banished from our vocabulary. It has been replaced by the word depressed. For every patient who confesses to unhappiness, a thousand now claim to be depressed. What was once considered to be an inescapable part of the human condition has been elevated (or is it reduced?), by a semantic change, to an illness. And since good health care is now regarded as a right, the corollary of unhappiness being an illness is that people believe themselves to be entitled not merely to the pursuit of happiness, but to the thing itself.
A right being unconditional (or else it would not be a right), the pursuit of happiness must therefore always end in success, rather as the bear-hunting of such leaders as Brezhnev and Ceausescu had always to end in ursine slaughter, thanks to the minions who drove tranquilized bears to be mown down at point-blank range by the leaders. The pride of Brezhnev and Ceausescu in their hunting prowess was ersatz, of course, and the author of this book contends that much of our contemporary happiness is likewise ersatz.
It is Dr. Dworkins argument that doctors have been complicit, or at least instrumental, in bringing about this widespread state of ersatz happiness. His analysis does not always make it clear whether he believes that doctors have been the conscious originators of, or mere blind participants in, this development, which he says is pregnant with problems for society. He foresees a time when the population will consist entirely of blandly contented people who have no concern for one another, or indeed for anything other than the continuation of their own vacuous, artificial happiness. A society composed of such people would not only be decadent and defenseless, but scarcely worth defending.
According to Dr. Dworkin, doctors have helped to spread a state of artificial happiness in three connected ways. First, they have responded to the publics dissatisfaction with the decline of personal doctoring (the result of the ever-increasing technological sophistication of medical practice) by accepting that unhappiness is a medical condition brought about by chemical imbalance in the brain, to be righted by drugs such as Prozac, which they then prescribed in vast quantities. Second, they neutralized the threat posed to orthodox medicine by alternative medicine, whose very irrationalism appealed to a population avid for a spiritual dimension to life, but unwilling to submit to the discipline of genuine religious belief, by cynically accepting it into the hospital fold and thereby co-opting and taming it. Alternative medicine works, to the extent that it does work, by inducing a state of anodyne, complacent, and almost decerebrate contentment in its clientele: a state of mind, or of no mind, much less threatening, and more lucrative, to doctors than that of critical intelligence.
Third, and finally, doctors came to accept that prevention and not just cure was part of their duty towards their patients, and that therefore the management of lifestylefor example, by recommendation of strenuous exercisewas an essential component of medical practice. People who carried out or even over-fulfilled doctors orders began to see themselves as not merely prudent with regard to their health, but virtuous in the moral sense, and with their virtue went another form of artificial happiness, the beatific knowledge that they were doing the right thing no matter how painful.
The medical profession has thus promoted and benefited from the notion that the attainment of happiness can, and indeed ought to be, detached from the way life is lived, apart from taking tablets and exercise under its direction. It has thereby achieved an unassailable position as the arbiterthe sole arbiterof how life should be lived, only a few short decades after its wisdom and achievements were coming under sustained attack from skeptics, sociologists, historians, philosophers, and the like. The medical profession alone knows the meaning of life: to live as long and as happily as possible. If religion conduces to this end (and empirical evidence so far suggests that it does), religious belief should be encouraged; if not, its too bad for God. Health, longevity, and happiness (however achieved) are the only ends in themselves.
While I have sympathy with Dr. Dworkins argument, he uses both evidence and logic somewhat loosely. His book is suggestive rather than demonstrative; he is on to something, without quite defining what it is that he is on to.
For example, he appears to think that the new generation of antidepressants, of which Prozac was the first, was much more effective as antidepressants than the old, such as imipramine and amitriptyline. This is not so; their discovery was much less of a therapeutic breakthrough than is often supposed, and they owe their widespread use not to their superior effectiveness (if anything, they are less effective), but to their less serious side effects, which makes doctors more cavalier about prescribing them to the unhappy. In any case, very nearly half their efficacy in cases of severe depression is attributable to the placebo effect, and it is this placebo effect, rather than any true pharmacological action, that causes them to effect change in the lives of those who are dissatisfied with their situation.
Dr. Dworkin half-accepts the view of one of the silliest books of the past decade, Dr. Peter Kramers Listening to Prozac, that we are at a stage when we know so much about neurochemistry that we will soon be able, with the help of a few drugs, to design our own character. Take but a little of drug x, and you will change from an introvert into an extrovert; take but a little of drug y, and you change from impulsive to extremely cautious. Whereas Dr. Kramer welcomed this possibility, Dr. Dworkin is horrified by it, but both assume it is, or could be, an imminent (and thereafter immanent) reality. Compared with this view, Alice in Wonderland, with its bottles of DRINK ME, is a work of social realism.
Dr. Dworkin implies almost Machiavellian motives to the medical profession in its use of antidepressants. I think something rather more banal has been at work: Most doctors would think that it is worse to withhold antidepressants from a single real case of depression than to give relatively minor side effects to ninety-nine people who do not need antidepressants. Since it is not always easy to distinguish real melancholia from dissatisfaction with spouses or bosses at work, especially in the few minutes that a medical consultation these days is allowed to take, it is better to prescribe than not to prescribe. There is more rejoicing in the medical firmament over one true cure than over ninety-nine unnecessary treatments; though of course the class-action lawyers may soon change all that.
The doctors acceptance of the hocus-pocus of alternative medicine is perhaps new, though they have rarely in the past eschewed hocus-pocus of their own, and indeed it is possible, though in my view unfair, to see the whole history of western medicine up to quite late in the day as the triumph of hocus-pocus over common sense. (The Oxford University Press has just published a history of medicine of which this is the central insight or master thought.)
Moreover, it is not accurate to say that doctors involvement in their patients way of life is a new phenomenon. There are works on regimen in the Hippocratic corpus, and in the first half of the eighteenth century, for example, the most celebrated British doctor, George Cheyne, wrote books such as An Essay on Long Life and The English Malady in which he recommended such well-known preventatives as moderation in eating and exercise. This was advice that he was not always able or willing to follow himself, since at some time in his career he weighed over five hundred pounds and was hardly able to move without the help of others.
But perhaps the key defect of Dr. Dworkins book is that it fails to tell us how to distinguish artificial, and therefore false, from natural, and therefore true, happiness. I feel instinctively that there is a real distinction to be made here, but Dr. Dworkin does not make it, much less define it. His book is thus a sketch for an important work, rather than an important work itself.
As it stands, such distinction as he makes has an aura of intellectual and social snobbery about it. One can almost hear him sighing as he recounts to someone of like mind (to me, for example) the absurdity of what some people find satisfying in life. When I see the extreme joy of football supporters at the triumph of their team, I think, Lord, what fools these mortals be! But then I recall the words of Somerset Maugham at the beginning of his short story The Book Bag: By the standards of what eternity, Maugham asks, is it better to have read a thousand books than to have ploughed a thousand furrows? No doubt football supporters would find my joyadmittedly expressed with less exuberance, and considerably less likely to cause a public nuisanceat the discovery of some obscure and dusty volume in an antiquarian bookseller at least as mystifying as I find theirs at the winning of a championship by a collection of men of doubtful character with whom they have absolutely no personal connection. But who am I, and who are they, to say that their and my happiness are not real? What is the test by which various types of happiness may be adjudicated?
I thinkor perhaps I should say that I hopethat this question is susceptible to an answer, but if so it requires very considerable philosophical thought. It requires nothing less than an examination of the proper end of a mans life. It is no criticism of Dr. Dworkin that he fails to answer this question once and for all, but if you are going to say that millions of your fellow citizens are in a state of artificial happiness because they have contented themselves with the achievement of unworthy goals, such as those attained by the consumption of Prozac or obsessive exercise, it is question that needs to be asked. I hope that Dr. Dworkin will turn his attention to it in his next book. After all, doctors do know best.