November 9, 2007

Is Taking Nothing Legal?

Provigil, a "wakefulness promoting agent,"  is banned at the Olympics, even though, probably, it has no effect on physical performance. Despite what the Olympics says, it isn't a stimulant.

If Provigil has any effect on a specific athlete's physical performance beyond keeping them awake, I'd argue it was placebo effect. So a drug with a placebo effect is illegal. Fine.

But what about the reverse situation: what about giving an actual placebo to an athlete, and telling them it's oh, I don't know, growth hormone? Or Ritalin?

The Economist describes a study in the Journal of Neuroscience in which repeated precompetition doses of morphine were then replaced by placebo on the day of competition; the placebo, like real morphine, helped them endure pain during the competition.  In fact, the placebo had an opioid- mediated analgesic effect (the effect was prevented by the opioid antagonist naloxone)-- it may as well have been actual morphine.  So now what?  Ban placebo?

Well, you say, the simple solution is to ban substances not just in competition, but during training as well; say, 2 years before a competition.  Except you can't ethically ban pain killers during training-- can you?

It should be mentioned that the World Anti-Doping Code bans any "substance or method [that] has the potential to enhance..." so I suppose placebo-doping is a technical violation, though it's hard to see how anyone could catch it.  Perhaps the solution is to monitor the amount of morphine used pre-competition as a clue to the "method" (unreasonable amounts of morphine daily might suggest...)    Perhaps, but in this study the placebo effect was seen even after only two morphine doses, separated by a week.

I bring this up not because I'm worried about "placebo effect conditioning" (hasn't really caught on (I think...)), but because the idea here speaks to several social questions.  Do we care about what causes something, or what was caused?  Do we ban the specific substance morphine, but leave open the pathways of analgesia, or do we ban opioid-mediated techniques, e.g. anything that promotes analgesia?

Sports are fun, I'll admit, but let's take this exact study and alter it by a word.  Replace "competition" by-- murder.  I don't think it's hard to imagine morphine "facilitating" a murder.  (Forget about whether it actually does or not; just accept with me that it's not totally preposterous.)  So?  Two doses, separated by a week, with a placebo response on the day of murder?

You say: come on, that's pushing credulity.  Ok.  Replace competition/murder with-- car accident.  And the issue can be used by both sides: DA: "Your honor, I know he didn't actually take any morphine that day, but he thought it was morphine, so his intent was to DUI, and, in fact, technically it was a DUI." Or, defense: "he wasn't fully responsible for the accident-- he was drugged by placebo."

This extends to discussions on the impact of psychiatric disorders on behavior.  Ready?  Oh, you're not ready.  Ready?

I've discussed how labeling a person as a psychiatric patient earns them certain privileges not afforded to regular people.  The malingering guy in the ER, who does not actually have a psychiatric illness, who then shoots the psych nurse, gets to argue that he is a patient by virtue of the fact that he is in the ER.  I'm not saying he'll win, just that he gets to argue it.  Well, imagine this: a psychiatrist erroneously diagnoses someone with bipolar disorder.  Does the knowledge of "having" bipolar disorder change the person's behavior?  I don't simply mean that he begins to act "bipolar;" I mean does he become bipolar, physiologically, in a placebo effect fashion?  (If it helps, imagine you erroneously diagnose someone with diabetes, and this causes a reflexive hyperglycemia.)

If you say, "but that doesn't actually happen" then you are missing the point.  The point is that any interpretation of behavior or identity as context specific is always artificial, and always inadequate.  Saying someone did something because they were bipolar puts a primacy on the bipolar that is completely arbitrary.  You may as well say astrology was involved.  Oh, silly?  But 1500 years ago it would have been silly to blame bipolar over God and the stars.  If you want to put behavior in the context of bipolar, then you have to put the bipolar in the context of 2007, which has to be put in the context of the Nazis not winning WWII, which has to...

To even fantasize that you have some ability to quantify the contributions of an infinity of forces on an otherwise "volitional" action is to assume not that God doesn't exist, but that you are God.  That you know what counts and what doesn't when in talking about a behavior.   That you see through the Matrix.

That's why, ultimately, a man has to be judged on his actions, not on his identity.  Anyone can be anyone they want to be.  But no one can do what they don't want to do.