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.


Thank you for hurting my br... (Below threshold)

November 9, 2007 9:15 PM | Posted by Fargo: | Reply

Thank you for hurting my brain a little.

From my own perspective, the law is primarily concerned with actual events. Obviously circumstances can influence the harshness of a penalty, but rarely negate whether or not someone is at fault. The only part of a placebo influenced event that the legal system would likely be concerned with is whether any action should be pursued against the person giving them the placebo.

I dunno though. Seems like something that could easily become very complex.

I'll leave you with this- "I thought the cop was a prostitute."

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"But no one can do what the... (Below threshold)

November 10, 2007 3:36 AM | Posted by Anonymous: | Reply

"But no one can do what they don't want to do." Wait, I'd thought that the law recognized the possibility of coercion, and psychiatry recognized compulsion, as doing exactly that to a person?

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It's unfair to Wittgenstein... (Below threshold)

November 10, 2007 1:09 PM | Posted by bipolar2: | Reply

It's unfair to Wittgenstein not to give him credit for the last proposition in the Tractatus. Especially since you use it as a motto without attribution. That's simply plagarism. And, intellectual dishonesty.


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Please let us know your fir... (Below threshold)

November 11, 2007 8:39 PM | Posted by Common Reader: | Reply

Please let us know your first name. Otherwise I'll have to name my next child "Last."

Alone's response: The.

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i have a headache now, and ... (Below threshold)

November 12, 2007 3:58 PM | Posted by anonymous mom: | Reply

i have a headache now, and nothing to add to the discussion because i'm still not sure what is you're saying here.

and on a monday no less. i'll be back later to try again.

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test... (Below threshold)

November 12, 2007 4:16 PM | Posted by Alone: | Reply


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The issue of responsibility... (Below threshold)

November 13, 2007 8:48 AM | Posted by Anonymous: | Reply

The issue of responsibility and mental illness is one issue that hurts my brain. I look at some of my behavior during the time when I went days without sleeping due to the cocktail of psych meds I was on and can't help but think that had something to do with my behavior during that time. How could it not? However, I turned cartwheels I didn't kill people. So, maybe I just had this deep hidden desire to turn cartwheels that was realized once I received my diagnosis and drugs.

It would be interesting to see what would happen if we took a group of psychiatrists put them in a psych hospital against their will, forced them to strip in front of someone, loaded them up on stimulants or conversely antipsychotics and then examined their behavior. I suspect they would act in ways they wouldn't ordinarily act.

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I stumbled this - interesti... (Below threshold)

November 15, 2007 1:31 PM | Posted by David: | Reply

I stumbled this - interesting stuff.

The law recognises such a thing as diminished responsibility. I assume that you believe such a thing exists. So lets take extreme cases - I am injected with a powerful hallucinogen against my will and I then get into a fight with a stranger. The law would not hold me fully responsible for my actions and rightly so.

Or another case, someone tries to assault me and I fight back and seriously injure the attacker.

So now consider cases of mental illness. I'm suffering from paranoid schizophrenia and I attack a stranger because I think he's going to attack me - diminished responsibility in the eyes of the law and surely rightly so.

So now how about bi-polar? Well this is just a question of where to draw the boundary - we wouldn't allow someone diminished responsibility just because they had a bad day so we have to draw a line somewhere. Bi-polar is a recognised psychiatric illness however - one that seems to have a physical basis - as such it seems wrong to say this shouldn't be taken into account. If you accept the other examples you should accept this one too.

Mental illness is not a question of identity. I'm not saying someone should be let off because they're an angry person or because they hold some important position in society. I'm saying that a serious mental illness is something which has a large effect on behaviour and so someone who has such an illness should not be considered as responsible for their actions as they otherwise would be.

This doesn't mean I claim to understand all the influences on a person's behaviour - it just means that I believe the evidence suggests mental illness is a big enough influence that it should be taken into account.

Or are you saying that bi-polar is not a genuine mental illness?

Finally - the fact that people employed superstitious and non-evidence-based explanations of behaviour in the past is neither here nor there. Consider - people used to believe that lightning was made by Thor, therefore the modern explanation that it's electrical discharge is wrong - ridiculous.

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