Depression and Moral Health: A Response to the Commentary

S. Nassir Ghaemi tells us that whereas “neurologists are sometimes accused of admiring disease rather than treating it,” psychiatrists seek to cure disease even when they do not understand it. At the same time, he notes that Freud had both theoretical and practical interests that occasionally point in different directions, and psychiatrists have learned that theoretical understanding of the sources of suffering does not always translate directly into useful clinical practice. For their part, philosophers are often criticized for indulging in armchair speculation that yields neither empirical understanding nor practical efficacy. Writing as a philosopher in “Depression: Illness, Insight, and Identity,” I had hoped to engage both scientific and therapeutic interests while linking them to humanistic concerns about values. Ghaemi’s emphasis is primarily therapeutic—to help, to heal—but he seems generally sympathetic to my goal of integrating moral and therapeutic perspectives. I benefited from his cautions about the need to pursue that integration with close attention to therapeutic imperatives.

My essay is part of a larger project of interweaving morality and therapy as applied to an array of human problems, or rather of elaborating on an integration that has already evolved in our society, and which now permeates self-help literature, talk shows, sermons, and much psychotherapy (Martin 1999b). This integration resonates with Plato’s daring intuition in Republic that morality and mental health are fundamentally linked through a concept of moral health. Moral health is something more than a metaphor. It refers to active capacities that are essential for both moral life and psychological coping. But Plato went too far when he equated virtue and mental health: “Virtue is as it were the health and comeliness and well-being of the soul, as wickedness is disease, deformity, and weakness” (1945, trans. Cornford). So did humanistic psychologists, such as Erich Fromm, who attempted to derive moral principles from psychological facts (1947). Certainly we must not make moral judgments about dementia, consider episodic wrongdoing simply pathological, or lapse into the patronizing notion that the higher reaches of moral commitment are merely signs of sound health. Nevertheless, I am convinced that Plato glimpsed a larger truth than his critics allow (Kenny 1973).

Certainly we need to dissolve any rigid dichotomy between moral and therapeutic perspectives on depression, while still appreciating that different practical purposes warrant different emphases. Two powerful trends have undermined the moral/therapeutic dichotomy during the twentieth century, and yet have also made it difficult to see where we now stand. On one hand, the therapeutic trend has medicalized moral problems by approaching them in terms of health and therapy. On the other, the unmasking trend reveals that therapy itself embodies moral values, thereby debunking its pretension to function as a morally neutral replacement for morality. Both trends are at work, for example, in the case of alcoholism.

Alcoholism is a disease, according to the dominant view in the therapeutic community. Citizens and law enforcement agencies, however, continue to regard alcohol abuse as something for which individuals should be held accountable. Furthermore, Alcoholics Anonymous, the most popular form of alcoholism therapy, conjoins an insistence that alcoholism is a disease with moral (and religious) values about accepting personal responsibility. In my view, alcoholism is typically both a sickness and something which involves wrongdoing (Martin 1999a). It is a sickness insofar as it constitutes impaired agency, and it is concerned with wrongdoing insofar as it violates responsibilities to care for one’s health and to be accountable for one’s drinking behavior. Responsibility does not vanish once alcoholism has ravaged one’s capacity directly to control drinking, for even then there remains a duty on the alcoholic’s part to seek and to cooperate with available therapeutic help. Nevertheless, the different social constituencies dealing with alcoholics have strikingly different emphases: therapists emphasize nonjudgmental helping, law enforcement personnel accentuate punishment for alcohol-related crimes, insurance companies focus on alcoholism’s cost liabilities, and legislators formulate laws that provide incentives for responsible drinking behavior. All of these emphases overlap at various junctures, and as a society, we need a comprehensive perspective that renders them coherent.

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