Changing our minds

2 Changing our minds
There are two basic ways to go about changing someone’s mind.
What we might call the traditional way involves the presentation of
evidence and argument. This way of going about things raises ethical
problems of its own, all of which are familiar: Under what circum-
stances is it permissible to present false evidence? If it’s in the per-
son’s own interests to come to have a false belief, must we
nevertheless present them with the truth? What if we know that
the available evidence is misleading? Can we hide the evidence in the
interests of the truth? These questions and others like them con-
stitute a small part of the traditional turf of moral philosophy.
Traditional psychotherapy is, in many ways, an extension of
this familiar method of changing minds. The goal of the earliest fully
developed method of psychotherapy, Freudian psychoanalysis, is
truth, and the concomitant extension of the power of rational
thought over libidinal impulse. ‘‘Where id was, there ego shall be,’’
Freud famously wrote: the powerful unconscious drives of the id, the
forces that tyrannize the neurotic patient, shall be replaced by the
conscious forces of the rational ego, the I. To be sure, psychoanalysis
does not take a direct route to truth. It does not seek to change minds
by argument, or at least not by argument alone. Freud thought that it
was not sufficient for the patient simply to be told the truth regarding
his or her neuroses and their origins. Instead, the patient had to
‘‘work through’’ traumatic events, reliving them under the guidance
of the analyst, in order for the cure to be successful. The truth has to
be accepted emotionally, and not merely intellectually, if it is to have
its curative effects.
Psychoanalysis and related psychotherapies raise ethical ques-
tions of their own, some of which concern the extent to which their
departures from the pure form of the traditional way of changing
minds – presenting reasons and arguments – are permissible. But

the degree to which psychoanalysis departs from tradition pales
into insignificance compared to the second way in which we
might go about changing someone’s mind (putting concerns about
extended cognition to one side for the moment, and assuming that
the mind is wholly bounded by the skull): by direct manipulation of
the brain.
Of course, there is a sense in which presenting evidence is a
kind of (indirect) manipulation of the brain – it alters connections
between neurons, and might contribute, in a very small way, to
changing the morphology of the brain (enough evidence, presented
over a long enough period of time, can produce alterations which are
large enough to be visible to the naked eye: a study of London taxi
drivers demonstrated that the posterior hippocampus, which stores
spatial information, was larger in drivers than in controls [Maguire
et al. 2000]). But direct manipulation of the brain differs from indirect
in an extremely significant way: whereas the presentation of evi-
dence and argument manipulates the brain via the rational capacities
of the mind, direct manipulation bypasses the agent’s rational
capacities altogether. It works directly on the neurons or on the larger
structures of the brain. There are many different kinds of direct
manipulation in use today: electroconvulsive therapy (ECT), in
which a current is passed through the brain, inducing seizures; psy-
chosurgery, which may involve the severing of connections in the
brain surgically, or may involve the creation of lesions using radio
frequency; transcranial magnetic stimulation of superficial struc-
tures of the brain; and deep brain stimulation.
1
But the most widely
used kind of direct manipulation is, of course, pharmacological.
Many millions of people have taken one or another drug designed to

alter brain function: antipsychotics, lithium for manic-depression,
Ritalin for attention-deficit/hyperactivity disorder (ADHD) and,
most commonly, antidepressants. Here we shall focus, mainly, on
psychopharmacological treatment of depression; the issues raised by
changing our minds
70
this kind of intervention overlap significantly with those raised by
other forms of direct manipulation.
People are much more reluctant to countenance medication as
a treatment for depression than for psychosis. In part, no doubt, this
is due to the perception that psychosis is more severe than depres-
sion; there is a corresponding greater acceptance of psychopharma-
cology to treat major depression – which is a life-threatening
condition, as well as one that causes great suffering – than for the
treatment of ‘‘mere’’ anxiety. But even with regard to major depres-
sion, perhaps even psychosis, there seems to be a widespread pre-
sumption in favor of the traditional way of changing minds, other
things being equal (that is, if the costs, risks and benefits do not
favor, or perhaps if they do not decisively favor, direct manipulation).
If we can use the traditional means, we should, or so many people
believe. In some cases psychotherapy will prove too expensive, or too
costly, or too slow, and we will be forced to use psychopharmacology.
Nevertheless, many people believe, this is a necessity to be regretted:
direct means of changing minds are always ethically dubious.
Why is this intuition so widely shared? There are many rea-
sons, I suggest, for the presumption against direct manipulation,
some rational and some irrational. Some of these I wish to set aside
here, though they are nonetheless worthy of respect. First, there are
understandable safety concerns associated with the use of new
technologies: direct stimulation of the brain or the use of psychoac-

tive medications might have unforeseen, and potentially very ser-
ious, side effects. Deliberate lesioning of the brain will often produce
deficits in cognition and memory (there are some tragic cases of
people with complete anterograde amnesia – the inability to form
new memories – following neurosurgery for intractable epilepsy).
Second, many people are – once again, perfectly understandably –
reluctant to support with their custom a pharmaceutical industry
widely seen as having engaged in unethical practices: withholding
research findings detrimental to their products, preventing or delay-
ing the availability of generic drugs in the Third World, and so on
changing our minds
71
(Angell 2004). These are very serious objections to the use of
psychopharmaceuticals, but I set them aside here in order to focus
better on the philosophical issues, relatively narrowly construed.
The question I want to examine is not whether, given the current
state of the art, use of these drugs is advisable; rather I want to
concentrate upon in principle objections to direct manipulations. In
principle objections are objections that remain sound no matter how
much the technologies improve, and no matter what the political and
social context in which they are developed, prescribed and taken.
I therefore set aside these objections, and assume that the products
concerned are safe, or at least safe enough (inasmuch as their
expected benefits to patients outweigh their risks), and ignore con-
cerns about the industries that create and distribute them.
It might be objected that in setting these matters aside, we set
aside the ethics of neuroethics: the very heart and soul of the ques-
tions. There is some justice in this accusation: of course, it will be
necessary to factor these concerns back into the equation in coming
to an all-things-considered judgment of the advisability of using or

promoting these drugs in actual circumstances. But clarity demands
that we treat the issues raised by direct manipulation one by one, and
that requires isolating them from one another, not conflating them.
Moreover, in a book defending a conception of the mind as extended
and knowledge acquisition as distributed, it is not special pleading to
note that others – policy specialists, lawyers, sociologists and many
kinds of medical professionals – are better placed than philosophers
to analyze the issues set aside here. By focusing on the questions
where I can best contribute, I hope thereby to advance the entire
neuroethical agenda all the more effectively.
What remains, once we set these concerns aside? No doubt
some of the opposition to psychopharmacology that remains is
simply irrational. In part, it seems to be an expression of a deep-
seated prejudice against technologies regarded as ‘‘unnatural.’’ When
we investigate the roots of this kind of objection, we frequently find
that by ‘‘unnatural’’ people tend to mean no more than ‘‘unfamiliar’’
changing our minds
72
(few people regard the use of vitamin tablets as unnatural; fewer still
object to clothes). But there are also rational arguments against the
use of direct means of changing minds.
There is an important and much discussed distinction between
the treatment of disease, and the enhancement of traits that already
fall within the normal range. Treatment is widely seen as more
permissible than mere enhancement. In the next chapter, I shall
argue that the treatment/enhancement distinction cannot be drawn
in any defensible manner and is therefore morally irrelevant. For the
moment, however, I shall focus on changing minds where it is least
controversial: in the treatment of diagnosable illness. It is uncon-
troversial that when someone is undergoing a significant degree of

suffering, and we have the means of alleviating that suffering, we
ought to do so (other things being equal). If the only means, or by far
the best means (in terms of the balance of benefits over risks and
harms), involves direct manipulation, then we have a powerful rea-
son in favor of direct manipulation. Nevertheless, many people
think, it would be better if we could avoid direct manipulation, in
favor of more traditional means of changing minds, even in cases
involving treatment of serious illness. Why this presumption in favor
of the traditional means? In what follows, I shall set out a number of
considerations that have been, or might be, advanced in favor of the
presumption. Only once they are all before us shall I proceed, in the
next chapter, to evaluate them.
authenticity
One worry focuses on the authenticity of the agent. Authenticity is
one of the definitive values of modernity; it is a good highly valued by
most of the citizens of – at least – most of the countries in the
developed world. Authenticity, at least in the sense at issue in these
debates, consists, roughly, in being true to oneself. The authentic
individual finds their own way to live, a way that is truly theirs. They
do not passively accept social roles imposed upon them. They do not
simply select between the conventional ways of living that their
authenticity
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society makes available. Instead, they look for and actively create
their own way, by reference to who they, truly and deeply, are.
Authenticity is a modern ideal. It could not exist in premodern
societies, in which social roles were relatively few, and people had
little freedom to move between them. A medieval peasant had few
options available to him or her, and little leeway to choose between
them. Authenticity requires the growth of cities, and the consequent

decrease in the social surveillance and mutual policing characteristic
of village life. In the anonymity of the city, people were free to
remake themselves. They could, if they wished, break free (at least
somewhat) from the expectations of their family, their church, their
friends and even of social conventions, and remake themselves in
their own image.
2
Authenticity, the search for a way of life that is truly one’s
own, has gradually gone from a mere possibility to an ideal. Today,
most of us feel stung by the charge of inauthenticity. Conformism,
going along with the crowd, the herd mentality – all of these are, if
not quite vices, at least imperfections to be avoided. Of course, we
may authentically choose to do what most everyone else is doing, but
to choose it authentically is to choose it because it is right for us, and
not because it is what everyone else does.
Authenticity, as Charles Taylor (1991) has argued, exists in an
unstable tension with other ideals and standards of a good life. It can
easily tip over into selfishness and a shallow form of individualism. It
can lead us to overlook the fact that values are sustained socially, and
that each of us must forge our own way of life in an ongoing dialogue
with others: with those close to us, and with the ideals and standards
of our culture. Nevertheless, though it is an ideal that becomes self-
defeating if it is taken too far, it is unrepudiable by us moderns.
Authenticity is so deeply woven into our cultures and our values that
few, if any, of us can simply turn our backs upon it. It is true that
some of us choose to embrace, or to remain in, ways of life that are in
some ways antithetical to the ideal of authenticity – we join mon-
asteries, or adhere to religions that regulate every aspect of our lives,
changing our minds
74

even to the point of deciding who we shall marry and what careers (if
any) we shall have. But even when we embrace ways of life that
require us to cede control of our significant choices to others, we
often justify our decision in ways that invoke authenticity: we find
this way of life personally fulfilling; it is, after all, our way of being
ourselves.
It is easy to see why the use of direct manipulations of the
mind might be thought antithetical to the ideal of authenticity. To
be authentic is to find one’s way of life and one’s values within;itis
to make one’s entire life an expression of who one truly is. But
antidepressants, psychosurgery and the other technologies of direct
manipulation introduce an alien element into the equation: after
treatment with these technologies, I am no longer the person I was.
Either I have changed, as a result of this intrusion from outside me,
or (less radically) who I really am has been covered over by the foreign
element. This cheerfulness, this sunny disposition, this is not really
me; it is the antidepressants. As Carl Elliott, the bioethicist who has
insisted most forcefully and persuasively on the problem of inau-
thenticity puts it:
It would be worrying if Prozac altered my personality, even if
it gave me a better personality, simply because it isn’t my
personality. This kind of personality change seems to defy an
ethics of authenticity.
(Elliott 1998: 182)
To this extent, psychotherapy is preferable to direct manip-
ulation. Psychotherapy explores my self, my inner depths. It seeks
coherence and equilibrium between my inner states, and between
my inner states and the world. But direct manipulation simply
imposes itself over my self.
One might illuminatingly compare the effects of direct

manipulation in treating a mental illness to the effects of more
familiar direct manipulations of the mind: drugs consumed for
recreational purposes. When someone behaves aggressively, or breaks
authenticity
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