EXTRACT FROM THE NUFFIELD COUNCIL ON BIOETHICS
REPORT GENETICS AND HUMAN BEHAVIOUR: THE ETHICAL CONTEXT
13.13 Traits such as sexuality, aggression
and intelligence have in the past been thought of as outcomes
of inheritance, family background, socio-economic environment,
individual choice and even divine intervention. If research in
behavioural genetics identifies the influence of genes on such
traits, they may mistakenly come to be thought of as being fundamentally
determined by genetic factors and even as aspects of life which
belong to one's "fate" (see paragraphs 12.10-12.15).
Indeed, being diagnosed as at risk of disease may have a tendency
to make healthy people feel ill, or feel fatalistic about their
chances of survival, despite the existence of diets, life-styles
or treatments to avoid the development of disease. It is possible
that information about genetic factors that indicate susceptibility
to a disease may make people think that the unwanted outcome is
It has been suggested, that the word "genetic" is interpreted
as synonymous with something fixed or unchanging in Western culture,
when it is used in relation to disease.
With regard to behavioural traits, therefore, information about
genetic susceptibility might engender similarly fatalist beliefs.
13.14 As the reviews of the evidence indicate,
fatalism about genetics is a misconception. Even when behavioural
traits are influenced by genes, there are always other influences,
and the existence of genetic influences does not show that we
are powerless to change or modify our character: "scientists
may well identify an allele that causes a genetic predisposition
to shyness, but such a discovery does not mean that shyness cannot
Nonetheless, this misconception is pervasive and gives rise to
the anxiety that behavioural genetics will lead to the "medicalisation"
of those who are found to be genetically predisposed to certain
13.15 At the root of concerns about medicalisation
is the idea that behavioural traits that have previously been
regarded as "normal" will come to be viewed as "abnormal"
or pathological. In addition, behavioural traits within the normal
range may turn out to be amenable to influence by pharmacological
interventions as a result of knowledge about the biological factors
that affect them. Concerns about medicalisation have been expressed
for many decades, for example in relation to the increasing number
of psychiatric conditions that are recognised, and in the increasing
use of medicines. In the era of genetic research, the fear is
that the identification of the influences of genes will exacerbate
this trend, encouraging the re-classification of behavioural traits
as within the realm of medicine.
13.16 In some cases genetic research may indicate
that a behavioural trait is one for which medical interventions
are appropriate and welcome. Findings from research concerning
the biological basis of addiction to alcohol, and of autism, helped
to liberate individuals and parents from the charges previously
laid against them of moral weakness and of neglecting their children
respectively. In such cases, it should be acknowledged that this
"medicalising" tendency is beneficial: the research
helps to confirm the view that the individuals concerned should
be perceived as ill, rather than bad, and in need of medical help,
rather than discipline and punishment.
13.17 However, in other cases, medicalisation
may have adverse effects. One such problem is that of diagnostic
spread, or the tendency for disorders to be broadly defined so
that more and more individuals are caught in the diagnostic net.
This tendency may arise as a result of an erroneous assumption
that once a biological influence on a trait has been identified,
the trait becomes the proper subject of medical intervention.
Or, it may be that if medicines are developed that have an effect
on a trait, that trait will come to be seen as a disorder, or
something to be treated and altered.
13.18 An example of this latter phenomenon
is the prescription of methylphenidate (Ritalin) to children with
Attention Deficit Hyperactivity Disorder (ADHD). This example
is controversial because there are undoubtedly some children who
have serious behavioural problems and who benefit greatly from
the drug. It would be wrong to suggest that ADHD has been invented;
indeed, the condition has been recognised for many decades. However,
the advent of medicines that are effective in improving concentration
and reducing hyperactivity is a fairly recent development. In
1999, the US National Association of State Boards of Education
estimated the number of children taking Ritalin on a daily basis
at between 1.3 and 2 million. The National Institutes of Health
in the US has recently undertaken a study to examine prescribing
13.19 Similarly, the producers of new "anti-shyness"
drugs, such as Paxil and Luvox, have been accused of applying
to normal behaviour, interventions developed for pathological
Paxil is licensed in the US for the treatment of depression, Social
Anxiety Disorder (SAD), Generalised Anxiety Disorder (GAD),
Obsessive Compulsive Disorder, Panic Disorder and Post-traumatic
Stress Disorder. The Paxil website notes that approximately 10
million adults are diagnosed with GAD each year in the US.
The website encourages individuals to take an online "self-test"
for GAD, which involves answering three questions:
1. Do you worry excessively or are you anxious
a lot of the time?
2. Are you often bothered by the following:
Feeling restless, keyed-up,
or on edge?
Feeling tired, weak,
or easily exhausted?
Having difficulty concentrating?
Having difficulty sleeping?
3. Would you say your anxiety or worry interferes
with your work, family or social life?
Answering "yes" to more than one of
the complaints listed in question 2, even if the answers to questions
1 and 3 are negative, is sufficient to generate a response that
says the results are inconclusive and suggests discussing them
further with a health professional.
13.20 A similar self-test can also be undertaken
for SAD, the key symptoms of which are a persistent fear of and
an associated avoidance of social situations involving strangers.
In an article in the New York Times Magazine about SAD,
one commentator observed:
"until recently, it was thought to be a
rare disorder . . . Then in 1999, buoyed by the success of the
new psychotropic drugs, the pharmaceutical company SmithKline
Beecham began marketing its antidepressant Paxil as a treatment
for social phobia . . . Experts cited alarming new statisticsaround
13% of us were socially phobic, for exampleand magazines
dished up the requisite alarmist trend stories. A set of traits
and behaviours, at least some of which were once regarded as neutral,
or even desirable, re-emerged as a pathologya function
of brain chemistry, amenable to and indeed demanding pharmacological
13.21 These examples can be viewed as illustrations
of diagnostic spread, the re-classification of behavioural traits,
and the possibility of commercial and social pressure to make
use of medical interventions. While these examples are not the
result of findings in genetic research, they demonstrate the existence
of a tendency towards medicalisation, and corresponding problems,
to which findings in genetics may contribute.
13.22 A further potential problem related to
medicalisation is the tendency to focus excessively on the biological
factors that influence particular traits, rather than the social
or economic factors. In paragraph 3.17, we observed that those
factors that are described as the "cause" of a particular
trait are often those by which one hopes to control or alter that
trait. Thus, there is a risk that the role of genetic factors
will be over-estimated, so that genetic and medical interventions
can be provided, rather than focusing on the social and economic
environments which are also likely to play a vital role. This
may be so even though there is no scientific reason for assuming
that if genetic influences on a trait are identified that trait
will be easier to alter using medical or genetic interventions
rather than other forms. Examples of this phenomenon include the
risk that medicines may be prescribed for children who are disruptive
but do not have a clinical diagnosis of hyperactivity, rather
than investigating other approaches such as reducing class sizes,
and that medication may be used rather than diet and exercise
as strategies for dealing with hypertension or obesity.
13.23 Medicalisation is an issue that affects
many areas of life, not just behavioural genetics. In the case
of behavioural traits, since research into genetic influences
is at an early stage, it is not possible to say whether medicalisation
will be likely, or whether it will have, on balance, positive
or negative implications. However, examples of the deleterious
effects of medicalisation in other areas suggest the need for
awareness of potential problems. We conclude that research
in behavioural genetics has the potential to contribute to the
existing phenomenon of medicalisation. Deleterious effects that
should be borne in mind include shifting the boundary between
normal variation and disorder further away from the extremes of
variation; reducing social tolerance of previously "normal"
behavioural traits; and the routine selection of genetic or medical
interventions without adequate consideration being given to environmental
interventions and other options.
13.24 Any discovery of biological mechanisms
that influence behaviour, including genes, may aid in the development
of drugs which modify behaviour. We consider that there is potential
for the unhelpful widening of diagnostic categories, to encourage
the use of medication by people who would not necessarily be thought
of as exhibiting behavioural traits outside the normal range.
In addition to the potentially harmful effects already listed,
this could lead to unnecessary increased expenditure by the health
service. We recommend that health service providers, and in
particular the Department of Health, specifically charge a named
agency with monitoring and, if necessary, controlling, this means
of the deliberate medicalising of normal populations.
104 Senior, V, Marteau, T M & Weinman, J (1999).
Impact of genetic testing on causal models of heart disease and
arthritis: an analogue study, Psychol. Health 14, 1077-88. Back
Marteau, T M & Senior, V (1997). Illness representations
after the human genome project: the perceived role of genes in
causing illness. In Petrie, K J & Weinman, J A, editors. Perceptions
of Health and Illness: Current Research and Applications. Reading,
UK: Harwood Academic Publishers. pp 241-66. Back
Rothstein, M A (2000). Genetics and the work force of the next
hundred years. Columbia Bus. Law Rev. 2000 (3), 371-401 at p 383. Back
See for example Conrad, P & Schneider, J W (1992). Deviance
and Medicalisation: From Badness to Sickness. Philadelphia:
Temple University Press. Back
See for example Koerner, B I (2002). First, you market the disease
. . . then you push the pills to treat it. The Guardian, (30
July). Taken from Koerner, B I Disorders made to order. Mother
Jones magazine. July/August (2002). Back
GAD is psychiatric disorder which features in the two main classification
systems for mental illness, the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV) and the
ICD-10 Classification of Mental and Behaviour Disorders. Back
http://www.paxil.com (17 July 2002). Back
Talbot, M (2001). The shyness syndrome: bashfulness is the latest
trait to become a pathology. New York Times Magazine 24