Organización de los Gobiernos Locales

Despite these problems, I believe that there are many strengths of the reason-inclusive Medical Model B I just outlined. There may even be an inclination to suppose that the endogenous / reactive distinction eliminates the need for worries about the pathologisation of normal low mood. Some non-physiological sources for both having low moods or for being depressed have been established as relevant, and at least some normal low mood states will not be medicalised. Further, an embrace of environment-physiology interaction in treatment can be part of a richer therapeutic interaction between clinician and patient. This model accepts the evidence that a combination of medication and some kind of talk therapy is the most effective treatment for depression. In turn, this therapeutic attitude will better meet the ethical obligations that exist between clinicians and their patients.

Despite these positive aspects of this line of analysis, I wish, however, to argue that environmental sources of depression, as they are understood in the reactive/ endogenous

59 _{See Nolen-Hoeksema et al. 1999 for discussion.} 60 _{Pancner and Jylland 1996, 144-5.}

distinction, are construed non-intentionally. I believe that this approach does not engage with the potential intentional element of depression – it simply leaves it out. Suppose that good evidence could be garnered that pathological depression is indeed endogenous, not caused by typical environmental prompts for being depressed, and that which is considered a normal low mood always is always preceded by such an environmental prompt. For most medical practitioners, environment in this context is simply understood as operating as a material cause for certain brain states. A clinical interaction that places emphasis on this kind of causation will not treat sufferers of depression as suffering intentionally.

In looking beyond physiology, I am looking for intentionally-underwritten reasons for depression. The force of construing depression as a response to good reasons necessarily involves a normative element. When terrible things happen to someone, these stresses lead to depression in a normatively permissible way. The stress functions as an occasioning

intentional object. Sometimes, we might want to go even further and say in some cases that there is a very compelling fit between a potential occasioning intentional objects and

depression. This might mean that the person should become depressed, and a failure to do so indicates a negatively-evaluable lack.

For example, in some cases of the death of a loved one (e.g. through homicide that the survivor believes she might have prevented), we might think that a failure to manifest what would now count as pathological depression (e.g. her low mood would last longer than 2 months, it would be of great intensity, it would include beliefs about the worthlessness of life and a negative self-evaluation) would indicate that something was wrong with that person. In many situations, what is important is not that people just do become depressed, but rather that they should – or, at least, becoming depressed is an appropriate and understandable

response. George Graham writes that “were a person immune to depression in justifiably depressed circumstances, I think we should be inclined to think of him as psychologically deficient. Such an individual would either be self-deceived about his situation . . . or expressing some emotional confusion, or in some other way impaired.”61

An important difference between material and intentionally-linked causation is highlighted by the infinity that comes with material causation. Effects have causes, but causes must have causes, which must also have causes, and so on. Reasons operating as material causes, as they do in the aforementioned description, entail further causes. But reasons in the normative sense do not; they come to an end. When someone is depressed because (in the normative sense of ‘because’) her dog died, there is no more explaining to do. The causal analysis is complete. And this completed, normative causal chain can then be evaluated in a very different manner than material causal chains. We can ask, “Should she have become depressed in those circumstances?” This question makes no sense if we are discussing materially-caused effects as such. In some cases, we can sensibly endorse her reasons, even as we strive to avoid the result. Graham believes that, “[g]ood reasons may warrant a person to be depressed, even while reason warns of its possible harmful effects.”62

If the response that depression has received serves as a model, then it is likely that we will see broad erosion of acceptance of possible intentional accounts and normative evaluations of our affective responses. Insisting that a mechanism for determining whether or not some unpleasant affect is a disease-state is that it is pharmacologically treatable is basically to miss the point. Recent research is establishing the details of what we have long known. All affect

61 _{Graham 1990, 419.} 62 _{Ibid., 419.}

— normal, pathological, and all gradations in between — arises in conjunction with changes in physiology (e.g. neurotransmitters, brain structure, etc.). Under the approaches I have been describing, all affective responses are potential candidates for pathologisation.

These kinds of intentional causes cannot be easily integrated into either Medical Model A or B. Medicine clearly (and with many good reasons) has dedicated itself to the material/ physiological analysis of the world. Once material causes become established as the central explanatory mechanism for a particular disease, there is little impetus to investigate the possible intentional aspects of that disease. It seems to me, however, that this constitutes a substantial loss. Depression is often a response to meaningful events in its sufferers’ lives. This responsiveness can only be appreciated as long as the intentional objects that bring about depression continue to have a place in its description. The placement of depression strictly in the realm of the material does violence to an important element of our

understanding of affective responsiveness. I think considering and engaging with

depression’s intentional aspects will help us better understand and respond to the differences between pathological and normal low moods. I will argue for this position in the next chapter.

CHAPTER III

THE INTELLIGIBILITY OF DEPRESSION

In the previous chapter, I argued against two current medical models that I think implicitly deny that depression is intentional. In this chapter, I will present my positive view that moods, especially depression, are at least potentially intelligible. To see someone’s depression as intelligible is to understand its potentially discrete pieces – its intentional objects, its surrounding environmental conditions, its physiological responses, its affective valence, etc. – as a unified phenomenon. A crucial element of this potential intelligibility is that depression can and often does have an intentional object. I will explain this notion of intelligibility more fully in sections 2 and 3.

Once depression’s potential intelligibility becomes apparent, normative engagement becomes possible. Cases of depression can be explored by assuming the role of what I call an ‘affective interlocutor.’ Affective interlocution facilitates making the distinction between depression that should be pathologised and depression that should not be pathologised. Then, in section 4, I will argue that just as there are moral emotions, so too can there be moral moods. Depression’s (potential) intelligibility leads to the possibility that depression can be a ‘moral mood’ and can play an important role in our moral lives. In the final section, I will explore some of the implications of seeing depression as potentially intentional,

intelligible, and moral. That current medical approaches implicitly deny the depression can have an intentional object means that they turn a blind eye to this valuable feature of