Conditions of Permissibility

Let us assume for the sake of the argument that research programs do someday develop pharmaceutical interventions into love and relationships that are available to be used in patient care.^{Footnote 2} Although such interventions would be available, this would not necessarily mean that a clinician would be permitted to use them in all situations. In order to prescribe these pharmaceuticals, we suggest—building on earlier work by Earp and colleagues—that certain conditions of permissibility would have to be met.^{Footnote 3} These conditions concern issues relating to (1) aims and benefits, (2) consent, (3) authenticity, and (4) the necessity of prescribing these pharmaceuticals to an individual patient.

The aims-and-benefits condition requires, first, that a clinician’s aim in prescribing the pharmaceuticals must be to improve a patient’s well-being.^{Footnote 4} In order to improve well-being, the benefits of the intervention must outweigh the harms caused by the failure to diminish (or strengthen, depending on the case) the relevant relationship attachment, as well as potential side effects.^{Footnote 5}

The second condition holds that patients must understand, appreciate, and agree to use these pharmaceutical interventions into love.^{Footnote 6,Footnote 7,Footnote 8} Moreover, a patient must understand the efficacy limitations of the pharmaceuticals: he or she should not expect that the love drugs or antilove drugs would provide a silver bullet solution to his or her problems but should realize that they would only (at best) serve a conducive role in altering a patient’s relationships or higher-level experiences of love.

The third condition requires that the patient’s decision be authentic. The authenticity of a patient’s decision is assessed in relation to his or her (or the couple’s) higher-order values or goals. The decision to use a pharmaceutical intervention into love is authentic, we suggest, if it is consistent with patients’ second-order desires (e.g., to end an abusive relationship or to repair a deteriorating relationship), when acting on these second-order desires is blocked by first-order desires (e.g., strong attachment to an abusive partner or diminishing attachment to a loving partner).^{Footnote 9}

The final condition of necessity requires that other nonpharmaceutical treatment and intervention options, such as couples counseling or psychotherapy sessions, are not feasible or have already been tried to exhaustion. Pharmaceutical interventions into love are then used when they are the only—or at least the most practical and effective—way to diminish (or strengthen) the given relationship attachment.

These conditions would entail that the intervention would (1) be expected to improve the individual’s (and/or couple’s) well-being, all things considered; (2) be undertaken voluntarily and under conditions of informed consent; (3) help the individual patient (or couple) fulfill his or her higher-order goals or values; and (4) be the only way (or the best way) of achieving those first three outcomes, compared against alternative methods that had already been tried or thoroughly considered.^{Footnote 10} On these grounds, we contend, the intervention would be permissible.

Medical Professionals’ Ethical Responsibilities

Assuming that these conditions are reasonable, what would be the implications for medical professionals’ ethical responsibilities? To answer this question, we must first ask: What is the basis for such responsibilities in general? In this commentary, we suggest that it is the fiduciary relationship between the clinician and patient. In this relationship, the medical professional and the patient are engaged in a process of healing, which, broadly construed, aims at improving patient well-being.^{Footnote 11,Footnote 12,Footnote 13} Well-being is constituted by physical, psychological, and social elements and is, primarily, defined by the patient.^{Footnote 14} Although there are limitations and constraints to a patient’s ability to define well-being, it is ultimately the patient who must decide on the relative importance of health, happiness, and love and, in turn, what burdens, pains, and degrees of suffering are (or are not) tolerable to them.

Although clinicians have many professional ethical obligations and responsibilities to patients, at least one responsibility is for them to provide patients with the best possible care.^{Footnote 15} Although this responsibility is limited by contingent conditions of medical necessity, professional expertise, the availability of treatments and therapies, and safety (for both patient and professional), it provides a reasonable expectation that, all things considered, a clinician should provide patients with the best possible care.^{Footnote 16}

In the context of the present discussion, this ethical responsibility to provide patients with the best possible care suggests that clinicians may have a responsibility to prescribe pharmaceutical interventions into love, insofar as the previously stated conditions of permissibility have been met. Providing patients with the best possible care requires offering medical treatments and interventions that at least aim at improving a patient’s overall well-being. As indicated by ample empirical evidence—reviewed by Earp and colleagues in previous articles^{Footnote 17,Footnote 18,Footnote 19,Footnote 20,Footnote 21} —ending a dysfunctional relationship or improving a well-suited relationship bond that might otherwise break down is likely to improve a patient’s well-being. This improvement may occur relatively quickly, as in the case of someone ending an abusive relationship, or it may confer long-term benefits, as when a deteriorating relationship is repaired or strengthened.

Of course, clinicians do not have a responsibility to attempt to address every problem faced by patients who engage in conduct that is likely to threaten their well-being (such as remaining in an abusive relationship or failing to improve a relationship that could, with effort, be salvaged). As a common saying in healthcare goes, patients have the right to make poor decisions. Nonetheless, it is still possible to hold that, in some cases, clinicians do have an ethical responsibility at least to offer pharmaceutical methods for altering behavior and/or relationship attachments that are harmful to their patients. Consider, as an analogy, the practice of offering to prescribe pharmaceutical treatments to aid in smoking cessation. If a clinician judges that such treatment is the best method, in conjunction with other strategies, to aid the patient in giving up a harmful habit, then she or he may have a responsibility to offer such a prescription, even if the patient is likely to refuse the offer. Likewise, if a clinician judges that a pharmaceutical intervention into a relationship-affecting neurological system would, all things considered, be most conducive to the patient’s well-being, then the clinician (we suggest) has a responsibility to offer such an intervention.

Of course, there are numerous potential dis-analogies between these cases as well. That is, even though both smoking and harmful relationship attachments may have negative consequences for health (and for well-being more broadly construed), the role of each of these phenomena in patients’ lives, self-understandings, and experiences of the world are likely to be very different. Accordingly, it may be much easier to determine how, why, and under what conditions a given smoking habit may be damaging to a patient’s well-being than it would be for a bad relationship. If pharmaceutical interventions into relationships are ever to be employed in the way we have suggested, then, clinicians will need to develop a strong set of criteria for determining—in careful consultation with their patients—whether a given relationship attachment is in fact harmful (all things considered), and whether intervention with drugs is the best available treatment.