Something strange is happening in American medicine. No longer is it being used merely to cure illness. Medicine is now being used in the pursuit of happiness. In America, we take Viagra at bedtime and Ritalin before work. We inject Botox into ourwrinkled brows and rub Rogaine on our balding heads. We swallow Paxil for shyness, Prozac for grief, and Buspar for anxiety. For stage fright we use beta blockers; for excessive blushing and sweating, we get endoscopic surgery. We ask surgeons to trim down our noses, suck fat from our thighs, transform us from men to women, even amputate our healthy arms and legs in the pursuit of what some people believe to be their true selves. Twenty years ago, most doctors said no. Now many have changed their minds.
Not all of this is new, of course. Cosmetic surgeons were setting up shop as far back as the 1930s, and antidepressants and anxiety drugs have been around for more than 50 years. Nor are all these so-called "enhancement technologies" merely enhancements. Antidepressants can be used to treat severe depression as well as to make well people "better than well." Yet at no time in history have Americans been such enthusiastic consumers of these technologies. What has happened to bring about such a dramatic change?
One reason is the market. In the past two decades the US has moved steadily toward a market-based healthcare system. In this system, the pharmaceutical industry has achieved unprecedented financial power. Since the early 1990s, the pharmaceutical industry has been the most profitable industry in America, with margins exceeding 18%. With profit has come power.
In the 1999-2000 election cycle, the drug industry spent more money on political lobbying than any other industry, more than the oil and gas industry, more than tobacco, more than the insurance or automobile industry. The drug industry has also ratcheted up its spending on doctors. The number of drug representatives employed to make promotional pitches directly to doctors rose by 57% in the 1990s to a total of 88,000 by the end of the decade. Perhaps most remarkably, the drug industry now funds 40% of continuing medical education in American medical schools.
Because "enhancement technologies" are usually medical interventions, they must be prescribed or performed by a doctor, not as "enhancements", but as "treatments" for psychological or physical suffering. As drug industry profits have increased, so have the number of new medical disorders, from social anxiety disorder and premenstrual dysphoric disorder to erectile dysfunction and irritable bowel syndrome. The industry sells drugs by selling the illnesses they treat.
How does the industry sell illnesses? As psychiatrist David Healy has pointed out, they do it by funding patient support groups, sponsoring public awareness campaigns, funding symposia and special journal issues devoted to the disorders their drugs treat, and sponsoring "professional education" for physicians. When restrictions on direct-to-consumer advertising were lifted in the US in 1997, the drug industry began to bombard television viewers and magazine readers with ads for their drugs. In 2001, GlaxoSmithKline spent more money advertising Paxil (paroxetine) and the newly popular "social anxiety disorder" for which it is prescribed than Nike spent advertising its top shoes.
This is not simply a matter of the industry creating illnesses out of thin air. The suffering these interventions treat is often genuine. But much of it differs sharply from the kind of suffering that comes from ordinary medical conditions. Often (though not always) it is social in nature. If you have diabetes or heart disease, you suffer regardless of who is watching you or how they perceive you. But the suffering that comes from being too short, too shy or too small-breasted is bound up with the way these characteristics are seen by other people. Yet once social problems can be treated by medical technologies, they come to be seen as medical problems. Then doctors are much more comfortable treating them.
An example of this kind of shift can be seen in a recent turnaround by the US Food and Drug Administration (FDA) on the use of synthetic human growth hormone for short children. Growth hormone has been prescribed for decades for children who are extremely short because their bodies do not produce enough growth hormone. But the FDA had never approved it for children who are simply short for the usual reasons. In the early 1990s, the FDA even launched an investigation of Genentech, one of the makers of synthetic growth hormone, because of its apparent efforts to recruit potential candidates for growth hormone by donating heavily to a group called the Human Growth Foundation, which was sponsoring public awareness campaigns in schools and shopping centres for the treatment of short stature.
Yet in July, the FDA effectively reversed itself and approved synthetic growth hormone for ordinary short children. It cited studies showing that if an ordinary short child is injected with growth hormone for a period of several years, they may gain a few extra centimetres of height when they reach adulthood. Never mind that many studies have also shown that short children are just as psychologically healthy and happy as taller children. Many paediatricians (and perhaps many more parents) insist that being short is such a serious handicap for a child that it deserves medical treatment. One commentator in the New England Journal of Medicine has called the condition of being extremely short "psychologically disabling".
The same kind of transformation - from cosmetic intervention to medical treatment - helped cosmetic surgery get its foothold in the market. In its early days, it was mainly the province of quacks and swindlers. Reputable surgeons stayed away. Yet in the 1930s and 40s a shift occurred, and cosmetic surgery began its steady climb to medical respectability. According to the historian Elizabeth Haiken in her book Venus Envy, a key reason for the shift was the psychological concept of the "inferiority complex". If a person could develop psychological problems because of a sense of inferiority, and that sense of inferiority was a result of being homely, then surgery to make them less homely was no longer merely cosmetic. It was a medical treatment for the inferiority complex, or as Haiken called it "psychiatry with a scalpel."
Now America's hot new reality TV show is ABC's Extreme Makeover. Here plastic surgeons team up with fashion consultants, physical trainers, hair stylists and cosmetic dentists to transform the physical appearance of American volunteers
Is there really anything wrong with these technologies, as long as they are safe and effective? Perhaps, but the harms of enhancement technologies tend to be subtle, and like the conditions the technologies treat, they are often social in nature. Critics of antidepressants worry about the consequences of treating existential ailments as medical problems. Critics of cosmetic surgery point out the way that cosmetic surgeons exploit racist ideals of beauty, offering procedures to correct "Asian eyes" or the "Jewish nose". Critics of human growth hormone for short children note that men may want to be tall, but for there to be tall men there must also be short men.
Perhaps what is most striking about enhancement technologies is the language that people often use to describe them. People seem drawn to the language of identity and self-fulfillment. They speak about these technologies not simply as ways of improving themselves, but for shaping who they are. Even as people undergo the most dramatic transformations imaginable, from wallflower to party girl, from bookworm to bodybuilder, they describe the transformation as a matter of becoming their true selves. Samuel Fussell, an editor turned bodybuilder, writes that the reason he began taking anabolic steroids was that "I was so uncomfortable not being me." Amputee wannabes - candidates for healthy limb amputations - often compare themselves to transsexuals who are trapped in the wrong bodies. One person seeking amputation of his healthy leg told a BBC interviewer that his leg "is a wrongness, it's not a part of who I am." The image is striking. In each case, the "true self" is the one produced by medical technology.
Why should people be drawn to such language? Part of the answer lies in a moral ideal with deep roots in Western culture. The philosopher Charles Taylor calls it an "ethic of authenticity". Many people living in the late modern age do not expect to find the meaning of their lives by looking to God, truth, or any other external moral framework. Nor do they regard their identities as fixed entities, determined by their place in the social hierarchy and ratified by God and nature.
Instead, they expect to find meaning in their lives by looking inwards to the self. This is not merely a matter of getting in touch with your inner life. It is also a matter of social recognition. As Taylor points out, today we expect people to generate an identity, and what is more, it must be an individual identity. This is part of the ethic of authenticity. Recognition is critical, because the effort to generate an identity can fail. Others can refuse to recognise your identity, or refuse to grant it equal moral standing, or insist on seeing you in a way other than the way in which you see yourself. They may insist you are a man, even though you feel you are a woman.
There is a good reason why Taylor calls this an ethic. An authentic life is seen as a better life. Being in touch with your inner feelings, desires and aspirations has become necessary for living as a full human being. An unfulfilled life is a lesser life, one that has failed to meet the promise of what a human life could be. It is a life lived as a man, when you are really a woman; a life lived as a bashful blusher, when you should really be the life of the party; a life lived as Woody Allen when you feel you should be Cary Grant. Seen in this light, technologies such as Prozac, Ritalin, cosmetic surgery, growth hormone and sex-reassignment surgery are not merely ways to look and feel better. They are instruments of self-fulfilment.
Hence the mixed feelings that many of us have about enhancement technologies. These technologies have become a way for us to build or reinforce our sense of dignity while standing in front of the social mirror. The mirror is critically important for identity. Most of us can keenly identify with the shame that a person feels when society reflects back to them an image that is degrading or humiliating.
But the flip side to shame is vanity. It is also possible to become obsessed with that social mirror, to spend hours in front of it, preening and posing, flexing your biceps, admiring your hair. It is possible to spend so much time in front of the mirror that you lose any sense of who you are, apart from the reflection that you see.
· Carl Elliott teaches bioethics and philosophy at the University of Minnesota and is visiting associate professor at the Institute for Advanced Study at Princeton in 2003-4. He has written about enhancement technologies in Better Than Well: American Medicine Meets the American Dream (Norton, 2003).
