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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Delicate BalanceA Fragile LifeA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Mirror Is for ReflectionA Mirror Is for ReflectionA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Tapestry of ValuesA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst MarriageAgainst Moral 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Not to ChooseClinical Dilemmas in PsychotherapyClinical EthicsCloningClose toYouCoercion as CureCoercive Treatment in PsychiatryCognition of Value in Aristotle's EthicsCognitive Disability and Its Challenge to Moral Philosophy Comfortably NumbCommonsense RebellionCommunicative Action and Rational ChoiceCompassionate Moral RealismCompetence, Condemnation, and CommitmentComprehending CareConducting Insanity EvaluationsConfidential RelationshipsConfidentiality and Mental HealthConflict of Interest in the ProfessionsConsuming KidsContemporary Debates In Applied EthicsContemporary Debates in Moral TheoryContemporary Debates in Social PhilosophyContentious IssuesContesting PsychiatryCrazy in AmericaCreating CapabilitiesCreatures Like Us?Crime and CulpabilityCrime, Punishment, and Mental IllnessCriminal Trials and Mental DisordersCritical Perspectives in Public HealthCritical PsychiatryCrueltyCultural Assessment in Clinical PsychiatryCurrent Controversies in BioethicsCurrent Controversies in 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Challenged ProfessionsEthicsEthicsEthicsEthics and AnimalsEthics and ScienceEthics and the A PrioriEthics and the Discovery of the UnconsciousEthics and the Metaphysics of MedicineEthics at the CinemaEthics at the End of LifeEthics Beyond the LimitsEthics Case Book of the American Psychoanalytic AssociationEthics Done RightEthics ExpertiseEthics for EveryoneEthics for PsychologistsEthics for the New MillenniumEthics in CyberspaceEthics in Everyday PlacesEthics in Health CareEthics In Health Services ManagementEthics in Mental Health ResearchEthics in PracticeEthics in PsychiatryEthics in PsychologyEthics in Psychotherapy and CounselingEthics of PsychiatryEthics without OntologyEthics, Culture, and PsychiatryEthics, Sexual Orientation, and Choices about ChildrenEvaluating the Science and Ethics of Research on HumansEvilEvil GenesEvil in Modern ThoughtEvil in Modern ThoughtEvolution, Gender, and RapeEvolutionary Ethics and Contemporary BiologyEvolutionary Psychology and ViolenceEvolved MoralityExperiments in EthicsExploding the Gene MythExploiting ChildhoodFacing Human SufferingFact and ValueFacts and ValuesFaking ItFalse-Memory Creation in Children and AdultsFat ShameFatal FreedomFellow CreaturesFellow-Feeling and the Moral LifeFeminism and Its DiscontentsFeminist Ethics and Social and Political PhilosophyFeminist TheoryFinal ExamFirst Do No HarmFirst, Do No HarmFlashpointFlesh WoundsForced to CareForgivenessForgivenessForgiveness and LoveForgiveness and ReconciliationForgiveness and RetributionForgiveness is Really StrangeFoucault and the Government of DisabilityFoundational Issues in Human Brain MappingFoundations of Forensic Mental Health AssessmentFree WillFree Will And Moral ResponsibilityFree Will and Reactive AttitudesFree Will, Agency, and Meaning in LifeFree?Freedom and ValueFreedom vs. InterventionFriendshipFrom Darwin to HitlerFrom Disgust to HumanityFrom Enlightenment to ReceptivityFrom Morality to Mental HealthFrom Silence to VoiceFrom Valuing to ValueFrontiers of JusticeGender in the MirrorGenetic PoliticsGenetic ProspectsGenetic ProspectsGenetics of Original SinGenetics of Original SinGenocide's AftermathGetting RealGluttonyGood WorkGoodness & AdviceGreedGroups in ConflictGrowing Up GirlGut FeminismHabilitation, Health, and AgencyHandbook for Health Care Ethics CommitteesHandbook of BioethicsHandbook of Children's RightsHandbook of PsychopathyHappinessHappiness and the Good LifeHappiness Is OverratedHard FeelingsHard LuckHardwired BehaviorHarmful ThoughtsHeal & ForgiveHealing PsychiatryHealth Care Ethics for PsychologistsHeterosyncraciesHistorical and Philosophical Perspectives on Biomedical EthicsHoly WarHookedHookedHow Can I Be Trusted?How Fascism WorksHow Propaganda WorksHow to Do Things with Pornography How to Make Opportunity EqualHow Universities Can Help Create a Wiser WorldHow We HopeHow We Think About DementiaHuman BondingHuman Dignity and Assisted DeathHuman Dignity and Assisted DeathHuman EnhancementHuman 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EdenOut of Its MindOut of the ShadowsOverdosed AmericaOxford Handbook of Psychiatric EthicsOxford Studies in Normative EthicsOxford Studies in Normative Ethics, Volume 7Oxford Textbook of Philosophy of PsychiatryPassionate DeliberationPatient Autonomy and the Ethics of ResponsibilityPC, M.D.Perfecting VirtuePersonal AutonomyPersonal Autonomy in SocietyPersonal Identity and EthicsPersonalities on the PlatePersonhood and Health CarePersons, Humanity, and the Definition of DeathPerspectives On Health And Human RightsPharmaceutical FreedomPharmacracyPharmageddonPhilosophy and This Actual WorldPhilosophy of BiologyPhilosophy of Technology: The Technological ConditionPhysician-Assisted DyingPicturing DisabilityPilgrim at Tinker CreekPlaying God?Playing God?Political EmotionsPornlandPowerful MedicinesPractical Autonomy and BioethicsPractical EthicsPractical Ethics for PsychologistsPractical RulesPragmatic BioethicsPragmatic BioethicsPragmatic NeuroethicsPraise and BlamePreferences and Well-BeingPrimates and PhilosophersPro-Life, Pro-ChoiceProcreation and ParenthoodProfits Before People?Progress in BioethicsProperty in the BodyProzac As a Way of LifeProzac on the CouchPsychiatric Aspects of Justification, Excuse and Mitigation in Anglo-American Criminal Law Psychiatric EthicsPsychiatry and EmpirePsychological Concepts and Biological PsychiatryPsychology and Consumer CulturePsychology and LawPsychotropic Drug Prescriber's Survival GuidePublic Health LawPublic Health Law and EthicsPublic PhilosophyPunishing the Mentally IllPunishmentPursuits of WisdomPutting Morality Back Into PoliticsPutting on VirtueQuality of Life and Human DifferenceRaceRadical HopeRadical VirtuesRape Is RapeRe-creating MedicineRe-Engineering Philosophy for Limited BeingsReason's GriefReasonably ViciousReckoning With HomelessnessReconceiving Medical EthicsRecovery from SchizophreniaRedefining RapeRedesigning HumansReducing the Stigma of Mental IllnessReflections on Ethics and 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Virtues of FreedomThe Virtues of HappinessThe Virtuous Life in Greek EthicsThe Virtuous PsychiatristThe Voice of Breast Cancer in Medicine and BioethicsThe War Against BoysThe War for Children's MindsThe Whole ChildThe Woman RacketThe Worldwide Practice of TortureTherapy with ChildrenThieves of VirtueThree Generations, No ImbecilesTimes of Triumph, Times of DoubtTolerance Among The VirtuesTolerance and the Ethical LifeTolerationToxic PsychiatryTrauma, Truth and ReconciliationTreatment Kind and FairTrusting on the EdgeTry to RememberUltimate JudgementUnborn in the USA: Inside the War on AbortionUndermining ScienceUnderstanding AbortionUnderstanding CloningUnderstanding EmotionsUnderstanding EvilUnderstanding Kant's EthicsUnderstanding Moral ObligationUnderstanding Physician-Pharmaceutical Industry InteractionsUnderstanding TerrorismUnderstanding the GenomeUnderstanding the Stigma of Mental IllnessUnderstanding Treatment Without ConsentUnhingedUnprincipled VirtueUnsanctifying Human Life: Essays on EthicsUnspeakable Acts, Ordinary PeopleUp in FlamesUpheavals of ThoughtUsers and Abusers of PsychiatryValue-Free Science?Values and Psychiatric DiagnosisValues in ConflictVegetarianismViolence and Mental DisorderVirtue EthicsVirtue, Rules, and JusticeVirtue, Vice, and PersonalityVirtues and Their VicesVoracious Science and Vulnerable AnimalsVulnerability, Autonomy, and Applied EthicsWar Against the WeakWar, Torture and TerrorismWarrior's DishonourWeaknessWelfare and Rational CareWhat are you staring at?What Genes Can't DoWhat Have We DoneWhat Is a Human?What Is Good and WhyWhat Is Good and WhyWhat Is the Good Life?What Price Better Health?What Should I Do?What We Owe to Each OtherWhat Would Aristotle Do?What's Good on TVWhat's Normal?What's Wrong with Children's RightsWhat's Wrong with Homosexuality?What's Wrong With Morality?When Is Discrimination Wrong?Who Holds the Moral High Ground?Who Owns YouWho Qualifies for Rights?Whose America?Whose View of Life?Why Animals MatterWhy Animals MatterWhy Does Inequality Matter?Why Honor MattersWhy I Burned My Book and Other Essays on DisabilityWhy Not Kill Them All?Why Punish? How Much?Why Some Things Should Not Be for SaleWisdom, Intuition and EthicsWithout ConscienceWomen and Borderline Personality DisorderWomen and MadnessWondergenesWould You Kill the Fat Man?Wrestling with Behavioral GeneticsWriting About PatientsYou Must Be DreamingYour Genetic DestinyYour Inner FishYouth Offending and Youth Justice Yuck!
commonly distinguish between "treatment" and "enhancement".
The doctor's proper role is to treat diseases or conditions, returning patients
to a normal state. Treatment is necessary or, in the case of less serious
conditions, highly desirable. Enhancement, on the other hand, appears
gratuitous, going beyond naturally set limits. Whatever we may think about cosmetic
surgery, botox or the use of hormones to increase athletic performance, doctors
hardly have an obligation to carry out these procedures.
distinction is not merely academic, since insurance policies usually cover
treatments, but not enhancements. This provides an incentive to shift the
boundary between treatment and enhancement. Furthermore, a little reflection
shows that this line is blurry and often controversial. For example, is chronic
shyness simply a matter of having certain personality traits or a psychological
condition that needs to be treated? What about being extremely short, but not
having any recognized disease, such as a growth hormone deficiency? And to cite
a few examples, obesity, hyperactivity and depression, once considered outside
the domain of medicine, are now the focus of treatments.
and David Rothman explore this distinction in their fascinating history of
medical enhancement The Pursuit of Perfection. They survey the history
of estrogen replacement therapy, anti-aging medicine (including testosterone
supplements for normal, older men), liposuction and growth hormone, in each
case showing how a combination of social forces, economic interests and
institutional pressures encourage the spread of risky, often dubious practices.
The Rothmans document how, time and again, enhancement technologies become
available despite the fact that their efficacy is far from established and
their dangers far from negligible.
bulk of the book covers the rise of hormone replacement therapy, which provides
a template for other enhancement technologies. The Rothmans show how hormone
replacement therapy shifted over the last century from largely ineffective
anti-aging medicine to a recommended treatment for middle-aged women.
Researchers redefined menopause, once considered a natural, inevitable
condition, as a disease, something to be cured. Post-menopausal women are
defined as "neuters", suffering from an unnatural state to be
remedied by estrogen supplementation. Along with these sweeping claims about
the nature of femininity, doctors and pharmaceutical companies made often
unsubstantiated claims about the effect of estrogen on osteoporosis, mental
health and Alzheimer's disease. While largely accepting the potentially
positive effects, they downplayed or ignored the real possibility that it might
surprisingly, economic factors also played an important role in the spread of
these technologies. This isn't in itself disturbing, but, as the Rothmans show,
the medical profession largely accepted and promoted the interests of
pharmaceutical companies when it should have been providing checks and
balances. Warnings and protests were largely ignored, while selected
gynecologists received lucrative "research grants" from pharmaceutical
companies to endorse their products. The influence of the pharmaceutical
companies extended to the scientific community, where sympathetic researchers
were invited to give papers at company sponsored conferences. These papers were
then published in special volumes, circumventing the process of peer review and
giving products "scientific" legitimacy. These, and other
questionable partnerships between researchers, doctors and pharmaceutical
companies, were not considered out of the ordinary, despite the obvious
conflict of interest.
weren't for the real risks some of these technology, pharmaceutical companies
could simply argue that they were merely attempting to fulfill an enormous
demand. After all, society values youth and beauty. Though we might question
the emphasis placed on these qualities, criticism would be misplaced if it
turned out that these hormone replacement therapy was overwhelming beneficial
or harmless. But this isn't the case. In July 2002, a study funded under the US
Women's Health Initiative was abruptly stopped because the 65,000 women
receiving hormone replacement therapy had significantly higher levels of
coronary heart disease, strokes, pulmonary blood clots and breast cancer.
Though hormone replacement therapy did seem to have a positive effect on
colorectal cancer and hip fractures, the Journal of the American Medical
Association explicitly recommended against the use estrogen/progestin for
preventing chronic disease.
sections on liposuction – which has higher death rate than many non-elective
surgical procedures – testosterone, growth hormone, genetic modification and
anti-aging technology follow a similar pattern, which can be reduced to a few
factors. First, there is the technological imperative: despite the protests,
technology that can be developed will be developed. Even if we attempt to
restrain research, the thin line between enhancement and diseases makes this
difficult. Often, research may have multiple or ambiguous applications,
allowing enhancement technologies to be developed despite protests. At the same
time, heavy handed legislation could very well prevent important research for
preventing disease from being carried out. Second, economic factors encourage
this research. Doctors, scientists and pharmaceutical companies will continue
to work hand in hand because it pays very well. A third, related factor
concerns social pressures. As mentioned above, cosmetic surgery is a
multimillion dollar enterprise because there is a market for it. Finally,
people come to accept once controversial technologies. In vitro
fertilization, now a generally accepted practice, once received the same
controversy as cloning. The might can be said for hormone replacement therapy
there is a fault with the Rothman's book, it is the fact that it doesn't
provide much guidance for people trying to think critical about enhancement
technologies. In fact, one is left with the feeling that these technologies,
given our contemporary zeitgeist, are inevitable. All of these economic,
social and technological factors lead to treatments becoming available before
they have been sufficiently tested. What, if anything, does their study tell us
about the distinction between treatment and enhancement? How should governments
and concerned citizens react when faced with this technology? What are the
implications of their study for genetic modification, cloning and other
technologies that may soon become common place? These and other questions are
left largely unanswered.
this book is recommended to anyone who wants to grasp the history of medical
enhancement and reflect on its future. It provides a valuable survey of a
fascinating period that each year becomes more relevant.
© 2004 Alex
writes about himself:
I'm a philosopher and writer, married to a Mexican lawyer.I am
currently doing a Ph.D. in philosophy at L'Université de Montréal. In my thesis
I am proposing a model of our moral psychology combining the insights of
cognitive science, developmental psychology, evolutionary psychology and other
disciplines. I believe that most philosophers are still using psychology from
the 18th century, ignoring many of the recent scientific advances, and suggest
that there is evidence our minds contain a number of innate, distinct faculties
that allow us to make moral judgments in different domains.