Bioethicians
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.

This
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.

Sheila
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.

The
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
cause cancer.

Not
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.

If it
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.

            The
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
and liposuction.

If
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.

Still,
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
Sager

Alex Sager
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.

Categories: Ethics, Philosophical