Andrew Stark's The Limits of Medicine tackles timely issues. As the possibilities for medical intervention expand it is increasingly important for us to decide what the limits of medicine should be. When does disorder shade into normality? When is a treatment just an enhancement? When might a cure be cultural genocide?

The book falls into three chapters. The first considers when a condition is a disorder and when it is just a normal variation. Stark considers the different ways in which conditions can be distributed in the population. Many biological features are normally distributed (height and IQ, for example). Stark notes that a normal curve supplies no objective grounds on which a certain part of the curve might be cut off and considered abnormal. He concludes that we might equally well consider the extreme 1%, or 5%, or any other percent, of the population to be abnormal. As a consequence, Stark suggests, all those on any part of a normal curve, with the exception of the very best off, are free to choose whether to consider themselves normal or in need to treatment. On the other hand, when we are faced with a skewed distribution, while those on the hump can choose whether to consider themselves normal or abnormal, those on the tail have no choice – cystic fibrosis, say, is objectively an abnormality.

The second chapter, titled "A visit to the Kantian doctor" considers cases when we feel unease about proposed treatment because it seems to threaten a patient's authenticity. Such concerns were famously raised by Peter Kramer's (1997) Listening to Prozac. Several of Kramer's patients considered themselves "better than well" while on Prozac, and this raised worries as to whether the drug-taking patients remained themselves. In considering such cases, Stark links authenticity to struggle. He thinks that the reason we feel unease when character change is brought about by drugs but not when years of therapy produce the same effect is that the therapy is harder work. And, when an effect is brought about by hard work we tend to hold that the person themselves is responsible for the effect. As he links authenticity with struggle, Stark holds that treatment is justified in so far as it does not undermine effort. We can legitimately use drugs so long as we continue to strive to better ourselves as much as we would previously have done.

The final chapter considers cases where proposed treatments cause concern because they may undermine the cultures that are associated with the condition to be treated. So, for example, Deaf activists have opposed the use of cochlear implants on the basis that such "treatments" are a form of cultural genocide. They worry that the loss of deaf children threatens the continued existence of Deaf culture. Stark's consideration of such cases revolves around the idea that some conditions have "cultural spouses". A cultural spouse occurs when the culture that develops around a disorder shares features with aspects of the mainstream culture. So, for example, Stark considers that the culture around physical deafness has a cultural spouse that is built up around the idea that people can be metaphorically deaf.  For example, within Deaf culture one can find jokes that hinge on communication problems, and within mainstream culture one can find similar jokes that depend on "metaphorical deafness". Stark thinks that as a result, even if Deaf people ceased to exist, elements of their culture would live on – we would still have culture and art concerned with the fallibility of human communication. When a condition has a "cultural spouse", Stark holds that even if all of those with the condition are cured, the associated culture need not be destroyed.

The basic problem that I had with The Limits of Medicine is that I found Stark's basic intuitions strongly counter-intuitive. Take, for example, the claim that everyone on a bell-curve except the very best off can legitimately consider themselves abnormal and request medical help to bring them up to the ideal. Now suppose that I am very well off in some respect – I have a near perfect nose. Stark claims that, because there are still some humans who have nicer noses than me, it is open to me to consider myself abnormal and seek treatment. Now, I accept that there is room for debate on the question of whether we should consider the extreme 5% or 10% or 20% of the population to be abnormal, but for there to be some leeway in cut-off point surely need not mean that all choices are equally justifiable. To hold that 95% of the population might fairly be considered abnormal still strikes me as perverse.

Or, to take another example, Stark holds that our authenticate attributes are those that we struggle to obtain. He also seems to think that struggle is in itself a good, and associates such a view with Kant. I'm unsure where any of this comes from. Consider the view that those attributes that I have to work for are authentically mine. Now, at the moment I'm a woman, and being female is presumably part of my identity. But, being a woman doesn't seem to take much effort on my part, I was simply born female. On the other hand, if I wanted to become a man, a lot of work would be required, and quite plausibly the end result would be less authentic than a less-effortful sex. Stark's account seems to give the wrong result in such cases.

Finally, consider again the idea of cultural spouses. The idea that the culture that surrounds metaphorical deafness is anything like the culture of Deafness strikes me as bizarre. Deaf culture has built up over generations. It depends far more on a community that possesses a shared language and shared history than on jokes about miscommunication. Jokes about miscommunication might well remain even if there were no longer any Deaf people, but to think that Deaf culture would thus be preserved in any meaningful sense is very odd

All in all I found The Limits of Medicine a frustrating book. Stark is clearly a clever man, but his arguments start with highly implausible premises.

© 2007 Rachel Cooper

Rachel Cooper, Ph.D., Lecturer in Philosophy, Institute for Environment, Philosophy and Public Policy, Furness College, Lancaster University, UK

Categories: Philosophical, Ethics