The Pursuit of Perfection

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.