What's wrong with enhancement  technologies?

CHIPS Public Lecture, University of  Minnesota, February 26, 1998 Carl Elliott, Center for Bioethics, University of  Minnesota
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My topic this afternoon will be some of the ethical issues involved in
so-called enhancement technologies.  By enhancement technologies I simply
mean the idea of using medicine, or surgery, or other kinds of medical  technology not just to cure or control illnesses but rather to enhance,  or improve, human capacities and characteristics.  Some of these are  fairly obvious and have been around for a long time.  Cosmetic  surgery, for example, or the use of anabolic steroids so that athletes  can be more competitive.  An enhancement technology that might not  be as familiar to you is beta blockers.  Beta blockers are a blood  pressure medication, of course, and they work by blocking the  effects of the sympathetic nervous system.  When your sympathetic  nervous system starts working your heart races, your palms and  forehead sweat, your face turns red, and so on.  Beta-blockers  block these effects.  Now beta blockers treat high blood pressure,  but they are also very useful for other people who aren't ill, such as  performers -- musicians, actors, people who do public speaking.   These people may get very nervous at being on the stage, and so  their voices tremble, they flush, their heart races, their palms sweat  and so on.  Beta blockers can diminish these effects, and so a  performer may perform better.   A beta blocker does not affect your  mind, however.  Unlike, say, Valium, it doesn't make you any less  anxious or nervous.  It just blocks the outward effects of your  nervousness.

So beta blockers are a kind of enhancement technology.  But they are
also pretty innocuous kind of enhancement technology.  The kinds that
have some people worried are much different, and these are the kinds of
things that we are looking at in our research group, which is focusing
on the relationship between enhancement and human identity.  The debate  over enhancement got started at the time of the first gene therapy,  which involves the manipulation of a person's genetic constitution.   The first gene therapy involved the treatment of a genetic disease  called ADA deficiency, or adenosine deaminase deficiency, which  causes a child to have severe problems with their immune system.   The point of controversy is not really about (somatic cell) gene  therapy for curing genetic diseases, but about the possibility of using  gene therapy to improve people -- to make them smarter, or better  looking, or to change their personalities, and so on.  And this was  worrying to many people.  So a distinction was developed between  'therapy' on the one hand and 'enhancement' on the other, with  therapy being called morally acceptable, and enhancement morally  worrying.  The idea here was to allow things like gene therapy for  ADA deficiency or cystic fibrosis, but to discourage people from  trying to monkey around with the genetics of things like personality  and intelligence or physical appearance.

What sorts of enhancement technologies are being debated? One of the
earlier debates concerned the possibility of using growth hormone to
increase the height of short children.   Now growth hormone is commonly
given to children who have a genetic deficiency of growth hormone -- that
is, children whose bodies don't produce growth hormone themselves.  The  question is whether it should be given to short children who are not  growth hormone deficient.  The American Academy of Pediatrics  issued a policy statement last year on the ethics of growth hormone  therapy, which said that it is ethically acceptable for some non- growth-hormone-deficient children, such as those with Turner's  Syndrome or chronic renal disease. The problem is that growth  hormone therapy is very expensive -- it could cost upwards of  $50,000 a year.  Also, it is not clear if it works for non growth  hormone deficient kids.   So even at 50,000 a year you may wind up  with no increase in height.

The second enhancement technology I'll mention is the one that has been
on the cover of all the news magazines over the past few years, and that
is Ritalin. Now Ritalin, of course, is a treatment for Attention Deficit-
Hyperactivity Disorder. For children with ADHD, it improves attention and
their concentration.  But there is some evidence that it also improves  attention and focus in children who don't have ADHD.  Whether that  is the case or not, it is certainly true that the annual U.S. production  of Ritalin increased by 500 percent from 1990 to 1995, and an  estimated 2.6 million people are now taking Ritalin in the U.S., the  majority of whom are children between the ages of 5 and 12.

Another medication worth mentioning is Prozac and the other SSRIs. You
may have heard the phrase "cosmetic psychopharmacology", which is a term
of art used by Peter Kramer in his book "Listening to Prozac". Prozac, of  course, is an antidepressant, but what is so intriguing about it is not  what it does for patients who are clinically depressed but what it  does for those who aren't patients who are shy and withdrawn, or  who have poor self-esteem, or who are rather compulsive.  What  some psychiatrists have reported is that a minority of patients on  Prozac (not all or even most of them) underwent what seemed at the  time to be a change in personality.  Some of the more controlling,  compulsive types became more laid-back and easy-going, for  example; some shy people became more self-confident and  assertive. It is this kind of effect that Kramer calls cosmetic  psychopharmacology, and it worries him.  And what worries him is  not something as simple as Prozac making sad people happier but  less interesting or less creative.  What is more deeply worrying is that  for at least some of the patients on Prozac, their personality changes  really do seem to be for the better.  Kramer's patients say things like,  'I feel like I've been drugged all my life and now I'm finally clear- headed,' or, 'I never really felt like myself until now.'  Some patients  seem to be able to see themselves in a way that they had been  incapable of before.  They don't just get well; they are, in the words  of one patient, 'better than well.'

Another, perhaps more fanciful area that the enhancement technologies
group is looking at is the issue of genetics and aging. It is often
assumed that aging is a natural part of human life - that the limits
of human lifespan are more or less fixed, and that growing old is
naturally associated with decline.  Your body just wears out. But this
isn't necessarily true. For example, geneticists have learned to extend
the life spans of some lower animals, such as nematodes and fruit flies,
very dramatically.  And many of the physiological effects of aging can be  slowed down.  Research on aging has generated speculation about  the possibility of extending human life, and of retarding the  physiological deterioration that accompanies old age.  So should we  think of aging as a natural part of human life, or would it make more  sense to think of it as a disease, which we can control?  Are  interventions to reverse or slow the effects of aging properly thought  of as enhancement technologies, or as medical therapies?  Would  there be anything wrong with doing this in humans?

These are just a very few of the possible uses of enhancement technologies.
What I want to do now is just to stop for a minute and ask: so what? What's
wrong with any of this?  Is there anything wrong with wanting to be taller,
or better-looking, or happier, or to be able to concentrate better?   Should we be worrying about any of this?  Saying just what might be  morally worrying about enhancement technologies is not as easy as it  might seem, since many of the characteristics many people want to  enhance are generally seen as positive changes, which would not be  worrying if they were achieved through, say, education, or work, or  some sort of psychotherapy. 

One possible worry about some enhancement technologies is what the
Georgetown University philosopher Maggie Little calls the problem of
"cultural complicity." The demand for certain technologies is created
by cultural forces that many of us would see as harmful.  They are
harmful because they make some people feel inadequate, or unhappy with
the way they are. One example would be the desire of some Asian girls and  young women to have surgery in order to make their eyes look more  like those of Westerners.  Another more obvious example is the  pressure that many American women feel to conform to a certain  body type, and which leaves many women and girls feeling that they  are too fat, or that their breasts are too small, and so on.  At the  extreme end of the spectrum these cultural pressures help to produce  psychiatric illnesses like anorexia nervosa. 

These kinds of forces leave you with a dilemma. On the one hand you
might see them as harmful, and you think we'd be better off as a society
if we were free of them; yet on the other hand they are real. So you feel
them, and if you are a parent, you feel their effects on your child. The
problem is that if you give in to them you become complicit in them, to some  extent.  By getting breast augmentation surgery you are complicit in  the norm that creates the pressure for women to have large breasts.   By boosting your child's height using growth hormone you are  complicit in the norm that creates the pressure for men to be tall.  By  taking Prozac for shyness you are complicit in the cultural norm that  makes shyness something to be ashamed of.  And so on.  By giving  in to the pressure you are helping to reinforce that pressure.

Which leads to the next problem, the problem of "relative ends". What I
mean by this is that the success of some technologies depends on others
not using them or in the technologies not working.  Here is an example.
Boys and men want to be tall, but 'tall' is a relative concept; being tall
is dependent on others being short.  6'5' is tall because the average
American man is 5'10'; if the average American man were 6'5' then 6'5
would no longer be tall. In other words, not everyone can be tall; for  tall men to exist there must be short men.  For short men to exist  there must be tall men.   At best, everyone could be the same height,  but even then I suspect that there would still be tall and short, only  they might be measured in millimeters rather than inches.  The  situation here is like Gore Vidal's remark, that it's not enough to  succeed; others must fail.

The seminal text here, of course, as any of you who have small children
will know is Dr Seuss's story, "The Sneetches". The key characteristic
for Sneetches, if you remember, is whether you have a star on your belly.
As Dr Seuss says:

"But because they have stars, all the Star Belly Sneetches
Would brag, we're the best kind of Sneetch on the beaches"

For Sneetches there is a demand for stars on the belly, and the supplier
who fills that demand is an entrepreneur called Sylvester McMonkey McBean,
who rides into town with a machine to put stars on the bellies of the
Plain-Belly Sneetches.  But then, of course, the appeal of having a star
on your belly is gone when everyone has a star. What Sneetches want then
is to have their stars removed, which McBean is happy to do as well.   And so the Sneetches get caught in a sort of vicious circle, adding  and removing stars from their bellies, which McBean happily does  for them, collecting their money each time.

Which brings up a third worry, that of capitalism and medicine. What
I mean here is that regardless of the moral arguments, the American
economy, and increasingly the American health care economy, is powered
by the engine of capitalism.  If you want to know where it is going,
follow the money.  There is lot of money to be made by selling people
what they want, and if there is money to be made by selling people what  they want, then there is also money to be made by persuading people  that they want something.  There is tremendous market potential with  these technologies.  Prozac, for example, is worth over 1.73 billion  dollars a year to Eli Lilly.  The drug companies are also becoming  much more sophisticated with their advertising.  What was before  being marketed to doctors is now being marketed directly to  patients.  The moral question here is whether there is anything wrong  with selling people what they want.  Some people would say not, that  this is how a capitalist economy works.  Others would say that selling  people what they want is wrong if it preys on their fears or  insecurities or weaknesses, like tobacco company executives who  don't smoke themselves but make their living by persuading others to  smoke. 

The fourth worry I want to mention is a little trickier. I'll call it
the problem of authenticity, and probably the best way to illustrate
it is with a problem that Peter Kramer discusses in Listening to Prozac.
Like other psychiatrists, Kramer finds that when he puts some of his
patients on Prozac they tell him things like, 'This is how I was always
meant to feel.'  He writes about one patient who was probably close to
being clinically depressed.  She has few friends, lots of obligations,
poor self-esteem. She goes on Prozac and soon, she is happier, more  outgoing, more self-confident, knows when and how to say no.   Her  life is much better.  Kramer tapers her Prozac and then takes her off  of it; in a few months, she comes back and says, 'I just don't feel like  myself anymore.' Remarkable: she has returned to the very state in  which she has been for twenty or thirty years, her entire life apart  from the past several months, and she says 'I don't feel like myself.'  Instead, she says feels like herself on Prozac. 

What do we make of these kinds of remarks? It's clear that this patient
changes quite a lot on Prozac. But is the appropriate language to use a
transformation to a new self, or a restoration to a true or authentic self?
Or something else? Some of us might be willing to say that at least in
some cases Prozac restores a true or authentic self, a self that has been
masked by pathology.  The authentic self is the one that has the proper levels  of serotonin in the brain.

But there are other cases in the book that seem to point in the opposite
direction. Kramer tells of one patient who is not a success on Prozac.
Before Prozac he is bitter, sarcastic, rather cynical in a way that he
seems to have cultivated. And he's unhappy. On Prozac, he becomes less bitter,  less cynical; he loses that sarcastic edge.  And he is happier.  But he  doesn't like it.  He doesn't like what he has become, and so he goes  off Prozac.  For him, Prozac doesn't seem so much to restore an  authentic self as to create a new one, and a new one that he thinks  isn't really him.

Now I find this kind of language of the true self very interesting.
Another area of medicine where you hear patients talks about finding
their true selves, interestingly enough, is in the explanations that
people give for undergoing transsexual surgery.  They say, "I am really
a woman, trapped in a man's body", that the surgery let them be who they  really are.  This sounds similar, in a peculiar way, to what Arthur  Frank calls a 'restitution narrative' in his book The Wounded  Storyteller.  A restitution narrative has the basic form, 'I was healthy,  then I got sick, and then I was restored to health.' This is like the  restitution narrative, but the restitution is to something that never  existed before, only wished for -- not restoration back to health, but  restoration to an ideal of health that had never before been realized.   What interests me is not so much whether this narrative is true or not,  whatever that would mean, but how persuasive it is.  Even people  who are troubled by the idea of a person changing his or her sex find  themselves swayed by this kind of story: 'I really am a man, trapped  in a woman's body.' It is a Cartesian explanation: a ghost locked in  the wrong machine.  And it sounds plausible to us in a way that it  might not sound plausible to someone in a time and place without our  tradition of body/mind dualism.  

My own feeling is that these kinds of explanations tell us less than they
seem to tell us. It's like the line in Casablanca where somebody asks
Bogart what kind of man Claude Rains is, and he says, "He's just like any
other man, only more so." You can use the language of authenticity either
way. If you think a given technology is a positive thing, you'll be more
likely to describe it as restoring an authentic self that has been masked by  pathology or the circumstances of a person's genetic inheritance; and  if you think it is a bad thing you will be more likely to describe it as  changing the self, or altering who the person is.

The final worry I'll mention is what I'll call the problem of cultural
relativism. What I mean by this is simply that illnesses, by and large,
are not objective entities which look the same to all people at all times.
Rather, what counts as an illness is a product of a particular time and place,
and a particular set of cultural understandings.  Homosexuality was officially  considered a mental disorder up until the 1970s and was listed to the  APA's Diagnostic and Statistical Manual. Today it is thought of as  simply part of a person's identity, a constituent of the way some  people are.  And of course, we also slide easily in the other direction,  from identity to illness.  Some years ago a person with 3 copies of  chromosome 21 was called a  mongoloid; now she has a genetic  disease, Down Syndrome.  Whereas we used to think of her as a  different type of human being, now we think of her as sick.  We have  redefined identity as illness.

The reasons for this are complex, of course. Very often what counts as
an illness is a consequence of the discovery of a way to correct it. As
Willard Gaylin has pointed out, before various reproductive technologies
were developed, infertility was simply a fact of nature.  Now that it can be  treated, it is a medical problem.  Before the invention of the lens,  poor vision was simply a consequence of getting old.  Now it is  something to be treated by a medical specialist.  Psychiatry is another  striking example.  Before the development of psychotherapy at the  end of the 19th century, mental illness was limited to psychotic  disorders; now it includes phobias, obsessions, compulsions,  personality disorders and so on.  Today it is very easy to speak of  any disagreeable personality trait as if it were an illness -- and even  some that are not so disagreeable, like shyness, which is being  discussed more and more often in the ethical and psychiatric  literature as if it were a kind of mental disability.  The point is that in  each of these cases what was once simply an unavoidable aspect of  some people's lives was conceptually transformed by technology into  a medical problem.

My point here is simply that what we see as a straightforward example of
a medical treatment will look differently to people from other times and
other places, and that the line we often draw between enhancements and  treatments is not as sharp as we would like to think.  Let me take a  deliberately provocative example -- the way we respond to  intersexed infants, or children born with ambiguous genitalia.  The  standard medical response to such a child is to assign the child a sex  as soon as possible, male or female, and to treat the child over a  period of time with surgery and hormones to ensure that the child's  physical appearance conforms as closely as possible to that of a boy  or a girl.  Human beings are either male or female, and if they don't  look like one or the other then something must be medically wrong  with them.  Our conceptual system has no room for anything in  between.

But things need not necessarily be this way. Contrast, for example, our
Western attitudes towards intersexuals with those of 1930s Navaho, who
didn't think of intersexuals as uncategorizable and in need of medical
treatment, as we do, but rather thought of them as blessed by the gods.
They were revered, even held in awe.  The classic study here is one by
the American anthropologist Walter Hill.  One Navaho interviewed by  Hill in his study tells him, '(Intersexuals) know everything.  They can  do the work of both a man and a woman.'  'They are responsible for  all the wealth in the country', says another.  'If there were no more  left, the horses, sheep and Navaho would all go.'  The Navaho of the  1930s made intersexuals the heads of the family and gave them  control over family property.  For them idea of surgically fixing an  intersexed infant would seem strange, even morally objectionable.  It  certainly would not be treating an illness.

My broader point here is that like intersexuality, our understandings of
illness and personality and beauty are culturally located in particular
places. And we have to realize that our present understandings are probably
not going to look the same to someone who is not immersed in our  culture, and that they probably won't look the same to us in fifty  years.  This is not to say that we can easily change these cultural  understandings: we can't just extract ourselves from our circumstances
and see the world like the Navaho of the 1930s. An intersexed child has
to live in our society, and so do children who are short, or shy, or heavy.
Even so, I think simply the realization that our own contemporary understanding
of the world is not fixed and immutable should make us cautious about embracing
new enhancement technologies, and especially about embracing them so readily.

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