Nature (1999) 396: 222-223.
As biomedical science progresses, ever more effective medical technologies are devised for the treatment of illnesses, and this is, of course, a good thing. But how do we feel about the use of such technologies by people who are healthy to start with in order to become more than healthy? Many such enhancement technologies are already widely available. Cosmetic surgery is used for aesthetic enhancement of the body, beta-blockers such as Propranolol by musicians to block the physical symptoms of performance nerves, thereby enhancing the quality of their playing, and the antidepressant Prozac is used as an agent of what Peter Kramer has called cosmetic psychopharmacology, or alteration of personality, to make people less shy, less compulsive, more confident. We have to assume that with time more enhancement technologies will become available - many more, employing surgery, genetics, pharmacology, and heaven knows what else, directed in particular at cognitive function and longevity. Are enhancement technologies a good thing? Overall, attitudes towards them are ambivalent in the extreme. After all, we regard self-development through education and exercise to become wiser and fitter as a virtue, almost a duty. Why not pursue these ends by means of enhancement technologies? Yet to many people, enhancement technologies evoke eugenics, Nazi conceptions of the superman, and Huxley's Brave New World.
The appearance of Enhancing Human Traits represents something of a landmark with respect to discussion of these thorny issues. This is the product of a project co-ordinated by the philosopher Erik Parens at the Hastings Center, that brought together thinkers from a number of fields, including philosophy, law, sociology, theology and women's studies, to discuss the rights and wrongs of biological enhancement. The book contains 13 very different essays on distinct facets of this complex subject. These involve two sorts of discussion about enhancement. The first focuses on the distinction between treatment and enhancement, and concerns what doctors should and should not do, and what healthcare systems should and should not provide. The second deals with the broader issue of the value of enhancement technologies per se. As Parens puts it, the first discussion of enhancement concerns the goals of medicine, and the second the goals of society.
Upon closer inspection, the treatment/enhancement distinction is problematic in a number of ways. To a degree, what counts as illness is culturally constructed. Until recently being gay was regarded as an illness; likewise, among the Punan Bah people of Borneo, giving birth to twins is regarded as a dreadful misfortune. Some of the problems of nosological elasticity can be overcome by defining health as the full expression of species-typical function. However, as Anita Silvers points out in her contribution, this approach falls downs when confronted with the functionally different, yet rich and rewarding ways of life of many disabled people. We can understand why some members of the Deaf community sarcastically label the hearing as "signing impaired".
Of the contributing academic disciplines, the clearest analyses of what is most worrying about enhancement technologies come from women's studies, particularly from Margaret Little and Susan Bordo. If the experience to date with cosmetic surgery gives a good indication of how other enhancement technologies will come into use in future, then we have plenty to worry about. Particularly alarming is the convergence of enhancement technologies and capitalism. It is only too easy to create markets for cosmetic surgery by convincing people that they possess defects that only surgery can repair. This marketing of ersatz illness has generated a newspeak of inadequacy: a woman with little breasts becomes "micromastic", and the dimples on her thighs become "cellulite" - conditions requiring treatment. Legislation may be necessary to guard against such insidious, market-driven medicalisations.
A more awkward sort of problem involves what Little calls the ethics of complicity. Consider a plastic surgeon approached by a woman discriminated against because of her large breasts or African appearance, seeking breast reduction or de-Africanisation ˆ la Michael Jackson. As Little points out, by agreeing to operate, the surgeon becomes complicit with harmful conceptions of normality - in this case, norms that are oppressive to women, or racist. On the other hand, the suffering of those seeking cosmetic surgery - including that resulting from oppressive standards of normality - may be very real. Little suggests that the surgeon may act ethically by performing the surgery, but only if she also works elsewhere to fight the system of unjust practices and attitudes.
The significance of enhancement technologies is also discussed by reference to ideas about what makes life meaningful and worth living. As theologian Ronald Cole-Turner points out: "Technologies such as psychopharmacology and human genetic manipulation fit very well within the broad program of Western religions and philosophy". In this context philosopher Carl Elliott expresses concern that drugs such as Prozac could be used to treat alienation or existential anxiety - or, as contributor Gerald McKenny might put it: "to relieve the human condition". To Elliott, seeing this sort of unhappiness as a psychiatric issue represents a category error, "like seeing holy communion as a dietary issue". One way to see what is so disturbing about, say, a happy, smiling August Strindberg on Prozac, is that he might no longer be Strindberg. Elliott refers to what the philosopher Charles Taylor has called an ethics of authenticity: the idea that our lives can only have meaning in so far as we are true to ourselves, and on this basis develop our own life project. Thus, altering one's personality by means of Prozac may potentially be an act of self-betrayal resulting in a seemingly happy, yet phoney and pointless life.
This is a fascinating, challenging and important book, and a major achievement by Erik Parens. While written by academics, the style of most of the contributions is obviously meant for a broader audience, and employs clear and accessible language - Dan Brock's essay in particular. I predict that this book will open a debate that will play a significant role in shaping our culture in the years to come.
David Gems is in The Galton Laboratory, Department of Biology, University College London, London NW1 2HE, UK.
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