Better Than Well?

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2-30-1

Should We Use Technology to Be Better than Well?

Bioethicists Arthur Caplan and Carl Elliott debate the ethics of human

enhancement

By Arthur Caplan and Carl Elliott

PLoS Medicine

12/30/2004 2:41 PM

A variety of biomedical technologies are being developed that can be used

for purposes other than treating disease. Such " enhancement technologies "

can be used to improve our appearance and regulate our emotions, with the

goal of feeling " better than well. " While these technologies can help people

adapt to their rapidly changing lifestyles, their use raises important

ethical issues.

American bioethicists Arthur Caplan and Carl Elliott recently debated the

issues in the open-access journal PLoS Medicine. Caplan is chair of the

Department of Medical Ethics at the University of Pennsylvania School of

Medicine in Philadelphia. Elliott is associate professor at the Center for

Bioethics at the University of Minnesota in Minneapolis, as well as the

author of Better than Well: American Medicine Meets the American Dream.

Here is their debate—Caplan's viewpoint, followed by Elliott's, followed by

rebuttals.

Arthur Caplan's viewpoint: Nobody is perfect—but why not try to be better?

Perfection has come in for a lot of bad press recently. A torrent of books

and articles has recently appeared [1,2,3,4,5,6,7,8,9], all raising serious

ethical questions about the wisdom and morality of trying to use biomedical

knowledge to perfect ourselves or our offspring.

Biomedical scientists and physicians might be inclined to ignore this

literature as just so much abstract philosophical handwringing. After all,

it is almost impossible to find mainstream scientists arrogant enough to

proclaim their interest in perfecting anything, much less themselves or

their fellow human beings.

Beating up on the pursuit of perfection is silly. As Salvadore Dali famously

pointed out, " Have no fear of perfection—you'll never reach it. " Critics of

those who allegedly seek to perfect human beings know this. While often

couching their critiques in language that assails the pursuit of perfection,

what they really are attacking is the far more oft-expressed—albeit far less

lofty—desire to improve or enhance a particular behavior or trait by the

application of emerging biomedical knowledge in genetics, neuroscience,

pharmacology and physiology. Those who might accurately be termed

" anti-meliorists " wonder how we will ever resist the obvious temptation to

put this knowledge to use to alter ourselves. They are quick to note that we

have already given in to such temptation—we augment our breasts, smooth our

wrinkles and pump ourselves full of antidepressants.

Putting the brakes on biologically driven human betterment would have real

consequences for science. Some lines of research would be slowed or

restricted [3,5,8]. Their application would be declared off-limits or at

least tightly regulated [1,2,3,4,5,7,8,9].

Why is the drive to improve ourselves so disturbing to the anti-meliorists?

Their arguments cluster around three key worries: that the pursuit of

perfection by biomedical means is vain, selfish, and unrewarding

[1,2,3,6,7], that improving ourselves is unfair [1,3,4], and that

enhancement or improvement violates human nature [2,4,5,7,8,9] and may

actually destroy it [2,5,7,9]. It is the last of these arguments that is at

the core of anti-meliorist concerns.

It cannot simply be the pursuit of improvement that is making

anti-meliorists nervous. Many religious traditions and spiritual movements

seek perfection [10,11,12,13], but these evoke no negative commentary from

the anti-meliorists. Nor do efforts to improve animals and plants set this

crowd aflutter. Rather, it is biomedical knowledge being applied to you and

me that is the crux of their concern. They fear that in applying new

biomedical knowledge to improve human beings, something essential about

humanity will be lost. If biomedical tinkering is allowed, we will destroy

the very thing that makes us human—our nature.

Anti-meliorism rests, however, on a very shaky foundation. To support their

position, the anti-meliorists must state what human nature is. They do not.

They must also be very clear about why they see human nature as static. They

are not. And they must advance an argument about why human nature, which has

presumably evolved in response to an enormous array of random forces, tells

us anything about what is good or desirable in terms of the traits humans

should possess. They cannot.

The fight over whether there is any such thing as human nature is a

long-standing one [14]. But one can concede that we are shaped by a causally

powerful set of genetic influences and still remain skeptical as to whether

these produce a single " nature " that all members of humanity possess. Is

there a single trait or fixed set of traits that defines the nature of who

we are and have been throughout our entire existence on this planet? Unless

they can articulate this Platonic essence, anti-meliorists do not have a

foundation for their argument that change, improvement and betterment are

grave threats to humanity.

Worse still for anti-meliorists, we are clearly creatures who have long

tinkered with ourselves, using all manner of technologies from clothing to

telescopes to computers to airplanes. Our view of our " nature " is closely

linked to the technologies that we have invented and to which we have

adapted [15]. We are already technological creatures.

Nor is there any normative guidance offered by our evolutionary history that

shows why we should not try to improve upon the biological design with which

we are endowed. Augmenting breasts or prolonging erections may be vain and

even a waste of scarce resources, but seeking to use our knowledge to

enhance our vision, memory, learning skills, immunity or metabolism is not

obviously either.

Ultimately, anti-meliorism posits a static vision of human nature to which

the anti-meliorists mandate we reconcile ourselves. If anything is clear

about human nature, it is that this is not an accurate view of who we have

been or what we are now, or a view that should determine what we become.

Carl Elliott's viewpoint: Pharma's gain may be our loss

Those of us who worry about medical enhancement are usually less worried

about the technologies themselves than about the larger social effects of

embracing them too enthusiastically. Just as you do not need to object to

cars to worry about urban sprawl, you do not need to object to enhancement

technologies to question where these technologies may be taking us. It is

not just technophobes who wonder whether a society that consumes 90% of the

world's supply of methylphenidate (Ritalin), where the most profitable class

of drugs is antidepressants, and where cosmetic surgeons perform liposuction

on prime-time television is a society that has somehow lost its way.

Let's look at three of the most commercially successful medical enhancements

of recent years: selective serotonin reuptake inhibitors, hormone

replacement therapy and the diet drug fenfluramine-phentermine (Fen-Phen).

What can we learn from these interventions?

First, the manufacturers of enhancement technologies will usually exploit

the blurry line between enhancement and treatment in order to sell drugs.

Because enhancement technologies must be prescribed by physicians, drug

manufacturers typically market the technologies not as enhancements, but as

treatments for newly discovered or under-recognized disorders. Selective

serotonin reuptake inhibitors were marketed not as personality enhancers, or

even only as treatments for clinical depression, but as treatments for

questionable illnesses like " premenstrual dysphoric disorder " [16]. Fen-Phen

was sold not as a mere diet drug but as a treatment for obesity, which

Wyeth, the manufacturer, portrayed as a dangerous public health problem

[17]. Estrogen replacement therapy was initially marketed as a risk-free way

for women to extend their youthfulness. But when a 1974 study found that

estrogen replacement therapy was associated with an increased risk of

endometrial cancer, the manufacturers added progesterone, renamed the

combination " hormone " replacement therapy, and recast it as a treatment for

medical problems associated with menopause such as osteoporosis [6].

Second, an alarming number of supposedly risk-free enhancements have later

been associated with unanticipated side effects, some of them deadly. Wyeth

has set aside over $16 billion to compensate the thousands of patients who

have developed valvular heart disease and pulmonary hypertension after

taking Fen-Phen [18]. A 2002 National Institutes of Health study found that

hormone replacement therapy was associated with such an elevated risk of

heart disease, stroke, pulmonary emboli and breast cancer that the study was

stopped prematurely [19]. Selective serotonin reuptake inhibitors are

currently embroiled in controversy over whether they are associated with an

elevated risk of suicide [20].

Third, the most successful enhancement technologies have been backed by

tremendously influential public relations campaigns. These campaigns have

included ghostwritten journal articles, industry-funded front groups and

lucrative payments to academics, professional societies and university

centers [21]. For example, GlaxoKline marketed paroxetine (Paxil) by

promoting the previously obscure diagnosis of " social anxiety disorder "

through phony support groups, celebrity spokespeople, a direct-to-consumer

illness awareness campaign and generous payments to key opinion leaders

[22]. The manufacturers of estrogen replacement therapy marketed the hormone

in the 1960s by funding a " research foundation " for , the

gynecologist and author of the best-selling book Feminine Forever [6]. Wyeth

marketed Fen-Phen by funding obesity research centers, launching public

fitness campaigns, contracting with a medical education company to produce a

series of ghostwritten journal articles and making generous payments to

academic physicians who then published extensively and testified for the

drug's safety to the Food and Drug Administration [17].

The traditional worry about enhancement technologies is that users of the

technologies are buying individual well-being at the expense of some larger

social good. I may improve my own athletic ability by taking steroids, but I

set off a steroid arms race that destroys my sport. I may get cosmetic

surgery for my " Asian eyes " or use skin lighteners for my dark skin, but I

reinforce the implicitly racist social norms that say that Asian eyes or

dark skin are traits to be ashamed of. The worry is that some aspect of the

way we live together, collectively, is going to be damaged by actions that

we take individually [4].

A market-driven healthcare system brings this worry much closer to home. The

pharmaceutical industry is now the most profitable and politically powerful

industry in the United States [23]. It also has a huge financial interest in

creating a demand for enhancement technologies. The pharmaceutical industry

can buy politicians to pass industry-friendly legislation; it can buy

academic scientists to publish favorable journals articles; it can buy

professional societies and patient support groups to spread the word on the

newly medicalized disorders that its interventions are developed to treat

[24]. It can even buy bioethicists to dispense with any moral concerns [25].

In this kind of political and economic climate, how likely is it that

dissenting voices will have any effect before it is too late?

Caplan's response to Elliott's viewpoint

Elliott professes to be unhappy about enhancement. What arguments does he

present to support his unhappiness? Not many, and the arguments that he does

offer miss the point completely.

If people want to feel better, sleep less, have fewer hot flashes, better

vision or fewer wrinkles, then they may want to use enhancement technologies

to achieve these things. Technology in itself isn't driving us in any

particular direction—I believe that we decide where it should go. Elliott,

however, gravely warns us that you and I do not really decide a direction

when it comes to matters of enhancement. It is—listen carefully for the

Darth Vader-esque hissing—drug companies!

The rest of Elliott's viewpoint amounts to what is his increasingly familiar

harangue against the pharmaceutical industry. The drug companies sucker us

into buying enhancement by getting us hooked on pseudotherapies. The drug

companies rob us of our will to fend off their siren-like messages of better

living through their chemistry. And the drug companies get us feeling so bad

about ourselves that we empty our wallets on their latest overpriced

geegaws.

Pharmaceutical companies may be evil incarnate. And we may be putty in their

pecuniary little hands. But that has nothing at all to do with the question

of whether there is anything wrong with pursuing enhancement. When Elliott

eagerly dons his hair shirt to bemoan Big Pharma, he finds so much sin to

revel in that he forgets to give a reason, any reason, why enhancement is,

in itself, immoral.

At most he presents an argument for keeping the pharmaceutical industry out

of enhancement. Okay, so let's take Big Pharma out of the picture. If we

left the encouragement of enhancement to the government, the military,

schools, foundations, doctors or parents, would this now be morally

acceptable? I think sometimes it would be. And nothing that Elliott says

provides any reason to think otherwise.

Elliott's response to Caplan's viewpoint

Caplan does not defend medical enhancement so much as attack its critics. Or

rather, he attacks a small group of conservative critics who want to

preserve " human nature. " He dispatches those critics with admirable

precision, but I am not sure why he believes that group of critics includes

me. My worry about enhancement technologies has little to do with human

nature. My worry is that we will ignore important human needs at the expense

of frivolous human desires; that dominant social norms will crowd out those

of the minority; that the self-improvement agenda will be set not by

individuals, but by powerful corporate interests; and that in the pursuit of

betterment, we will actually make ourselves worse off.

It's no secret that many Americans are deeply ashamed of their personal

shortcomings and inadequacies. Nor is it any secret that these shortcomings

and inadequacies can be exploited for commercial profit. But do we really

want to submit our healthcare system to the same forces that have made

millionaires out of motivational speakers and diet book authors?

Skepticism about enhancement technologies is not equivalent to a wish to set

back medical research and declare some applications off-limits. This is a

debate about enhancing human traits, not curing human illness. To say that

our medical research agenda will be set back if we restrict enhancement

technologies makes no more sense than saying that cancer surgery will be set

back if the American Broadcasting Corporation cancels its cosmetic surgery

reality TV show Extreme Makeover.

We live in a country where 46 million uninsured people cannot get basic

medical care, while the rest of us spend a billion dollars a year on

baldness remedies. It is not just the inequity here that is so impressive.

It is the fact that we have gotten so accustomed to the inequity that we do

not see it as obscene.

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Copyright © 2004 Caplan and Elliott. This is an open-access article

distributed under the terms of the Creative Commons Attribution License,

which permits unrestricted use, distribution and reproduction in any medium,

provided the original work is properly cited.

Citation: Caplan A, Elliott C (2004) Is It Ethical to Use Enhancement

Technologies to Make Us Better than Well? PLoS Med 1(3): 52.