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[Definitie:] "An ergogenic aid is any substance or phenomenon that enhances performance."
(Wilmore and Costill) 
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3 1 - 1 2 - 2 0 0 4 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
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. He was a member of Dupont's biotechnology advisory panel, advising on genetically modified organisms. He previously served on the scientific advisory board of Celera genomics. From 1997–1999 he served as a consultant to Pfizer on the launch of sildenafil (Viagra) as part of the company's scientific/ethics advisory board. Subsequently Pfizer sponsored a course on research ethics presented by the Center for Bioethics at Pfizer headquarters in which he was one of the lecturers.
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. He declares that he has no competing interests.
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, 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. Their application would be declared off-limits or at least tightly regulated. 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, that improving ourselves is unfair, and that enhancement or improvement violates human nature and may actually destroy it. 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, 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. 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. 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".
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.
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.
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. 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. Selective serotonin reuptake inhibitors are currently embroiled in controversy over whether they are associated with an elevated risk of suicide.
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.
For example, GlaxoSmithKline 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. The manufacturers of estrogen replacement therapy marketed the hormone in the 1960s by funding a "research foundation" for Robert Wilson, the gynecologist and author of the best-selling book Feminine Forever. 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.
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.
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. 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. It can even buy bioethicists to dispense with any moral concerns. 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.
3 1 - 1 2 - 2 0 0 4 Costing an Arm and a Leg
The victims of a growing mental disorder are obsessed with amputation
By Carl Elliott
Baz remembers first seeing an amputee when he was a 4-year old boy in Liverpool. By the time he was 7 he had begun to think, "This is the way I should be." It was not until Baz was in his 50s, however, that he actually had his leg amputated. Baz froze his leg in dry ice until it was irreversibly damaged, then persuaded a surgeon to complete the job. When he awoke from the anesthetic and his left leg was gone, he says, "All my torment had disappeared."
Whole, a riveting new documentary by Melody Gilbert that recently premiered at the Los Angeles Film Festival and will soon be shown at festivals in Calgary and London, is about an increasingly visible group of people who call themselves "amputee wannabes." Wannabes desperately wish to have their healthy limbs removed, and some have succeeded in having it done. Kevin, a university lecturer and one of several wannabes featured in the film, had his leg amputated by Robert Smith, a surgeon in Scotland who has amputated the legs of two otherwise healthy people. George Boyer shot his own leg off with a shotgun. Others have used chain saws and homemade guillotines. Why? Nobody really knows, including the wannabes themselves, who often say they have had the desire since they were children. "It's obviously peculiar," admits Kevin. "But knowing it is peculiar and saying it is weird does not do away with the problem."
My interest in amputee wannabes began several years ago when I was writing my book Better Than Well: American Medicine Meets the American Dream. I was trying to understand why so many people have begun to use the tools of medicine for purposes other than curing illness, such as self-improvement and self-transformation. I noticed that in the same way that some people said they only felt like themselves after, say, getting sex-reassignment surgery, or even taking Prozac, many wannabes said they would not feel like themselves without an amputation. I published an article about wannabes for the Atlantic Monthly and another on the legality of such amputations with my colleague Josephine Johnston for the academic journal Clinical Medicine. It was after reading about wannabes in the Atlantic Monthly that Gilbert decided to make her film.
Gilbert's sensitive film allows wannabes to speak for themselves. Many are so articulate and likable that no matter how difficult you find it to understand their desire, you will come away from the film with sympathy for their strange predicament. Yet perhaps the most disturbing figures in Whole are the clinicians. Even as the wannabes admit how baffling they find their own desires, the mental health professionals in the film speak with absolute confidence. The film features a social worker and clinical psychologist who have counseled Boyer in Florida, as well as Michael First, an academic psychiatrist at Columbia University, who has organized several meetings of wannabes and clinicians in New York. First says that the purpose of these meetings is to "facilitate treatment" for the condition, by which he says he means surgical treatment. His apparent certainty that nothing short of amputation can help these people is underscored by ominous music and a screen shot that reads, "There are no medications or therapies known to help wannabes."
This claim is not so much false as incomplete. No formal research studies on treatments for wannabes have ever been undertaken. In fact, nobody really knows much about this condition. Only a handful of articles about it have been published, most of them small case studies in obscure medical journals. You might think that clinicians would want to be certain that all options had been exhausted before recommending that patients have their arms or legs amputated, yet the clinicians in the film do not mention alternative treatments. The only person who expresses a hint of uncertainty is Robert Smith (the Scottish surgeon mentioned above); he wonders how the amputations he has performed will be perceived in 20 years.
Dissenting voices of any kind are largely absent from Whole. In her eagerness to document the extraordinary stories her subjects tell (and perhaps to gain their trust), Gilbert has produced a film that uncritically accepts those stories at face value. The patients explain what this condition is and how it should be treated, and the clinicians obediently nod their agreement. The only skeptical voice in the film comes from Jenny, the wife of an American wannabe living in France. When Jenny decides she cannot stay married to a man who wants to cut his own leg off, her husband accuses her of being narrow-minded.
Oddly, the film also glides past the sexual aspect of the condition and views it as a problem of identity, like gender identity disorder. (A rare exception is a moment in which George Boyer points to a sketch of a boy amputee and says, obliquely, "I could even get turned on by that.") In the few medical articles where the condition has been discussed, it is known as "apotemnophilia," because clinicians view it as a paraphilia—a displaced sexual desire like transvestism, voyeurism, and pedophilia. This is because many wannabes are attracted to the idea of themselves as amputees, and some are attracted to other amputees.
When I first wrote about this condition in the Atlantic, I worried that more people might start to identify themselves as wannabes and seek out amputation. Anyone with a rudimentary familiarity with the history of psychiatry cannot help but be struck by the way that mental disorders come and go. Conditions like social anxiety disorder, post-traumatic stress disorder, attention deficit-hyperactivity disorder, gender identity disorder, multiple personality disorder, anorexia, and chronic fatigue syndrome were once seen as rare or nonexistent, then suddenly they ballooned in popularity. This is not simply because people decided to "come out" rather than suffer alone. It is because all mental disorders, even those with biological roots, have a social component. While these new conditions are very different from one another, they share several important features.
First, the conditions are usually backed by a group of medical or psychological defenders whose careers or reputations depend on the existence of the disorder and who insist that the condition is real.
Second, there is usually no hard data about the causes or the mechanism of the condition.
Third, no independent lab tests or imaging devices are available to provide objective confirmation of the diagnosis, which is usually made solely on the basis of the narratives and behavior of their patients.
Finally, there is often (but not always) a treatment for the condition even in the absence of knowledge about its causes and mechanism. The diagnosis of social anxiety disorder, for example, was driven by the development of profitable medications to treat it, such as antidepressant drugs.
Soon the new conditions are discussed in journals and at conferences; clinicians start to diagnose the disorder more and more commonly; the conditions themselves become part of popular discourse and are discussed in support groups, therapy sessions, Internet venues, and in articles like mine and films like Whole. Patients begin to reinterpret their own psychological histories in light of what they hear, and their behavior changes to match what is expected of people with the condition they believe they have. Often they diagnose themselves and decide on the proper treatment. "I want you to accept that this condition exists," Baz says emphatically in the film, "and that the only way it can be sorted out is surgery."
Perhaps, but this can only be determined through careful study. What needs particular attention are the reasons why some people come to be sexually attracted to amputees or to the image of themselves as amputees. The form paraphilias take differs not merely among individuals, but from one culture and historical period to another. When Richard von Krafft-Ebing was writing about paraphilias in 19th-century Vienna, he described men who were sexually obsessed with handkerchiefs. That paraphilia has largely disappeared. Yet many others have emerged. What is it about our own time and place that has helped create an obsession with amputees?.
By all indications, the number of people identifying themselves as wannabes is growing. Robert Smith, the Scottish surgeon, has six more acceptable candidates for amputation. A popular wannabe listserv, whose membership was 1,400 two and a half years ago, has 3,670 subscribers today. A group of clinicians at Columbia University has set up a Web site to provide information about the condition. They are redefining it as "Body Integrity Identity Disorder." In the meantime, psychiatrists are no closer to understanding the condition, and they are proposing no therapy other than amputation.
Carl Elliott teaches at the Center for Bioethics at the University of Minnesota and is currently a visiting associate professor in the School of Social Sciences at the Institute for Advanced Study at Princeton. He is the author of Better Than Well: American Medicine Meets the American Dream.
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