Better than well: American medicine meets the American dream (review)

In Better Than Well: American Medicine Meets the American Dream, Carl Elliot offers a vivid description of the socio-cultural landscape behind the consumption of enhancement technologies in the United States. Enhancement technologies, as commonly defined by bioethicists, are those techniques, procedures, or drugs whose goals are not to cure illness but rather to augment the character traits or abilities of otherwise healthy individuals. Elliot's examination does not aim to offer an explicitly normative account of these technologies; rather, he analyzes them as a means to explore the nature of identity in the West. Elliot's intention "is not to make an argument so much as a diagnosis" (xx). This diagnosis concerns the morally cautious, yet nevertheless enthusiastic, reception with which these technologies are met. This ambivalence, argues Elliot, is symptomatic of "the architecture of the American self," and its attendant notions of self-representation, self-fulfillment, and authenticity.

Drawing from Charles Taylor's account of identity formation, Elliot argues that we are caught between two competing desires. On the one hand, we long for recognition and social status. Our imaginations and daily lives are preoccupied with concerns over how others view us. On the other hand, Americans possess a deeply entrenched moral esteem for authenticity and an allegiance to the (re)discovery and fulfillment of the "true self." Self-realization is experienced as a sort of obligation or duty; if we do not discover and live the life we are meant to lead, we have somehow failed. These competing desires converge at, and are complicated by, the consumption of enhancement technologies.

Elliot claims that our struggle for self-fulfillment is a pursuit of an end point that we cannot name. That is to say, we have agreed that some definitive goal exists but don't know what the content of that ambition entails. Nevertheless, we pursue it relentlessly, becoming participants in the competition for social status and recognition. In Elliot's own words, "If I never know for certain whether the quality of my experience matches up to yours, I am always susceptible to the suggestion that it could be improved" (302). Enhancement technologies may alleviate this sense of self-doubt, thus guiding oneself along the path to self-realization. Surgery reduces blushing. Beta-blockers ease anxiety. We are "freed" to be more "ourselves." Authenticity is pressed into serving as the moral justification for our consumption of these technologies.

Elliot suggests that our context is such that we can no longer understand ourselves outside of these technologies. Our identities are infused with them and the consumerist culture that creates and supports them. Elliot traces the historical shift from an ethic of production to an ethic of consumption, wherein what and how we consume becomes a means of shaping and defining one's identity. The primacy of this ethic is operative to such an extent that "authenticity can be put to work for capitalism" (128). Even the anti-consumerist is bound by these parameters of identification. Instead of buying designer clothes and the latest consumer gadgets, she buys local, green, organic, second-hand, earth-friendly goods.

Elliot's work positions him alongside those who are concerned with the increasing medicalization of ostensibly normal human variation. His approach, however, differs in that he moves away from the traditional bioethical framing of the debate as a matter of autonomy and individual choice. Rather, Elliot seeks to address the conditions that make possible the widespread consumption of these technologies. In this respect, his work is akin to Ian Hacking's Rewriting the Soul and Mad Travelers that examine the cultural climate of particular eras that enabled the possibility of defining one's lived experience from within a psychiatric framework.

Unlike Hacking's work, Elliot assumes a much more journalistic tone. He employs a rich variety of examples, including the likes of growth hormones, psycho-pharmaceuticals, accent-reduction clinics, cosmetics, and sex-reassignment surgeries. The book is interspersed with personal anecdotes and conversations with friends, voluntary amputees, and...