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  • The Perfect Storm of Enhancement
  • Arthur W. Frank (bio)

Authors writing about medical enhancement face two editorial problems that reflect the ethical dilemmas of enhancement. The immediate problem is what material to include and what to leave out. Enhancement treatments attract ethical concern precisely because their boundaries are fuzzy: at what point do medical actions intended to cure a malfunctioning body morph into enhancements of a body that would get along well enough (and often better) without intervention? The second, complementary problem is that provocative stories of apparently excessive treatments are easily found, and the visceral reactions these stories provoke seem to be products of personal taste and aesthetic judgment (exactly how unattractive is that body part?), neither of which seems a proper basis of reasoned argument. Pity, then, those who write on enhancement, for it is clear neither what is to be included in the topic nor how to talk about whatever that is.

But editorial troubles do not stop treatments from happening, and the stakes are high. Among the questions to be answered: What counts as a medical treatment at all (as in the politically valued phrase "medically necessary")? Which treatments should be afforded third-party reimbursement? What benefits outweigh what risks? How should medical resources be distributed and with what degree of justice? Who sets the agenda—including the limits—of medical practice? And, related to that, how far are individuals entitled to use personal resources to command professional services that thus become defined as available at the demand of the consumer? These issues are crosscut by the dilemmas of taste and aesthetics: Who can judge someone else's desires to be trivial or their unhappiness to be a normal life expectation?

In their new book on enhancement, Sheila Rothman and David Rothman approach these problems with the professionalism that their earlier classic works in the social history of medicine would lead readers to expect. The Pursuit of Perfection is a substantial contribution not only to the issue of enhancement, but to broader thinking about the future of twenty-first-century medicine. The Rothmans provide a powerful indictment of how consumer culture, medicine (both clinical and bench science), and the pharmaceutical industry combine to produce a perfect medical storm when they turn their considerable powers to the enhancement of bodies.

The Rothmans approach the topic of enhancement by limiting their story to the use of hormone treatments in the last century. This restricted scope solves the problem of what to include in the discussion, and our historical distance from the treatments makes it easier to evaluate them, yet the Rothmans still find plenty of room to explore how different facets of enhancement reinforce each other.

Enhancement stories begin with medicine "taking human unhappiness as its province" (p. xi), although this medical initiative soon becomes indistinguishable from the complementary phenomenon of people expecting medicine to remedy any and all forms of unhappiness. What makes the storm perfect is that all parties want what the others are readily willing to provide: patients provide unhappiness and money, physicians provide promises of happiness backed by interventions, and drug companies provide products—and recently, direct-to-consumer advertising that provokes more patient unhappiness and expectation, although DTC advertising is not a major topic here. (A complementary enhancement story could be told about surgery.)

The second element of the story is a pharmaceutical product that ought in principle to work, and when it does not work (except in exceptional cases that take on inflated significance), the failure has little effect on continued prescription and research. As obviously wrong as the treatment now seems to us, the argument that taking ovarian extracts could, as a monograph of 1905 put it, "relieve menopausal women whose ovaries had 'atrophied'" (p. 29) is not without a measure of common-sense logic. When these extracts were ineffective, the "negative results had little impact because gynecologists confronting patients who did not improve blamed failure on the patient (as in, the patient failed the therapy) or switched to another compound or regimen" (p. 31). The same medical logic was repeated throughout the century: "Because it should work and someday will work, it now does work," and "Better to give something...

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