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 health-care 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?