The Pursuit of Happiness

Carl Elliott, the author of Better Than Well, talks about amputee wannabes, Extreme Makeover, and the meta-ethics of bioethics

Better Than Well

Better Than Well: American Medicine Meets the American Dream
[Click the title
to buy this book] by Carl Elliott
357 pages, $26.95

Earlier this year, the pharmaceutical manufacturer Allergan announced the "Be The True You 2003 Mall Tour," a traveling roadshow of sorts making the rounds of the nation's shopping centers, offering customer testimonials and consultations with doctors about Botox, a wrinkle-smoothing compound derived from botulinum toxin that won FDA approval for use as a cosmetic last year. When it hit the market, Botox was hailed in the media as the newest, strangest thing under the sun, and to the extent that it's not every day that a close cousin of botulism is touted as the latest route to youth and beauty, such fanfare was understandable. But for all its apparent novelty, Botox was only the most recent of a host of innovations promising renewal and redemption via scalpel, needle, or pill.

Such is the focus of Carl Elliott's new book, Better Than Well, an ambitious and accessible look at how people use medical "enhancement technologies" from Botox to beta-blockers in the seemingly endless struggle to look younger, feel better, and declare themselves happy and fulfilled. Elliott is uniquely qualified to deal with such issues of body and mind—after finishing medical school, he pursued a Ph.D. in moral philosophy instead of entering clinical practice—and in his book he digs deeply, examining such transformative standbys as cosmetic surgery and antidepressant drugs, as well as subtler innovations like piercing, tattoos, and speech therapy for people looking to shed their regional accents. Though the methods Elliott writes about range widely, they are all similarly entangled with delicate issues of identity and self-esteem.

While personal anxiety is a driving force behind the demand for enhancement technologies, Elliott notes that other factors—not least the macroeconomics of the pharmaceutical industry—can hardly be left out of the equation. (A tagline on the Web site promoting the Botox tour is instructive on this point: "CONSULT a Physician at your Local Mall".)

And as he sifts through the occasionally risky and often controversial answers medicine has offered in response to our discomforts and insecurities, Elliott comes up with nearly as many questions of his own: Is it moral to improve oneself through artificial means? Can medical solutions address deep social needs? When you reinvent yourself, who do you become? Elliott observes that our preoccupation with medicalizing and diagnosing all that ails us may not necessarily hold the key to the wholeness, comfort, and happiness that the popularity of enhancement technologies suggests we crave. Indeed, this clinical impulse has the potential to obscure as well as to explain. Elliott writes:

On Prozac, Sisyphus might well push the boulder back up the mountain with more enthusiasm and more creativity. I do not want to deny the benefits of psychoactive medication. I just want to point out that Sisyphus is not a patient with a mental health problem. To see him as a patient with a mental health problem is to ignore certain larger aspects of his predicament connected to boulders, mountains, and eternity.

Carl Elliott is a professor of bioethics and philosophy at the University of Minnesota, and a visiting associate professor at the Institute for Advanced Study at Princeton. He is the author of The Rules of Insanity (1996) and A Philosophical Disease (1998), and a co-editor of The Last Physician: Walker Percy and the Moral Life of Medicine (1999). He lives in Minneapolis with his wife and three children.

We spoke recently by telephone.

—Benjamin Healy

[A portion of Better Than Well first appeared as "A New Way to Be Mad" in the December 2000 Atlantic.]

Among the "enhancement technologies" you discuss in your book, there are those such as plastic surgery and Viagra, which are really concrete and provide very distinct, measurable benefits, and then there are other things that are less concrete, like accent-reduction clinics or the idea of gender-reassignment. Could you talk a bit about how you defined the term "enhancement" as you were going through this project, and how you distinguished "enhancement technologies" from the larger pool of all medical treatments?

Carl Elliott
Carl Elliott   

You know, the term "enhancement technologies" is not mine, and as I said at the beginning of the book, I'm not entirely happy with it, but it's the term that bioethicists have started using. And in the absence of being able to come up with anything better, I decided to use it. As far as trying to figure out what to leave in and what to leave out, I decided that for the most part I would try to stick to enhancements that doctors perform or prescribe rather than what people were doing to themselves. But in a lot of ways the whole book is not so much about enhancement as about self-transformation. I was really interested in how people were using or were trying to use these technologies as a means of changing their identity—working on their inner psychic state with psychopharmacology, or on their self-presentation with something like accent-reduction or cosmetic surgery, for example. I wanted to look at the kinds of impressions that people give off to other people and that they see reflected back in that social mirror.

A lot of the phenomena you discuss in your book feel like very recent developments, but there have been ways to change one's self-presentation ever since the first cave person applied the first cosmetic to her face. When do you think the questions raised by enhancement technologies became a matter of bioethical concern?

I think it came when doctors got into the business. Bioethicists tend to be interested in the kinds of things that go on in doctors' offices and hospitals. Even though you're right that this kind of thing has been going on in some way for some time, in a lot of different cultures and historical periods, it hasn't been until fairly recently that it took off in such a big way in medicine itself. The term "enhancement technologies," as far as I can tell, started back in the late eighties, when there was a lot of debate about gene therapy and modifying the genome. At that point the question arose: If it's okay to treat genetic illnesses, would it then be okay to make more positive changes in the genome? That made people very antsy, and so that treatment/enhancement distinction was one way that bioethicists came up with of drawing a line between what was okay from an ethical perspective and what was not okay. But then the term caught on, and people used "enhancement technologies" to talk about all kinds of different things that straddle the line between treatment and enhancement. Peter Kramer used the term "cosmetic psychopharmacology" in Listening to Prozac, and when he did that, people started thinking, Well, the same kinds of lines we were using to talk about the difference between genetic enhancement and genetic treatment might be useful in talking about psychopharmacology as well.

But enhancement technologies are still not a big topic of debate in bioethics. Ever since the announcement of the Human Genome Project there has been a debate about genetic enhancement, but most of the things that I talk about in the book have been fairly marginal to bioethics. A lot of them have been talked about elsewhere, but not really so much in the bioethics community.

I'm curious about the role of religion in all this, and the extent to which you see a spiritual component in the modifications that people submit to, and the search for the "true self" that you describe. Have religious leaders weighed in on the morality of these technologies? What happens to the soul as the body and the self change in these ways?

Actually, I never really thought about the question of how organized religion would see some of these things. I do think that there is a religious component—and I tried to outline this in one of the early chapters in the book—embedded within the language of identity and self-fulfillment. At one point people who were looking for meaning and how to live their lives thought that the answer could be found by getting in touch with something outside themselves. For Christians and Jews, it was getting in touch with God; for secular philosophers it was with Truth or Rationality. You still see some of that in philosophy, and we haven't left that aspect of religion completely behind, of course. But what you see now, and what has changed over the past two hundred years is that there is this sense that if you want to live a fully human, meaningful life, you have to look inward to achieve fulfillment. And that, I think, is relatively new. It has a spiritual aspect to it. The idea is that a fulfilled life is somehow a higher life—there is a moral component to that. If you're not fulfilled you're somehow missing out on something that other people have, you're wasting the time that you have on earth.

After you finished medical school you got a doctorate in philosophy. What influenced your decision to study philosophy? How has having that extra foot planted in a different field affected your outlook as a clinician and cultural diagnostician?

It'd probably be closer to the mark to ask, How did going to medical school influence me as far as being a philosophy professor? Because that's basically what I do now. I don't see patients. In fact, I've never seen patients. I went straight from medical school to graduate school. And I went to medical school mainly because I couldn't think of anything else to do. I come from a family of doctors. I grew up in a small southern town, and there didn't seem to be that many choices. There was medicine, maybe law, maybe the ministry. None of the other options seemed all that appealing to me, so I wound up in medical school. I was miserable. I found it intellectually deadening. I'd done some philosophy as an undergraduate at Davidson College, and so the unhappier I got in medical school the more I started thinking, Wasn't it great back at Davidson? Medical school is so infantilizing—you're treated like a kindergartner, you're told exactly what you have to do and what to study, and you're very much socialized into a medical view of the world. So when I finished, I packed up, left South Carolina, and did a Ph.D. in moral philosophy at Glasgow University in Scotland. It was great. I thought, Why didn't I think of this earlier?

Your book casts a very wide conceptual net: everything from Wittgenstein to Chuck Yeager to The Wizard of Oz—it's all in there. Did you start out with that kind of broad canvas in mind, or did the book just pick up its own eclectic momentum as you went along?

It was kind of a gamble, actually, and it takes a little patience for a reader to see the threads that run through it. They have always been evident to me, but I'm glad they're evident to the reader too. Part of the challenge, I think—I know I'm going to say something I'll regret here, it's going to make the book sound terrible—but the thing is, my interest in the book is primarily the issue of identity and how to live a life. The technologies themselves are secondary. I had lots of thoughts, often random thoughts, on various philosophers whom I was reading, and movies, and works of fiction. I was seeing all these threads having to do with identity and the good life, and I could see the connection to things like growth hormone and the kind of changes that you see in a person as a result of Paxil, and so on. The challenge was trying to get all of it in, and do it in a coherent way. If you look at the book, you'll see that most of the chapters actually are organized around philosophical topics rather than particular technologies. There's a chapter on identity, one on self-presentation, and one on marketing and consumer culture, and so on. The difficulty, in a way, is how to make philosophical ideas interesting and readable—as interesting to a reader as they are to me.

You return to Walker Percy several times in your book, quoting from his novels to illustrate some of the anxieties that enhancement technologies have risen to meet. You've also co-edited a book of essays about Percy's dual identity as a doctor and a novelist. How has reading Percy influenced your work?

Percy's my favorite. I discovered him at the very worst point in my medical education, when I was the most miserable. Percy had quit medicine himself. He began a pathology internship shortly after he finished medical school, and then he got tuberculosis and had to quit. He always said that tuberculosis was the best disease he ever had, because it let him quit medicine. I can remember reading that and thinking, Damn, how do I get tuberculosis? I'm a southerner, like Percy. I went to medical school, like he did. And I quit medicine, like he did. He spent about a decade writing obscure philosophical articles for philosophy journals before he published The Moviegoer. So I can't help but look at him and think, That's the way I'd like to be.

Have you ever thought of trying your hand at fiction?

A lot of people have asked me that. I don't know. Part of my reluctance is that my experience of reading The Moviegoer was so much a matter of identifying with the hero of that novel, Binx Bolling, and thinking, God, these are exactly the things I've always thought. I have always felt that Percy had already written the books that I would have written. His books are so philosophically sophisticated, and so funny. And such great stories, too. I guess I might like to try fiction, but I would be way too intimidated. If I were to write a novel, it would be a very bad copy of The Moviegoer.

On the flipside of that, the lessons we draw from literature can become confining as well, as you point out when you write about your frustration with the media's knee-jerk over-reliance on Brave New World as a template for making sense of new advances in genetic engineering and the like. We always get the same headlines: "Brave New Medicine," "Brave New Babies," "Brave New Minds," and so on. How do you think we can break out of that sort of mold and broaden our understanding of these themes, so that every time a new idea that deserves our attention comes up it doesn't necessarily get funneled through the same conceptual channels?

That's a good question. I don't know why we keep going back to Brave New World, because there are plenty of good alternatives. One that I like, and one that I talked about in the book, is Percy's novel Love in the Ruins, which has in it this device he calls the "ontological lapsometer," a caliper of the human soul. It was a device with which Tom More, the psychiatrist in the book, could diagnose and treat existential ailments. I thought Love in the Ruins was a terrific book, and it seemed to me as if Percy had predicted Prozac ten or fifteen years before Prozac ever appeared. All the worries about psychopharmacology, they're right there in that book, if people would just read it. But it's a hard book. In a lot of ways it's a much harder book, and also a much richer book, than Brave New World is. But we all read Brave New World when we're in high school. They make us read it. And I don't think a high school student could read Love in the Ruins. I mean, maybe they could, but I don't think most high school students could get it. And it would probably ruin it for them anyway.

Perhaps the most surprising chapter in your book deals with a rare psychological disorder called apotemnophilia. Apotemnophiles (or "wannabes," as they are commonly known on Web sites devoted to the subject) feel a strong desire to become amputees, and have been known to seek the loss of their limbs by medical means or otherwise. [A version of this chapter appeared in the December 2000 Atlantic.] How did seeing such an extreme and specific and intense longing that's so difficult for other people to identify with affect your understanding of the issues of identity and enhancement that you deal with in your book?

When I first heard about the amputee wannabes, I actually had a fair bit of the book finished. But what struck me was that these people were describing their condition and how the amputation made them feel, or how they imagined an amputation might make them feel if they hadn't had it yet, and it was exactly the same kind of language that other people were using for standard medical technologies. They were saying, "I'll feel complete"; "I'll feel like myself"; "I feel whole"; "This is the way I always wanted to be"; "This is always the way I felt inside"—and that was exactly the same way that people were talking about Prozac and Paxil and anabolic steroids and sex-reassignment surgery, and all these other things. I was writing this book that was ostensibly on the idea of enhancement, but which I thought was really about self-transformation. And here I had these people who were insisting that what everybody else saw as a mutilation would for them be an enhancement, or at the very least a treatment.

What kind of response did your Atlantic article about apotemnophilia receive from readers and clinicians? Did anybody write to you and say, "I didn't discover my true identity until I read your piece and realized I'm an apotemnophile"?

Nobody told me that, but I did get a surprisingly receptive response from a number of amputee wannabes. Part of what I was predicting about the diagnosis is happening, too. I think clinicians who started to look at this condition were very resistant to the idea that they are involved in any way in helping create a mental disorder. Very often, in a very naïve way, psychiatrists think of what they're doing as merely observing and describing what's out there in the world. And so if more people who want to have their limbs cut off come to see them, that just means that they're getting better at diagnosing the condition. Or that people are getting better at recognizing the condition themselves. But you know, anybody with even a rudimentary familiarity with the history of psychiatry has got to be impressed with the amazing number of psychiatric diagnoses that have either emerged out of nowhere in the past few decades or were once seen as very rare and are now seen as extremely common. And they're very different from one another. Multiple-personality disorder is one of the most famous. But you could say the same thing about social-anxiety disorder, post-traumatic stress disorder, panic disorder, or anorexia. There's got to be some sort of social making of these categories that's going on. For example, one of the new things that has happened since I wrote that piece is there's now a group at Columbia University that's studying the disorder and that has meetings with amputee wannabes once a year. They have renamed apotemnophilia "body integrity identity disorder." A number of people are involved in those meetings, and every year the meetings get bigger. The amputee wannabe listserv that I wrote about in the Atlantic article in 2000 had, I think, about 1,400 people on it then. Now it has about 3,700 people. And there's a new movie out, a documentary that just premiered at the Los Angeles Film Festival. It's called Whole, directed by Melody Gilbert. She's from here in the Twin Cities, and she came to talk to me about it when she was thinking about making the film. I tried to talk her out of it, but she insisted on doing it.

During your discussion of apotemnophilia, you mention the rash of dissociative fugues that struck France in the nineteenth century, when young men of a certain social position suddenly began traveling compulsively around Europe, an occurrence that some have speculated arose out of social and political conditions particular to that time and place. Today in this country, there is always the threat of terrorism hanging overhead, and people who are already perhaps hard-wired for a certain amount of anxiety are being subjected to a steady stream of color-coded alerts and the like. I don't know what the contemporary American analogue might be, but do you think we could see some sort of new psychiatric disorder suddenly arise out of this volatile mix?

You know, I'm not sure. The philosopher Ian Hacking (whose book Mad Travelers was my source for the material about the fugues) argued that for these people in France, the possibility of escape was a huge motivator. You had these young men trapped in their lives in different ways, and they didn't have any way to get out. They weren't vagabonds, on the one hand, so they couldn't just wander, and they weren't the bourgeoisie, on the other hand, so they couldn't travel in the way that middle-class people were beginning to. They weren't members of the upper class either. And so, when you're talking about people who are trapped in small towns, or trapped in the military, or trapped in their lives in some way, fugue states became a means of escaping that. Hacking wrote another book, Rewriting the Soul, about multiple-personality disorder, in which he linked the multiple-personality-disorder epidemic to the obsession with uncovering child abuse in memories of forgotten trauma in childhood. It seems to me that if an epidemic like that were to happen again you would need some sort of deeper cultural hook for it. The fear over terrorist threats and so on is more a marketing opportunity. I think the drug industry has seen that if people are anxious, or if they have been through some sort of trauma, then that is an opportunity to tag them with a diagnosis of generalized anxiety disorder, for example, or post-traumatic stress disorder, or some other psychiatric disorder for which they're marketing a treatment. I wouldn't rule out the appearance of something new, but I'm not good enough at predicting to see how it might happen.

You also write about the role of television in all this, both as a disseminator of trends and anxieties, and as a cultural product that has helped us see ourselves as imperfect (but perfectible) objects. A glance at the TV listings shows your chosen themes right there on display. There's a show that just started on FX, called Nip/Tuck, which deals with plastic surgeons in Miami, and then, during this past season, there was the reality show Extreme Makeover on ABC. What do you make of the way that these themes, which have always been implicit in the culture of celebrity, are now making themselves a bit more explicit?

I'm not a big watcher of reality shows, so maybe this is true of other ones as well, but what struck me about Extreme Makeover was just how stylized the story lines were. Every person had essentially the same story. You have this person who to most people would look like a perfectly ordinary-looking person, often even an attractive-looking person. But this person says, "I've always been self-conscious about my looks. I'm very unhappy. I was teased as a child. And I'm miserable." And then the host says, "Congratulations, you've won an extreme makeover," and they whisk them away to California. There they get all these procedures performed on them—plastic surgery, eye surgery, cosmetic dentistry, personal trainer, fashion consultant, the whole bit. And then they bring them back home, and everybody is thrilled. You know, "Oh, they look so terrific." And then the show stops, and they live happily ever after. That's the story every time. Occasionally, you get these hints that things are not quite as they seem, like someone comes out on the stage at the coming-home party, and their kids burst into tears. And then there's a voiceover that says, "Actually, those are tears of happiness."

Good of them to clarify that.

Yeah. You know, what I keep thinking when I'm watching these shows is, God, here are these people who have just told us how self-conscious they've been all their lives, and how unhappy they've been, because they feel they're so ugly. And how embarrassed they are about their looks. And then they are made to take off their clothes and pose in their underwear on national television. It seems like such exploitation.

There's clearly a very close and complicated relationship between the desires of doctors to heal people and help them feel better on the one hand, and the economic motives driving pharmaceutical companies to promote new products on the other. What do you make of the tension between the two?

Well, let me answer that in an indirect way. When I was writing the book, I sent the manuscript to a few friends. One friend in particular, Leigh Turner at McGill University, gave me some really helpful comments. One of the things he said about the book was, "There's a weird thing going on here with the voice of the book. Most of the book has a meditative, self-reflective voice that's very comfortable and reassuring and easy to read. But sometimes, the voice changes, and you start to sound like Gertrude Himmelfarb writing in The Public Interest, and I can just imagine you shaking your finger and lecturing." He said, "That's a very angry voice." I went back, and I found out he was right. Most of the times when that angry voice emerged were when I was talking about the drug industry. Probably what he saw were my mixed feelings—actually, a lot of people have these mixed feelings—about these technologies. On the one hand, it's just a fact that a lot of people who want these things are suffering. And some of them are suffering very badly. You may think that they're confused; you may think they need psychiatric help rather than surgical help; you may think they need therapy rather than medication; you may think all kinds of things. But you can't help but be impressed by the amount of psychological suffering that they're going through. I think you naturally feel very sympathetic toward those people, and you don't want to be terribly critical of them personally. Essentially, you want to help them. You want to give them whatever it is that will stop their suffering. On the other hand, I think a lot of people get very worried when they find that for the past ten years or so the drug industry has been the most profitable industry in America, and that the best-selling class of drugs are antidepressants. There's got to be something wrong with that. It's very easy to get angry. I think people ought to be angry. Because it's one thing to help people who are suffering; it's another thing to do your best to try to exploit peoples' suffering in order to make a profit. That's what I see the drug industry doing. That's why the self-righteous, angry voice started to kick in. And so I had to do some editing.

Do you think that trend is likely to escalate along those same lines? Is there a point at which there can only be so many drugs for so many disorders? Or is it a positive feedback system that will just keep feeding itself?

Well, I would hate to go on record making any kind of optimistic statements about getting the drug industry under control. I'm not optimistic. It seems to me that one of the big changes that has happened over the last decade or so is that doctors are now in the pocket of the drug industry, without realizing it. There is so much money going to universities to fund academic departments, to fund continuing medical education, often to fund doctors themselves—to fund their research, to pay them for giving talks, and so on. And doctors are absolutely convinced, absolutely adamant, that this makes no difference in their clinical judgment. But there is so much evidence in the medical literature that it does, that doctors who take money from the drug industry are more likely to prescribe the industry's drugs. They're more likely to report positive research findings. They're more likely to request changes to the hospital's formulary to include the drugs from the company that they're getting money from. Despite all that, which is well documented, doctors still insist it makes no difference in their clinical judgment at all. Which is perfect for the drug industry, because they're changing doctors' behavior, and doctors don't even know it.

But just recently there's been an encouraging change. There was a guidance paper issued by the Office of the Inspector General that comes down fairly hard on the practice of giving doctors honoraria just for listening to sales pitches, or the practice of ghostwriting articles for them and then paying them to sign their names. It addresses a lot of the really crooked things that the industry's gotten up to, and it's fairly explicit, so I think that's a hopeful sign.

What do you think the bioethics community will need to do to keep up, as doctors become able to do more and more ambitious things, even things that we can't even conceive of right now?

I think that bioethicists so far have mainly followed trends. Generally, something will hit the news, and it will become very controversial--like cloning or stem cells or various kinds of research abuses. And then bioethicists react to it. It's very much an event-and-abuse-driven pattern. The ethical problems with these kinds of technologies—which are different from the spectacular technological developments, or abuses, or deaths that bioethicists usually react to—are much more subtle, so the analysis has to be a lot more subtle. The thing that worries me about bioethicists and these technologies is that so many of the innovations are driven by marketing. And with a handful of exceptions, bioethicists have generally not paid that issue any attention at all. The drug industry has just gotten more and more powerful over the last decade, and bioethicists don't seem to be worried at all. In fact, a lot of bioethicists are now on the drug-industry payroll themselves.

Really? How does that work?

Well, there are a few things. There are a handful of bioethics centers that actually solicit funding from the drug industry, and there are a handful of independent bioethics think tanks that also get drug-industry funding. Bioethicists also work as consultants for the drug and biotech industries, serving as ethics advisors, ethics consultants, and members of ethics advisory boards. And there has been a move over the past decade, particularly over the past five to seven years or so, where most of the drug-industry research money that was going to universities is beginning to go to private contract research organizations. And with private businesses rather than universities getting the money and carrying out the research, there's a niche for a new kind of ethics review board—so-called "non-institutional review boards." That's another way for bioethicists to get in on the industry money.

Wow. I had no idea that that was even happening.

I wrote a piece in The American Prospect about two years ago about this. And there have been a handful of other articles about industry-funded bioethics. Bioethicists got very upset about this, because their own ethics were being called into question. So in a lot of those pieces, various defenders of taking industry money said, "Well, you know, our professional society is working on it. We set up a task force on this. Just wait until the report comes out." And then, of course, by the time the report came out, nobody was paying attention anymore. That report, from a task force set up by the American Society for Bioethics and Humanities and the American Society for Law, Medicine and Ethics came out last summer, and the remarkable thing was that the task force actually endorsed the practice of bioethicists' taking industry money. In fact, they even endorsed bioethics advertising.

What was the underpinning for the endorsement?

That there's a market for it. That we should pay attention to conflict of interest, but basically, bioethicists have a right to make a living just like anybody else does.

That seems like a pretty dramatic redrawing of the ethical map.

I was stunned. There were ten people on the task force, and they had a little blurb at the end saying that they actually refused to disclose what companies they had worked for. But eight of the ten members of the task force had done for-profit industry consulting.

I found much to get worked up about in your book, and it paints a pretty bleak picture sometimes. But near the end there was a bit of an affectionate nod toward that searching part of the self—our inner Gatsby, our inner Huck Finn—that is just going along and trying to make sense of the self in its own scrappy way. It was brief, but it struck me as sort of a ray of hope. Ultimately, do you think we're on a good path? Will we be okay as a culture?

I really don't know. I tend to be pessimistic about things like that. World-weary cynicism is my preferred stance. I think the signs are not looking good, let me put it that way. You've got this hugely powerful drug industry, and you've got a health-care system that is becoming more and more market-oriented all the time. You've got doctors who feel as if their professional identity is under attack and who have in a lot of ways given up and now work for large corporations. We might be okay as a culture, but medicine is not in the best shape at the moment.