The identity clinic

Happiness has become the goal of medicine - and it will make us miserable

Carl Elliott

"Become who you are," wrote the German philosopher Friedrich Nietzsche. A century later, millions of people are taking Nietzsche's advice to heart. Instead of turning to philosophy, however, they are using drugs and surgery. "I feel like myself again on Seroxat," says the woman in the anti-depressant advertisements; and so do users of Prozac, Ritalin, Botox, Propecia, Xenical, anabolic steroids, cosmetic surgery, hormone replacement therapy and even sex-reassignment surgery.

Even as people undergo dramatic self-transformations, altering their personalities with psychoactive drugs and their bodies with surgery, they describe the transformation as a matter of becoming who they really are. It was only by using steroids, writes the bodybuilder Samuel Fussell, "that I looked on the outside the way I felt on the inside". With sex-reassignment surgery, writes Jan Morris, "I achieved identity at last." If Nietzsche were alive today, he could be pitching anti-depressants for Pfizer.

Although it is striking to hear self-transformation described in the language of authenticity, these descriptions are not as surprising as they initially seem. The ideal of authenticity has deep roots in western thought. Many people living in the late modern age do not expect to find the meaning of their lives by looking to God, truth, or any other external moral framework. Instead, they expect to find it by looking inwards.

Being in touch with one's inner feelings, desires and aspirations is now seen as a necessary part of living a fully human life. A fulfilled life is a higher life, and to be fulfilled you must be in touch with yourself. The language of authenticity has come to feel like a natural way to describe our aspirations, our psychopathologies, even our self-transformations.

What is new is the involvement of doctors in fulfilling the desire for self-transformation. In recent decades, doctors have become much more comfortable giving physical treatments to remedy psychological and social problems. They give synthetic growth hormone to short boys to remedy the stigma of being short; perform rhinoplasty to remedy the stigma of having a "Jewish nose"; and give Propecia to middle-aged men to remedy the stigma of having a bald head. Now that the enhancement of psychological well-being has come to be regarded by some as a proper goal of medicine, the range of potentially treatable medical conditions has expanded enormously.

Is the success of these technologies a problem? In many cases, no. Some of these drugs and procedures alleviate the darkest kinds of human misery. For every person using an anti-depressant to become "better than well", there is another using the same drug for a life-threatening depression. And if sex reassignment surgery can effectively relieve a person's suffering, then the question of whether or not it is treating a proper illness seems rather beside the point.

Yet it is hard to remain completely untroubled by all this medical self-transformation. One worry is about what the philosopher Margaret Olivia Little calls "cultural complicity". As hard as we may find it to condemn individuals who use drugs and surgery to transform themselves in accordance with dominant aesthetic standards, on a social level these procedures simply compound the problems they are meant to fix. The more East Asians who get plastic surgery to make their eyes look more European, for instance, the more entrenched the social norm that says East Asian eyes are something to be ashamed of. The same goes for light skin, large breasts, Gentile noses or a sparkling personality.

Market pressures compound this worry. For several years now, the anti-depressants have been the most profitable class of drugs in the US, and one of the most lucrative in the UK. But the anti-depressants are not used simply to treat severe clinical depression. They are also widely used to treat social anxiety disorder, post-traumatic stress disorder, generalised anxiety disorder, obsessive compulsive disorder, eating disorders, sexual compulsions and premenstrual dysphoric disorder. Many of these disorders were once thought to be rare or even non-existent. Yet once a pharmaceutical company develops a treatment for a psychiatric disorder, it acquires a financial interest in making sure that doctors diagnose the disorder as often as possible. This may mean transforming what was once seen as ordinary human variation - being shy, uptight or melancholy - into a psychiatric problem. The more people are persuaded that they have a disorder that can be medicated, the more medication the drug company can sell.

The results have not always been benign. In the US in the 1990s, Wyeth-Ayerst aggressively marketed its diet drug combination Fen-Phen for weight loss. But when Fen-Phen was linked to pulmonary hypertension and heart valve disease, it found itself forced to settle one of the largest class action lawsuits in American history. In the 1960s and 70s, hormone replacement therapy was touted as an anti-ageing remedy. Gynaecologist Robert Wilson's argument for the benefits of oestrogen, Feminine Forever, sold 100,000 copies in its first six months, and within a year it was available in 17 countries. But in July 2002, the largest trial ever of HRT had to be stopped prematurely because it was proving to be so risky. Women on HRT had more coronary artery disease, more strokes, more pulmonary blood clots and more breast cancer.

We are now seeing a similar turnabout of opinion with anti-depressants. For years the SSRI anti-depressants have been an extremely profitable class of drugs, largely because they are prescribed for so many conditions other than major depression. Recently, however, regulators in Britain, Canada and the US have taken steps to warn clinicians and patients that in some cases these anti-depressants may be linked with an increased risk of suicide.

Perhaps the hardest worry to pin down about enhancement technologies is what the political theorist Michael Sandel calls "the drive to mastery". Sandel is worried less about the possible consequences of enhancement technologies than about the sensibility they reflect - a sensibility that sees the world as something to be manipulated and controlled. When people charge that genetic engineering is "playing God", for example, at least some of them are objecting to the lack of humility entailed by this sensibility - the arrogance of placing such extraordinary faith in human reason.

Perhaps we could design a world in which we all have equal access to mood-brightening drugs and cosmetic surgery, in which athletes have equal access to safe, performance-enhancing drugs, in which we can all safely choose and manipulate the genetic traits of our children, and in which we eat factory-farmed pigs and chickens genetically engineered not to feel pain. Yet many of us would resist such a world. And the reason we would resist is not because such a world would be unjust, or even because it would lead to a world with more pain and suffering, but because of the extent to which it has been planned and engineered. We would resist the idea that the whole world is there to be manipulated for human ends.

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Carl Elliott is the author of Better Than Well: American Medicine Meets the American Dream.

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