Perfect People

I WAS READING A SPECIAL SECTION on the ethics of enhancement in the Summer 2000 issue of the Cambridge Quarterly of Healthcare Ethics¹ when genome researchers unveiled a rough draft of the human genetic code. Medicine was headed for its newest revolution. It could now create the perfect children each parent wants. Pick a height. Pick an eye color. Pick a physique. Pick a skill. Pick a personality.

CQ's authors, most of them moral philosophers, raised thoughtworthy ethical questions. McGee noted the irony that, despite the pressure to ration care, Viagra, the choice of a sperm donor, adolescent use of Prozac and Ritalin, and an incredible array of cosmetic surgeries had changed the medical role from an obligation to cure, palliate, or prevent to one of enhancing life.

Treatment versus Enhancement
McGee agreed that enhancement aims to improve a condition considered to be in the normal range, while treatment aims to 1) reduce disease symptoms; 2) stabilize patients for evaluation or diagnosis; 3) prevent symptoms or diseases; or 4) pursue an agreed-upon short-term goal for a futile condition. Still, the treatment-enhancement line did not unfailingly differentiate obligatory from non-obligatory medical interventions.

Instead, Daniels proposed that medicine and third-party payers are obliged to restore patients to "normal, species-typical functioning." It is generally better, he said, to mitigate the effects of inequalities than to insist on "equalizing" people's talents and skills by "highly inefficient" enhancement. His critics said Daniels gave insufficient attention to cultural and personal values in defining "normal, species-typical functioning."

Others, in trying to sculpt a more sensitive "species-typical normal functioning," moved toward a pragmatism in which professionals and patients would define disease and therapy in their unique social and cultural context. The market place would reflect the pressures of economic and resource shortages, competing incentives, and personal and social values.

Goering voiced her distrust for the market place. Remembering past eugenics programs gone awry, she methodically examined somatic cell therapies, which benefit individuals but not their progeny, and germline therapies, which benefit unidentifiable future generations. She concluded that the marketplace would either enhance the "haves" and neglect the "have-nots" or lead to a highly homogenous society. Either would be disastrous.

Shickle acknowledged the uncertain consequences of largely untried technology and suggested calling it "genetic manipulation" rather than "genetic enhancement." Genetic manipulation might satisfy an intermediate objective, but have unwanted long-term consequences. Selective breeding of animals and plants produced more milk and meat and higher yielding crops, but created more abnormalities or disease susceptibility. We lost the protection of genetic diversity.

Despite altruistic aims, Shickle warned, systematic "culling" of "useless" or "aberrant" genes could destroy "potential options in a species' evolutionary future." If society "enhances away" its marginalized members, it could lose the enriching value of genetic and cultural diversity. Better to accept, even appreciate, difference and eliminate the need for prejudice.

I was pondering that, when I discovered a mole in the CQ intelligence system.

Cosmetic Surgery
Among the essays was one by two physicians and a philosopher. It was about cosmetic surgery, not genes. One co-author is a plastic and reconstructive surgeon who heads the University of Michigan Medical Center's Hand Center.

Despite not being covered by health insurance, cosmetic surgery is a fast-growing medical practice just when physicians' incomes and autonomy are decreasing. The four most common cosmetic procedures (liposuction, breast augmentation, eyelid surgery and facelift) were performed nearly half a million times in 1997, an increase of 150 percent over 1992. The estimated total expenditure for cosmetic surgery was between $1 and $2 billion.

The authors saw this as a consumer-oriented entrepreneurial practice, heavily promoted by advertising, not medically indicated for a diagnosable medical condition, and posing risks, causing side effects, and subject to complications. They asked, "Is it a medical privilege or an abuse of medical knowledge and skill?" (Isn't there something between privilege and abuse?)

They agreed on the goals of medicine, but added a limitation: it is not within the purview of physicians to try to relieve all pain and suffering, only that related to conditions that qualify as "maladies." (The World Health Organization defines health more broadly.)

The authors held that the ancient "internal morality" that has guided and constrained medicine, distinguish the profession of medicine from business. It calls for technical and humanistic competence, avoidance of unnecessary harm, avoidance of fraudulent claims, and faithfulness to the patient's well-being. Medicine has its patients; business its consumers. Patient sovereignty and consumer sovereignty are not the same. In a market, consumer sovereignty is central; subjective preference and money determine access to goods and services. In medicine, consumer sovereignty is attenuated. Physicians diagnose, recommend and provide medically indicated intervention, but are expected to provide only what is consistent with diagnostic criteria, medical indications and professional judgment ~ not whatever a patient may demand.

Cosmetic surgery is one of many commercial and consumer activities devoted to enhancing appearance. As long as consumers have adequate information about risks and complications, have the freedom to choose or reject, are not subject to fraudulent marketing, and receive technical services from competent practitioners, cosmetic surgery does not violate business ethics ~ but does it violate the internal morality of medicine?

Cosmetic surgery may intensify a fixation with body image and culturally prescribed standards of beauty, and may stigmatize aging and the appearance of "deviant" ethnic groups. However, none of this violates the internal morality of medicine, the article concluded.

Reconstructive procedures that correct the ravages of disease, injury and gross physical abnormalities constitute a core medical practice, but liposunction and facelifts are entirely matters of subjective judgment. Yes, prolonged suffering from a negative body image often precedes cosmetic surgery, but is the suffering within the purview of medicine? What is lacking, the authors held, is suffering connected with an objectively diagnosable malady.

The article accuses cosmetic surgeons of taking on an aura of medical legitimacy by creating diagnostic categories, like "inferiority complex." If cosmetic surgeons truly believed they were treating psychiatric maladies, they would work with mental health teams and offer nonsurgical options to at least some patients, as do centers that perform transsexual surgery.

Advertising
In business, advertising is a standard means of linking sellers and buyers. The Federal Trade Commission has successfully challenged the AMA ban on physician advertising. Yet patient vulnerability and the imbalance of knowledge and power between physicians and patients continue to make advertising by physicians ethically problematic, although legal. (Like pharmaceutical advertising.)

Informational medical advertising may alert individuals to appropriate treatment for medical needs, but, the authors hold, ads that stimulate demand for interventions that are not medically indicated potentially compromise professional integrity and may violate the internal morality of medicine.

Ads that juxtapose sex with markers of professional competence; that offer free consultation, computerized imaging, and financing plans; that play on widespread dissatisfaction with body image and foster unrealistic expectations; or that omit indications of risks or complications or the chance of less than fully satisfying outcomes violate the ethical guidelines laid down by the American Society of Plastic and Reconstructive Surgeons in 1992.

The authors recommend that cosmetic surgeons who are serious about the internal morality of medicine should refrain from ethically suspect advertising and minimize the profit-making orientation of their practice ~ even more than physicians "whose daily work is more safely nestled in the core of medicine."

Shocked, we turned to local physicians practicing cosmetic surgery. One response follows.

The Limits of Medicine
Medicine is not confined to treating and preventing maladies. Physicians give contraceptive advice, yet pregnancy is not a malady needing treatment or prevention.

In my early days in psychiatry, psychoanalysis was fashionable. A useful therapeutic, teaching and research tool had become a symbol of sophistication. Psychoanalysis was the rhinoplasty and liposuction of its day.

That was without today's commercialism. No ads showed the beautiful people before and after psychoanalysis. No commercials promised or implied happiness after insight. Analysis costs about as much as complex cosmetic surgery, but is spread out over time. There were no third-party payers; patients paid the full tab. Physicians with the skills to treat major mental illnesses were more lucratively engaged in enhancing the dissatisfied than in treating the disordered. Like reconstructive surgery today?

Who determines whether psychoanalysis and cosmetic surgery are treatment or prevention or enhancement? Patients? Doctors? Payers? To ignore the suffering that brings most people to psychoanalysis or cosmetic surgery is to devalue their desperation. Self-indulgence to some is survival to others. Who decides and how?

Resnick was the only philosopher-essayist in the series who considered enhancements morally acceptable ~ provided they honor the norms of beneficence, non-maleficence, autonomy and justice. He found that philosophies generally accept enhancement as inherently moral. Only natural law strongly implies that tampering with the human form is inherently wrong; that the human form has inherent worth and any change defiles or destroys that worth ~ and is ultimately foolhardy.

Resnick challenged this neo-Darwinian view. Natural selection is not perfect, he wrote. It has left us with useless traits (e.g., the appendix) and without useful ones (e.g., an enhanced immune system). Despite our many failures, such as Nazi use of eugenics, said Resnick, we have had some successes, such as prostheses and eyeglasses.

Maybe psychoanalysis and cosmetic surgery are also examples of successes. Let's just be careful out there.

Ed_Rudin@macnexus.org

1. The International Journal for Healthcare Ethics and Ethics Committees. Summer 2000. 9(3) Cambridge University Press, New York, NY (ISSN 0963-1801). Available on-line at http://www.journals.cup.org