Sounding out the idols of American culture…

Over the past half-century, American doctors have begun to use the tools of medicine not merely to make sick people better but to make well people better than well. Bioethicists call these tools “enhancement technologies,” and usually characterize them as “cosmetic” technologies or “lifestyle” drugs. But terms such as “enhancement” can be misleading, and not just because most enhancements can also be accurately described as treatments for psychological injuries or illnesses. They are misleading because the people who use the technologies often characterize them not merely as a means of enhancement but as a means of shaping identities. These are tools for working on the self.

Yet there is something puzzling about these tools. Even as we use medical technologies to transform ourselves, often in the most dramatic ways—face-lifts, personality makeovers, extreme body modifications—we describe these transformations as a way of finding our true selves. Medical technology has become, in the popular imagination, a way of revealing and displaying an identity that has been hidden by nature, circumstance or pathology. If you want to understand America, you must first understand how a country whose citizens are known the world over for their outgoing self-confidence should emerge as a leading consumer of drugs for social anxiety; how a nation dedicated to the freedom of the individual should enforce standards for physical beauty with such rigidity that grown women race to restaurant toilets to throw up their dinners; and how a nation famed for its dedication to the pursuit of happiness should also be such a fertile market for antidepressant medication.

This vocabulary of identity is not uniquely American, of course. People in other countries talk this way as well. But a vocabulary of identity may well be typically American, like the technologies we use it to describe. …

[I]t would be a mistake to think this is merely a matter of the market creating an illness. It is also a matter of a technology creating an illness. Wherever we can make the tools of medicine work, the condition that we are working on tends to be reconceptualized as a medical problem. It used to be the case that some people could not have children. This was not a medical problem; it was an unfortunate fact of nature. But once new reproductive technologies—such as in vitro fertilization and sperm donation—came on the scene, that fact of nature was reconceptualized as a medical problem. Now it is called “infertility” and is treated by medical specialists. This kind of reconceptualization runs throughout the history of psychiatry. When the new disorder of “neurasthenia” arose in the 19th century, we also got the new treatment of “rest cures” in private clinics. When the new disorder of “gender dysphoria” arose in the mid-20th century, we also got new surgical techniques for sex reassignment. When anxiety disorders became widespread in the 1950s and ’60s, we also got “minor tranquilizers” such as Miltown and Valium. And when the concept of hyperactivity became widespread in the 1970s, we also got an upsurge in prescriptions for Ritalin.

For people who worry about the extent to which enhancement technologies are being used nowadays, it is tempting to look for something or someone—the pharmaceutical industry, psychiatrists, cosmetic surgeons, the fashion industry or sometimes simply “the culture”—to blame. In the end, however, these technologies could not have taken off in the way they have without the traction provided by the American sense of identity. In America, technology has become a way for some people to build or reinforce their identity (and their sense of dignity) while standing in front of the social mirror. We all realize how critically important this mirror is for identity. Most of us can keenly identify with the shame that a person feels when society reflects back to him or her an image that is degrading or humiliating. But the flip side to shame is vanity. It is also possible to become obsessed with the mirror, to spend hours in front of it, preening and posing, flexing your biceps, admiring your hair. It is possible to spend so much time in front of the mirror that you lose any sense of who you are apart from the reflection that you see.

Some people call this narcissism, but if they are right, it is a kind of narcissism that is peculiarly dependent on things outside ourselves; that is to say, what other people are saying and thinking about us. This is not just a matter of your looks or personality failing to meet the standards of the culture. It is an underlying set of social structures that demand so much of the way you present yourself to others. In America, your social status is tied to your self-presentation, and if your self-presentation fails, your status will drop. If your status drops, so does your self-respect. Without self-respect, you cannot be truly fulfilled. If you are not fulfilled, you are not living a truly meaningful life.

Such is the cruel logic of our particular moral system.

These excerpts are from Carl Elliott’s “American Bioscience Meets the American Dream.”

Carl Elliott is a philosopher and a medical doctor.  He is Professor in the Center for Bioethics and the Departments of Pediatrics and Philosophy at The University of Minnesota.  His book-length treatment of the issues discussed in the article above is entitled Better than Well: American Medicine Meets the American Dream (Norton, 2003.)