"Whoever wants to know the heart and mind of America had better learn baseball." When Jacques Barzun made this famous diagnosis of American life in 1954, Wallace Laboratories was preparing to introduce the nation to a new drug called Miltown. Marketed as a "tranquilizer," Miltown was the first prescription drug developed specifically for the anxiety of ordinary life. Within two years of its introduction, Miltown had become the most popular prescription drug in America. It would remain popular into the 1960s, when it gradually ceded its place as America's favorite to Valium, another tranquilizer. By the early 1990s, another psychopharmacology boom had begun: American consumers, mostly children, were ingesting 90 percent of the world's supply of Ritalin. Today, the pharmaceutical industry has settled comfortably into its place as the most profitable business in America, and its most profitable class of drugs is antidepressants. Barzun's heart was in the right place but his mind was on the wrong subject. If you want to understand America, you must first understand Prozac.
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.
But as clinicians say, the cases speak for themselves. What are the users of these so-called enhancement technologies telling us?
Case One: Steroids. In his memoir Muscle, Samuel Fussell describes how, at the age of 26, he found himself working at a New York City publishing house. But Fussell had a problem with New York: The city terrified him. He was terrified of the crime, of the deranged strangers on the streets. It was this terror that led Fussell to bodybuilding. Fussell's moment of realization came when he read the Arnold Schwarzenegger autobiography, Arnold: The Education of a Bodybuilder. Soon Fussell was working out with free weights, reading bodybuilding magazines and buying 70 eggs a week at the supermarket. He quit his publishing job and moved to southern California, where he was soon taking anabolic steroids -- or, as his bodybuilder friends called it, "the juice."
The transformation in Fussell's appearance is astonishing. Photographs in his memoir show a shy-looking 22-year-old man, bony and longhaired, legs crossed and seated in a lawn chair. Several years later, they show a man so changed it is difficult to imagine it is the same person: an enormous, oiled, steroid-enhanced bodybuilder with a buzz cut, muscles bulging freakishly, eyes glazed, veins popping out all over his body, strutting and preening on a stage in southern California. But how does Fussell describe the change? As a transformation into his true self. It was his need to discover and reveal himself that drove him to steroids. "I, for one, couldn't wait three or four or five more years to become myself," Fussell writes. "I was so uncomfortable not being me that I had to have (steroids) now."
Case Two: Paxil. "I was 23, a millionaire and had everything, yet I was never more unhappy in my life," said Ricky Williams, an NFL running back. Williams' problem was his pathological shyness, or, as his official diagnosis had it, his "social anxiety disorder." So intense was his fear of public scrutiny that Williams had become known for giving media interviews with his football helmet on. He dreaded the thought of going to the grocery store or unexpectedly meeting a fan.
When Williams began giving public interviews about his condition several years ago, it was as a paid spokesman for GlaxoSmithKline, the makers of Paxil, the first antidepressant approved by the Food and Drug Administration for social anxiety disorder. Williams explained to the press that medication had allowed his true identity to emerge. "As part of my treatment program," Williams said, "my physician prescribed the antidepressant Paxil, in combination with therapy. Soon thereafter I was able to start acting like the real Ricky Williams."
Case Three: LSD. Cary Grant was not ordinarily an easy man to interview, writes Jay Stevens in his popular history, Storming Heaven, but as reporters gathered around Grant for questions on the set of the 1959 movie Operation Petticoat, the actor was uncharacteristically forthcoming. "I have been born again," he told the astonished group. "I have been through a psychiatric experience which has completely changed me." The psychiatric experience to which Grant was referring was the result of LSD, which he claimed to have used more than 60 times. As he sat tanning himself on the deck of a pink submarine, Grant described the way that LSD had put him in touch with his inner self. "I found I was hiding behind all kinds of defenses, hypocrisies and vanities," Grant said. LSD allowed him to get past the mask that had hidden his true nature. "I had to face things about myself which I had never admitted," Grant said. "I was an utter fake." Only with LSD was he able to overcome this fakery and become who he really was inside.
Case Four: Ritalin. By the mid-1990s Americans had become accustomed to idea of schoolchildren on Ritalin, but we were just beginning to hear about Ritalin for adults. Newsmagazines and self-help books such as Driven to Distraction told us that adults, too, could suffer from Attention Deficit/ Hyperactivity Disorder (ADHD). Many parents of children with ADHD began to suspect that they also had the disorder, and that their distractibility and poor concentration could be remedied with stimulant drugs. To many adults, the knowledge that their problems were due to an illness came as a relief. "I know this is not a personality flaw," said one executive who had begun taking stimulants. Many people concluded that stimulants had restored to them a true self that had been hidden by pathology. One patient taking Ritalin told Time magazine, "I had 38 years of thinking I was a bad person. Now I'm rewriting the tapes of who I thought I was to who I really am."
Case Five: Sex-reassignment surgery. "I was three or perhaps four years old when I realized that I had been born into the wrong body, and should really be a girl." This is the opening sentence of Jan Morris' memoir, Conundrum. For the first 35 years of her life, Jan Morris was James Morris, a celebrated Welsh writer. The transition from James to Jan began when Morris came across a book called Man Into Woman, which tells the story of a Danish painter who had undergone sex-reassignment surgery. Realizing that a transition from male to female was a medical possibility, Morris started taking female hormones and using the name Jan in 1964. In 1972, at the age of 45, Morris traveled to Casablanca, Morocco, and underwent sex-reassignment surgery. After the operation, Morris felt clean, felt normal and, most of all, felt like ... herself. "I was not to others what I was to myself," Morris writes. "All I wanted was ... to live as myself, to clothe myself in a more proper body, and achieve Identity at last."
Case Six: Voluntary amputation. In 2000, British newspapers announced that a surgeon in Scotland had amputated the limbs of two physically healthy people at their own requests. When asked to justify the amputations, the surgeon explained that some people "genuinely feel that their body is incomplete with their normal complement of four limbs." He and colleagues in psychiatry compared these patients to people who needed sex-reassignment surgery. One of the patients, explaining his desire for amputation, told a BBC interviewer, "I felt like at the age of 14, 'I'm in the wrong body and I should have a leg amputated.'" Another patient who had not yet undergone surgery said, "For me to have been born without my lower right leg would have been more the perfect theme of what I see my body as. It's almost ... a deformity. It's a wrongness, it's not a part of who I am."
As jarring as the language of authenticity and fulfillment may sound in some of these stories, it is the product of a moral ideal that is deeply rooted in modern Western culture. The philosopher Charles Taylor describes that ideal like this: "There is a certain way of being human that is my way. I am called upon to live my life in this way ... and not in imitation of anyone else's life." Taylor traces the ideal of authenticity to the 18th-century notion that each of us has a moral sense or conscience, a feeling for what is right and wrong. Over time, being in touch with your feelings came to be a moral ideal in itself. Authenticity eventually came to be something we must attain if we are to be true and full human beings.
As Taylor points out, it is important to acknowledge the moral pull of this idea. To say that people are using these technologies in pursuit of self-fulfillment is not necessarily to say that they are being selfish or narcissistic. Many people today feel called to pursue self-fulfillment. They have the sense that a fulfilled life is somehow a higher life, that if they do not discover a path that is true to themselves, they are missing out on what life could be. It is in pursuit of self-fulfillment that many people devote themselves single-mindedly to a career, for example, or cultivate their looks through severe diets and punishing workouts, even if it means ignoring their children, their partners, their God, their communities or any of the other things that people at other times have thought essential to a good life. When Morris writes that all of her fellow patients in Casablanca were deliriously happy, having finally achieved fulfillment, she is articulating something of this ideal. True happiness cannot be attained without fulfillment, and fulfillment requires being true to yourself.
In medicine, the ethic of authenticity has given the pursuit of psychological well-being the same kind of moral imperative once reserved for treating illnesses. Doctors used to find it relatively easy to draw a sharp ethical line between interventions for treating illnesses and those for cosmetic purposes. But today those lines have been hopelessly blurred. Once we take seriously the idea that people can be genuinely harmed if their aspirations to self-fulfillment are blocked, interventions that used to look like cosmetic procedures start to look a lot like medical treatments.
A good example of this transformation is cosmetic surgery. At the beginning of the 20th century, cosmetic surgery was a marginal practice, performed mainly by hucksters and quacks. By the end of the century, it had become a multibillion-dollar industry, performed by reputable surgeons. The turning point, according to Elizabeth Haiken in her superb history of cosmetic surgery, Venus Envy, was the notion of the "inferiority complex." The inferiority complex came out of ideas developed in the 1930s by the psychologist Alfred Adler, who argued that people could develop a sense of personal inferiority -- and, as a result, psychological problems -- because of the way they looked. The inferiority complex gave surgeons the ideal ethical justification for cosmetic surgery. Soon cosmetic surgery was not merely cosmetic; it was a medical treatment for the inferiority complex. As Haiken puts it, cosmetic surgery became "psychiatry with a scalpel."
It is easy to laugh at that phrase now because nobody talks about beauty doctors and the inferiority complex anymore. What we talk about instead is stigma. Our ethical debates today are about using medical technology to prevent people from being ashamed or humiliated. We give short boys synthetic growth hormones because short stature is stigmatized; we perform surgery on intersexed children because ambiguous genitalia is stigmatized; we prescribe Paxil because shyness is stigmatized; we give Botox injections because being old is stigmatized. This is not psychiatry with a scalpel; it is sociology with a scalpel. No longer do we simply see the possibility of treating social problems with medical technology; we see an ethical rationale for doing it. People who are stigmatized, unhappy or unfulfilled are genuinely suffering, and their suffering can be addressed by doctors.
Which is not to say that their suffering is not truly felt. In a famous passage in The Souls of Black Folk, W.E.B. DuBois wrote about the "double consciousness" of African Americans, the sense of "looking at one's self through the eyes of others." African Americans always feel their "twoness," DuBois thought, because the way they see themselves is distorted by the way they are seen by others. This distortion has not gone unnoticed by cosmetic surgeons or cosmetics manufacturers, of course. From plastic surgery for the "Jewish nose" or "Asian eyes" to skin lighteners and hair straighteners for African Americans, the market for enhancement technologies has always had an uneasy relationship with American racism.
Skeptical doctors sometimes attribute the extraordinary popularity of enhancement technologies to the FDA's 1997 relaxation of its ban on direct-to-consumer advertising of prescription drugs. According to a recent study, GlaxoSmithKline spent more money -- $91 million -- in direct-to-consumer advertising for its antidepressant Paxil in 2001 than Nike spent advertising its top shoes. Yet direct-to-consumer advertising remains only a fraction of the drug industry's advertising budget, most of which is aimed not at patients but at doctors. The pharmaceutical industry plies doctors with gifts, meals, trips, entertainment, drug samples, honoraria, consulting fees, even money for signing their names to ghostwritten articles. Doctors have become the instruments by which the pharmaceutical industry sells its products.
How has this happened? One example can be found in the history of the antidepressants. Before the 1960s, as the psychiatrist David Healy has pointed out, clinical depression was thought to be an extremely rare problem. The drug industry stayed away from depression because there was no money to be made there. Anxiety was where the money was. So when Merck started to produce its new antidepressant, amitriptyline, in the early 1960s, it realized that to sell antidepressants it needed to sell depression. To that end, Merck bought and distributed 50,000 copies of a book by Frank Ayd called Recognizing the Depressed Patient, which instructed general practitioners how to diagnose depression. The strategy worked. Prescriptions for amitriptyline took off, though amitriptyline was not even the first antidepressant on the market. (Imipramine, a drug of the same class, had been on the market since the mid-1950s.)
Yet it 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.