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An interview with Carl Elliott

Michael Szpir

Philosopher and bioethicist Carl Elliott's latest book (Better Than Well: American Medicine Meets the American Dream, Norton, $26.95) explores the modern American pursuit of happiness through "enhancement technologies"— products of medical science that are used not just to cure a disease or a disability but to upgrade or enrich our capacities. Science has provided us with the means—Prozac, Viagra, cosmetic surgery and sex-reassignment surgery—for "self-improvement," and Elliott wonders how and why so many of us have become so obsessed with these physical and psychological enhancements.

Carl ElliottClick to Enlarge Image

Although Better than Well will appeal to those interested in questions of personal identity, it is not a self-help book. Far from it. Instead it's a rare piece of writing: part philosophical tract and part social commentary that is as engaging as a good novel. In fact, Elliott often turns to some of the best American novelists—Walker Percy, Richard Ford and Richard Yates—to develop his ideas. The movies and television also make an appearance, and the reader soon comes to recognize that Elliott is not only a serious scholar, but a hip observer of popular culture—which is exactly the kind of tour guide you'd want for an exploration of both the mundane and the exotic parts of the modern American psyche.

Elliott recently moved to Princeton, New Jersey, for a sabbatical year at the Institute for Advanced Study, where he is visiting associate professor in the School of Social Science. He was trained as both a physician and a philosopher. Senior Editor Michael Szpir interviewed Elliott by e-mail shortly after his arrival at Princeton in early September.

How did you come to write a book about identity and "enhancement technologies?" The deeper question, I suppose, is how did you become interested in identity and self-invention?
It started in medical school when my friend Daniel Fort introduced me to the novels of Walker Percy. Percy's third novel, Love in the Ruins, is about an alcoholic psychiatrist and ex-mental patient named Thomas More. At that point in my medical training, becoming an alcoholic psychiatrist was looking like a pretty attractive career option, so I read the novel very carefully. Tom More invents an instrument called The Ontological Lapsometer—or as he calls it, a "stethoscope of the human soul." With the Ontological Lapsometer, More can diagnose and treat existential problems. If you're alienated or anxious or lonely, a quick temporal lobe massage with the Lapsometer will put you right.

What really struck me about Love in the Ruins, what made it cut really sharply, is that More's patients don't just feel good after a treatment with the Lapsometer. They feel fulfilled. They feel energized and creative and liberated. They feel like themselves. Their lives have meaning again. Now, a drug that gives meaning to an otherwise meaningless life: Here is a truly terrifying idea.

Love in the Ruins was published in 1971. When Prozac came along 20 years later, I started talking about it with my brother Hal, who is a psychiatrist at Wake Forest University Baptist Medical Center and a serious Percy reader. And for us, of course, the obvious parallel was the Lapsometer. Some of the people taking Prozac sounded eerily like the characters in Percy’s novel. They were saying things like, "On Prozac, I feel like myself again."

So the question became: If this drug really does make you feel fulfilled and authentically yourself, what's wrong with that? Well, maybe nothing. A lot of people think not, and it’s true that antidepressants are an essential part of standard treatment for full-blown clinical depression. Percy has a much darker view, of course. At one point in the book Tom More is approached by Art Immelman, who wants to buy the rights to the Lapsometer and market it for the drug industry. He tells More, "Doc, we’re dedicated to the freedom of the individual to choose his own destiny and develop his own potential." Art Immelman, of course, is the devil.

What is the origin of the phrase "enhancement technology"?
I'm not entirely sure. In the mid-1990s, Erik Parens assembled a group of people to work on enhancement technologies at the Hastings Center. I was involved with that group, and I remember that "enhancement technologies" seemed to have become a term of art by that point. The distinction between treatment and enhancement had become important for people trying to think about gene therapy. A lot of people thought that it was fine to treat genetic disorders but were worried about using genetics to enhance or improve human beings. Genetic enhancement had the smell of eugenics, which most people were unwilling to endorse because of its racist history.

Erik had us working not just on genetic enhancement but also on cosmetic surgery and psychopharmacology. The debates over Ritalin and Prozac were starting to heat up; athletic organizations were getting worked up over performance-enhancing drugs; and then came Viagra, which quickly became the fastest-selling prescription drug in pharmaceutical history. Third-party payers started scrambling to figure out whether they were obligated to pay for Viagra, which seemed to depend on whether it was prescribed as a way to enhance sexual performance or as a treatment for "erectile dysfunction." Pretty soon, bioethicists were using the term "enhancement technologies" to describe any kind of medical intervention that could be used to improve a person's abilities or appearance.

For the most part science seems to play a passive role in our wish to fulfill our visions of ourselves by providing the technology (drugs, surgical procedures) to alter ourselves. But you also imply that science has played an active role in this regard. For example, you suggest that the drug companies have hyped the notion of social phobia to market drugs such as Paxil. Could you elaborate on the relation between science/technology and the creation of identity in our culture? I know this is a big question. . . .
That's a complicated question, so I'll duck it. Instead, let me point out two shifts that I think have helped make enhancement technologies such a success. The first shift is a subtle change in the ethos of the medical profession. Doctors are now a lot more comfortable with the idea of giving physical treatments to remedy psychological and social problems. Today doctors give growth hormone to ordinary short people to fix the stigma of being short, perform double eyelid surgery on Asian Americans to fix the stigma of having "Asian eyes," and give Propecia to middle-aged men to fix the stigma of having a bald head. Once you take on the idea that the purpose of medicine is to improve a person's psychic well-being, then the range of conditions you can treat expands enormously.

A second shift has been an enormous growth in the power of the pharmaceutical industry, which is now the most profitable industry in the United States. The pharmaceutical industry has an obvious financial interest in expanding the diagnostic categories for which their drugs are prescribed. The more people with social phobia there are, the more drugs for social phobia the industry can sell. The more short kids there are, the more synthetic growth hormone the industry can sell. This is not to say that there is no such thing as social phobia, any more than it would be to say that there is no such thing as being short. It's just what happens when medicine starts to take on market values.

You say in your introduction that you are not offering an argument so much as a diagnosis. I wonder if you could summarize your diagnosis, and whether you could offer a prognosis. Are we on a slippery slope to becoming cyborgs?
What struck me about the way people were describing enhancement technologies was the way that so often they used this language of identity and authenticity: "I became myself on Prozac," or "I started taking steroids so that I would look on the outside the way I feel on the inside," or "With my sex-change surgery, I became who I really was." Here you had these people undergoing these radical self-transformations, and yet they described the transformation as a way of achieving their true selves. So the question became: What's going on here? Why this kind of vocabulary? What are these people getting at?

Part of the answer, I think, is that many people living in the late modern age don't expect to find the meaning of their lives by looking to God, truth or any other external moral framework. And they don't think of their identities as fixed entities, determined by their place in a social hierarchy and ratified by God and nature. Instead, they expect to find meaning in their lives by looking inward to the self. You have to get in touch with yourself in order to live a meaningful life.

Now, it's easy to make that sound trivial. Just spend a few hours watching daytime television or browsing through the self-help section of a chain bookshop, and you'll see just how trivial it can get. But this idea of getting in touch with your inner depths as part of living a meaningful life goes a lot deeper than that. Think about psychoanalysis, for example, and the idea that we have to look inward to understand who we really are. Think about the idea of the conscience, where you look inward to decide what's right or wrong. Think about democratic society, and the notion that we should all have the right to pursue our own personal, individual vision of the good life. All this is related to the way that authenticity and individual identity have become so enormously important over the past 200 years.

The other piece of this is social recognition. As the philosopher Charles Taylor points out, today we expect people to generate an identity for themselves. And it has to be an individual identity. This is part of the ethic of authenticity. Recognition by other people is critical, because the effort to generate an identity can fail. Others can refuse to recognize your identity, or insist on seeing you in a way other than the way in which you see yourself. And for complicated reasons, this can be genuinely damaging.

Taylor calls this an ethic of authenticity, and there's a reason he uses the word "ethic." It's because an authentic life is seen as a better life. Being in touch with your inner feelings, desires and aspirations has become necessary for living as a full human being. An unfulfilled life is a lesser life. If you're not fulfilled, your life is not measuring up to the promise of what a human life could be. That means that technologies such as Prozac, Ritalin, cosmetic surgery, growth hormone and sex-reassignment surgery are not just ways to look and feel better. They're instruments of self-fulfillment.

Now, of course I don't think this story explains all enhancement technologies. For example, I certainly wouldn't want to put sex-reassignment surgery on the same moral plane as baldness cures. But this language of authenticity is one of the more interesting strands running through a lot of the technologies.

You nicely articulate the existential despair that the suburban life is supposed to impose and the history of the anxiolytic drug Miltown, which was developed in the 1950s and might be called the first "lifestyle drug." Drugs such as Prozac and Ativan, which can be used to treat "everyday melancholy," are doing better than ever, and I wonder if you see any other way out for the "suburbanite." In other words, is the answer ultimately in urban planning or some form of social engineering?
Hmm. The phrase "social engineering" reminds me a little too much of what an entertainment director does on one of those Caribbean cruise ships. There aren't many things more soul-destroying than that.

The problem is a lot more complicated than creating better suburbs. The mystery is why an alienated suburbanite feels so much better after watching George Romero's movie Dawn of the Dead, which features bloodsucking zombies marching through an air-conditioned shopping mall in the suburbs with Muzak playing in the background, but feels a lot worse after reading an interview with me telling them what they need to do to improve their lives. Personally, I can't think of many things more likely to plunge me into existential despair than reading a book by an expert on how to achieve personal growth and self-fulfillment.

You introduce philosopher Charles Taylor's notion of "instrumental rationality," in which we remake the world to suit our personal designs and so rob it of its intrinsic value. In this light you say that the story of technology in America is also the story of how we transform a "thing" into a "device." I wonder if you could elaborate a little on these ideas. Do you think instrumental rationality is an inevitable consequence of a technological society, or is it more a product of capitalism?
Both, I think. A technological society encourages an instrumental view of the world, and capitalism puts a price on it. Both flatten out the world, but in different ways. I suspect we probably pay too much attention to the ways technology can fix problems and too little attention to the way technology works on our own sensibilities. Often those changes are invisible to us, but we can feel them working on us anyway. Whenever I walk into a suburban shopping mall or one of those wholesale shopping warehouses, I can feel a kind of force field draining the life out of me. I've been reading the Harry Potter books to my kids, and my favorite characters are the Dementors, the prison guards with no faces who wear black cloaks and can suck your soul away. They remind me of the greeters at Wal-Mart.

You mentioned Albert Borgman's distinction between a "thing" and a "device." I thought about this again last month when I was back in New Zealand, where I used to live. I met a couple while I was there, Jennifer and Roger Ngahooro, who told me in passing that they had refused to buy a dishwasher. They insisted on washing their dishes by hand, because that was the time of the day when everyone in the family really talked seriously to one another. Their theory was that it was easier for people to talk to one another while they were actually doing something with their hands, and not looking directly at one another across the table. They saw the value in the practice of washing dishes together. Whereas most Americans, I think, would simply look at the dishwasher as a device. The only point of washing dishes is to get them clean, and a dishwasher can do it faster and more efficiently, with less work for everybody. That is a kind of instrumental rationality.

Another slightly different example: I was just reading a paper by an analytic philosopher about Prozac. He was arguing that there was no important difference between Prozac and psychotherapy, because both were just ways of changing brain chemistry. That's a more subtle kind of instrumental rationality—seeing a practice, or even language itself, in purely instrumental terms. It's also reductive and simplistic, of course, but it reduces a complex practice into a device for changing brain chemistry.

This isn't necessarily an argument against technology, only an argument for thinking more carefully about what exactly technology is doing to us. Given the choice, my kids would much rather make a homemade fishing pole out of bamboo and string, with a piece of cork for a bobber, than use an expensive rod and reel from the sporting goods shop. Some people would see that as deeply irrational. Surely the kids would catch more fish the other way, and save themselves a lot of trouble in the bargain. That’s true. But the homemade fishing pole is a lot more fun, for mysterious reasons.

Technology is a lot more mysterious than a lot of technophiles like to admit. Some technologies seem to have a kind of magic to them that lingers on even after the technology is technically obsolete. Ham radios, for example, or hot air balloons. Others can be technically brilliant but still alienating and oppressive. What is it about a thoroughly modern kitchen that makes some people want to put their heads in the oven?

Physicists have been wringing their hands ever since we dropped the bomb on Hiroshima, but it seems that biologists are a little slow to consider the consequences of their actions. Is it just because the effects of biological technologies are more subtle or complicated?
One big difference between the physical sciences and the life sciences is the emergence of an entire professional cadre of bioethicists who earn their living by teaching and writing and consulting on ethical issues in the life sciences. You don't see that development nearly so much in the physical sciences. Whether that's an improvement or not, I can't say.

The book talks a lot about authenticity, and it seems impossible that you could have written it without a lot of self-examination. (Just reading it made me stop and think about my identity and what I'm searching for in life.) Do you feel that you became more aware of who you are after you wrote it, and if so, how?
Well, I grew up in Clover, South Carolina. My parents are from South Carolina, and their parents, and so on, back for hundreds of years. I went to Davidson College in North Carolina, then to medical school in Charleston, South Carolina. At the age of 25 I quit medicine, left South Carolina and moved to Scotland to study philosophy. Over the next several years I lived in Chicago, New Zealand, South Africa, Montreal, North Carolina, Minneapolis and now Princeton. My wife, Ina, is from Germany, and my kids carry three passports. So I went from this very thick, inward-looking Southern upbringing to a kind of rootless expatriate life. That kind of change makes you very self-conscious about your own identity, both about the things that you share with other people and the kinds of things that make your own background unique. It also gives you an outsider's eye on your own culture. I wrote a good part of that book sitting outside a hut in Bali.

So here's an offbeat question: If you could partake of just one enhancement technology that hasn't been created, what would it be? If you don't like that one, how about: Which enhancement technology do you think the world needs most?
You know, for years we had a research group thinking about these things, and the most intriguing idea I can remember came from David Gems, who is a geneticist at University College London. David's an extraordinary character, and one of the most interesting people I've ever found to talk about ideas with. He's an ex-punk, used to dig graves in Guatemala, worked in an Icelandic fish packaging plant, hung out with the Sandinistas in Nicaragua for a couple of years. When we were sharing a flat in Glasgow back in the 1980s, he'd disappear for weeks, and when he came back it would turn out that he'd been bumming around the Soviet Union—which really wasn't easy to do back in those days. And now he's a geneticist of aging with his own lab and a Royal Society fellowship, publishing his papers in Science and Nature. Anyway, David had this idea for what he calls "ontological enhancements." You know that famous paper by the philosopher Thomas Nagel, "What Is It Like To Be a Bat?"? That's the kind of thing David is thinking about—interventions that could dramatically alter your subjective experience of the world. What would it be like to have a new kind of sensory perception, like a bat's sonar? What if there were a drug or a procedure that would let straight people know what it is like to be gay, for example—or vice versa? The idea of "ontological enhancement" is at the root of at least some of the kinds of self-transformations I talk about in the book, like John Howard Griffin's experiment in Black Like Me. Now, whether the world really needs this kind of technology I wouldn't venture to say, but it's a lot more interesting than, say, drugs to make you run faster, or go without sleep.

So what are you working on now? Are you planning another book?
I've got a couple of projects in the works. One is about the advice industry, and especially the rise of a quasi-professional class of advice experts that we call "bioethicists." I work in a bioethics center myself, of course, but I feel very ambivalent about calling myself a bioethicist. A lot of my friends and colleagues do too, for complicated reasons. Who are we to advise other people how to behave? Why has our society invented this social role called "ethicist"? Why do so many bioethicists insist that they are not really bioethicists? I'm a fan of the novelist Nathanael West, and I'm thinking of calling this book Miss Lonelyhearts Visits the Hospital.

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