Literature and Medicine

Literature and Medicine 22.2 (2003) 269-272

Carl Elliott. Better Than Well: American Medicine Meets the American Dream. New York: W. W. Norton & Company, 2003. 320 pp. Clothbound, $26.95.

Bioethics professor Carl Elliott's Better Than Well: American Medicine Meets the American Dream offers a wide-ranging, ironic, and gently mocking (while still very serious) consideration of the emerging partnership between American medicine and the biotech century. Elliott's topic puts him in the company of a host of contemporary scholars who sense something unusual and something worrisome about the current techno-medical moment. These scholars argue that the emerging biotech century dramatically ups the ante of biomedical interventions because it so thoroughly increases biomedicine's reach into the fabric of our daily lives.

Like other scholars in this area, Elliott uses new terminology to articulate his concerns. Where others use terms like cyborg,posthuman,body projects, or cosmetic psychopharmacology, Elliott uses the current bioethics terminology of enhancement technologies. Elliott explains that the phrase "enhancement technologies" entered the bioethics literature in the 1980s with the advent of new gene therapies. Bioethicists worried that the potential for human genetic treatment would also bring the peril of new eugenic manipulation. They attempted to parse the good from the bad by drawing a bright line distinction between treatment and enhancement—with treatment being the good genetic manipulation and enhancement the bad genetic manipulation. Other health-care experts followed suit, and the phrase "enhancement technologies" is now routinely applied to an array of new biotechnologies. Experts hope that the treatment-enhancement distinction will help determine which technologies deserve support and which technologies pose a public threat.

But, as Elliott demonstrates, the treatment-enhancement distinction does not hold up well. The new biotechnologies prove too slippery for rigid binaries and absolute hierarchies. With the advent of Prozac, Ritalin, Viagra, Propecia (for baldness), Protropin (growth hormone), Botox, aging science, sex-reassignment surgery, cochlear implants, and the explosion of cosmetic surgeries (just to name a few of the interventions Elliott discusses), the priorities of the treatment-enhancement distinction can often flip. Enhancement can become more desirable and more valuable than treatment. Plus, the treatment-enhancement distinction can blur beyond recognition when the same technology is used as either a treatment or an enhancement.

As a result, efforts to constrain biotech excess in medicine by calling some interventions "enhancement" have dismally failed, and the [End Page 269] biotech gold rush in medicine is now under way. Investors consider this moment a watershed for biomedical speculation because, more than any other life-sciences sector, human biological manipulation leads the biotech century forward. Elliott does not estimate how big the enhancement-treatment gold rush has become, but TheWall Street Journal reports that in 1999 the pharmaceutical industry alone generated $343 billion in revenue, which was an increase of 11 percent from the year before. With that kind of growth, the Harvard Business Review predicts that the biotech industry will eventually become the "largest industry in the world." ¹

Refreshingly, Elliott enters the techno-medical domain not by reproducing the treatment-enhancement distinction or by separating medical interventions into "good" and "bad" categories. Elliott considers instead the broad cultural and historical context of these new technologies. For Elliott, "we need to understand the complex relationship between enhancement technologies, the way we live now, and the kinds of people we have become" (p. xxi). The important issue for Elliott is not so much "enhancement" as "identity." He finds identity and identification a better framework for considering these technologies because the concerns they create are not purely medical but address deeply "the kinds of people we want to be" (p. 27). If we have mixed feelings about these technologies, it is largely because we have mixed feelings about "the good life these technologies serve" (p. 27).

Elliott's curiosity about American identifications with the new biomedical technologies extends not only to America's eager consumption of the new technologies but also to America's lingering anxiety and unease about that consumption. He makes his diagnosis of Americans' "anxious enthusiasm" by...