Book Review

Better Than Well: American Medicine Meets the American Dream

N Engl J Med 2003; 348:2368June 5, 2003

Article

Better Than Well: American Medicine Meets the American Dream
By Carl Elliott. 357 pp. New York, W.W. Norton, 2003. $26.95. ISBN: 0-393-05201-X

This is a subtle, yet provocative book that picks up where Lauren Slater's excellent Prozac Diary (New York: Random House, 1998) and Peter D. Kramer's groundbreaking Listening to Prozac (New York: Viking, 1993) leave off. Like Slater, Elliott explores basic questions of selfhood in a society in which people increasingly turn to what he calls “enhancement technologies,” such as drugs and cosmetic surgery, to improve their feelings about themselves. What does it mean for the definition of self, he wonders, when someone says, as many people happily taking antidepressants do, that she feels “more like herself” when she is taking Prozac than when she is not? And where, Elliott wonders, like Kramer, who wrote the foreword to this book, is the slippery core of the endless maze of mirrors in which one's self is constantly reflected back by others?

Elliott contends that Americans see their lives as projects, as endless quests for self-fulfillment, and that this drive fuels the enhancement-technology industry. “In other times and places, success or failure in a life might have been determined by fixed and agreed-on standards. You displeased the ancestors; you shamed your family; you did not accept Jesus Christ as your personal savior.” In America, he observes, “we are compelled to pursue fulfillment through enhancement technologies not in order to get ahead of others, but to make sure we have lived our lives to the fullest.” We have become a society, he says, in which “a drug for your self-presentation will improve your mental state, and a drug for your mental state will improve your self-presentation. . . . The health of the self and the presentation of the self are so mutually dependent that to treat one is also to treat the other.” Are we really better off, he wonders, for rewarding the happy, the outgoing, and the perky-breasted (regardless of what it took to get there) than we would be accepting the nonmedicated, non–surgically-enhanced brooders — saggy-busted, flabby, and gray-haired though they may be?

Many of the issues Elliott explores are not new. Are we saving or overmedicating children with attention-deficit–hyperactivity disorder? Are face-lifts a way of caving in to sexist standards of beauty, or a shortcut to meeting these standards and thus getting on, more happily, with life? Elliott, a professor of bioethics and philosophy at the University of Minnesota, is at his best when he explores the rarer, more biologically interesting stuff, such as what a sense of self means to transsexuals, who argue, often quite convincingly, that they have always felt that they were born in the “wrong” body and that they can be happy only when their bodies are changed surgically to conform to their self-image. In a particularly fascinating chapter, Elliott describes people who seek to improve their self-image by having parts of their body (chiefly legs, arms, and fingers) chopped off surgically (or, in cases of desperation, in do-it-yourself operations). There seems to be — believe it or not — quite a cadre of folks out there with “apotemnophilia,” the attraction to the idea of being an amputee (which should not be confused with “acrotomophilia,” the attraction to amputees). Curiously, these folks, some of whom Elliott interviewed, sound a lot like transsexuals; they say such things as “I have always felt I should be an amputee.” As with those who feel like themselves only when taking Prozac or after a sex-change operation, with amputee wannabes, muses Elliott, “the true self is the one produced by medical science,” not the one available naturally.

The problem with this book, for me at least, is that Elliott shies away from answering many of the provocative questions he raises. Perhaps that was deliberate. He is, after all, a philosopher. But the fluency with which he argues all sides of these issues left me wanting to know where he really stands. Is our endless quest for self-improvement a good thing or a bad thing? Or is it simply who we are, whatever that may be?

Judy Foreman, Ed.M.
Harvard Medical School, Boston, MA 02115
judyforeman@myhealthsense.com