The Pursuit of Perfection: The Promise and Perils of Medical Enhancement, by two professors at Columbia University, focuses on an important question in modern medicine, but raises many other issues that will also be of interest to neurologists and the general medical community. The book is concerned with attempts not to make a sick person well, but to improve otherwise well people, taking them from standard to better levels of performance. A historical approach is used to grapple with the manner in which such endeavors have an impact on individuals and on society.
It is hard to define disease and the need for medical intervention. Standards are constantly being refined such that today's normal values are tomorrow a cause for intervention. Changing definitions of normal (optimal) serum cholesterol levels or of hypertension, for example, have led to the treatment of people who, only a decade ago, were considered to be in good health. A case can be made for considering advanced age a disease in its own right, with its associated frailty, sarcopenia, weakness, cutaneous changes, osteoporosis, cognitive alterations, and other accompaniments.
THERAPIES TO TREAT DISEASE OR ENHANCE
A basic tenet of this provocative book, then, is that a distinction is possible between the treatment of disease and a therapeutic intervention to enhance normal function. This is not always the case, as the authors themselves indicate. For example, disease prevention in itself can be considered a form of enhancement. Nevertheless, the constant barrage of e-mails that all of us receive daily – offering to enlarge various bodily parts, improve mental or physical performance, and the like – leaves no doubt that the distinction is often easily made.
Few would deny that reconstructive surgery for a burn victim is often very important and fully justified. Is it equally justified for a person scarred not by fire but by time? If it is reasonable to correct micrognathia by surgery, why is it not equally acceptable to correct a “weak chin” when this is distressing to the subject? Is it wrong to treat persons so that they feel happier and have a better self-image? Are treatments that delay aging justified, particularly if they improve performance and prolong life expectancy? Is intervention justified in response to fantasies if it can make these fantasies a reality, and should the risk-benefit ratio be considered differently in that circumstance? These are some of the issues that are raised in this book.
Some years ago, it seemed – at least to me – that human evolution would cease to occur on a physical level, but would occur primarily on a social level that depended on our ability to regulate the environment, permitting the survival of those who would otherwise fall by the wayside. Others believed that we might be able to influence our physical evolution, and recent advances in molecular biology and genetics have brought their view closer to reality than was conceivable even 20 years ago. A similar view was held in the early part of the 20th century with advances in endocrinology. Hormone replacement therapy was developed for those with specific deficiencies, especially while young, but has been used increasingly over the years to maintain or enhance function in the elderly, with little scientific evidence for efficacy.
COMMERCIALIZATION OF THERAPIES
The authors devote a large part of this book to discussing estrogen and testosterone replacement therapy, with particular emphasis on its commercialization as a means of retarding aging. In so doing, they provide a serious indictment about the manner in which clinicians have moved advances from the laboratory into clinical practice without any understanding of either the expected benefits or potential risks involved.
They have also provided a brief summary of the relationship between the pharmaceutical industry and the medical profession, from the time when over-the-counter patent medicines were widely available to the development of “ethical drugs” that were advertised to physicians and available to the public only by prescription.
FOCUS ON BROWN-SéQUARD
Of particular interest to neurologists will be the references to the early pioneering work of Brown-Séquard in hormone replacement therapy. As the authors point out, his work had an impressive logic, even though he himself has come to be regarded as something of a buffoon because of his self-experimentation with testicular extracts. I was disappointed that the authors nevertheless chose to include several of the disparaging remarks made by others when referring to this work, and chose to ignore his early work on the adrenal glands, which showed that these glands were essential to life.
Brown-Séquard is widely regarded as one of the founders of experimental endocrinology (for his work on the adrenals) and hormone replacement therapy (for his work on testicular extracts), as well as being one of the leading neurologists and experimental scientists of his day.
Neurologists will also be particularly interested by the account of the use of estrogens to prevent dementia, as well as many of the other changes that occur in the aging population. It is a miserable story, with its ambiguities, vacillations, political and economical nuances, and unending claims for benefit or attempts to discount apparent complications of estrogen replacement therapy as recently as 2003. The self-serving shabbiness of some of the major figures in this story is an embarrassment. The same is true for the growth hormone story that is also recounted from its beginning as a treatment for hormone-deficient children; this led to the enhancement of growth in short but otherwise normal children, and then to the attempted enhancement of the physical condition of the elderly. Yet again, the commercialization of medicine led to disquieting consequences.
Another chapter focuses on the development of lipoplasty, initially by an obscure French surgeon in a working-class area of Paris. His work, which led to major advances in body contouring, was initially ignored by the French medical community. Details of the subsequent attempts of groups of specialists to monopolize such procedures for purely financial reasons are disturbing. They dispel the notion of physicians as highly principled people caring for the welfare of others, and instead highlight the business of medicine, with its focus on marketing strategies, neglect of morbidity, and competing interests. They raise concerns about the willingness of physicians to generalize from a limited experience – say of 20 patients undergoing a new procedure – and thereby conclude that a new procedure is safe (and financially rewarding).
We continue to face the issues discussed in this book. The concept of genetics as a limiting factor is being replaced by the belief that the means are now available for redesigning individuals by manipulating their gene pool. But the consequences (both good and bad) have rarely been considered, especially since genes have more than one function. These concerns are brought out as the reader is introduced to a brief discussion about the genetic bases for memory, behavior, and alcoholism.
In summary, this book raises important questions that will interest not only neurologists and neuroscientists, but the general public. There are no answers, but this is not a limitation of the book: the issues first need to be raised and discussed widely. Thus, this book is timely, relevant, and provocative, and I can strongly recommend it to clinicians, investigators, and other health-care professionals. I enjoyed it enormously.