The point of medicine is to make sick people “well,” which is really just
another way of saying “afflicted with roughly the same diseases as everyone else.” But as we’ve seen in this special issue, we are belly-flopping our way into a world in which more and more medical interventions hold the promise of making us better than well, to borrow a memorable coinage from Peter Kramer’s 1993 book Listening to Prozac. We’re working on an entire suite of biological enhancements: smart drugs to improve memory beyond normal, doping methods that promote muscle growth by inhibiting certain proteins, gene therapy to stimulate the birth of neurons in the brain to above-normal levels. If you can imagine it, some scientist is mucking around in it. I know this firsthand. In my lab at Stanford University, we’re developing gene-therapy approaches to, among other things, transfer genes into the hippocampus–an area of the brain involved in learning and memory–with the goal of making a rat learn better under stress, a state that typically impairs cognition.
What we’re really talking about here is becoming above average, and that’s where things get tricky. The average person often has trouble with the mathematics of averageness. So even though air travel is safer than traveling by car, most people fear the former more than the latter because people like to be in control and because the average person considers himself to be a better-than-average driver. Or there’s the physician who ignores findings in clinical research in favor of her gut feeling, because the average physician thinks she is a better-than-average physician. And then there are the mathematically challenged social critics who sincerely believe that our schools should be producing nothing but above-average children. The ideal of fostering an above-average society is, by definition, doomed.
Still, with an imagination steeped in science-fiction literature–and a deep-rooted trust in our ability to solve humanity’s problems–it’s not hard to dream up fanciful ways in which science will make us better than well. But I think it’s a good idea to consider whether this sort of tinkering is a good idea. What are some of the worrisome aspects of us White-Labcoat Guys futzing with our bodies and minds? A partial list:
What if a wondrous intervention backfires?
This is the scenario of “Wait a second . . . this gene-transfer breakthrough was supposed to make humans photosynthetic, and instead now we’re just vulnerable to Dutch elm disease.” This concern had better top the list, given the rich history of such disasters, stretching from at least as far back as the Medieval Medical Association advocating leeches for when you’re feeling under the weather all the way up to the recent discovery that a gene therapy designed to cure a life-threatening immunological disorder happens to cause leukemia. And the earnest assurance of “But we’re being extra, extra cautious this time” doesn’t cut it–we scientists have always been careful people intent on not screwing up, but nonetheless, unpredictable things happen when cruising the unknown. The unpredictable isn’t the only peril we face, though. There are all sorts of things that should worry us even when the intervention works exactly as planned.
What fun is it now?
So we figure out how to get a bunch of bumblebee mito-
chondria into the fingers of some pianist, who can now play the fastest trills in the history of music. Great, but it’s unlikely to make the playing actually sound better. Or suppose the big question this season is whether the Pistons, with the new titanium fibril implants in their quads, will beat
the Spurs, with their prosthetic forearm extenders. Who cares? It’s as exciting as watching to see if the PC team defeats the Macs at virtual synchronized swimming.
Where does the line go?
There is nothing intrinsically wrong with making us better than well, but there are certain lines that should not be crossed. One boundary I hear often is that we should not alter the normal chemistry of the brain. In this scenario, it would be fine to perform gene therapy in, say, the bladders of aging men, to banish the inevitable increase in what a polite doctor might call urinary urgency, so that middle-aged men would need to go to the bathroom only once a day, at exactly noon. The problem with this “keep the brain sacrosanct” strategy is that we already alter the brain’s neurochemistry all the time. The average person who has gotten no sleep the previous night is pretty useless–unless she makes herself neurochemically better than well with the timely ingestion of a cup of caffeine.
Another popular do-not-cross line involves inheritance: We should not manipulate the germline, which would allow hardwired genetic changes to carry on to the next generation. In this view, if you want to splurge for cosmetic surgery to get some fancy neon antler implants, that’s your puzzling prerogative. Just don’t manipulate your germline so that you pass on the antler trait to your kids.
But couldn’t controversial science also determine what traits are not passed between generations? Consider Tay- Sachs, a congenital disease in which massive deposits of lipids build up in the brain, destroying it–and the child–within a few years. Most people would agree that this constitutes a less-than-well disease state, and they would be comfortable with prenatal screening to eliminate the disease from the gene pool. But what about other ideas for manipulating the germline by elimination? It is generally considered an example of “well” to be able to have healthy children. But in parts of China and India, being guaranteed to have a healthy boy would count as better than well. Is it OK to determine the gender of a child through in-vitro techniques, allowing only a certain type of sperm to cozy up to an egg?
Who here wants superpowers?
Once we have the means to make someone better than well, what should we do with that ability? Suppose Big Pharma develops a smart drug to manipulate cognition so that an individual thinks better and learns better under stress instead of having those abilities impaired. What’s wrong with that? As I mentioned, my lab is working on this; to me it seems like a good idea to give such a drug to safety workers whose actions could determine whether the next Chernobyl occurs. But should it be something a student can take in preparation for an SAT exam? How about the stressed-out death-squad commander making a snap decision as to how best to ethnically cleanse a village of civilians?
The rich get richer. Do the well get better than weller?
The great promise of technology in Western civilization is that it will make all our lives better. It’s a nice sentiment, but it rarely works this way. In their book The Axemaker’s Gift, James Burke and Robert Ornstein document how most technological innovations have done precisely the opposite of leveling the playing field, concentrating more power into the hands of the few, starting with the first dawn-of-man guy to invent a really good cudgel.
The same applies in medicine. It is those high on the socioeconomic ladder who are most likely to hear about a medical innovation, to understand its implications, to have a cousin whose friend’s sister can get them at the top of the list to receive it, and to be able to afford it (whether thanks to health insurance or deep pockets). During the past few decades, the U.S. has had an unprecedented economic boom, has been at the core of the biotech revolution, and has spent the highest percentage of its GDP on health care of any country on Earth. Despite that, we rank something like 29th in life expectancy, in large part because we’re moving in the direction of a dichotomized nation–where our urban poor are elderly by age 60, crippled with heart disease, obesity and diabetes, while our wealthy septuagenarians are wrestling with the decision of whether to go for the knee replacement this close to ski season. The best of our biomedical science doesn’t always trickle down very far.
Who’s well, anyway?
Before you opt for prosthetic x-ray eyes or genetically engineered opposable big toes–or whatevers –to make you better than well, you have to have de-cided what constitutes well. And this is where we, as individuals and societies, have a pretty bad track record of making sensible judgments about what counts as normal. For example: In the early 1990s a hormone called leptin, which suppresses appetite, was discovered. People went hog-wild at the news, assuming that we’d found the magic fat pill for society at large. As it turns out, though, most overweight people don’t suffer from a shortage of leptin.
There are certain people, however, who have a mutation resulting in extremely low leptin levels. An article in the journal Science reported on three Pakistani families whose members were described, in an unexpected departure from scientific argot, as “chubby.” You know what happens next–in swoops the Leptin SWAT Team to give these people synthetic leptin, suppress their appetites, melt away their chub, propel them toward a successful life of winning elections, having strings of highly publicized affairs with glitterati, appearing on the cover of People, et cetera.
But here’s where the leptin Albert Schweitzers ran aground: The family refused the treatment. “These people are from a culture that considers it a status symbol to be chubby,” reported Science. And thus you are left with the boggling specter of having to convince people that according to the dominant culture, there’s something wrong with them, in order to then cure them of their wrongness.
This is a disturbing domain. We are already in a world that promises ways to make people better than well with a nose job, breast implants, cosmetic products to straighten out their kinky hair, or tanning salons to keep them bronze year-round. Such modifications sometimes do wonders for the quality of someone’s life. But we don’t need fancier science to be even better at egging on and then accommodating people’s insecurities or their shame at who they and their people are.
Ironic ending department
Finally, one of the best reasons to stop and question some of these better-than-well advances is that when they work, they may ultimately accomplish nothing. We are a terribly invidious species. Psychology studies have shown that, for example, people are not happy receiving x more dollars in salary if it means that their neighbor gets 2x more. In reality, none of us wants to be rich; what we want is to be richer than other folks. Similarly, there are few reasons to be tall, in absolute terms; in fact, there are some health risks associated with being extremely tall. There are, however, ample societal benefits to being taller than other people.
Which brings us back to the mathematical difficulties so many people have with averageness: No matter how marvelous the state-of-the-art science, no matter what miracles are accomplished by my kindred Bio-Elves of the Laboratory, the majority of society will still not be able to be taller than average, smarter than average, more beautiful than average, and so on.
You can imagine plenty of better-than-well interventions that would be appealing for their own sake. Personally, I would find it very pleasurable to have genetically engineered cochleas that would allow me to hear gorgeous birdsong from many miles away, or gills that would make exploring coral reefs simpler or, as long as we’re at it, a nifty prehensile tail. But if science is being recruited to make someone better than well to gain the advantages it would bring in society, it’s a dead end. All you’ll be doing is buying into an ever-spiraling arms race of needing to be better than well, and then needing to be better than the new and improved well, and then . . . well, you get the picture.
I think it’s scarier than average.
Robert Sapolsky is a professor of neuroscience at Stanford University, a MacArthur “genius” Fellow, and author of five books, including Why Zebras Don’t Get Ulcers.