For quite a while now, I’ve had the idea that I’d like to write something about the purpose of medicine – it’s something I’ve been adding on job applications for about 5 years, but I’ve not got around to doing all that much about it yet.  The question as I saw it was whether medicine is properly concerned with making us well, or with assisting us in our projects.  The latter may be a condition of the former – indeed, it may be a criterion of the former – but it’s not the same, because we could have all kinds of odd projects that’re only tenuously health-related.  For example, cosmetic surgery – and here I mean potentially quite extreme body modification – might potentially belong to medicine if we go for the latter option.  It might not be the sort of thing that medics should prioritise, but it could still be on their list of concerns.

Where’s this preamble leading?  Well, Alice Dreger has been considering a similar sort of question over on the Hastings Center’s blog.  It’s cosmetic surgery that worries her:

I’m not naïve; as an historian of medicine, I know that medicine has always advanced itself by offering improvements of patients’ social status, primarily by making patients healthier, but also by legitimizing their complaints.

But the noble profession has historically been primarily about something nobler than boob jobs and Botoxing wrinkles. The medical profession’s primary goal, historically speaking, has been prevention and relief of real suffering.

I can’t believe I even have to assert that. If the great men and women of medicine could come back from the dead and watch television today, what would they make of the fact that a large percentage of the medicine that is represented is cosmetic?

They might conclude, reasonably, that this reveals medicine’s success. Only in a world of astonishingly good anesthetics, infection management, and surgical technique would patients dare seek these procedures. But they might also reasonably conclude that something very strange has happened.

There’re some interesting considerations raised in the piece – I do recommend it.  However, there’s also a couple of things with which I’d pick a dispute.  The conclusion doesn’t strike me as powerful, for example.

Let’s just call these practices what they are: barber surgery. That way, when one of my idealistic, smart, principled students hears that the student next to her is going into “cosmetics,” she can just answer, “Really? And here I thought we were in medical school.”

Dreger is fairly clear that she goes along with the first of my options above – that medicine is about wellness – but I’m not sure that that’s right: I don’t think I see wellness as an end in itself.  Rather, I see it as something that’s valuable (and comprehensible) only within the context of a certain set of projects.  So it’s those projects that do the work – in which case, cosmetic medicine (or barber surgery – call it what you will) is, if not exactly back on the menu, at least chalked up on the “Specials of the Day” board.  The “and I thought we were in medical school” retort wouldn’t stick.

And I think that the tone of the article more generally suggests something important and interesting about the cultural background of bioethics as pursued on the other side of the Atlantic. Firstly, I don’t think that the availability of cosmetic surgery has anything to do with autonomy.  Dreger suggests that

I know, these procedures are offered in the name of patient autonomy. But as any first-semester ethics student understands, real autonomous choice requires knowledge, and it does not appear that many patients who are literally sold the belief that these procedures will improve their lives have been told that what little evidence we do have suggests their hopes are false.

Imagine if a patient came in and said “I think my cholesterol is probably high because I saw your advertisement and the actor looked like me, and so I want drug X because I want to feel better like the actor did,” and the doctor simply said, “OK! You’re autonomous!” and gave the prescription?

Except that this isn’t autonomy as I recognise it.  Autonomy, for me at least, is about maintaining moral integrity – it means, in Kant’s phrase, that one is a law unto oneself.  What Dreger is describing, though, looks more like the freedom to be a law unto others.  By concentrating on the knowledge aspect, she forgets that the medic has no obligation based in autonomy to accede to positive requests – noone in their right mind thinks that the mere fact that a patient is autonomous means that we have to be their performing monkey.  Autonomy isn’t about having others allow you to do what you want, and to help if and when necessary – it’s about regulating what you want, and about others not being able to regulate it for you.  What Dreger outlines is a consumerist bioethic; and consumerism may have something importantly to do with a certain account of liberal (or libertarian) individualism – but autonomy stricto sensu it ain’t.

Things get really strange after that:

And here’s the other thing that worries me about “cosmetic medicine”: the great genius of the founding fathers was to plant a seed that said that our bodily differences should not be used to limit our social and political lives. In their own time, the Fathers bravely overturned the idea of “birthright” – of “blue blood” – being the key to power.

Later democratic American geniuses took it from there. Civil rights activists rejected the idea that skin color matters to our rights; women’s rights activists rejected the idea that sex differences matter to our rights; disability rights activists rejected the idea that needing a wheelchair means you should be barred from entering your own public schools, courts, and libraries.

So what does it mean when our doctors participate in – even sell – the regressive idea that our wrinkles, our hairlines, our breast and genital sizes should limit us? What does it mean when “free at last!” is supposedly achievable through a Botox injection and a tummy tuck? What does it mean when our doctors are saying we should, in fact, be judged by the color (or shape) of our skin, rather than the content of our characters?

I think it means “cosmetic medicine” represents a corruption of the core principles of both medicine and democracy. I think it means it is time for the medical profession to say, “Enough.” It’s time to make medicine safe for democracy, time to take back the name of the noble profession.

I really have little idea of what to make of this.  What on Earth have democracy and the political ideals on which the USA was founded have to do with the practice of medicine?  Even if the civil rights analogy fit – and it doesn’t – then the appeals to democracy are just baffling.  (The analogy doesn’t fit because being black or female or gay or whatever is neither good nor bad: it is (or should be) just another detail of no particular moral significance; by contrast, it is better to be better looking.  I don’t have any problem in admitting that; there is a value to aesthetics.  Being healthy is part of the good life; so is being wealthy, good looking, and no doubt any number of other things.  Being a white male, on the other hand, isn’t.)

I admit it: I’m not the world’s leading fanboy of democracy – at the very least, my version of democracy owes much more to Rousseau and the benevolent dictatorship of the demos through the volonté générale than anything we see in operation today.  But, whatever its flaws, democracy deserves better to be brought into a claim about the value of cosmetic surgery in such a blithe, empty and bewildering manner.  Ditto the patriotic appeals.  It’s possible to present a moral argument without either, and we should – because even if you think that democracy and patriotism are desirable, they’re presumably desirable for a moral reason.

They aren’t a moral reason in themselves.  To treat them as though they are is specious, empty, and just a bit complacent.