The Limits of Medicine
By Andrew Stark
Cambridge University Press, 256 pages, $25.99
Beyond the Hippocratic Oath:A Memoir on the Rise of Modern Medical Ethics
By John B. Dossetor
University of Toronto Press, 298 pages, $39.95
Bioethicists used to amuse themselves circulating a satirical poem called The Schmoctor's Song. A schmoctor uses medical training and medical technology to do things that are outside the boundaries of real medicine. Instead of being a real doctor, such a practitioner is a schmoctor. The joke made fun of for-profit medicine that capitalized on people's desires for quick and easy self-improvement. That poem does not circulate much any more. The issue has become too serious. As Andrew Stark writes, what counts as "legitimate" medical work is uncertain. As John Dossetor observes, profit has become pervasive in driving medical agendas.
John Dossetor and Andrew Stark approach bioethics from different generations and different professions. Both their books are specialized and will probably be read mostly by specialists, Dossetor by medical historians and Stark by philosophers. I want to praise both books without recommending them for everyone. The Canadian origins of both books should make us all proud. We Canadians have our doubts in the right places.
Andrew Stark is a political philosopher at the University of Toronto and writes from a philosopher's perspective. Stark's topic is narrower than his title implies. He seeks to determine whether medicine should cure conditions that sit on the boundary between being medical because some body parts are not functioning — deafness is the clearest example — and being cultural because they involve preferences for achievements or aesthetics. Having what Stark calls "plain facial features" is one example of a cultural condition, and being a physically slow runner is another. Is curing such conditions proper work for doctors? At worst, would such cures eliminate a vital source of cultural difference?
Stark seeks to establish principles on which society should make the "cut" between what is legitimately medical and what is "enhancement." Enhancement refers to using medical expertise and technology not to fix bodies but to improve them, whether in strength, appearance or mental focus. Making the cut is not easy, because what one person counts as improving the body, another will claim is only fixing it. Enhancement looks more like cure when people tell moving stories about how it has allowed them to live full, authentic lives as persons who are finally whole.
Questions abound. Consumers are interested in whether an enhancement is safe and whether it actually does what is promised. Insurers, both private and government, are concerned with escalating demands to cover diverse treatments. Policy makers worry about the enhancement market skewing resources available for other medical needs.
What makes Stark's approach to enhancement so specialized is that he proceeds by the honourable philosophical method of suspending most crucial real-life considerations, in order to strip the issue to bare essentials. First, Stark suspends problems of patient safety and product effectiveness. For example, his analysis is not about real-life Prozac with its risks and variable efficacy, but rather about an imagined super-Prozac that does exactly what it promises, all the time, for everyone who takes it, and this super status extends to steroids, surgery and other interventions.
Second, Stark suspends worries about cost and justice. Medically generated inequality is not an issue in Stark's world "without financial limits." He assumes universal insurance for everything, so no one is disadvantaged by not being able to pay.
Stark's serious scholarly point in constructing this medical utopia is to ask whether, even in that world, medicine has any business curing conditions like physically slow running or plain facial features. I wish that Stark had, in a final chapter, taken the principles he has developed back into the real world; he stops short of that.
