. . . .” How can we, who have (some) of these advantages—advantages in the games we indeed play—moralize carelessly about the others who want them? When that moralizing starts to happen, one looks around for some reasons for it, reasons having to do with cui bono; and usually they are not far to seek. I’m just as vulnerable to such self-serving moralizing as anyone else, but here I want to try to resist it. The point is not to insist on one of these lives in preference to the other; still less is it to evangelize—for others—a life that none of us actually lead. The point is first of all to realize that there are at least two sorts of lives there to be lived, to realize that our common conceptions, and common life, is a historical construction, not the plain sense of things. This, I think, is Heidegger’s great virtue: he reminds us that the life of technological ordering is not the only life there has ever been. Even if we are not yet in position to take its measure, and to measure it against the life we ordinarily live, such measuring will come only when the alternatives are clear to us. Thus the philosophical work we need to do is not, as we might think, to find within our ordinary ethical lives the wherewithal to say yea or nay about Prozac or other “enhancement technologies,” and it’s not even to deprecate those lives in favor of some other, radically altered version of them. Both those reactions, the complacent and the eschatological, strike me as too easy, and too easily seductive. I think we need to do something slower, more difficult, and probably less attractive. We need to explore, sensibly and carefully and critically, the possibility that we—some of us—can and should live differently than we do. Until we have done that, and until we have ourselves experimented with what we’ve discovered, I suspect we will stay pretty much on the surface of the problems we would like to resolve. References 1. M. Foucault, The Care of the Self, tr. R. Hurley (New York: Vintage Books, 1988), p. 54. 2. Think, in this connection, of what Christians call the Passion of Jesus, the pain and death he had to undergo, to suffer: passion is “pathos.” 3. P. Kramer, Listening to Prozac (New York: Penguin Books, 1994), pp.1-21. 4. For the best short account see M. Heidegger, “The Question Concerning Technology,” in The Question Concerning Technology, tr. W. Lovitt (New York: Harper and Row, 1977), pp. 3-35. 5. M. Heidegger, “What Are Poets For,” in Poetry, Language, Truth, tr. A. Hofstadter (New York: Harper and Row, 1971), pp. 91-142. 6. See J. C. Edwards, The Plain Sense of Things: The Fate of Religion in an Age of Normal Nihilism (University Park, Penn.: Penn State Press, 1997), Chapter 5. Prozac, Enhancement, and Self-Creation b y DAV I D D E G R A Z I A A person can be true to oneself even while transforming and even creating the person one is. One’s self is not something merely waiting to be discovered, after all. To some extent, part of the human endeavor is deciding and trying to become who we want to be. David DeGrazia, “Prozac, Enhancement, and Self-Creation,” Hastings Center Report 30, no. 2 (2000): 34-40. 34 H A S T I N G S C E N T E R R E P O R T M arina’s history is notable for significant childhood neglect. After her parents split up when she was four, her father became distant and mostly uninvolved and her mother suffered from depression and a borderline case of alcoholism. Although involved in Marina’s day-to-day life, she was inconsistently available on an emotional level. Because Marina was the oldest child and apparently “had her shit together,” she was often called on to help out with her younger sister and two brothers, who had a variety of problems ranging from depression to juvenile delinquency to significant obsessivecompulsiveness. Due to the distraction of other family members’ more dramatic struggles, many of Marina’s own needs were never met. However nurturing this “parentified” child was, she never felt nurtured. March-April 2000 Although by her own account she had a troubled adolescence—doing less well than she wanted in school, flirting with drug use and reckless sexual encounters—she managed to get accepted to a good university. Settling down considerably, she excelled in college and got into a top business school, where she continued her academic success. Throughout this period, her primary source of emotional sustenance came from several close friendships. Although these relationships were generally strong, Marina sometimes bristled from perceived putdowns and betrayals by those she held dear. Her family’s demands for advice and assistance persisted, but coming to understand how her overreaching family oppressed her, she established some reasonable boundaries with her mother and siblings, an achievement made easier by living in a different city. Her romantic life she considered a failure. Her intense work ethic afforded little time for dating, and the men she wound up with tended to be distant, rejecting, and sometimes emotionally abusive. Marina has also always been somewhat obsessional. She has been disturbed by thoughts about death since adolescence and overly concerned with the possibility of tragedy befalling her or her family, although these thoughts occur fleetingly and do not disrupt her functioning. For many years, her recurring sexual fantasies have featured powerful older men. She is troubled and disgusted with herself when these fantasies drive her to consume late-night hours pursuing the half-hearted titillation of sex-oriented internet chat rooms. As she approaches age thirty, Marina is rather successful in nearly everyone’s estimation: She is a wellpaid manager for a large computer company, she has close friends, and she has several pastimes that she genuinely enjoys (especially bicycling and guitar). Yet Marina finds herself brooding and pensive, wondering about her life and its direction. She seeks out a psychiatric consultation, which takes place over four sessions, March-April 2000 and accepts the psychiatrist’s conclusion that she has no diagnosable disorder. When he suggests that psychotherapy might nevertheless be of help to her, she is inhibited by the prospect of paying for many sessions out of pocket (since her HMO will not cover them). Still, she wants changes. At work, she feels overly tentative, unsure, too prone to worry about possible errors. In her social life, she hates how she endlessly interprets the latest transactions with friends and the way she is attracted to men who are bad for her. She feels alienated by her obsessional thoughts, considering them ridiculous and bothersome even if not very harmful. After extended periods of introspection, fueled by her impending birthday and the discussions that took place in the psychiatric consul- means of using a prescription drug morally problematic? If so, why? In a highly insightful set of reflections on Prozac, Carl Elliott makes the provocative claim that deliberately changing one’s personality through use of Prozac is inauthentic because it results in a personality and life that are not really one’s own. Thus he states that it “would be worrying if Prozac altered my personality, even if it gave me a better personality, simply because it isn’t my personality”; and he asks, “What could seem less authentic, at least on the surface, than changing your personality with an antidepressant?”1 Elliott’s thesis suggests that it would be inauthentic, and therefore morally problematic, for Marina to use Prozac for the purpose of changing her personality; indeed, if the drug had its intended ef- There is a misleading image of the self as “given,” static, something there to be discovered. In fact, a transformation can be an authentic piece of self-creation. tation, Marina decides that she wants to become more outgoing, confident, and decisive professionally; less prone to feelings of being socially excluded, slighted, or unworthy of a good partner; and less obsessional generally. She calls the psychiatrist who provided the consultation, whom she likes, and explains that she has heard that Prozac sometimes produces transformations like the ones she seeks—and more quickly and less expensively than could be expected from therapy. Marina requests a prescription for Prozac. Is Marina’s request morally problematic? Should a psychiatrist refuse to prescribe Prozac in a situation like this one? What may give us greatest pause about her request is that she wants to use a medication to change her personality and become a different sort of person. Is either the goal of major self-transformation or the fect, the resulting personality would not really be hers. But however intuitively appealing this reasoning may be, it is undermined by its misleading image of the self as “given,” static, something there to be discovered. One can be true to oneself even as one deliberately transforms and to some extent creates oneself. In fact, a transformation such as Marina proposes can be a perfectly authentic piece of what I will call selfcreation. What is at issue here is clearest in cases of personality change that, like Marina’s, are uncontroversially cases of enhancement, that is, of “interventions designed to improve human form or functioning beyond what is necessary to sustain or restore good health.”2 Often, enhancements are understood as interventions to produce improvements in human form or function that do not respond to genuine medical needs, where the latHASTINGS CENTER REPORT 35 ter are defined in terms of disease, normal functioning, or prevailing medical ideology, but sometimes enhancements are picked out by the nature of their means rather than their goals. Some means of self-improvement, such as exercise or education, are considered natural, virtuous, or otherwise admirable. By contrast, means that are perceived as artificial, as involving corrosive shortcuts, or as perverting medicine are often thought to render the intended selfimprovement morally suspect (as with steroid use to improve athletic performance). Marina’s intended use of Prozac implicates the concept of enhancement both because she is not mentally ill and because many would see her use of Prozac as an artificial shortcut that perverts the medical enterprise. Her case, and those at issue in this paper, are cases of what Peter Kramer calls “cosmetic psychopharmacology” in his landmark book, Listening to Prozac.3 Kramer uses the term to describe Prozac’s effect on patients who are not really ill and who become “better than well”: more energetic, confident, and socially attractive. It is worth noting that to varying degrees, certain other drugs—such as Ritalin and other “smart drugs,” Propranolol for reducing normal anxiety and enhancing musical performance, and the “happy pill” ginseng—raise at least some of the issues associated with cosmetic psychopharmacology.4 But this paper will concentrate on Prozac, which apparently produces the most extensive transformations of personality and therefore presents the issues of enhancement and self-creation in the clearest light. Projects of Self-Creation E lliott’s remarks about Prozac and authenticity occur within a broader discussion of the values pervading contemporary American culture. I do not dispute Elliott’s claim that having a sense of spiritual emptiness (reflecting our culture’s hollowness) can be preferable to Prozac- 36 H A S T I N G S C E N T E R R E P O R T induced complacency.5 What interests me here is his description of the ethics of authenticity, to which he ascribes two leading ideas, and the possible implications of this approach for people like Marina (pp. 181-82). The first idea Elliott identifies is that life is a project whose meaning depends on how we live and for which we are largely responsible. I agree with this claim. The second idea may be broken into two parts. First, figuring out how one should live requires introspection, because there is no unique external standard for living meaningfully. Here again I agree (while noting the role introspection plays in Marina’s growth). Second, one has to discover and be true to oneself in order to live an authentic life. To the extent that this assertion suggests that the self is “given,” a pre-existing reality that might be discovered and to which one’s actions should conform or “be true,” it strikes me as highly problematic. And it seems fair to read this assertion as depending on the image of a static self, since Elliott uses the assertion to argue that Prozac-driven changes of personality are inauthentic and lead to a personality that isn’t really one’s own. (I don’t mean to suggest that he fully embraces the image of a static self, just that his remarks on Prozac appear to promote this image to a degree that I consider disturbing.) The ideas of authenticity, of being true to oneself, and of self-creation provoke issues pertaining to personal identity. But what sense of identity is at issue? One sense of the term, analyzed by Locke, Parfit, and kindred philosophers, is that of numerical identity over time: a thing at one time is numerically identical with something at another time if and only if they are one and the same object, even if that object undergoes qualitative change. In this sense of identity, the problem of personal identity is to specify the conditions that must be satisfied for a person to continue to exist through time. While this sense of personal identity raises interesting practical issues concerning, for example, the definition of death and the authority of advance directives, it is not central to this discussion. The sense of personal identity at the heart of the concepts of authenticity and self-creation is connected with our self-conceptions—with what we consider most important to who we are, our self-told narratives about our own lives. Your inner story allows you to get your bearings when you act, especially when confronting difficult or momentous decisions.6 It is what comes apart when a person has an identity crisis, when she is left wondering, in an important sense, who she is.7 In this sense of identity, one could become a different person by undergoing a major change of outlook and values. And this is the notion Kramer has in mind when he describes the transforming effects of Prozac: Someone on Prozac might acquire a new sense of self—or identity—and strike others as having become “a new person.” All of this suggests that the self, in the second sense of the identity, can change over time. Indeed, the feeling that a self might undergo too much change may underlie some of the common discomfort with cosmetic psychopharmacology. But how malleable is the self, and to what extent can one actively change oneself? It is important to have a tenable view on these issues before considering whether self-creation via Prozac can be authentic. One possible view envisions the self as completely “given,” although to discover its shape and true colors one may have to dig (with reflection, therapy, or the like). One can find the self but not change it; any change is due to forces outside one’s agency. One version of this view takes a person’s “inner core,” the values that define the individual, to be entirely constructed by society.8 In another possible position, essentially the opposite of the first, the self is as amorphous and malleable as Silly Putty. In Sartre’s view, we March-April 2000 human beings are thrown into the world without any determinate nature. What we choose determines what we are, so we are completely responsible for what we become. With nothing except ourselves determining our actions and identity, we shoulder the burden of “radical freedom.” Thus we may shape ourselves into one form one day without limiting what we can shape ourselves into the next day. In this view, we are entirely self-creating, leaving no room for discovering anything about oneself except perhaps what one freely chooses to be.9 These two extreme views about self-malleability strike me as highly implausible. A little reflection suggests that we can reshape ourselves to some extent. We may try with some success to become more disciplined—or less disciplined, for the workaholics and perfectionists among us. We may work at being more generous or more patient or more willing to stand up to authority, and sometimes we may succeed. We may aspire to orient ourselves more toward a relationship—or less. And when we accomplish change in ourselves, it does not seem that this change is entirely independent of our agency (as it would be if the impetus were simply social forces, human nature, or one’s genetic makeup). But if human phenomenology suggests a capacity for self-change through our agency, it does not suggest an unlimited capacity. Persons with addictions and obsessive-compulsive disorders, for example, know that their will is not the only force driving their actions. And all of us are frequently reminded that there are limits to what we can accomplish in changing our characters and behavior just as there are limits to what our bodies can achieve in sports. If such self-shaping is possible, it is only one crucial process that determines what we and our lives become. The possibilities for self-creation are limited by its enmeshment with other crucial processes and factors (p. 138). One of these is the genetically deterMarch-April 2000 mined cycle of life, which we are not free to escape: the neediness of infancy and childhood, the relative turbulence of adolescence, the gradual loss of physical powers in advanced age, and so on. Other crucial factors concern the tools we are given to work with, especially our particular genetic endowment and the quality of our early environment. A final crucial influence derives from the unexpected, random, yet momentous consequences of the things we choose. I once decided somewhat reluctantly to attend a Halloween party where I happened to meet the woman who later became my wife and the mother of my child. While self-creation is possible, the range of possibilities available to an individual is at once opened up and limited by other major processes and factors that shape our lives. na loses these characteristics, will the resulting person really be Marina?11 Elliott’s remarks about Prozac suggest not, but I think a negative answer here is profoundly mistaken— and not just because of the associated image of a static self. For, again, what is identity in the relevant sense all about? It is about one’s self-conception, what a person considers most important to who she is, her self-told inner story. That means that it is ultimately up to Marina to determine what counts as Marina and what counts as not-Marina; the story is hers to write (within the constraints set by the various factors beyond her control). And she wants to get rid of the traits in question, if she can. In general, whether certain personality traits are definitive of someone depends on whether she identifies with them—that is, whether she owns It is ultimately up to Marina to determine what counts as Marina and what counts as not-Marina; the story is hers to write. In this moderate view, self-creation is conceived of in the way suggested by Jonathan Glover, for whom it is a process in which we are “consciously shaping our own characteristics.”10 I understand Glover to mean specifically the conscious and deliberate shaping of one’s own personality, character, or life direction. Glover captures the interplay of self-directed shaping as well as its limits by comparing the self to wood that can be sculpted, “respecting the constraints of natural shape and grain” (p. 136). People who are engaged in selfcreation seek to change themselves. Marina, for example, wants to change her personality. While she has been tentative, socially a bit mistrustful, and somewhat obsessive for as long as she can remember, she would like to be free of these personality traits. But this raises a conceptual issue: If Mari- them (pun intended!) autonomously. An example will help make the point. Imagine two people, Nina and Xena, both of whom are inveterate, addicted cigarette smokers. Both spend a lot of money on the habit, both find it very inconvenient at times, and both are unsure they could muster the willpower to quit if they tried. Is being a smoker part of their respective identities? In my view, that depends on further detail. Suppose that they have different attitudes toward their addiction. Nina finds it alien and out-of-character and wishes she never smoked that first cigarette. Xena, meanwhile, delights in being contrarian and knows that smoking and addiction generally are contrary to what most people consider good sense. While in a way her addiction deprives her of the freedom not to smoke—she just has to light up periodically—Xena is auHASTINGS CENTER REPORT 37 tonomously a smoker, precisely because she identifies with smoking along with its delightfully contrarian associations. So while both women are smokers, being a smoker is part of Xena’s identity but not part of Nina’s, and the difference lies in their distinct value systems. This consequence should not be surprising, since who we are has everything to do with what we value. Further, what we value largely determines our projects of self-creation. Thus if Marina is able to rid herself of traits with which she doesn’t identify, and decides that the “real Marina” does not have those traits, no one is in a position to correct her. What legitimate basis might there be, then, for the idea that it would be inauthentic for Marina to change her personality? Do the means of making a personality change—in this case, using Prozac—matter here? Some would answer affirmatively, contending that these means represent an unnatural or artificial shortcut to selfimprovement. But consider a path to desired self-change that would be regarded as natural, admirably laborious, and clearly within the bounds of accepted psychiatric practice: psychotherapy. Successful psychotherapy sometimes produces a shift in personality that the patient considers an improvement.12 Now suppose Marina wanted to change her personality through the long, hard work of therapy. If she were willing to pay for it, I can imagine no reasonable objection to her enhancement project (“cosmetic psychotherapy,” we might call it, keeping in mind that she is not genuinely ill). So I take it that therapy is an authentic and otherwise legitimate way of facilitating self-creation, even where enhancement is the goal. The question is, why should the supposedly unnatural shortcut of Prozac use make any significant difference to the authenticity of Marina’s self-creation project? That it is “unnatural”—that it works directly on her biochemistry rather than indirectly, as therapy does—simply seems 38 H A S T I N G S C E N T E R R E P O R T irrelevant; the shortcut would still be authentic because Marina’s values and self-conception are the basis for the chosen means. That it involves a shortcut might even, in some ways, make it admirable from a prudential standpoint. After all, it is her time and money that will be consumed here. While therapy may offer a patient some advantages that Prozac does not, if Marina believes those advantages do not offset the efficiency she hopes to find in Prozac, it is hard to see the justification for paternalistically judging that her values and self-conception are not authoritative for her own life. If they are admitted to be authoritative for judging what is good in her life (her best interests), then they should be authoritative for determining what constitutes her life, thus what is authentic for her. If this is right, then Prozac, no less than psychotherapy, can be an authentic part of a project of self-creation. Some Remaining Worries I f the preceding arguments have been sound, they show that using Prozac can be an authentic part of a self-creation project, even in cases that involve enhancement. This conclusion of possible authenticity seems generalizable to other cases of cosmetic psychopharmacology—at least assuming that an adult with decisionmaking capacity is deciding only for herself, since decisions for children and incapacitated adults raise special issues.13 But even if the charge of inauthenticity is wrongheaded, it does not follow that cosmetic psychopharmacology is ethically justified or wise. There remain some substantial ethical concerns about cosmetic psychopharmacology for capable adults like Marina. In the end, I do not think these concerns demonstrate that Marina’s psychiatrist should refrain from prescribing Prozac for her, or that Marina should exclude Prozac from her project of self-creation. But I will only gesture in the direction of an adequate reply to each concern. One concern is that Prozac, and other pharmaceuticals that could be used for enhancement purposes, are not available to all who might want and stand to benefit from them.14 Forty million or so Americans lack health insurance, and many others are insured by plans that do not cover prescriptions for psychiatric medications or that provide coverage only when one has a diagnosible illness. Of course, the relatively wealthy can still opt to pay out of pocket. But the overall picture is one in which cosmetic psychopharmacology is likely to benefit mainly those who are relatively well off and otherwise advantaged. Thus by exacerbating existing gaps between the haves and have-nots in our society, cosmetic psychopharmacology raises issues of social and economic fairness. These concerns about unfairness are legitimate. But the unfairness derives from our economic system—including our system of health care finance, which promotes the interests of the private insurance industry at nearly everyone’s expense—rather than from Marina’s or her psychiatrist’s choices. In my view, they and everyone else should fight for greater justice in the distribution of income, wealth, and health care access, but doing so is compatible with Marina’s use of Prozac. In fact, if Marina is right that taking Prozac would cost less than psychotherapy, her project raises a milder problem about justice than does therapy, since the more expensive approach would be available to even fewer people. Another worry is that cosmetic psychopharmacology tends to promote some very troubling cultural values. Part of what drives Marina’s interest, for example, is her desire to be more efficient at work and her longing for a more attractive personality. Since she is already professionally successful and has good friendships, one might think her desire for self-improvement reflects our culture’s disturbing tendency to valorize hyper-competitiveness and “designer” personalities. Thus her plan and her March-April 2000 psychiatrist’s involvement (if he goes along) raise the issue of complicity with suspect social norms.15 I agree that our society overvalues competitiveness and other yuppie qualities. But it seems to me that reasonable people could disagree with this judgment, and that in any case, responsibility for this problem too should be located in our broader culture, not placed in the laps of Marina and her psychiatrist. If there is a responsibility to change the culture, it is everyone’s, and it should not be arbitrarily imposed on particular individuals in ways that interfere with their self-regarding projects. Some critics also feel that widespread use of Prozac and similar drugs, unlike psychotherapy, promotes biopsychiatry’s agenda of reducing emotional and personal struggles to mechanistic terms—as if these struggles were just another form of pain to be treated with a new pill.16 According to critics, this agenda threatens our self-conceptions as reasonable agents. But people might not be equally troubled by the possibility that using Prozac supports biopsychiatry’s agendas. In any event, Marina and her psychiatrist have no obligation to promote the image of human beings as reasonable agents. We are such agents, but we are also feeling creatures; self-esteem problems, suspiciousness, and compulsiveness are connected with our agency, but they are also closely connected to unpleasant feelings, which Prozac may help to alleviate. Besides, even if Prozac lends itself to a mechanistic view of the self in some ways, Marina’s plan for changing herself and her life direction is a powerful expression of her own agency. Another concern is that cosmetic psychopharmacology can encourage social quietism because patients may favor drug-induced complacency over active struggle to change the social conditions that contribute to their discontent, with the result that these social problems are left untouched.17 But while there may be some risk of social quietism, the risk March-April 2000 attaches to all uses of mood-improving drugs, not just to cases of cosmetic psychopharmacology, as well as to mainstream religions and many other clearly acceptable practices and institutions that can brighten our outlooks. Critics have also pointed to problems that may arise if people pursue cosmetic psychopharmacology for competitive reasons, such as Marina’s desire to become a more confident businessperson. If nearly everyone in a particular competitive environment makes the same choice, the result will be self-defeating: there will be the expense and other personal costs of taking the drug but no advantage acquired over others (just as most law school applicants take an LSAT prep course without gaining a competitive advantage).18 Meanwhile, those who cern highlights the importance of an informed consent process that includes a responsible, balanced, and thorough discussion of risks; it does not justify paternalistically preventing use of the drugs in question. Permissibility and Prudence A s the tone of this essay may have revealed, I believe the kind of self-transformation Marina proposes can be quite admirable. At the very least, transformation via cosmetic psychopharmacology can be a perfectly authentic piece of self-creation, in that the resulting personality and life are very much one’s own. One can identify with certain traits, authentically pursue them, and change oneself—while maintaining one’s identity—within a project of self-creation. Transformation via cosmetic psychopharmacology can be perfectly authentic, in that the resulting personality and life are very much one’s own. would prefer not to take the drug may feel social pressure and possibly coercion to do so; they may fear falling too far behind.19 At least with respect to Prozac, however, concerns about self-defeating drug enhancements and excessive social pressure to take it are rather speculative. We are still far from such a scenario.20 What to do if and when it arrives is not at all obvious (just as there is no obvious solution to the problem concerning the LSAT prep course), but the mere possibility of such a scenario does not cast significant moral doubt on Marina’s enhancement project. Finally, we should not ignore whatever risks are associated with the drug in question, especially since some risks may remain unknown while others may be hard to discern accurately amid the glitter of the drug’s celebrated benefits. This con- At the same time, the wisest path toward desired self-creation may often include the slow, arduous road of psychotherapy, despite its considerable costs. For those who are willing to work and confront some unpleasantness about themselves or their lives, and who possess at least ordinary introspective capacities, psychotherapy offers insights that are generally not available from other sources or activities. Moreover, the changes in personality, character, or life plans that result from this vigorous work stand a decent chance of enduring, while people who go the route of cosmetic psychopharmacology may need to take the drugs indefinitely to maintain the desired changes. In effect, it may turn out that therapy is the less expensive option after all, at least in the long run. If Marina were my friend or famiHASTINGS CENTER REPORT 39 ly member, I would urge her to consider extended therapy very seriously. I might even try to make the case that its likely benefits more than offset its added costs. But the values that ultimately count here, the ones that must be translated into benefits and costs of various weights, are Marina’s. If she assesses her options with her eyes wide open, she should be allowed to select that which she believes is best for her. It is, after all, her identity. References 1. C. Elliott, “The Tyranny of Happiness: Ethics and Cosmetic Psychopharmacology,” in Enhancing Human Traits: Ethical and Social Implications, ed. E. Parens (Washington, D.C.: Georgetown University Press, 1998), pp. 177-188, at 182, 186. Erik Parens, who edited the excellent anthology that contains Elliott’s article, seems to concur with him. Thus Parens speaks of “appreciating that drugs like Prozac are good at promoting self-fulfillment as opposed to authenticity” (E. Parens, “Is Better Always Good? The Enhancement Project,” in Enhancing Human Traits, pp. 1-28, at 23). 2. E. T. Juengst, “What Does Enhancement Mean?” in Enhancing Human Traits, pp. 29-47, at 29. 3. P. D. Kramer, Listening to Prozac (New York: Viking Press, 1993). 4. See L. H. Diller, “The Run on Ritalin: Attention Deficit Disorder and Stimulant Treatment in the 1990s,” Hastings Center Report 26, no. 2 (1996): 12-18; C. Mills, “One Pill Makes You Smarter: An Ethical Appraisal of the Rise of Ritalin,” Report from the Institute for Philosophy and Public 40 H A S T I N G S C E N T E R R E P O R T Policy 18, no. 4 (1998): 13-17; P. J. Whitehouse et al., “Enhancing Cognition in the Intellectually Intact,” Hastings Center Report 27, no. 3 (1997): 14-22; J. Slomka, “Playing with Propranolol,” Hastings Center Report 22, no. 4 (1992): 13-17; and J. Glover, What Sort of People Should There Be? (London: Penguin, 1984), pp. 71-72 (on ginseng). 5. See ref. 1, Elliott, “The Tyranny of Happiness,” pp. 178, 186. 6. J. Glover, I: The Philosophy and Psychology of Personal Identity (London: Penguin, 1988), p. 152. 7. Marya Schechtman emphasizes this point in what may be the strongest theoretical exploration of this sense of personal identity (The Constitution of Selves [Ithaca, N.Y.: Cornell University Press, 1996], esp. Part II). 8. This position is helpfully explored and criticized in ref. 6, Glover, I, ch. 17. 9. J. P. Sartre, Being and Nothingness, tr. H. E. Barnes (New York: Philosophical Library, 1943). 10. See ref. 6, Glover, I, p. 131. 11. Kramer raises this conceptual issue in the case of his own patients (ref. 3, Listening to Prozac, pp. 18-19). 12. Sometimes a personality change may result from the patient’s rewriting her inner story, since this story is about who she is. Cf. ref. 6, Glover, I, p. 153. For a classic background work, see Sigmund Freud, Introductory Lectures on Psychoanalysis (New York: Norton, 1960 [1920]). 13. Much of the concern about Ritalin, for example, focuses on parental consent on behalf of children, sometimes in apparent conflict with their best interests. See ref. 4, Diller, “The Run on Ritalin” and Mills, “One Pill Makes You Smarter.” 14. D. W. Brock, “Enhancements of Human Function: Some Distinctions for Policymakers,” in ref. 1, Enhancing Human Traits, pp. 48-69, at p. 59. . 15. Cf. ref. 1, Elliott, “The Tyranny of Happiness.” Regarding this problem in connection with Ritalin, see ref. 4, Diller, “The Run on Ritalin,” p. 17; and regarding the more frightening case of prescribing for children, see ref. 4, Mills, “One Pill Makes You Smarter,” pp. 16-17. For an insightful discussion of complicity with suspect cultural norms, see Margaret Olivia Little, “Cosmetic Surgery, Suspect Norms, and the Ethics of Complicity,” in ref. 1, Enhancing Human Traits, pp. 162-76. 16. This viewpoint is powerfully developed in Carol Freedman, “Aspirin for the Mind? Some Ethical Worries about Psychopharmacology,” in ref. 1, Enhancing Human Traits, pp. 135-50. 17. See ref. 1, Elliott, “The Tyranny of Happiness,” p. 180; ref. 4, Glover, What Sort of People Should There Be?, pp. 72-73 and ref. 4, Diller, “The Run on Ritalin,” pp. 14-15. 18. See ref. 14, Brock, “Enhancements of Human Function,” p. 60. 19. See ref. 4, Diller, “The Run on Ritalin,” p. 16 and Slomka, “Playing with Propranolol,” p. 15. 20. We are probably closer in the cases of Ritalin for schoolchildren and Propranolol for professional musicians (see cites in previous note). My sense is that the associated difficulties are so closely tied to the features of a particular drug and the social context in which it is used, that we cannot profitably generalize from a viable solution for one drug to cosmetic psychopharmacology in general. March-April 2000
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