Sunday, November 16, 2008

Review of The Limits of Medicine by Andrew Stark

This review appeared in Philosophy in Review, Volume 27, Number 3 (2007), pages 227-230.

Andrew Stark. The Limits of Medicine. New York, Cambridge University Press, 2006. Pp. 256. $70.00 (Cloth: ISBN 978-0521856317); $25.99 (Paper ISBN 978-0521672269)

The Limits of Medicine addresses the enhancement debate in philosophy of medicine. Stark, a professor of strategic management at the University of Toronto at Scarborough, proceeds methodically through three main issues, using eight sorts of cases of purported enhancement to explain and develop his view. There are three chapters, bookended with an introduction and a conclusion. The first chapter examines the distinction between cure and enhancement; the second chapter asks when enhancements may reduce the authenticity of those who get them; and the third chapter scrutinizes when enhancements might be a form of cultural genocide. The eight conditions Stark considers for each chapter are "physical slowness for competitive runners, mild depression, black racial features, plain facial features, deafness, blindness, obesity, and anorexia" (17).

Stark rejects biological approaches to defining normality. He argues we need to use social norms in defining what counts as a medical condition, so that in one society, a condition can be normal, while in another the same condition can be abnormal. Specifically, his approach is that a condition can be seen as abnormal when the group of people who have that condition legitimately view their condition as socially abnormal. Clearly, a great deal of weight rests on the concept of legitimacy here.

According to Stark, when the frequency of a condition (mood, for example) is distributed over a bell curve, the curve itself gives us no help in determining the lines of normality. One reason for this is that a bell curve "has no landmarks," he says, quoting Edmond A. Murphy (36), and so it does not tell us where to draw the limits between normality and pathology. He says that standard deviations are not of "much help in precluding debate over the cutoff of norm on a bell curve" (37). By way of contrast, Stark argues that other distributions give more direction about where to make the demarcation between normality and disease. He argues that when "a group's condition falls not on the hump at all but on the recognizable tail of a skewed curve, it conclusively lies outside the norm" (39). He concedes in a footnote that "It's true that there can be disagreement as to where exactly the tail of a skewed curve begins" (208). Stark's point that some distributions of frequency of conditions are more easily separated into normal and pathological than others seems reasonable, but his suggestion that a bell curve gives no help in making the division is overstated. Having a bell curve distribution does not dictate where to draw the line between normal and abnormal, but it provides some help, and makes the decision at least slightly less arbitrary.

The approach taken by Stark allows for the medicalization of many conditions. He summarizes his view as follows: a condition is medical "if members of the group harboring the condition can legitimately view their phenotypic condition as falling outside the social norm ... or deem others to have reached the social ideal" (83). He argues that seven of his "eight conditions" are medical; only having black racial features would not count as a medical condition on his view. Maybe the least convincing case here concerns the slow runners. He defines a slow runner as someone "for whom there are always other runners capable of beating him, assuming that he and they all engage in the same rigors of training, exercise, and diet" (72). Stark argues that if they so wish, runners who are faster than the average for runners can still legitimately count themselves as in need of a cure (although not necessarily abnormal) because there are other people who are faster than them. He emphasizes that the fastest runner cannot claim a disordered status, because in order to count as disordered, one has to be slower than an actual runner, not just a possible runner, on his view.

It is implausible that Stark will capture all ordinary intuitions about what counts as a medical problem with his approach. While his general stance is clear enough, and he examines various cases in some detail, it is often difficult to discern the central ideas that motivate his approach. This elusiveness characterizes the second and third chapters as much as the first. Stark sets out what he calls a "Kantian" view of authenticity, which he explains has two main points. First, it is egalitarian in that people should not have advantages over others due to their inborn attributes or dispositions so it is legitimate to cure those with medical conditions to make them equal to others. Second, and with top priority, "cure should never diminish a person's genuine, struggle-born achievement, whatever it may be" (93). The basic idea seems to be that personal struggle and striving is good and provides authenticity, so cures should not be used to reduce struggle. Stark's insight here about the central role of struggle in the debate about the inauthenticity or artificiality of enhancements is important and worth emphasizing. Stark argues that when a person uses a technology to change herself and achieve more, this is compatible with an authentic life so long as she continues to struggle. This is clear enough, but when he argues that it would be inauthentic for slow runners to use steroids, on the grounds that this would erode genuine achievement, it is difficult to specify why this sort of case is different from the other seven cases.

The third chapter addresses the concern about enhancement enabling a cultural genocide of minority groups such as the deaf, the blind, the depressed, and so on. He introduces conceptions of "cultural spouses" and "cultural siblings" and with a complex argument arrives at the conclusion that the only group for which we might have a medical cure (remember that race is not a medical condition on his view and so is not a candidate for cure) that should not be used due to cultural considerations is that of the plain featured. Again, readers will likely finish the chapter unsure of how to assess the arguments.

The Limits of Medicine is intriguing yet ultimately disappointing. Stark would do well to restate his central arguments more succinctly in shorter papers making clearer the heart of his logic.

Christian Perring, Dowling College

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