The mixed promise of genetic medicine.

I n the early decades of the 20th century, most Americans considered cosmetic surgery to be just a few steps removed from quackery. Many observers saw the desire for cosmetic surgery as a mark of vanity, and physicians tended to believe that such surgery violated their ethical injunction to do no harm. Yet by the end of the century , cosmetic surgery had become a multibillion-dollar business, and it is now an accepted part of mainstream medicine, with its own professional journals and associations. Cosmetic-surgery clinics are sponsored by elite academic centers such as Stanford, Johns Hop-kins, and the Mayo Clinic. Even some feminists embrace cosmetic surgery as a tool for self-fulfillment. What happened to produce such a dramatic change? One relevant development may have been the rise of academic psychology and its acceptance by consumer culture. By midcentury, at least some Americans had been persuaded that cosmetic surgery could be seen as a medical treatment for psychological problems such as the inferiority complex. According to this view, cosmetic surgery was not quackery or vanity or even merely cosmetic; as historian Elizabeth Haiken writes, it was " psychiatry with a scalpel. " 1 This view lined up nicely with a more expansive, holistic conception of medicine itself. If a legitimate purpose of medicine is to improve a patient's psychological and social well-being, why not accomplish that purpose with sur-gery? The transformation of " enhancements " into " treatments " is now a familiar part of medicine, of course, and it has been accelerated by medicine's move into the consumer marketplace. Physicians today prescribe drugs to lengthen attention spans, strengthen erections , and smooth out wrinkled brows, even when they are not entirely convinced that what they are treating is a medical need rather than a consumer desire. Many others write prescriptions for conditions that blur the boundary between pathology and ordinary human variability: synthetic growth hormone for idiopathic short stature, antidepressants for social anxiety disorder, and hormone replacement therapy for the effects of menopause. The line between what consumers want and what patients need has become very hard to draw. It may become even more difficult with the advent of genetic medicine, which, according to its advocates, promises us even greater control over our own constitutions. Not only will we be able to eliminate genetic disorders, claim the advocates, but we will produce genetically superior people. With the new " …