The Identity Clinic

"Become who you are," wrote the philosopher Friedrich Nietzsche. A century later, millions of people are taking Nietzsche's advice to heart. But instead of turning to philosophy, they are using drugs and surgery.

"I feel like myself again on Paxil," says the woman in advertisements for that antidepressant; so, supposedly, do users of Prozac, Ritalin, Botox, Propecia, Xenical, anabolic steroids, cosmetic surgery, hormone replacement therapy, and sex-reassignment surgery. Even as people undergo dramatic self-transformations, altering their personalities with psychoactive drugs and their bodies with surgery, they describe the transformation as a matter of becoming "who they really are."

"It was only by using steroids," writes the bodybuilder Samuel Fussell, "that I looked on the outside the way I felt on the inside." With sex-reassignment surgery, writes Jan Morris, "I achieved Identity at last." If Nietzsche were alive today, he might be pitching antidepressants for Pfizer.

Many people nowadays do not expect to find the meaning of their lives by looking to God, Truth, or any other external moral framework. Instead, they expect to find it by looking inward. Being in touch with one's inner feelings, desires, and aspirations is now seen as a necessary part of living a fully human life. To be fulfilled, you must be in touch with yourself. The language of authenticity has come to feel like a natural way to describe our aspirations, our psychopathologies, even our self-transformations.

What is new is the involvement of doctors in fulfilling this desire for self-transformation. In recent decades, doctors have become much more comfortable giving physical treatments to remedy psychological and social problems.

Today doctors give synthetic growth hormone to short boys, or Propecia to middle-aged men to remedy the shame of baldness. Now that enhancement of psychological well-being is regarded by some as a proper medical goal, the range of potentially treatable conditions has expanded enormously.

Is the success of these technologies a problem? Not necessarily. Some drugs and procedures alleviate the darkest of human miseries. For every person using an antidepressant to become "better than well," another is using it for a life-threatening sense of hopelessness. If sex reassignment surgery can relieve a person's suffering, then the question of whether or not it is treating a conventionally defined illness seems beside the point.

Yet remaining untroubled by all this medically induced self-transformation is hard. One worry is about what the philosopher Margaret Olivia Little calls "cultural complicity." As difficult as we may find it to condemn individuals who use drugs and surgery to transform themselves in accordance with dominant aesthetic standards, on a social level these procedures compound the problems they are meant to fix.

The more Asians get plastic surgery to make their eyes look European, for example, the more entrenched will become the social norm that says Asian eyes are something to be ashamed of. The same goes for light skin, large breasts, Gentile noses, or a sparkling personality.

Market pressures compound this worry. For several years now, antidepressants have been the most profitable class of drugs in the US. These antidepressants are not used simply to treat severe clinical depression. They are also widely used to treat social anxiety disorder, post-traumatic stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, eating disorders, sexual compulsions, and premenstrual dysphoric disorder.

Many of these disorders were once thought to be rare, even non-existent. But once a pharmaceutical company develops a treatment for a psychiatric disorder, it acquires a financial interest in making sure that doctors diagnose the disorder as often as possible. This may transform what was once seen as an ordinary human variation - being shy, uptight, or melancholy - into a psychiatric problem. The more people who are persuaded that they have a disorder that can be medicated, the more medication the company can sell.

Perhaps the hardest worry to pin down is what Harvard political theorist Michael Sandel calls "the drive to mastery." Sandel is worried less about the possible consequences of enhancement technologies than about the sensibility they reflect - a sensibility that sees the world as something to be manipulated and controlled.

As Sandel points out, perhaps we could design a world in which we all have access to mood-brightening drugs and cosmetic surgery; in which athletes have access to safe, performance-enhancing drugs; in which we could safely choose and manipulate the genetic traits of our children; and in which we eat factory-farmed pigs and chickens that are genetically engineered not to feel pain.

Many of us would resist such a world -- not because such a world would be unjust, or because it would lead to more pain and suffering, but because of the extent to which it has been planned and engineered. We would resist the idea that the world exists merely to be manipulated for human ends.