BIOETHICS
October 1, 1999

Viagra® and Other Dilemmas of Enhancement Medicine

Lately, a number of my friends have told me that they are considering getting some Viagra®. Not because they have "erectile dysfunction" — at least, not that they know of. But most of them have been married for many years and sex for them has become, well, somewhat predictable.

Getting the drug would be easy, even though it would be for a use for which it isn't supposed to be prescribed. Physicians are free to prescribe drugs for unapproved uses, subject only to potential liability for malpractice if the patient is injured. Yet, there have been reports of serious side effects. Most of my friends and their wives are sufficiently committed to one another that, if they decided for safety reasons not to take Viagra®, their marriages probably would go on much the same as before.

But what if their wives were much younger and/or the husbands even older? Or suppose the men weren't married but still dating. Viagra®, then, might be much more important for them. Without it, they might not be able to compete successfully in the sexual marketplace, particularly given the number of men using the drug.

People long have taken various substances to improve performance, from caffeine, nicotine and amphetamines for alertness and concentration, to steroids (American baseball home run king, Mark McGuire, acknowledged using a non-prescription, dietary supplement steroid), erythropoeitin and human growth factor for athletic ability. Until Viagra®, however, the primary legitimate medical technique for personal enhancement has been cosmetic surgery, comparatively expensive and uncomfortable.

Better-Thinking Drugs
Being relatively cheap, easy-to-use, and apparently highly effective, Viagra® ushers in a new era of widely available enhancement medicine. In its wake will be drugs that enhance our ability to think, which are being developed to treat Alzheimer's and other cognitive impairments but which, like Viagra®, will be demanded by "normal" people looking for a brain boost.

Still farther off, but not so far off that they can be ignored, are enhancement technologies that will grow out of the Human Genome Project, including new classes of drugs to enhance heritable traits, genetic selection of optimal embryos, and, ultimately, genetic engineering. Individuals with access to these technologies will gain significant, perhaps decisive advantages over others.

Who, then, will gain access to enhancement medicine and genetic engineering? It depends on how expensive they are and how much a person can afford. Like cosmetic surgery, expensive enhancements will be beyond most peoples' budgets. Even Viagra® is too costly for the poor. Health plans will refuse to cover enhancements, just as they exclude coverage for cosmetic medicine. Fearing to become embroiled in disputes over when an intervention is therapeutic or merely enhancing, many plans simply will throw up their hands and deny payment for whole classes of products, as illustrated by the refusal of many state Medicaid programs to pay for Viagra®.

Plans that continue to cover only therapeutic uses will find themselves intruding even further into the patient-physician relationship and into their enrollees' private lives. (Imagine having to prove to a health insurer that you really do suffer from erectile dysfunction.) Similarly, most genetic technologies would probably not be covered, since they would be used not for curing a disease but for enhancing normal characteristics, such as raising I.Q.

This, in turn, will mean that only those individuals who are relatively well off will gain access to advantageous enhancements, thereby further cementing their economic and social well-being, and creating, in effect, a genetically-based caste system. In competitions for scarce social rewards, poorer people won't stand a chance.

There are no simple solutions. The cost of paying for even relatively inexpensive items or services to large numbers of people makes it unlikely that public or private health plans can afford to provide widespread access to enhancement medicine. Making enhancements illegal would spawn a massive black market. Banning research on enhancements is unrealistic, since no one will want to prevent the realization of so much therapeutic potential. Expecting physicians to limit patient access in the interests of society arguably misinterprets their proper professional role.

Can the Playing Field Be Leveled?
The most creative response would be to try to level the playing field so that individuals could not take advantage of their enhanced abilities in competitions with the unenhanced. But, as the difficulty of interdicting the use of performance-enhancing drugs in sports demonstrates, this would require an accurate method of detecting when someone was enhanced, along with a willingness to demand widespread blood or urine sampling, say, before negotiating a contract, taking a college entrance exam, or buying a major appliance or a new car.

Different techniques will need to be employed depending on the circumstances. Some enhancements, perhaps the kind of genetic manipulation that affects future offspring will be made illegal. The government will pay for some enhancements under its entitlement programs and will mandate coverage in some cases by private insurers. A lottery open to every adult could provide access to a package of genetic enhancements equal to what could be purchased on the open market. Courts will undo unfair deals between enhanced and unenhanced parties. Kids will be screened for enhancements before being allowed to take SATs. The important thing is to be alert to the threat that enhancement medicine represents to the principle of equal opportunity and the risk of unfairness that it creates in interpersonal transactions.

In the meantime, some of my friends are no doubt planning romantic evenings with their wives, as soon as they get back from the drug store.
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