The Pursuit of Perfection: The Promise and Perils of Medical Enhancement

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What does it mean to live in a time when medical science can not only cure the human body but also reshape it? How should we as individuals and as a society respond to new drugs and genetic technologies? Sheila and David Rothman address these questions with a singular blend of history and analysis, taking us behind the scenes to explain how scientific research, medical practice, drug company policies, and a quest for peak performance combine to exaggerate potential benefits and minimize risks. They present a ...
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Overview

What does it mean to live in a time when medical science can not only cure the human body but also reshape it? How should we as individuals and as a society respond to new drugs and genetic technologies? Sheila and David Rothman address these questions with a singular blend of history and analysis, taking us behind the scenes to explain how scientific research, medical practice, drug company policies, and a quest for peak performance combine to exaggerate potential benefits and minimize risks. They present a fascinating and factual story from the rise of estrogen and testosterone use in the 1920s and 1930s to the frenzy around liposuction and growth hormone to the latest research into the genetics of aging. The Rothmans reveal what happens when physicians view patients’ unhappiness and dissatisfaction with their bodies—short stature, thunder thighs, aging—as though they were diseases to be treated.

The Pursuit of Perfection takes us from the early days of endocrinology (the belief that you are your hormones) to today’s frontier of genetic enhancements (the idea that you are your genes). It lays bare the always complicated and sometimes compromised positions of science, medicine, and commerce. This is the book to read before signing on for the latest medical fix.

ABOUT THE AUTHORS:

Sheila M. Rothman is Professor of Public Health at Columbia University. Her books include Living in the Shadow of Death. Her articles in the New York Review of Books and other periodicals, often cowritten with David Rothman, address human rights and medicine. She is now investigating the social and ethical implications of linking race and ethnicity to genetic disease.

David J. Rothman is Bernard Schoenberg Professor of Social Medicine and History at Columbia University. His books have explored the history of prisons and mental hospitals and the impact of bioethics and law on medicine. He has just been named president of the Institute on Medicine as a Profession, funded by George Soros.

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Editorial Reviews

The New York Times
Noting the ''admittedly flimsy line between cure and enhancement,'' the authors shrewdly look backward at the history of medical innovation over the past century. The Rothmans (she is professor of public health, he is professor of social medicine and history at Columbia University) argue that many medicines begin as therapies for clearly recognized diseases but quickly assume second careers as medical enhancements -- a transition, they note, increasingly driven by the sophisticated marketing of powerful pharmaceutical companies (think Viagra). Their conclusion (though they never quite gather this sentiment in a satisfyingly declarative way) is that many future treatments will also turn out to be negligibly effective as enhancements while posing real risks to long-term health. There is no free lunch in biology. — Stephen S. Hall
The Washington Post
Is being short a medical problem that warrants treatment? What about the diminished strength that accompanies lower testosterone levels in men as they age? Is treatment for these and similar conditions, even if it proves harmful or deadly years later, justified if it alleviates personal unhappiness, even misery? These are among the provocative questions that Sheila M. Rothman and David J. Rothman, a married pair of eminent medical historians from Columbia University, thoughtfully explore in their new book, The Pursuit of Perfection: the Promise and Perils of Medical Enhancement.The book wisely eschews answers to these endlessly debatable questions. Instead the authors provide a frequently eye-opening view of the skimpy or dubious scientific evidence that resulted in the aggressive marketing of hormone replacement therapy for women, testosterone enhancement for men, human growth hormone for short children and liposuction for unwanted flab. — Sandra G. Boodman
Publishers Weekly
This thoughtful but inconclusive book sends a mixed message as to whether it's the proper role of doctors to medicate or perform surgery on patients whose only medical complaint is unhappiness or inconvenience. Professors, respectively, of public health and of social medicine and history at Columbia University, Sheila Rothman and David Rothman consider the various uses of estrogen, testosterone, human growth hormone, liposuction and genetic manipulation, showing that these options have from the beginning blurred the line between cure and enhancement. Focusing heavily on how pharmaceutical corporations and physicians profit in the promotion of enhancement therapies, the authors argue that products were marketed to the public without due attention to their possible risks and that studies questioning their benefits and citing related health hazards have been consistently downplayed. At the same time, however, they acknowledge that consumers continue to demand enhancement therapies even when risks are known. Liposuction, for example, has become the most commonly performed plastic surgery, despite a "startling" mortality rate of one in 5,000. Since there is "no consensus on the meaning of enhancing the body" and because consumers perceive liposuction as easy and desirable, the procedure is here to stay. The prose is dry, and there's a shortage of interesting medical case histories, but the book ends with an intelligent exploration of how genetic research could lead to procedures that would double existing life spans. Admitting the serious ethical reservations such a possibility raises even among physicians themselves, the authors end on a disappointingly equivocal note: "Yes, there will be risks-but just imagine enjoying the benefits of an extra seventy years." Photos not seen by PW. (Nov. 4) Copyright 2003 Reed Business Information.
Library Journal
The Rothmans (both medical historians and professors, Coll. of Physicians and Surgeons, Columbia Univ.) examine the history of medical enhancement to further our understanding of the current genetic engineering revolution. Central to their analysis is the blurring of the definitions of cure and enhancement by the medical and research communities and the industries that benefit from this confusion. At risk, they say, is the consumer-patient (most often a woman) sold therapies by a system that has historically underrepresented risks and ambiguous research results. The authors examine the development of hormone replacements (e.g., estrogen, testosterone, and growth hormone), plastic surgery, and the rise of the cosmetic and pharmaceutical industries, revealing a system out of balance; Viagra and herbal supplements are missing, even though they seem within the book's scope. The Rothmans conclude that enthusiastic patients, physicians, and marketing departments are likely to forge a similar path into the field of genetic engineering. Although academic in focus, this excellent distillation of the historical record-thorough but not overbearing in length-is well suited to larger public libraries.-Andy Wickens, King Cty. Lib. Syst., WA Copyright 2003 Reed Business Information.
Kirkus Reviews
A critical look at the historical record of medical enhancements as influenced by science, medicine, culture, and commerce, and the lessons to be learned from past experience. The Rothmans, both historians at Columbia, examine how what started out as cures have turned into enhancements. Beginning with the new science of endocrinology in the 19th century, they reveal how hormones came to be seen as offering a promise of reshaping lives. With the growing relationship of research and commerce in the 20th came a dramatic increase in the sale of prescription drugs, especially hormone preparations such as estrogen. Gynecologists and endocrinologists extolled their use, and many women demanded them, assured that they could, with estrogen's help, remain forever feminine. The assumed benefits long overshadowed the potential risks. Similarly, testosterone was promoted as the male equivalent, but, as the Rothmans report, it was the lack of patient demand, not the reluctance of physicians to prescribe it, that kept it from becoming a bestseller. The story of liposuction offers further evidence of how the allure of enhancements for some people and the potential for financial gain for some physicians has muted the attention paid to the risks involved. The use of human growth hormone for children of below-average height is a story of the turning of a socially undesirable or disadvantageous condition into a disease. Children have not been the only ones to be subjected to questionable interventions. Soon the use of human growth hormone products to enhance the physiques of adults was being promoted in anti-aging clinics, with the emphasis on benefits taking precedence over cautions about possible adverseside effects. The Rothmans argue that experience with such technologies demonstrates that routine oversight will not be adequate to protect consumers making decisions about the enhancements that genetic research will offer, nor will the advice of individual physicians, medical societies, or government regulatory agencies. What consumers need is to better understand the nature of the research and the reliability of the results. A loud and clear caveat emptor, backed up by undeniably disturbing facts regarding the risks and benefits of present-day procedures and future possibilities.
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Product Details

  • ISBN-13: 9780679439806
  • Publisher: Knopf Publishing Group
  • Publication date: 11/4/2003
  • Pages: 320
  • Product dimensions: 6.36 (w) x 9.42 (h) x 1.12 (d)

Meet the Author

Sheila M. Rothman is Professor of Public Health at Columbia University. Her books include Living in the Shadow of Death. Her articles in the New York Review of Books and other periodicals, often cowritten with David Rothman, address human rights and medicine. She is now investigating the social and ethical implications of linking race and ethnicity to genetic disease.

David J. Rothman is Bernard Schoenberg Professor of Social Medicine and History at Columbia University. His books have explored the history of prisons and mental hospitals and the impact of bioethics and law on medicine. He has just been named president of the Institute on Medicine as a Profession, funded by George Soros.

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Table of Contents

Introduction
1 Penetrating Nature 3
2 The Female Principle 22
3 Making Up, Making Over 46
4 Controversies Forever 67
5 The Body As Turf 103
6 Borrowed Manhood 131
7 The Price of Growth 168
8 Peak Performance 208
Notes 235
Acknowledgments 275
Index 277
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First Chapter

Penetrating Nature

For the past 150 years, the biological sciences have been at war with nature, determined to penetrate its secrets in order to perfect it. Investigators are eager to intervene, tamper, modify, and revise the forms and substance of animal life and human life. They may share a grudging respect or even wholesale admiration for the complexity of a biological system or a particular organism, but their readiness to improve on it is not inhibited. The proposition that the natural represents what can be or should be is altogether alien. No matter how intricate the existing design, it may still be enhanced, even if the result might be unusual or unimagined. Biology has no fixed boundaries, only opportunities.

When confronting resistance from a secular or religious spokesmen, some biologists attempt to deflect criticism by conflating scientific methods with scientific goals. Since their methods are objective and neutral, their findings should be considered objective and neutral. Others emphasize the tangible benefits of the research, offering many examples of better and longer living through biology. To be sure, critics challenge their contentions, rejecting the idea of scientific neutrality or the premise that a longer life is a better life. Although their negativity may appear to represent a post-atomic age or post-genomic era response to science, its roots are much deeper. In 1818, Mary Shelley was asking whether Dr. Frankenstein ought to be plundering the graveyards of body parts in order to try to create a living being, and in 1896, H. G. Wells wondered whether Dr. Moreau ought to be transplanting body parts between animals so as to construct a moreperfect beast. But however persistent the hostility, modern biology has not altered its fundamental approach to nature.

Its ambitious, even combative, attitude was articulated with particular brilliance and confidence by the pioneering figure in the field, Claude Bernard. Chair of the Department of Medicine at the Collège de France and a founder of the discipline of physiology, Bernard unabashedly defined nature as the enemy to be conquered. His 1856 book, An Introduction to the Study of Experimental Medicine, set forth a history of science and a method for future biological research.1 His predecessors, Bernard contended, had done little more than use their senses to observe biological processes. Early medical practitioners, for example, felt a patient's pulse, looked to see if the face was flushed, examined the urine, and listened to the chest. If they found a rapid pulse, they tried one remedy; if the urine was cloudy, they tried another. But they never actively intervened to understand the mechanisms responsible for one or another physical condition. In more modern times, biologists and physicians went one step further, observing nature through careful groupings of facts and testing of hypotheses. They treated patients with a drug, analyzed the results, and tried to evaluate its efficacy. But this approach, too, had only limited value, for the physician remained a mere observer of symptoms and outcomes.

Bernard championed a third and very different kind of biology, the "active observation" of nature. To characterize it, he quoted an aphorism from his French naturalist colleague Georges Cuvier: "The experimenter questions [nature] and forces her to unveil herself."2 As Bernard went on to explain: "Experimenters must be able to touch the body on which they act, whether by destroying it or by altering it, so as to learn the part which it plays in the phenomena of nature. . . . It is on this very possibility of acting, or not acting, on a body that the distinction will exclusively rest between sciences called sciences of observation and sciences called experimental."

Bernard's language demonstrates how aggressive experimental science sought to be. The investigator "touches" the body, not gently or respectfully but in ways that alter or even destroy it in order to learn about its functioning. Like a sexual predator, he forces nature to "unveil herself" so he may penetrate her mysteries and fathom her secrets. For Bernard, this very aggression differentiated an older and weaker science of observation from a newer and wiser science of experimentation.

This approach, Bernard predicted, would empower biology to transform nature. "Man becomes an inventor of phenomena, a real foreman of creation. . . . We cannot set limits to the power that he may gain over nature through future progress." Once a scientist made phenomena appear "under conditions of which he is the master," that is, in his laboratory, he would be able to "dominate nature . . . to conquer living nature, act upon vital phenomena and regulate and modify them."6 Bernard was acutely aware of a cultural resistance to the idea of scientist as foreman of creation. But rather than compromise his position, he urged colleagues to ignore popular opinion. Since "it is impossible for men, judging facts by such different ideas, ever to agree . . . , a man of science should attend only to the opinion of men of science who understand him."7

Bernard's vision for biology won over the discipline not only because it promised to unleash the power of science but because it fit so well with the new and powerful framework that Charles Darwin provided to order the natural world. Biological change, as Darwin explained, was inevitable and seemingly ungovernable. On the Origin of Species made clear that the static, hierarchical, and fixed vision of nature that marked earlier thinking had to be replaced, really swept away, by a far more fluid vision consistent with the dynamics of evolution. Darwin, as his biographer E. Janet Browne observes, was inviting people to "believe in a world run by irregular, unpredictable contingencies." A particular species appeared at one stage, adapted itself at another, and become extinct at still another. The mechanisms responsible for these changes were "natural," that is, the result of a non-human (and non-divine) process of selection that no one could control. "The fitness of an individual organism to its environment," as another Darwin scholar, Gillian Beer, has noted, "increases the chance of survival." But the environment is "a matrix of possibilities, the outcome of multiple interactions . . .

prone to unforeseeable and uncontrollable changes." Precisely because the "everyday does not last forever," either on an individual or collective basis, "will and endeavor must always be insufficient. They can never control all the multiple energies of life." The variegated and all-powerful forces of nature would overwhelm the best efforts of any single individual or organism.

But rather than intimidate biology, Darwin actually liberated and emboldened it. His impact is well exemplified in the ambitions of Jacques Loeb. Now more famous in his fictional than in his real-life guise-he was the model for Max Gottlieb in Sinclair Lewis's Arrowsmith-Loeb was a well-honored biologist in the opening decades of the twentieth century. More cogently than others, he staked out a position that his biographer, Philip Pauley, aptly labels the "engineering standpoint" in biology, and helped embed it in American biology.

Loeb made Darwin his starting point for promoting science as a form of action, encouraging biologists to manipulate nature. Giving the "natural" a privileged position within biology made little sense because the natural was nothing more than the result of a mutation that provided one animal with an advantage in survival over another. By definition, this mutation was accidental in origin even as it became the standard for the species; change was driven by chance. Why, then, should biologists give deference to the outcome of chance? Why not encourage science itself to create the variation? Surely human forethought and design were no less desirable than accident in altering nature.

Accordingly, Loeb proposed that biology "gain a deeper and more certain insight into the possibilities for the transformation of the species beyond that which we have at present." The challenge was open-ended, carrying limitless possibilities that Loeb readily described. A biology that was free to innovate might enable investigators to transform human life to the point of preventing "the wasting of the body in old age." They might even discover the means of transforming dead matter into living matter (Frankenstein's ambition realized). The decisive element was to liberate the laboratory from restraints, ideological and doctrinal, so that it could make "the attempt of controlling at will the life phenomena of animals and of bringing about effects which cannot be expected in nature." Here was the foundation for a biology of enhancement.

Yet another consideration drove this ambition forward-the exuberance that came with biology's initial successes in improving upon nature. By the opening decades of the twentieth century, scientists were exhilarated by the knowledge and power that they had already achieved, and with almost childish enthusiasm, anticipated future achievements, provided, of course, that no one blocked their way. Perhaps the most extravagant expression of this outlook came from one of England's most versatile scientists, as comfortable in chemistry as he was in biology, J. B. S. Haldane. To appreciate how confident investigators were about remaking nature and adopting the role of biological and social engineers, the best place to begin may well be Haldane's short and best-selling 1924 book, Daedalus, or Science and the Future.

Haldane's premise was that science must enjoy complete freedom to pursue new knowledge. Indeed, he was remarkably confident that this freedom would be realized for two shrewd and interrelated reasons. The essential spirit of capitalism, which rewarded all types of entrepreneurial activity, was now joined to a pervasive "competitive nationalism," which led countries everywhere to place a premium on scientific advancement. These two forces combined guaranteed that few impediments would block "the advantages accruing from scientific research." With remarkable prescience, Haldane recognized that the drive for markets together with patriotic zeal would ensure that science would be both handsomely supported and left independent.

To Haldane as well as to most other biologists, religious objections

to tampering with the natural or secular sensibilities that privileged

the natural carried no weight. As Haldane dismissively put it: "There is no great invention, from fire to flying, that has not been hailed as an insult to some God." Unrestricted by superstition or ignorance science had already made great progress. Haldane predicted further innovations in travel and communications that would enable "any two persons on earth . . . to be completely present to one another in not more than 1/24 of a second." (The Internet foreseen?) Biology and medicine had already extended the life span of individuals and it was not fanciful to contemplate "the abolition of disease."14 Not only cures but also enhancements were certain to follow. Haldane expected medicine to realize "the direct improvement of the individual," especially through endocrinology. "As our knowledge of this subject increases," he predicted, "we may be able, for example, to control our passions . . . to stimulate our imagination . . . [and] to deal with perverted instincts by physiology rather than prison." Forecasting the synthesis of the female hormone estrogen, he speculated that as biology better understood the chemical substances produced by the ovaries and then isolated and duplicated them, "we shall be able to prolong a woman's youth, and allow her to age gradually as the average man."

Along with other biologists across the political spectrum, Haldane linked the science of eugenics to social advances. New laboratory techniques would create what he called "ectogenic children," born from embryos that had been fertilized and nurtured outside the womb. (It was Haldane's ectogenic fantasy that inspired Aldous Huxley to write Brave New World and popularize the idea of test-tube babies.) Predicting that by 1968 France would be using test tubes to produce 60,000 specially gifted children a year, that the pope would condemn the procedure, and that many people would miss the "old family life," he blithely concluded that "the effects of selection have more than counterbalanced these evils." The "output of first-class music" and "decreased convictions for theft" were two of his examples. "Had it not been for ectogenesis," he declared, "there can be little doubt that civilization would have collapsed within a measurable time owing to the greater fertility of the less desirable members of the population in almost all countries."

In all, Haldane was certain that "scientific knowledge is going to revolutionize human life," asserting the proposition with a vigor that seems not merely excessive but naive to a post-Nazi, post-Hiroshima generation. To be sure, he conceded that "man armed with science is like a baby with a box of matches."18 But scientific progress would allow man to conquer space, conquer time, overcome "the dark and evil elements in his own soul," and ultimately refashion "his own body and those of other living beings."

These fantasies were shared by others, none more inventive than H. G. Wells, the British science fiction writer and socialist agitator. In 1895, Wells published a brief essay, "The Limits of Individual Plasticity," and not only the title but also the contents have a distinct postmodern ring. Invoking Darwin, Wells saw no reason to "give mere subservience to natural selection, or to respect inherited traits as though a living thing is . . . nothing more than the complete realization of its birth possibilities." Rather, "we overlook only too often the fact that a living being may also be regarded as raw material, as something plastic, something that may be shaped and altered . . . and the organism as a whole developed far beyond its apparent possibilities." Through science, "a living thing might be taken in hand and so moulded and modified that at best it would retain scarcely anything of its inherent form and disposition." Biology would so extensively recast physical and mental capacities as to "justify our regarding the result as a new variety of being." Wells did not specify just how the discipline would fulfill this grand challenge, but he did speculate about a future rich with organ transplantation and plastic surgery accompanied by medicine's ability to modify "the chemical rhythm of the creature . . . and methods of growth." He did not "believe that the last word, or anything near it, of individual modification has been reached." We could look forward to living creatures made over "into the most amazing forms."

Biology's impatience with nature and its readiness to improve on it also received preeminent expression in the life's work of Nobel Prize winner Hermann Muller. In the 1930s, Muller demonstrated that the application of X rays to fruit flies created mutations. Not all of these induced changes, of course, were favorable to the survival of the species, but his X-ray technique exemplified the ability of science to alter the genetic composition of living things, and, in effect, to shape the course of evolution. Through its ability to create amazing forms-now in fruit flies but eventually, perhaps, in humans-science was confirming that purposeful activity by man could replace the accidents of nature.

Muller was especially articulate about the propriety and benefits of such strategies. The very title of his 1959 essay, "The Guidance of Human Evolution," in which he reviewed his research career, expressed the essence of his position: "Natural selection is too opportunistic and shortsighted to be trusted to give an advantageous long-term result for any single group of organisms." Among the various species, mankind had been fortunate, so far, to survive and not vanish like so many others, but Muller worried that in time humans might suffer such a fate. He also feared that medical advances joined to an expanded sense of social responsibility might corrupt future genetic stock.
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  • Anonymous

    Posted January 6, 2004

    Interesting Questions, Badly Answered

    The Rothmans' are good at raising questions but questions without answers are an endless source of frustation. As I read this book, I couldn't help but thinking of Lucy Grealy heartbreaking book, 'Autobiography of a Face.' (Go buy it! It is amazing). As a very young girl, Ms. Grealy was diagnosed with a horrible and nearly always fatal form of her cancer that required the removal of nearly 1/3 of her entire jaw. Her faced was remarkably deformed and as a girl and young adult she was subjected to countless taunting and ostracization by her peers and society. She underwent over 40 surgeries to try and repair her jaw, all of them painful and none of them successful. But while it was mainly beauty that Lucy Grealy was seaking, there were also serious medical reasons for her wanting her face back. Was Lucy Grealy seeking an 'enhancement' or a 'cure'? Were Lucy Grealy's doctor wrong to help her seek her jaw back? Does it change the answer to know that Lucy Grealy's pain (from both the surgeries and societal pressures of beauty) led to her drug addiction and ultimate death? So do tell us Drs. Rothman, do women who have double mastecomies have more 'right' to a breast implants then women who are simply seeking their ideal of a female body? How do we begin to draw the line? These are fascinating questions. And I would love to read a book that helped me think through them. Unforutantely this is not that book. The Rothmans' barely even raise these question much less answer them. They preach about risks and costs but this is a life of gray zones. And it so easy to say that women in LA shouldn't seek liposuction to obtain the perfect butt, but much more difficult to say that the woman who had her face slashed with a razor by a mugger on the New York City subway a decade or so ago shouldn't have access to plastic surgery to 'repair' her face. Was her surgery 'elective' or not? It was certainly comestic and not medicially necessary. But if she were your daughter or your wife, and you had to look across the table at her on Thanksgiving and wake up next to her and be confronted with the memory of her slashing every day, or whenever you touched her face, tell me, what would you do? So tell us Drs. Rothman, what are the principals that say 'nea' to one and 'yeah' to the other. Isn't this ultimately personal? And if one accepts the risks who are the Rothmans or anyone else to say otherwise?!? Life is full of risks. Crossing the street is a risk. Investing in the stock market is a risk. Travelling to a Third World country is risky. Getting liposuction is risky. What makes some risks okay and other not okay? Why do I care about the Drs. Rothman opinion on what is and is not acceptable?!? Of course the line between enhancement and cure is fuzzy (do we really need a 320 page book to tell us that!). A series of cases would have been very helpful to get us thinking. And that is what I have tried to provide in this short review. We don't need history lessons. Real life examples would have been so much better. Finally I am deeply disturbed by the distinction the Rothmans' make between endocrinology and genetics. It is really the same thing. Diabetes can be inherited after all. Shocking that two professors at a medical don't see this. But it is exactly this lack of deep and clear thinking that the book is missing and makes it such a frustrating read.

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  • Anonymous

    Posted November 6, 2003

    Silly and Shallow Book

    After seeing David Rothman's interview on the Daily Show, I was eagerly awaiting this release of the book. It is every bit as stupid as I thought it might be and just clueless as David Rothman appeared to be. The Rothmans vacillate between doctor worship and then utter detest of the medical profession. They seem to believe in the myth of the doctor as honorable soul and then are disappointed when the docs do not live up to it. Huh? They believe that the line between cure and enhancement is blurred. But aas it ever really been there though? Is it really dependent on technology, as the authors argue? Or this really nothing more than a red-herring of a distinction? If we could replace eyesight for the blind should we do it? Would that be a cure or an enhancement? If alcoholism is a disease is one ever cured? Is mental illness ever cured? Or is your increased cognitive ability just an enhancement? You're never cured of diabetes but your life is certainly 'enhanced' by having your blood sugar regulated. Does this distinction make any sense in any setting and who cares? It seems as silly as the natural vs. the unnatural. After all jackets aren't natural but I don't see too many right-wing homophobes arguing against them on cold winter days. Are artifical distinctions really worth of 325 page books and $25.00? I wasted my time and money, don't you do it too.

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