Emily's Scars: Surgical Shapings, Technoluxe, and Bioethics

Author(s): Arthur W. Frank

Source: The Hastings Center Report, Vol. 34, No. 2 (Mar. - Apr., 2004), pp. 18-29
Published by: The Hastings Center
Stable URL: http://www.jstor.org/stable/3527682 .
Accessed: 03/03/2011 09:37
Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at .
http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless
you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you
may use content in the JSTOR archive only for your personal, non-commercial use.
Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at .
http://www.jstor.org/action/showPublisher?publisherCode=hastings. .
Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed
page of such transmission.
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of
content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms
of scholarship. For more information about JSTOR, please contact support@jstor.org.

The Hastings Center is collaborating with JSTOR to digitize, preserve and extend access to The Hastings
Center Report.

http://www.jstor.org

F4Ut'.

4S

S64rs
SURGICAL

SHAPINGS,
by /ARTHUR W. FRANK

TECHNOLUXE,

AND
medicineis used to remodel, revise,
Increasingly,

BIOETHICS

and rrevampas much as to heal and mend. It is tempting

to sa)y that people make merely personalchoices about

for
these new uses. Butsuch choices have implications
everyybody,and they ought to be made cautiously,slowly,
and irn a way that opens them to discussion.

The limits are unknownbetweenthepossibleand the

impossible,what is just and what is unjust,legitimate
claimsand hopesand thosewhichare immoderate.
EmileDurkheim,Suicide (1896)

ny illusion that the Hastings Center project

on SurgicallyShaping Children (SSC) was
bout otherpeople-people with rareconditions including achondroplasia(genetic dwarfism),
anomalous genitalia,and craniofacialdeformitieswas lost one day as I went for a walk. I passeda person with a physical characteristicthat was normal
enough but still precipitatedmy thinking, "I'mglad
my body'snot like that."And then without discernable pause: "But if it were, I could get that sort of
thing fixed."At that point, moral and sociological
sense returnedand I noted that my judgmentalreaction to another'sbody was shapedby my coincidenArthurW. Frank,"Emily'sScars:SurgicalShapings,Technoluxe,and
Bioethics,"HastingsCenterReport34, no. 2 (2004): 18-29.
18

HASTINGS CENTER REPORT

tal assessmentthat surgeonswork on conditions like

that. Judgment conflates the body itself with the
qualityof work done on that body or the potentialto
havethatwork done. The possibilityof fixing renders
inescapablethe question of whetheror not to fix-a
problem affecting far more people than the groups
studied duringthe SSC project.
My unworthy but useful reaction to my fellow
walker led me to realize how uneasy my sense of
boundariesis betweenwhat I considerfixableabout
my body and what I believeI am called upon to live
not only with but as. I wash, groom, exercise,and reflect on my diet; I convince myself-or am I convinced by an increasinglyundifferentiatedmixtureof
commercial advertisementsand health promotion
campaigns-that these actions have not only practical benefitsbut moralimplications:caringfor myself
in these ways enhancesthe person I am. It is a short
step along the continuum to seeking medical advice
on mattersnot only potentiallycriticalbut also mundane:physiotherapyand wart removal.These consultations seem to raiseno ethical issues. But my fix-it
2004
March-April

reaction to my fellow walker raises

the question of where to draw limits
of self-fixing.My initialmodernistreaction is to phrasethe issue in individualistterms:Is there some core of
me that I shouldworkwith, not work
on; or are some body parts no more
than unwanted contingencies, like
warts, that temporarily intrude on
my life?If the latter,is the decisionto
fix determined only by a comparatively simple cost and risk/benefitassessment?Need I ask only whether
the promised improvement will be
worth the time, trouble,and pain to
me that the fixing involves?
The bioethics appropriateto such
cost/benefit questions is a kind of
consumer protectionism; it insists,
for example, on full disclosure of
risks, preferablybased on follow-up
studies of how such fixings have
worked,or not, in past interventions.
Protectionistbioethicstakes the presuppositions of consumerism for
granted;thus it wants people to know
exactly what is being delivered at
what cost and with what risk. The
ethicalstandardsareliberal,requiring
medical professionalsto be responsible salespeopleand then leaving the
choice to patient/consumers.One (of
many) problemswith this project is
the difficultyof accuratelyspecifying
the potential benefits, costs, and
risks. On a less functional level, this
kind of bioethics has trouble taking
seriously how one individual's
choice-not only what is chosen, but
also being in a position to chooseaffectsothers.
Of course there has always been
anotherkind of bioethics,which can
be called Socratic.Socraticbioethics
what
protectionist
questions
bioethicstakesfor granted;it asksdisconcertingquestions about the good
life and what kind of healthis partof
this good life. These questionswiden
the scope of concernedpartieswhose
needs ought to count in any individual'shealth-relateddecisions.No one
lives a good life alone. In this Socratic mode, whethermy fix-it reactionis
conducive to the kind of person I
want to be depends on whether my
2004
March-April

reactionis conduciveto my participation in the communitiesthat support

my good life. I then have to specify
which partsI play in which communities, and how those partsneed to be
played for those communities to be
good-as I understand"good."My
understandingof goodis not fixedbut
remains perpetually open to questioning from all sides, with specific
decisions responding to that questioning.
This article follows the Socratic
approachto bioethics,but unlike the
Platonic Socrates, I am more concernedwith practicesand experiences
than with the logic of arguments.I
startwith the social context in which
surgicalmodification makes sense as
a solution to bodily conditions that

limb lengthening, intersex surgery,

and craniofacial surgery-make
sense. The technologies of medical
intervention presupposethe willingness to use these technologiesin certain ways. The problem of who is
willing to do what in orderto achieve
what end is endemic to the cultureof
high modernity. The sociologist
Emile Durkheim, writing in 1896
about the relation of suicide to
modernity,raisedthe question, "how
[to] determine the quantity of wellbeing, comfortand luxurylegitimately to be cravedby a human being?"'
The SSC project is yet another attempt to wrestle with Durkheim's
question,which we have now learned
will not and cannot be answered.
What Durkheim understood clearly,

ocratic bioethics asks disconcerting

questions

about the good life and what kind of health is

part of this good life.
are perceivedas troubles.I then considerwhat people say about decisions
for surgicalmodification. My objective is not to offerguidelinesfor practice; it seems more useful to open up
the discourses in which peopleboth professionalsand potential patients-are able to think about how
their actions affect themselves and
their communities.
Socraticbioethicsseeksto offer alternativecoursesof action as realpossibilities for people who face deciIf consumer-protection
sions.
bioethicscan be beneficialto people's
physical, emotional, and economic
welfare,Socraticbioethicscan be liberating,in the senseof helpingpeople
to realizethey have more options for
how they live than they had imagined.
The Context in which Children
Are Surgically Shaped
at a certain historical and
cultural moment do the surgeriesconsideredby the SSC project-

Only

more than a century ago, is that the

energyof modernityis alwaystoward
more:the cultural impetus is to expand what it is legitimateto crave.In
reactingas I did to my fellow walker,
I was being no less than modern.
Three aspectsof the contemporary
context of the SSC surgeriescan be
singledout to suggestwhy these surgeriesmake sense to people:neo-liberal medicine, the idea of the body as
project, and the moral language of
personalauthenticity.
Neo-liberal medicine denotes the
political-economicideology that considersit properfor the for-profit,corporate sphere to set the agenda for
professional medicine.2 This corporate agenda makes it increasingly
commonsensicalto understandmedical servicesasproducts.Health maintenance organizations refer to the
"productlines"that they sell, and that
languagediffusesinto the way people
think of deliveringand receivingservices. Recently I heard a radio interview with a physicianwho used the
words "patient"and "client" interHASTINGS CENTER REPORT

19

changeably,so faras I could tell, with

no apparentawarenessof a distinction between them. Patientsbecome
consumers of medical products-a
statusthat empowersthosewith sufficient resources and disenfranchises
otherswho lack these resources.3
Within neo-liberalmedicine, the
boundariesof professionalmedicine
increasingly blur. During the past
century these boundarieswere fairly
clear, but in the nineteenth century
they were less clear,4so there is no
reason to suppose that professional
boundarieswill remain as they have
been. In the centurywe havenow entered, physicians, especiallybut not
exclusivelyAmerican physicians,become the deliveryagentsof corporate
products, and corporateentities deliver these physicians'time as a product. Physiciansremainprivilegeddelivery agents-privileged in what
they can do and in how much they
are paid for doing it-but they take
their place as one category of
providers,with increasingoverlapsbetween what different providers can
offer patients,who are also known as
clients and customers.5Neo-liberal
medicine can be recognizedby this
breakdown of traditional labels for
who people are: physicians become
providers; patients become consumers.As new interestsassertthemselves,differentsortsof actorshaveto
be identified in ways that suggest
their new roles and entitlements.
Neo-liberal medicine happens at
the same time that an increasing
numberof people regardtheir bodies
The fleshas God-givenreasprojects.6
ality-for betteror worse, this is how
I am-gives way to the flesh as stuff
to be workedwith by varioussorts of
body workers-among whom physicians are but one, albeit privileged,
type. Cosmetic surgerywebsites feature the image of the surgeonas flesh
artist.7At the interventionistextreme
of the continuum of body projectsis
the FrenchperformanceartistOrlan,
who incites reflectionon body modification by orchestratingsurgeriesto

ic surgeries that she directs while

underlocal anesthetic.Her art is both
her face itself and the videos of her
surgeries.She treats surgeons as instruments of her art and speaks of
using them, as a traditional artist
would use a brushto paint or a chisel
to sculpt. Orlan is sculpting herself,
using surgeryas her artisticmedium.8
Neither most middle-class consumers of traditionalcosmetic surgeries nor younger body modifiers
among whom tattooing and discrete
piercing are popularhave ever heard
of Orlan, but she affects the milieu
that eventually,throughlayersof diffusion, makesa navelring seem like a
moderate choice for a suburban
housewife. Orlan pushes to new extremes both the materialuse of her
body as a projectand the self as inextricablytied to how that projectis realized.What she does with her body
becomesas reala moralresponsibility
for her, in the twenty-firstcentury,as
what people did with their souls was
realin earliercenturies.
The body as project extends the
trajectorythat CharlesTaylorargues
emergedin the late eighteenthcentury, when for the first time in history
each individual life became something new, a self. Life became a project of finding each self's unique
point; asTaylorwrites,it becamepossible to miss the point of your life.9In
other words, one's life became something-raw material-that people
expected themselvesto do something
with. The contemporarytwist on the
modern project of the self is that
many of us moderns-most observersagree the number is increasing-include doing things with our
bodies among the ways to seek the
unique point of our lives. At the extreme, the point of one's life can be
the modificationof one'sbody.10
Here lies the crucialdifferencebetween contemporary body projects
and variousforms of body modification that havebeen practicedin traditional societiessince the beginningof
humanity.Traditionalbody modificahas tion, includinginitiationceremonies,
reshapeherself.Orlan'sreshaping

througha seriesof cosmet- marksthe body'smembershipin a

proceeded
20

HASTINGS CENTER REPORT

group;particularmarkingsindicate a
prescribedstatus in that group. Undergoing these modifications is not
something that individuals decide
upon or negotiate.Markingsexpress,
which is a
but they are not expressive,
modern concept requiringa post-Romantic self. Markingsare a non-negotiable expectation,expressingsuch
mattersas a member'sgender,family
status,and age group (such as having
attainedpuberty).11Those who elect
contemporarybody projectsspeakof
these projectsin a languageof personal decision making and individual
choice. At least in the eyes of the
modifier,although not necessarilyas
perceived by others, tattoos and
piercings (not to mention more extreme modifications like branding
and scarification)aremarksof unique
individuality.When body modifications do expressmembership-such
as when membersof sportsteams get
a common tattoo at the end of the
season-those affiliationsareindividually chosen and often competed
for.12The tattoo or more extreme
modification is understood to say
somethingabout the individual,since
the affiliationsare expressiveof who
individualis. Contemporaryindividualism includes memberships, but
the marksof membershipareelective,
not prescribedexpectations.
To illustratehow these contextual
elements of neo-liberal medicine,
body projects,and moral claimsconjoin, and to complicate the question
of what ought to be fixed by surgery,
I offera singleexample:feet. Looking
at what people are doing with their
feet, or more specifically,the cultural
thresholdof what it now makessense
to do with one'sfeet, is a provocative
way to suggest the uses of surgery
that already make sense to people
when they find themselvesconfronted with decisions about surgically
shapingchildren.
Surgically Shaping Feet

In March2003, Voguerana storyin

its "beauty,health & fitness"section-a concatenationof topics typi2004
March-April

cal of neo-liberal medicine-titled

power and the forest to be seen as a ery agents of serviceswithin an array
"theflawlessfoot."13The story inter- sourceof lumber.The waterbecomes of agentsofferingcomplementaryserviewed severalNew York podiatrists "standingreserve"for the powerplant vices. But my main point is the
whose surgicalpracticeincludesshap- and the trees standing reservefor the Prozac-likelanguage of transformaing women'sfeet so that they can fit sawmill.17Levinepresentsthe foot as tion and life change as a justification
into and can look good wearing de- standing reservefor surgery,which is for surgery.These patientsand Vogue's
signershoes.These shoes "requirede- how Heidegger describespatients in writer may well have read Kramer,
signerfeet."14As Voguetold the story, clinics.18But she then broadens the but whetherthey have or not the difsurgical practice is being pushed by frame as she presentsthe practiceof fusion of Kramer'slanguagesets their
patient-consumers,who in turn are surgeryas standing reservefor fashbeing pushed by shoe designs. Thus
Voguequoted a "Manhattan-based
podiatristand podiatricsurgeon"who
echnoluxe" depends, first, on a view of the body
said: "Until recently, my patients
G>
would have surgery only to relieve
as something to shape and life as a project of
painful foot deformitieslike ingrown
toenailsand plantarwarts. Now they
shaping. It depends equally on the idea that
come in for a consultation, pull a
strappystiletto out of their bag, and
projects are realized through acts of
say,'I want to wearthis shoe.''"5This
scene is certainlynot typicalof twenconsumption.
ty-firstcenturymedicine, but the descriptioninstigatesa culturalexpectation among Vogue'smany readers. ion. What comes first is the shoe, rhetoricalexpectations,and they perWhether or not these readersactually which then dictatesthe shape of feet. petuatethe diffusionof this language.
have their feet reshaped, Voguepre- If the shoe does not fit, then perform
Voguerefersto this form of podiatricpracticeas "technoluxe,"a useful
sents a potent lesson in what patients surgeryon the foot.
The moral justificationof this or- descriptionof what neo-liberalmediare entitled to expect from their
physicians, as well as what people dering of prioritieslies in what Vogue cine bringsabout.2 Technoluxecomcalled "awoman'sconfidence.""I got prises both product lines and condishould expect of their bodies.
The cultural resonanceof Vogue's tired of burying my toes in the sand tions of delivery. Neither discrestory is suggestedby the appearance when I went to the beach. It was hu- tionarymedicalservicesnor high-end
of a similar-the unkind adjective miliating," says a woman who had deliveryis new;when I was a boy, one
would be clone-story that appeared surgeryto shorten severaltoes. Cin- floor in the local hospitalwas referred
in June 2003 in the "style"section of derellastoriesare ancient and cultur- to as the gold coast. But in those days,
Toronto'sGlobe&dMail,one of Cana- ally diffuse;this woman'sdescription the gold coast could offer little
The of the effect of surgery sounds like more-though no less-than more
da's two national newspapers.16
Globe's story focuses on Suzanne PeterKramer'sbiotech version of the comfortable surroundings in which
Levine,the same New Yorkpodiatrist Cinderellaplot, told in his best-sell- to receivethe same medicine.What is
who is quoted extensivelyin Vogue's ing Listeningto Prozac.19Kramerde- new is the profusion-the sheer
story. Her statement expresses the scribes patients who experience quantity and accessibilityat different
valuesof neo-liber- Prozacas a transformationof self. "At income levels, in different sites-of
taken-for-granted
first I thought I was just being nit- medical product lines. Technoluxe
al medicine:
picky," the podiatric patient says. depends,first, on the increasingpubThe shoesout thererightnow are
"But the transformationis amazing. lic and professionalacceptanceof the
like looking at jewelry.I just saw
And I was back in high-heels in less body as something to shape and life
these sandals, with stones and
than two months."20"It changed my as a project of shaping. It depends
gems. . . they're gorgeous. You
life," says another woman, speaking equally on the idea that projectsare
want to be able to wear them. If
not about medicalpodiatrybut about realizedthroughactsof consumption.
your foot is unsightly,it detracts
the effect of treatments from those Those who are disturbed by techfromthe shoe.
medical adjuncts whom Voguede- noluxe have to ask a question that
This statement lends a new twist to scribes as "expertpedicuristsat Buff specifies the problem of modernity
Martin Heidegger'scritique of mod- Spa in Manhattan'sBergdorfGood- that Durkheimand Heideggerbroodern technology.In two of Heidegger's man."21I note these expertpedicurists ed over: what exactly is wrong with
to have, and to use
examples,technologycausesthe river as an exampleof the point made ear- the aspiration
to
medicine
to be seen as a sourceof hydroelectric lier, that physicianspracticeas delivproduce,designerfeet?

//

2004
March-April

HASTINGS CENTER REPORT

21

One objectionis functional. Vogue

quotes one sole medical dissenter,a
podiatristfrom Moline, Illinois, and
the rhetoricof locating dissent there
is interesting,since the other pro-surgical podiatristsquoted in the article
areall New Yorkers."WhenI operate,
my goal is to alleviatepain,"says the
mid-Western medical traditionalist.
"The risk with all podiatric surgery,
no matterhow minor, is that it fundamentallyaltersthe structureof the
foot and the way you walk, which
may cause new callusesand pain you
didn'thave to begin with."23Especially in the world of technoluxe medicine, caveat emptor applies. As the
patient becomes more of a consumer-a buyer-the need to beware
intensifies. But I do not regardthe
functional objection, important as it
is, to be the most provocative,since it
relegatesthe moralquestionof should
we?to the level of whetherit works.
If the only objection were functional, then it could be argued that
the rich do the rest of us a favor by
acting as guinea pigs for new medical
technologies.24The objection I consider more significantfor more people, more of the time, is that technoluxe medicine distorts the allocation of medical servicesand distracts
medicine from its original and stillThis purpose
predominantpurpose.25
is clearlystatedby the dissidentpodiatrist:"to alleviatepain." But pain is
not what it used to be, and here I return to the moral justificationof the
satisfiedmedical consumer who says
going to the beach pre-treatmentwas
"humiliating."I react to this statement as an inflation of the language
of pain: if having unfashionabletoes
counts as humiliation,in what words
can we describethe livesof people living with massive facial deformities?
But as troublingas I find the usageof
humiliatingin this instance, it is importantto hear the very realproblem
that this woman is working to express.
This woman exists, like all of us,
in what PierreBourdieucallsa field.26
What counts most about fifields for
the presentargumentis that positions
22

HASTINGS CENTER REPORT

within them are hierarchical, and

one's place depends on possessing
capital. Bourdieu delineatesdifferent
forms of capital, including physical
capital,and callsattentionto how differentforms of capitalcount in some
fields but not others, and how some
forms of capital hold their value between fields.27This woman'scapital,
in at leastone of the multiplefieldsof
her life, includes being able to go
barefoot or wear scandals and have
her feet look a certainway. The field
determineswhat this certain way is.
Fieldsset the terms of what countsas
capital,and fields arealso sites of perpetual contestbetween rival forms of
capital.This woman, in her field, is
doing with her feet what all members
of any society, including bioethicists,
do with our bodies and with our talents: we shape and allocate them in
orderto make them count as capital.
Feet can be a form of capitalnot only
in dating and marriagemarkets,but
in job marketsas well.
What counts as capital goes well
beyond the feet themselves.Reshaped
feet displaythe willingnessto reshape
onesbodyto conform to the demands
of the field. The woman'sfeet mark
her ability to read properly what
counts as capitaland to endurewhat
has to be enduredto accruethat capital. This interpretive skill and the
complementary endurance are the
woman'srealcapital.Any self-reshaping, whether of body, language(as in
Shaw's Pygmalion, a resonant plot
later adapted to become My Fair
Lady),or skills (in education, certification and recertification)is properly
brought off when and because it
demonstratesthe person'sattunement
to the demandsof a specific field. In
modernity, attunement is no longer
an automatic corollary of membership. Membersof traditionalsocieties
acceptedbeing told when and how to
reshape their bodies. Their decision
was binary:eitherparticipateor leave
the group. In contemporarysociety,
each individual is responsible for
choosing and effectinghis or her own
reshaping,thus demonstratinghis or
her fitness for membershipwithin a

given field. Hierarchicalposition depends on displaying attunement to

the field, and what counts as capital
changes; people have to anticipate
shifts. Bourdieuemphasizesthroughout his writing that playing in any
field requiresthe correct assessment
of what counts as capital there,and
then, including what kind of body
counts as right. The right body
demonstrateshaving made the right
assessment of capital, and thus becomes a potent display of rights to
participationand position.
If Bourdieu's argument stopped
here, it would be a neo-liberaldefense
of anyone doing anything that enhances his or her market position.
This defense would effectively end
ethical discourse, since our capacity
to claim that some actions are good
and others are not so good would be
determined only by what counts as
capital in specific fields. Nothing
could be further from Bourdieu's
point, which is to oppose neo-liberalism. I lack space to pursue this argument, however.I use Bourdieu'sideas
not to make technoluxesurgerylegitimate, but only to show that it is
plausible.
Recognizingthe demandsof capital and fields allows us to take a generous view of the podiatry patient
who seeks designerfeet, and it complicatesthe question of what'swrong
with these feet. Unless this woman
leads a charmed life, she will have
other experiencesthat will shift her
scale of what counts as humiliation.
But for now she is doing what we all
do: she is tryingto hold her own. And
so is her podiatrist. The website of
Suzanne Levine, the podiatrist who
wants to shape feet to fit designer
shoes, tells us that only 8 percent of
podiatristsare women, and Levine's
successis singularfor a woman in this
field.28Although she may not be a
feminist hero, she too, in her field, is
workingto hold her own.
To suggest what may be troublesome about how they are holding
theirown, I turn to the SSC surgeries.

2004
March-April

In the Gravitational Field of

Technoluxe

is a personaldecisionthateveryindividualwhose lives [sic] can be

functionallyimprovedby the procedureshouldbe allowedto make
for him/herself, without being
judged by anyone for that decision.

That her choice affectsothersdoes

not impugn the validity of what she
chooses. When, as a young teenager,
she is sent to a medical presentation
he
SSC
are
not
surgeries
shaping
T
on limb lengthening, she too cannot
children so that they can wear
avoidchoosing. Some people'sdiscovdesigner shoes, but the same basic
ery of choicesthat they find liberating
equationapplies:if the body does not
will force others to confront choices
fit, reshapeit. The problemof how to
respond to these surgeriesis tied to This dual emphasis-that only the they would rather not have recogthis equation. The SSC surgeries- individualcan decide for him/herself, nized in the first place; this chaining
most evidently limb-lengthening
surgery-can be presented as the
leading edge of a slipperyslope that
relegatesall medicine to technoluxe
"for
one of us chooses anything consequential
market values: those who have the
most resourcesto put into their bodhim/herself." As we choose for ourselves, we
ies can producebodiesthat accruethe
most capital in the most rewarding
also confront others with choice.
fields. The body is called forth as a
site of investmentand accrual,and in
neo-liberal society, those who have and that no one else can judge that of possibilitiesseems inevitable. But
the most to invest have the first call decision-is repeatedin Internetchat Mueller should be aware that her
on services.Alternatively,these surg- groupsof people who areplanningor choices affect other Little Peoples'
eries can be defended as medicine in considering
limb-lengthening abilityto choose, and she should take
the cause of democratic humanism: surgery.32Moreover,Mueller'sstate- responsibilityfor how she framesthe
they offer the best chance for people ment is entirely consistent with the choices that do affect others. The
who have been allocatedlow physical languageof people who practiceboth recognition that none of us chooses
capital to get back onto as level a conventionaland extremebody mod- anythingconsequential"forhim/herself" seems fundamental to moral
playingfield as possible.And who can ification.33
for
rationale
Mueller's
that
not
have
should
undergoing participationin society. That means
say they
matters only that we must choose carefully,
to
mundane
have
chance?29 Both perspectives
surgeryappeals
of
writes
some merit, which is what makes of convenience-she
driving becauseas we choose for ourselves,we
bioethicalresponseso difficult.A be- an unmodified car and reachingob- also confrontotherswith choice.
The choice of limb-lengthening
ginning is to considerthe moraljusti- jects on supermarket shelves. She
ficationspeople offer for each type of downplaysissues of identity, writing surgeryis a form of normalizationthat beforeher surgery,"I knew I re- fitting the body to the demandsof sosurgery.
The language of moral justifica- ally was no different from anyone ciety ratherthan calling on society to
tion for limb lengthening surgeryis else, and I knew if I set my mind to it create accommodationsfor different
The following state- I could do anythingany averageper- bodies-and normalizationhas a bad
individualistic.30
ment is taken from a long article son could do, if not more. .. [M]y name in an age of disabilityrights.34
posted on the website of the Little mother made sure I came home to a Yet who among us of normal height
People of America. The author is a place where I knew I was loved for wants to tell Gillian Muellerthat she
Little Personnamed Gillian Mueller, who I was, even though I was small." has no right to a technologyallowing
whose experienceof limb lengthening But the "eventhough"qualificationis her the advantagesshe claims?What,
was the subject of a 1992 article in inescapable,and the decision to have then, needs to be offered to those
Peoplemagazine.Her updatedstory is surgery reinforces how much "even who are affected by the expectations
in their
posted on the LPA website, dated though" counts. By asserting how that her decision generates
are
These
lives?
typical of
questions
September2002.31 Mueller describes much betterher life is since she made
of
characteristic
her near-total satisfactionwith how herself less small, she makes "even modernity,a defining
of
limb lengtheninghas affectedher life. though"count for others as well. She which is the dislocation people's
She concludes:
necessarilyposes a choice whether or lives by technologies.These dislocanot to make it count less. When tions have always brought benefits
Undergoinglimb-lengtheningwas
being small is presentedas a choice, and losses, often to the same people.
clearlythe right decision for me.
the "eventhough"-becomesa heavier At this stage in modernity,bioethics
That is not to say it is the answer
can offer those who must choose the
weight.
for everyone,or evena majority.It
reflective observation that practices
7

2004
March-April

HASTINGS CENTER REPORT

23

reinforce each other's acceptability;

bioethics can heighten people'ssense
of the connections between practices
and their sense of connection with
other people.
Simply the reporting of technoluxe podiatryin Vogue,followedby
various clone stories, regardless of
how many feet are actuallyreshaped
-even in Manhattan-affects the acceptability of surgically reshaping
limbs. In a technoluxe context,
achondroplasiais readilyunderstood
as anotherindividualproblemthat requires medical fixing. Surgicalintervention is one of a seriesof available
choices for fixing some part of one's
life-choices from pharmacologyto
promisesof gene therapy.
In this frameworkof choice, living
with achondroplasiabecomes understood as a choiceof bodyprojects.This
understandingcan be either liberating or constraining, or both. What
constitutes liberationand what constitutes constraintdepends on values
and politics and will remaincontested. Participationin disabilityrightsclaiming one's disabilityas a cultural
difference,even as a positivevalue-is
one availablebody project. Another
project is to minimize disability
through surgery. Many peopleprobablyan increasingnumber-will
mix both projects,since the projects
aremutuallyexclusivein theorymore
than in practice.Decisions of which
projectto pursue-when to pursueit,
how farto go, and to what extentthat
pursuit excludes other projects-depend on expectations that are constantlybeing conditioned.The conditioning of expectationsis not unidirectionalfrom technoluxeto disability; it cuts the other way as well: once
limb lengtheningbecomes known as
a standardof surgicalbody modification in the causeof convenience,cosmetic podiatric surgeries like
bunionectomieswill seem like pedicures.
The consequences of normalization darkenwhen we move from the
legs to the genitals.Limb-lengthening
surgery is performed on teenagers
who participate in the decision for
24

HASTINGS CENTER REPORT

surgery,as Mueller carefullyspecifies

she did. Intersexsurgeryis usuallydecided between parentsand surgeons,
excludingthe child from the decision.
Children are often considered too
young to be informed-infants clearly are too young, but age of consent
becomes contested as children grow
older35-or, in some of the most disturbing stories we heard in this project, older children are intentionally
misinformedas to what surgerywill
do to their bodies. The stories of
those who have been subjectedto this
surgeryare filled with expressionsof
shame and recriminationsfor familial
secrecy.Both academic researchand
the website of the IntersexSociety of
North America (ISNA) present stories of people who feel mutilated by
surgeriesthat sought to correctdifferWhat we lack are
ences in genitalia.36
the storiesof the decisionmakers.
The observations of the SSC
group, while falling short of formal
ethnographic research, suggest that
surgeonspresenta three-foldjustification for their interventions.First,surgeons believe that they carryout the
wishes of the parents, who are the
child's surrogate decisionmakers.
When pressedas to why they operate
on infants so soon after their birth,
surgeons appeal to the level of
parentaldistressand their responsibility to relieveit, a responsibilitythat is
equated with intervening as fast as
possible. Second, they claim to
achieve the surgicaloutcome of normal-appearinggenitalia and support
that claim by showing numerousbefore-and-afterslides. Third, their descriptionsof their patients'lives foreground the risk of social humiliations-in locker rooms and other
change rooms and in public bathrooms-that could make embarrassment over one's toes seem trivial. If
patient stories are about shame and
loss as the effectsof surgery,surgeons'
storiesareabout how surgerycan prevent teasing, and they claim the
moral responsibilityto do so.
In intersex surgery as in technoluxe podiatry,it is no surprisethat
the need to reinforceself-esteem or

confidence-whatever words are

used-is presentedas a moral trump.
Self-esteem is a crucial resource for
the modern self preciselybecausethis
self's uniqueness entails being out
thereby itself, on its own, responsible
for itself. Surgeonshave good reason
to believe that medicine must use its
resourcesto protect this self-esteem.37
Again there is a functional objection, this time expressedin personal
accountsof loss of genitalsensationas
a resultof surgery,as well as the trauma of repeatedoperations for more
complex conditions. Too often professionalsurgerychooses not to hear
these stories. One such refusalto listen-an angry response to a video
producedby the ISNA, in which several people described not only their
sense of physical loss but also their
sense of violation-was perhaps the
most dramatic, confrontationalmoment in the SSC meetings.What is at
stake is crucial for medicine: Whose
opinion trumps in the determination
of surgicalsuccess?And basedon that
question, whose opinion ought to
count in decisionsabout futureinterventions? But again, surgeons have
considerablejustification for believing that they are doing what those
around the intersexedperson-if not
that person him or herself-wants to
have done.
In contrast to Mueller'sstory of
limb lengthening, people who have
had surgery for intersex conditions
believe that their familiesand society
at large find them acceptableonly if
their anomaly is fixed. Many believe
that the attemptedfixing createdonly
a crude simulacrum of normality.
They remain marginalizedfrom the
society of normal genitalia,and they
are alienated from the bodies they
had been born with.
We can only speculateabout why
parents elect surgical correction for
their children's intersex conditions.
Those stories would be difficult to
elicit.38The SSC projectmeetingsleft
us with grave reservationsabout the
quality of medical information on
which parentsbase their consent for
surgery.As importantas standardsof
2004
March-April

practice for patient information are,

the use of any informationconfronts
an inherent limitation. Information
alwaysrequiresinterpretationin order
to be acted upon, and even the most
accurate, appropriate information
will be interpretedwithin dominant
culturalparadigms.Thus any advice
concerningsurgeryrisksbeing understood within the same equation that
appliesto feet: failing to fit the fashion is humiliating, and surgeryprovides a fix. Most of these parentsundoubtedlywould feel they had failed
to be responsibleif they did not offer
their childrenthe more approximately normalfuturethat surgerypromises.
This same hope for a normal future pervadesdecisions around craniofacialsurgeries.It may be easyto regardintersexsurgeryas medicine acting to police physiologiesthat threaten the conventionalbinariesof gender normality-and more threatening still, physiologies that people
claim to take pleasure in-but this
critique of surgical normalizationis
difficult to apply to the craniofacial
surgeriesthat our project group saw.
Our seeing again took place through
the conventionalmedical rhetoricof
before-and-after slides, and these
slides, like the word deformity,depend on normative visual convention, and those conventions need to
be contested.39Yet it would challenge
most observersto see these pictures
and not feel the appropriatenessof
this language of deformity. Faced
with such faces, it is difficult not to
affirmthe value of surgeryas at least
an improvementin what are readily
(perhapstoo readily)perceivedas lifeimpairing conditions. Moreover,
there is no craniofacialgroup equivalent to ISNA: no survivorsof craniofacial surgeryprotest what has been
inflicted on them and claim they
would have better lives if they had
been left alone. The problem craniofacial surgerypresents is not understanding why surgeryis first undertaken. The question is deciding
when, after years of operations,
surgeryought to end.
2004
March-April

JeffreyMarsh, a craniofacialsurgeon and a member of our project

group, crystallizedthe issue when he
saidthat afterwhat is often more than
a decade of operations, the current
surgeryis being undertakento ameliorate the effects of earlier surgery.
Candidates for continuing surgery
eventuallyhaveto askwhen is enough.
Is the next surgicalrevisiongoing to
affect any improvement in appearance, or will it only rearrangepast
damage?Perhapsmore to the point,
the potentialpatient, much of whose

/edicine

ularlya better self-if one moremedical step is taken.40

Craniofacial surgery, like limb
lengthening and intersex surgery,
takes place in the gravitationalorbit
of technoluxe.Many of the surgeons
operating on what might be agreed
upon as facial deformity are or have
been engaged in cosmetic surgeryas
well, and assumptions,like language,
diffuse between activities.Yet craniofacial surgery differs from limb
lengthening and intersexsurgerybecauseamong human body partsfaces

becomes the business of rewriting

what counts as reality.

life has been invested in undergoing
surgery,eventuallyhas to askwhether
she or he needs that promised improvement (even if surgery achieves
it) to get on with the life she or he
needs to get on with. This life may
not be the one that the personwould
prefer,and the difficultylies in reconciling the difference between what
has been hoped for with what now
seems to be the reality.
Medicine, in a varietyof contemporary forms that the SSC surgeries
represent, becomes the business of
rewritingwhat counts as reality.In response to any patient's condition,
some surgeonsomewherewill probably offer the possibility-which from
anotherperspectiveis a fantasy-that
the face and the life that goes with it
could be a great deal better if only
that last surgicalrevisionis agreedto.

When we askedwhy both craniofacial and intersex surgical interventions continued past a point when it
seemed to our group, as detachedobservers,that little could be gainedand
harm was being risked, the best answerwe found was that the momentum of previousdecisionsmade stopping difficult to consider as an option. Momentum reinforcesthe quality that intersexand craniofacialsurgeries share with technoluxe: the
promiseof a betterlife-more partic-

have a unique place. Potential patients of cosmetic podiatry can

choose to wear other shoes, even on
the beach. In our intersexmeetingwe
heard stories of young people who
managedto keep their genitalsout of
public view. Living with a face that
will attract horrified stares from
strangersis where the word humiliation seems to find its most uninflated
and unavoidableusage.41The public
visibilityof the face and the symbolic
importancethat links facesto character-exemplified by the aphorismattributedto Lincolnthat aftera certain
age a person is responsiblefor his or
her own face-make facialdeformity
a problem of a different magnitude,
and that differencecommandsour respect.
Here we reach the crux of what
makes responding to these surgeries
difficult. How far do we expand the
sphere of persons to whom we offer
that respect?I believe that trying to
compare forms of suffering-comparingthe woman humiliatedby her
toes with a young person deformed
by a facial hemangioma-is not useful. The attractionof such a comparison is that it promises apparently
clear-cutmedical guidelinesfor practice. Unfortunately,practicewill have
to confronta realitythat is not clearly
divisible into categories. The issue
HASTINGS CENTER REPORT

25

may be betterthought of not in terms

of what sufferingwe allow as legitimately in need of fixing, but rather
what form of decisionmakingwe respect.
What Is a Bioethical Response
to Surgical Shapings?
Isuggested earlierthat there are two
forms of bioethics. Bioethics as
consumerprotectionrespondsby recommending proceduresthat seek to
protectthose subjectto surgicalshaping; those protectionsinclude but are
hardlylimited to more fully informed
consent. The need for whateverprotection bioethicscan instigateis most
pressing in intersex surgery.What I
have called Socratic bioethics poses
questions about what sort of people
we become by choosing to act as we
do. My sociological Socraticism
broadensthe scope of those who are
involved when questioning who we
are becoming. It calls attention to
connections: connections between
practices, so that people recognize
how one practicereinforcesanother,
and also connectionsbetweenpeople,
breakingdown the idea that any decision can be strictlyindividual,insofar
as that word suggests that one person'sdecisiondoes not affecthow another personchooses. In conclusionI
want to suggestanotherdimensionof
Socraticbioethics:the significanceof
dialogue. In Socraticdialogues, people are having a good deal more than
a pleasantchat.
Dialogue takeson a distinctivesignificanceas a responseto two features
of neo-liberalsociety and the medical
practicesthat seem naturalwithin it.
One defining characteristicof neoliberalismis the absenceof any alternative political-economic discourse
that challengesit; the old Marxist-socialistalternativeis effectivelydead as
any kind of opposition.The resulting
fatalismis relievedby the glitz of consumerism,including technoluxe,and
diverse panics, including epidemiological panics. Second, the pervasive
myth of the marketprivilegesan assumption that personal choice
26

HASTINGS CENTER REPORT

trumpsin all matters.I suggestedthis

language of personal choice in the
discussion of rationales for limblengthening surgery as the individual'sprivatedecision.The personalis
equatedwith the private.In this neoliberalcontext, dialoguemeans opening an oppositionalspace that is too
often closed, and it means recognizing that the personalis communal.A
Socratic bioethics can instigate dialogue that informs people's sense of
how their particulartroublerelatesto
others' troubles, and how their proposed solutions might cause others
more trouble.
The technoluxe podiatry patient
who is humiliatedby her toes is, as I
wrote, trying to hold her own, and
such efforts are worth a certain respect. The limit of this respect depends on whether this person thinks
about how her strategiesfor holding
her own affect others' capacity to
hold their own. If I am reluctantto
call the woman'ssense of humiliation
trivial,I am willing to say she is not
looking aroundvery far or talkingto
a sufficientrangeof people. She is responding to her field, but only to her
field and her need to position herself
in this field. To paraphraseMichel
Foucault, she knows what she is
doing, but she seems to have little
awareness or interest in what her
doing does.42In a world in which
medicine has more work than it can
do alleviatingpain, how far anyone is
entitled to plead ignorance of the
needs of others is questionable.It is
questionable whether surgeons who
operate on anomalous genitalia can
ignore the testimony of those who
havehad these surgeries;this testimony may not take the form of controlled trials, but as organized by
ISNA, it is a compellingaggregation.
Technoluxe patients and overly aggressivesurgeonsboth lack sufficient
participationin dialogueas a process
of testing their needs and assumptions againstothers'realities.
Lisa Hedley, anotherSSC projectgroup member,providesa specific illustration of dialogue as a kind of
talk.43She writesaboutwhat it meant

when her daughter, LilyClaire, was

born with achondroplasia, an unknown condition in theirfamily.One
day soon after LilyClairewas born,
Hedley saw a Little Person, approached him and told him-as a
stranger-that her daughterwas also
a LittlePerson.I imaginehim looking
at her as people do when they arenot
sure on what basis strangershave approached them. He replied, "Right,
well, is she healthy?"That simple
questionshifted Hedley'ssense of her
daughter's having achondroplasia.
The question repositioned
Hedley:her
daughter'scondition was no longer a
problem, though problems might
certainlyoccur relatedto that condition. Socratic bioethics recognizes
that bodies and diseasesare not there
to be solved, but how one lives with
them depends on how one positions
oneself with respect to them. Of
courseHedleywas alreadyopen to dialogue. The bioethical problem is to
lead those not yet open to dialogue
towardthat openness.
Hedley'sstorysuggeststhat Socratic bioethics often proceeds best
through questions that are not especiallyclever;in that sense,my allusion
to the philosophicalSocratesis misplaced.44 But Socrates remains a
founding figure for this form of
bioethicsfor severalother reasons:he
worked in the public square, where
he talkedto people about their everyday problems;he forcedpeople to account for why they held the opinions
they believed to be true; despite his
cleverness,he operated in ordinary,
accessiblelanguage;he did not make
it the measureof his success to disturbpeople, but his questionsdid disturb; and most important, he kept
people focused on idealsof truth and
the good while keepingthe content of
these ideals unfixed.45Truth and the
good seem to have more to do with
sustainingthe processof dialoguethan
with being outcomesof dialogue.
Yet medicine, especiallysurgery,is
about acting and producing an outcome; dialogical surgerycan seem a
contradictionin terms.A hard lesson
of the SSC project is that surgery
2004
March-April

must be dialogicalin orderto be ethical: focused, mutual inquiry about

what surgerycan do must be open to
multiplevoices, and decisionsneed to
be held open longer;these arerecommendationsfor practice,though they
arehardto wrestleinto formalguidelines. In stories about surgical outcomes that most of the SSC group
felt were bad-though our feelings
could be contested-the trouble
began when not enough people were
involved in the conversationover a
long enough time. The fullest range
of possibleoutcomes,and theirfullest
rangeof consequences,were not considered;nor was the fullest range of
alternativesexplored. These alternatives include that posed implicitlyby
the Little Person who responds to
Lisa Hedley by asking,in effect, why
she thinks she has a problem.
Another distinction now cuts
acrossmy initial distinction between
consumer-protection bioethics and
Socratic bioethics. There are problems that arisein the courseofmedical
practice-such as consent issuesand thereare problemsthat ariseas a
result of the possibility of medical
Consumer-protection
practice.
bioethicsis more usefulrespondingto
the former sort of problems, since
these problemsseem amenableto solution. Socratic bioethics presents
very different kinds of responsesto
the latter problems because these
problems are ones that we cannot
solve insteadmust learn to live with.
Medical technologiesand science, almost instantaneously transformed
into marketedcommodities,will continue to presentproblemsthat require
individuals and communities to rethink who they want to be, just as my
reactionto the person I passedwhile
walking-the story that begins this
article-required me to rethinkwho I
was becoming and whether I wanted
to be that person.46
Limb-lengthening, intersex, and
craniofacialsurgeriesall pose problems about what constitutes a good
life, and aboutwhen medicineshould
be used and when refusedin pursuit
of the good life. In a neo-liberalage it
2004
March-April

is difficult to convince people that

they cannot lead good lives by themselves. The neo-liberal subjectivity
does not readilyaccept that "personal"decisionsimplicateothers,because
any person's good life depends on
others also leading good lives.47At
this point neo-liberal economic
thinking convergeswith a postmodern philosophical recognitionwhich probablyfinds its earliest,most
explicit statementin Nietzsche-that
thereis no gold standardof the good.

an ethicalseal of approval.We cannot

adjudicateeither what forms of suffering are sufficiently authentic to
warrantmedicalinterventionor what
medical interventionsare sufficiently
effective to be ethical responses to
that suffering.What seems useful is
to show how decision making can
proceed in ways that command respect.
Our meeting on limb lengthening
was attended by Emily SullivanSanford, a young woman who had this

t seems both politically and culturally naive to

believe that bioethics can draw lines between
types of surgeries and give some but not
others an ethical seal of approval.
CarlElliott ends his recentconsideration of issuescomplementaryto SSC
by observing: "Our problem, of
course, is that most of us don't have
Aristotle'sconfidence about the purpose of human life."48I especiallylike
Elliott's "of course." It is no longer
news that old certainties are gone.
The question is how to live after.
SociologistAlan Wolfe puts an optimistic spin on this lack of confidence, calling it "moralfreedom."49
The people whom Wolfe interviewed
about what they understoodas moral
problemsdemonstratetheirwill to do
the rightthing alongsidetheirdistrust
of canonical standards of what is
right. They seem to be using the interviewsas occasionsto engage in dialogue; testing their sense of what is
right in some specific situation
against the interviewer'sreaction to
their stories of moral action. That
perpetual process of testing one's
views against the reactionsof others
seems to be the dialoguethat Charles
Taylor,among many others, believes
is fundamentalto morallife.
It seems both politically and culturallynaive to believe that bioethics
can respond to the SSC cases by
drawinglines between types of surgeries and giving some but not others

surgery several years earlier.50She

wore a sleeveless top, and on her
upper arms were prominent rectangularscarswhere, during surgery,the
bone had been broken and pins inserted,so that the bone'slength could
be increased by continually pulling
the two fragmentsapart, preventing
healing and generating new bone
growthoverseveralmonths.The scars
were not neat, surgicalscars.The skin
looked well healed, but the past trauma was visible.
Emily talked about her scars at
some point in our discussion. She
said she had been encouragedto have
a skin graft to remove them, but she
refused.They were an emblem of the
ordealshe had gone through.She was
clearabout her choice of word, ordeal.
Her scars reminded me of an interview in Habits of the Heart, a major
study of Americanvalues by Robert
Bellahand his colleagues.They quote
a woman whom they call Ruth Levy,
who tells this story:
"Thewomanwho took careof my
daughterwhen she was littlewas a
GreekJew. She was very young,
nine, ten, eleven, when the war
brokeout, andwaslyingat the crematoriumdoor when the AmeriHASTINGS CENTER REPORT

27

can troopscame through.So that

she has a numbertattooedon her
arm.And it was alwayslike being
hit in the stomach with a brick
when shewouldtakemy babyand
sit andcircleherwith herarm,and
therewas the number."51
Scars do hit us like a brick, as they
connect immediate persons to imagined forms of sufferingand thus render that sufferingtangible.
Bellahand his colleaguesuse Ruth
Levy'sstory as an example of what
they call communities of memory, a
term that does not quite fit Emily's
situation.52Memory is one issue for
Emily,but her scarsalso look forward
to the person she is becoming; they
hold her surgeryas partialfoundation
of that becoming.What kind of community Emily and her scarswill figure in remainsunknown. We do not
yet know what to call a communityof
those who will define themselvesas
sharingsome aspectof Emily'sexperience, or what aspects of her experiences will be sharedwithin different
communities.

Emily is normalized in height;

when I first saw her acrossa room I
did not identifyher as a LittlePerson.
But to suggestthat Emily underwent
surgeryto trade a disabilityidentity
for a normal identity-that her limb
lengthening is a form of passingwould underestimate both Emily's
moral awarenessand the complexity
of surgicalshaping. Emily negotiates
multiple resources,including medicine, to live in multiple fields. She is
awarethat she does not act for herself
alone;like our other SSC guestswho
had had the surgerieswe were discussing, she came to our meeting to
talk about what limb lengthening
means for others.Her moralfreedom
is embodied in her scarsand her selfconscious decision not to fix them.
Her scarskeep open both her identity
and the dialogueabout disabilityand
difference.That opennessis good, for
us all.

28

HASTINGS CENTER REPORT

C. Shilling, The Body and Social Theory

(London:Sage,1993).
My thanks to my colleagues on the
7. I drawthe term"fleshartist"fromM.
SurgicallyShaping Children project, es- Atkinson, Tattooed:The Sociogenesisof a
pecially to Erik Parens and Jim Ed- BodyArt (Toronto:Universityof Toronto
wards for specific advice on this article, Press,2003).
to Alice Dreger for her researchon in8. For discussionsof Orlan and other
tersex surgeries, and to Lisa Hedley, bodyperformance
artists,seeV. Pitts,In the
Paul Miller, and Tom Shakespearefor Flesh:TheCulturalPoliticsofBodyModification (New York:PalgraveMacmillan,2003)
help on limb lengthening. Research
materials on feet were generously pro- and K. Davis, "'MyBody Is My Art':Cosvided by Rachael Meziere. A much metic Surgeryas FeministUtopia?"in K.
DubiousEqualities&eEmbodiedDifshorter version of this article was pre- Davis,
(Lanham,Md.: Rowman& Littleferences
sented at the "Vital Politics" conferfield,2003), 105-116.
ence, London School of Economics,
9. C. Taylor,TheMalaiseof Modernity
September 2003; particular thanks to (Concord, Ontario:Anansi, 1991) (pubMonica Greco. The SurgicallyShaping lished in the United Statesas TheEthics
of
Children project is funded by the Na- Authenticity).
Fora complementary
perspectional Endowment for the Humanities. tive, see U. Beck and E. Beck-Gernsheim,
Institutionalized
IndividuAdditional research support for my Individualization:
work is from the Social Sciences and alism and its Social and Political ConseHumanities ResearchCouncil of Cana- quences(London:Sage,2002).
10. A frequentlydiscussed example is
da. Perhapsmost of all, thanks to Emily
Sam
Fussell'sautobiographyof bodybuildof
Sullivan Sanford for the quality emof an
bodied witness that she, along with ing; S.W. Fussell,Muscle:Confessions
Avon
York:
(New
Unlikely BodyBuilder
Cheryl Chase and CassandraAspinall, Books,
1991). Fora recentcommentarysee
to
the
SSC
meetings.
brought
C. Elliott,BetterThanWell:AmericanMedicineMeetstheAmericanDream(New York:
Norton,2003). Forotherexamplesof makReferences
ing what is done with one'sbody the point
1. E. Durkheim, Suicide, tr. J.A. Spauld- of one'slife, see Pitts,In theFlesh.
uses
11. NelsonMandela's
autobiography
ing and G. Simpson(New York:The Free
such a languageof externaldetermination:
Press,1951), 247.
see "When I was sixteen, the regent decided
2. Foran overviewof neo-liberalism,
A that it was time that I became a man,"
B. Smart,Economy,Cultureand.Society:
which requiredritualcircumcision."AnunNeo-Liberalism
Sociological Critique of
circumcisedXhosa man is a contradiction
Open Uni(Buckinghamand Philadelphia:
in terms,"Mandelacontinues;"forhe is not
versityPress,2003).
considereda man at all, but a boy. For the
the
on
Given
their
3.
emphasis
primacy Xhosa
people, circumcisionrepresentsthe
of the market,neo-liberalsrestrictthe role
formal
incorporationof malesinto society."
of governmentsto reacting to corporate
N. Mandela,LongWalkto Freedom(Lonagendas.Government'smost consequential don: Abacus,
1995), 30. CompareManrole is that of a safetynet that catchesthe
to the languageof thoseinterleast profitable, most expensive patients dela'saccount
in
studieslike Atkinwho would derailprofits,if the corporate viewed contemporary
and Pitts,In theFlesh.
son, Tattooed,
for
them.
For
were
held
responsible
sphere
12. For examplesand a more nuanced
discussionof medicalservicesas commodidiscussion
of the relationalaspectsof body
ties,see S. HendersonandA. Petersen,eds.,
see A.W. Frank,"SurgicalBody
projects,
Health:
The
Commodification
of
Consuming
HealthCare(London:Routledge,2002), in- Modificationand AltruisticIndividualism:
A Case for CyborgEthics and Methods,"
cludingA.W. Frank,"What'sWrongwith
QualitativeHealth Research,13, no. 10
MedicalConsumerism?"
13-30.
1407-418.
(2003):
4. P. Starr,The SocialTransformation
of
13. E. Lamont, "The Flawless Foot,"
American
Medicine(NewYork:BasicBooks,
Vogue,March2003, 437, 442, 444.
1982).
14. Ibid.,442.
5. Among numerousexamplesof this
15. Ibid.
language, see the Special Issue on Consumers and CollaborativeCare, Families,
16. T. Pearce,"The new T & A," The
Systems&eHealth, 18, no. 2 (Summer Globe& Mail,June24, 2003.
2000).
17. M. Heidegger,"The QuestionCon6. If not the originalsourceof "bodypro311-41 in BasicWritcerningTechnology,"
jects,"certainlyone of the firstdiscussionsis ings, ed. D.E Krell,revisedand expanded
Acknowledgment

2004
March-April

edition (New York:HarperCollins,1993),

320-22.
18. In Heidegger's
terms,Dr. Levinepresents medicineas a technologywith which
fashionsetsuponthe body;medicinelegitimates the capacityof fashion to challenge
the body. The contested issue is whether
and how this subordinationof medicineto
fashionaffectsthe moralstandingof medicine as a social enterprise.Partof what is
contested is how much moral standing
medicine has anyway, and what sort of
moralstandingit ought to have.
19. PD. Kramer,Listeningto Prozac
(New York:Viking, 1993). For discussion,
seeT. Chambersand C. Elliott,eds., Prozac
as a Wayof Life(ChapelHill, N.C.: University of North CarolinaPress,2004).
20. Vogue,442.
21. Ibid.,446.
22. The complementaryterm is "boutique medicine."See, for example, D.C.
Cascardo, "Boutique Medicine: A New
ConceptBasedon TraditionalIdeals,"MedscapeMoney& Medicine4, no. 2 (2003),
www.medscape.com,accessed September
17, 2003.
23. Vogue,446.
24. This argument is proposed by P.
Self TheEndof NaturBaldi, TheShattered
al Evolution(Cambridge,Mass.:MIT Press,
2001), 217 n13.
25. In Heideggerianlanguage(see note
18, above),the conflictconcernswhat will
enframemedicine:will medicinebe called
forthas reliefof painor as technoluxe?
26. See P.Bourdieu,TheLogicofPractice,
tr.RichardNice (Stanford:
StanfordUniversity Press,1990), and PracticalReason:On
the Theoryof Action (Stanford:Stanford
UniversityPress,1998).
27. Bourdieu'sideas on physicalcapital
are discussed by N. Crossley, The Social
Body:Habit, Identity,and Desire(London:
Sage,2001).
accessedAugust
28. www.footfacial.com,
2003.
29. KathyDavismakesthis argumentby
reviewing the career of the pioneering
Frenchcosmeticsurgeon,"MadameNoel,"
who wroteeloquentlyaboutherwomenpatients'fear"oflosingtheirjobsas theirfaces
begin to show the first signs of aging"(p.
27). MadameNoel consideredher surgical
practicean expressionof her feminism-a
self-imageforwhich Davisprovidesconsiderablejustification.K. Davis, "Cosmetic
Surgeryin a DifferentVoice,"in Dubious
Equalitiesand EmbodiedDiferences,(Lanham, MD: Rowman& Litdefield,2003):
19-39.
30. Disabilityrightsactivistscertainlyexpressobjectionsto limb lengthening,but in
my searchof publiclyavailablematerials-

2004
March-April

quickweb hits-those voicesare compara- on theManagementof SpoiledIdentity(Entivelyhiddenbehindissuesof functionthat glewoodCliffs,N.J.: PrenticeHall, 1963).
askwhetherit will work, at what cost, and
42. Quoted in H.L Dreyfusand P.Rabiwith whatrisk.
now, MichelFoucault:BeyondStructuralism
secondedition(Chicago,
31. G. Mueller,"ExtendedLimb-length- and Hermeneutics,
ening: Setting the Record Straight." Ill.: University of Chicago Press, 1983),
Revised
187.
09-27/02.
posting,
43. L.A.Hedley,"AChildof Difference,"
http://www.lpaonline.org/library_ellmueller.html,accessedAugust31, 2003.
New York Times Magazine, October
32. See Frank,"SurgicalBody Modifica- 12, 1997; availableat http://home.earthlink.net/ dkennedy56/dwarfism_nytmag.h
tion andAltruisticIndividualism."
and Pitts,In tml, accessedSeptember21, 2003.
33. See Atkinson,Tattooed,
44. Perhaps I should call it Parzival
theFlesh.
34. Amongmanycritiquesof normaliza- bioethics,in honor of the wise simpleton
Dis- who, alone among the Arthurianknights,
tion, see L. Davis,Enforcing
Normalcy:
the moral sense to ask the wounded
and
the
Body (London: has
ability, Deafness,
Fisher King the obvious but previously
Verso,1995).
unaskedquestionof what'swrongwith him.
35. See P.Alderson,ChildrensConsentto
This
simple but profoundquestionbreaks
Surgery(Buckingham and Philadelphia: the
and relievesthe King'ssuffering.
spell
Press,
1993).
Open University
Wolframvon Eschenbach,Parzival,tr.A.T.
36. See A.D. Dreger,ed., Intersexin the Hatto
(London:Penguin,1980).
Ageof Ethics(Hagerstown,Md.: University
45. Socratesalso sought the sort of uniPublishingGroup,1999).
versalattributesthat my line of argument
37. These surgeonsare acting in accorFor an especiallyuseful discussion,
dancewith moralnormsdeeplyingrainedin rejects.
see B. Flyvbjerg,
MakingSocialScienceMatmodernitythat privilegethe face.With ref- ter:WhySocialInquiryFailsandHowIt Can
erence to diffuse social usage, Goffman Succeed
Again,tr. S. Sampson(Cambridge:
made the face his trope for that which
UniversityPress,2001), espeCambridge
membersof a socialgrouphavea responsi67-71. Flyvbjergarguesfor an Ariscially
bilityto protect;boththeirown faceandthe totelianphronesisas the basisof social scifacesof otherpeople.See E. Goffman,"On ence. Bioethicscan choose what it needs
FaceWork"(pp. 5-45) and"Embarrassment fromboth
philosophers.
and Social Organization"(pp. 97-112) in
46. A.W. Frank, "The Bioethics of
BeRitual:Essaysin Face-to-Face
Interaction
Alternative Claims of
havior(GardenCity, N.Y.: AnchorBooks, Biotechnologies:
PosthumanFutures,"in S.J. Williams, L.
1967).
Birke,and G. Bendelow,eds., DebatingBi38. Anothersurgicalrationalefor quick,
on Health,MedReflections
ology:Sociological
earlyinterventionis that infantswill be too icine, and Society (London: Routledge,
young to rememberthe experience.Family 2003), 261-70.
secrecybeginsin the parentalhope that the
47. Thus LisaHedleywrites:"Earlyon I
interventioncan effectivelydisappear,the
learnedthat the way other people respond
child growingup as if she or he had been
to a child of differencebecomesintegralto
born with the genitals that surgery has
your
experienceof the world."Hedley,"A
hear
never
like
ISNA
recreated.Groups
of Difference."If this statementfalls
Child
fromthosepeoplefor whom this strategyis
at the personalend of a continuum,at the
effective.
globalend is the theologicalideal, empha39. The slidesalso raisethe problemof sizedin but not exclusiveto Buddhism,that
consent to create public images of one's no
person'ssufferingcan be fully relieved
body:how freelygivencanconsentbe when until everyone'ssufferingis relieved.
it is requestedby the surgeonon whom a
48. Elliott,BetterThanWell,199.
patienthas ongoingdependence?
49. A. Wolfe,MoralFreedom:TheSearch
40. Limblengtheningcanalsooffera few
Virtuein a Worldof Choice(New York:
for
more centimeters,but the procedureis so
Norton,
2001).
makesno
extensivethat the term "revision"
50.
Emily'ssurgeryis depicted in Lisa
sense.The problemof enoughdoesnot seem
Abelow
Hedley'sfilm, "Dwarfs:Not a Fairy
had
have
who
for
so
to loom large people
Tale."A projectof the Childrenof Differlimb lengthening.
ence Foundation.Emily'sname is used in
41. Erving Goffman defines stigma as
this articlewith her permission.
allow
that which spoils identity. Stigmas
51. R.N. Bellahet al., Habitsof theHeart:
variouskindsof managementof the effects
in American
and Commitment
Individualism
as
of this spoiling;at the extreme,"passing"
normalallowsthe conditionto remainun- Life, updatededition (Berkeley:University
noticed.Goffmanpresentsfacialdeformity of CaliforniaPress,1996), 138.
52. Ibid., 152 ff
as the exemplarof stigmatizingconditions
thatdo not allowpassing.See Stigma:Notes
HASTINGS CENTER REPORT

29