Be all that you can be - or more

The drug industry has something just for you

"Makeover" is a tantalizing word. Who can fail to be intrigued, however fleetingly, by "before" and "after" pictures showing the transforming power of a stylish haircut and artfully applied makeup or weight loss and a face lift? Dentists even advertise "smile makeovers" featuring teeth shaped into rows of dazzling white Chiclets. Sunglasses, please.

But physical transformation represents only part of the burgeoning makeover industry. Those seeking self-improvement can now alter their emotions and behavior as well, even if no "before" and "after" photos can quite register the change. Feeling shy? Just take Paxil. Depressed? No problem - pop a Valium. Need calming? Reach for Ritalin. Want greater sexual prowess? Try Viagra. For every "social phobia" that ails you, there's a pill designed to increase confidence and self-assurance.

These "enhancement technologies," as Carl Elliott calls them in his engaging and provocative book, "Better Than Well," are closely connected to questions of identity - questions, he says, that involve "finding the self, changing the self, improving the self, or betraying the self."

Elliott, a professor of bioethics and philosophy at the University of Minnesota, traces the beginning of this complex search to the early 20th century, when the first self-help titles began appearing. Until then, Americans had emphasized the virtues of building character. Now personality became the focus, essential for carving out successful careers and forming satisfying relationships. The subtle new message floating through the air was: To make it, you may have to fake it by trying to hide the person you really are.

At first, those masks and makeovers had their limits. In the 1920s, skin-care preparations were acceptable, but makeup - or "face painting" - was seen as "a kind of deception." By the 1930s and 1940s, though, the idea of the "inferiority complex" became widespread, justifying cosmetic surgery in a world that regarded self-presentation as critically important.

The pharmaceutical industry, too, learned to capitalize on people's perceived inadequacies. Manufacturers realized that to sell psychiatric drugs, they needed to sell the illnesses those drugs treat. Before the 1950s, drug companies assumed they could not make money selling antidepressants, because clinical depression was considered a rare problem. But when Merck produced an antidepressant in the early 1960s, the company distributed 50,000 copies of a book telling doctors how to diagnose depression. Presto! Prescriptions for the drug tripled.

By 1999, the market for self-improvement had mushroomed. Thirteen of the 50 drugs most heavily promoted through direct ads to consumers were used for treatment of everything from baldness and wrinkles to impotence and social anxiety.

Yet as enhancement technologies appear to help one problem - people's images of themselves and the world's perception of them - those same drugs and procedures perpetuate deeply ingrained attitudes about standards of beauty. Elliott calls it "cultural complicity," adding, "The problems that enhancement technologies are meant to fix are the result of social values and attitudes that ought to be changed. Yet not only do enhancement technologies do nothing to improve those attitudes, they may also make them worse."

In addition, he warns, "we may fail to recognize the deeper source of our spiritual malaise when we focus entirely on brain states."

Adults are not the only ones yearning to be calmer, happier, and better, of course. What Elliott terms "pediatric enhancement technologies" are spurring ethical debates about their use on the youngest Americans. Should short children be given growth hormones?

And what about Ritalin, the widely prescribed, hotly debated drug to alleviate children's attention deficit/hyperactivity disorder? In 1970, an estimated 150,000 children were using some sort of stimulant medicine. By 1995, 2.6 million were taking Ritalin - even toddlers. Between 1990 and 1995, the annual US production of Ritalin increased by 500 percent.

Elliott asks whether it's good for 1 in 10 children to take stimulant drugs. No studies have tracked their long-term effects. At the same time, the moral issue underlying this debate over enhancement technologies boils down to: What kind of person do you want this child to be?

As Elliott considers Americans' yearning for self- improvement and fulfillment, he takes readers on a refreshingly quirky journey, its twists and turns dotted with cultural and literary references.

Debates like these will grow even more complex as genetic engineering becomes a reality. In a technological, medical, makeover age, the old question, "Who am I?" could be updated to sound like a line straight out of a TV quiz show: "Will the real me please stand up?"

• Marilyn Gardner writes about social issues for the Monitor.