Ethical issues in moral and social enhancement

5.3.7. Exponential growth of costs and the undermining of non-medical coping 
arguments 
As medicalization expands the category of what warrants medical treatment, the 
cost of medical treatment grows exponentially, which makes it increasingly harder 
for any government to pay for medical care for all (Conrad et al. 2010). Moreover, 
critics of medicalization may worry that the indirect costs of side-effects may have 
to be added to the costs of medical services. Medicalizing what can otherwise be 
seen as moral failures, increases that cost further.
As it stands, this objection is weak. The claim that it is better not to develop 
medical means of addressing problems because it will increase the costs can be 
responded to easily: we can choose to pay or not to pay for additional services 
depending on what we can afford and are willing to pay for healthcare as opposed 
to other government-subsidised or privately purchased goods. In relation to moral 
modification, there still will be a choice of achieving set objectives through 
traditional means like moral education (also not always cheap: for example moral 
education at a university level is quite expensive) as well as medical means, such 
tools derived from psychotherapeutic approaches and drugs. We can choose to use 
available services or not, depending on whether it is worth it.

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Rationing has been done for a very long time (as the care can always be better) and 
although looking at problems as medical may spark a pragmatic or moral 
imperative to try to address them, we can choose our priorities both on an 
institutional and on an individual level. Similarly, the indirect costs may not be 
obvious or known at the start, but as the intervention is applied and we get a better 
idea of the costs and benefits, we might re-visit the cost-benefit analysis and factor 
those costs in. Moreover, as the creation of tools to deal with problems in medical 
ways progresses, generally speaking, the cost of remedies is likely to fall. While 
new remedies are likely to be created and not be affordable, the old ones will 
become more affordable and cost-effective.
Although this view of the process is a generalisation, and thus subject to exceptions 
and problems (e.g. medical research and development targets the maladies of rich 
countries) as well as needing certain conditions to occur (e.g. preventing companies 
from only providing the most expensive treatments while withdrawing the cheaper 
but more cost-effective when needed, while providing a sufficient economic 
incentive for research and development to happen – e.g. through a suitable patent 
system), the subsequent increases in welfare justify the trouble. Even when we 
might not be able to afford all care for everyone, it would be unjustifiably 
perfectionist to only develop remedies that we can currently provide to all. Thus, 
the argument about the rising costs of healthcare is strongest as an argument for 
appropriate prioritisation, management and development, rather than against the 
process altogether.
However, the argument can be supplemented with reference to the 
change of 
attitudes
which will influence the consequences of medicalization, choices about 
healthcare provision and judgements about outcomes of successful healthcare 
delivery. In 
Medical Nemesis
, Illich (1975) describes what he calls social and 
cultural 
iatrogenesis
. 
Illich attributed medicalization ‘to the increasing 
professionalization and bureaucratization of medical institutions associated with 
industrialization’ (Gabe et al. 2004, p. 61).
He argues that although healthcare 
consumes an ever growing proportion of the national budget, the benefits to the 
patients and society are increasingly unclear. The more people are exposed to 

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healthcare, the sicker they can feel. Accordingly, medicalizing the problems can 
play into their perpetuation.
One of the ways in which this happens, assording to Illich, is via
social 
iatrogenesis, which refers to 
harms to health that are due to the socio-economic 
transformations which have been made attractive, possible, or necessary by the 
institutional shape health care has taken. Illich argues that:
‘[the] medical bureaucracy creates ill-health by increasing stress, by 
multiplying disabling dependence, by generating new painful needs, 
by lowering the levels of tolerance for discomfort or pain, by 
reducing the leeway that people are want to concede to an individual 
when he suffers, and by abolishing even the right to self-care. Social 
iatrogenesis is at work when health care is turned into a standardized 
item, a staple; when all suffering is “hospitalized” and homes 
become inhospitable to birth, sickness, and death; when the language 
in which people could experience their bodies is turned into 
bureaucratic gobbledegook; or when suffering, mourning, and 
healing outside the patient role are labelled a form of deviance.’
 
(1975, pp. 14-15)
Illich (1975) argues that we should be concerned with the erosion of already 
developed ways of dealing with pain, sickness and death. For example, as the 
mental health field promotes its technologies as necessary interventions in almost 
all areas of life, what people pick up is that they are not expected to cope through 
their own resources and networks – and non-medical ways of enduring and coping 
wither away. The same argument can be applied to medicalizing the imperfections 
in capacity for moral reasoning and action. Community’s ways of regulating 
morally relevant conduct and developing abilities that contribute to the capacity for 
moral agency such as impulse control, empathy, reasoning about moral issues, 
caring about other people’s interests, reflective helping, emotion regulation, etc., 
can be undercut by the reliance on medicine. The idea here is that once a problem is 
constructed as medical, it is ever harder to reconcile and cope with the everyday 
issues. As a consequence, a vicious circle is created: the more resources are 

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provided for mental health services, more are perceived to be needed and health 
provision becomes a part of the problem. Medicalization can be seen as creating the 
same issues that medicine subsequently has to deal with, thus creating a vicious 
circle of need.
Several doubts can be raised about this account. Firstly, this view depends on the 
empirical facts about the impairing effects of the presence of medicine on the 
ability of individuals to cope. For example, it might be that those who can cope via 
their own resources will continue to utilize those resources while those who lack the 
social networks might benefit from medicine’s support (e.g. older people whose 
children live elsewhere and who do not have an extensive social network). 
Secondly, one could question whether medicine causes the problem or simply fills 
the void created by other social forces (medicine is not the cause of people’s 
disrupted social networks for example, but increasing labour mobility may be). 
Third, it is not clear that it is just to leave agents without the opportunity to be 
assisted if they need assistance. For example, it is unclear why should the degree to 
which agents fare well (whether the issue concerns a good such as happiness, 
coping with adverse life events or capacity for moral agency) depend solely on the 
quality of their social networks and their self-developed ability to cope with or 
‘bear’ suffering and illness. Fourth, the lowering level of tolerance for discomfort 
may be problematic, but may also be a result of the increased attention we pay to 
peoples’ wellbeing, and thus constitute progress. For example, that there is a lower 
level of ‘tolerance of discomfort or pain’ resulting from sexual assault or domestic 
violence, and that such issues are now discussed more openly with the use of 
language that could be easily described as a ‘