What’s the Difference Between Hearing Aids and Puberty Blockers?

Nature makes mistakes. It endows us with degenerative diseases, missing limbs, faulty senses, warped spines, cleft palates, and severe mental defects. Even those fortunate enough to be born reasonably whole may still have to contend with the onset of malocclusion, hemophilia, arthritis, schizophrenia, and Tourette syndrome. Ride the subway in any major city, look around you, and you will see firsthand the painful provisions of, as Kant puts it, “a stepmotherly nature.”

Yet nature, which was parsimonious in so many ways, was generous in one great one: it gave us reason, and with that reason we would pry into it with every instrument of our devising and wrest away the means to control our fortunes, right down to the bodily defects that plague us. Was it wrong for us to do so? Penicillin, polio vaccines, eyeglasses, life-saving surgical interventions, you name it. By treating nature as raw material for our manipulation, we routinely escape the endless cycle of poverty and disease. This is the modern bargain. For the most part, we take it and don’t look back.

I am myself a particular beneficiary of this bargain. I was born mostly deaf — proof of nature’s stinginess — such that I barely heard sounds before the age of three. Until the recent past, I would have remained that way, relying upon a combination of sign language and lip-reading to communicate with the wider world, and limited in musical appreciation to the loudest percussion and the deepest bass notes.

Consequently, I’ve given more than a little thought to the relationship between technology and nature. In my case nature was indeed an unfit mother, sending me into the world without 90 percent of the hearing the average person enjoys. Meanwhile, technology has corrected nature’s parsimony: the use of hearing aids allows me to hold conversations, enjoy music, and generally experience what we might call normal life.

I mention all this not because it is especially remarkable, but because it isn’t. Medical and technological alteration for a vast array of cases is something we have come to accept as part of the basic fabric of modern existence.

Other cases, however, generate controversy. One of these controversies — the development of cochlear implants — is not terribly well known. Another — gender transition — is presently inescapable.

As it happens, both controversies largely arose from the efforts of dedicated activists. But there is something of a puzzle here: in the case of cochlear implants, activists fought (mostly unsuccessfully) to oppose medical intervention, while in the case of gender transition they have fought and are fighting still to expand it.

Despite their opposed orientations, however, both groups of activists were operating from certain shared premises about the relationship between nature and technology. Examining this relationship may help us better understand our own positions on these and similar controversies.

I was born with what is called severe-to-profound hearing loss — a broad description for significant loss that falls short of total deafness. At the time, in the early 1980s, I was fortunate enough to be able to rely on hearing aids to amplify sound to the normal range, and indeed I still do. But those who were completely deaf had no available technological solution then. There was effectively no hearing to amplify for them.

That same decade saw the initial development of commercially viable cochlear implants — a neuroprosthesis that is, as the name indicates, surgically implanted in the cochlea in the inner ear. Whereas hearing aids amplify sound before sending it to the ear, cochlear implants bypass damaged portions of the ear and directly stimulate the auditory nerve, which connects to the brain. Consequently, cochlear implants could benefit deaf people in a way that traditional hearing devices could not.

By the early 1990s, the technology for cochlear implants had advanced to the point that they were being implanted in children as young as two years. It was around this time that they became the focus of a wider political controversy initiated by activists within the deaf community. (In an interesting coincidence, the young son of a family friend was the first child recipient of these implants within my home state, affording a close view of this controversy as it played out.)

For many deaf activists, the implantation of cochlear devices in children represented a threat to the continued existence of deaf culture. They argued that these children would be better off retaining their “deaf identity” than being regarded as candidates for medical treatment. Many of the activists were content to claim only that deafness had produced a unique form of cultural expression (which it had), and they did not wish to see it wholly effaced by technological advances. But some of the more strident voices went further, arguing that widespread administering of cochlear implants amounted to cultural genocide.

It is important to note here what this view leaves out. Deafness correlates robustly with other eminently undesirable conditions, such as depression and mental illness. Conversely, the implantation of cochlear devices (as with hearing aids) had measurable benefits for cognitive development and education. More broadly, being deprived of hearing means being unable to orient oneself within the world in one of the primary ways humans do, and thus unable to feel at home within the world. This means most obviously music, but also the speech of other people, the rustle of wind and the song of birds, and the clattering and commotion that are simply part of shared human experience. Even silence means something different when set against sound than when it is all one knows. To be closed off from the world of sound is a form of isolation, and we know that isolation is hard for most people to bear.

Does this mean that those who are deaf are somehow less human? No, of course not. It does mean, however, that they are not able to participate in a large share of experiences that we understand to be characteristically human.

Admittedly, what those with cochlear implants are “hearing” is not direct sound; the implant bypasses acoustic hearing altogether by stimulation of the auditory nerve with electrical pulses. There is an artificiality to this solution. This was not, however, the critique advanced by the more extreme deaf activists. They opposed cochlear implants not because they were an imperfect solution but because they were presented as a solution at all. They simply denied that deafness might be a suboptimal condition in need of correction. For myself, I never found this argument very persuasive. I have tried it both ways — with and without hearing aids — and one really is better.

In a sense, this entire debate is an expression of the age-old tension between custom and nature — what the ancient Greeks called nomos and physis. The advocates’ contention implicitly rejected looking at nature as a standard, suggesting instead that hearing was no more natural than deafness, and our ordinary preference for hearing merely represented a kind of cultural convention or prejudice.

Now, the distinction between nature and custom is easily overstated. To return to my own situation, I have for nearly the entirety of my life relied upon a variety of hearing aids, not just to function but to hear almost any sound at all. It is not too much to say that I have virtually no unmediated experience of the audible world. Is my hearing natural? In an obvious sense, no. I use manmade devices that rely on electronic amplification and batteries. And over time, hearing aids have only progressed (or regressed) further from nature with the development of digital technology, encoding those beautiful swooping sound waves as so many 1s and 0s.

But I am still using nature as a standard. I use hearing aids because I have some conception of normal, natural hearing that I measure my own situation against. Human beings, understood as a natural kind, are normally possessed of five working senses. And I am not convinced that, just because some people are born with hearing and others without, both are natural in the same way.

To qualify the statement about my case then — and by extension the cases of those who receive cochlear implants — it would be better to say that technology has corrected nature with a view to a higher understanding of nature.

The controversy over cochlear implants proved to be something of a tempest in a teapot — though it created no small amount of trouble for those undergoing the procedure and for their families. In the years that followed, despite the harshness of the early invective, cochlear implants would become increasingly mainstream for both children and adults. The limited effects of the protests seemed at the time to be evidence that some understanding of the natural human still broadly prevailed in our culture.

In retrospect, however, I have come to think otherwise — that deaf activists’ inability to find broad support for their claims had less to do with their philosophical radicalism and more to do with how their rejection of medical intervention made them appear to be enemies of progress. My change of mind occurred in recent years as I have thought about activist arguments in another debate: that over gender transition.

The arguments of transgender activists appear on their face to be diametrically opposed to those of deaf activists. Deaf activists decrying cochlear implants claimed that deafness was not a defect in need of correction, especially not in the form of surgery. Trans activists argue in the opposite direction, that the apparent mismatch between a person’s subjective self-image and physical body can, and often should, be resolved, even through surgery. Though they don’t tend to use this language, they typically present gender transition as correcting a defect in nature: the sex with which the person is born, which mistakenly doesn’t match the gender.

Deaf activists seemed to be arguing that we should let nature take its course, allowing those born deaf to remain deaf rather than mess about with technological fixes. By contrast, trans activists, together with hospitals and medical organizations, present gender transition as ordinary medical care, no different in kind from cancer treatments and diabetic supplies.

Another difference between the two movements is that, with cochlear implants, the arguments in favor of leaving biological nature as it is generally came from progressives, whereas in the trans debate it is conservatives who defend the same position.

Yet despite the incongruity of the two activist positions on the surface, they share a deeper foundation: a profound ambivalence about nature as a standard for health. The salient factor in understanding them both is not the practical question — to intervene or not to intervene? — but a philosophical one: Where does nature stand in relation to these procedures? The implicit answer in both cases is: nowhere. Nature is an unfit mother. Not only can it throw us into the world with missing senses; it can deliver us into the wrong bodies as well. But in the choice between replacing or accepting what we are given, nature as such can no longer guide us. The question is what, if anything, can.

Much of the modern world is premised upon the inadequacy of nature — an inadequacy we have corrected with remarkable success. Yet modernity is more than simply the overcoming of nature. Modernity denigrates nature even as it relies upon it as the source of our understanding. After all, it was the natural skies rather than the heavens of medieval cosmology that Galileo’s telescope revealed. It is nature, whose laws explain the properties of matter and the causes of motion, that we rely upon for our great feats of engineering.

That said, the Baconian project of improving on nature was always a somewhat dicey proposition where medical science was concerned, for it meant subjecting to our manipulation not only the world “out there” but our very selves. That manipulation — from painkillers to synthetic insulin to organ replacement and much besides — has traditionally been oriented toward a broadly shared notion of natural human health. But whereas the hostility of the natural world is clear enough — floods, earthquakes, hurricanes, and more — broadening that hostility to include the ways our bodies themselves betray us brought us to the edge of that view of natural human health. What is a natural human lifespan and how far should we extend it? Which causes of death do we accept as natural, and which ones do we try to eliminate? And so forth.

Nonetheless, medical practice mostly remained bounded by an implicit understanding that nature provided an intelligible standard. Hence, for example, ethical constraints have historically prevented physicians from performing extreme body modification, regardless of patient desires. A doctor could remove a limb to preserve the life of a patient, but not because the patient simply found it ugly.

But the tension was real. The modern project had created a fault line between, on the one hand, looking to nature as a standard for human health to guide our decisions about how to correct our bodies and, on the other, the belief that nature could provide no such standard and all we have to go by is human will and desire.

The question of gender transition maps that fault line. Some would say that transgender surgery is merely another case of modern medicine correcting nature’s inadequacy, supplying the body that nature failed to provide. But this is not the argument that all trans advocates make. Some reject the idea of a mistaken natural sex needing correction, arguing instead that what is at issue is that human agency should override any natural status, that people should be free to choose their sex and their gender regardless of biological facts.

Now, it is clear enough that it makes little sense to speak of our bodies as inevitably fixed in every case — the entire history of medicine is premised upon the notion that neither sickness nor health are inevitable, that we have a significant amount of agency in choosing one over the other. If we didn’t, the infant mortality rate would remain forever high, and we would have no workable theory of disease or even an idea that such a theory was possible. For myself, I would have never been able to hear Mozart’s piano concertos or Relaxin’ with the Miles Davis Quintet.

But the question remains whether we still actually possess a distinct understanding of the healthy and able human body, one that can guide modern medicine. Given the pace of technological progress, along with the emergence of ambitious philosophical arguments for treating human beings as material for transformation, the relevance of this question goes well beyond the transgender issue.

From venture capitalist Bryan Johnson’s highly public attempts to indefinitely forestall aging to the various forms of “biohacking” now in vogue among technologists to ever more radical forms of body modification being promoted on social media, we are witnessing the retreat of the traditional conception of the purpose of medicine. At the same time, these and other ventures are couched in the language of medical solutions. What is novel is the idea of the problem being solved.

What we are left with in all these cases is the form of medical intervention without the substance that a robust understanding of sickness and health might supply. Meanwhile, what the above examples suggest is that new practices can more easily stretch the conventional understanding of healing when they present themselves as medical remedies. As for the deaf activists who demonstrated against cochlear implants, it was their rejection of medical solutions rather than their underlying philosophical commitments that limited their impact. Their rejection of medical intervention appeared sectarian — even regressive — whereas the seeming imitation of conventional medical practice by proponents of gender transitions, biohacking, and so on has helped normalize what were once considered radical measures.

Nonetheless, the ethos of the deaf activists is now general. I don’t mean to suggest that they necessarily influenced the later movements. But their implicit rejection of nature as a standard of medical evaluation in favor of more subjective factors like culture and identity presaged the claims of those movements.

Of course, it might be that these novel developments merely represent the next logical stage in the Baconian project of controlling nature for our benefit and our happiness. Who is to say that what we construe as good for us must be limited to existing accounts of what it is to be human? Why shouldn’t we reject nature’s constraints in favor of an unfettered pursuit of happiness?

And yet, without some account of human nature, it is difficult to see how one could speak intelligibly of what will make us happy among the array of possibilities offered by medical and technological invention. Here I recall the concluding stanza of William Butler Yeats’s “Sailing to Byzantium”:

Once out of nature I shall never take
My bodily form from any natural thing,
But such a form as Grecian goldsmiths make
Of hammered gold and gold enamelling.

While many today would also choose to leave flawed nature behind altogether, in my heart of hearts, I can’t quite bring myself to believe that there is a Byzantium for them on this earth.