Enhancements are so obviously good for us that it is odd that the idea of enhancement has caused, and still occasions, so much suspicion, fear, and outright hostility. In particular, two influential sets of arguments by philosophers who do not in principle oppose enhancements have nonetheless attempted to place severe constraints on the legitimacy of using enhancement techniques. These objections have been made in terms of either the motivation or the objectives to be achieved on the one hand or on the tests that enhancements have to meet on the other, tests that constrain enhancements in ways that seem hard to justify.
We do not need a new or complex definition of the term “enhancement.” In the context of interventions which impact on human functioning, an enhancement is clearly anything that makes a change, a difference for the better.1 This is simply what is ordinarily meant by the term. We cannot necessarily say in advance what will constitute a change for the better, since we cannot predict all future states of the world or states of the individuals who might wish to consider an opportunity to make things better. What we can say, and what I will argue in detail in this chapter, is that enhancements are not plausibly defined relative to normalcy, to normal species functioning, nor to species-typical functioning; rather, as we shall see, a different account altogether must be given.
I will here consider three essays on enhancement, two of which seem to place unsustainable constraints on the use of enhancement technology as much as on the concept of enhancement itself. I will use these accounts as a way of trying to state more clearly what the moral and indeed political justifications for enhancements are and to further refine the arguments of chapter 1.
We will start with two important essays that discuss enhancement in some depth. In doing so I will look again, very briefly, at a now rather antique discussion of enhancement in my own book Wonderwoman and Superman.2
The essays, two of the most interesting on these themes, are by Norman Daniels3 and Allen Buchanan and coworkers.4 Much of what I want to say is critical of the approach taken in these two essays, but they constitute icebergs in the ocean of discussions of enhancement. They must be negotiated in one way or another if we are to proceed.
Wonderwoman and Superman was concerned with the ethics of both changing for the better the genetic constitution of the individual and changing people on a scale that would affect both society and the world at large, and with the question of what “change for the better” means. Society-wide changes are now often framed in terms of changes to populations. I argued that if the gains were important enough (sufficiently beneficial) and the risks acceptable, we would want to make the relevant alterations and be justified in so doing, indeed that we would have an obligation to make such changes. The ethical question seems still to be the same as then envisaged, and whether any proposed changes amount to changes in human nature, or to involve further evolution, seems ethically uninteresting. In particular, whether the enhancements might be judged to involve creating a new species, “a new breed,” or amount to “self-evolution” or “post humanism” or “transhumanism” are not moral issues.
In Wonderwoman and Superman5 I discussed modifications to humans that will be advantageous in terms of powers and capacities, and might change people in ways that made them oddities to nonenhanced individuals and perhaps initially even to one another. This is not the place to revisit these issues at great length. Suppose we were to make it possible for humans to “have eyes in the backs of their heads.” This might be advantageous (although I imagine not greatly so, since we can look around with our present ocular configuration). However, this might also make people thus modified so sexually and arguably aesthetically repulsive that it is bad for you, all things considered.6 While I maintain that the abnormality of a characteristic relative to other humans does not affect its value, if the abnormality was also odd in a way that attracted hostility or opprobrium to the enhanced individuals, the consequences of that oddity might make things worse overall. We would have to weigh up costs and benefits carefully in each case. If the benefits were great, the simple fact that the alteration made us either nonhuman or very odd would not be decisive. Suppose that further depletion of the ozone layer made humans very vulnerable to melanoma and it was discovered that green skin afforded complete protection. Suppose further that a safe intervention would change skin pigmentation to the required shade of green. I am sure I would go green, and if I had to make the intervention in newborns I would do it for my children. Others might prefer their children normal and cancerous. I would not impose on them, but I hope they would permit me to save my own life and that of my kids. My kids might have a hard time until all their friends were dead, but I imagine there would be enough caring greens like me to provide them with more durable companions—and they would have the last laugh.7
The use of the terms “transhumanist” or “transhumanism” is much in vogue, but these terms seem to imply an agenda. Espousal of such terms can seem to be a way of characterizing (and often embracing) a movement or quasi-religion which promotes, encourages, and indeed has as its objective the creation of a new species of “transhumans.” This idea has, I believe, no special merit aside from the ways in which the changes that (might) lead to the creation of a new species are justified and indeed mandated by the good that they will do for us and our successors. To say you are a transhumanist is like saying you are a “born-again Christian” or a “fundamentalist Muslim.” It is both a program and an identity. I have no transhumanist program or agenda. I do think there are powerful moral reasons for ensuring the safety of the people and for enhancing our capacities, our health, and thence our lives. If the consequence of this is that we become transhumans, there is nothing wrong with that, but becoming transhumans is not the agenda; improving life, health, life-expectancy, and so on is, however, not only part of a defensible moral agenda, it is a mandatory dimension of any moral program.
We noted in the previous chapter that UNESCO’s IBC, reflecting on the ethics of tinkering with the genes, has maintained that “the human genome must be preserved as common heritage of humanity.”8 Very many people talk as though being human was a moral imperative. The use of expressions like “what it is to be human” or “she is a person of exceptional humanity” or “it is only common humanity to act in this way” or “humanity requires that we do this” seem to reinforce this idea. The contrast with being human is of course intended to be “being less than human,” being “subhuman” or “inhuman” or, worse, being “bestial” or “like an animal.” Here the extent to which expressions like “human” or “inhuman” are used act as indices of morality and perhaps also culture. Hitherto exceptional conduct or ability which seems to be positive has been regarded as evidence of what humanity is capable of or as a benchmark of all that is best about being human. Some exceptional abilities or some capacities for exceptional conduct may in the future also involve something which we are forced to regard as involving a step change beyond humanity or a change of degree which also involves a change in kind, from humankind to some other kind. If we are feeling euphoric, we may be inclined to say that such changes “transcend” common humanity and maybe also uncommon humanity. Changes to the human genome may be thought of themselves to involve a move away from our current species identity; more radical changes may make such a reevaluation of our nature inevitable. In chapter 4 we will consider one such change, increased longevity, which may eventually amount to the creation of immortals. Since for millennia humans have used the term “mortals” or its equivalent to distinguish our kind from other kinds—”immortals,” for example, who may also be gods—it may be difficult to avoid this change in our understanding of ourselves and what is fundamental to our nature.
It is difficult, for me at least, to see any powerful principled reasons to remain human if we can create creatures, or evolve into creatures, fundamentally “better” than ourselves. It is salutary to remember that we humans are the products of an evolutionary process that has fundamentally changed “our” nature. We have noted the absurdity of our common ape ancestors in Africa getting together with a simian agenda to block evolution so that simian nature would be preserved as “the common heritage of simian kind.” If that had happened you would not be reading this book nor would I have written it! (No bad thing you might think, and you might be right; but then you would not be thinking anything because you would never have existed.)
In recent literature a distinction has often been drawn between the supposed moral significance of changes to the germ line and changes to the somatic line; that is, between changes that involve the gametes, and so are transmissible via reproduction to future generations, and those which, because they do not affect the gametes, remain one-off changes to the individual him-or herself. Changes to the germ line, once demonstrated to be safe enough, would surely be the therapies of choice owing to their massive advantage in terms of efficiency. If the change is important enough to make in the individual, then, if it can be made on the germ line and passed on indefinitely to future generations, that simply avoids the necessity of a separate alteration to each and every future generation. However, we should note that radical enhancements which raise issues of species identity or membership, if introduced into the germ line, might create new types of beings and not simply mutant variants of an existing type.
Daniels has reminded us9 that the high safety standards routinely now applied to human subject research will often rule out enhancements, whereas Buchanan et al. have suggested that the motive for all enhancement therapy must be, or at least include, the pursuit of equal opportunities. If the ethics of changing human nature or changing the nature of individuals (creating freaks, as Daniels calls this) is principally a matter of cost–benefit analysis, safety versus advantage, then the question as to what an appropriate safety standard might look like becomes crucial. This is one of Daniels’s main themes so we will start with Daniels’s stimulating and fruitful analysis of what might be meant by changing human nature.
To summarize the lessons from my excursion into fruit fly nature: fruit fly nature is a population concept: to characterize the nature of fruit flies we must aggregate phenotypic variations across allelic variations among fruit flies. It is a dispositional concept, since the phenotypic traits we take to be the “nature” of fruit flies vary within some range under different conditions. Finally it is a selective, theory-laden concept: not every trait of fruit flies is likely to be considered part of their nature, but only those that we use to explain something of importance to us about them. Putting these points together, the concept of fruit fly nature applies to what we consider the central explanatory features of the phenotype fruit flies manifest under some range of conditions.…
So we can modify human nature, but it takes a very tall tale. We must affect the (or at least a) whole population of humans, and we must do so with a trait central to that nature.
Still, what the modification does at most is change the particular individual’s nature into something beyond human.… By itself, this does not alter human nature. It creates freaks. If it operated on a population level, we might well, as we have seen, count it as a change in human nature. A world full of mind readers instead of liars would be one in which we would not encounter human nature as we know it. Not many traits fit this description, I suspect.10
Daniels believes the concept of human nature is problematic in ways that can be elucidated by reference to the fruit fly.
Daniels then is rightly skeptical about the idea that most changes about which people worry can in a meaningful sense be thought of as changes to “human nature.” He thinks, surely correctly, that for most likely changes this is the wrong question to ask or a misleading specification of the task. He concedes that we can change the nature of some humans (if not human nature), creating the equivalent of freaks. However, while we may have justifiable motives for running the inherent risks in order to ameliorate dysfunction, Daniels believes we do not have such justification for improving upon an “otherwise normal trait”:
For example, if we are trying to ameliorate or eliminate a serious genetic disease, or disease for which there may be some genetic or other medical remedy, the probability of potential benefit from the experimental intervention may plausibly outweigh the certainty of catastrophic illness. But if we are trying to improve on an otherwise normal trait, the risks of a bad outcome, even if small, outweigh the acceptable outcome of normality. So we cannot ethically get there from here.
I believe this argument has great force.
Talking of a cognitive trait, improvement in short-term memory loss, he says:
We would have to know that the increased short-term memory involved here actually plays a role in enhancing the more complex cognitive task rather than … interfering with it.… Without some clear sense of these complex issues, we could not have any confidence that improving the component capability has the intended or desired effect on the more complex one. And all of this information goes well beyond the standard worry that the intervention itself carries with it risks that noninterference lacks. In short, a careful human research protocol would most likely stop this experiment in its tracks.
Daniels notes that in some fields (he cites plastic surgery) surgeons routinely experiment by modifying techniques “on the hoof” but he seems to feel that
our incomplete adherence to appropriate patient-protection concerns should not count as an argument in favor of ignoring them in the case of medical—genetic or not—interventions to improve on human cognitive or behavioral traits.
It is difficult to know whether the caution that Daniels regards as mandatory is better founded than that of UNESCO already considered. It is also unclear whether Daniels’s precautionary approach is intended to apply only to cognitive and behavioral traits or whether he would also include enhancements to achieve longevity, or resistance to disease. These may all involve the same degree of “incomplete adherence to patient-protection concerns” and “the standard worry that the intervention itself carries with it risks that noninterference lacks.” With the result that “a careful human research protocol would most likely stop” experiments like these in their tracks.
These arguments illuminate the ethics of enhancement in important ways. In Wonderwoman and Superman11 I considered many of these issues in some detail and concluded on an optimistic note; Daniels has not provided arguments powerful enough to destroy this optimism:
For my own part I welcome the possibility of a new breed of persons with life chances not available to us now. Of course engineering genetic protections of various kinds into the human genome will not automatically make the world a better place to live in, nor will it necessarily make people happier. We will still have to work as hard as ever to reduce disease, new diseases are after all always liable to arise. We will still have to work as hard as ever to reduce prejudice, including prejudice against the new breed, to combat injustice, to eliminate poverty, starvation, cruelty and the thousand unnatural shocks that flesh is heir to; as well as the natural ones.
But the fact that we cannot cure everything has never been an argument for failing to cure something, particularly when it is something that causes pain, misery and premature death.12
It is traditional to draw a distinction between repairing or curing dysfunction on the one hand and enhancing function on the other. Those who, like Boorse,13 Daniels,14 and others, define disease in terms of a departure from normal species functioning or species-typical functioning are often drawn to this distinction because for them enhancement is also a departure from normal species functioning and species-typical functioning. Repairing dysfunction is on this view restoring species-typical functioning from below, so to speak, whereas enhancement is departing from species-typical functioning in an upward trajectory. On this view, treating disease is restoring species-typical functioning, whereas enhancement is interrupting species-typical functioning. However, it is of course always true that restoring species-typical functioning is enhancing for the individual concerned unless they are functioning above par and the restoration is injurious or damaging to them. Most of what passes for therapy is an enhancement for the individual relative to her state prior to therapy.
Another problem for this distinction between therapy and enhancement arises because the very same interventions which, for some, might help restore normal, or as I would prefer to characterize it “better or more adequate” functioning, may for others be radically enhancing. Regenerative stem cell treatments for people with brain damage would clearly be therapy. The same treatment in those with normal or undamaged brains might, however, enhance brain function; likewise, treatment for memory loss in damaged brains might enhance memory in normal brains.
Elsewhere I have criticized the therapy–enhancement distinction, relying, as above, on the friendly ozone layer to provide the telling illustration:
Suppose due to further depletions to the ozone layer, all white skinned people were very vulnerable to skin cancers on even slight exposure to the sun, but brown and black skinned people were immune. We might then regard whites as suffering substantial disabilities relative to their darker skinned fellows. And if skin pigmentation could be easily altered, failure to make the alterations would be disabling.… [I]n such circumstances whites might have disabilities relative to blacks even though their functioning was quite species-typical or normal.15
We do not die of old age but of the diseases of old age.16 It is species typical of us to die of these as we normally do, but it is not necessarily necessary that we do. If we could systematically treat these diseases in a way that enabled tissue to regenerate (using stem cell therapy perhaps) and at the same time switch off the aging process in cells, this too would be enhancing but would be another case in which treating disease in particular ways also constituted enhancement. Systematically treating the diseases of old age with the result that people lived substantially longer to the extent perhaps that some would even become immortal would appear to constitute both therapy and enhancement. This, however, is only because treating disease seems typical of therapy, not because normal species functioning does or can play any role at all in the argument.
However, as Boorse and Daniels define disease, treating the diseases of old age would not be therapeutic (indeed, the diseases of old age would not be diseases) in any sense because diseases of old age are species typical (or of course constitute normal species functioning), and it is species typical and a part of normal functioning that we cease to function in old age and that we die.
In an earlier essay on this theme Daniels claimed that
it is our norms and values that define what counts as disease, not merely biologically based characteristics of persons.… Pointing to the line between treatment and enhancement is not, then, pointing to a biologically drawn line but is an indirect way of pointing to the valuations we make.17
If this is true, we must ask what the relevant evaluation is. The answer must surely be that we have a strong rational preference not to be harmed in a particular way and it is this that leads us to make the evaluation that draws the line. Occam’s razor, that wonderfully enhancing surgical tool, comes to our aid here and shows us that we do not need to use our values to create a spurious distinction (the normal–abnormal divide), which Daniels insists is the route to distinguishing therapy from enhancement. After the surgical strike we are left not with a process that leads from our norms, through a definition of disease and the normalcy–enhancement distinction to a moral difference between therapy and enhancement, but one which moves directly from our values to a rejection of harm and an acceptance of benefit whether called therapy or enhancement. This shows that the enhancement–therapy distinction does not depend on conceptions of normalcy at all and the moral imperatives either to provide therapy or enhancements come from the fact that we value minimizing harm. Normalcy plays no part in the definition of harm and therefore no part in the way the distinction between therapy and enhancement is drawn.
Of course in view of these examples those who wished to cling to the therapy–enhancement distinction could simply say “yes, therapy and enhancement sometimes amount to the same thing, but not always.” But now consider that many routine therapies—vaccination, for example—are enhancement technologies for the simple and sufficient reason that they enhance and the moral significance of the distinction as well as its utility collapses. It does not draw either a morally significant or an explanatorily significant distinction and so fails utterly to be useful. We will shortly return to the question of what is a morally relevant distinction in this field.
This forces a reconsideration of the distinction between therapy and enhancement and a reconsideration of the question of our motives for and the justification of our interference in the natural lottery of life. Here it is fruitful to look at the attempts by Buchanan et al. to grapple with this.
In one of the most famous and influential philosophical books on this subject, Allen Buchanan, Dan Brock, Norman Daniels, and Dan Wikler have argued that the motive we have for intervening to treat or cure disability (and the same would presumably go for the treatment of disease) is “for the sake of equal opportunity.” Buchanan et al.18 say “some of our most basic social institutions reflect a commitment to intervening in the natural lottery for the sake of equal opportunity.” To be sure, the main concern of Buchanan et al. is to show how the concept of equality of opportunity requires extension to embrace what Scanlon and others have termed a “brute bad luck” conception of equal opportunity—a conception which believes in intervening to mitigate disadvantaging factors which are beyond the control of the subject of those factors.19 This is a constantly repeated, but not universal, gloss on the moral reasons Buchanan et al. give for therapeutic or even enhancing interventions. Again,
[i]n other words, equal opportunity has to do with ensuring fair competition for those who are able to compete and with preventing or curing disease that hinders people from developing the abilities that would allow them to compete.20
Buchanan et al. are self-consciously following Daniels and Rawls here: “As Norman Daniels has argued, the case for a moral right to health care relies, at least in part, on the fact that health care promotes equal opportunity.”21 Here the move from simply extending a conception of equality of opportunity to confirming that conception as an important part of the moral right to health care becomes clearer. It is this idea—the idea that the moral reasons we have for pursuing health or for enhancing the functioning of human beings (in short, our “commitment to intervening in the natural lottery” of life) has much to do with equal opportunity or the “ability to compete”—that is genuinely bizarre.
Of course, equality of opportunity is something we should try to maximize in the delivery of improvements in health or in functioning, but it seems only tenuously and contingently connected with our moral reasons for so doing. Suppose there was a painful condition which affected some people but not others. It did not, however, affect people’s ability to compete or affect the pursuit of opportunities. I believe we would have exactly the same compassionate motive and moral reasons for intervening in the natural lottery to remove this condition as we would have if it was also “competition affecting.” This latter factor seems to add nothing to our moral reasons for alleviating the condition.
The reverse is also true. Where a feature frustrates equal opportunity, that fact also provides a sufficient and complete moral justification for trying to remove it. What it does not do is provide a necessary justification.
The commitment to intervene in the so-called “natural lottery” would (or should) surely be compelling quite independently of any contribution it makes to equal opportunity, although, as I have indicated, in pursuing health and/or enhancement for the good reasons we have for so doing, we should attempt to ensure equal opportunity to access such goods. But the claim that “the case for a moral right to health care relies, at least in part, on the fact that health care promotes equal opportunity” seems false. Equal opportunity might in some circumstances be a further additional reason to support the moral right to health care, or of course a separate one, but to regard equal opportunity as an essential part of the moral basis for such a right or indeed the moral motivation for establishing such a right is doubtful. I have argued elsewhere22 that where the provision of health care will prevent harm to human beings, the moral argument for delivering that care is as complete as it needs to be. Equal opportunity can say something about selecting who to help in conditions of scarcity but it seems an inappropriate candidate for a factor which might have any priority in explaining or justifying “a commitment to intervening in the natural lottery.”
Suppose, now, that all people were affected by a debilitating condition so that there was no inequality of opportunity, but, inter alia, the opportunities for all were reduced. The unnecessarily reduced opportunity would itself constitute sufficient moral reason for “intervening in the natural lottery,” not for the sake of equal opportunity (nor surely for the sake of competition), but for the sake of enhanced opportunity or enhanced functioning. Equally, if, as we discussed when considering enhancement, a new protective treatment were to be developed, then, even though before implementing it all would be equally disadvantaged by not having the treatment, the moral imperative to introduce it would not refer to equal opportunity at all and that case would not be enhanced by any such appeal.
Buchanan et al.23 note that
[i]t is possible, however, that some natural inequalities are not departures from normal species functioning24 but nonetheless so seriously limit an individual’s opportunities that he or she is precluded from reaching the threshold of normal competition. In such cases, genetic intervention might be required if it were necessary to remove this barrier to opportunity.
Anticipating the question as to the precise circumstances in which this might be true, Buchanan et al. answer: “Whether it does will depend on what the normal distribution of various characteristics is and how that relates to the most fundamental requirements for successful participation in social cooperation in a given society.”25 It seems implausible to think that either normal species functioning or successful social cooperation are the key ideas that license interference in the natural lottery of life, and it is not hard to see why.
Consider again the enhancement technologies we discussed earlier: those involving engineering resistance to HIV and cancer into cells or enhancing the life expectancy of human beings. These two sets of possibilities would be radically enhancing to the extent that if we manage to find ways to make such changes permanent, to insert them into the germ line, for example, “we” might no longer be human; we would perhaps have evolved into a new distinct species. Whatever one thinks of these prospects, it is parochial in the extreme to imagine that our ethical response to them would depend on whether or not the failure to introduce these possibilities would “so seriously limit an individual’s opportunities that he or she is precluded from reaching the threshold of normal competition.” We have to ask what is the motive to introduce these and other new therapies in the first place? It cannot be to restore normal species functioning because immunity to cancer is not part of this. Nor would we plausibly want to make people immune to cancer in order to help people to reach “the threshold of normal competition” because we have a much better reason for so doing as I demonstrate below. Normal competition and normal species functioning do not constitute reasons for considering the introduction of these and many other new therapies or enhancements. Nor could the idea of equal opportunity help us here: opportunity perhaps, but not equal opportunity.26
Imagine twin sisters, both of whom suffer from cancer. One is curable, the other not. We do not think that equal opportunity requires us to leave the curable twin untreated because we cannot treat both. And our moral motive and reason for treating the curable twin has nothing to do with equality. It has everything to do with saving a life that can be saved or alleviating pain, suffering, and distress when presented with an opportunity so to do.
The moral imperative for David Baltimore’s work, for example, is that it is required for what Hobbes referred to as “the safety of the people”27 and for what others have called “beneficence or nonmaleficence,” or welfare. These are imperatives quite independent of their impact on or compatibility with equal opportunities or equal justice. A moment’s reflection shows why this must be so. There is a vast shortfall in the availability of donor organs for transplantation in the world, certainly in the United States and in the United Kingdom. As I have already shown, while we cannot treat all who need lifesaving transplants, we treat as many as we can and we do so because to fail to do so would cost lives. We do not say we will perform no transplants at all unless and until we can secure equal access to transplants for all those who need them. Hopefully we allocate access to those organs that become available in ways that are consistent with equal opportunity; but the reason why we save lives in this way is not to secure equal opportunity or to secure access to “normal competition.”
What is clear is that the moral motive for using technology to intervene in the natural lottery of life is for the sake of the goods that this will bring about. Equality of opportunity may sometimes be one of these goods, fair equality of opportunity may also be sometimes one of these goods, it may even be fairer than (presumably unfair or less fair) equality of opportunity, but neither are plausible candidates for a prime moral imperative in these contexts. More usually, equality of opportunity, fair or less fair, will be a constraint on the way the goods may be legitimately be achieved. Saving lives, or what is the same thing, postponing death, removing or preventing disability or disease, or enhancing human functioning are the more obvious and usually the more pressing reasons. These are the primary reasons we have to prevent or mitigate disability and to treat or cure disease.
In view of the moral imperatives that underlie enhancement just identified, Daniels’s precautionary approach fails in its prime protective function. Consider again his argument for precaution:
For example, if we are trying to ameliorate or eliminate a serious genetic disease, or disease for which there may be some genetic or other medical remedy, the probability of potential benefit from the experimental intervention, may plausibly outweigh the certainty of catastrophic illness. But if we are trying to improve on an otherwise normal trait, the risks of a bad outcome, even if small, outweigh the acceptable outcome of normality. So we cannot ethically get there from here.
I believe this argument has great force.28
Daniels’s argument here has two essential elements. In the first he suggests that the benefits of intervening in the natural lottery may outweigh the risks where there is a “certainty of catastrophic illness” as the alternative. It is important here to be clear as to whether the certainty of illness is statistical or personal. For example, where we seek to engineer immunity to HIV/AIDS into the genes of future people there is no certainty that any individual will be exposed to HIV, let alone contract it, but the risk to individuals and to populations is such that the lack of certainty in any particular case seems irrelevant to the justification of taking the requisite risk. Of course, the degree and magnitude of risks that might be worth taking to protect ourselves from major diseases are importantly relevant, but the assessment of these seems not to depend upon the certainty of contracting the disease in question. The same was true of vaccination for smallpox, polio, and other diseases. This is a case where there may be no direct benefit to the subject of the research or therapeutic procedure but where the procedures are justified by their expected benefits to society or to populations and to the interests of the subject more broadly conceived.29
This of course challenges some of the standard elements of the international conventions that purport to govern research. For example, when Daniels notes above that “a careful human research protocol would most likely stop this experiment in its tracks,” he is perhaps thinking of paragraph 5 of The Declaration of Helsinki, which notes: “In medical research on human subjects, considerations related to the well-being of the human subject should take precedence over the interests of science and society.”30 However, the coherence of this provision is challengeable and depends crucially on how narrowly the interests of the subject are conceived.31
The second element of Daniels’s argument places great weight on the idea that if we are “trying to improve upon an otherwise normal trait the risks of a bad outcome, even if small, outweigh the acceptable outcome of normality.” It is not clear here what Daniels thinks the link is between the normality of a trait and the acceptability of the outcome. He seems to imply that normal traits are of themselves acceptable, perhaps because he thinks that disease is always a departure from the normal and hence that normality is a disease-free state. But, as we have seen, disease and unnecessary death are hideously normal and although they impair normal functioning at some stages of life they do not do so in old age, when it is normal to succumb to them. In old age the diseases of old age are part of normal functioning; what is not normal in old age is to be disease free, have perfect vision and hearing and no increased vulnerability to colds, flu, and other diseases.
Clearly, if we are trying to improve upon an otherwise acceptable trait, then small risks may not be worth running. The problem even with this formulation is that awareness of the possibility of improvement is likely to affect the acceptability of a trait. Shortsightedness at a certain age is normal and was perhaps acceptable before spectacles; and the pains of childbirth were thought not only acceptable but mandatory even after the advent of effective analgesia; painful birth is certainly perfectly normal species functioning.
Increases in life expectancy are an even clearer case. It is certainly not normal for humans to live beyond 100 years and so far as we know no one has yet lived beyond about 122 years, although many believe it probable that the first 150-year-old person is already alive and some serious commentators believe the first 1,000-year-old person is already alive.32 Dying of old age is acceptable33 only because it is regarded as inevitable. Absent the inevitability, the acceptability is problematic. We can, perhaps somewhat artificially, try to separate dying of old age and dying of the diseases of old age. We have noted that dying of the diseases of old age is normal, but perhaps if we were able to combine regenerative treatments of the diseases of old age with the ability to switch off the aging process in cells, even longer and healthier life expectancy might be achieved. This would even more clearly have little to do with normal functioning and yet this fact seems of little help in thinking about either the ethics or the desirability of such enhancements, let alone about the question of which risks it might be worth running to achieve them.34 If we are trying to improve on an otherwise normal trait, like old age, it seems implausible simply to assume or to stipulate that “the risks of a bad outcome, even if small, outweigh the acceptable outcome of normality.”
The normality of the trait in question is clearly doing no work at all in the assessment of its moral acceptability or of the risks it might be worth running to change things. If we subtract the acceptability from the normality we are left with nothing of moral, nor of argumentative force. Traits in short are not acceptable (in the normative rather than of course the simply descriptive sense of “acceptable”) because they are normal, they are acceptable because they are worth having. If they are not worth having, or if they are worth not having, their normality seems bereft of interest or force. This, it seems to me, obviously applies to saving life, that is to postponing death or to increases in longevity, resistance to the diseases of old age and to those which strike at any time like HIV, cancer, and heart disease. Whether it also applies to enhancements in cognitive function like memory or other processing skills, or to personality, is more problematic only insofar as the benefits are more problematic in many ways. There seems to be no difference in principle here and thus no difference in the relevant ethical considerations.
When Daniels says “we cannot ethically get there from here” this seems doubtful; and I am unclear as to why he believes “this argument has great force.” The problem seems to be an unjustified assumption that normal traits are acceptable by reason of their normality and that the risks of new “treatments” are justifiable only when the alternative is an inevitable catastrophic disease. Weaken or qualify the argument so that the inevitability applies on a population but not an individual basis, and so that normal traits are only acceptable when they are desired or beneficial, and the argument revives, but only at the cost of abandoning the therapy–enhancement distinction altogether, and only if disease is defined relative not to normal species functioning or species-typical functioning but to possible functioning.35 The only remaining question then is whether or not the possibilities are worth attempting given the benefits on offer and the degree or magnitude of the risks involved. Reference to normality or to disease is not required in order to answer this question.
What is required is, as we have noted, the recognition that the moral imperative and the most usual moral motive for using technology to intervene in the natural lottery of life is for the sake of the harms this will prevent and the goods that this will bring about. Saving lives or—what is the same thing—postponing death, removing or preventing disability or disease, or enhancing human functioning are examples of these goods. The only remaining question is which risks are worth running to achieve these goods either for individuals or for populations. Where the risk is only to the individual, she surely should decide for herself. Where the risk is to future individuals or to future populations, society must have a say, which is why it is societies rather than populations which should stay in our central focus. The principles upon which societies may decide these things are not a subject to be tackled in this chapter.36 What can now be said, however, is that societies have a responsibility to address these issues and that their responsibility is not clarified or simplified by reference to what is normal, natural, or species typical. Nor is it much use thinking about how disease or illness or disability have traditionally been defined, nor is reference to equal opportunity except helpful insofar as this refers to equal opportunities to access the relevant technologies.
The moral question is and remains: how beneficial will be the proposed enhancements and whether or not the risks of achieving them are worth running for individuals or societies? The moral imperative is the safety of the people and the duty to compare risks with benefits, not on the basis of the normality of the risks or of the benefits, or on the basis of their contribution to equality of opportunity, but on the basis of their magnitude and probability, on whether they will save life or—what is the same thing—postpone death and on how much harm and suffering may be prevented or avoided by the enhancements in question.
Rehearsing his commitment to defining treatment as “anything to do with maintaining normal function,” Daniels, with a somewhat magisterial waft, records that he sees “the issue as largely semantic and not central to the distinction between treatment and enhancement. Indeed, had we no vaccine for HIV/AIDS, and no genetic modification providing protection, but instead found a diet that included dandelion leaves gave protection, we would hardly say we had enhanced human nature.”37 I do not see the differences between Daniels’s approach and my own as “largely semantic” and I do not see how Daniels can dismiss them in this way either, since whether something is treatment rather than enhancement makes crucial differences in the moral reasons we have to make interventions both in Daniels’s system and in that of Buchanan et al.
Daniels’s analogy with dandelion leaves seems to me to be unconvincing. At first sight it looks as though it would be like saying in the context of a debate about the ethics of radical surgery: “indeed had we no option of bilateral mastectomy for breast cancer, but instead found a diet that included dandelion leaves gave protection, we would hardly say we had undertaken radical surgery.” The point of Daniels’s example is to counter a definition of enhancement, but this it signally fails to do. Of course, I was not assuming that all methods of achieving an objective would be enhancing if any of them were, it is obviously more likely that only some (but not all) methods of protection constitute enhancement, but even here the distinction is difficult to draw and more difficult to sustain; ultimately it collapses altogether. Consider Daniels’s dandelions: depending on an understanding of their mode of operation and the durability or permanence of the protection afforded, we might come to think of dandelion leaves as the ultimate enhancement technology! When Daniels says, “[i]n another sense, providing the vaccine stimulates a normal immune system to produce antibodies it is capable of producing so that individuals and a population are protected against serious diseases,”38 he begs the question: because the immune system would not normally do this, doing it is therefore not part of normal functioning.
On the issue of mode of operation Daniels says:
I have generally characterized vaccines as part of the array of “treatments” for departures from normal functioning—although this is stretching the idea of treatment to include preventive measures, a stretch I have made explicit in my writings. In effect, anything to do with maintaining normal function falls under the scope of “treatment” as opposed to enhancement.
But this simply assumes the point at issue, which is whether making a normal immune system do something it normally doesn’t do constitutes “normal functioning.” We can imagine a radical enhancement, say a stem cell treatment that caused brain cells to proliferate, increasing brain capacity and function by a factor of ten. Daniels might still say “this treatment stimulates a normal brain to produce cells it is capable of producing so that individuals and a population have bigger brains.” This sleight of hand enables Daniels, if he wants, to define literally anything as therapy so long as it operates on a normal physiology and causes it to do something abnormal. If it successfully makes a normal bodily system do something, then obviously this is something that it is capable of doing. On this view the elixir of life, operating on a normal physiology and making it immortal, would not in Daniels’s view be an enhancement!
Many of those hostile to enhancement trade, as Daniels does, on insisting that radical enhancement of functioning, so that people cease to be vulnerable to diseases or conditions which it is normal or species typical of us to succumb to, does not count as enhancement at all. Perhaps they think of enhancements in terms of things like “bat sonar” that would enable people to avoid bumping into objects in the dark or breeding red-nosed reindeer called “Rudolph” or human equivalents, so that sleighdrivers delivering Christmas presents would not bump into chimney pots. Such objections have in mind that enhancements should be, ought to be,39 things that change the nature of the human condition. They think perhaps that “immunity to cancer just allows normal species functioning—it does not augment it,” conveniently forgetting that cancer is a major killer precisely because it is all too normal a part of our species functioning. If we could eradicate cancer and heart disease, that would certainly change the nature of the human condition.
Daniels and others treat treatment and enhancement as if they are necessarily mutually exclusive: an intervention is either one thing or the other and different consequences follow from how interventions are classified. His assumption that vaccines are treatments and indeed are also preventive measures is of course unassailable. But my point is that treatments or preventive measures which protect humans from things to which they are normally vulnerable or which prevent harm to that individual by operating on the organism, by affecting the way the organism functions, are also necessarily also enhancements. That goes for drugs, foods, vaccines, implants, and whatever else, whether they are “natural” or “artificial” and regardless of whether they are part of a self-selected diet or treatment or are recommended or prescribed as a result of scientific research. The boundaries between treatment and enhancement, between therapy and enhancement, are not precise and often nonexistent, nor are these categories mutually exclusive as Daniels seems to think they must be. If we wear a suit of armour and the slings and arrows of outrageous fortune simply bounce off, that may not constitute an “enhancement” of the human being (though it seems to me that even here the protection–enhancement distinction, in the way that Daniels sees it at least, is on the borderline of fracture to the point at which I myself am unclear as to which side of the border we are on). We already use prostheses and implants (heart pacemakers, for example) as technological and mechanical aids or enhancements. Although the more familiar prostheses replace, say, lost limbs or teeth, or even breasts, they often do things that the originals could not do! In the future, silicon chips and other electrical and computer prosthetic devices or implants may assist and enhance memory, vision, and many other functions. Nanotechnology may enable us to make some of these so tiny and lightweight as to be unnoticeable. On the other hand, if we change human physiology or metabolism or genetics, or whatever, by dietary modification, vaccination, stem cell therapy, dandelions, or other organic means so that the organism becomes immune or resistant to slings and arrows, or automatically repairs the damage they do from within, the changes may seem more natural and more intrinsic to the human organism as traditionally understood. Either way, the distinction between therapy and enhancement, between protection and improvement, cannot be coherently or consistently maintained. Whatever else this distinction does, it fails to identify two mutually exclusive categories, and those wonderful dandelions will have enhanced human functioning.
Another reason the issue is not largely semantic is because consequences flow from whether or not something is classified as or “semantically constitutes” normal functioning. As Daniels (2007) admits: “anything to do with maintaining normal function falls under the scope of ‘treatment’ as opposed to enhancement”—for Daniels maybe! However, for many people, including most doctors and those who run health care systems, treatment constitutes an obligation in a way that enhancement (as yet) does not.
The overwhelming moral imperative for both therapy and enhancement is to prevent harm and confer benefit. Bathed in that moral light, it is unimportant whether the protection or benefit conferred is classified as enhancement or improvement, protection or therapy. For Daniels it does matter, because for him “anything to do with maintaining normal function falls under the scope of ‘treatment’ as opposed to enhancement” (my italics), and for many purposes (although for none of mine) therapy is given a higher priority than enhancement. For Buchanan et al. the most important moral imperative seems to be equality of opportunity. I have shown that both these views fail to capture the moral purposes which both therapy and enhancement standardly and most appropriately serve. I have also shown that existing and accepted enhancements, such as vaccination, make more sense when seen as conferring benefits or protecting from harms than when seen as serving either the interests of equal opportunity or those of restoring normal functioning.
Since the therapy–enhancement distinction goes nowhere in identifying where on the permissibility–impermissibility distinction an intervention lies, we need to move to the main question which is: are there limits to freely chosen enhancements, and if not would there be legitimate constraints on opportunities offered to enhanced individuals—in terms of education, employment, freedom to compete in sports, arts, and other commercial and recreational activities? I have tried to indicate some answers to this question in my 1992 book Wonder-woman and Superman, but for present purposes the answer may be summarized as indicated above, namely the overwhelming moral imperative for both therapy and enhancement is to prevent harm and confer benefit. The remaining questions concern the detail of how to calculate where that balance lies in any particular case.