Chapters 9, 10, and 11 were my attempt to pull all the conclusions from previous chapters into a single, all-things-considered conclusion about whether developing life extension is a good thing. I concluded that it is.
In this chapter, I’ll discuss a kind of concern that lies outside the line of argument developed in chapters 2 through 11 and requires separate discussion. I am referring to concerns about biomedical enhancements. A biomedical enhancement is any technology or intervention that makes humans physically or psychologically superior in some way—that is, superior to what is normal for human beings. Enhancements might take the form of making humans smarter, or giving them stronger immune systems, or improving their memory, or making them physically stronger, or even improving their moral character by making them more altruistic. These things might be done though drugs, genetic engineering, or some kind of mechanical implant. Enhancements might raise humans to a level that only a few humans currently reach (making us all as smart as Stephen Hawking) or raise them to a level no human has ever reached (making us smarter than any genius in the history of the human race). Life extension is an enhancement if anything is, and when people write about enhancement, life extension is one of the most common examples.
Although enhancement sounds like a good thing, many writers have raised moral concerns about it. Concerns about enhancement first surfaced in public discourse in the late 1990s and early 2000s among a group of bioethics thinkers sometimes known as the bioconservatives. They are not necessarily conservative about all political issues, but they tend to favor conserving the physiological basis of human nature—our genome and all that rests upon it—largely as it is. They include Leon Kass, Michael Sandel, Francis Fukuyama, and Jürgen Habermas, among others.1 Sandel and Fukuyama were members of the President’s Council on Bioethics under George W. Bush, and Kass was chair. Kass began warning against enhancement in the late 1990s, and the President’s Council issued two book-length reports dealing with enhancement in the early 2000s: Beyond Therapy: Biotechnology and the Pursuit of Happiness and Human Cloning and Human Dignity.2 The council warned against seeking “perfection” in human nature or going “beyond therapy.”
When bioconservatives warn against enhancement, they’re reacting to a group known as the “transhumanists” or “posthumanists.” Transhumanists see human nature, or at least the physical basis for it, as an engineering project. Nick Bostrom, associated with Humanity+ (the leading transhumanist organization) and director of the Future of Humanity Institute at Oxford University, defines transhumanism as “the intellectual and cultural movement that affirms the possibility and desirability of fundamentally improving the human condition through applied reason, especially by using technology to eliminate aging and greatly enhance human intellectual, physical, and psychological capacities.”3 Transhumanists advocate improving our intelligence, memory, affect, immune system, physical strength, and stamina, among other things, using a variety of biotechnologies, including drugs, bionic implants, nanotechnology, genetic engineering, xenotransplants, tissue regeneration, cloning, exocortexes and cyberware (physical devices that mediate between computers and our brains to improve upon and augment brain function), and even uploading minds into computers or cyberspace. They are particularly interested in life extension, but their agenda is far broader than that. That broad agenda is what the bioconservatives are responding to when they worry about enhancement and perfecting human nature.
However, although there is some unity to that agenda, no one—including bioconservatives—argues that enhancement is always bad or wrong, though bioconservatives are often characterized as if they think it is. In other words, no one thinks all enhancements are necessarily bad. Leon Kass, who believes the pursuit of “perfection” is the most neglected topic in bioethics, also says that we should set aside questions about enhancement and ask, “What are the good and bad uses of biotechnical power?”4 Kass concedes that perfecting ourselves is not per se wrong: “By his very nature, man is the animal constantly looking for ways to better his life through artful means and devices; man is the animal with what Rousseau called ‘perfectibility.’”5 It’s not fair to charge the bioconservatives with making a blanket objection to all enhancements.
There’s a reason no one thinks enhancement is per se wrong: it clearly isn’t. Several philosophers have effectively demolished the claim that it is, in case anyone is tempted to say so. Some of them make a continuity argument, pointing out that literacy, running shoes, computers, and many other things enhance human capabilities (to remember, to think, to communicate, to calculate, to run). Those enhancements are not morally problematic; therefore, enhancements in general are not morally problematic.6 Frances Kamm has a “shifted baseline argument” against the antienhancement view: suppose that what’s normal for us were actually abnormal—would it be wrong to improve ourselves to our current baseline? If, for example, our intelligence were naturally 30 IQ points below the current average, would it be wrong to raise them by 30 points? Presumably not. Therefore, there is nothing wrong with enhancement per se.7 John Harris argues that the distinction between harms and benefits is not morally relevant and that treatments prevent harms while enhancements confer benefits. If it does not matter morally whether you are harmed or fail to receive some benefit, then the treatment/enhancement distinction doesn’t matter either. Since treatments are not bad, neither are enhancements.8
However, showing that enhancement isn’t always bad doesn’t show that it’s never bad. Various kinds of enhancement or uses of enhancement may be morally problematic for various reasons. There are several concerns that dominate the antienhancement literature. Many of them pertain to some enhancements and not others. I am speaking of “enhancement concerns” in a narrow sense, of course. Broadly speaking, one could say that any ethical issue concerning some kind of enhancement is an enhancement concern; in that sense, this entire book is a book about enhancement ethics. However, such a broad definition of enhancement ethics is not helpful, for there’s no ethical issue that is common to all and only biomedical enhancements. We will focus on concerns that are, in some sense, about the very fact that humans are being enhanced, even if none of these concerns assumes that enhancement per se is necessarily bad.
We’re concerned with only one kind of enhancement: human life extension. Therefore, rather than trying to assess the entire range of possible enhancements, I will consider the major enhancement concerns one by one, and for each one, I’ll ask whether that concern applies to life extension. If it does, I will then ask whether it’s a valid concern, at least when it comes to life extension. I will argue that not all enhancement concerns are valid and that none of the valid ones apply to life extension.
As we proceed, bear in mind that life extension is an enhancement in a very particular way. It enhances us by giving humans a life span no human has ever had before, but at any given time during that life span, those humans are lot like humans who have not been enhanced. Assuming they have received no other enhancements, they’re not smarter than other humans, or equipped with more powerful memories or immune systems, or physically stronger. They’re much like young(ish) humans with normal life spans, except that time and experience probably give them the kind of wisdom that comes with age.
The first concern we’ll consider is not unique to enhancements, but it does arise in a particularly strong form for certain enhancement techniques: nanotechnology, germline genetic engineering (genetic changes that would be passed on to offspring), transplanting genes from other species, and devices (still to come) that would link our brains to computers for added brain power. The human body is a delicate and complicated set of systems that evolved over millions of years, and some writers argue that we shouldn’t try to improve upon something so complicated, so important to our welfare, and that we don’t fully understand unless we have very, very good evidence that the alteration is not too risky.
Some people may believe that life extension is too risky. We discussed several possible dangers in previous chapters. Some say that extended life might not be good for us. It’s likely that making life extension available to the Haves will cause distress and other harms to the Have-nots, possible harms to the Will-nots, possible Malthusian consequences, and other undesirable social consequences. Each of these may either fail to materialize or turn out to be outweighed by the advantages of making life extension available, but still, there’s a risk that the downside will outweigh the upside. Developing life extension is something of a gamble.
This is a valid point, but the fact that something is a gamble doesn’t mean we should never take that gamble. We must assess the risk and then decide whether the possible benefits outweigh the possible dangers. I’m not talking about assessing what the risks are—that is, estimating the probability of some harm. I’m talking about deciding whether to run some risk once we know the odds—or at least know as much as we can about them.
One way of making such decisions is particularly prominent in discussions of novel technologies: the precautionary principle. There are different forms of this principle, but in general, they all recommend taking action to prevent harm even when the evidence that harm will occur is less than conclusive. There are two classic versions of the precautionary principle, both developed for environmental protection but sometimes proposed for other contexts. The earliest appears in the Rio Declaration on Environment and Regulation (1992), which states:
In order to protect the environment, the precautionary approach shall be widely applied by States according to their capabilities. Where there are threats of serious or irreversible damage, lack of scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation.9
The other is from the Wingspread Conference on the Precautionary Principle in 1998:
When an activity raises threats of harm to human health or the environment precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. . . . In this context the proponent of an activity, rather than the public, should bear the burden of proof.10
The Rio version of the precautionary principle is weaker, for it says merely that a lack of “scientific certainty” that serious or irreversible harm may occur is not a reason to postpone measures to prevent that harm. The Wingspread version says that too but also says that protective measures “should” be taken and that the party who wants to undertake the potentially harmful activity has the burden of proving that it’s safe enough.11 When it comes to new technologies, the precautionary principle seems to require us to err on the side of playing it safe and to place much greater weight on the possible risks than on the possible benefits of that technology.
However, while the precautionary principle may be a plausible policy or rule of choice for climate change and some other environmental issues, it’s not a good policy for all new technologies. It’s highly risk averse. It overlooks the possible benefits of a new technology and fails to consider the possibility that sometimes not intervening carries extreme risks.12 In other words, the harm some new technology will help us avoid may be greater than the harm that technology might cause. Consider a simple example: Suppose some new drug might cause serious liver damage but has a high probability of eliminating some form of deadly cancer. To prevent harm to the liver, we would have to avoid using that drug and run the risk of dying from an otherwise untreatable cancer. Harris and Holm call this the “precautionary paradox”: we are to pause lest we cause harm, but pausing may cause great harm too.13 In short, the general problem with the principle is that it’s often not clear in which direction caution lies—that is, what poses the greater risk of harm: doing something novel to solve a problem or not solving that problem.14
So which choice is more risky: normal aging with painful senescence toward the end and death within a century or life extension with its harms? If we’re talking about harms to those who extend their own lives, the safer choice is to extend your life and run the risk of boredom and reduced death benefits, especially given that you can always go off your life extension meds (so to speak) and resume aging. If we’re talking about harms to the Have-nots (or to everyone), such as Malthusian harms, then we’re not talking about risk—we’re talking about justice. We talked about justice at length in several earlier chapters. If you’re a Have-not or Will-not, the issue is not whether life extension has more upside for you than downside; it has no upside for you at all. The issue is whether it’s fair to impose some downside on you so that the Haves can enjoy the upside. That’s a serious issue, but it’s an issue of justice.
I have always maintained that the Malthusian and justice issues are the most serious objections to life extension, and I don’t take them lightly. All I’m saying here is that they aren’t issues about decisions concerning risk. The precautionary principle is the wrong instrument for thinking about issues of justice, for to think about justice, we must think about how the harms and benefits are distributed. The precautionary principle takes the standpoint of someone who doesn’t know how things will turn out for them. To use it for an entire society obscures the fact that we know quite a lot about how things may turn out for each group and that they won’t turn out the same for everyone.
So we don’t have sufficient reason to think that making life extension available is the riskier choice. However, there’s an interpretation of the precautionary principle that requires no such evidence. Instead, it requires merely that we don’t know the degree of risk. Stephen Gardiner argues that the precautionary principle is a version of the maximin rule of rational choice. The maximin rule tells us to make the choice whose worst possible outcome is better than the worst possible outcome of any other choice. If we interpret the precautionary principle in this way, it seems to tell us to avoid developing life extension, for the worst possible (though not necessarily likely) outcome of a world with life extension is a Malthusian catastrophe that makes life intolerably bad, while the worst possible outcome of a world without life extension, all else being equal, is that everyone lives a normal life span under conditions where life is not intolerably bad.
However, the maximin rule is meant for choice under uncertainty, not for all choices under risk. A decision about risk is what you make when you know the probabilities of some harm occurring; a decision under uncertainty is what you make when you don’t know that probability. Moreover, the maximin rule is not plausible under all conditions of uncertainty. It’s plausible when you attach far more value to avoiding the potential harm than you attach to gaining the potential benefit.15 You might, for example, think that enhancements have something like diminishing returns, that normal health is good enough, and that for anything beyond “good enough,” the risks are too high. In other words, you might think that if you already enjoy normal health, the additional gain in welfare promised by some enhancement is less valuable than the same gain in welfare when you are unhealthy and some medical treatment will restore you to normal function and capacity.16
So situations where the maximin version of the precautionary principle applies have two features: we don’t know the odds, and we attach much more value to avoiding the potential harm than to gaining the potential benefit. Neither of those features is present in the context of life extension.
First, we do have some sense of the odds, at least for some of the possible bad consequences. We know that it’s likely that those who lack access may feel distress and sense that their deaths are somehow worse, and we know that it’s likely that not everyone will have access, at least for some time. However, we also have reason to believe that someday, it will be possible to provide it to anyone who wants it. We know that there’s a non-negligible chance of some Malthusian consequences down the road and that there’s some danger the gap between Haves and Have-nots will get wider, perhaps increasing the economic and political power of those who are already better off. We also know that it’s possible—though difficult—to control our population well enough to avoid Malthusian consequences and that societies sometimes succeed in equalizing the distribution of wealth and power. And we know that they often fail to do so. Whether the odds and magnitude of these harms are such that we should try to inhibit the development of life extension is debatable, but we know enough to have some sense of the odds involved in that decision. There’s some uncertainty about those odds in the sense that we aren’t certain what those odds are, but this is not a decision under uncertainty in the strict sense. We do have a rough sense of those odds. This is a decision about risk, so the maximin version of the precautionary principle does not apply here.
The second feature is not present here either, at least not for everyone: not everyone attaches more value to avoiding the risks of life extension than they do to enjoying the benefits of extended life. Many people already say they would prefer to run those risks (or consider them negligible) and enjoy dramatically longer life. Of course, that raises a further issue about how to balance the wishes of those who want to live in a world where that is an option and the wishes of those who want to live in a world where no one has that option, but that too is an issue of justice, not an issue of decisions about risk. For both of these reasons, the maximin version of the precautionary principle is not appropriate for deciding whether to develop life extension and therefore isn’t a reason not to develop it.
One of the most common concerns about enhancement is that it will undermine authenticity. The ideal of authenticity tells us that we should be true to ourselves. According to Erik Parens, the “moral ideal of authenticity . . . is that each of us finds our own way of being in the world. It is my job as a human being to find my way of flourishing, of being true to myself.”17 Authenticity concerns about enhancement take two forms.
First, some writers have objected to certain enhancements, such as drugs that give you greater courage or greater physical prowess, on the grounds that getting such qualities through drugs and not through hard work means those qualities are not really yours. Kass believes that such enhancements pose the risk of “disrupting the relation between what we do and what we become.”18 More generally, if our qualities are installed in us through biomedical enhancements, we either don’t develop character or we can’t take credit for our character. To develop character, we must struggle to develop other qualities and not get them from a pill or an implant. This concern often arises in connection with the use of performance-enhancing drugs in sports. The resulting athletic achievements are said not to be authentic; the athlete is not fully responsible for those results.
Second, Carl Elliott has argued that Prozac, which can be seen a happiness enhancer that gives you a better personality, also gives you a false self, and a false self is clearly not an authentic self.19 I suppose this depends on the patient and the drug. Having used antidepressants myself, I can tell you that I feel that I am much more my “true self” on antidepressants than off, but perhaps not all cases are like this. In any case, Elliott’s concern is not that we can’t take credit for the personality the drug gives us (though perhaps we can’t, if all we do is take a pill every morning). His concern is that the personality a drug gives us is not our real personality. However, this concern would arise even if we had to work very hard for a long time to get that drug and could thereby take a kind of credit for the result.
I’m not rejecting these concerns, but neither version of the authenticity objection applies to life extension. Consider Kass’s version first. Life extension keeps you physically youthful longer than normal, but it doesn’t give you courage or strength or anything else you didn’t have during your healthy adult years—it just helps you keep that health for a longer time. Whatever you do with that extra time might result in changes to your character, but those are changes you can take credit for. True, you can’t take credit for getting the extra years (or maybe you can, if you earned the money to pay for life extension), but you can’t take credit for a normal life span either, so that’s irrelevant. Moreover, no young person can take credit for being youthful. Life extension merely extends that state of affairs over a longer span of time.
As for Elliott’s worry about acquiring a false personality, that too doesn’t apply to life extension. Slowing or halting aging doesn’t alter your personality in the way that taking Prozac is said to do. If living longer in a youthful state does result in changes to your personality over time, those changes occur in the way that personality changes usually do: over a long time, influenced by the life you lead. If that results in a false self, then we all acquired false selves long ago.
Michael Sandel is concerned about two kinds of human enhancement in particular: enhancing athletes so that they perform better and enhancing children. He worries that enhancing human beings in these ways exhibits a defect in our attitude toward our own strengths and abilities. His concern is similar to the concern about authenticity, but his concern is not that we won’t be able to take credit for our characteristics. Instead, his concern is that we’ll take credit for our characteristics when we shouldn’t:
The problem is not the drift to mechanism but the drive to mastery. And what the drive to mastery misses and may even destroy is an appreciation of the gifted character of human powers and achievements.
To acknowledge the giftedness of life is to recognize that our talents and powers are not wholly our own doing, nor even fully ours, despite the efforts we expend to develop and to exercise them. It is also to recognize that not everything in the world is open to any use we may desire or devise. An appreciation of the giftedness of life constrains the Promethean project and conducts to a certain humility. It is, in part, a religious sensibility. But its resonance reaches beyond religion.20
What does it mean to say that the “drive to mastery,” the project of enhancing people, exhibits a lack of “appreciation of the giftedness of life”? Part of what Sandel means is this: when you appreciate the “giftedness” of life, you recognize that your talents and powers are not wholly your own. You can’t take credit for being smart, or good at music, or having a robust immune system and rarely getting ill—you’re simply lucky to be that way, and you should be grateful, even humble about it. You fail to appreciate the “giftedness” of life in this way when you think those abilities, strengths, or capacities are something you can take credit for—that they’re something like personal achievements.
Moreover, according to Sandel, enhancing ourselves can lead to two further problems. First, we will become responsible for a wider range of traits. For example, parents will become responsible for aspects of their children that are now a matter of genetic luck. Second, we’ll have a diminished sense of solidarity with those who are less fortunate, presumably because they aren’t able to enhance themselves. This might, for example, undermine the insurance market.21
The first thing to say here is that it’s not clear that Sandel’s concern extends to life extension. Sandel is concerned about designer babies and bionic athletes. He’s concerned with ways of giving us advantages or desirable characteristics that we weren’t born with. Life extension, however, doesn’t give us enhanced intelligence, happier affect, a better memory, or the ability to run a four-minute mile. It does gives us more robust health because it makes us more youthful and the young tend to be robust, but it doesn’t give us new desirable characteristics or get rid of any old ones. It merely lets us keep some of our desirable characteristics for a longer span of time.
But let’s suppose for discussion that life extension does make us somewhat arrogant about the advantages of youth (as some of us were when we were young). Sandel is right that we should be humble about talents, abilities, and capacities that we are born with or at least acquire through luck. However, he takes this point too far. There are four problems with his argument not just with respect to life extension but with respect to all enhancements.
First, there’s no reason to appreciate something as a gift when it’s not a gift at all. Right now, having a good memory is a gift (we can think of it as a fortunate endowment even if there’s no God). If, however, you pay a clinic to improve your memory, then your memory (or at least the margin by which it was improved) is not a gift—it’s something you paid for. Of course, if you received the money as a gift or earned it partly as the result of some competitive advantage in life, then perhaps you should regard your improved memory as a gift or at least acknowledge that you purchased it with a gift.
Second, even if we have a duty to be grateful for what is given to us, that doesn’t mean we must never improve the gift or that we must be grateful for all improvements to it. Gratitude for whatever intelligence I have is not a reason to refrain from enhancing my intelligence with drugs; at most, it means that I should be grateful for the original quotient of intelligence I started with. It doesn’t mean I should be grateful for the increased quotient of intelligence I get from the drugs. More important, it doesn’t mean that I should not enhance my intelligence at all, lest I seem ungrateful or unappreciative of the original quotient of intelligence I started with.
Third, it makes no sense to be grateful for everything (malaria, reality TV, cockroaches). Here is where Sandel’s arguments, even if valid for the enhancements he discusses, break down when it comes to life extension: Why is having an 80-year life span rather than a much longer life span a thing to be grateful for? Refraining from extending life so that we won’t seem ungrateful for the gift of that life span is like refraining from chemotherapy so that we won’t seem ungrateful that the incidence of cancer isn’t higher.
Sandel doesn’t mention life extension, but perhaps he would say that extended life is not good for us; therefore, we should be grateful we don’t have it. If that’s what he means, speaking of gratitude, giftedness, and mastery is an obscure way to say so. Instead, he should talk about whether extended life is a good life to have. I argued in chapters 2 and 3 that extended life is good for us, but even if I’m wrong, that problem with life extension is not that we would exhibit a lack of appreciation for our gifts. Rather, that problem would be that we don’t know what’s good for us. This is a mistake about what’s in our interests, not a case of taking personal credit for something that’s really a product of luck.
Finally, the value of an enhancement can outweigh the moral weight of whatever duty of gratitude we might have; the importance of gratitude does not always outweigh everything else. I should be grateful for a coat I received for Christmas, and it may seem ungrateful to exchange it for something else at the store, but if the coat doesn’t fit me, I should take it to the store and exchange it for one that does. The value of my health and comfort outweighs the duty to be grateful.
However, Sandel denies that other moral considerations might outweigh the duty or virtue of gratitude. His argument is somewhat obscure, so let’s see the passage:
I am suggesting [that] . . . the moral stakes in the enhancement debate are not fully captured by the familiar categories of autonomy and rights, on the one hand, and the calculation of costs and benefits, on the other. My concern with enhancement is not as individual vice but as habit of mind and way of being.22
Here he says that what’s wrong with lacking appreciation for giftedness is not a matter of good or bad consequences, or rights and self-determination, or the virtues. For most philosophers, those three categories exhaust the range of things that can have moral value, but Sandel believes there is more:
The bigger stakes are of two kinds. One involves the fate of human goods embodied in important social practices—norms of unconditional love and an openness to the unbidden, in the case of parenting; the celebration of natural talents and gifts in athletic and artistic endeavors; humility in the face of privilege, and a willingness to share the fruits of good fortune through institutions of social solidarity. The other involves our orientation to the world that we inhabit, and the kind of freedom to which we aspire. . . . Changing our nature to fit the world . . . deadens the impulse to social and political improvement.23
This passage raises two issues.
First, norms of unconditional love for one’s children, humility, and a willingness to share good fortune with those less fortunate seem to fall within familiar moral categories. They might be seen as virtues (love, solidarity, generosity, humility), or as duties (to love unconditionally, to help those worse off), or as consequences that are good (children who are loved unconditionally are better off, and sharing good fortune tends to shift resources to those who will receive more utility from them that those who already have enough). In any case, they don’t seem to fall outside “the familiar categories of autonomy and rights, on the one hand, and the calculation of costs and benefits, on the other.”
Second, even if Sandel has identified a new moral category, he hasn’t established that this new moral category, whatever it is, always takes moral priority over anything else it might conflict with. The mere fact that it does not involve appeals to consequences, virtues, or duties, does not entail that it’s morally more important than consequences, virtues, or duties. If he thinks it’s morally more important than any other moral considerations, he needs to explain why. Merely showing that it’s different (if he’s done even that much) doesn’t show that it can’t be outweighed by other moral considerations.
The enhancement literature contains many references to nature, human nature, and something called “the natural.” Some observers take that to mean that opponents of enhancement think that what’s natural about human nature has moral value by virtue of being natural and that altering it results in a less natural, and hence less valuable, human nature. The first thing to say about this is that few (if any) bioconservatives or other opponents of enhancement have made such an argument. However, it appears that some people are concerned about this, so let’s see what might lie behind this concern.
Richard Norman attempts to reconstruct an argument for this concern.24 Norman doesn’t believe that interfering with nature is necessarily wrong, nor does he find this argument convincing, but he believes it might help us understand this concern better. The argument doesn’t require claiming that altering what is natural in human nature is per se wrong. Instead, it raises a concern about hyperagency—“a state of affairs in which virtually every constitutive aspect of agency (beliefs, desires, moods, dispositions and so forth) is subject to our control and understanding.”25 In other words, we can choose to control any aspect of human nature that influences what we choose to control and how. (This appears to be a close cousin to Sandel’s concern about giftedness.)
According to this argument, hyperagency would undermine the meaning of our lives. The argument rests on two claims: a “logical” claim and a psychological claim. The logical claim is that there’s no standpoint from which to regard one choice as better than another if everything is a matter of choice. At least some things have to be good or bad, right or wrong, independently of our choices and preferences, or we can’t make choices in a nonarbitrary way. In order to make “meaningful” choices, we need things that are beyond choice. He calls these “background conditions.”26
The psychological claim is that humans are disposed to use features of their biology as background conditions. These conditions tend to be facts about birth and death, maturing and aging, having to work in the world and overcome adversity, or sexual relations and relations among the generations. Exactly where these boundaries are drawn varies from culture to culture and generation to generation. For example, some people object to using ovarian tissue from aborted fetuses in assisted reproduction or to using Prozac and other antidepressants on the grounds that these interventions alter aspects of our biology (and perhaps psychology) that must not be altered.
Norman contends that if we alter these aspects of the human condition too much, we are threatened with a loss of meaning in our lives. Those who find contraception unnatural, for example, may believe that sex is more meaningful when it’s closely tied to reproduction and that we lose some of the meaning in our lives when we separate sex and reproduction. Those who feel this way have identified the procreative aspect of sex as a background condition. Those who object to antidepressants as unnatural may feel that part of life’s meaning comes from struggling against adversity, grappling with pain, and that happiness without a struggle lessens that meaning.27 Those who feel this way have identified our unmodified range of moods as a background condition.
People who object to enhancements as unnatural may not put their objection in these terms, but Norman believes that something like this lies behind their concerns even if they don’t realize it. As I said, Norman is trying to reconstruct a possible argument for a point of view he doesn’t really share. He believes the logical claim is true, but he also believes that which aspects of our biology seem beyond choice is something that changes over time and varies from culture to culture and that objections to altering human nature are usually not strong objections, for we can incrementally adjust our sense of what is natural. Over time, we can decide, for example, that using ovarian tissue or Prozac is acceptable. The boundaries of what is natural migrate over time. Presumably we then find meaning in life in other ways. For example, using ovarian tissue may cease to threaten the meaning of our lives when we find the meaning of childbirth and parenting less in genetic continuity with the parents and more in parenting and nurturing itself.28
I have no quarrel with Norman’s psychological claim as a description of a common way of thinking, though many people (including myself) do not think that way. That said, I think the argument works (if at all) only on an implausible reading of the logical claim. The logical claim is correct insofar as we have no basis for choosing one thing over another unless “something is accepted as given and not open to choice.” We can’t make moral choices unless we have normative standards, principles, or values that enable us to rank our options, and those normative standards cannot be yet another set of options equally open to choice. However, neither the logical claim nor the psychological claim, nor both together, imply that the “given” is some feature of the natural world, let alone some feature of human biology. They imply merely that something has to be the standard and that many people think the standard has something to do with not altering what is natural. The argument Norman presents does not establish that those people are right—that what is natural operates as a moral standard. Moreover, if people or societies have some discretion over which aspects of human biology are a background condition, then a dilemma arises. Either the background condition is a matter of choice, which contradicts the logical claim, or at least some of those people or societies mistakenly identified something as a background condition when it’s not, in which case we should be all the more skeptical of what people think is the standard.
The argument for concern about what is natural seems fatally defective, but before we move on, let’s look at Norman’s suggested way of applying it to life extension. He suggests that our background conditions include “the temporal and biological structure of a normal human life.”29 Our natural life span, in other words, can be seen as a background condition, and if we extend our life span too far, we have defied the background condition and our lives will lose some of their meaning. (It’s not clear whether Norman agrees with this application of the argument or uses it merely for illustration.) Many of our projects, and their meaning, assume the scale of a normal life span, and their importance depends partly on their location in that life span (the book you want to finish before you die because it’s the culmination of your life’s work, for example). Norman agrees that our life span could get longer without losing those aspects but believes that living forever (or at least for millions of years) would deprive us of them.30
Notice, however, that this argument can be made without any reference to “the natural” as something it would be wrong to alter. All this argument requires is the claim that events and experiences get some of their meaning from their relation to other parts of our lives and their place in the overarching narrative of a life span. We saw that argument in section 3.10, and it didn’t require any reference to the natural. We saw a very similar argument in sections 2.2 through 2.4, where we considered the concern that extended life might become intolerably boring, and another similar argument in section 3.6, where we considered the argument that an extended life might have less meaning because valuable things become less valuable the more of them we have, and the longer we live, the more we get. None of these arguments require the claim that a natural human life span is something we cannot alter too much because it’s natural. They require merely the claim that if we alter our life span, it may lose meaning of a certain kind. The fact that our current life span is natural is beside the point.
Let’s consider another concern about a natural life span. Extended life is longer than our natural life span and hence unnatural in that respect. Is an unnaturally long life span morally problematic?
Proponents of such an argument would have to explain what has moral value: the fact that our life span of roughly 80 years is natural or the fact that it’s a life span of 80 years? Neither version makes much sense so far as our interests are concerned. The former version suggests that any life span that is natural is best for us, so if we had a natural life span of 45 years, then a 45-year life span would be best for us, which is silly. The latter version of the objection suggests that having a natural life span of 125 years would somehow be worse for us, which is equally silly.
Moreover, it’s arguable that our current life expectancy is not truly a natural life span anyway. As I discuss at greater length in section 12.9 and section A.4, there are three mainstream theories of the evolution of aging. (It’s possible that all three of them are correct to some degree.) All three rest on the fact that even if we never aged, we would live only so long in the environment where we evolved. Consider this example: Suppose you had a mouse that never aged. How long would that mouse live in its natural habitat? According to field biologists, about two and a half years, for the number and size of predators, the incidence of disease, and the availability of food in its native habitat are such that death is highly likely by the time two and a half years have passed even if the mouse doesn’t age. It takes metabolic energy to defend against the cellular-level processes of aging, and if the mouse isn’t going to last longer than two and a half years anyway, it makes more sense to allocate that energy to feeding, reproduction, fighting, and fleeing. That is just what evolution has selected, for as it happens, roughly two and a half years is a mouse’s natural life span. Evolution did not select for longer-lived mice because, in their natural habitat, mice would not live longer anyway. Why waste metabolic energy making them last longer?
The same is true for us. We evolved at a time when we had no agriculture and had to deal with large predators (the Pleistocene era, saber-toothed tigers). The archeological record tells us that we died by our mid-40s. This means that our natural life span is around 45 or so; living into our 70s is an unnatural effect of civilization, and our current life span is unnatural.
Moreover, our natural life span is a function of our size relative to other predators and a few other factors during the Pleistocene era. It does not result from an evolutionary design process that worked to satisfy our interests as we individual humans see them. There is no reason to attach moral value to a natural life span and no presumption in favor of what evolution hath wrought. The fact that nature gave us a particular life span is not a reason to avoid seeking to extend it.
Sometimes those who introduce new biomedical technologies are accused of “playing God.” This way of putting things is not common among bioconservative writers, so we shouldn’t lay this at their doorstep. However, it is common among laypersons who express opposition to some forms of biotechnology, so let’s address it.
Playing God can mean a couple of things. First, we might play God in the sense of trying to do a job that’s reserved for God—invading his jurisdiction, as it were. What that means depends on your theology, but one might argue, for example, that God has a plan for the natural order and that humans are allowed to modify that design only within certain limits: we can create new breeds of livestock but not new breeds of human.
This version of the objection requires an explanation of what is and what is not in God’s jurisdiction and why. Even among believers, there’s no consensus about what jurisdiction God reserved to himself when it comes to biotechnology or what his plan calls for. Moreover, some citizens who hold religious beliefs also believe that we shouldn’t appeal to such beliefs when we make arguments to one another about matters of public policy. Finally, some citizens consider all religious beliefs false. These problems don’t mean that arguments about divine jurisdiction are wrong, but they do indicate that disputes about this are likely to be interminable. Those who wish to make such an argument are welcome to take up the challenge, but merely making the accusation of “playing God” is not enough to meet that challenge.
Second, there is a nontheological, cautionary sense of “playing God.” This means taking on a task we don’t have the information, expertise, or wisdom to do well. The idea is not that we’re violating divine law, just that we’re taking on a task we’re not smart enough to do well. This way of warning us against playing God is another way of warning us to be careful, go slow, and not overestimate our powers. This is a theistic way of raising concerns about risk—a concern we considered when we discussed the precautionary principle.
Francis Fukuyama is a bioconservative who claims that human rights are based on human nature. He says that if we alter human nature, we endanger the rights that rest upon it: “Human reason . . . is pervaded by emotions, and its functioning is in fact facilitated by the latter. Moral choice cannot exist without reason, needless to say, but it is also grounded in feelings such as pride, anger, shame, and sympathy.”31 Fukuyama believes that if we alter human nature, we’ll lose our moral status (presumably by losing our capacity for making moral judgment) and thereby lose our moral rights.
It’s not clear why losing one’s capacity to make sound moral judgments results in losing one’s moral status or moral rights. Animals, after all, have moral status: it’s wrong to torture them. Perhaps Fukuyama means that we can’t have the full range of rights we do have unless we have a faculty of reason, for only creatures that are rational and self-aware have the kind of moral status we do—and the kind of rights that go with that moral status. It’s plausible that there are some things we can’t reason about unless we also have a capacity for emotion and affect generally and that morality is one of those things. However, that doesn’t amount to losing our ability to reason altogether. Moreover, even if we change our affects and emotional responses, we’re not eliminating them—we merely have different emotional responses and affects than we used to have. (No one is talking about turning humans into Vulcans.) Without knowing more about the changes in question, we can’t even say whether those changes degrade the kinds of reasoning that Fukuyama has in mind—for all we know, those changes might improve them.
In any case, even if Fukuyama’s objection is sound with respect to enhancements that alter our affective responses, his objection does not apply to life extension. There’s no reason to expect that slowing or halting aging or living for centuries will disrupt the relationship between affect and thinking, or degrade our capacity for moral judgment, or strip away our affect and capacity for emotional response. If anything, living far longer might improve our moral judgment, as life experience tends to do.32
Occasionally you hear a suggestion that life extension is wrong because aging is not a disease. As with some of the other objections considered in this chapter, it’s hard to find a bioconservative (or anyone else) who actually says this. It does come up now and then, however, and it’s closely related to the objection that life extension is wrong because it’s an enhancement, for enhancements are often distinguished from treatments, and treatments treat diseases while enhancements (it is sometimes argued) do not treat diseases. The connection, then, is that if aging is not a disease, then slowing aging must be an enhancement. Thus, arguing that aging is not a disease is a way of arguing that life extension is an enhancement. Of course, that point was conceded at the outset of this chapter for reasons unrelated to whether aging is a disease.
Still, the treatment/enhancement distinction does pertain to a particular kind of objection to enhancement, for that distinction might be relevant when we’re deciding what society should pay for in a program of subsidized universal healthcare. The treatment/enhancement distinction is related to the concept of “medical necessity” in health insurance. One can argue that paying for conditions that aren’t diseases or impairments may result in paying for extravagant personal preferences, such as cosmetic surgery for people who are merely plain or growth hormones for children who are merely slightly shorter than average. One can also argue that we have a moral right to healthcare based on a right to equal opportunity—we need to achieve normal function in order to have the normal range of opportunities but above-average function would give us above-average opportunity.33 However, arguments that health insurance and subsidized healthcare need not cover enhancements are largely irrelevant to life extension. I argued in earlier chapters that life extension should be subsidized for the Have-nots, but those arguments are grounded in egalitarian arguments that have nothing to do with healthcare and did not assume that everyone has a right of access to life extension because aging is a disease.
Aside from concerns about health insurance and equal opportunity, it’s hard to understand what’s wrong with “fixing” conditions that are not diseases. Just because something is not a disease doesn’t mean we have no reason to prevent or remove it, and even if life extension isn’t medicine, that doesn’t mean we shouldn’t practice it (as if only the only legitimate way to make our physical lives better is medicine).34
That said, this issue does raise some interesting questions in the philosophy of biology concerning how to define aging and disease, and I will close this book by discussing those questions. I will conclude that aging is a disease.
The best thinking about how to define aging isn’t done by philosophers, it’s done by biologists, so let’s see what they have to say. Some biologists deny that aging is a disease on the grounds that aging is universal to all members of a species, while diseases are not.35 Some go further and say that unlike aging, a disease can sometimes regress or be cured or treated, though not all diseases can regress on their own. (Of course, this distinction breaks down if we learn how to slow or halt aging.) Aging is not a disease, according to Leonard Hayflick, because
biological aging is a loss of molecular fidelity—an increase in molecular disorder throughout the body caused by random events—that occurs after reproductive maturation in animals that reach a fixed size in adulthood. Biological aging is an expression of the Second Law of Thermodynamics, or increasing entropy, or disorder, in a system. Aging is not a disease.36
Hayflick is referring to the fact that most organisms (including us) produce, order, and replace molecules with fidelity up to around the time the organism is likely to reproduce, given the hazards of that organism’s natural environment. Natural selection does not give organisms the ability to maintain molecular fidelity indefinitely, perhaps because organisms that devote energy to repairing and maintaining molecular integrity are thereby devoting less energy to feeding, breeding, fleeing, or fighting and thus may not reproduce as much as they do.37 Hayflick sees this as entropy at the cellular level, and entropy is not a disease. We can put his point this way: Entropy is no more a disease than getting hit by a car while crossing the street is a disease. Both processes disrupt the body’s molecular organization. The latter process is merely messier and faster.
Other biologists argue that aging is a disease. David Gems, a geroscientist at University College, London, argues that aging is a multifactor genetic disease, and the diseases of aging are symptoms of an underlying syndrome. According to Gems, aging is a disease in spite of being universal. It involves dysfunction and deterioration at the molecular, cellular, and physiological levels, and the diseases of aging are symptoms of a larger syndrome: aging itself.38 In a similar vein, philosopher Arthur Caplan has argued that aging can be regarded as a disease. The fact that aging is inevitable and universal does not mean aging is not a disease—so are high blood pressure, sore throats, colds, and tooth decay, yet they are diseases. He also argues that aging results from a lack of evolutionary foresight; it has no function or purpose for us. Finally, the processes of aging look a lot like disease processes: they produce discomfort, they have symptoms and manifestations, and they impair our functions.39
The debate presented in the previous two paragraphs is happening at too high an altitude. To settle that debate, we need to get closer to the biological ground and then ask whether we draw a valid distinction between aging and age-related diseases. There are three possibilities. First, aging might be nothing but a collection of diseases that tend to correlate with age. In that event, aging is not distinguishable from disease at all. It then follows that aging itself is a disease or at least a set of diseases. Second, aging might include age-related diseases—that is, those diseases are part of aging (which diseases are part of it may vary from organism to organism)—but also includes something else that’s not an age-related disease. In other words, aging might be a combination of age-related diseases and something else that’s not a disease. If aging includes some element that is not a disease, then it may turn out that we cannot fully treat the age-related diseases without also slowing or halting aging. In that case, treating age-related diseases may not be completely distinguishable from slowing or halting aging itself. In other words, the distinction between medicine and life extension might break down even if the distinction between aging and age-related diseases still holds, at least in part. Third, aging might not include age-related diseases at all.
So are aging and age-related diseases completely distinct? If they are, then it’s possible to age without disease and die of causes other than disease or violence. Geroscientists who think they are completely distinct sometimes speak of “normal aging”: aging without disease. Normal aging happens when someone ages without any heart disease, cancer, Alzheimer’s, diabetes, Parkinson’s disease, or any other maladies that are associated with age and also considered to be diseases. The concept of normal aging has a counterpart in the concept of “natural death”: death without disease. Those who die a natural death die of old age and nothing else. Everyone agrees that normal aging and natural death—if they exist at all—are quite rare.40 However, not everyone agrees that there are such things as “normal aging” and “normal death.”
It’s also possible that there are some age-related diseases that are completely distinct from aging itself and other age-related diseases that are not.41 (This is the second possibility mentioned above.) For example, some geroscientists distinguish between diseases whose pathogenesis seems to involve basic aging processes (such as type 2 diabetes, osteoporosis, cerebrovascular disease, Alzheimer’s disease, and Parkinson’s disease) and diseases that don’t involve basic aging processes but are age-related, either because they occur more frequently in the aged (such as gout, multiple sclerosis, amyotrophic lateral sclerosis, and many cancers) or because they have more serious consequences in the aged (such as some infectious diseases). Those in the first group would be aspects of aging itself, while those in the second and third groups would be age-related diseases.
It’s often hard in practice to distinguish between aging and age-related disease. Consider some examples. Bone loss is age-associated, but it’s considered a disease only if it has the magnitude to have a clinical impact.42 Until 1990, systolic blood pressure of 140–160 mmHg was not considered hypertension; now it is, and counts as a disease.43 Atheroma (lesions of atherosclerosis) can be considered a degenerative process if it results from molecular-level or cellular-level changes in the artery wall, but it can be considered an age-related disease if it results from injury or infection of the vascular wall.44 Cataracts (arguably an age-related disease) result from normal changes in proteins that increase their opacity (arguably part of aging). Menopause is age-related, but it poses an increased risk of osteoporosis and atherosclerosis. The prostate gland enlarges as men age and leads to hormone changes that can result in cancer.45
Another reason it’s hard to distinguish between aging and age-related diseases is that aging makes organisms more vulnerable to stress and infections and increases the incidence and severity of accidents and disease. Infectious diseases, for example, are often worse or more common in the elderly.46 For that reason, one could argue that a particular episode of some infectious disease is an age-related disease on the grounds that the patient would not have been infected at all if he were young. One could even hold that people do not die from age-related diseases; they die from whatever changes in the body made them more vulnerable to such diseases.47 Finally, when people are elderly, often there are so many age-related diseases that it’s hard to single out any of them as a cause of death. When that happens, perhaps we should say that the patient died from the underlying cause of all those diseases: aging itself.
I conclude that we can’t distinguish, either conceptually or in practice, between aging and age-related diseases, and therefore, aging is a disease—or at least a set of diseases, where the members of the set vary from organism to organism.
Life extension is a continuation of medicine by other means.