oxford handbook of bioethics

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Consider biosynthetic testosterone. Testosterone is the masculinizing or androgenic hormone. It can be found in the bodies of women as well, but at much lower levels than in men. A relative abundance of testosterone results in voices with lower pitch, hair on the chest and face (and, in time, less of it on the head), and increased muscle mass among other effects. The so-called anabolic steroids are chemical knock-offs of testosterone. By the 1960s athletes had discovered that by incorporating anabolic steroids into their training routines they could throw objects farther and lift heavier weights. The Olympics banned the use of anabolic steroids along with many other drugs athletes were using to enhance their performance. By the 1990s drug testing of steroids had advanced to the stage where biosynthetic testosterone was the anabolic steroid of choice, because finding testosterone in the human body told the testers nothing about how it got there. In time, testers began looking at the ratio of testosterone to another endogenous hormone, epitestosterone, which normally exist in roughly a one-to-one ratio in the body. If the so-called T/epi – T ratio was grossly abnormal, that was regarded as evidence that athlete had taken testosterone.

A young man who was a world-class sailor and hoped to qualify for the Olympic Games asked his national organizing committee for permission to take testosterone. Although only in his early twenties, both of his testicles had been removed because of testicular cancer. His body could no longer make a normal male amount of testosterone. Without an external supply, his physique would become increasingly feminine. He sought permission to take testosterone much like people with diabetes take insulin to make up for their pancreas’s inability to produce it. Some members of the committee that heard his plea were deeply skeptical, suspecting that he might intentionally overshoot his testosterone dose in order to gain an advantage over his competitors. One committee member suggested that it was absurd to think that any other athlete would intentionally find an excuse to have his testicles removed merely so that he could inject testosterone to gain a competitive edge (Noble 1996). Other committee members, including some with decades of experience working with athletes, were not so sure.

Understanding the ethics of enhancement begins with getting clear about the concept, as well as the factors likely to move people to pursue biomedical enhancement. We will consider in the next section the usefulness of the distinction between therapy and enhancement for understanding the ethics of enhancement. Once the conceptual underbrush has been cleared away, we can move on to ethics. The following section will examine critically a number of arguments that have been offered to defend biomedical enhancement, or, at least, to claim that efforts to deter it are either ethically or practically mistaken. Finally, we will consider a set of arguments that take the ethics of enhancement to be a serious matter and that give reasons to question whether some biomedical enhancements, for some purposes, may be ethically suspect.

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enhancement that goes beyond medicine’s domain of expertise . . . biomedicine should restrict its ambitions to the sphere of bodily dynamics, which it knows something about, and leave the sphere of social dynamics in the hands of the other human values specialists: Parents, educators, preachers, counselors, accountants, and coaches. (Juengst 1998: 43)

Enhancement, that is, leads us outside the terrain of medicine into the larger world of goals, values, and social institutions.

Enhancement as Moral Signpost

When we look at people contemplating whether to attempt to enhance themselves or their children, the concept of enhancement, Juengst suggests, acts like a moral signpost warning that we are approaching unsettled moral territory (Juengst 1998). Recognizing enhancement as a signpost does not settle moral questions, but it alerts us that important values may be at stake. Good parents seek appropriate medical care for their children to treat or prevent illness. Parents regularly seek non-biomedical means of enhancement for their children such as language or music lessons. But what if the means are biomedical but the end unrelated to health? It is clear that certain ‘enhancements’ — education, training in the moral virtues, immunization against infectious diseases — are not only good but may be important moral obligations of rearing adults to the children for whom they are responsible (Brock 1998). Calling something an enhancement tells us little about what our moral attitude towards the intervention should be. Furthermore, the intrinsic properties of the intervention — that it is, for example, an injection (as in immunizations, hGH, or biosynthetic erythropoietin, EPO) — don’t tell us whether it is ethically wrong, permissible, or required. Our task is more difficult, if also more interesting: to ground our moral judgments in an understanding of the goods sought and the values prized in the sphere of human practices at issue.

Enhancement Versus Therapy

There are at least three difficulties with assuming that for biomedical interventions the key distinction is between enhancement and therapy.

First, in an important sense all therapy can be understood as enhancement. Many wise physicians understand their ministrations as building upon the intrinsic healing processes of the body and mind. Their aim is to aid the body in its effort to restore homeostasis. Antibiotics can be understood as a means to enhance the body’s capacity to fight off infection; the anti-statin drugs enhance the body’s ability to correct the mismatch between our evolutionary adaptation to a subsistence diet and the abundance of saturated fats in the foods now plentifully available to us.

Second, there are a set of biomedical interventions that aim unequivocally at health, yet are just as clearly a form of enhancement: vaccines. Classical vaccines

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human end or value must be served for an alteration to be an enhancement. Not all desired, goal-directed changes are best understood as enhancements. Some count as therapies, which are presumptively good because the goal of therapy, restoring health, is itself presumptively good. The goodness of any particular enhancement, on the other hand, depends first of all on the goodness of the goal to which it is directed.

For example, people with chronic anemia seek to increase the number of red blood cells circulating in their bodies because more red cells mean more energy and generally better health. For a world-class athlete in the Tour de France, more red cells enhance performance by increasing the flow of oxygen to muscles working at the limits of human endurance. Athletes have many means at their disposal: relentless preparation; a strategy known as ‘Train low, rest high’ (train at low altitudes where because oxygen is plentiful one can train hard and long before reaching exhaustion; rest at high altitude so that the body at rest will make more red cells to compensate for the lower concentration of oxygen); sleeping in tents or rooms that simulate high altitude; and EPO, a hormone that increases the production of red cells. People suffering from chronic anemia are more likely simply to use EPO. All of the means go through a similar intermediate state — more red cells. But their ends are distinct: relieving anemia to restore health is therapy; taking EPO to pedal a bicycle at astonishing speeds on the flats and up steep, switchback roads in the Alps and Pyrenees is an ethically contentious enhancement.

Human growth hormone shows the need to think clearly about ends. Here the means are limited — hGH alone or in combination with other hormones that promote growth of the long bones; or limb-lengthening surgeries. If hGH is chosen, there is, as far as is known, one common intermediary state — an increased amount of hGH in the body signaling the tissues in the epiphyses — the zones at the ends of the bone where elongation takes place — to grow. But increased height is not in itself the end; rather, it serves other ends important to persons.

If heightism ceased to exist and height conferred no advantages, what justification could parents give for subjecting their child of normal stature to a thousand injections, the unremitting attention to one dimension of their existence, and the risks that follow years of hGH administration? This looks like a case of child abuse. However, in a world where being tall is advantageous, parents who seek hGH for their children of average stature can recite the benefits that being taller purchases.

What of parents whose children would be very short as adults? If height didn’t matter at all, had no influence on a person’s education, career, social life, or ability to navigate the world successfully, there would be no reason to use growth hormone and, perhaps, no demand for it. But parents of very short children have reasons to believe that their children’s lives may be easier if they were taller. Adults with short stature are looked down upon, metaphorically as well as literally. (Even a cursory reflection on the English language reveals that it is shot through with heightism.) Taller people are more likely to hold prestigious, desirable, high-paying

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jobs. Parents may worry that their short child may be regarded as a less desirable partner for relationships. (I must note that in my experience height seems to have no correlation with the ability to establish the most important, lasting relationships in people’s lives. Tall people can have miserable relationships or wonderful ones. Precisely the same is true of short people.) Parents may also be concerned that their children will have difficulty navigating an adult world constructed for people taller than their child (Murray 1987).

These are not trivial worries for parents who want to prepare their child for adult life. Whether on the whole giving hGH to children of short stature benefits them is not a simple question to answer. On average, such children gain approximately 4 inches in height. But height per se is not the ultimate goal. The goal is to enhance that child’s chance for a good and fulfilling life — a life not marred by discrimination or undue difficulty navigating the world; a child whose confidence is not crushed under the oppressive conviction that she or he can never ‘measure up’. But is a biomedical intervention the surest and wisest path to a fulfilling life? Here the evidence is equivocal. A child who might have been 10 inches below average adult height is now, after growth hormone injections, 6 inches below average. Meanwhile, a thousand injections and many visits to the pediatric endocrinologist have driven home the message that height is very, very important. Meanwhile, those same resources might have gone into promoting and perfecting that child’s talents — those ways the child does not ‘come up short’ — in music, intellectual pursuits, inventions, fixing things, creating art, or any of the myriad of valued human activities. Perversely, the world being as it is, we tip the balance towards the biomedical intervention. Human growth hormone treatment may be subsidized by health insurance, while parents are likely to bear the full cost of developing their child’s talents and interests.

THE DEFENSE OF BIOMEDICAL

ENHANCEMENT

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Five arguments for embracing or, at least not resisting, biomedical enhancement are commonly advanced. We can call them, respectively, the incoherency argument, the line-drawing objection, the argument from liberty, the ‘resistance is futile’ claim, and the heroic, romantic, or Promethean assertion that people should shape themselves.

First is the incoherency argument, the claim that there is no rational basis for distinguishing between acceptable and unacceptable means of enhancement. One implicit premise in this argument is that no ethical distinction can survive unless it is based upon a coherent conceptual distinction. The incoherency accusation goes on to claim that no such conceptual distinction can be found in the case of biomedical enhancement.

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This is a common objection to bans on performance-enhancing drugs in sport (Fost 1986). Steroids, on this view, are no different from improved running shoes. Olympic officials therefore had no more justification for stripping Ben Johnson of his gold medal because he used steroids than for the shoes he wore. This objection also pops up in other spheres, for example, in concerns about technologies to choose or shape the characteristics of our children. What is the difference, skeptics say, between preimplantation genetic diagnosis (PGD) to select genes for musical talent or political success, on the one hand, and buying superb instruments and hiring gifted instructors or sending your child to prestigious prep schools and universities, on the other?

There are problems with this argument. For one thing it implies that all means of reaching a goal — say, a faster time in the 100 meter dash than your competitors — are equivalent. But this is not true. Clearly, some means are ethically prohibited: we are not permitted to threaten or intentionally injure our competitors. Other means alter the practice so radically that it threatens what we value in the practice. (More on this point later.) Finally, some means are entirely praiseworthy. In the Olympic 100 meter dash we admire such factors as intensive training, determination, and dedication to perfecting one’s talents.

A second problem with the incoherency complaint is that it forgets that means also matter, not only ends. The means chosen to reach a given end may be themselves a valued part of the activity. The discipline and mastery needed to achieve athletic excellence are morally valuable in themselves — in contrast to pharmacological short cuts. Different means can work on different intermediary states, via different paths, and on different objects. Means, then, can matter morally.

The third problem with this complaint is that it ignores the complexity and multiplicity of ends. Achievement in sport is often measured by a simple quantity: how fast I covered this distance; how far I threw this object; how many points I scored. (Some sports invite immensely more complicated calculations. Baseball, notably, inspires encyclopedias of arcane statistics meant to shed light on the performance of individual players. My brief exposure to cricket fans suggests their preoccupation with equally obscure quantitative analyses.) But life, like much of sport, is far too complex to be reduced to a single criterion, let alone a simple quantity. The slogan ‘He who dies with the most toys wins’ is an eloquent (one hopes ironic) testimony to the folly of simplistic, shallow, quantitative measures of the value of one’s life. Even in sport, reducing the goal to a single measure risks shrinking a rich and complex practice into one bare number. The ends of sport are complex and many; they can include developing physical and psychological abilities as well as moral capacities: fitness, strength, and speed; determination, focus, and mental agility; fortitude, courage, and perseverance. Different means favor different combinations of ends.

There is abundant evidence that we make intelligible, consistent, and coherent conceptual and ethical distinctions among different means to achieve the same

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ends. But, the skeptic may add, show me where and how you draw the line between the acceptable and the unacceptable. This leads to the second objection, the line-drawing problem.

The line-drawing objection must concede that we can see differences between the ends of the spectrum (improved training versus trampolines as ways of improving performance in the high jump, for example), but it insists that drawing a line anywhere on that continuum is unavoidably arbitrary and therefore indefensible (Allen and Fost 1990).

This objection conflates two senses of arbitrariness. In the first sense, we describe something as ‘arbitrary’ when there is no justification that can be offered other than perhaps sheer power or will: ‘You must do this, because I say so’. But there is a second meaning of the term that is not morally offensive. When there is a good reason to draw a line on some continuum, and when good reasons can be offered for drawing a line at a particular point — even if a reasonable case could also be made for drawing the line at a slightly different point — then the point chosen can be described as ‘arbitrary’ yet be readily defended. An example may help.

The game of basketball is played by five players on a side. This is an arbitrary rule in the sense that the rules could specify four or six per team rather than five. The game would look similar, although strategies would evolve that alter the game somewhat from the game we know. Now imagine that no line were drawn — that each team could send as many players as it wished onto the court. Why would any team stop at five if more players increased its chance to win? A likely outcome is a court with players jammed shoulder to shoulder — say forty to a side — and a contest that looks nothing like the quick, slashing, occasionally elegant game we know. Alternatively we could draw the line at two. Indeed, there is a variant of basketball known as two-on-two. It can be enjoyable to play or watch. But it unfolds as a distinct game from the five-on-five version. There is less opportunity for complex team play, a loss from the more intricate basketball played by a full complement of five.

So, there are reasons to draw a line somewhere — otherwise the game could become a matter of sheer brutal numbers rather than skill, teamwork, and grace. And there are reasons to draw the particular line at five — although one could probably also make a case for four or six. Is the rule arbitrary? Yes: But only in the second, unobjectionable sense. And so the line-drawing complaint loses its moral force. Where one can offer good reasons for drawing a line in the first place, and also good reasons for drawing it at this particular place, calling the line ‘arbitrary’ makes no important philosophical or ethical point.

The third claim frequently encountered is that people should be free to choose whatever ends they value and whatever means they want to reach those ends. Call this the argument from liberty (Murray 1983). Assertions of liberty pop up frequently in discussions of assisted reproductive technologies, or ARTs, that would permit parents to choose or shape the characteristics of their children. Liberty is

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also cited in response to paternalistic worries about athletes hurting themselves by taking performance-enhancing drugs such as anabolic steroids.

One problem is that liberty tends to be treated as a kind of rhetorical trump card. Liberty comes to be seen as an end in itself, rather than having a complex relationship with the ends we pursue. Liberty is vital to the development of dispositions and virtues such as integrity, dignity, agency, and efficacy; liberty is also instrumental in allowing persons to align the possibilities before them with choices based on their preferences rather than the unfettered will of others. But there are circumstances under which the defense of unaccountable liberty is difficult.

When parents attempt to shape their children’s characteristics to match their own preferences and expectations, such an exercise of free choice on the parents’ part may harm their child’s prospects for flourishing. A common riposte to this argument is that many if not all choices made by parents similarly shape and affect their child’s prospects in life. True as far as it goes; but the increasing power and specificity that may come with ARTs to choose or shape our children’s characteristics may be so different in their magnitude and precision that they justify the increased ethical concern. And concern about children’s well-being is justified even if the actual effectiveness of these technologies is much less than parents believe. The harm to the child’s future flourishing flows as readily from narrowed parental expectations, and from the disappointment that follows when the child fails to fulfill parental fantasies, as it does from actual, successful engineering of traits.

Opposition to drug use in sport has often been framed in paternalistic terms. This is unfortunate, because the harms attributed to drugs used in sport have sometimes been exaggerated, and athletes are quick to sniff out hypocrisy. For an adult athlete who engages in a sport that carries a substantial risk of injury, the argument that you shouldn’t use a performance-enhancing drug because you might hurt yourself sounds hollow and insincere. A much better response to the argument from liberty in this instance is to point out that the intensely competitive nature of sport means that one person’s liberty to use a drug that significantly enhances performance affects the other competitors. Their liberty to compete fairly and equally without using drugs is severely constrained by the drug-using athlete’s actions (Murray 1983).

The fourth claim can be put colloquially as ‘resistance is futile’. In its less sophisticated form, the argument for the claim is based on some notion of historical inevitability: boundaries were shattered in the past, therefore boundaries will fall in the future. A more nuanced version of the ‘resistance is futile’ claim rests on what is deemed to be the ineluctable outcome of values, social forces, and incentives. In athletics people value performance and victory; the stakes are high and there are networks of scientists, coaches, and others more than willing to supply enhancements and help the athlete evade detection. In the quest for the ‘perfect’ child, the value placed on reproductive autonomy combined with every parent’s desire to have a healthy, successful child, and the eagerness of reproductive entrepreneurs to sell their services create a potent mix. In The Pursuit of Perfection,

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Sheila M. Rothman and David J. Rothman describe how plastic surgery grew into a major industry that paid little attention to risks. Consumers, they observe,

typically focus on the benefits, ignoring risks almost completely . . . From the profession’s perspective, plastic surgery demonstrates the extraordinary competition that a new enhancement technology sparks among different specialties. When no one group owns a procedure and when the market for it is lucrative, a variety of specialties try to capture a greater share. In the process, they not only publicize the procedure but also experiment with more powerful and riskier techniques. In the end, patient safety is compromised, although the patient may be the last one to know. (Rothman and Rothman 2003: 103)

The ‘resistance is futile’ claim has problems. For one thing, it is not, in the first instance, a moral claim. It does not say that all forms of enhancement are morally desirable or defensible. It simply asserts that attempts to restrict access to enhancements will be unsuccessful because people will pursue them anyway. True, some attempts at restriction are widely regarded as miserable failures. Prohibition in the United States is a leading example. Many people did not accept the assumptions underlying Prohibition, flouting of the law was widespread, and it had the perverse effect of allowing organized crime to profit from a monopoly. On the other hand, there are restrictions that we regard as ethically justifiable and even necessary for a civilized community. We prohibit theft, murder, and sexual assault. Some people commit these crimes nevertheless, but we don’t rush to repeal the laws on the grounds that ‘people will do it anyway’. In the absence of widespread moral opposition, efforts to restrict access to particular enhancements are no more likely to be successful than Prohibition was. But, if communities are convinced that certain enhancements are ethically indefensible, restrictions can be justified. They can never be expected to be perfectly observed and enforceable, any more than laws against theft or violence. But they can make a palpable difference in the community’s life nonetheless.

The fifth and last objection to controlling enhancement is the claim that could be dubbed heroic, romantic, or Promethean: that people should shape themselves. Willful self-design, from this perspective, is a distinctly human enterprise and therefore to be valued for its own sake. We are meant to be self-makers. The Rothmans report a vivid example of this view among the writings of feminist film critics, some of whom ‘scoff . . . at interpretations of the anorexic woman as weak and self-destructive’. What appears to be pathological is really independent behavior. The Rothmans (2003: 129) quote Noelle Casky on anorexia: ‘Anorexia’, Noelle Casky maintains, ‘is the cultivation of a specific image as an image — it is a purely artificial creation and that is why it is so admired. Will alone produces it and maintains it against considerable odds.’ This romanticizing of anorexia may offend people who have struggled with it or who have loved, and perhaps lost, children with anorexia. It does, though, capture the spirit of the heroic – romantic – Promethean ideal.