oxford handbook of bioethics

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Whatever its appeal, the heroic – romantic – Promethean take on enhancement encounters serious difficulties. Anorexia threatens to extinguish the very self that is both agent and object of these impulses towards self-design. There is also a remarkable naivety in the portrayal of such image cultivation as the product of individual will, rather than a complex interaction between social norms, which can be oppressive, and the individual’s sometimes desperate search for identity and acceptance by self and the world at large. It is no coincidence that anorexia occurs principally among young women: young because identity is still in formation; women, because of strong cultural preferences for slimness.

What of the link the heroic – romantic – Promethean view makes between the distinctively human quality of self-making and the intrinsic value of such a project? There are many distinctively human things that we value enormously: love, art, poetry, charity, and self-sacrifice to name a few. But other distinctively human capacities are not so honored, among them war, genocide, torture, and other forms of intentional cruelty. There is no necessary link between a project’s or capacity’s distinctively human character and its moral desirability. Some are good, some wonderful; others are unmitigated and shameful horrors. The bare fact that humans are distinctively capable of something does not tell us whether it is morally good.

The romantic notion that the essence of human nature is its plasticity is itself an affirmation that one’s view of human nature can have significant moral content. The romantic view is not, of course, the only possible one. Other commentators have tried to find in human nature sound reasons to limit enhancement. There are a number of arguments for placing limits on efforts to enhance human beings. But because the argument for limiting enhancement based on conceptions of human nature has been so prominent, it will be considered first.

CAN HUMAN NATURE BE OUR GUIDE?

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If enhancement of humans, by humans, and for — at least some — humans is the issue, can human nature be our guide through the thickets of the ethics of enhancement? This is the central assumption in a report of the US President’s Council on Bioethics, Beyond Therapy (2003). Before examining the Council’s argument in detail, consider three ways of thinking about the relationship of human nature to the ethics of enhancement: human nature as raw material; human nature as contours of the given; and human nature as normative guide.

Human nature as raw material. On this view, human nature, with one exception, has no moral significance. Our nature is raw material to be molded as we desire. Today we can sculpt our bodies with surgeries and decorate them with tattoos and piercings; we are learning to use drugs to bend our moods to our will; and tomorrow, perhaps, we will alter the genetic structure of our cells to shape

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ourselves — and our children — into the creatures we imagine we want to be. The exception — the morally singular aspect of human nature — is the ability to intend coupled with the skill to remake ourselves according to our own designs. This is the romantic – Promethean view of humans and their nature. Plasticity is all. Tinkering is celebrated as an affirmation of human will and cleverness (Silver 1998).

Human nature as contours of the given. This view acknowledges that we are creatures of a particular kind — embodied, finite, capable of great courage and abiding love; capable also of cowardice, treachery, and indifference. Our natures, always complex and often morally ambiguous, tell us something about the boundaries of what is possible and desirable. If we are irremediably social creatures, if we rely on one another for our flourishing, then a project to make us all indifferent to the feelings — of love or compassion — to those around us is fatally flawed at its core. Another project, directed, say, at preventing premature death, encourages the formation of vital relationships while reducing the likelihood that they will be suddenly, violently sundered. This, of course, is a description of the project of therapeutic medicine and public health. So, this view has teeth: some supposed ‘enhancements’ are out of bounds; others fit well within the contours of our given nature.

In contrast to the romantic – Promethean view, a focus on the realities of human nature as given (intimations of mortality, if you like) differs in three ways. First, it does not assume that human nature is limitlessly manipulable. Second, it does not elevate human willfulness and technical skill over all other human capacities. And third, it suggests that modesty is in order both concerning our abilities to alter our natures and concerning our wisdom in deciding which alterations are desirable.

Human nature as normative guide. It is worth quoting at length the assertions made in a crucial passage in Beyond Therapy because they provide a concise, current, and widely circulated account of the claim that human nature, properly understood, serves as a normative guide.

For only if there is a human ‘givenness,’ or a given humanness, that is also good and worth respecting, either as we find it or as it could be perfected without ceasing to be itself, will the ‘given’ serve as a positive guide for choosing what to alter and what to leave alone. Only if there is something precious in our given human nature — beyond the fact of its giftedness — can what is given guide us in resisting efforts that would degrade it. When it comes to human biotechnical engineering beyond therapy, only if there is something inherently good or dignified about, say, natural procreation, the human life cycle (with its rhythm of rise and fall), and human erotic longing and striving; only if there is something inherently good or dignified about the ways in which we engage the world as spectators and appreciators, as teachers and learners, leaders and followers, agents and makers, lovers and friends, parents and children, citizens and worshippers, and as seekers of our own special excellence and flourishing in whatever arena to which we are called — only then can we begin to see why those aspects of our nature need to be defended against our deliberate redesign. (President’s Council on Bioethics 2003: 289 – 90)

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For anyone worried that the romantic – Promethean view will dominate debate over the use — and opposing any constraints — on efforts at human enhancement, this passage has an undeniable appeal. But it is worth attending carefully both to the structure of the argument as well as to where it all too easily leads.

Although the loftiness of the language makes it difficult to sort out precisely what is being claimed, the argument seems to be premised on a series of categorical assertions. Take the first sentence: ‘For only if there is a human ‘‘givenness,’’ or a given humanness, that is also good and worth respecting, either as we find it or as it could be perfected without ceasing to be itself, will the ‘‘given’’ serve as a positive guide for choosing what to alter and what to leave alone.’ The ‘given’, that is, human nature, can be a ‘positive’ guide to our choices concerning enhancement if and only if what is given is also ‘good and worth respecting’. What then is the relationship between the given and the good? The authors of Beyond Therapy have already acknowledged that not all that is given is good — some things, we’ve been told, should be avoided like the plague — the plague itself, indisputably natural and given, among them. The question has been begged: How among all that is given or natural are we to know which are ‘positive’ guides and which are to be avoided like the plague? And what does it mean that the guide is ‘positive’? The connotation of ‘positive’ suggests that it does not merely warn us against blundering into dangerous territory, but that it also shows us the correct way, the proper object of our aspirations. But again, how are we to know which aspects of the given are trustworthy guides?

The second sentence does little to clarify matters: ‘Only if there is something precious in our given human nature — beyond the fact of its giftedness — can what is given guide us in resisting efforts that would degrade it.’ Here the focus has shifted from aspirations to be pursued to degradations to be avoided — if and only if, we are told, ‘there is something precious in our given human nature’. We are once again chasing our tails: Does being part of our nature make something indisputably precious? But that cannot be or else we would embrace and celebrate the most extreme forms of human suffering and evil along with all the ills to which the flesh is heir. We need some way to distinguish those aspects of our givenness, our human nature, that have moral meaning and value from those we can and should flee from whenever possible.

The long list that follows in the third sentence shows where the authors are heading. It cites one widely admired human capacity after another. But yet again the question is begged: Surely these capacities are ‘given’ and natural — otherwise they wouldn’t be human capacities at all. But the bald fact that they are human doesn’t distinguish them from other capacities — astounding cruelty, deception, violence, and betrayal among them — that are just as indisputably human. The problem with the underlying theoretical approach in Beyond Therapy is its insistence on looking inward — to some account of our natures rooted, as later passages make clear, in the tension between ‘the transcendent longings of the soul and the limited capacities

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of our bodies and minds’ (2003: 299). According to this account, only that which is given and natural can be good, and all that is other than natural and given is suspect.

I introduced the hypothetical case of a drug that steadies the surgeon’s hand into the enhancement debate long ago to illustrate that not all forms of drug-induced performance enhancement are obviously wrong. Imagine a drug with no significant side-effects (an admittedly shaky assumption) that neurosurgeons involved in delicate procedures could take that reduces the normal tremor and unsteadiness all humans experience. This drug, let us say, has been shown to lower dramatically the morbidity and mortality that usually accompany these procedures. Suppose further that someone you love is about to undergo precisely one of these operations. Between two otherwise equally adept surgeons, which one would you choose: the surgeon who, citing her commitment to her own flourishing as an active, self-aware, self-directed agent (see President’s Council on Bioethics 2003: 131), refuses to take the drug, or the surgeon who, citing the benefit to her patients, affirms that she uses the drug faithfully every time she operates?

I would not wish the first surgeon ill, but this is not a tough choice: I would go with the surgeon most likely not to injure or kill my beloved. The goal, after all, of surgical interventions such as this one is to preserve the life and health of the patient — not to show off the virtuosity of the surgeon, although that may be a secondary effect. Suppose the first surgeon also preferred to use antiquated instruments: ‘Oh sure, she says, the new scalpels, retractors, and the like are easier to use and safer for the patient — but the old tools sharpen and display my technical skills much better’. Our response should be: ‘That’s nuts!’ Or, in a more reflective frame of mind, we might explain to her that she is missing the point of her practice. Of course, we want her to flourish — but her professional flourishing comes through placing the patient’s welfare first. Pursuing personal excellence follows rather than precedes in importance the social goods we seek — restoring to health, saving life, sparing from injury.

The effort to ground an ethics of enhancement on an inward-looking account of human nature fails. Not all that is natural is good, and not all unnatural enhancements are bad. But between human nature as inferior raw material and human nature as ultimate unambiguous and infallible guide to right living, there remains a third possibility: human nature as a framework for the possibilities of human flourishing. Human nature, understood as the tension between our higher longings and our worldly biology, enfolds the possibilities of such flourishing. Our natures establish the contours within which humans flourish or flounder. But, within the context of their biologically given nature, human beings create relationships, practices, and institutions that give structure to their interactions and meaning to their aspirations. Understanding the relationship between social practices, institutions, and human flourishing allows us to consider other reasons for taking the ethics of enhancement seriously.

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REASONS FOR ETHICAL CONCER N AB OUT

ENHANCEMENT

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We err in lumping together a diverse array of possible uses of biotechnology as ‘enhancements’, assuming that a single overarching moral analysis will serve equally well for all. Different spheres of human life, different practices with different ends, properly call for analyses responsive to our understandings of them, the means appropriate to pursue the ends valued within each. Similarly, of the reasons for ethical concern described below, some will apply more clearly and forcefully to certain uses of biotechnical enhancement than to other uses.

Undermining human nature. The fear that biotechnologies will rob us of what gives shape and motivation to human lives runs though the work of Leon Kass in general, and the prospect of life extension in Beyond Therapy in particular. The Council’s report (2003), echoing Kass’s long-standing concerns, worries that without the spur of finitude all higher human aspirations will dwindle. Without the prospect of death, he fears that we will become ever more complacent and self-centered. The themes that animate our greatest art will shrink to historical curiosities; the motivation to create will evaporate like steam from an uncapped boiler.

Kass’s critique is in the thrall of the same Promethean fantasies being peddled by biotechnology hucksters. We may be on the threshold of learning to manage some of the diseases that cause great sorrow and early death. But we are nowhere near to knocking on the door of eternal life. Rooting our analysis of biotechnological enhancement in a far distant fantasy of unlimited life extension may be visionary. But it may also be a colossal distraction from the actual challenges posed by enhancement technologies. The concern with undermining human nature that runs through Beyond Therapy is a provocative framework for thinking about the apotheosis of biotechnological life prolongation. But there are more immediate sources of moral concern.

The denial of giftedness. Michael Sandel is the most prominent recent proponent of the idea that biotechnological enhancement threatens to blind us to the giftedness of life. Sandel, although a member of the President’s Council on Bioethics, takes issue with Beyond Therapy’s judgment that human agency, rather than respect for the given, for human life as a gift, is at the heart of what is threatened by enhancement. Sandel disagrees with what he describes as Beyond Therapy’s assertion that ‘the main problem with enhancement and genetic engineering is that they undermine effort and erode human agency’. Instead, he asserts: ‘The deeper danger is that they represent a kind of hyperagency — a Promethean aspiration to remake nature, including human nature, to serve our purposes and satisfy our desires. The problem is not the drift to mechanism but the drive to mastery’ (2004: 54).

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Is human agency the threat or the threatened? Sandel argues: ‘If bioengineering made the myth of the ‘‘self-made man’’ come true, it would be difficult to view our talents as gifts for which we are indebted, rather than as achievements for which we are responsible.’ What’s the problem with that? He argues that such a view would have a baleful impact on ‘three key features of our moral landscape: humility, responsibility, and solidarity’ (2004: 60). Humility opens to the given and unexpected; it reins in the powerful temptation to try to control, for example, the traits of our children. If nothing is left to chance then we are responsible for everything — including our children’s talents and interests. As for solidarity, Sandel argues that health insurance, for example, as a way of sharing the financial burdens of unexpected illness, will wither away as the predictability of medical misfortune increases. Solidarity, in his view, is dependent on human frailty and its unpredictability.

Proponents of the Promethean view of biotechnological enhancement may disagree. If, though, Sandel is correct that a goodly measure of humility, a strong pull towards solidarity, and a nuanced view of responsibility are important to a morally vigorous society, then the overthrow of giftedness in favor of hyperagency is, indeed, reason for worry.

An emphasis on giftedness seems particularly well suited for thinking about applying biotechnological enhancements to athletes and to our children. When we look to athletes for excellence or seek athletic excellence in ourselves, we expect to see natural talents and their virtuous perfection. By undermining the very idea of ‘natural’ talents, biotechnological enhancement strips athletic excellence of what we value in it. When we aim to design our children, we abet the temptation to tyranny; at the same time, we put at risk what makes the parent – child relationship such a vital path to human flourishing.

The temptation to tyranny. Complaints about overweening efforts to control our children’s characteristics are often parried by a menu of things parents do now to shape the course of their children’s lives. But that menu, even if it lacks a precise ordering, reveals huge variations in moral digestibility. Giving your child a baseball or violin or enrolling them in Little League or music lessons can enlarge their horizons, sharpen their appetites, and teach the connection between natural talent, virtuous training, and success. Parents who fail to open possibilities for their child risk narrowing the range of their children’s hopes and dreams. Parents who insist that their child pursue only those goals that the parents dictate and no others, or who similarly insist that their child be just this sort of person, with precisely these character traits, aspirations, and affections, are narrowing that child’s horizons to the point of tyranny. The fact that some parents now behave tyrannically even without the tools of biotechnology is no argument for embracing the new forms of tyranny biotechnology may later offer.

It is worth noting that the concern about temptations to tyranny does not require that the technologies successfully deliver the precise control that their promoters

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promise. If, on the one hand, the technologies of selection and control are highly effective, then the tyranny is accomplished. But, if parents think that because their child is tall, or musical, or has uncommon curiosity or blue eyes, this will assure the life they envision, they will be sorely disappointed. It is one thing to have perfect pitch, another to have the desire and drive to become a successful musician. Making sure that your child is tall or has blue eyes seems more straightforward. But it would be more than a little odd for parents to want their child to have those anatomical traits just to have them. It seems likely that parents see those traits as serving other goals; and if being tall and blue-eyed confers social advantages, for example, our fortunate (and expensive) child had better capitalize on those advantages! Even with highly refined control over traits (a dubious prospect scientifically) the prospects for conflict are rich. Of course, the idea that we soon — or ever — would have such precisely targeted control is improbable. The more we learn about the complexity with which genes interact with one another, about the capacity of a single gene to make multiple proteins with distinct functions, and about the unpredictability of development, the more we undercut the assumption that precise control is possible.

What if parents’ aspirations for control are disappointed? If the technologies work less effectively than they hope, does the temptation to tyranny fade as a concern? Unfortunately, no. Frustrated tyrants are no less a danger to the individuals under their thumb than satisfied ones. What will be the impact of selection and enhancement on what is morally vital in the relationship between parent and child?

Undermining the relationship of parents and children. With apologies to Dante, there should be a sign above the gateway to parenthood that reads ‘Abandon all hope (of control) you who enter here!’ It has never been a good idea for parents to try to design and mold their children to meet their fantasies. For one thing, as I noted above, the quest for control is doomed largely to failure. For another, children are not the mere passive recipients of parental instruction like a statue onto which the shaper can endlessly add gobs of clay until the desired result appears. Children act and react; they may accept one influence but rebel against the next. Finally, and most importantly, unrelenting attempts at control choke off the growth of mutual love and respect. The central point here is that we cannot fully understand the ethics of biomedically enhancing children without understanding what is ethically crucial in the relationship between children and parents.

Sandel argues for the importance of accepting the ‘givenness’ of our children — as they are, with their appetites and enthusiasms, fears and aspirations, however that personal reality might diverge from our idealized image of the child we dreamt of having. The idea of givenness or giftedness fits well with a conception of the relationship between parents and children that stresses mutuality.

The usual distinction between human moral motivations — self-interest and altruism — fails to capture a crucial feature of parents’ motivations in caring for their children. Good parents discover that they derive deep satisfaction and great personal growth as their children thrive under their care. Growth and

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satisfaction come when parents aim not at their own well-being but at their children’s flourishing. By acting to advance another’s well-being — the classic paradigm of altruism — parents also further their own — what we would usually think of as self-interest. But in parents’ love and care for their children, altruism and selfinterest are inextricably intertwined in a way neither label adequately captures: hence the need for the concept of mutualism as a third type of moral motivation. The archetype of mutualism, so common and pervasive, is embodied by parents caring for their children (Murray 1996).

Relationships of mutuality are vitally important to moral and emotional growth and maturity. Erik Erikson, who famously coined the phrase ‘identity crisis’, refers to the challenge that typically gathers force in adulthood as ‘generativity’ (Erikson 1964). Do we learn to care for people and projects beyond ourselves? Becoming a caring parent may be the most common way adults grapple with the challenge of generativity, but it is by no means the only path. In parenthood, as in other vital relationships that depend upon mutuality, overweening efforts to control the other are anathema to the flourishing of both. These relationships depend upon respect for the other person’s individuality and — in the case of children, slowly evolving capacity for — agency. The over-controlling parent damages the child by constraining the child’s horizon of possibilities and impairs the child’s emerging sense of agency and efficacy. Tyrannical parents suffer as well when children’s love is smothered or withheld and ultimately withdrawn. Love freely returned for love generously given is a far more precious reward. Such love is both the source of and the reward for mutuality. When biomedical enhancement is enlisted in the service of fantasies of parental control, all that is most precious and beautiful in the relationship between parent and child is threatened.

There are other reasons why efforts to alter our children’s characteristics in the name of enhancement can be misguided. Enhancement can be a foolish waste of resources; it can become complicit with unjust norms; and it can reinforce patterns of injustice. Human growth hormone illustrates all three.

A foolish waste of resources. Human growth hormone to increase final adult height is an expensive and extended proposition, requiring frequent injections over years costing tens of thousands of dollars. Some parents seek hGH for their children who are projected to be well below average in height. Especially for children with a demonstrated deficiency in biologically active hGH, such measures look very much like therapy for other significant hormonal abnormalities such as diabetes. But other parents seek hGH for their children who would be average or above average in height. No case can be made that administering hGH to such children is treating some underlying disease; this is a straightforward example of enhancement.

What, though, is being enhanced, and to what end? Earlier I distinguished between ends, means, and intermediary states. The means are clear enough: growth hormone injections. But it is important also to discern what counts as an end and what as an intermediary state. Increased height is not an end in itself. The whole

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point of trying to make one’s child taller is to give that child the advantages that height provides. Height, then, is an intermediary means. The ends are whatever competitive social and economic advantages height affords.

Earlier I raised questions about whether hGH for short children was the best means of reaching the reasonable parental goals of trying to build one’s child’s self-confidence and to avoid discrimination. For very short children, increasing height can also be seen as averting what would otherwise be a disability — albeit a mostly socially constructed one: navigating a world constructed for adults within a certain range of heights. The quest for a few additional inches of height has its costs, not least in giving a message to that child that being short is such a significant problem that it is worth all this money, time, and attention. For a child who will nevertheless end up much shorter than average, this is not an entirely supportive message. But, all things considered, the parents of such children are the appropriate agents to weigh advantages and disadvantages and decide on their child’s behalf. What about children who are not short?

Years ago I learned of a case in which the parents of a tall young woman sought hGH for her because her high school volleyball coach told them that if she were 4 inches taller he could assure her a full scholarship to any university in her country with a women’s volleyball program. That case may be exceptional in its promise of immediate and tangible rewards for a successful course of hGH injections. More common is the general desire to capture for one’s child the advantages of heightism. Suppose that all parents thought the same. Imagine that all children were given hGH and that all children ended up on average a few inches taller than they would have been otherwise. Who is better off?

Among those most likely to benefit are the companies that manufacture hGH, the physicians and others who monitor its effects, and fabric manufacturers — because we will all need to wear larger sizes. Your child, however, will not be any better off. He or she will still be in roughly the same percentile of height as before; the entire curve will have shifted to the right, but there will still be the shorter-than- average and the taller-than-average. Children as a group will surely be worse off: having to endure a thousand or more injections, running the risks that accompany long-term administration of hGH, becoming more conscious than ever about the social advantages of being tall and the disadvantages of being short.

Universal administration of hGH to make children taller would be a foolish waste of social resources. No valuable social good would be advanced. Massive resources would be squandered. This example underscores the need to think beyond the isolated individual case and ask what good such an ‘enhancement’ would do if in good Kantian style we universalized that action or judgment. To an individual parent, hGH might look like a reasonable investment in one’s child’s future. But that investment creates no increase in social good: no improvement in the available stock of virtue, no progress in the pursuit of justice. And if all other parents did the same it would entail risks and the pain of injections while offering nothing

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positive even to your own child. For hGH and height, the means are now available, the intermediary state (being a few inches taller) achievable, but the ends — a comparative advantage for my child rooted in a social prejudice — remain ignoble, carrying no intrinsic value and promising no increase in social good, and, if other parents do the same, are ultimately futile.

Enhancement via hGH teaches us to look beyond the individual case and to consider carefully what social value or good is being advanced. Some other enhancement, say of cognitive functioning, general health, or resistance to disease, might add materially to the stock of human well-being. As vaccines enhance the immune system and diminish the misery and premature death wrought by infectious diseases, so certain other instances of biomedical enhancements may do good on the whole. Each proposed ‘enhancement’ must be evaluated in its full social context.

Complicity with unjust norms. Sometimes a supposed enhancement becomes complicit with and reinforces unjust norms. Cosmetic surgery is often accused of just this offense, and often with good reason. Surgically sculpting one’s body to resemble more closely idealized images of youthful slenderness and firmness may help an individual to feel good, and may make that person a hotter property in the dating market. One might argue that it also results in a more comely and attractive world for all of us. But there is no doubt that enhancing one’s appearance with cosmetic surgery or botox injections underscores the power of norms of physical appearance that most aging bodies cannot meet without assistance — and that most youthful bodies fall short of as well.

Margaret Olivia Little (1998: 170) proposes that complicity exists ‘when one endorses, promotes, or unduly benefits from norms and practices that are morally suspect’. So, for example, surgically reshaping women’s bodies to resemble Barbie dolls would make surgeons complicit along with the women whose bodies are being altered. Overseeing a course of hGH injections for a child slightly shorter than average would also count as complicity with unjust norms — given that height should not be a measure of a person’s worth.

Little recognizes the quandary surgeons and others are thrown into when we accuse them of complicity with unjust norms: sometimes patients are suffering, are seriously disadvantaged because these norms, however unjust, weigh down their lives. For a woman deeply unhappy with her body, convinced — perhaps with good reason — that her life would be better with a smaller waist and larger breasts, it seems harsh to say that she should stop complaining and just accept the body she was born with. It feels even crueler to insist that a child cease whining and resign himself to the social disadvantages that come with short stature. Physicians’ and surgeons’ duties are to their individual patients first of all. If an intervention can alleviate suffering — even if that suffering comes about only because of oppressive and unjust social norms — why should not clinicians do what helps their patients?