Miah, A. (2011) Ethical Issues Raised by Human Enhancements, in: Gonzalez, F. Ethics and Values for the 21st Century, BBVA Spain, 199-233 [Also in Spanish].
Introduction
Over the last 30 years, the evolutionary status and trajectory of the human species has been brought into question by rapid progress within the fields of nanotechnology, biotechnology, information technology and cognitive science. These NBIC sciences suggest ways in which technology could allow people to make themselves 'better than well' (Elliot 2003, Kramer, 1994) in such a way as to transform what we regard to be species typical functioning for humans. Such modes of enhancement may involve the modification of our brains to increase memory, reasoning, modification to our biology to make us more resilient to the environment or give us new capacities, life extension, or alterations to our appearance to make us more attractive or more aesthetically distinct.[i] Such interventions as laser eye surgery that can yield better than perfect, high definition vision, or the use of cognitive enhancers, such as Ritalin, to help students study for exams, each suggest how humanity is entering a transhuman era, where biology is treated as something to be manipulated at will, depending on one's lifestyle interests, rather than health need. Yet, questions remain about how far society is prepared to accept these kinds of applications and what ethical issues they creates.
The prospect of human enhancement has attracted considerable attention from bioethicists, the media and policymakers alike, each of whom have debated the ethical and moral desirability of such circumstances and the practical social and legal implications arising from a culture of human enhancement. Indeed, over the last 10 years alone, various governments have investigated these prospects, interested in understanding the magnitude of these trends for society. One cannot understate the breadth of these implications, as both advocates and critics of human enhancement agree that they will change fundamental parameters of human existence (Fukuyama 2002, Harris 2007). For instance, in a world where achievement is brought about more by technological intervention than effort, the entire system of justice that underpins society is brought into question. Alternatively, if a patient can request a doctor to ensure that their therapeutic intervention has an enhancing rather than simply reparative outcome, then the role of medicine and health care, along with the relationship between the doctor and patient changes considerably.
Determining the legitimacy and desirability of such changes is crucial to a global economy, as the transformation to healthcare and welfare that is implied by human enhancement, has critical implications for how society is organized. Thus, healthier people will mean the prospect of longer lives, which in turn will mean a growing, ageing population. This situation will have an impact on various social provisions and the broader economic infrastructure of a society, requiring people and governments to revise their expectations about the duration of the working life, the economics of pension funds, and the provision of health insurance. It may also influence what kinds of lives people lead, such as when they have children, or what kind of career they pursue. Thus, the consequences of human enhancement pervade all aspects of modern life, creating demands on social systems that may bring about their collapse, if they are not rethought. This is why it is important for governments to understand the rise of human enhancement technologies, in order to address their overarching implications for the future of humanity.
A number of important contributions to this debate have already been made from such diverse fields as philosophy, social science and public policy. As such, it is helpful to summarize some of the key concerns articulated by these contributions, before offering a critique and re-articulation of the key priorities that should concern future ethical, social, legal and policy debates in this area. However, before doing so, the first part of this essay provides some conceptual clarity on different types of human enhancement. This clarity helps to establish some overarching parameters to the ethical debate over which kinds of enhancement technology are appropriate for people to use.
What are Human Enhancements?
One of the difficulties with the human enhancement debate is the lack of consensus around what counts as an enhancement. It is often argued that the ethically questionable practice of human enhancements may be distinguished conceptually from the more accepted practice of human repair or therapy. However, it is misleading to suggest that medicine has always confined itself to just repair, or that there is agreement on the acceptability of how medicine is typically practiced today. Indeed, contemporary medical practice draws on a definition of health that is informed by the broader socio-cultural construct of well-being, which acknowledges that health care needs are not always about some physiological deficiency. Instead, they may be a matter of changing lifestyle conditions that could have an impact on health. Alternatively, such practices as in-vitro fertilization to treat infertility, abortion to avoid the possible psychological trauma of bearing a child, or physician assisted suicide to ease the suffering of people at the end of the lives, are each topics that are an established part of medical practice today. Yet, there is ongoing controversy about whether these interventions are consistent with the proper role of medicine.
Equally, it is untrue to presume that the conditions treated by therapeutic medicine can be detached from some lifestyle that a patient has led. Whether it is alcohol consumption, too much sun-bathing, smoking, lack of exercise, or playing high-risk sports, the lives people lead contribute to their eventual need for medical care. To this end, the proper role of medicine is the business of making people well for a particular kind of life they wish to lead, rather than just making people healthy in some general sense. For example, a dancer may need physiotherapy to treat an injury arising from their profession, or a student may need cognitive enhancers to address anxiety caused by the prospect of difficult exams. These examples reveal that it is often not possible to consider medical interventions that are divorced from social circumstances.
In this respect, one may identify two different definitions of health, one which relies on biomedical markers of medical need, and another which draws attention to the biocultural characteristics of ill health. For the former, one may be more inclined to discuss the biological indicators of good or ill health, while the latter will discuss health as a social concept, whereby medical intervention is explained with recourse to the social and cultural conditions that determine an assessment over whether a subject is leading a healthy life or in need of medical assistance. Good examples of this are various forms of disability which, beyond the medical treatment of the condition require various societal changes to ensure that the debilitating effects of the condition are not made worse by feelings of exclusion or inability to function within the social world.
In sum, it is erroneous to suggest that medicine proper simply treats people in a therapeutic way, insofar as this can be contrasted with enhancement. Indeed, medicine undertakes preventive measures with healthy subjects, before any health care need is apparent, as in the case of childhood inoculations. These examples reveal how humanity is generally predisposed to pursue new forms of medical intervention that can prolong survival, though these are not generally what are considered to be human enhancements. Consider another example - the fluoridation of tap water, which is commonly practiced in numerous countries which aim to reduce levels of teeth and gum decay. Over the years, the amount of fluoride within the drinking water of many countries has risen, as dietary habits and ingredients, along with dental hygiene standards may have decreased. However, the more general point is that from a purely economic perspective, one of the most effective contributions a nation may make to the oral health – and thus general health – of its citizens it is to include fluoride in the water. In each of these examples, we encounter medical interventions that test the boundaries between therapy and enhancement, but each reveals that the line is far from clear.
Additionally, one may even argue that the natural trajectory of medical practice is towards an era of human enhancements, as humans are rationally predisposed towards living long, healthy lives for as long as possible. Indeed, society's condemnation of suicide as an irrational interest is evidence of this fact. To put it another way, any person who values life will value its continuation and the pursuit of means that are likely to promote this possibility, which may broadly be defined as human enhancement technologies. Thus, the pursuit of these goals is consistent with the philosophical premise that a life worth living should be sustained for as long as is feasible.
The examples of fluoride in tap water or childhood inoculations also reveals the delicate balance required to ensure that any particular enhancement optimizes rather than harms humanity. Thus, too much fluoride in the tap water would have a harmful effect on people's health, as indeed could protection against a disease by vaccination which, in some countries may lead to a vulnerability towards another condition. Indeed, these examples are also characterised by a lack of consensus about their value. For instance, the fluoridation of water is considered by some to be unethical insofar as it prohibits the consumer to exert any degree of choice over the enhancement. Some countries have even decided to stop adding fluoride to tap water out of concern about its efficacy.
In any case, these examples are far removed from what many people typically regard to be the core content of the human enhancements debate, which is the improvement of biological conditions to such a degree as to bring into question whether the modified people are human at all. This may involve the creation of new human capabilities, that are achieved only by the technology, or the increased functionality of already familiar human capabilities. Each of these prospects suggests how technology may transform the species in such a way as to create a new, posthuman era and the presumed difference between such persons and today's populations, along with the expected loss of humanity that many have argued that it implies, is the locus for ethical concern. This is not to say that all forms of human enhancement involve scientific or technological manipulation. After all, some of the most effective means of enhancing humanity have very little to do with direct biological manipulation, such as education, a good diet or exercise.
In response, it is important to acknowledge how the biological characteristics of the human species have always been changing. Beyond the broad evolutionary point, the last 100 years has brought about dramatic changes in the living conditions that have brought about a transformation in what kinds of expectations people have about their health. In short, what is considered to be normal health today is radically different from what it was 200 years ago. Today, people in developed countries can expect to survive many previously life-threatening conditions, while life expectancy and even such biological parameters as height have changed considerably. Many of these changes have become constitutive features of modern medicine and have been achieved by scientific discoveries or insights that are, again far removed from debates about human enhancement, such as knowledge about sanitation and hygiene. Yet, these examples have certainly enhanced humanity, thus bringing into question, again, where one focuses the current debate about the ethical concerns arising from human enhancements.
There is also a normative challenge with the term human enhancement in that it may imply an evaluative judgement about something having been improved when, in fact, this claim is contested. Thus, while we may rightly conclude that having healthier teeth is, in one sense, an improvement of our life, the diminished autonomy that it implies by a nationwide fluoridation of drinking water may be regarded as, on balance, an unreasonable cost. To this extent, it is a value judgement, rather than an appeal to facts, as to whether the modification can be rightly regarded as an enhancement of humanity or not. Indeed, this concern appeals to the idea that it is not life circumstances in themselves that matter, but the means by which we come to enjoy them, a theme that will be explored further in the subsequent section.
In sum, various authors have attempted to derive a model for conceptualizing human enhancements. For example, Conrad & Potter (2004) study human growth hormone and identity three possible uses 'normalization, repair and performance edge' (p.184). Yet, often the debates about futuristic scenarios where humans have become some very different kind of species are conflated with the more immediate ways in which the therapy-enhancement distinction is creating new forms of wellness that, nevertheless, disrupt what we consider to be normal. Miah (2008) proposes such a typology of human enhancements that is divided into three principle categories, with further sub-divisions in the final category. This typology is modified in the following version, which builds on the 3 main categories, with further elaboration on their differences and, subsequently, clarification on how they assist in the ethical debate about human enhancements.
- Enhancing Health-Related Resilience (eg. fluoridation of tap water or inoculations)
- Enhancing Lifestyle Functional Capacities (eg. Breast enhancements, height enhancement)
- Enhancements Beyond Species-Typical Functioning
- Extending Human Capabilities (eg. height enhancement)
- Engineering New Kinds of Human Function (eg. changing colour, flight).
- Within the realm of known biological possibility (eg. flight capability)
ii.Outside of known biological possibility (eg. capacity to live in non-gravitational environments)
Importantly, this typology does not map neatly on to degrees of ethical concern. However, it does endeavour to convey a continuum of enhancements that begins with examples that are closely aligned with how medical practice operates today, towards interventions that may be practiced in the future. Equally, any single example of a technology may fit into any number of the categories depending on how it is used. For example, a prosthetic leg may provide a disabled person with mobility (Categories 1& 2 are engaged) or allow them to run faster than the biological counterpart (Category 3).
Among each of these categories and sub-categories there is considerable ambiguity over where a specific intervention might fit. More specifically, any single case of an intervention could fit into anyone of these categories, depending on its precise application. Consider an example that may fit into category 1 or 2 – physical exercise. Here, we might consider questioning the ethical appropriateness of a doctor's advocacy of exercise within a consultation, as either a health-related resilience enhancer, or an enhancer of lifestyle functionalities. After all, the evidence to support the claim that exercise optimizes health is complex. For instance, there are differences of opinion about how much exercise is optimal. Equally, society's need to reduce the burden of health care may lead to coercive tactics to ensure people exercise and this may be regarded as unethical. Thus, the development of health credits in the USA, which are connected to the amount of physical activity an individual undertakes may be seen as an unreasonable imposition on an individual's life. However, there would be little sense in discussing whether it is ethical or not for a person to choose to undertake exercise at all, should they believe it to improve their lives. Alternatively, denying treatment on the basis of not having led a lifestyle that deserves medical assistance – as in the case of decisions over rationing and smoking – may infringe upon the individual's right to be treated without prejudice.
In conclusion, this typology reveals the differences between ways in which one may conceptualize enhancements, beyond a simple binary distinction between therapy and enhancement. This may assist debates about the ethics of human enhancement by restricting discussion to only the relevant implications, rather than drawing too heavily on the broader rhetoric of futuristic transhuman scenarios.
The Ethical Issues
Ethical debates about human enhancements have taken place within various bodies of literature, including bioethics, animal ethics, environmental ethics, political science and the social scientific study of medicine. Each of these areas approach the significance of human enhancement from quite different perspectives. For example, Dvorsky (2008) argues that the capacity to enhance human biology must also imply an obligation to 'uplift' the capacities of other animals as well. Alternatively, bioethicists have argued that the possibility of human enhancement requires us to consider what sorts of people there should be, alluding to the prospective use of germ line genetic modifications or selection. To this extent, there is no single set of ethical issues that is engaged by all possible forms of enhancement. For example, enhancing an athlete's performance in sport may raise very different ethical concerns compared with enhancing a child's height to ensure it reaches a level that is closer to a population's average height. Alternatively, genetic enhancement is likely to have different implications from using a pharmaceutical product or a prosthetic device to yield a similar effect. Indeed, debates about the ethics of human enhancement are already so nuanced as to be focused on specific kinds of enhancement, such as neurological, biochemical, or physiological modifications.
As such, an overview of the ethics of human enhancement must first take into account the fact that one can, at best, provide only a compendium of general concerns that may be engaged by specific examples of enhancement. Equally, while some ethical concerns involve clearly identifiable stakeholders, for others they are much more diffuse. For example, if asking whether a doctor may facilitate an human enhancement for a patient, one would appeal to their professional code of ethics to assist in answering this question. Very few other stakeholders are relevant to this moral dilemma, though it may also involve appealing to the moral conscience of the doctor, as is often discussed in cases of abortion. In contrast, if asking whether germ-line genetic enhancement is morally sound, then it may be necessary to consider the interests of the patient along with other members of her family, community, society, and, perhaps even the entire world's population – along with future generations. This is because such interventions may have an affect on a much wider population, due to the possible transference from one generation to the next that such modifications imply.
Furthermore, it is necessary to clarify the relationship between moral and ethical, as they are often conflated within debates about human enhancement. Generally speaking, one would discuss ethical issues in the context of a specific practice community, such as the ethical code underpinning medical practice. Alternatively, morality is concerned with broader questions of value for which there may be no formal codes that are broken. For example, one might have a general moral concern about the prospect of a society compromised of genetically enhanced people, hough this may be come about without violating any specific ethical code. In cases of moral violations, it is more difficult to determine whether any specific principle has been violated by an action, or whether the moral concerns arising from this are, overall, outweigh the benefits that may arise from it. To this end, it is more difficult to derive an uncontested answer as to what people ought to do, which is why a common response to difficult ethical dilemmas is to rely on consensus of opinion, via some form of representative democratic decision. Nevertheless, one may find assistance in deriving ethical principles by studying human societies and the norms that have emerged around behaviour within culture. Through subjecting such discoveries to a process of reflective equilibrium, one may develop a clearer sense of the ethical principles that should govern decision making within practical contexts.
Given these complications, how ought one distinguish between types of ethical issue related to human enhancement? One approach is to treat human enhancements as any other form of biological modification and subject them to the same ethical scrutiny of the practice that facilitates the enhancement. For example, if the enhancement is to use autologous blood transfusions as a way of increasing stamina for an athlete who is running a marathon, then one may refer either the ethics of sports practices, or the ethics of medical practice to determine whether they are acceptable. Thus, one may refer to the ethical principles of sports or medicine, to ascertain whether the treatment can be undertaken without jeopardizing other values. However, one may also argue that the use of human enhancement is so different from all other forms of biological modification that it requires a completely different ethical framework from which to determine their acceptability. One may argue this case on the basis that, say, traditional medical ethical principles have been framed from the minimal interest to make people well, whereas the goals of enhancement are quite different. However, this exceptionalist approach finds a practical challenge in that many of the tools of human enhancement are regulated by those who hold the former view, whereby any use of a medical intervention for a non-medical purpose must satisfy the regulatory expectations of standard medical care. In this respect, it is unreasonable to expect a radical overhaul of this highly established system of governance over the use of new or established medical substances, products and methods. Indeed, change in this respect is even more unlikely when one takes into account the likely fragility of enhancements, which may require ongoing medical monitoring and possible correction.
An alternative route towards establishing an ethical framework of human enhancements is to examine how the debate has taken place thus far within a range of intellectual spheres – both theory and practice - and to provide some form of synthesis of the arguments and concerns. One of the challenges with this approach is that there is no consensus over which ethical issues are the most salient. Moreover, relying just on what has already been identified as a key ethical concern may overlook an essential issue that has yet to be discovered. Indeed, this approach has led to specific studies focusing on specific ethical concerns, to the omission of others. Nevertheless, a review of the literature reveals clear trends in what are seen by many commentators to be the key concerns and it is useful to build on this previous research. This is most adequately summarized in Allhoff et al. (2009), which frames the ethics of human enhancement under the following categories: Freedom & Autonomy, Fairness & Equity, Societal Disruption, Human Dignity & Good Life, Rights & Obligations, Policy & Law (ibid). Yet, one of the difficulties with this approach is that it does not distinguish between the different levels of decision making that operate around ethical dilemmas, from the individual to the societal.
In response, the following sections provide an overarching analysis of the various approaches to articulating the ethical issues that are engaged by human enhancements. It is structured in terms of three primary categories, which provide a useful heuristic through which to identify types of ethical concern. The assumption is not that these three domains can be neatly separated, but that there is value in categorizing ethical issues in terms of what Singer (1981) describes as the 'expanding circle' of moral concern. Thus, separating these concerns out into distinct units may assist in clarifying where the ethical dilemma resides and what kind of action – individual, professional or societal - is required An individual ethical issues relates directly to the interest of the subject who is undertaking the enhancement themselves. The professional concerns category relates to the individual or institution that is facilitating the enhancement, whereby there may be formal guidelines over ethical conduct. Finally, the societal concerns relate to the broad interests of society, which may be frustrated by the adoption of human enhancement.[ii] Within each of these categories, individual moral concepts are engaged in slightly different ways. For instance, an individual may consider whether they find it morally just to utilize cosmetic surgery for personal enhancement, while society may consider whether it will overall improve society to permit such surgery. In each case, the balance of reasoning will differ considerably, while the ethical principle may remain the same.
Individual Concerns
It should be considered uncontroversial to claim that there are good reasons for why human beings would want to enhance themselves generally. Indeed, as noted earlier, humans have always sought to enhance themselves, where some of the more familiar methods include education, exercise or a good diet. Undertaking these pursuits may lead to much greater capabilities than one would have and this may also lead to an advantage over those who choose not to indulge in such practices. To this end, what is it, if anything, that distinguishes these accepted methods of enhancement from those that cause moral concern, such as using drugs or the prospect of genetic modification? First, it is important to note that it is inadequate to devise moral rules that apply to people in general. Rather, people always operate within different social contexts, where different moral and ethical expectations exist. Thus, a university student may also be a musician, a youth group leader for a religious community, and a part-time sales assistant at a retail outlet. In each of these spheres, the moral expectations will change, while there may also be a sense of there being an abstract self-identity that operates across each of these domains. This is an important realization when attempting to determine what may be an ethical choice for someone to take, as any action may violate the ethical expectations of one practice, while not the other. Equally, it would be naïve to suggest that this university student can make general decisions about their well-being without being mindful of how it affects their ability to operate within either one of these practices. For example, using a cognitive enhancer to pass an exam may violate a university code of ethics – in actual fact, it is unlikely to - but it may be considered an enrichment of his performance within the orchestra, where there is greater ambivalence over the whether such use is ethical. The nuances of individual lives is an important reminder that there are not often formal ethical codes that govern our daily lives. Instead these are moral frameworks that may guide our actions or organize social conduct. Yet, in each case, there ma
Means Matter
One common argument that is used to challenge the value of human enhancement is to appeal to the idea that the means by which people achieve their goals in life matter. As such, if one adopts a technological shortcut to achieve some goal, then this may undermine its value. For instance, if one is a mountaineer and decides to reach the summit of the mountain by using a helicopter rather than one's body, then not only has the value of the achievement been undermined, but we might not even claim that a mountain has been climbed at all. This argument extends to many other forms of enhancement, from using coffee to make one more alert each day, to using cosmetic surgery to improve one's appearance. Yet, in these cases the degree to which these means matter varies considerably. For instance, if drinking coffee allows a scientists to reach a discovery that otherwise she would not have made, then we are unlikely to be concerned about this fact. Rather, our interest will be in the fact that a discovery has been made at all. Equally, if a person uses botulinum toxin (botox), or any form of cosmetic surgery to improve their appearance, in order to increase their chances of attracting interest from others – whether it is romantic or professional – then this is unlikely to arouse ethical condemnation. Certainly, it may invite moral criticism in its giving primacy to the value of appearance over other qualities, such as personality. However, in this area there exists considerable cultural differentiation, which limits the degree to which one would chastise such actions as being morally problematic. For, if one is willing to criticise the use of botox, then one may need also criticise other attempts to improve personal appearance, such as wearing expensive clothes, makeup or even smiling.
In each of these cases – the mountaineer and the botox user – there are no ethical rules that are violated, only moral concerns that may be engaged, or an ethos that may be violated by the modification. For example, the mountaineer community is not defined by a code of ethics, but there is an ethos in place whereby different expectations exist about how members practice the activity. To this end, it is unlikely to be a grounds for some form of prohibitive action from the state. Instead, there would need to be more serious harms arising to others for such cause to be required.
An Authentic Life
Closely allied to the concern about how one attains achievements is a concern that has been articulated often in relation to psychophmaracological substances, such as Prozac (Elliot 1999). In these cases, it is argued that they are morally undesirable forms of enhancement, as they will transform a person into somebody else and that this disconnection is logically undesirable. Such arguments are discussed in Elliott (1999), The Presidents Council on Bioethics (2003) and DeGrazia (2003). This may have something to do with the sociological concept of selfhood, which locates meaning within our lives in the various ways in which people cultivate their identities that, in turn, become the locus for moral concern. Indeed, Riss et al. (2009) discover that people are 'much more reluctant to enhance traits believed to be more fundamental to self-identity...than traits considered less fundamental to self-identity' (p.495).
This conclusion reinforces the earlier claim that there is no single ethical principle about any particular enhancement that one may appeal to in order to determine what may be ethically appropriate for people in general to do. After all, where one person may value their extroverted personality, another may loathe it. Nevertheless, to the extent that a life is lived in such a way as to limit the possibility to claim that it reflects the persona of a person, as opposed to a persona that is facilitated by a drug or other form of enhancement, it may be argued that this kind of life is less rewarding to live.
Open Future
A further reason for caution over any particular human enhancement is that it may unreasonably narrow one's prospects in life. While there may be some question over whether such modifications could legitimately be called enhancements, this alludes to the fact that an enhancement – like any health status – may have a limited life, or may improve only a fixed number of lifestyle choice one makes. This concern is similar to what some authors have also discussed in relation to the problem of irreversibility. In this case, whether an enhancement can be reversed may be reason for caution against its use, assuming that one may hold different aspirations in the future that are disabled by the enhancement.
This concern has similar scope to what some philosophers referr to as the principle of prudence, whereby decisions about actions are based on what are more likely to lead to long-term benefits, rather than short term gains. Thus, if a human enhancement were to promote success early in life, but lead to serious disability later, then one may caution against its use. A typical example of such ehanements may be the use of drugs that illicit a short term gain – perhaps stimulating creativity or physical strength – but which may also imply long term health riskss. In these cases, Feinberg (2007) argues that modifications which violate the principle of preseving as open a future as possible should be restricted.
Morphological Freedom
Despite these various concerns, some authors have argued on behalf of what Sandberg (2001) describes as 'morphological freedom', a concept that should trump other ethical preoccupations. In this case, the argument favours autonomy, arguing further that it should be a human right, rather than something that the state should aim to govern.
In closing, it is important to recognize that individual actions take place within specific social contexts, which can, in turn, dictate how one evaluates the moral content of any human enhancement. This may appear to be a morally relativist position, but it in fact acknowledges the possibility of universal moral rules, while recognizing that not all decisions are taken within the same conditions. This is best explained by providing two examples where the same kind of human enhancement is used. Thus, consider the creation of a new prosthetic leg, which may be used by two different people, one is an elite athlete, the other is not. If one assumes that, in both cases, the prosthetic device can make a person run much faster than any other person – whether or not they are considered disabled – then it is immediately apparent how, for the athlete, this may pose an ethical dilemma which is not evident for the non-athlete. The latter is interested in functionality, day to day living and is not in direct competition with any other person whom may feel that the new limb creates some form of unfairness. However, the athlete is engaged in a practice whereby the interests of the other participants may be frustrated by the use of this new technological device, in part because a prior agreement had been made between parties about how they would participate.
If one extends this case to other enhancements, it quickly becomes apparent how the conditions of the debate change. For example, consider the use of a cognitive enhancer, such as modafinil, which is used to treat narcolepsy, but which may be used in a non-therapeutic way to keep people alert for longer in periods of extreme tiredness. In this case, the athlete might, again, be undertaking a morally dubious practice, if they use it to improve their performance in competition. Yet in this case, the non-athlete may also be violating some sense of social justice, since it is difficult to claim that they are not, in some broad sense, in competition with other people in society. Whether the non-athlete is going to work a day job in bank, or is a Grand chess Master, the wonder drug disturbs the conditions of the competition whereby those who are not using it may be placed at a disadvantage. The banker may benefit from the enhancement in terms of winning promotion within his job or annual bonuses, whereas the chess Master may win global renown through beating all other opponents. Each is morally relevant and morally problematic.
The context of the ethical debate changes further when considering, say, the enhancement of a military personnel, where gaining an advantage over the opposition is less of an ethical matter and more of a strategic necessity. In this case, the ethics of war may permit the use of such enhancement technologies, but there may be good reasons for why the state should not permit its government to require soldiers to undertake such modifications, since this may undermine the soldier's right to choose or personal autonomy. Yet, one may argue that, by necessity, military personnel operate within a context where there is an acceptance of diminished autonomy – following orders etc, - perhaps justifying such use. Moreover, the use of drugs that otherwise would be unethical to give to a healthy subject may be life-saving in a military context. For example, a stimulant may allow a soldier in a period of sleep deprivation to continue their mission or avoid capture. In this case, one may debate the legitimacy of their having placed in this situation, but when faced with the circumstances, the ethical compromise of using a drug versus the fact of being captured seems a reasonable trade off.
There are many examples of human enhancement where the perceived benefits depend on the context. As such, one of the challenges in knowing whether it is wise to enhance is having certainty over the kinds of lifestyles that people may seek to lead. For instance, the agonizing practice of leg-lengthening that is increasing within China might be valuable if you aspire to be a Chinese politician – which stipulates a minimum height of 5ft 7in for men and 5ft 3in for women (Watts, 2004), but has limited value if one aspires to be a jockey. While there are undoubtedly very few Chinese politicians who subsequently seek to become jockeys, it is important to recognize that many enhancements will also close off the enjoyment of certain other lifestyle opportunities.
Professional Concerns
Human enhancements that rely on some form of scientific or technological adaptation also engage a range of professionals, whose conduct is governed by strict ethical codes. This may encompass the way in which research and development is underpinned by procedures that are necessary to follow before any particular technology can be used within society. Indeed, this is a crucial dimension of the human enhancement debate, as many of the ways in which people could enhance themselves will involve adapting interventions that are otherwise restricted to just therapeutic use by established regulatory authorities. Thus, in order for enhancement to be possible, it will be necessary to achieve consensus on the value of applying an otherwise medical intervention to the non-therapeutic or enhancing context. Clearly, this has taken place in some areas of life, particularly cosmetic or reconstructive surgery, which is a thriving commercial industry, though it is less clear that similar decisions would be made any time soon in many other areas, such as the use of known pharmaceutical products. Indeed, the challenge here is that one of the cornerstones of medical research is that it does not involve healthy subjects. In the case of enhancement, it may be necessary to develop products that are tested with otherwise health subjects in order to ensure they are safe for use. Alternatively, it may be that the way in which enhanced humans come into being will be through the use of therapeutic interventions – that is, for unhealthy subjects – whereby the intervention is able to elevate the level of functionality beyond the biostatistic norm.
One of the challenges with deciding whether a professional is in violation of their code of ethics when facilitating human enhancement is that the merit of the enhancement is ambiguous. For instance, it is reasonably uncontroversial to say that laser eye surgery is both beneficent and non-malfeasance and that he overall result improves the life of the client/patient. However, even laser-eye surgery has benefits for only a limited number of years after which the ageing process will most likely degrade vision inn such a way as to negate the positive effect of the surgery. Ion this case, there seems a reasonable trade-off. However, if the laser eye surgery were to exacerbate the degradation arising from the ageing process, then its merit may further be brought into question. Here again, one must expect that reasonable standards of safety and cost-benefit analyses are undertaken, but it is for the client to decide, which level of risk they choose to accept. In short, in the absence of certainty, individual autonomy is elevated as the guiding principle in such decisions.
Societal Concerns
Perhaps the primary ethical issues that govern the use of human enhancements relate to the societal governance of their use. Thus, in order for a number of enhancements to be available, it will require a range of decision-makers to develop policy that supports their utilization and will imply a social system whereby people can have affordable access to them. This is true whether or not the intervention involves a professional facilitator – as in the case of surgery – or the simple taking of an over-the-counter pill. In each case, some form of governance is likely, insofar as the effects of the modification are likely to affect the overall health fortunes of the individual.
Of course, if there are no harms at all arising from the enhancement, then this assumption will disappear and an entirely different structure of regulation will be required, if required at all. In any case, accepting that societies are likely to set rules around the use of enhancements, these decisions will precede most peoples decision about whether or not to use them. This aspect is also the reason why the development of human enhancements concerns a global community, as it is increasingly possible for people to undertake medical tourism to simply visit a country where the enhancement rules are more liberal. In such a situation, the ability to maintain a restrictive domestic policy may be more socially divisive than permitting such use.
Fairness & Justice
One of the initial concerns that is raised from a societal perspective about human enhancement is how they would be financed. Underpinning this concern are questions about fairness and justice. Thus, in a world where national health care systems struggle to make ends meet and where private health is often criticised to be overall detrimental to the common good, the prospect of using national funds to enhance people may seem to much of a stretch of resources and, potentially, contrary to the principle of social solidarity. Certainly, one would not expect the needs of people seeking enhancements to trump those who are seeking some kind of medical treatment for dysfunction or suffering arising from a health problem. However, one may argue further that making people better than well and, indeed, ensuring future generations are more resistant to illness, would, in the long term, ease the social burden of health care. On this basis, one may argue that a society cannot afford not to enhance humanity. This being true, human enhancements would be offered to all people on a similar basis to how national health care is offered, following principles of distributive justice. In turn, this would alleviate the concern about social divisions between wealthy and poor, which may otherwise be exacerbated by a society of privately funded enhancements. By implication, it would go some way to avoiding a situation where people are discriminated against on the basis of poor genetics, since enhancements will be available to all.
The Yuck Factor
A further societal concern that is often invoked is that changing humanity by human enhancement would undermine some essential quality of our human identity that we would wish to preserve. This may otherwise be described as the argument from naturalness (Barilan 2001; Reiss and Straughan, 1996; Takala 2004), though there are subtle differences. Thus, a concern that human enhancement may be contrary to some natural essence may not imply a revulsion for artifice, but it may reveal an underlying intuition that there is something about human biology that ought not be changed for fear of altering something that either corrupts some fundamental part of human identity. Even if the 'yuck factor' is a difficult to articulate, some philosophers have argued that such a deep-seated intuition has moral weight when deciding whether or not to undertake biological modifications such as enhancements. Notably, Kass (1997) describes this as 'the wisdom of repugnance', though it is a view that many have criticized. Probing further into this concern, one finds a reliance on such concepts as 'human dignity' which are invoked to claim that there is a fundamental quality to human sensibility that must both be preserved by elevating certain rights, but which may also be violated by altering biology too much (Fukuyama 2002).
There are other moral concerns that are often folded into this fear over biotechnological change, notably the view that undertaking such changes is akin to 'Playing God'. In this case, the moral anxiety describes a concern that undertaking such changes oversteps some sense of the delimited authority of humanity over its evolutionary trajectory. In short, the argument states that since humans have no oversight in their own evolutionary trajectory, it would be foolish to attempt actions that would, as Harris (2007) describes it, enhance evolution. Arguments of this kind of often – mistakenly I would argue – discussed in the context of eugenics and the idea that state wide policies to engineer people would invoke the kinds of moral monstrosities that are associated with Nazi germany, human experimentation and the general disregard for certain kinds of people over others.
Practical Concerns
There are a number of practical ethical probems associated with human enhacnement that desire special mention. For example, if societies are unable to impleent effective regulation of human enhancements, then this may provide a moral reason for restricting use. One form of argument in this area is the 'slippery slope' argument, which states that it would be morally undesirable to provide permission to undertake the desirable action X, if the regulatory structure is unable to prevent claims to also undertake the socially undesirable action Y (Burg 1991; Resnik 1994). Equally, an inability to restrict the scrutiny of the state may be a further reason for moral concern over enhancements. For example, the use of memory enhancements may be desirable for some people, but it may be undesirable to permit the state to require an individual to undertake a memory enhancement in order to pursue some national interest. Wagenaar (2008) discusses this case in the context of judicial hearings where they may be an argument favouring forced memory enhancements in order to ascertain the truth about a crime. Finally, there may also be reasons of safety that lead to restrictions of use, such as the levels of toxicity that may be released into the environment when using human enhancements or the possible, unforeseen risks associated with any particular use.
The Zero Sum Problem
A final concern relates to the efficacy of human enhancements, though not from an individualist perspective. Indeed, while it is possible that increasing height or speed could yield benefits for the individual concerned, but in a society where all people undertake similar enhancements, then the overall benefit is nullified. Instead, the long term consequence of this permissive enhancement culture is simply a shift in what is biologically normal and in an economy where having exceptional talents or capabilities is required in order to flourish, the eventual outcome of a society where all have access to enhancements is a zero-sum game, where there is, in fact, little change to the overall fortunes that people experience.
Of course, not all enhancements are like this. A world where everyone is more intelligent will have a cumulative benefit for society, unless of course there is a trade-off between characteristics, say where increased capacity for logic is to the detriment of an ability to empathize with people or where altruism decreases. While there is no evidence to support this concern, it is important to be mindful of the complexity of some neurological constructs – such as intelligence – which may imply improving the functionality of a number different forms (emotional intelligence, rational intelligence), before one can reasonably claim that it has been improved.
Conclusion: What should we do?
To conclude, there remain a number of practical and moral obstructions to the widespread use of many human enhancements. Many cultures still struggle to regulate the health care system for the purpose of making people well and this should provide caution to those who consider there to be a simple route towards an effective regulate of human enhancements. When establishing ethical guidelines, it is crucial to clarify the perspective from which the question is being asked, in order to understand the breadth of the ethical concern invoked by human enhancements and the scope of answers. If the matter is of personal morality alone, then it will not be necessary or ethical appropriate to involve professionals within such choices. In turn, a matter that concerns society at large should take precedence over individual morality.
At all levels, it is crucial to establish some general principles that govern ethical conduct of human enhancement. These should involve widespread, independent consultation and investment into research principles. Equally, one may derive some minimal conditions of ethical practice that are informed by other forms of medical intervention, such as the promotion of autonomy, concern about justice and welfare and so on. Finally, perhaps the most pressing issue is the degree to which the use of human enhancements requires a global response, rather than just domestic policy. While such work has become from research leadership in a number of countries around the world, there is still much more to achieve before either a clear sense of the global implications of human enhancement has been achieved, as well as a reasonable strategy has been formulated.
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