Question: Genetic And Emhnacement1. Distinguish Between Genetic Treatment And Enhancement.2. Summarize Glannon, Savulescu, And Sandel’s Reasons For Considering Genetic Enhancement Ethically Acceptable Or Unacceptable.3. Explain Your Own Position In Relation To Theirs.4. Finish Your Response By Briefly Discussing One Technological Development That Creates Ethical …

624 PART 3: LIFE AND DEATH Reich, the treasury secretary in President Clinton’s first administration, is just one example of how one can achieve very much in life despite diminu- tive stature. If a child’s stature significantly limited his functioning and opportunities, then growth hormone injections should be considered therapeu tic treatment. If his stature were not so limiting, then the injections should be considered enhancement Admittedly, there is gray area near the baseline of adequate functioning where it may be difficult to dis- tinguish between treatment and enhancement, Ac cordingly, we should construe the baseline loosely or thickly enough to allow for some minor deviation above or below what would be considered normal functioning. An intervention for a condition near the baseline that would raise one’s functioning clearly above the critical level should be considered an en hancement. An intervention for a condition making one’s functioning fall clearly below the baseline, with the aim of raising one’s functioning to the critical level, should be considered a treatment. For example, an athlete with a hemoglobin level slightly below the norm for people his age and mildly anemic may want to raise that level significantly in order to be more competitive in his sport. To the extent that his actual hemoglobin level does not interfere with his ordinary physical functioning an intervention to significantly raise that level would be an instance of enhancement In contrast, for a child who has severe thalassemia and severe anemia, with the risk of bone abnormali- ties and heart failure, an intervention to correct the altogether different from the example of immune system enhancement. There would be no dimin ing marginal value in the degree of competiti advantage that one could have over others for the social goods in question and presumably no limit to the value of enhancing the physical and mental pacities that would give one this advantage. Not having access to the technology that could man late genetic traits in such a way as to enhance the capacities would put one at a competitive disadvan tage relative to others who would have access to it Advancing an argument similar to the one wed by those who reject the treatment-enhancement dis tinction, one might hold that competitive goods col lapse the categorical distinction between correcting deficient capacities and improving normal ones. Thi is because competitive goods are continuous, coming in degrees, and therefore the capacities that enable one to achieve these goods cannot be thought of a either normal or deficient. Nevertheless, to the extent that any form of genetic intervention is motivated by the medical and moral aim to enable people to have adequate mental and physical functioning and fait equality of opportunity for a decent minimum level of well-being, the goods in question are not compe the but basie. In other words, the aim of any medical intervention by genetic means is to make people better off than they were before by raising or restoring them to an absolute baseline of normal physical and mental functioning, not to make them comparatively better off than others. Competitive goods above the baseline may be continuous; but the basic goods that enable someone to reach or remain at the baseline are not. Given that these two types of goods are distinct and that they result from the distinct aims and pras tices of enhancement and treatment, we can affirm that enhancement and treatment can and should be treated separately. We can uphold the claim that the purpose of any genetic intervention should be to treat people’s abnormal functions and restore them to normal level, not to enhance those functions that af disorder would be an instance of treatment. The main moral concern about genetic enhance ment of physical and mental traits is that it would give some people an unfair advantage over others with respect to competitive goods like beauty, socia bility, and intelligence… Enhancement would be unfair because only those who could afford the tech nology would have access to it, and many people are financially worse of than others through no fault of their own. Insofar as the possession of these goods gives some people an advantage over others in ca reers, income, and social status, the competitive nature of these goods suggests that there would be no limit to the benefits that improvements to physical and mental capacities would yield to those fortunate ready are normal gave some people an advantage over others in Poll enough to avail themselves of the technology. This is As I have mentioned, genetic enhancement that sessing competitive goods would entail considerable unfairness. Alikely scenario would be one in which parents paid to use expensive genetic technology to raise the cognitive ability or improve the physical could end up being self-defeating on a collective Chapter 9: Genetic Choices 625 beauty of their children. This would give them an advantage over other children with whom they boosting children’s mental capacity on a broad rative would compete for education, careers, and income. level. More specifically, one probable side-effect of Children of parents who could not afford to pay for the technology would be at a comparative disadvan and affective impairment in some of the children who tage. Even if the goods in question fell above the received the genetic enhancement. The net social cost pormal functional baseline, one still could maintain of using the technology would outweigh any social that such an advantage would be unfair. It would advantage of everyone using it. If no one is made depend on people’s ability to pay, and inequalities in better off than others in their possession of social income are unfair to the extent that they result from goods, but some people are made worse off than they were before in terms of their mental functioning. some factors beyond people’s control. We could not appeal to the notion of a genetic reason for prohibiting collective geneticenhancement then the net social disadvantage would provide a lottery to resolve the problem of fairness regarding genetic enhancement. For, as I argued in the last sec There is another moral aspect of enhancement that should be considered. I have maintained that in tion (of Genes and Future People], such a lottery is equalities above the baseline of normal physical and better suited to meeting people’s needs than their mental functioning are of no great moral importance preferences, and enhancements correspond to peo- and may be neutral on the question of fairness. Al- ple’s preferences. Moreover, a lottery might only ex- though equality and fairness are closely related, one acerbate the problem by reinforcing the perception does not necessarily imply the other. Again, fairness of unfairness, depending on how losers in the lot pertains to meeting people’s needs. Once these needs tery interpreted the fact that others won merely as a have been met, inequalities in the possession of result of a random selection. One suggestion for re- goods relating to preferences are not so morally sig. solving the fairness problem (short of banning the nificant. Thus, if the idea of an absolute baseline im- plies that people’s basic physical and mental needs use of the technology altogether) would be to make have been met, and if people who are comparatively genetic enhancement available to all. Of course, how better or worse of than others all have functioning at this system could be financed is a question that or above the baseline, then any inequalities in func admits of no easy answer. But the more important tioning above this level should not matter very much substantive point is that universal access to genetic morally. If this is plausible, then it seems to follow enhancement would not be a solution. Indeed, the that there would be nothing unfair and hence noth- upshot of such access would provide a reason for ing morally objectionable about enhancements that prohibiting it. made some people better off than others above the would mean that many competitive goods some Universal availability of genetic enhancement baseline. Nevertheless, this could undermine our belief in the importance of the fundamental equality people had over others would be canceled our colle of all people, regardless of how well off they are in tively. The idea of a competitive advantage gradually absolute terms. Equality is one of the social bases of would crode, and there would be more equality self-respect, which is essential for social harmony Imong people in their possession of goods. There and stability. Allowing inequalities in access to and would not be complete equality, however, Differing parental attitudes toward such goods as education could mean differences in the extent to which cogni Vive enhancement was utilized. Some parents would be more selective than others in sending their chil dren to better schools or arranging for private tutors So there still would be some inequality in the general outcome of the enhancement. But quite apart from this, the process of neutralizing competitive goods possession of competitive goods at any level of func- tioning or welfare might erode this basis and the ideas of harmony and stability that rest on it. Al though it would be difficult to measure, this type of social cost resulting from genetic enhancement could constitute another reason for prohibiting it. Yet, suppose that we could manipulate certain genes to enhance ournonicompetitive virtuous traits, 1 out of points 626 PART 3: LIFE AND DEATH would not. Second, if we tried to remedy the firs such as altruism. generosity and compassion. problem by making genetic enhancement univer Surely, these would contribute to a stable, well- sally accessible, then it would be collectively sdf. society and preserve the principle of fair equality of opportunity. Nothing in this program defeating. Although much competitive unfairnes at the individual level would be canceled out at the would be incompatible with the goal of medicine as collective level, there would be the unacceptable the prevention and treatment of disease. But it would social cost of some people suffering from adverse threaten the individual autonomy essential to us as cognitive or emotional effects of the enhancement moral agents who can be candidates for praise and Third, inequalities resulting from enhancements blame, punishment and reward. What confers moral above the baseline of normal physical and mental worth on our actions, and indeed on ourselves as functioning could threaten to undermine the con agents, is our capacity to cultivate certain disposi- viction in the fundamental importance of equality tions leading to actions. This cultivation involves the exercise of practical reason and a process of critical as one of the bases of self-respect, and in turn social self-reflection, whereby we modify, eliminate, or re- solidarity and stability. Fourth, enhancement of inforce dispositions and thereby come to identify noncompetitive dispositions would threaten to me with them as our own. Autonomy consists precisely dermine the autonomy and moral agency essential in this process of reflection and identification. It is to us as persons. the capacity for reflective self-control that enables us to take responsibility for our mental states and the NOTES actions that issue from them. Given the importance 1. Jon Gordon, “Genetic Enhancement in Humans, Sier of autonomy, it would be preferable to have fewer vir 283 (March 26, 1999): 2013-2014- tuous dispositions that we can identify with as our 1. Eric Jengst. “Can Enhancement Be Distinguished from own than to have more virtuous dispositions im- Prevention in Genetic Medicinel.” Journal of Medicine planted in us through genetic enhancement. These Philosophy 2 (1997) 135-142, and “What Does Enhance would threaten to undermine our moral agency be- ment Meant.” in Erik Parens, ed., Enhancing Human Thai cause they would derive from an external source. Eritical and Social Implications (Washington, DC Even if our genes could be manipulated in such a way Georgetown University Press, 1998: 27-47, at 23. Ale that our behavior always conformed to an algorithm Dan Brock, “Enhancements of Human Function: Some Distinctions for Policymakers.” Ibid., 48-69 for the morally correct course of action in every situ- ation, it is unlikely that we would want it. Most of us 3. The Ethics of Human Gene Therapy (New York: Odford University Press, 1997), 130, Instead of distinguishing would rather make autonomous choices that turned tween treatments and enhancements, Walters and Palmer out not to lead to the best courses of action. This is because of the intrinsic importance of autonomy and distinguish between health-related and non-health-related enhancements. But I do not find this distinction to be very making our own choices under uncertainty. The dis- Brock points this out in “Enhancements of Human Function. 59. Marc Lappe makes a more compelling can for the same point in The Tao of Immunology (New York: the moral growth and maturity that come with helpful. Penum Press, 1997) positions with which we come to identify, imperfect as they may be, are what make us autonomous and responsible moral agents. Enhancing these mental states through artificial means external to our own exercise of practical reason and our own process of identification would undermine our autonomy by making them alien to us In sum, there are four reasons why genetic en hancement would be morally objectionable. First, it would give an unfal advantage to some people over others because some would be able to pay for 5. Kavka develops and defends the idea that competi goods are continuous in “Upside Risks Social Conse quences of Benecial Biotechnology. in Carl Cracord. Are Genes Us? The Social Consequences of the New New Trunswick, NJ: Rutgers University Press, 1994 & Kavka, “Upside Risks. 167. Also, Brock, “Enhancen of Human Function.” 60, and Buchanan et al. From to Choice (New York: Cambridge University Press, cool 15-179. & 164-165 expensive enhancement procedures while others chia. 6. 7. Rawls makes this point in A Theory of whic (Cambridge, MA: Harvard Belknap Press, 1971).7-Il Chapter : Genetic Choices 627 and in Social Unity and Primary Goods.” in A. Sen and Williams, eds., Utilitarianism and Beyond (Cambridge: Cambridge University Press, 1982). 16. See also Daniels, just Health Care (New York: Cambridge University Press, 1985) & Walters and Palmer present this thought-experiment in Drawing on the work of Lind Trilling and Charles Taylor Carl Elliott discusses cognitive and effective enhancements that undermine what he calls the ethics of authenticity in *The Tyranny od Happiness Ethics and Cosmetic Poychophar macology,” in Parens, Enhancing Human Traits. 1097-188. Also relevant to this issue is Harry Frankfurt. “Identification and Externality. in Frankfurt, The Importance of What We Care About (New York: Cambridge University Press, 1918- The Estics of Human Gene Therapy. 123-128. As they note. Should There Be? (Harmondsworth: Penguin, 1984) Jonathan Glover introduced this idea in What sort of People Genetic Interventions and the Ethics of Enhancement of Human Beings JULIAN SAVULESCU Julian Savulescu is an Australian philosopher and bioethicist and the Vehiro Profes- sor of Practical Ethics at the University of Oxford. Savulescu explores the morality of genetic enhancement, presenting three arguments in favor of the ethical use of enhancement while critiquing the main objections to it. He asserts that not only is enhancement permissible, it is a moral obligation Should we use science and medical technology not just to prevent or treat disease, but to intervene at the most basic biological levels to improve biology and enhance people’s lives? By enhance, I mean help them to live a longer and/or better life than normal. There are various ways in which we can en- hance people but I want to focus on biological en hancement, especially genetic enhancement There has been considerable recent debate on the ethics of human enhancement. A number of promi- hent authors have been concerned about or critical of the use of technology to alter or enhance human beings.citing threats to human nature and dignity as ne basis for these concerns. “The President’s Council Report entitled Beyond Therapy was strongly critical of human enhancement. Michael Sandel, in a widely discussed article, has suggested that the problem genetic enhancement is in the hubris of the de signing parents, in their drive to master the mystery of birth…. [I]t would disfigure the relation between parent and child, and deprive the parent of the humility and enlarged human sympathies that an openness to the unbidden can cultivate…. The promise of mastery is flawed. It threatens to banish our appreciation of life as a gift, and to leave us with nothing to affirm orbehold outside our own will.” Frances Kamm has given a detailed rebuttal of Sandel’s arguments, arguing that human enhance ment is permissible. Nicholas Agar, in his book. Liberal Eugenics, argues that enhancement should be permissible but not obligatory. He argues that what distinguishes liberal eugenics from the objec. tionable eugenic practices of the Nazis is that it is not based on a single conception of a desirable genome and that it is voluntary and not obligatory. … I want to argue that far from being merely permissible, we have a moral obligation or moral reason to enhance ourselves and our children. Indeed, we have the same kind of obligation as we have to treat and prevent disease. Not only can we with enhance, we should enhance…. From Julian Savulescu, “Geneti Interventions and the Ethics of Enhancement of Human Beings in Oafand Handbook of Bioethics, ed. Honnie Steinbock (Oxford Odlord University Press, 2007). pp. 516-35 (httpol www The Ethics of Enhancement I will now give three arguments in favor of en- hancement and then consider several objections. people and increase their opportunities in life. We training are all used to make our children better train children to be well behaved, co-operative and e looking at way intelligent. Indeed, researchers are to make the environment more stimulating for 628 PART 3: LIFE AND DEATH First Argument for Enhancement: Choosing Not to Enhance Is Wrong Consider the case of the Neglectful Parents. The Neglectful parents give birth to a child with a spe cial condition. The child has a stunning intellect but requires a simple, readily available, cheap dietary supplement to sustain his intellect. But they neglect the diet of this child and this results in a child with a stunning intellect becoming normal. This is But now consider the case of the Lazy Parents. young children to maximize their intellectual de velopment. But in the study of the rat model of Huntington’s Disease, the stimulating environment acted to change the brain structure of the rats. The drug Prozac acted in just the same way. These en ronmental manipulations do not act mysteriously clearly wrong They have a child who has a normal intellect but if they alter our biology. The most striking example of this is a study of they introduced the same dietary supplement, the rats which were extensively mothered and rats who child’s intellect would rise to the same level as the were not mothered. The mothered rats showed child of the Neglectful Parent. They can’t be both netic changes (changes in the methylation of the ered with improving the child’s diet so the child DNA) which were passed on to the next generation. remains with a normal intellect. Failure to institute As Michael Meaney has observed, “Early experience dietary supplementation means a normal child fails to achieve a stunning intellect. The inaction of the can actually modify protein-DNA interactions that Lazy Parents is as wrong as the inaction of the Ne- regulate gene expression.” More generally, environ glectful Parents. It has exactly the same conse- mental manipulations can profoundly affect biol- quence; a child exists who could have had a stunning ogy. Maternal care and stress have been associated intellect but is instead normal. with abnormal brain (hippocampal) development, Some argue that it is not wrong to fail to bring involving altered nerve growth factors and cogni- about the best state of affairs. This may or may not be tive, psychological and immune deficits later in life. the case. But in these kinds of case, when there are no Some argue that genetic manipulations are dif- other relevant moral considerations, the failure to introduce a diet which sustains a more desirable state ferent because they are irreversible. But environ is as wrong as the failure to introduce a diet which mental interventions can equally be irreversible. brings about a more desirable state. The costs of inac- Child neglect or abuse can scar a person for life . I tion are the same, as are the parental obligations. may be impossible to unlearn the skill of playing If we substitute “biological intervention for the piano or riding a bike, once learned. One ma “diet,” we see that in order not to wrong our chil- be wobbly, but one is a novice only once. Just as the dren, we should enhance them. Unless there is example of mothering of rats shows that environ something special and optimal about our children’s mental interventions can cause biological changes which are passed onto the next generation, so to can environmental interventions be irreversible, or very difficult to reverse, within one generation. Why should we allow environmental manipult manipulations? What is the moral difference be tween producing a smarter child by immersing that child in a stimulating environment, giving the child a drug or directly altering the child’s brain or istry is Prozac. It is a serotonin reuptake inhibitor One example of a drug which alters brain chent Early in life it acts as a nerve growth factor. But may alter the brain early in life to make it physical, psychological or cognitive abilities, or something different about other biological inter- ventions, it would be wrong not to enhance them, Second Argument: Consistency Some will object that, while we do have an obliga. tion to institute better diets, biological interven tions like genetic interventions are different (from) dietary supplementation. I will argue that there is no difference between these interventions In general, we accept environmental interven tions to improve our children. Education, diet and genes logical effects. prone to stress and anxiety later in life, by altering the pleasures outweigh the risks of smoking, and receptor development Science, 29 October 2004). Chapter 1 Genetic Choice 620 People with a polymorphism that reduced their se rotonin activity were more likely than others to so on. Life is about managing risk to health and life become depressed in response to stressful experi to promote well-being Beneficence–the moral obligation to benefit ences (Science, 18 July 2003). Both drugs like Prozac and maternal deprivation may have the same bio- people-provides a strong reason to enhance people insofar as the biological enhancement increases their chance of having a better life. But can biologi- If the outcome is the same, why treat biological cal enhancements increase people’s opportunities manipulation differently from environmental ma. for well-being? There are reasons to believe they nipulation? Not only may a favorable environment might improve a child’s biology and increase a child’s Many of our biological and psychological char- opportunities, so too may direct biological inter- acteristics profoundly affect how well our lives go ventions. Couples should maximize the genetic op- In the 1960s Walter Mischel conducted Impulse portunity of their children to lead a good life and control experiments where 4-year-old children were a productive, cooperative social existence. There is left in a room with one marshmallow, after being no relevant moral difference between environmen- told that if they did not eat the marshmallow, they could later have two. Some children would eat it as tal and genetic intervention. soon as the researcher left, others would use a vari ety of strategies to help control their behavior and Third Argument: No Difference to Treating ignore the temptation of the single marshmallow. Disease A decade later, they reinterviewed the children and If we accept the treatment and prevention of dis found that those who were better at delaying grati- case, we should accept enhancement. The goodness fication had more friends, better academic perfor of health is what drives a moral obligation to treat mance and more motivation to succeed. Whether or prevent disease. But health is not what ultimately the child had grabbed for the marshmallow had a matters–health enables us to live well; disease pre- much stronger bearing on their SAT scores than did their 10 vents us from doing what we want and what is good. Health is instrumentally valuable– valuable as a Impulse control has also been linked to socio- economic control and avoiding conflict with the law. resource that allows us to do what really matters The problems of a hot and uncontrollable temper can that is lead a good life. be profound What constitutes a good life is a deep philo Shyness too can greatly restrict a life. I remem sophical question. According to hedonistic theories , ber one newspaper story about a woman who what is good is having pleasant experiences and blushed violet every time she went into a social situ being happy. According to desire fulfillment theo ation. This led her to a hermitic, miserable exis ries, and economics, what matters is having our tence. She eventually had the autonomic nerves to preferences satisfied. According to objective theories, her face surgically cut. This revolutionized her life certain activities are good for people developing and had a greater effect on her well-being than the deep personal relationships, developing talents, understanding oneself and the world, gaining Buchanan and colleagues have discussed the value of all purpose goods.” These are traits knowledge, being a part of a family, and so on. We which are valuable regardless of which kind of life need not decide on which of these theories is cor a person choose to live. They give us greater all Tect to understand what is bad about ill health. around capacities to live a vast array of lives. Exam. Disease is important because it causes pain is not ples include intelligence, memory, self-discipline, we want and stops us engaging in those active patience, empathy, a sense of humor, optimism ties that giving meaning to life. Sometimes people trade health for well-being-mountain climbers take on risk to achieve, smokers sometimes believe that treatment of many diseases. what and just having a sunny temperament. All of these tal poin 630 PART 3: LIFE AND DEATH characteristics–sometimes may include virtues- may have some biological and psychological basis capable of manipulation with technology Technology might even be used to improve our moral character. We certainly seek through good instruction and example, discipline and other methods to make better children. It may be possible to alter biology to make people predisposed to be more moral by promoting empathy, imagination, sympathy, fairness, honesty, etc. Insofar as these characteristics have some ge- netic basis, genetic manipulation could benefit us. There is reason to believe that complex virtues like fairmindedness may have a biological basis. In one famous experiment, a monkey was trained to per form a task and rewarded either a grape or piece of cucumber. He preferred the grape. On one occa- sion, he performed the task successfully and was given a piece of cucumber. He watched as another monkey who had not performed the task was given a grape. He became very angry. This shows that even monkeys have a sense of fairness and desert- or at least self-interest! At the other end, there are characteristics which we believe do not make for a good and happy life. One Dutch family illustrates the extreme end of the spectrum. For over 30 years this family recognized that there were a disproportionate number of male family members who exhibited aggressive and criminal behavior. This was characterized by ag- gressive outbursts resulting in arson, attempted rape and exhibitionism. The behavior has been doc. umented for almost forty years ago by an unaffected maternal grandfather who could not understand why some of the men in his family appeared to be prone to this type of behavior. Male relatives who did not display this aggressive behavior did not ex press any type of abnormal behavior. Unaffected males reported difficulty in understanding the be. typical IQ of about 85 (females had normal intelli gence). When a family tree was constructed, the pattern of inheritance was clearly X-linked tecer sive. This means, roughly, that women can carry the gene without being affected: 50 percent of men at risk of inheriting the gene get the gene and are al fected by the disease. Genetic analysis suggested that the likely defer tive gene was a part of the X chromosome known as the Monoamine Oxidase (MAO) region. The MAO region codes for two enzymes which assist in the breakdown of neurotransmitters. Neurotransmit ters are substances that play a key role in the con duction of nerve impulses in our brain. Enzymes like the monoamine oxidases are required to de grade the neurotransmitters after they have per formed their desired task. It was suggested that the monoamine oxidase activity might be disturbed in the affected individuals. Urine analysis showed a higher than normal amount of neurotransmitters being excreted in the urine of affected males. These results found were consistent with a reduction in the functioning of one of the enzymes (monoamine oxidase A) How could such a mutation result in violent and antisocial behavior? A deficiency of the enzyme results in a buildup of neurotransmitters. These abnormal levels of neurotransmitters result in cessive, and even violent, reactions to stress. This hypothesis was further supported by the find ing that genetically modified mice which lack this enzyme are more aggressive. This family is an extreme example of how gere can influence behavior. This mutation has only been isolated in this family. Most genetic contribe tions to behavior will be weaker predispositions Yet there may be some association between geno and behavior which results in criminal prosecution How could such information be used? Some U.S. which stated that their genes caused them criminals have attempted a “genetic defense in the commit the crime. This has never succeeded. How ever, it is clear that a couple should be allowed to use this test to select offspring who do not have the And if interventions were available, it might tation which predisposes them to act in this way and other antisocial behavior. havior of their brothers and cousins. Sisters of the males who demonstrated these extremely aggres- sive outbursts reported intense fear of their broth- ers. The behavior did not appear to be related to environment and appeared consistently in different parts of the family, regardless of social context and degree of social contact. All affected males were also found to be mildly mentally retarded with a Chapter 1: Genetic Choices 631 what benefited society. Modern eugenics in the form of testing for disorders, such as Down syndrome. occurs very commonly but is acceptable because it is voluntary, gives couples a choice over what kind of child to have and enables them to have a child with the greatest opportunity for a good life. There are four possible ways in which our genes and biology will be decided 1. Nature of God 2. “Expertsº-philosophers, bioethicists, psychologists, scientists 3. “Authorities”–government, doctors 4. By people themselves –liberty and autonomy It is a basic principle of liberal states like the UK rational to correct it. Children without this muta- tion have a better chance of a better life. “Genes, Not Men, May Hold the key to Female Pleasure ran the title of one recent newspaper ar- ticle. It r