Enhancement Uses of Medical Technology
ENHANCEMENT USES OF MEDICAL TECHNOLOGY•••
In bioethics, one frequently encounters the belief that there is an important moral distinction between using biomedical tools and products to combat human disease and attempting to use them to "enhance" human traits. Thus, people argue that using biosynthetic human growth hormone to treat an inborn growth-hormone deficiency is praiseworthy, but that the use of the same product to increase the height of a short but hormonally normal child is not (Daniels, 1992). Similarly, while the use of human gene-transfer techniques to treat disease enjoys widespread support from secular and religious moral authorities, a line is usually drawn at using the same protocols to attempt to improve upon otherwise healthy traits (Anderson; Baird).
Even those unwilling to condemn the enhancement uses of biomedicine outright generally concur that ethics demands that therapeutic applications of these tools be given priority for research and development (Walters and Palmer). As a result, this distinction has been enshrined in policies at both professional and governmental levels, and it continues to inform much of the public discussion of new biomedical advances (Parens, 1998). The distinction is explicated in several different ways, however, which have different merits as moral boundary markers for medical research and practice. In fact, it often seems in danger of evaporating entirely under conceptual critiques even before the question of its moral merits is entertained.
Professional Domain Approaches
One approach to the enhancement/treatment distinction is to define it in terms of the accepted limits of professional medical practice. Under this view, treatments are any interventions that physicians and their patients agree are useful and proper, while enhancements are simply interventions that are considered to fall beyond a physician's professional purview. Thus, physician-prescribed physical therapy to improve muscle strength would be considered legitimate medical treatment, while weight lifting under a coach's supervision to achieve a particular physique would be considered an enhancement. This view resonates well with a number of contemporary social-scientific critiques of bio-medicine, which suggest that medicine has no natural domain of practice beyond that which it negotiates with society (Good). It also provides a simple normative lesson for professionals concerned about their obligations in specific cases. Given medicine's fundamentally patient-centered ethos, one takes one's cues from the patient's value system, and thus negotiates toward interventions that can help achieve the patient's vision of human flourishing (Engelhardt).
Unfortunately, these same features also deny this approach the ability to be of help to those attempting to use the treatment/enhancement distinction in order to regulate biomedical research. Some argue that medicine's lack of an essential domain of practice means that a coherent distinction between medical and nonmedical services can never be drawn in the first place (Davis). Others accept the distinction between treating and enhancing, but question traditional values of medicine by arguing that privileging treatment over enhancement is itself wrong (Silvers). Still others argue that, for psychological and economic reasons, a professional medical line between treatment and enhancement will be impossible to maintain in practice (Gardner). To the extent that useful "upper-boundary" concepts are required at the policy level—for societies making healthcare research allocation decisions, for example—this impotence is an important weakness.
The Normalcy Approach
Fortunately, another approach to interpreting the treatment/enhancement distinction is framed explicitly as a policy tool for separating legitimate healthcare needs from luxury services. The most developed exposition of this view is Sabin and Daniel's endorsement of what they call the "normal function" standard for determining the limits of "medically necessary" (and therefore socially underwritten) health services (p. 13). Sabin and Daniels argue that an appropriate boundary between medically necessary treatments and optional enhancements can be drawn by thinking about how to provide medical services fairly within a population. Following Daniels' earlier work, they construe healthcare as one of society's means for preserving equality of opportunity for its citizens, and they define "healthcare needs" as those services that allow individuals to enjoy the portion of the society's "normal opportunity range" to which their full array of skills and talents would give them access. This is done by restoring or improving the patient's abilities to the range of functional capacities typical for members of his or her reference class (e.g., age and gender) within the human species. Any interventions that would expand an individual's range of functional capacities beyond the range typical for his or her reference class would be deemed a medically unnecessary enhancement. Others have used similar understandings of human malady to help explicate a distinction between "negative" (e.g., therapeutic) and "positive" (e.g., enhancing) human genetic engineering (Berger and Gert).
The advantage of the normal-function approach is that it provides one relatively unified goal for healthcare, toward which the burdens and benefits of various interventions can be relatively objectively titrated (measured against one another), balanced, and integrated. The normal-function approach comes close to accurately reconstructing the rationale behind many actual "line drawing" judgments by healthcare coverage plans and professional societies (Brock et al.). Unfortunately, this approach also faces conceptual challenges in an important way. The first serious problem is that of prevention. While efforts at generic "health promotion" straddle the border of biomedicine, efforts to prevent the manifestation of specific maladies in individuals are always accepted as legitimate parts of biomedicine, and thus are automatically located on the treatment side of the enhancement boundary. On the other hand, one of the ways one can prevent a disease is to strengthen the body's ability to resist it long before any diagnosable problem appears. These forms of prevention attempt to elevate bodily functions above the normal range for the individual (and in some cases the species), and to that extent seem to slide into enhancement (Juengst). If human gene–transfer protocols like these are acceptable as forms of preventive medicine, how can it be claimed that healthcare practitioners should be "drawing the line" at enhancement?
Probably the most common rejoinder to the problem of prevention is to distinquish the problems to which prevention efforts respond. Treatments are interventions that address the health problems created by diseases and disabilities ("maladies" in the helpful language of Clouser, Culver, and Gert). Enhancements, on the other hand, are interventions aimed at healthy systems and normal traits. Thus, prescribing biosynthetic growth hormone to rectify a diagnosable growth-hormone deficiency is legitimate treatment, while prescribing it for patients with normal growth-hormone levels would be an attempt at "positive genetic engineering," or enhancement (Berger and Gert). Thus, to justify an intervention as appropriate medicine means to be able to identify a pathological problem in the patient. If no medically recognizable malady can be diagnosed, the intervention cannot be "medically necessary," and is thus suspect as an enhancement.
This interpretation has the advantages of being simple, intuitively appealing, and consistent with a good bit of biomedical behavior. Maladies are both objectively observable phenomena and the traditional target of medical intervention. They can be discovered through diagnosis, and it will be clear when one has gone beyond medicine when no pathology can be identified (Juengst). This interpretation is used by professionals working at the boundary, like cosmetic surgeons, to justify their services in terms of relieving "diagnosable" psychological suffering rather than satisfying the aesthetic tastes of their clients (Morgan), and it is also used when insurance companies insist on being provided with a diagnosis before providing coverage for surgery.
However, this interpretation does also face at least two major difficulties. The first problem that any disease-based interpretation of the enhancement boundary faces is, of course, biomedicine's infamous nosological elasticity. It is not that hard to coin new maladies for the purposes of justifying the use of enhancement interventions. By interpreting the boundary of medicine in terms of maladies, this approach puts the power for drawing that boundary squarely in the profession's hands, with the corresponding potential for abuse.
The more important problem, however, is that no matter where the line is drawn, most biotechnological interventions that could become problematic as enhancement interventions would not have to cross that line in order to be developed and approved for clinical use, because they will also have legitimate therapeutic applications. In fact, most biosynthetic biologicals and gene-transfer protocols with potential for enhancement uses will first emerge as therapeutic agents. General cognitive-enhancement interventions, for example, are likely to be approved for use only in patients with neurological diseases (Whitehouse et al.). However, to the extent that they are in high demand by individuals who are merely suffering the effects of normal aging, the risk of unapproved, or "off-label," uses of these products will be high (Mehlman). This last point is critical for policy purposes, because it suggests that the real challenge to regulation in this area may not be the development of enhancement interventions or "enhancement research," but downstream off-label uses of gene therapies for nonmedical enhancement purposes. The policy problem then becomes controlling access and use of the technologies, not their research and development. This presents another set of challenges for the law, since the novelty of enhancement technologies will make it difficult for judges and juries to ascertain the reasonableness of physician behavior (Mehlman).
These realities have pressed those who would use the treatment/enhancement distinction for policy purposes to articulate the moral dangers of genetic enhancement more clearly. After all, personal improvement is praised in many spheres of human endeavor, and biomedical interventions such as cosmetic surgery are well accepted, at lease in American society, as means to achieving personal improvement goals.
The Moral Dangers of Enhancement
There are two lines of thought that have emerged from this work. The first focuses on the idea that biomedical enhancements are a form of social cheating. In this view, taking the biomedical shortcut erodes the specific social practices that make the analogous human achievement valuable in the first place. Thus, some argue that it defeats the purpose of the contest for the marathon runner to gain endurance chemically rather than through training, and it misses the point of meditation if one can gain Nirvana through psychosurgery. In both cases, the value of the improvements lie in the achievements they reward as well as the benefits they bring. The achievements (successful training or disciplined meditation) add value to the improvements because they are understood to be admirable social practices in themselves. Wherever a biomedical intervention is used to bypass an admirable social practice, then, the improvement's social value (the value of a runner's physical endurance or a mystic's visions) is weakened accordingly. To preserve the value of the social practices considered to be "enhancing," it may be in society's interest to impose a means-based limit on biomedical enhancement efforts.
Interpreting enhancement interventions as those that short-circuit admirable human practices has special utility for policy analysis. To the extent that biomedical shortcuts allow specific accomplishments to be divorced from the admirable practices they were designed to signal, the social value of those accomplishments will be undermined. Not only will the intrinsic value be diminished for everyone that takes the shortcut, but the resulting disparity between the enhanced and unenhanced will call the fairness of the whole game—be it educational, recreational, or professional—into question. If the extrinsic value of being causally responsible for certain accomplishments is high enough (like professional sports salaries), the intrinsic value of the admirable practices that a particular institution was designed to foster may start to be called into question (Murray). For institutions interested in continuing to foster the social values for which they have traditionally been the guardians, a choice will have to be made. Either they must redesign the game (of education, sports, etc.) to find new ways to evaluate excellence in the admirable practices that are not affected by available enhancements, or they must prohibit the use of the enhancing shortcuts. Which route an institution should take depends on the possibility and practicality of taking either, because ethically they are equivalent.
Unfortunately, some of the social games people can play (and cheat at) do not turn on participants' achievements at all, but on traits over which individuals have little control, such as stature, shape, and skin color. The social games of stigmatization, discrimination, and exclusion use these traits in the same manner that other practices use achievements: as intrinsically valuable keys to extrinsic goods. It is becoming increasingly possible to seek biomedical help in changing these traits in order to short-circuit these games as well. The biomedical interventions involved, such as skin lighteners or stature increasers, are enhancements because they serve to improve the recipient's social standing, but only by perpetuating the social bias that inspired their use. When enhancement is understood in this way, it warns of still another set of moral concerns.
What makes the provision of human growth hormone to a short child a morally suspicious enhancement is not the absence of a diagnosable disease or the "species atypical " hormone level that would result—it is the intent to improve the child's social status by changing the child, rather than by changing her social environment, that is questionable (White). Such enhancement interventions are almost always wrong-headed, because the source of the social status they seek to improve is, by definition, the social group and not the individual. Attempting to improve that status in the individual amounts to a moral mistake akin to "blaming the victim": it misattributes causality, is ultimately futile, and can have harmful consequences. This is the interpretation of enhancement that seems to be at work when people argue that to use Ritalin to induce cooperative behavior in the classroom inappropriately "medicalizes" a social problem. In such cases, the critics dispute the assumption that the human need in question is one that is created by, and quenchable through, the human body, asserting instead that both its source and solution really lie in quite a different sphere of human experience.
This interpretation of the enhancement concept is useful to those interested in the ethics of personal improvement because it warns of a number of moral pitfalls beyond the baseline considerations that the enhancement/treatment distinction provides. Attempting to improve social status by changing the individual risks being self-defeating (by inflating expectations), futile (if the individual's comparative gains are neutralized by the enhancement's availability to the whole social group), unfair (if the whole group does not have access to the enhancement), or complicit with unjust social prejudices (by forcing people into a range of variation dictated by biases that favor one group over others). For those faced with decisions about whether to attempt to enhance themselves or their children through gene transfer, this way of understanding enhancement is much more illuminating than attempts to distinquishing it from medical treatment, because it points to the real values at stake. Ideally, gene transfer should not make an existing social problem worse, even if exacerbating injustice would further one's own interests.
On the other hand, protecting these values is difficult in a pluralistic society, because it means developing ways to police individuals' complicity with suspect social norms (Little). Under the historical shadow of state-sponsored eugenics programs, the U.S. government is unlikely to promulgate lists of acceptable and unacceptable enhancements, even if the intent of the lists are to protect the interests of those who are unenhanced.
Clearly, all of the ways of understanding enhancement as a moral concept reviewed here have limitations. However, all these interpretations do seem to be alive and well and mixed together in the literature on the topic. It is not possible to cleanly assign the different interpretations of enhancement to different spheres of ethical analysis. But there do seem to be some rough correlations that might be made. Thus, the interpretations that contrast enhancement interventions with treatments seem most useful where it is the limits of medicine's expertise that are at issue. Whether medicine's boundary is defined in terms of concepts of disease, or in sociological terms as the scope of medical practice, or in terms of some theory of the human norm, this interpretation at least provides tools to draw that boundary. Moreover, all other considerations being equal, the line that it draws is the boundary of medical obligation, not the boundary of medical tolerance. Using this tool, enhancement interventions such as cosmetic surgery can still be permissable for physicians to perform, but it is also permissable to deny them to patients.
This has important implications for social policymaking about healthcare coverage, to the extent that society relies on medicine's sense of the medically necessary to define the limits of its obligations to underwrite care. Again, all other considerations being equal, this interpretation of the concept suggests that few enhancement interventions should be actively prohibited by society or foregone by individuals, even when they are not underwritten as a part of healthcare, since there is nothing intrinsically wrong with seeking self-improvements beyond good health.
In contrast, the interpretations of enhancement that focus on the misuse of biomedical tools in efforts at self-improvement seem the most relevant to issues of personal, rather than professional, ethics. Concerns about the authenticity of particular accomplishments are moral challenges to the individual, but find little purchase in the professional ethics of biomedicine, with its focus on the physical safety and efficacy of its tools. The primary policy implications of this interpretation are for the social institutions charged with fostering particular admirable practices, for enhancement interventions that offer biomedical shortcuts to achievement force reassessments of the values these institutions stand for, as well as the practices designed to foster them.
Finally, at the other end of the spectrum, enhancement interventions that seem to commit the moral mistake of trying to address social problems through the bodies of the potentially oppressed do seem to mark a stronger set of moral boundaries for all concerned. For biomedicine, this concept marks an epistemic limit beyond which medical approaches to problem solving are not only unnecessary, but conceptually wrong-headed. For individuals, parents, and society, these kinds of enhancement interventions risk either backfiring (by exacerbating the social problems they are intended to address) or being futile (if they merely result in a shift of the normal range for a given social trait).
eric t. juengst
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