Recent posts have called for reflection on the “ends” of medicine. Though not directly addressed to the specific questions raised in those posts, this series will touch on related themes and so will be relevant to that larger discussion. With that in mind, I invite my readers and fellow bloggers to add their comments and observations into the mix, with a view toward drawing connections between these reflections and the broader questions under discussion on this site.
As I noted in my recent posts (2/11/13 and 03/04/13), Allen Buchanan’s Better than Human: The Promise and Perils of Enhancing Ourselves is an extended argument to the conclusion that “[t]here are powerful reasons in favor of a society like ours embarking on the enhancement enterprise, and there are no objections to enhancement that are sufficient to outweigh them, at least at the present time” (p. 181). In advancing his case for this conclusion, Buchanan explicitly eschews an appeal to what he terms “religious assumptions”—not, he emphasizes, because he is “antireligious,” but because he is “trying to discuss enhancement in ways that are accessible to most people, whether they are religious or not” (p. 145). Along the way, however, Buchanan ends up committing himself to some fairly robust assumptions that may or may not be “accessible” to “most people,” especially those who approach these issues from an explicitly religious or theological standpoint. In this post—the first of a multi-part series—I want to spend some time identifying and considering the ramifications of at least some of these assumptions. We will also consider two other recently published works—Jonathan Glover’s Choosing Children and Michael Sandel’s The Case Against Perfection, respectively—with a similar objective of examining (some of) their underlying assumptions, and with a view toward bringing these works into conversation with one another.
I begin, first, with a brief synopsis of Buchanan’s argument. This will, of course, omit or gloss over many details and nuances of his argument as presented throughout the book. Nevertheless, the following summary encapsulates key elements of his larger project, points that will serve as a launching pad for reflection in this and subsequent posts. Toward the end of this post, I will very briefly focus in on a specific methodological issue, one that recurs throughout the book and which, in my judgment, renders the larger argument problematic at best. A more detailed discussion of that issue, however, will be deferred until the next post.
In the first chapter, entitled “Breathless Optimism, Hysterical Loathing,” Buchanan sets out his overall objective—namely, the task of steering between the two extremes (“breathless optimism” and “hysterical loathing,” respectively) to which analyses of biomedical enhancement are frequently prone. By contrast, he aims to advance a pro-enhancement argument that nevertheless acknowledges and grapples with the risks inherent in the enhancement enterprise. In service of this objective, the first chapter provides an overview of the argument to be developed throughout the rest of the book; subsequent chapters are devoted to developing each of the major lines of reasoning to which Buchanan appeals in support of his thesis.
Buchanan opens this first chapter with the provocative statement that “It’s too late to ‘just say no’ to biomedical enhancements: They’re already here and more are on the way” (p. 3). As Buchanan notes, people already employ a whole host of biomedical enhancements. For example, some college students (particularly at elite American universities) have been known to take Ritalin to boost their cognitive performance, even though they do not themselves have Attention Deficit Disorder (ADD), the condition for which Ritalin is normally prescribed. Using a fictitious scenario in which two students at an elite American university (“Michelle” and “Carlos”) debate the propriety of this sort of cognitive “enhancement”—to which scenario Buchanan will return, in various iterations, throughout the book—he identifies two key issues that are highlighted by the fictional case scenario.
First, there is the issue of what Buchanan refers to as back door versus front door enhancements. An example of an enhancement of the “front door” variety would be if a drug were developed, approved by the FDA, and marketed explicitly for purposes of improving “normal” memory capacities. By contrast, the use of Ritalin by persons who do not have ADD, for the purpose of improving cognitive performance, would be an example of a “back door” enhancement. “At present,” Buchanan observes, “biomedical enhancements don’t come through the front door. They come through the back door, as spin-offs of efforts to treat diseases or disorders” (p. 7). Examples include the use of SSRIs (such as Prozac) by individuals who are not clinically depressed, in order to feel better emotionally; and the use of Viagra by young men “so that they can perform like the Energizer Bunny, even when they’re drunk” (p. 7). (Such is the “brave new world” we’ve inherited!)
As Buchanan notes, enhancement can also come about as an unexpected or unanticipated side effect of treatment for some condition. Modern prosthetics can, for example, potentially enable a runner to achieve faster speeds than his or her “able-bodied” counterparts (consider the controversy over Oscar Pistorius’ status in Olympic athletic competition; I will resist the urge here to pontificate on the more recent controversy that he finds himself in, except to note the obvious: “enhancement” of one sort—physical, emotional, cognitive, etc.—certainly doesn’t entail “enhancement” in the moral domain, and vice versa). Similarly, while undergoing modern laser eye surgery to correct a variety of vision problems, one can also opt simultaneously to improve or “enhance” one’s vision to a better-than-20/20 level.
The upshot of all this is that “[b]iomedical enhancements will keep coming in through the back door as long as we continue to make progress in treating diseases and disorders. So, just saying no to biomedical enhancements isn’t really an option—unless we want to stop medical progress” (p. 8). But, Buchanan goes on to say, “…if biomedical enhancements continue to come in through the back door, we’ll have serious problems.” For example, those individuals who take Ritalin to improve cognitive function (rather than to treat ADD) are taking a drug for a purpose for which it was not intended, where the safety and efficacy of the drug for that purpose has not been evaluated through clinical trials or other objective measures. These and other such “back-door” enhancements could potentially pose serious health or other hazards to individuals and/or the public at large. But “[s]o long as biomedical enhancements come through the back door, we won’t be in a good position to evaluate their safety or even whether they really work for everybody who takes them” (p. 8).
The second issue to which the “Michelle-Carlos” scenario draws our attention is the question of the relative “novelty” of biomedical enhancements, and the ethical issues raised by them, in comparison with other types of enhancements (particularly of a cognitive variety). Consider, for example, the fact that millions of us use two commonly available “cognitive enhancement” drugs on a daily basis—namely, nicotine and caffeine. Or consider some of the other major “enhancements” that, historically, have had the effect (among other things) of improving human cognitive capacities, resulting in wealthier societies and higher standards of living—e.g., “nonbiomedical cognitive enhancements” such as literacy, numeracy, and modern science; and “institutional enhancements” such as the market.
The problem, Buchanan observes, is that “…in current discourse, the term ‘enhancement’ is usually attached only to interventions that involve biomedical technologies. This blinds us to how pervasive enhancements are in our lives and how central they have been to the origin and evolution of our species” (p. 10). The lesson to be learned here, according to Buchanan, is that we need to resist the temptation of what he terms biomedical enhancement exceptionalism—“the dogmatic assumption that because an enhancement involves biotechnologies (pills, computers, fiddling with embryos, etc.) it’s somehow off the moral scale, that our ordinary moral tool kit is useless for coping with it.” Buchanan’s point is not that biomedical enhancement poses no moral challenges; rather, it is simply to observe that “human history—or at least human progress—is in great part the story of enhancement” (p.10), of which distinctively biomedical enhancement is simply one further iteration.
Of course, these observations do not stop critics of biomedical enhancement from claiming that there is something unique, something distinctively problematic about that form of enhancement over against others. Why might someone think that biomedical enhancement is unique in this way? Here, Buchanan considers four candidate arguments to that conclusion—namely,
(1) biomedical enhancements are different because they change our biology; (2) biomedical enhancements are different because (some of them) change the human gene pool; (3) biomedical enhancements are different because they could change or destroy human nature; (4) biomedical enhancements are different because they amount to playing God (p. 12).
Each of the subsequent chapters of this book is devoted to investigating and responding in detail to one of these arguments. Here, I will simply set out the broad contours of Buchanan’s response to each of the arguments; in subsequent posts, I will go intro greater detail.
In response to the “playing God” objection (Ch. 4), Buchanan argues that this really amounts to a warning against hubris—being overly confident in our technological prowess and other capabilities. As an action-guiding principle, however, it is relatively uninformative and therefore unhelpful.
With respect to the “changing the human gene pool” objection (Chs. 2 & 5), Buchanan observes that the human gene pool is always changing, regardless of what we do. The real question, he says, is whether or not natural selection is “doing a good job of changing the gene pool.” We shouldn’t assume, from the outset, that changing the gene pool would always be a bad thing. Those who do assume this a priori, Buchanan suggests, are relying on an “unsupported dogma”—namely, a “pre-Darwinian understanding of nature as teleological” (p. 16), as a consequence of which they assume “that evolution is doing a good job and that our efforts are likely to make things worse” (p. 16).
Buchanan’s response to the “changing biology” objection (Chs. 2 & 3) runs along similar lines: since “our biology is a product of evolution” (p. 20), and is therefore always changing, the salient question is “whether we might have good reasons for deliberately changing our biology in some respects” (p. 20).
Finally, in responding to the “changing/destroying human nature” objection (Ch. 3), Buchanan notes, first, that on most accounts of human nature, including Christian and other theologically oriented accounts, human nature as we know it is, at best, “a pretty mixed bag,” one that includes both “awful as well as admirable features” (21). So, prima facie, it’s not immediately clear that “human nature” is necessarily something we should even want to preserve in its present form; perhaps, instead, we should try to improve human nature so as to get rid of, or at least to ameliorate, some of those “awful” features. Arguments to the contrary, Buchanan suggests, typically rely on what he terms the Extreme Connectedness Assumption (ECA), the notion that “…if we try to ameliorate the bad parts of human nature we will inadvertently destroy the good parts” (p. 22). But why, Buchanan asks, should we accept the ECA? In deciding whether or not to accept that assumption, he says, we should look at the “evidence” about what human nature is like. What sort of “evidence” would be relevant to this inquiry? For Buchanan, the answer to that question is obvious: we should look to “scientific evidence about what evolved organisms like us are like. In other words, we have to look to biology” (p. 22).
After having (in his view) dispensed with each of these objections, Buchanan then goes on to consider two additional types of arguments: (a) consequentialist arguments having to do with the potential for distributive injustice (Ch. 5, “Will the Rich Get Biologically Richer””); and (b) a virtue-oriented objection to the effect that the pursuit of enhancement is inherently morally corrupting (Ch. 6, “Is Enhancement Corrupting?”). Buchanan believes he has answers to these objections as well, and so arrives at the aforementioned conclusion that “[t]here are powerful reasons in favor of a society like ours embarking on the enhancement enterprise, and there are no objections to enhancement that are sufficient to outweigh them, at least at the present time” (p. 181).
Detailed critical engagement with Buchanan’s argument will have to await the next and subsequent posts. By way of preview, I close this post with a crucial question regarding methodology. I noted above that, for Buchanan, the only source of relevant “evidence” is (evolutionary) biology. This trope—that the pronouncements of (evolutionary) biology are the only sources of data relevant to an inquiry concerning what human nature is like—recurs throughout Buchanan’s book. (It is, of course, a common theme found in much of the contemporary bioethics literature generally.) But, as a former professor of mine was fond of saying, “why think that?” Why think that evolutionary biology is the only relevant source for information concerning human nature? What about other possible sources, such as theology and philosophy? Surely these other domains of knowledge might have something to contribute to the discussion?
This question will be the subject of my next post.
Works Cited in this Post
Buchanan, A. (2011). Better than Human: The Promise and Perils of Enhancing Ourselves (Philosophy in Action Series). New York: Oxford University Press.
Glover. J. (2008). Choosing Children: Genes, Disability, and Design (Uehiro Series in Practical Ethics). New York:
Sandel, M. (2007). The Case Against Perfection: Ethics in the Age of Genetic Engineering. Cambridge, MA: Harvard University Press.