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Bilt-ekon organ inform zdrav 2010; (26)3: 1-5 hUman enhanCement and health Care:
some ethiCal issUes
izBoljŠeVanje ^loVeKa in zdraVstVeno VarstVo: neKaj eti^nih VpraŠanj in motenj, hkrati pa lahko iste metode slu`ijo tudi za izbolj{evanje nekaterih lastnosti in zmo`nosti modern biotechnologies make treatment of diseases pri zdravih ljudeh. modafinil je npr. sredstvo za and disorders increasingly attainable, but often the zdravljenje narkolepsije, vendar lahko tudi opazno same methods can be used just as successfully for izbolj{a spomin, medtem ko lahko amfetamine, ki se enhancement of certain traits in otherwise healthy pogosto uporabljajo za povrnitev nekaterih funkcij people. For example, modafinil is a treatment for pri po{kodbah mo`ganov, uporabljamo tudi za narcolepsy, but can also be used to improve memory, izbolj{evanje zbranosti in koncentracije.
while amphetamines, which are often used for Ve~ina ponudnikov zdravstvenega varstva in improvement of certain functions after brain injuries, zavarovanja trdi, da nudijo oz. pokrivajo izklju~no can be used to enhance focus and concentration. zdravljenje, ne pa tudi izbolj{evanja. ^eprav je most health care (and especially health insurance) tovrstna delitev videti smiselna, mnogi avtorji trdijo, providers claim that they only provide treatment, da je razmejitev med zdravljenjem in izbolj{evanjem but not also enhancement, and while this distinction dejansko bistveno manj jasna kot je morda videti na seems sensible enough, many have argued that the prvi pogled. Kot ka`e, razmejitev ne temelji na »naravni« line between treatment and enhancement is in fact delitvi med zdravjem in boleznijo, temve~ na kulturnih much more elusive than it initially appears. this line in dru`benih normah, ki so skozi zgodovino do`ivele turns out to not be based on some “natural” conception {tevilne spremembe. tudi ~e nam uspe dose~i soglasje of health and disease, but rather depends largely on glede razmejitve med zdravljenjem in izbolj{evanjem, to cultural and societal notions, which have changed ne re{i problema, saj ka`e, da ponudniki zdravstvenih considerably throughout history. moreover, even if storitev in zavarovanja pove~ini `e pokrivajo stro{ke we can find some non-arbitrary defining line of what nekaterih metod, ki niso strogo namenjene zdravljenju should count as treatment and what as enhancement, (vsaj v skladu s trenutno sprejetim razumevanjem most health care and health insurance providers already pojma zdravja), temve~ izbolj{evanju dolo~enih cover certain methods that are clearly not meant to lastnosti ali okoli{~in, da bi olaj{ali na{e `ivljenje. in improve or protect our health (at least not according ~e bolni{nice in zavarovalnice dejansko `e pokrivajo to current conceptions of health), but rather simply stro{ke nekaterih vrst izbolj{evanja, se poraja vpra{anje, to enhance some of our traits or circumstances with na kak{ni osnovi naj se odlo~amo, katere metode the intention of making our lives easier to manage. if izbolj{evanja so sprejemljive in katere ne.
insurance providers already offer coverage of some Klju~ne besede: izbolj{evanje, zdravljenje,
forms of enhancement, the question arises how to zdravstveno varstvo, zdravstveno zavarovanje decide which enhancement methods it is reasonable
to cover, and which not.
Key words: enhancement, treatment, health care, 1 introdUCtion
many recently developed approaches to treatment of particular disorders, diseases, and injuries are becoming an increasingly debated topic, especially when they involve the kinds of interventions which sodobne biotehnologije omogo~ajo vedno bolj can help us restore people’s health in ways that weren’t u~inkovite mo`nosti zdravljenja razli~nih bolezni even imaginable just a few decades ago. Certain 1 Univerza na primorskem, primorski in{titut za naravoslovne in tehni~ne vede, muzejski trg 2 6000 Koper e-po{ta: tea.logar@upr.si Bilt-ekon organ inform zdrav 2010; (26)3: 1-5 methods of treatment (like genetic interventions, and foremost to those in need of treatment, rather complex prostheses, brain surgeries, pharmaceuticals than to healthy individuals who just want their already such as mood stabilizers, and so on) are of interest not healthy capabilities or faculties enhanced further. only to experts, such as medical doctors and scientists, this approach certainly seems reasonable, but, as we but also to the general public. one of the main reasons will see, this seemingly commonsense notion about for this interest is the fact that these approaches can the supposed priorities of health care and insurance be used not just for treatment of those who need betrays an unwarranted assumption that there is an such interventions to restore them to health, but objective and non-arbitrary dividing line between because many of them can also be used to improve treatment and enhancement. the topic of this paper is certain functions in otherwise healthy people. these an analysis of arguments against the use (and insurance methods are especially interesting when they concern coverage) of certain enhancement methods, as well as so-called “positional goods” – the types of goods that an examination of the possibility of reliable criteria for are of worth to us only if (most) other people don’t differentiation between treatment and enhancement have access to them (1). examples of these kinds of interventions involve substances that can help enhance athletic performance or cognitive functions, and they are appealing precisely because they give the recipient an “edge” over her competitors: an athlete with growth hormone therapy will perform better than those without such interventions, and students who modern biomedical advances that make it possible take ritalin will be able to study with more focus and to improve functioning in both healthy and diseased for a longer time, which gives them an edge over their or injured people include different kinds of surgeries, fellow students who rely on caffeine instead. however, uses of various substances (herbal, pharmaceutical, many other methods of enhancement are appealing etc.), prostheses, genetic interventions (germline not because they can make us better at competing with and somatic), etc. allen Buchanan has introduced a others, but simply because they make our lives easier: useful distinction between kinds of intervention and mood enhancers can help make us feel better, while modes of intervention that can be used for treatment some other drugs or interventions can help increase or enhancement. the modes of intervention include our energy levels or help us stay alert longer and thus spend our time more efficiently, or just spend more “genetic engineering of human embryos and gametes (the insertion or deletion of naturally occurring While these methods seem very promising, genes, either from humans or from other species; they are in fact highly controversial and very much the insertion of artificial chromosomes or products disputed. many experts and scientists, as well as the of synthetic biology; and the manipulation of gene general public, argue that we should only use modern regulatory functions); pharmaceutical enhancements biotechnologies in order to treat, i.e., restore people to (administration of drugs that affect the mind or the normal health, but that we should refrain from using body); human–machine interfaces; and laboratory- these same methods in order to merely enhance, i.e., grown organs and tissues (presumably using stem cell improve our capacities beyond those of a healthy, technologies and possibly even synthetic biology).” normally functioning human being. there are many different kinds of reasons for opposing the use of these the kinds of intervention, on the other hand, methods for enhancement, and i will briefly introduce include those that affect our physical capacities (e.g. the main arguments. some of the objections concern strength, stamina), cognitive capacities (e.g., memory, enhancement methods’ practical consequences attention), and affective capacities (e.g., mood, (dangerous side effects, increasing social inequality), while others are more concerned with philosophical different modes of enhancement draw different issues, such as the effect enhancement interventions are reactions as to their acceptability: while no one likely to have on our human nature and the authenticity objects to the use of healthy food, meditation, or of our achievements, and these arguments are often moderate exercise as acceptable means to improve accompanied by worries about eugenics, “playing our mood, physical fitness, and ability to focus, the god”, and even “brave new world”.
use of pharmaceuticals or gene manipulation with the reason why health care and health insurance the aim of improving those same capabilities is much providers usually oppose enhancement coverage, more controversial. and while most people accept however, often persists even when the above- the use of pharmaceutical and genetic approaches for mentioned objections to enhancement are absent or treatment of actual illnesses and injuries, many object overcome. given that coverage resources are limited, to employing these same methods on individuals that it only makes sense that providers are devoted first are considered healthy and “normally functioning”. Bilt-ekon organ inform zdrav 2010; (26)3: 1-5 most of these methods can namely be used for both treatment and enhancement: we can, for example, use unpersuasive, given the lengths we already go to ssri’s in order to battle depression, but also with the when treating people and saving lives, without aim of merely improving our mood; human growth thinking for a moment that we should let “nature hormone can be used to increase strength and muscle take its course”. We interfere with nature whenever mass in those with actual growth hormone deficiency, we try to correct someone’s poor eye-sight, prescribe but it can also be used to even further increase strength antibiotics, vaccinate children, or even save people’s in athletes who already possess normal levels of the lives through sometimes rather aggressive means. hormone, yet want to enhance their abilities; modafinil We further affect people’s moods and personalities is a drug originally manufactured to help those suffering not only directly through psychiatric interventions, from narcolepsy, but it can also improve focus and but also indirectly by improving the quality of their energy in those that don’t suffer from the illness.
lives through eradicating their disabilities, healing the question whether such methods should be their injuries, and increasing their general wellbeing allowed either for treatment or for enhancement is widely in many other ways. letting nature take its course discussed, and possible unforeseen consequences and is not something medicine is supposed to do – it is side effects are often quoted as arguments against them; precisely fighting against the natural course of things even when these methods are used for treatment, that makes medicine so valuable. this doesn’t mean, rather than enhancement, potential harms and benefits of course, that we shouldn’t take the above-mentioned must be carefully weighed before we can make an objections to enhancement seriously, but we should informed decision whether to prescribe a particular definitely be wary of accepting them at face value, intervention. if it turns out that side-effects are highly without first exploring more thoroughly the notions unpredictable or dangerous enough, we will refuse and assumptions they rely on (for a useful overview treatment even to those who are ill, so it seems obvious of responses to objections against enhancement that we can do nothing but oppose such methods when (especially cognitive enhancement) see (7). note that all the subject is generally healthy and just wants some the above objections depend heavily on the assumption “improvement”. this, however, is not an in principle that a clear, objective, and non-arbitrary dividing line objection against enhancement: as long as we can can be drawn between what counts as treatment and show that the likeliness of unwanted side effects from what as enhancement; yet, many authors have pointed a particular intervention is sufficiently low, we can drop out that such an assumption is unwarranted, and this this type of objection against enhancement – yet many is the problem i wish to address next.
still continue to oppose it for other reasons. one of the more persuasive arguments against enhancement concerns an increasing inequality between people who can afford such interventions and those who cannot: if those with enough money can pay for drugs or procedures that can make them smarter or stronger, then of course they will fare those who oppose enhancement usually try to better in school or sports or as job candidates, and draw the line between treatment and enhancement this will only exacerbate the problem of inequality by in as descriptive and non-normative way as possible, increasing the gap between the rich and the poor even so as to avoid criticism of arbitrariness or subjectivity. further (1). While even this objection can be dealt with, Usually, the definition of enhancement depends on the at least in theory, by guaranteeing everyone equal definition of treatment, and the definition of treatment availability of enhancement methods (for example, in turn depends on the definition of health. health through universal health insurance coverage), some is usually defined in terms of absence of disease, other objections to enhancement are based on more dysfunction, disorder, and injury (8), and treatment is than mere practical issues that concern safety and then understood as any substance, procedure, or other inequality. some authors, for example, argue that using type of intervention required to correct a disorder or these methods of enhancement can forever affect the restore an individual to health. according to these authenticity of our achievements and even change guidelines, laura Colleton proposes the following our humanity (3); that it may endanger our autonomy (4); that it leads to the “brave new world” scenario “a procedure or intervention that aims to improve a (5), and so on. still others argue that the fact that we person’s physical or mental health, beyond the level of can use these methods doesn’t mean that we should functioning that is typical or normal, in the absence be allowed to do so – the criticism is that intervening of injury, dysfunction, disease, and disorder, that is, in with nature to such an extent displays arrogance and hubris on our part and that we should be wary of health is often defined in terms of “typical” or “normal” functioning or, more specifically, in terms of Bilt-ekon organ inform zdrav 2010; (26)3: 1-5 a “species-typical functioning” which appeals to the implies that our conception of what counts as a disease “natural functional organization of a typical member is vastly influenced by our surroundings – by socially of the species”. (10) the problem with “typical” as and culturally shaped aspirations and expectations. the sole criterion of “healthy” is that it seems to imply many authors have proposed that perhaps we should that, if the majority of humanity developed diabetes understand disease as a social construct that reflects or asthma or became short-sighted, to name a few the society’s current values, expectations, and ideals examples, none of these would have to be considered of human flourishing, rather than trying to tie it to a disease or a disability any longer (since they would some “natural” functions (13). this means that what is become typical, and thus normal), and they would considered treatment and what enhancement changes therefore no longer require treatment, which certainly through time and between cultures, often closely seems absurd: a disease doesn’t cease being a disease following medical and technological innovations just because most humans have it. on the flipside, and advances. We can already see that what is david resnik argues that “someone who deviates from considered treatment today may have been considered species-typical functions could be considered healthy enhancement yesterday (think of antidepressants), and in a society that views that deviation as healthy”. (11) we can be just as certain that some of the things that relying on the notion of species-typical functioning in are considered enhancement today will be considered order to determine who is healthy doesn’t seem very treatment tomorrow. it needs to be admitted that promising in light of these considerations.
the line between health and disease, and therefore another problem with this view of health is that between treatment and enhancement, is much more it seems to imply that its proponents would have to elusive than it might seem at a first glance.
oppose immunizations, since immunizations seem to be based on the rationale that a normal human body functions in ways that are incapable of dealing with certain diseases (namely the ones that we need immunization from). most people need immunization precisely because our “species-typical” bodies are not if the distinction between treatment and enhancement capable of defending themselves and cannot cope by is truly (even if partially) determined by culture, then protecting themselves from certain viruses. Besides, what does this mean for health insurance providers, vaccinations are normally performed on healthy who limit their coverage to treatment and draw the people, that is, those who have not yet contracted the line at enhancement? most health care providers virus, so vaccinations are used precisely in order to make it a part of their mission statement that they enhance one’s immune system and make it better at are primarily concerned with treating and preventing fighting disease – better than a typical human body is at diseases, and most health insurances similarly pledge resisting that same disease. as leroy Walters and julie to only cover what is considered “medically necessary”, palmer point out, when justifying immunizations, we rather than what is merely desired or wanted, but not usually employ the following line of thinking: truly needed (14). although the notion of medical “the immune system that we inherited from our necessity has many proponents, its role in successfully parents may not be adequate to ward off certain viruses differentiating between treatment and enhancement is if we are exposed to them. therefore, we will enhance the capabilities of our immune system by priming it to some authors argue that even if we admit that we cannot rely on the idea of species-typical functioning as When one takes all these observations into account, a guideline, and that we therefore have to accept that and adds to that the general understanding of treatment the notion of health depends at least to some extent and enhancement as explained above, immunizations on cultural norms, we must nevertheless acknowledge begin to seem much less like treatment and much more that debilitating pain, open wounds, and diseases and injuries that threaten one’s survival have been it therefore seems that we cannot rely on a species- considered worthy of treatment in all societies at all typical functioning as our guide to defining health, and times. the problem with this interpretation of medical thus to the treatment vs. enhancement distinction, if we necessity as the only valid criterion of treatment is its want to keep treating asthma and diabetes as diseases implication that many interventions that are currently even in the case the whole of humanity starts suffering covered by health insurance should henceforth be from them. the crucial point is that certain things can removed from coverage as long as they are not aimed be considered diseases, disorders, or disabilities even if at saving one’s life or limb, or at least at curing a they are “typical” statistically speaking, and this is due severe disability. the norm of medical necessity may to the simple fact that they cause suffering and often therefore allow us to treat diabetes and asthma even render people incapable of functioning in ways that are in the event that they become “species-typical”, but expected in their social and cultural surroundings. this this same norm would have to rule out coverage of Bilt-ekon organ inform zdrav 2010; (26)3: 1-5 corrective lenses, migraine drugs, skin rash ointments, “the overwhelming moral imperative for both hay fever medicine, and many other interventions that therapy and enhancement is to prevent harm and confer are not medically necessary by these standards. sabin benefit. Bathed in that moral light it is unimportant and daniels, proponents of the species-typical function whether the protection or benefit conferred is classified based understanding of health, recognize this problem, as enhancement or improvement, protection or “the normal function model holds that health care insurance coverage should be restricted to disadvantages caused by disease and disability unless society explicitly decides to use it to mitigate other forms of disadvantage as well.” (14) Keeping in mind these considerations, it seems according to this perspective, health insurance that we need to admit that the line between treatment providers could decide to follow the constantly and enhancement – the line insurance providers often changing cultural norms of what counts as worthy appear to take as some fixed, permanent line – is in of coverage, and shape their policies accordingly: fact highly elastic, and increasingly shifting, because if it becomes generally accepted that depression of the advances in biomedicine and biotechnologies, requires treatment, then insurance providers will be which in turn shape our values and expectations. expected to cover for it. sabin and daniels’s approach While insurance providers can maintain that they will can also be used to justify coverage of common only cover for treatment, the actual substances and cold medicine, aspirin, various interventions that procedures they cover will be changing constantly. as can be used to combat short-sightedness, allergy has been pointed out, what is considered enhancement drugs, not to even mention contraception, ritalin, today will be viewed as treatment tomorrow, and if and wigs for chemotherapy patients, all of which are insurance providers decide to stick to this dividing line typically covered by universal health insurance, at between treatment and enhancement as a demarcating line for how far their coverage extends, then they will on the other hand, it could also be argued that have to adjust – and this means expand – their coverage insurance providers also help shape, rather than merely follow, what is perceived a disease or a disability in the first place, especially since they already cover certain substances and procedures that are not meant to merely treat or prevent diseases, but also some 1. singer p. parental Choice and human improvement. that are obviously aimed at enhancing capabilities in: savulescu j, Bostrom n, editors. human of individuals who are not considered diseased or enhancement. new york: oxford University press, injured, as is shown by the above-mentioned examples. Because so many people insist that health care and 2. Buchanan a. moral status and human enhancement. health insurance should only cover what is medically philosophy and public affairs 2009; 37(4): 346- necessary, pharmaceutical companies are in a sense “encouraged” to frame the targets of their interventions 3. Kass l. life, liberty, and defense of dignity: the as diseases or disabilities, and the substances that are Challenge for Bioethics. san Francisco: encounter supposed to alleviate them as “treatment”. When it is agreed that depression, obesity, anxiety, etc. require 4. Fukuyama F. our posthuman Future: Consequences actual treatment, people will be much more likely of the Biotechnology revolution. new york: to accept their coverage by insurance. so, while it is in the interest of pharmaceutical companies to have 5. the president’s Council on Bioethics. Beyond more and more “afflictions” recognized as genuine therapy: Biotechnology and the pursuit of diseases or disorders, insurance companies want the exact opposite: only what is strictly medically necessary 6. sandel m. j. the Case against perfection: ethics should be recognized as worthy of treatment. this utter in the age of genetic engineering. Cambridge: disagreement may just be the best illustration of how artificial the line between treatment and enhancement 7. Bostrom n, sandberg a. Cognitive enhancement: in fact is: each party draws it where it most serves methods, ethics, regulatory Challenges. science her own interests. the disagreement also supports and engineering ethics 2009; 15(3): 311-341.
the view that we should drop an attempt at a reliable 8. schwartz p. defending the distinction between distinction altogether, and simply try to incorporate treatment and enhancement. the american journal societal expectations into our health policies. john harris makes a good point on the (un)importance of 9. Colleton l. the elusive line Between enhancement and therapy and its effects on health Care in the Bilt-ekon organ inform zdrav 2010; (26)3: 1-5 U.s. journal of evolution and technology, 2008; 13. juengst e. t. What does enhancement mean? in: parens e, editor. enhancing human traits: 10. daniels n. just health Care. new york: Cambridge ethical and social implications. Washington d.C.: georgetown University press, 1998: 29-45.
11. resnik d. the moral significance of the therapy- 14. sabin j, daniels n. determining ‘medical necessity’ enhancement distinction in human genetics. in: in mental health practice. hastings Center report singer p, Kuhse h, editors. Bioethics: an anthology. oxford: Blackwell publishing, 2006: 209-218.
15. harris j. enhancing evolution: the ethical Case 12. Walters l, palmer j.g. the ethics of human gene for making Better people. new jersey: princeton therapy. new york: oxford University press,

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