3 The presumption against direct manipulation the trea tment/enha ncement distinct ion In the last chapter, we set out the objections that seem to underlie the presumption in favor of traditional means of changing minds (here- after, ‘‘the presumption’’). In this chapter we shall consider these objections in detail. Before we begin treating them, however, we need to consider another, more general, question, one that cuts across all the other objections and across a range of possible neurological interven- tions. Many people – laypeople, philosophers, bioethicists and neu- roscientists – have importantly different responses to actual and potential neuroscientific (as well as medical) interventions, depending upon what they are being used for. Interventions to treat diseases and impairments are regarded as significantly more permissible (perhaps even obligatory) than interventions aimed at enhancing normal capa- cities. Treating disease is generally regarded as an intrinsically worthwhile activity, and we are therefore under a (possibly defeasible) obligation to engage in it, but enhancing already normal capacities is a luxury, which is at best permissible, and not obligatory, and at worst impermissible. Different thinkers make different uses of the treat- ment/enhancement distinction. For some, it marks the difference between the kinds of medical interventions which it is incumbent upon the state to provide, and the kinds of interventions which can permissibly be bought and sold, but need not be provided as a matter of justice; for others, it marks the difference between interventions which are permissible, and those which ought to be banned. Despite these disagreements, there is a broad consensus that the treatment/ enhancement distinction marks a difference that is morally significant. The traditional home of the treatment/enhancement distinc- tion is medical ethics. However, it seems just as pertinent to the field of neuroethics. Suppose that the presumption against direct manip- ulation can be sustained. In that case, these manipulations are to be avoided, whenever possible; they can be used only when they give us the sole, or the sole practicable, means of treating conditions that impose significant suffering on patients (and those close to them). In that case, it follows quite directly that the use of direct manipula- tions to enhance already normal capacities will always be imper- missible. Moreover, if the treatment/enhancement distinction can be sustained, it provides us with additional reasons to doubt the per- missibility of enhancements, over and above that provided by the presumption: enhancements constitute a kind of cheating, and would exacerbate existing inequalities. enhancements as cheating Suppose Billy and Beth are both scheduled to sit an important examination. Both are talented students; both are hardworking and conscientious. Both are looking for that extra edge in the exam, since they know that performing well on it will open doors to better employment opportunities. Both therefore avail them- selves of the full range of means traditionally employed to achieve success. They both sit practice examinations, look at past papers and talk to people who have already been through the process, seeking advice and helpful hints. But Beth goes further: she takes Ritalin, which is widely used by college students to enhance con- centration and to boost performance on problem-solving tasks (Farah 2002; Farah and Wolpe 2004). Her performance is corre- spondingly better than she would have achieved without the drug. Her final score is a couple of precious percentage marks higher than Billy’s, and she has pick of the rewards that come from suc- cess at the exam. Billy is normally a gracious loser, but not this time. When he learns that Beth’s performance was drug-enhanced, he feels cheated. enhancements as cheating 89 Drugs and other biological interventions that enhance sporting performance have received a great deal of attention from ethicists (Mottram 2003; Savulescu et al. 2004). But the problems that arise from the use of enhancements of the mind can be expected soon to dwarf those arising from their use on the sports field. With our aging populations, there is a huge potential market for drugs which slow or even reverse the loss of memory and cognitive function typical of dementia. Of course, few people would object to such treatments of a tragic disease. But these same drugs may prove useful in enhancing the memories of normal adults (Farah 2002; Glannon 2006a). Research into drugs that enhance learning in different ways is also well advanced. The adult brain learns at a slower rate than the child’s, and part of the reason seems to be that the child’s is more plastic. Some researchers are therefore investigating ways of enhan- cing learning by increasing neural plasticity. One promising line of work explores the role of gamma-aminobutyric acid (GABA) in nor- mal learning. GABA is a neurotransmitter that plays an inhibitory role in the human brain; in normal skill-acquisition, GABA levels fall, allowing the brain to rewire itself, and thus lay down the path- ways that will underlie the skill. Ziemann and his colleagues (2001) have published preliminary results, from studies of human subjects, suggesting that deliberately manipulating GABA levels may increase plasticity, and therefore enhance skill acquisition. Ziemann et al. suggest that this might provide us with a therapy to aid the recovery of patients who have suffered some kind of neurological insult. But – if the technique proves safe and effective – it may find a bigger market among normal people looking for that extra edge, or a short cut to new skills and knowledge (Gazzaniga 2005). Antidepressants are already sometimes used to enhance the lives of individuals who do not meet criteria for any psychiatric disorder. Of course, most people who take such medications look to them for a boost in mood, but, whether as an intended effect or incidentally, antidepressants may also aid them in achieving goals in their work, study and relationships. Small-scale studies of the effects the presumption against direct manipulation 90 of SSRIs on normal subjects indicate that they make people more cooperative and less critical of others (Knutson et al. 1998) – traits which are likely to be attractive to employers. Other studies have confirmed that healthy subjects given antidepressants show greater social affiliative behavior, associated, perhaps paradoxically, with a decrease in submissiveness (Tse and Bond 2002; 2003). In many ways, antidepressants seem tailor-made for achieving the personality pro- file stereotypically associated with success. And there is evidence (most of it anecdotal) that people taking antidepressants are more successful (Kramer 1993). But it is easy to see why many people would begrudge them success achieved by pharmaceutical means. Just as it is widely regarded to be cheating to use steroids to achieve athletic success, so we might regard the use of psychopharmaceuticals to enhance memory or concentration as a kind of fraud. Here’s one way of jus- tifying this intuition: it is a deeply held principle of modern Western societies that opportunities ought to be distributed according to merit. Thus, jobs ought to be open to talent, not reserved for the members of some hereditary caste, or for the members of a particular race or gender. Rewards should be deserved. But Beth does not deserve her greater success. She worked hard, true, and hard work is deserving of praise. She is also talented. But Billy is just as talented, and worked just as hard. He therefore deserves as much success as does Beth. Beth achieved greater success, and perhaps she did it within the rules. But she contravened the spirit of the rules. She cheated. Note that this objection to the use of direct interventions is limited only to their use as enhancements. Were Beth suffering from a disease that prevented her from using her talents, few people would begrudge her the use of psychopharmaceuticals, or whatever the treatment might be. Rather than constituting cheating, her use of psychopharmaceuticals would simply correct for her disadvantage, in the same manner as, say, eyeglasses correct for short-sightedness. It is because Beth uses the drugs to raise herself above her already enhancements as cheating 91 normal, or better than normal, level that Billy feels that she has cheated. The same point applies to our next objection, the objection from inequality. inequality Enhancements of the mind like those we have just reviewed are already available and may become commonplace. But it is extremely unlikely that they will be available to everyone who wants them anytime soon. The cost of pharmaceuticals puts them beyond the reach of the literally billions of people who live in extreme poverty, mainly in developing countries. Indeed, those drugs which must be taken continuously if mental function is to remain enhanced (such as Ritalin and SSRIs) are out of the financial reach even of much of the population of the developed world, at least in the absence of gov- ernment subsidy. Other possible neurological enhancement tech- nologies, such as the portable transcranial magnetic stimulation device envisaged by Allan Snyder (Osborne 2003), as a way to bring out the savant-like abilities he and his colleagues believe to be latent in us all (Snyder et al. 2003), would probably prove even more expensive. So the new enhancements will be available, in practice, only to the wealthier members of our society. But these people are already better off than average, and their advantages extend to their minds. They may not be more intelligent than their fellow citizens, but they are better placed to develop their intelligence to the full. They send their children to the best schools, where they receive the best education; private tutoring is available to them if it is needed. More importantly, perhaps, they are brought up in an environment in which thought is respected and in which intellectual achievement is seen as a genuine possibility, a possibi- lity for them in particular. It is not a strange world, from which they are alienated or to which they do not think they can ever belong. Their parents are professionals – lawyers, physicians, academics – and the world of professional achievement beckons to them. More- over, they have better health care and better nutrition, both of which the presumption against direct manipulation 92 are conducive to higher intelligence. Birth weight, which reflects the nutritional and health status of the mother, is correlated with IQ, even when we restrict our attention to the normal range of weights, thereby excluding children born into extreme poverty (Matte et al. 2001). Higher socio-economic status is already associated with higher intelligence (Hunt 1995). But if neurological enhancements become widely available, we can expect the gap to grow ever greater, both between countries, and between the wealthy and less wealthy citi- zens within countries. Since intelligence, in turn, is a key to pros- perity and therefore further wealth, neurological enhancements are likely to speed up the rate at which a circle, which is already in motion, turns: enhancement leads to greater intelligence and suc- cess, which leads to wealth which enables further enhancement. Meanwhile, the less well-off languish in their unenhanced state. Now, there are several reasons to worry about the exacerbated inequalities that these enhancements might produce. First, they might (further) diminish feelings of social solidarity. The rich may not feel that they are in the same boat as the poor, so different are they from one another, and this might translate into a reduced willingness to contribute to the general welfare. They might demand a lowering of tax rates, failing which they might move their assets offshore. They might refuse to contribute to campaigns which aim to alleviate famine and the effects of natural disasters around the world. They may regard the poor as natural slaves (in Aristotle’s phrase), who are born to serve their needs. Second, many people regard inequality, at least undeserved inequality, as intrinsically undesirable. The wealthy have been lucky: lucky in their genes, lucky in the environment into which they were born and lucky, in our scenario, that they are able to translate their existing advantages into neurological enhancements. Since we do not deserve our luck, we do not deserve the extra advantages it brings; correspondingly, the poor do not deserve their lower status and their lower standard of living. inequality 93 probing the distinction Though most writers on the topic are convinced that a defensible treatment/enhancement distinction can be drawn, there is little agreement as to how best to draw it. There are two main approaches: the distinction can be defended by way of the contrast between dis- ease and non-disease states, or by reference to the notion of species- typical functioning (Jeungst 1998). I shall argue that both these approaches have insurmountable difficulties, and that the treatment/ enhancement distinction ought to be abandoned. It cannot, I shall suggest, do the work that writers on the topic hope for it: it cannot provide us with an independent standard to which we can appeal to settle moral arguments. Instead, it is already (at best) a thoroughly moralized standard. We ought, therefore, to recognize that it is a moralized standard, and assess it on moral grounds. Treatment, as the word suggests, might be defined as medical intervention aimed at curing, reversing or halting the progression of diseases and disabilities. On this view, an intervention would count as an enhancement only if it is not aimed at treating disease. Unfortunately, the distinction between disease and other undesir- able conditions is itself rather unclear. We might hope to define ‘‘disease’’ in terms of alterations of somatic function as a result of non-endogenous elements, where an endogenous element is any- thing specified in our genome. But – quite apart from the problem, to which we shall return, of making sense of the notion of something being specified in our genome – this won’t do. Normal functioning is itself dependent upon a range of external elements, from the bacteria which help our digestion and which help maintain the health of our skin and eyes, to the nutrients we need to absorb from the environ- ment in order to remain alive. Now, suppose that Beth is more intelligent than Billy because her ‘‘gut flora’’ enables her to absorb nutrients from food more efficiently, and this has given her a developmental advantage over him. Does Billy have a disease? If he does, it is caused by the lack of an external (external, that is, to his genome) element. Perhaps Billy’s intelligence is within the normal the presumption against direct manipulation 94 range, though lower than it might have been. In that case, is medical intervention an enhancement, not a treatment? If we say that it becomes treatment as soon as Billy’s IQ falls below the normal range, then, it seems, it is not the disease conception of the distinction to which we are appealing, but the species-typical account. Part of the problem for the disease-based approach to the treatment/enhancement distinction is that the concepts of disease and disability are far more malleable than proponents are willing to recognize. A ‘‘disability’’ might be regarded as any impairment of functioning which departs far enough from the social norm. What counts as a disability is therefore relative to the norm: dyslexia is a disability only in literate societies (Buchanan et al. 2000), and being tone deaf is a disability only in societies which speak a tonal lan- guage. Of course, it might be replied that we are only interested in the extent to which an impairment counts as a disability here and now, and that therefore the fact that an impairment would or would not be a disability elsewhere (that it might even be an advantage) is irrelevant. But to appeal to departure from the norm, here and now, is to give up the disease-based defence of the treatment/enhance- ment distinction in favor of the species-typical conception. Alter- natively, we can appeal to our intuitions about disease to defend the distinction. But the treatment/enhancement distinction is supposed to give us a means of evaluating whether a proposed intervention aimed at correcting for an impairment is permissible (or obligatory, or ought to be state-funded, depending upon the account) or not. If we appeal to the notion of disease to defend the distinction, and then appeal to intuition to defend the conception of disease we prefer, we implicitly appeal to intuition to defend the distinction – and in that case we have abandoned the claim that the distinction offers us an independent test of our intuitions. In that case, it is likely that it is in fact our moral judgments about the permissibility of intervention that are driving our intuitions about the distinction, rather than the other way round. Indeed, I suspect that that’s pre- cisely the case. probing the distinction 95 There is another, deeper, problem with drawing the distinction between treatment and enhancement on the basis of the disease model. But the problem – that in fact no sense can be made of one term of the contrast, and therefore of the contrast itself – obviously generalizes beyond the disease approach. I shall postpone discussion of it until we have the second major approach to the distinction firmly before us. I turn now to the second popular approach to dis- tinguishing between treatment and enhancement. The species-typical functioning approach is primarily asso- ciated with the work of Norman Daniels (1985; Buchanan et al. 2000). Daniels argues that treatment is medical intervention aimed at restoring the patient to normal functioning. In this approach, as in the first, disease is invoked, but it does not play a foundational role. Instead, what counts as disease or disability is defined by reference to normal or species-typical functioning. Treatment is medical inter- vention aimed at disease or disability, where disease or disability is adverse departure from normal functioning. An attractive element of this account of the distinction is that it gives us a natural explanation of why enhancement is less important, from a moral point of view, than treatment. Treatment aims to restore individuals to normal functioning, not because the normal is somehow intrinsically good in itself, but because normal functioning is necessary for equal opportunity. In Daniels’ account of the aims of a just health system, health care is designed to restore and maintain individual’s access to their share of ‘‘the normal range of opportunities (or plans of life) reasonable people would choose in a given society’’ (Buchanan et al. 2000: 122). Since equal opportunity is (extremely plausibly) itself a valuable good, worth protecting, restoring the ability of individuals to pursue it is itself worthwhile. The normal functioning view aims to restore individuals to their baseline capacity, the capacity that is naturally theirs. Diseases are departures from this state; so are impairments due to past unjust social practices and discrimination. But simply being less intelligent than average is not, on this account, a disease or impairment that we the presumption against direct manipulation 96 are morally obliged to treat. My lack of intelligence, or of good looks, or athletic ability, is simply the result of my bad luck in the natural lottery, and such bad luck does not impose any obligations on others. We ought to restore people to the natural baseline that is theirs, in virtue, presumably, of their genetic endowment. Raising them above that baseline is not treatment, but enhancement. Obviously, this view depends upon our being able to identify a natural (or ‘‘natural,’’ as Buchanan et al. 2000 would have it) baseline from which disease or disability is a departure. The problem with this approach is simply that we can’t do this. The very idea is bio- logical nonsense. To show this, it is necessary to make a short excursion into the way in which genes function in building pheno- types – the observable characteristics of organisms. All commentators, including Buchanan et al.(2000) reject the idea of genetic determinism. That is, we all now recognize that our genome does not simply encode our traits. The relationship between possession of a gene and the development of a phenotypic trait is a complex and mediated one. To be sure, there are some genes and gene-complexes that lead to predictable, usually adverse, con- sequences across the range of accessible environments. But most genes, and pretty much all genes for traits that are within the normal range, do not work like that. Instead, their phenotypic effects are the result of the way they interact with the environment and with each other. Despite the fact that everyone rejects determinism and accepts interactionism, many people continue to speak of the genome as a ‘‘blueprint,’’ which ‘‘encodes’’ traits; and about the natural baseline of capacities which is ours in virtue of our genome. None of these ideas make any sense, in the light of interactionism. The effect of any particular gene on the phenotype (leaving aside those that cause the relatively few congenital impairments, such as cystic fibrosis and Down’s syndrome, which produce adverse effects in all accessible environments – though even they merely complicate the picture, they do not falsify it) is the product of the probing the distinction 97 [...]... them, on ourselves or on others, in good conscience In other words, we ought to drop the presumption in favour of traditional means, and instead engage in the hard work of assessing each proposed use of direct manipulations on its own merits Authenticity Authenticity, as we defined it in the previous chapter, is the search for a way of life that is distinctively one’s own The authentic individual looks... because they facilitate, rather than preventing, self-knowledge and personal growth Mechanization of the self Some of the points made above with regard to both authenticity and to self-knowledge generalize to the question of the mechanization of the self That is, some of the traditional means of changing minds mechanize the self to just as great an extent as the new neuroetherapies do Some psychotherapies,... sought to alter their neurochemistry, one by antidepressants, and the other by exercise Why should suspicion fall upon one means of changing minds and not the other? It may be that the suspicion which falls upon direct manipulations has its source in the illegitimate transfer of intuitions regarding some kinds of manipulations, in cases where they are genuinely problematic, to others in which they are not... are predicated on the belief or suspicion that the change is neither deep nor permanent If she has changed, then we can’t accuse her of inauthenticity Since there is no inner essence to which she is compelled, indeed able, to conform, there is no reason at all to accuse someone who changes of inauthenticity (so long as they satisfy the Sartrean conditions on authenticity: roughly, they refuse to make... that there is always a cost associated with the use of the latter – is false Though there are reasons to be cautious in the use of direct manipulations, I shall claim, there is no reason to think that each and every use of such means is somehow suspect Very often direct manipulations are perfectly permissible, and sometimes even preferable to traditional means of changing minds; we can therefore use them,... criticisms of direct manipulations of the mind which apparently motivate the presumption against such manipulations? In the rest of the chapter, I shall consider the objections one-by-one It might be helpful, however, to signal the 103 104 t h e p re s u m p t i o n a g a i n s t d i r e c t ma n i p u l at i o n conclusion of this overview here I think that we ought to concede that at least some of the points... cooperate with the measures recommended If they lack insight, they may resist treatment; in these cases treatment is appropriate only if it satisfies the conditions that justify paternalism (for instance: the patient is not autonomous and the intervention has a reasonable chance of restoring their autonomy, or the patient is a danger to themselves or others) Now, as a matter of fact, psychotherapy has... it is in use (once again, unless the drug has costs that change the equation) We cannot, therefore, condemn direct manipulations on the grounds that they will necessarily cause the systematic worsening of our environment Nevertheless, they might have a tendency to do so, especially when they are pushed by powerful industries and by governments seeking to save money They may be used to allow people... long as the alteration is sustained and sustainable, and goes deep enough – so long, that is, as we can genuinely attribute the new personality to them – then there is no reason not to regard it as theirs authentically.1 Self-knowledge and personal growth Giving someone serotonin is not offering them a reason to be cheerful, nor is to helping them to understand what made them depressed in the first... but giving them a course of psychotherapy might enable them to come to understand themselves better Compare two agents cured of their depression, one by psychotherapy and one by antidepressants The first will possess significant knowledge that the second will not: knowledge about himself (about his history and about the structure of his psyche), and about his relationship to the world (about the kinds . respond to the criticisms of direct manipulations of the mind which apparently motivate the presumption against such manipulations? In the rest of the chapter,. 3 The presumption against direct manipulation the trea tment/enha ncement distinct ion In the last chapter, we set out the objections that