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: [email protected]
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
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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
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