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Enhancement Technologies and Human Identity
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Scope and objectives

The proposed project will investigate biomedical technologies which can be used not simply for treating illness and disability, but also for enhancing human capacities and characteristics. Some such enhancement technologies have been with us for some time already, such as cosmetic surgery and drugs that enhance athletic performance (Davis, 1995; Shapiro, 1991; Murray et al, 1984.) Others have generated controversy only in recent years, such as the possibility of using human growth hormone to make children grow taller, or the so-called "cosmetic" use of anti-depressants to make (non-depressed) people more outgoing and self-confident (Lantos, 1989; Kramer, 1993.) Still other technologies are as yet only possibilities for the future, such as genetic enhancement, interventions to slow the effects of aging and extend the human life-span, and drugs to improve memory and other cognitive abilities (Harris, 1992; Caplan, 1992.) These enhancement technologies and others raise important philosophical questions about the nature and normative limits of human identity, and about the ethical implications of using biomedical technologies to alter human identity. The purpose of this project is 1) to explore a range of enhancement technologies, 2) to consider their ethical and philosophical implications, 3) to articulate the values and arguments that need to be considered in evaluating such technologies, 4) to generate case studies and clinical examples of current and potential enhancement technologies, and 5) to make recommendations about whether we ought as a society to promote such technologies.

Relevance of project to objectives of theme (applied ethics)

The project has direct practical relevance to policy makers, health care workers as well as to the general public. Prospective users need to know how best to make decisions about enhancement technologies for themselves and for their children. Policy makers, jurists and governmental bodies will need a conceptual framework to make decisions about regulating, funding, promoting or prohibiting enhancement technologies. Physicians who will be prescribing or employing these technologies for patients need a way of ethically evaluating particular types of technologies and the clinical situations in which they can be ethically justified. These considerations require a framework for thinking about the implications for social policy of enhancement technologies in general, and they also demand careful attention to each particular technology, many of which differ from each other considerably and have unique characteristics of their own. The research team will aim to produce scholarship that is accessible and has practical relevance for clinical practice and health policy.

Relationship to ongoing research

Carl Elliott held an FCAR New Researcher grant, "Bioethics, Language and Culture," which expired in June 1997. His research for that grant concerned conceptual issues surrounding the relationship between culture and moral language, particularly in regard to ethical issues in medicine (such as competency, organ transplantation from living donors, neurologically damaged children, and the concept of personhood.) That grant was designed to fund work on two books, A Philosophical Disease: Bioethics, Culture and Identity (Routledge, forthcoming) and an edited collection called Bioethics and Wittgenstein (Duke University Press, forthcoming.) Also, Elliott's work on moral language and imaginative literature, which originated from that grant, has led to an edited collection with John Lantos, The Last Physician: Essays on Walker Percy, Medicine and Literature (Duke University Press, forthcoming.) An important part of this current work concerns issues surrounding the "cosmetic" use of antidepressants (such as Prozac) for patients who want the drug, but who are not clinically depressed and do not have any other mental disorder (Elliott, in press; Rothman, 1994.) (Part of this work was presented by Elliott at the Hastings Center in May 1996 as part of a Center project on enhancement technologies directed by Erik Parens.) This work is also connected to his edited collection with John Lantos on the work of the physician/novelist Walker Percy, who anticipated cosmetic psychopharmacology in his novels Love in the Ruins and The Thanatos Syndrome. The current SSHRC grant proposal extends this work on cosmetic psychopharmacology to a wider range of enhancement technologies, and it also relates directly to Elliott's broader philosophical interest in the relationship between culture and moral language (Elliott, 1992.)

Importance, originality and anticipated contribution of the project

Enhancement technologies have enormous potential to alter human experience in fundamental ways. Yet with the exception of gene therapy and genetic engineering, enhancement technologies have only recently begun to generate any scholarly interest. What interest they have generated has often been limited to a single scholarly discipline, such as gender studies or psychiatry, with little interdisciplinary communication. The proposed project is original in that it brings together scholars from a variety of disciplines and theoretical perspectives, and that it focuses on several particular problems for the Canadian situation. The proposed project will focus on three central areas: 1) mental enhancement, 2) genetics and aging, and 3) gender identity.

1) Mental enhancement

Peter Kramer coined the term "cosmetic psychopharmacology" to refer to the use of antidepressants, especially Prozac, to alter personality characteristics -- to make shy people more self-confident, mildly obsessive people more easy-going and relaxed, sad and alienated people happier and more comfortable with themselves (Kramer, 1993). But antidepressants are only one of a number of possible interventions that can enhance mental capacities. Performers, musicians and public speakers use propranolol as a way of lessening their anxiety about performing on stage (Slomka, 1992). Neurologists speculate about using cognitive enhancers developed for dementia to improve memory (Cardenas, 1993; Whitehouse et al, 1996). University students and others have embraced a variety of "smart drugs" in an effort to improve their academic performance (Dean, 1993; Canterbury et al, 1994). Pediatricians are pressured to prescribe Ritalin to improve childrens' attention and concentration (Diller, 1996). Philosophers and geneticists have speculated about the possibility of someday using gene therapy to improve human mental abilities (Glover, 1984). These technologies raise complex questions. Is there any morally relevant difference between improving one's mental abilities through drugs, and producing the same abilities through education and mental exercise? Is there any morally relevant difference between using drugs to achieve psychological insight, reduce anxiety or alter one's personality, and doing the same thing through psychotherapy? If Prozac produces long-term changes in one's personality, has it altered the "self" in any important way? Or has it instead restored an authentic self that was masked by pathology?

2) Genetics and aging

It is commonly accepted that aging is a natural part of human life: that the limits of human longevity are more or less fixed, and that growing old is naturally associated with physiological decline. Yet evolutionary biologists and geneticists have begun to challenge these assumptions (Rusting, 1992; Finch, 1990). For example, the life spans of some lower animals, such as nematodes and fruit flies, can be extended dramatically through genetic alteration. Many of the physiological effects of aging can be slowed. Research on aging has generated speculation about the possibility of extending human life, and of retarding the physiological deterioration that accompanies old age. Should we think of aging as a natural part of human life, or would it make more sense to think of it as a disease, which we can control (Caplan, 1992; Murphy, 1986)? Are interventions to ameliorate the effects of aging properly thought of as enhancement technologies, or as medical therapies? Some interventions aimed at ameliorating the effects of aging have already come to be thought of, at least in the West, as medical therapies -- for instance, estrogen for post-menopausal women (Lock, 1993). The possibility of developing therapies that would retard aging raise profound questions about mortality and the natural trajectory of a human life. To what degree (if at all) and under what circumstances should we attempt to extend the human lifespan? What sort of social and institutional changes would a dramatically longer lifespan bring about?

3) Gender identity

When a child is born with ambiguous genitalia, the conventional medical response is to make a gender assignment for the intersexed child as early as possible. The medical team then carries out surgical and hormonal treatments over the course of the child's life in order to fit the child into the gender that he or she has been assigned (Money, 1987; Meyer-Bahlburg, 1994). But some scholars and former patients have begun to challenge this medical approach to intersexuality (Epstein, 1990; Chase, 1993; Kessler, 1990; Herdt, 1994). Part of this challenge stems from concern over the effectiveness of surgically altering and constructing a child's genitalia. But scholars have also questioned the underlying assumption that human beings are naturally divided into categories of male and female, and that intersexed infants who fit into neither category are disfigured, disabled and in need of treatment. Anne Fausto-Sterling, for example, has argued that there are not two sexes, but five: male, female, true hermaphrodites, male pseudohermaphrodites and female pseudohermaphrodites (Fausto-Sterling, 1993). Clifford Geertz has pointed out that some other cultures do not see intersexed persons as unnatural oddities, as many Westerners do; the Navaho of the 1930s saw them as blessed by the gods (Geertz, 1984). Such arguments raise the question: should we see intersexuality a disability to be surgically corrected, or as another sexual category, apart from male and female? Some feminist theorists have argued that women undergo some forms of cosmetic surgery, such as breast augmentation, because of pressure to conform to socially desirable standards of physical appearance (Davis, 1995). How does the pressure to conform to socially desirable standards for physical appearance play into the decision to assign an intersexed child to the category of either male or female? Is sex assignment a medical treatment, or is it better seen as a way to shape and alter human identity? The problems associated with intersexuality raise broader questions about the nature of gender identity and the extent to which it is rooted in culturally particular conceptions of human nature (Herdt, 1994; Laqueur, 1990; Edgerton, 1964).

The debate over enhancement technologies is complicated by conceptual difficulties, not the least of which is the term itself. Can a bright line be drawn between what counts as enhancement and what counts as medical treatment (Daniels, 1992) ? Some interventions do not clearly fall into either category. Water fluoridation, for example, or immunizations to prevent infectious disease, straddle the line between enhancement and treatment (Brock, 1996). Another controversial example is that of correcting (or altering) ambiguous genitalia. Furthermore, even if clear lines between treatment and enhancement (and mere alteration) could be drawn, it is not clear that these distinctions would be useful. An intervention might be desirable even if it is not a medical treatment.

The most pressing question to be addressed, however, is whether enhancement technologies ought to be promoted. Many people feel that they should, at least in some cases. First, if we can agree that certain traits are good or desirable, such as intelligence, then, it might be argued, the means by which these traits are promoted is morally unimportant (Harris, 1992). Second, if enhancement technologies are available and safe, then people arguably have a right to make their own decisions about whether to use them. This is how we treat cosmetic surgery, for example. Third, even if a person's distress does not count as a symptom of an illness, it is nonetheless real, and cannot be simply dismissed. Thus even if we do not think that, say, shyness is properly seen as a psychiatric problem, it may still be a source of genuine suffering. Prohibiting a shy person from trying to overcome her shyness by using Prozac would be hard to justify (Sabin and Daniels, 1994).

On the other hand, enhancement technologies also raise some disturbing questions. For example, many people want enhancement technologies not because of anything inherent in their condition, but because of the way their condition is seen by others. Whatever distress people suffer from being short, shy, wrinkled, or small-breasted is a result of social attitudes towards these characteristics. Will enhancement technologies reinforce these social attitudes? Because of our tendency to marginalize differences and minority values, enhancement technologies may also undermine the respect that Canadians give to social and cultural diversity.

There are other concerns. How should enhancement technologies be tested? If ethical research protocols depend on an acceptable ratio of risks and benefits to subjects, who determines what counts as a benefit? Who should have access to enhancement technologies ? If access depends on a user's ability to pay, this creates problems of fairness. Enhancement technologies may give some people unfair advantages over others -- for example, by making them more intelligent, or taller, or more aggressive in the workplace. And as with the use of performance-enhancing drugs among athletes, the use of enhancement technologies among some people may create pressure for others to use them. On the other hand, making enhancement technologies available to everyone might create problems of a different sort. Could the Canadian health care system afford to provide universal access to such technologies? If not, would the health care system be undermined by a fee-for-service approach (Wright, 1994)? Universal access to some enhancement technologies would also be self-defeating. The social importance we place on men being tall, for example, depends on there being other men who are shorter. If everyone became taller, no one would gain height relative to anyone else and the technology would have been useless. Perhaps even more worrying is the possibility that by embracing enhancement technologies we might lose aspects of human life that we ought to value (Parens, 1995). For example, if a person is alienated and depressed by life as a North American consumer, should we be comfortable with an antidepressant that rids him of his alienation? Or are there some situations that properly call for a response of alienation (Elliott, 1994)?

How we answer these ethical questions will affect how we respond in terms of policy. A number of policy options are available for controlling enhancement technologies apart from the law. Technologies can be regulated by governmental bodies such as the Health Protection Branch, promoted through funding incentives, discouraged through taxation, or regulated less formally through professional bodies such as the Canadian Medical Association (Brock, 1996). Policy response will also depend on who is using the technologies -- whether adults are deciding to use the technologies themselves (as with cosmetic surgery), or for their children (as with gender assignment or the use of growth hormone), or whether governmental bodies are requiring them for citizens (as with immunization and water fluoridation.)

METHODOLOGY

Team members will use the methods of the humanities, especially analytic philosophy, to conceptualize and clarify what is at stake in the debate over enhancement technologies. This will involve careful attention to the scientific and medical facts involved in the technologies. However, speculating about the implications of potential enhancement technologies also requires imagination, for which fiction and other types of imaginative literature can be important tools.

Carl Elliott has argued against the notion of abstract, generalized ethical theory, and have suggested that the way we conceptualize and describe ethical issues is dependent on local, culturally contingent forms of life (Elliott, 1992a; Elliott, 1992b). This attention to culture is especially important to the evaluation of enhancement technologies for several reasons.

First, the types of enhancement technologies that people desire -- the characteristics and abilities that they want to enhance -- is culturally dependent. The desire to look young, to be tall, to be thin, to be outgoing and extroverted: these desires depend on the abilities and characteristics that are valued within a given society.

Second, how people conceptualize and divide up the world is culturally dependent. For North Americans, intersexuality is an anatomical anomaly; for the Navaho, a blessing. North Americans often treat menopause like an illness, characterized by symptoms and treated with hormones, whereas Mayan women report no symptoms and look forward to freedom from their childbearing years (Beyene, 1989). If concepts of health and illness vary across cultures, then so will concepts of enhancement.

Third, how we evaluate enhancement technologies depends on what we count as a benefit, and what we count as a benefit will depend on our vision of the good life. For example, if we think of life in terms of competition -- say, a successful life is one in which you have competed successfully for a job, a partner, a good education and so on -- then this will lead us to very different conclusions about enhancement technologies than we might reach if, say, we thought of a successful life as one that pleases God. The culture whose values a person has absorbed will crucially influence her vision of the good life. The aim of the project is to produce individual and collaborative research. Team members based at McGill will have regular meetings to plan, discuss and present their research and to develop collaborative initiatives.

THE TEAM

The ethical issues surrounding enhancement technologies are deeply intertwined with questions about human identity and its normative boundaries: issues concerning selfhood, personal identity, human nature, and the proper trajectory of a human life. Many of these questions are fundamentally philosophical, but they are also crucially related to social questions about cultural identity. Furthermore, they are also dependent upon scientific questions, particularly in genetics and psychiatry.

Because of the nature and scope of the project, a team approach is essential. Enhancement technologies span a wide range of highly specialized areas in biology and medicine, and exploring their ethical dimensions involves issues not only in philosophy, but also in cultural anthropology, law, genetics, psychiatry and religious studies. Most members of the research team have some background or interest in bioethics, and they come from a variety of academic backgrounds. Research team members were chosen in order to provide expertise in philosophy, cultural anthropology, feminist theory, law, religious studies, genetics and psychiatry. They represent a mix of junior and senior academics both within and outside McGill with a history of friendly collaboration.

  • Who are the team?

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