## 1. Introduction


### 1.1 Terminology


As our preface suggests, the ordinary use of the phrase "human
enhancement" covers a wide range of practices, most of which are
not explored in the enhancement ethics literature. To orient our
tour, both "human" and "enhancement" merit some
initial clarification, even before we pursue the ways they are
interpreted and debated in the literature. For example, as
section 2.3 below shows, equivocations between biological and
evaluative senses of the term "human" are rich sources of
many superficial disagreements in these debates. Is there anything
special about being a member of the biological species *homo
sapiens* that enhancements could threaten, or are those who
criticize enhancement as "dehumanizing" really thinking
about the loss of other markers of the moral status we confer on
persons? To look ahead, we think it will become clear in the sections
below that the ethical issues at the heart of the debate about human
enhancement are not about policing the biological boundaries of the
species *homo sapiens*. At this point, however, it is enough to
note that we are foreclosing neither sense of "human" from
the start, but will stay alert to both until it becomes important to
distinguish and relate them.


With "enhancement", on the other hand, it is helpful to
specify a working definition from the start. We understand the
practices that are being debated in the enhancement ethics literature
to be *biomedical interventions that are used to improve human form
or functioning beyond what is necessary to restore or sustain
health*. This broad definition flows from and reflects the
foundational literature in this area (Parens 1998), but it also has
several implications that are sometimes forgotten.


First, it means that simple line-drawing exercises aimed at
isolating "enhancement technologies" from other biomedical
interventions for special precautionary regulation or oversight are
destined to be ineffective (*pace* Anderson 1989). There
are no "enhancement technologies" *per se*. Whether
a given biomedical intervention counts as an enhancement depends on how
it is used. When ankle-strengthening surgery is used to improve a
bicyclist's competitive edge, it might raise enhancement
concerns, but as a treatment for a bicyclist's ankle injury, it
does not. This means that the developers of even the most outre
enhancement interventions will almost always be able to appeal to some
correlative therapeutic uses to justify their research, testing, and
release into the market (Mehlman 1999). On the other hand, simply
pointing out that biomedical technologies can have both therapeutic and
enhancement uses does nothing to collapse the logical distinction
between those uses, or to defeat the claim that those distinguishable
uses might warrant different ethical responses (Buchanan 2011).


Second, the definition of "enhancement" used in this
entry restricts the term to biomedical interventions, even though
other methods of increasing normal human capacities raise ethical
issues as well. Electronic and robotic tools that enable us to listen,
observe, help or harm at a distance, lifestyles designed to maximize
particular talents, and social practices that foster new forms of
human relationship all come with their own trade-offs and moral
concerns. But the focus of the enhancement ethics literature is
overwhelmingly on interventions that make biological changes in human
bodies and brains, using pharmaceutical, surgical, or genetic
techniques (Clarke, Savulescu, Coady, et. al., 2016). Standard examples
include:


* cosmetic surgery and the use of biosynthetic growth hormone to
increase stature (Miller, Brody and Chung, 2000; Little, 1998; White,
1993; Conrad and Potter, 2004),
* "blood doping" and steroid use to improve athletic
endurance and strength (Miah 2004; Murray 2009; Tolleneer, 2013),
* psychopharmaceutical approaches to increasing memory, elevating
mood, and improving cognitive capacities (Elliott 1998; Whitehouse,
et. al., 1997; Sandberg 2011; Glannon 2008; Levy, Douglas, Kahane,
et. al. 2014a; Duncan 2016; Earp 2018), and
* potential genetic and neurological manipulations to increase the
human life span, acquire new sensory-motor abilities, and, through
"moral enhancement", live together in more peaceable,
generous, and just ways (cf. Savulescu, ter Meulen and Kahane 2011;
Harris 2016; Wiseman 2016; Johnson, Bishop and Toner 2019).


Of course, the line between biomedical and other enhancements is
often blurry. Caffeine is a drug that can heighten alertness, but
coffee drinking is a social practice outside the biomedical sphere.
Meditation and prayer can have the same physiological effects as
drugs. The "cyborgs" of science fiction blend human
bodies with electronic and mechanical tools (Hughes 2004). The
prospect of uploading minds into computers to create bodiless human
life is sometimes characterized as "radical enhancement"
(Agar 2013). But as important and intriguing as these mixed cases are
from ethical and conceptual perspectives (Hogle 2005), this essay will
only engage them in two ways. The first is when they help advance our
understanding of core issues raised by the enhancement uses of the
emerging biomedical technologies. The second is when, inevitably, our
discussion of biomedical enhancements uncovers insights that reflect
back upon the ethical dimensions of these other practices.


Finally, our definition implies that enhancement interventions
attempt to improve specific human capacities and traits, rather than
whole persons. Unlike such comprehensive personal-improvement
strategies such as prayer, psychoanalysis, or "the power of
positive thinking", biomedical enhancements are, at best, a
piecemeal approach to human perfectibility. As a result, most
biomedical enhancements involve trade-offs. If extended life span comes
with prolonged frailty, or if enhanced altruism compromises survival
skills, the overall value of the enhancement can be called into
question (Shickle 2000).


### 1.2 Background


An important part of the orientation for those new to thinking
about enhancement ethics is the ways in which current debates are
shaped by the history of earlier efforts at perfecting people. At one
level, perfectionist and meliorist impulses have deep roots in Western
philosophical and religious thinking, which both modern science and
medicine have inherited (Keenan 1999; Comfort 2012). Most advocates
and critics of biomedical enhancement share these cultural
commitments, but have disagreeing visions of the ideal (Roduit,
Baumann, and Heilinger 2013; Parens, 2005). Other scholars, recalling
the historical imposition of hegemonic religious and political visions
of salvation and citizenship, fear the elevation of any canonical
account of existing human virtues, in favor of visions that prize
people's capacity to shape their own ideals through reason,
autonomy, and democratic deliberation (Sparrow, 2014; Buchanan
2011). Others, pointing to the consequences of modern individualism
for the common good (Persson and Savelescu 2012), feel confident about
being able to name the constellation of existing human traits that
should either be preserved (Kass 1997; Annas 1998; Agar, 2013) or
enhanced (Bostrom 2003). However, almost no one in this literature
eschews the development and use of new medical tools for healing
purposes (Kamm 2005; Kass 2003). Because of this, a first step in our
discussion is to scrutinize the distinction between treatment and
enhancement, to see if it can help demarcate where different
melioristic ideals diverge.


Another, perhaps more visible, backdrop for the enhancement ethics
literature is the history of the 20th century eugenics movement, which
attempted to "breed better people" and "improve the
human gene pool" through socially biased reproductive controls
and inducements (Wikler 1999). This background prompts questions
about the cultural authority of science and the social values it can
perpetuate, and raises fears of slippery slopes that can lead to
egregious forms of oppression, by providing a vivid recent
counter-narrative to endorsements of enhancement as a way to fulfill
our obligations to future generations (Sparrow 2011; Selgelid,
2013). The eugenics backdrop tends to skew the burden of proof the
other way in the debate, towards a more "precautionary"
stance that gives advocates of enhancement the burden of
distinguishing their proposals from old style eugenics in order to
defend the parts of that ideology that they share (Kitcher 1997;
Harris, 2007; Agar 2004).


Finally, in the historical foreground for enhancement ethics are
contemporary critiques of the commercialization (and homogenization) of
beauty through "aesthetic medicine" (Bordo 1993), the
evolving history of pharmaceutical performance enhancement in sports
(Hoberman 1992), and the scientific career of human gene transfer and
'genetic engineering' (Friedman 1998). Each of these
stories supports a literature of its own, which has contributed
important insights to the broader discussion of enhancement ethics.
From feminist and disability studies come critiques of the medicalization of
human beauty, focusing on complicity with unjust social norms
that can turn ordinary welfare meliorism on its head to prioritize the
enhancement uses of biomedicine over standard therapeutic applications
(Silvers 1998). Meanwhile, discussions of "doping" in
sport have illuminated the ways in which enhancement interventions can
undermine communal social practices that depend on presumptions of
equality, lifting the discussion above the level of individual choices
and transactions (Murray, 1987; 2009). Similarly the checkered career
of human gene therapy has kept on the table the need to anticipate the
physical risks of putative improvements, and how daunting they would
make the foreseeable prospect of any intergenerational "germ
line" enhancement intervention (Walters and Palmer, 1997;
Kimmelman, 2009).


All of these contextual "back-stories" to the
contemporary enhancement debates are worth exploring further. They
have shaped contemporary thinking about and reactions to enhancement
proposals and provide important cautionary tales to keep in mind when
evaluating those proposals. At the same time, these back-stories bring
their own assumptions and biases into the discussion, and can thereby
complicate a fresh philosophical assessment.


## 2. What are the Proper Limits of Health Care?


While much of the enhancement ethics literature leans towards
thought experiments set in the future, it is grounded in a set of
important debates about how health care should be defined today.
In these debates, the claim is often made that the distinction between
using biomedical tools to combat human disease and attempting to use
them to enhance human traits can provide practical guidance on a range
of issues, including the limits of health professionals'
obligations (Miller, Brody and Chung 2000), the scope of health care
payment plans (Daniels and Sabin 1994), and the prioritization of
biomedical research protocols (Mehlman, Berg, Juengst and Kodish 2011).
In each of these cases, the line between treatment and enhancement is
drawn to mark an upper boundary of professional and social obligations.
Just as the concept of futile treatment is used to indicate the limits
of a doctor's obligations when further intervention no longer can
achieve therapeutic goals, enhancement interventions are thought to
fall outside health care's proper domain of practice by going
"beyond therapy" in pursuit of other non-medical goals.
This means that patients have no role-related right to demand such
services from health professionals, fair insurance coverage plans may exclude
them, and those who do provide them bear a burden of justification for
doing so that does not apply to "medically necessary"
interventions.


As a biomedical boundary marker, the distinction between treatment
and enhancement has been enshrined in policies at both professional and
governmental levels, and continues to inform much of the public
discussion of new biomedical advances. However, this distinction is
explicated in several different ways, which have different merits as
boundary markers for biomedical research and practice. In fact, with
philosophical scrutiny, the distinction often seems in danger of
collapsing entirely under conceptual critiques even before the question
of its moral merits is entertained.


When it is used as a medical boundary concept, enhancement, like
futility, plays both descriptive and normative roles. To use these
concepts, we need to be able to identify our efforts as either futile
or enhancing and we need to know what the boundary means for going
further. Part of the practical challenge for policy-makers
is that for enhancement interventions, these descriptive and normative
implications seem to be at cross-purposes. While futile treatments do
no good, enhancements are by definition and description
*improvements* in personal welfare. Yet, the boundary function
of calling them "enhancements" in health policy settings is
to place them outside of sanctioned interventions. For a field
dedicated to pursuing improved welfare for its patients, the fact that
enhancements often look just like all the other improvements that
health care strives to achieve makes it difficult to discern when an
intervention transgresses the normative boundary that the concept
purports to mark.


This has provoked three major ways of operationalizing the
enhancement concept, each of which seeks to redress the weaknesses of
its predecessor, which are covered in the next three subsections.


### 2.1 Professional Domain Accounts


The first approach to defining the line between treatment and
enhancement appeals to the health professions' conventional
vision of their proper domain. Accordingly, "treatments"
are any interventions that the professional standards of care endorse,
while "enhancements" are any interventions that the
professions declare to be beyond their purview. Attempts by
professional societies to police their own frontiers by discouraging
particular practices as "enhancement" rather than
"treatment" reflect this approach, as do appeals to
"community standards" by health care payers seeking to
distinguish "elective" from "medically
necessary" interventions for payment.


For those committed to a particular account of the goals of health
care, this approach can offer normative guidance for internal
criticism of suspect professional practices (Kass 1985). But of
course, there are numerous competing philosophies of health care, none
of which command universal allegiance within the health
professions. In fact, this approach also resonates well with those who
argue that the health professions have no intrinsic domain of
practice, beyond that which they can negotiate with patients (Good
1994). For those influenced by this libertarian view of professional
autonomy, the normative lesson for professionals concerned about their
obligations in specific cases can be simple: whatever interventions
their patients will accept can be considered "treatments",
while "enhancements" are simply those interventions which
individual health professionals refuse to provide (Engelhardt
1990). Unfortunately, medical historians and sociologists point out
that the health professions have always been adept at adapting to the
cultural beliefs and social values of the institutions and communities
they serve. This is done by 'medicalizing' new problems so
that they come to be seen as a legitimate part of medicine's
jurisdiction (Conrad 2007). Given the health professions'
philosophical pluralism and political autonomy, their own conventions
seem to provide no principled way to exclude new interventions from
their domain. To the extent that useful "upper-boundary"
concepts are required at the policy level (e.g., for societies making
health care allocation decisions) this impotence is an important
failing for this approach to drawing the distinction.


### 2.2 Normal Function Accounts


There is another approach to interpreting the treatment/enhancement
distinction that seeks to provide a firmer theoretical foundation for
delimiting legitimate health care needs. On this approach, to be
healthy is to be able to do all that appropriately matched members of
one's own species can do, in our case what human beings of
similar age and gender can do. Legitimate health care needs or
"health problems" or "diseases" or
"maladies" are all characterized by a fall from that level
of functional capacity. All proper health care services, therefore,
should be aimed at getting people back to "normal", e.g.,
restoring an individual's functional capability to the
species-typical range for their reference class, and within that range
to the particular capability level which was the patient's
genetic birthright. Interventions which take people to the top of
their personal potential (like athletic training) or beyond their own
birth range (like growth hormone), or to the top of the range of their
reference class, or to the top of the species-typical range, or beyond
(!), are all to be counted as enhancements and fall successively
further beyond the responsibility of medicine or health care.


The advantage of the normal function account is that it provides a
single (relatively) unified goal for health care, towards which the
burdens and benefits of various interventions can be relatively
objectively titrated, balanced, and integrated. Normal functionalists
can use physiology to determine when they've achieved the
species typical range and clinical histories to determine when
they've brought a patient up to the baseline of his or her
personal capability range.


Some critics of the normal function approach take issue with its
focus on the "species-typical range", arguing that it is
insensitive to the diversity of ways in which human beings can
flourish in life. They point out that those born with disabilities may
be wary of biomedicine's "fatal attraction to
normalizing".( Silvers, 1998; Asch and Block, 2011) Moreover,
even when no amount of treatment can give someone "species
typical" functioning, there may be compensatory technologies
that can actually expand their range of opportunities beyond the norm
(Silvers 1998). Should powered wheelchairs be designed to slow and
stop at the same distance that walking humans would succumb to
fatigue, in order to keep them from "enhancing" their
users' abilities? By the same token, the naturally gifted may
find that they have no claim to treatment for injuries or accidents
that merely bring them down into the "normal range". If
our champion thinkers, athletes and saints can legitimately claim
treatment for problems that impair their species-optimal functioning,
bringing the rest of us up to their levels should count as proper
health care as well. But that leaves only the most extreme
improvements on the other side of the "enhancement"
boundary: if our species champions are the benchmark, only
interventions that create capacities no human has had before would
fall beyond medicine's proper domain. Individualizing the
optimal functional range to individual genomic potentials will not
resolve this problem, of course, to the extent that our genomes
themselves become biomedically malleable. Establishing the
"species-typical norm" for a particular human function is
a difficult enough task, even where descriptive statistics can
help. But when the boundary is "optimal" not
"normal" functioning, the evidentiary foundations of the
approach begin to come apart (Sculley and Rehman-Sutter 2008).


The second serious problem for the normal function approach is the
challenge of prevention. While some efforts at health promotion, such
as exercise, straddle the border of medical responsibility, many
preventive interventions (i.e., vaccines) are widely accepted as
legitimate parts of medicine's mission and are located squarely
on the treatment side of the enhancement boundary. One of the ways to
prevent disease is to strengthen the body's ability to resist
pathological changes before any diagnosable problem appears. But to the
extent that prevention attempts to elevate bodily functions above the
normal range for the individual (and, in some cases, even the species
typical range), it seems to slide into what the normal function
approach would call enhancement. If the normal function account is
taken seriously as a biomedical boundary marker, how does one defend
this kind of prevention? Conversely, if preventive interventions like
these are acceptable in medicine, what can it mean to claim that
researchers and clinicians should be "drawing the line" at
enhancement?


### 2.3 Disease-Based Accounts


Probably the most common rejoinder to the problem of prevention is
to distinguish the problems to which they respond. Treatments are
interventions that address the health problems created by diagnosable
diseases and disabilities--"maladies" in the helpful
language of Gert, Culver and Clouser (2006). Enhancements, on the
other hand, are interventions aimed at healthy systems and
traits. Thus, prescribing biosynthetic growth hormone to rectify a
diagnosable growth hormone deficiency is legitimate treatment, while
prescribing it for patients with normal growth hormone levels would be
an attempt at "positive genetic engineering" or
enhancement (Berger and Gert 1991). On this account, to justify an
intervention as appropriate medicine means to be able to identify a
malady in the patient. If no medically recognizable malady can be
diagnosed, the intervention cannot be "medically
necessary" and is thus suspect as an enhancement. This would
clear the way for safe and effective genetic "vaccines"
against predictable muscle damage (even if they provided better than
normal damage resistance) but would screen out as
"enhancements" efforts to improve traits that were at no
diagnosable risk of deterioration (Juengst 1997).


These accounts have the advantage of being simple, intuitively
appealing, and consistent with a lot of biomedical behavior. Maladies
are objectively observable phenomena and the traditional target of
medical intervention. We can know maladies through diagnosis, and we
can tell that we have gone beyond medicine when no pathology can be
identified. Thus, pediatric endocrinologists discourage enhancement
uses of biosynthetic growth hormone by citing the old adage "If
it ain't broke, don't fix it". This interpretation is
also at work in the efforts of professionals working at the boundary,
like cosmetic surgeons, to justify their services. They claim to be
relieving "diagnosable" psychological suffering
("mental maladies") rather than satisfying the aesthetic
tastes of their clients, and insurance companies insist on being
provided with that diagnosis before providing coverage for such
surgeries.


On the other hand, disease-based accounts also face at least two
major difficulties. The first is one they share with the Professional
Domain account: the problem of biomedicine's infamous nosological
elasticity. It is not hard to coin new maladies for the purposes of
justifying the use of enhancement interventions (Carey, Melvin and
Ranney 2008). Unless some specific (and usually contentious) theory
of disease is employed to give this approach its teeth, it puts the
power for drawing the boundary back into the profession's hands,
and raises the same worries about the social consequences of
medicalization (Parens 2013).


The more important practical problem is that no matter how the line
is drawn, most biotechnological interventions that could be seen as
problematic if used as enhancements will not need to be justified as
enhancements in order to be developed and approved for clinical use.
This is because most such interventions will also have legitimate
therapeutic applications. Indeed, most biomedical tools with potential
for enhancement uses will first emerge as therapeutic agents. For
example, general cognitive enhancement interventions are likely to be
approved for use only in patients with neurological diseases. However,
to the extent that they are in high demand by individuals suffering the
effects of normal aging, the risk of unapproved or "off-label" uses
will be high (Whitehouse, et. al, 1997).


This last point is critical for policy purposes, because it suggests
that, in countries like the USA, the real challenge may not be
regulation of the development of enhancement interventions, but rather
the regulation of downstream "off-label" uses of
therapeutic interventions for non-medical, enhancement purposes. The
policy problems then become problems about controlling access and use
of certain interventions, rather than their development. Of course, the
fact that a certain type of intervention is declared illegal for
physicians to dispense, does not immediately imply that it should be
immoral for everyone to pursue or other competent professionals to
provide. These realities have pressed those who would use the
treatment/enhancement distinction for policy purposes to articulate the
moral dangers of biomedical enhancement more clearly. Even if doctors
eschew such use on professional ethical grounds, are there independent
moral reasons why individual athletes, parents, students or other
"consumers" of enhancement interventions, should turn away
from their availability?


## 3. Is it Cheating to Use Enhancements?


One of the kinds of human enhancement that has received extensive
philosophical attention in recent years is the use of biomedical interventions to
improve the physical performance of athletes in the context of sports
(Miah 2004; Murray 2009; Tolleneer 2013). One reason athletic
performance enhancement garners so much attention is because of its
currency, given the epidemic of "doping" scandals in
contemporary sport. Another reason, however, is that it seems to serve
as a paradigm case for teasing out important dimensions of the problem:
it involves measurable improvements in biological capacities in a
social context that is both well outside health care and defined by
clear rules of engagement.


At first impression, the ethical problem with performance
enhancement in sport would seem to be simply a problem of cheating
(Schermer, 2008a). If the rules of sport forbid the use of performance
enhancements, then their illicit use confers an advantage to users
against other athletes (who either accept the rules of the game or do
not have access to the enhancement interventions). That advantage, in
turn, can create pressure for more athletes to cheat in the same way,
undermining the basis for the competitions at stake and exacerbating
the gap between those who can afford enhancements and those who cannot
(Murray 1987, Sparrow 2015). Extrapolating from sports to a
competitive view of society at large, critics argue that the social
acceptance of enhancement interventions in other spheres would also
create unfair advantages for those with access to them, and perhaps
lead to the development of new social divides between classes of
"genobility" and the "genpoor", raising
fundamental justice and human rights concerns (Mehlman 2003, 2009;
Buchanan, Brock, Wickler and Daniels 2000; Sparrow 2011).


 
Much of the rhetoric about "doping" assumes the very
claim that needs to be established by argument: that the rules of
sport (or the norms of social advancement) ought to ban the use of
biomedical enhancement. The rules of a game can be changed. In sports,
novel forms of performance enhancing equipment and training are
routinely introduced as athletic technology and expertise
evolve. Where issues of athletes' equitable access arise, they
can be dealt with in one of two ways. Sometimes it is possible to
ensure fair distribution, as for example, when the International
Olympic Committee negotiated an agreement with the manufacturer of the
new "FastSkin" swimming suit to provide suits to all the
teams at the Sydney Olympics. In other cases, inequalities may simply
come to be accepted as unfortunate but not unfair. This is, for
example, how many people would view a story about an equatorial
country that could not afford year-round artificial snow for its ski
team, and so could not compete evenly with the ski teams of northern
countries. If enhancement interventions can either be distributed
fairly or the inequities they create can be written into the rules of
the social game in question as part of the given advantages of the
more fortunate, then individual users no longer face a fairness
problem. For those who can afford it, for example, what would be
ethically suspect about mounting a mirror image of the "Special
Olympics" for athletes with disabilities: a "Super
Olympics", featuring athletes universally equipped with the
latest modifications and enhancements? (Munthe 2000) For answers to
that challenge, the critics of biomedical enhancement have to dig
beyond concerns about the fair governance of games to a deeper and
broader sense of "cheating", in terms of the corrosive
effects of enhancement on the integrity of admirable human practices
(Loland 2002; Schermer 2008a).


On this view, to the extent that biomedical shortcuts allow specific
accomplishments to be divorced from the admirable practices they were
designed to reflect, the social value of those accomplishments will be
undermined. If one's good grades are gained by drug fueled
"cramming" rather than disciplined study, their value as
evidence of learning diminish. This means that for institutions
interested in continuing to foster the social values for which they
have traditionally been the guardians, choices will have to be made.
Either they must redesign their games to find new ways to evaluate
excellence in the admirable practices that are not affected by
available enhancements, or they must prohibit the use of the enhancing
shortcuts. However, knowing which way to go suggests that one has a
theory of the social practice at risk and of the values that animate
it. The case of sport again leads the way down this path in the
literature, perhaps because, unlike most important social practices
that might be susceptible to enhancement shortcuts (like child-rearing,
education, love, politics, and spiritual growth), the stakes are
low enough to allow for some deliberate policy-making at the
international level.


For example, one prominent theory that has influenced the work of
The World Anti-Doping Association (WADA), the international
organization committed to policing performance enhancement in elite
sport, is the view that "just as healing is the point or goal or
end of surgery, so the virtuous perfection of natural talents is the
point or goal or end of sport" (Murray 2009). This statement has
several important features for the enhancement debate. Sport is
concerned with celebrating differences in natural talents and the
virtues that can be displayed in attempts to differentiate one's
own talents even further. The virtues that sport celebrates are
socially admirable habits and traits in and of themselves, and their
promotion is what gives sport social value as a practice. However,
within the practice, the virtues are instrumental (as either
side-constraints or facilitators) to the perfection of the
athlete's natural talents--i.e., to their differentiation
from other people's talents. Although the key role of
hierarchical ranking in sport is often ignored in the rhetoric of
sports organizations, philosophers of sport acknowledge that fixation
with hierarchical ranking--with competition, contest,
score-keeping, record-breaking, championship, victory and
defeat--is pervasive in the everyday practice of sport (Coakley
1998) and that "comparing and ranking two or more
competitors...defines sports characteristic social
structure" (Loland 2002, 10). Sport creates a system of values,
virtues, and practices that are designed to hierarchically grade people
in terms of their (virtuously perfected) inherited traits and glorifies
the best specimens as champions. What is unfair about enhancement, on
this view, is that enhancement interventions undermine the ability of
sport to distinguish those who passively inherited their talents from
their progenitors from those who actively acquired them from their
physicians (Sandel 2004).


But this outcome seems to display the very problem that the
fairness critique of enhancement was meant to combat: the danger of
fomenting distributive injustice by creating social hierarchies of
advantage on arbitrary grounds (Tannsjo 2000;
Tannsjo 2005). On one hand, of the many ways humans use
inherited traits to create interpersonal hierarchies, athletic
competition is amongst the most benign. When it is "just a
game", comparative interpersonal ranking in terms of genetic
identity in sports is a welcome substitute for blood feuds, racism,
and genocide. But when sport becomes a matter of national pride and a
source of economic opportunity, athletic losers risk more than simply
admiration and social status: like insurance applicants with genetic
susceptibilities, less naturally talented athletes risk access to
important social benefits and potential life plans. In this regard,
the challenge that performance enhancement poses to sport is its
indictment of the accepted social practice itself rather than its
threat to undermine it. The availability of biomedical abilities to
undermine competition simply raises the question: are there ways to
enjoy, appreciate and even show off our bodies and abilities without
requiring someone else to lose social standing on genetic grounds?


For the case of sports, it seems like this line of fairness
arguments ultimately backfires on the critics of enhancement. It opens
the door to thinking about enhancements as means to render the practice
more rather than less fair. Whether or not fairness arguments would
have a similar effect in debates about enhancement in the realm of
other social practices, like parenting or diplomacy, is still an open
question. But the theme of "cheating" has also been taken
in another direction by the enhancement ethics literature, into
concerns about the authenticity of accomplishments achieved with the
help of enhancements and the integrity of the enhanced individuals that
claim their rewards.


## 4. Do Enhancements Compromise Authenticity?


The intuitive worry of authors who take this question seriously is that
biomedical enhancements might not only create corrosive short-cuts
within valuable social practices, but also rob those who use them of
things they otherwise cherish about themselves--endurance,
determination, growth, faith, even luck--by substituting "hollow
victories" for authentic achievements. Losing the
experience of authentic achievements, in turn, diminishes the character
of the user (Sandel 2007), alienating them from themselves and those
around them (Agar 2013), and diminishing bonds of solidarity with
non-users (Sparrow 2014). Unpacking this intuitive concern into
arguments can take multiple paths. It matters, for example,
whether the actors are parents enhancing their children or adults
enhancing themselves (Habermas 2003), and whether accepted therapeutic
uses of the same tools should face the same critique (Elliott
2011).


In order to decide whether particular enhancements compromise
authenticity in the ways that these authors suggest, it is important to
be clear about what kinds of things are the appropriate targets of
attributions of authenticity. Do enhancements undermine the
authenticity of one's self, agency, achievements or actions?
Authenticity is widely understood to be a matter of being "true
to oneself". Many authors in these debates do not take the time
to carefully explicate their assumptions about "the self" and what it
takes to be "true to" it. It is, of course, a challenge to
characterize the self to which authentic individuals are true
(Trilling, 1971; Taylor 1991; Guignon 2004). If there is a self,
then there are difficult synchronic identification questions (i.e., at
a given time, what features are constitutive of an agent?) and
diachronic identification questions (i.e., across time, what features
must persist in order for the self to survive?) that must be resolved.
Derek Parfit, working in a tradition of "bundle theories of the
self", articulated the influential position that a person is
nothing over and above a series of person-stages that are linked across
time by certain psychological continuity relations (Parfit 1984). Given
the controversy surrounding these debates about the nature of persons
and personal identity, it is no surprise that there is little consensus
about whether enhancements undermine authenticity of the self.


In the enhancement debate it is important to distinguish the
concerns and the arguments that are provided for and against the moral
and ethical significance of various types of enhancement. In this
particular domain, the rhetoric is often intense and feverish and it
is important to be mindful of whether one is examining a
*concern* or an *argument* about the moral
permissibility of a particular kind of enhancement (Buchanan
2011). While evaluating these authenticity concerns, it is helpful to
bear in mind the scope of the authenticity concern under
scrutiny. That is, it is important to be clear about whether the
authenticity concern that is being expressed purports to (1) show
that all enhancements are immoral, (2) show that most
enhancements are immoral, or (3) show that a particular
enhancement is, or would be, immoral (Buchanan 2011).


One style of argument for the claim that enhancements undermine
authenticity is to contend that we could claim no personal credit for
accomplishments that are the result of biomedical enhancements,
because the biomedical interventions that caused improvements in our
capacities would supersede our own agency in authoring the achievement
(Sandel 2007). Defenders of this perspective argue that while, for
example, education, training, and practice proceed through
"speech and deeds" that are comprehensible by those who
are learning a new skill, when biomedical enhancements are used they
have "their effects on a subject who is not merely passive but
who plays no role at all. In addition, he can at best feel their
effects without understanding their meaning in human terms"
(Kass 2003, 22). One reply to this argument is that if one has freely
chosen to use an enhancement on the basis of "speech and
deeds", it is unclear how those enhancements are passive or less
authentic than traditional methods of improving one's capacities
(Kamm 2005). Moreover, just as we hold those with enhanced abilities
to higher standards of responsibility for negligence and harm (Mehlman
2003), our expectations for enhanced achievements may be
correspondingly high (Carter and Pritchard 2019). But in both
situations neither the enhanced actors' agency in improving
themselves nor their authorship of the results seems to be in question
(Cole-Turner 1998).


Other critics of biomedical enhancements that appeal to
considerations of authenticity acknowledge that enhanced individuals
do author their accomplishments, but question whether those successes
carry the same value as "authentic" unenhanced
achievements (Habermas 2003; Sandel 2007; Bublitz and Merkel
2009). They maintain that when a marathon runner gains endurance
chemically rather than through training, or when a mystic gains
Nirvana through psychosurgery rather than meditation, each misses the
point of these types of accomplishments. In the cases of marathon
running and meditation, the outcomes of the activity cannot be
separated from the activity itself: the value of the accomplishment
lies in the personal activities they reward as well as the benefits
they bring (Schermer 2008a; Spitzley 2018). However, even if these
criticisms show that authentic, unenhanced achievements are valuable
for reasons that do not apply to the enhanced achievement, they do not
show that the unenhanced approach is, overall, better. Such criticisms
merely establish that the two are valued differently. It is still
possible that the enhanced achievement may have its own distinctive
type of value. As the history shows, the character-building struggles
that we admire seem adept at keeping pace with our tools. Legend has
it that Celtic warriors eschewed body armor (and even clothing!) in
battle because they thought it diminished the glory of a true
victory. Some authors used to insist that keyboards corrupt the
writing process. According to this historical narrative, biomedical
enhancements have provided humans with important tools for
self-creation that should be embraced (DeGrazia 2000; Agar 2004).


Another set of authenticity concerns arises in arguments that focus
on enhancement interventions performed by parents in conceiving and
raising their children (Habermas 2003). Here, the claim is that
offspring who have no agency in deciding whether or not to be enhanced
are (existentially) cheated of their authentic identities and the
autonomy to create themselves as others normally do. Taken literally,
this argument runs into the logical problems of identity that plague
"wrongful birth" suits in the law (these children have no
prior identity to lose), and depends on too extreme a version of
genetic or biological determinism to be credible, given the plausible
causal efficacy of any of the possible enhanced interventions under
discussion (these children's futures are no more restricted than
any other participant in the natural genetic lottery) (Buchanan 2011).
As a result, a more common approach is to use such claims to draw
attention to parental or social attitudes about procreation and
parenting that seem morally problematic, whether or not their offspring
are directly harmed or wronged by being enhanced (Davis, 2010)
Evaluating these arguments also requires one to get clear about the
nature and scope of the moral right to be a parent and the duties of
parents to their children (LaFollette 1980; Liao 2006a).


## 5. Are Enhancements Dehumanizing?


In the background of the debates over both the boundaries of
medicine and the ethics of self-improvement looms a third important
set of philosophical concerns, which are about the implications of new
biomedical enhancement interventions for our common understanding of
human nature and the future of our species. Critics emphasize
"dystopian nightmares" and worry that enhancement
interventions may rob us of central normative features of our identity
as human beings (Mehlman 2012). Enhancement enthusiasts, on the other
hand, embrace the possibility that biomedicine might change human
nature for the better, and some even look forward to the emergence of
the trans-humans or post-persons as the next step in (intentionally
directed) human evolution (Bostrom 2003; Harris 2007). At stake in
these debates is whether, or how much, normative weight to assign
features of the human condition that have traditionally been taken as
given (e.g., the families into which we are born and our natural
talents and abilities) or inevitable (such as, pain and ageing).


Moral philosophy has a long history of making normative appeals to
human nature. There are thorny philosophical issues about whether such
appeals are ever legitimate. Even since David Hume warned us not to
derive an "ought" from an "is", philosophers
have been wary of making strong inferences about what ought to be done
directly from claims about human nature. However, the tradition of
virtue ethics is much more comfortable with adopting a naturalistic
approach that holds that human nature is the basis for what
constitutes human well-being and the virtues (for human beings)
(Fitzgerald 2008; Keenan 1999). Explaining what is worth cherishing
about being human is an intuitive starting point for making sense of
ourselves, our relationships with other human beings, and the world
around us. The task of getting clear about what we do and should value
about being human has important implications for the ethics of
biomedical enhancements.


Three features of human nature are at the center of many debates about
the ethics of biomedical enhancement. The first feature is human
vulnerability. According to one prominent view, human beings are
creatures that suffer, age and die, and our struggle to deal with this
vulnerability is a central aspect of what makes human life valuable
(Parens 1995). There are several sub-groups within the group of
theorists that emphasize the value of vulnerability in understanding
the value of being human. The first group consists of "life cycle
traditionalists" who criticize ambitions to control the human
ageing process and extend the human life span (Callahan 1995). The
second group consists of the "personalists", who valorize
the way in which human limitations are humbling and encourage modesty
(Fitzgerald 2008). The third group consists of
"psychopharmaceutical Calvinists" who discourage easy fixes
to melancholy and sadness (Elliot 1998). The second feature of
human nature that is emphasized in these debates is discussed by
species preservationists and environmentalists who stress our
embodiment and place in nature alongside other organisms: "by
nature", we are biological creatures of a particular family,
defined by painfully evolved "species barriers", and
enhancements that blur or bend those boundaries by "directing
evolution" do so at our peril (McKibben 2004). The third feature
of human nature that is often discussed in these debates is our
sociality. According to these theorists, human beings are social
creatures that relate to one another through a complex nexus of
interpersonal commitments and hierarchical structures (Liao 2006a; Liao
2006b). Many sports theorists see the "virtuous perfection of
natural talents" as the goal of athletic competitions. If one
accepts this view, then victories fueled by biomedical enhancements
that subvert the natural interpersonal hierarchies that genetic
disparities in talent create can literally "dehumanize"
sport (Tolleneer, Steryck and Bonte 2013).


Each family of theories described above that emphasizes a feature
of human nature as the basis for its position in the enhancement
debate utilizes a tool that is double-edged. As defenders of
trans-humanism point out, each feature of human nature that can
produce positive value for humans can just as easily be a source of
human misery, which the history of technological progress has been
legitimately concerned with alleviating (Juengst 2004). In fact, the
enthusiasts argue, there are no static features of the human
condition: human vulnerabilities to our environment have steadily
decreased over history, our moral kinship communities have expanded,
and our tolerance for oppressive forms of social organization has
dwindled (Bostrom 2003). Accordingly, to appeal to these features of
human nature in abstraction cannot be helpful in deciding which
vulnerabilities to honor, which family loyalties to respect, and which
social arrangements to defend and develop. Where a biomedical
intervention alters one of these dimensions of human nature, this is a
signal that the moral stakes are high. But those stakes are not always
about what might be lost from the human experience. There are also
moral dangers in what might be perpetuated, if we allow the
preservation of these hallmarks of human nature to overshadow our
other values.


One popular response to the enthusiasm of the trans-humanists is to
draw a line against interventions that might take their recipients out
of our biological species altogether. This is usually framed as a
minimal proposal to ban the clearest possible cases of immoral
manipulation, on which everyone could agree. From proponents of
"responsible genetics" (Council for Responsible Genetics
1993) to defenders of our "genetic patrimony" as the
"common heritage of all humanity" (Knoppers 1991), to the
"anti-post-humanist" life cycle traditionalists, the
prospect of "species altering experiments" which might
"direct" human evolution is provoking resistance (Mehlman,
2012).


A classic example of this resistance is the appeal for a UN
convention on genetic technologies framed in terms of "the
preservation of the human species" (Annas, Andrews, and Isasi
2002). Its advocates claim that any intervention that would
"alter the essence of humanity itself by taking human evolution
into our own hands and directing it toward the development of a new
species sometimes termed the "post-human" should be
considered a "crime against humanity" because it would
undermine the "foundation of human rights" and set the
stage for human extinction.


Of course, species are not static collections of organisms that can
be "preserved" against change like a can of fruit; they
wax and wane with every birth and death and their genetic complexions
shift across time and space (Robert and Bayliss 2003; Juengst
2017). In our case, almost everything we do as humans has
ramifications on that process. To argue that everyone has the right to
inherit "an untampered genome" only makes sense if we are
willing to take a snap-shot of the human gene pool at some given
instant, and reify it as the sacred "genetic patrimony of
humankind"--which some come close to doing (cf. Mauron and
Thevoz 1991). 


There is a risk here of confusing the biological sense of
"human" as an taxonomic term (like "canine" or
"simian") and the word's normative use, as in
"human rights". In the biological sense,
'human' refers to the biological species *homo
sapiens* and to be human is to be a member of this biological
species. In the evaluative sense, 'human' refers to a
property that is the basis for having certain moral rights and a
particular kind of moral value. Obviously it is not enough to be
biologically human to enjoy human rights: human tissue cultures and
human cadavers show us that. Is it even necessary to be biologically
human to enjoy what we call human rights? There are many candidates for
the natural qualities that are the basis for moral rights, but none
hinge on a biological designation. So why is it that interventions that
"alter the species" "might cause the affected
children to be deprived of their human rights"?


Other opponents of directed evolution extend the argument
further. They acknowledge that post-humans may be capable of
claiming the same natural rights as humans by virtue of their
capacities, but argue that creating such a species would challenge the
notion that being human is sufficient for claiming those rights, in the
same ways that discovering rational extraterrestrials would. This, in
turn, would potentially disenfranchise the humans, like infants or the
mentally disabled, who cannot show adequate functional capacities to
qualify for equivalent species-neutral moral status. At the same
time, they argue, if the post-humans actually have expanded capacities,
they may claim natural rights to a proportionately expanded range of
opportunities and freedoms, beyond those to which normal humans are
entitled. This runs the risk of creating the kinds of oppressive
hierarchical society against which human rights are supposed to be the
antidote, and, potentially, to the return of coercive eugenic programs
aimed at the eventual extinction of the human species (Fukuyama, 2002;
Mehlman, 2012). 


Others point out that while the conceit that our human species
could be preserved forever is as absurd as the hope of individual
immortality, those facts provide no reason to accelerate either
senescence or evolution (Robert and Baylis, 2003; Agar 2013). Even in
the face of the inevitability of a post-human species, they argue, we
are justified in protecting our (admittedly)
"species-relativist" values by rejecting enhancements that
would serve to alienate their recipients from their former selves,
their families, and their communities. Normal evolutionary processes
provide the luxury of time for human populations to
"negotiate" their adaptations with the environments that
provoke them. Leaving evolution to these normal processes can thus
ensure that our evolution is both as deliberate and as tentative as
our species' technological history--and also that it is
like technological history in that key "threshold" changes
can only be seen retrospectively. From this perspective, the danger is
the abrupt provocation of biological speciation which radical
enhancements might provoke, if they created reproductive barriers
between the enhanced and the unenhanced. However, given that almost
none of the single capacity enhancement interventions under
discussion--cognitive, physical, moral, etc. --are likely to
immediately produce biological reproductive barriers in otherwise
species-typical enhanced humans, it is not clear whether the
introduction of even the most "alienating" enhancements
would create this risk. 


Finally, just as it is metaphysically impossible to
"preserve" our species from further evolution, it is
impossible for us to control the process "from the inside
out", because the genetic constitution of our species is shaped
by environmental forces of selection beyond human abilities to control
or even, as the phenomenon of emerging epidemics continues to
illustrate, anticipate. Moreover, as disability studies scholars point
out, humanity is in no better place to decide which human traits
deserve promotion today than during the heyday of the Eugenics
movement, even if society could tolerate the kinds of reproductive
policies it would require to manage just the human part of the
evolutionary equation. The striking correspondence between the
aspirations of old style Eugenicists and some proposals of
contemporary Transhumanists, unfortunately, provides some evidence to
back up this claim (Sparrow 2011). Such proposals assume that some
genotypes represent "jewels in the genome" (Sikela 2006)
while others constitute a form of expensive "toxic waste"
that could and should be cleansed from the gene pool (Buchanan, Brock,
Wikler, and Daniels 2000). According to critics of transhumanism, this
way of thinking reduces the identities of people to their genotypes,
and undermines our commitment to the moral equality of people despite
their biological diversity (Asch and Block 2011).


As hard as they are to rationally reconstruct, it is important to
listen to concerns that some form of biomedicine violates
human nature, even in public discussions of policy within a
pluralistic society. Whether the concern is the distortion of some
constant of the human condition, like senescence, or a "species
altering" threat to our collective gene pool, or the corruption
of practices designed to celebrate the inherited human traits we value
most, these appeals all signal that the intervention in question has
deep implications for who we want to be, given who we have
been. However, respecting what we have (or have not) inherited from
our parents does not in itself fulfill the need to decide which
promises we would like to make to our children. Invocations of
particular vulnerabilities, loyalties, or forms of sociality from the
past can provide fodder for arguing over the positive visions of human
nature that should guide those promises. But in communities that
accept the possibility of a pluralism of promises, such invocations
should also trigger another policy-making response: the need for
policy-makers to protect the interests of those excluded from their
visions, even while we discuss their merits. The natural human gene
pool has no top, bottom, edges or direction: it cannot be "used
up", "diverted", "purified" or
"polluted". The reservoir of human mutual respect, good
will and tolerance for difference, however, seems perennially in
danger of running dry. That is our human nature's truly fragile
heritage that we should seek to preserve--and some say even
enhance--in monitoring biomedical research on behalf of the
future.


## 6. Conclusion: Policy Perspectives


Nothing in the current debates over the ethics of human enhancement
convincingly supports the conclusion that the impulse that drives interest
in biomedical enhancement is inauthentically human or morally evil. To
the extent that all technology is construed as an effort to extend and
improve our inherited human capacities, the impulse to enhance
ourselves is a hallmark of our species, as legitimate to celebrate as
to disparage. On the other hand, just as specific technologies are
never "value neutral" in their design or use, specific
applications of biomedical human enhancement can be dangerous, unfair,
or vicious. Thus, it is reasonable to endorse the generic claim that
biomedical enhancement is morally acceptable as a human practice, and
still argue that specific biomedical enhancements would be unethical to
pursue.


As with other potent technologies, at some level the potential harms
of unethical enhancements will also justify social efforts to formally
control their development and use through regulation, law and public
policy. Even though this topic moves quickly beyond the biomedical
domain to fundamental tensions in political and social philosophy, it
does preoccupy enough of the practical ethics literature on biomedical
enhancement to warrant a brief concluding discussion here.


Some argue that firm lines should be drawn in public policy and
professional practice, against particular *degrees* of
enhancement, like "species-altering interventions" (Annas,
Andrews and Isasi, 2002) or "radical enhancements" (Agar
2013). The assumption here is that the moral problems raised by
enhancement intensify as the enhanced move away from the human norm,
and that a threshold can be identified beyond which prohibition would
be merited. Since drawing the line at all enhancement uses of
medical technologies would founder against too many contentious
borderline and benign cases, this threshold is usually set at the
boundary of our species identity, between the human and the
post-human. As we have seen, this leaves many problematic
enhancements in particular settings--like "gene
doping" in sports--unaddressed, and it is still not clear
what moral salience sheer taxonomy can have, apart from other ethical
considerations--especially when one recalls the pernicious
policies other human taxonomies have supported in the past. In
practice, such an approach would face all the classic line-drawing
problems, and the classic challenges of policing and enforcing
prohibitions in a pluralistic and globalized society. Most importantly,
however, if it is only those alterations that literally produce new
biological species that are of concern the vast bulk of potentially
problematic enhancement modifications would not fall within the
jurisdiction of this approach. 


At the other extreme are those who support a libertarian position,
eschewing any blanket public regulation of enhancement in favor of
free markets involving those who would develop enhancement
interventions and individuals who would use them (Engelhardt 1990;
Flanigan 2017). But this extreme position suffers the familiar
drawbacks of unregulated market economies: a toleration of severely
harmful transactions (e.g., purchasing tickets to a match of
gladiatorial combat), the exacerbation of economic inequalities, and a
permissive stance to transactions with long-term adverse consequences,
which lead to "tragedies of the commons" and environmental
devastation. As a result, even the more permissive authors qualify
their "utopian eugenics" proposals with the sorts of
regulatory protections that surround other consumer products in
free-market societies, in terms of safety, fraud, fair pricing and
environmental protection (Bostrom 2003), and argue that the political
justifications for those policies should support equivalent social
controls for enhancement interventions (Kitcher 1997; Harris
2007). Even with minimal legal regulations in place to ensure that
markets for biomedical enhancement technologies will be
"free", the libertarian emphasis on the legal
permissibility of these transactions is a blunt instrument for dealing
with the subtle ethical complexities involved in deciding whether to
use a particular enhancement technology.


Between the extreme positions of prohibition or an open market is a
moderate position, which grounds enhancement policy in three of the
observations we have made in our conceptual and ethical analyses
above:


First, policy will need to focus on governing the uses of technology
rather than preventing its development in the first place. This is
because of the conceptual flexibility of the boundary between
enhancement and treatment. Almost all potential enhancement
interventions will be developed first as interventions to treat or
prevent human health problems, pursuing goals that will easily offset
their potential unethical applications. Beyond that, even to
assess the potential harms of enhancement applications of approved
medical interventions will require research, even if it also helps pave
the way for their use. This means that interventions capable of being
used for enhancements will be inevitably invented and perfected as
by-products of biomedical scientific progress, and their social control
will have to focus on governing their dangerous, unjust or vicious uses
(Mehlman 1999).


Second, there are at least two possible responses to harmful
interventions, and policy-makers should keep both in mind. If one
won't work, the other approach *may*. On the one hand, one
can try to police and punish unauthorized uses of technology, or
alternatively one can focus on protecting the interests of those
disadvantaged by those uses. Thus, in sports, authorities screen for
and punish "doping" athletes, because they cannot fix the
essential genetic injustice of the spirit of sport. In the workplace
and in higher education, on the other hand, there may be more concern
to reduce the competitive stresses that would tempt people to rely on
stimulants rather than their native talents. In families and schools,
moreover, allowances are often made for those less capable in some
domains, like sports or music, in order to compensate for their
disadvantages there by enabling them to flourish in others. Affirmative
Action campaigns, the Americans with Disabilities Act, and other civil
rights policies also attempt to "level the playing field"
in ways that compensate for disadvantaging biological differences
rather than attempting to regulate the differences themselves. If we
are not interested in policing the enhancement uses of biomedical
technology, we may want to explore whether strategies like these might
work to undercut the incentives to enhance in unethical ways.


One trap that some authors have fallen into in pursuing this
compensatory course is to try to use the enhancement shovel to dig out
of the enhancement hole. Worried that an unregulated surge in
biomedical enhancement might open the door to injustice and social
harm, some are now arguing that the prerequisite for widespread access
to enhancement should be the widespread enhancement of our moral
faculties. Improved moral discernment and reasoning, keener senses of
empathy and fairness, and deeper sense of solidarity, it is argued,
will help mitigate the potential social harms by insuring that the
users of enhancement are equipped to do so responsibly (Tennison, 2012;
Persson and Savulescu 2012).


The irony of this argument, of course, is that accomplishing these
prerequisite moral upgrades would require a social gate-keeping system
as intrusive and draconian as any attempts to police the use of
particular enhancements themselves (Sparrow 2014b; Harris 2016;
Azevedo 2016). It would also open to debate the criteria by which such
moral upgrades would be made (Joyce 2013; Craigie 2014; Wiseman 2016;
Hauskeller and Coyne 2018; Johnson, Bishop and Toner 2019; Paulo and
Bublitz 2019). Would we still allow the enhanced to follow normal
views of when the obligatory becomes supererogatory, or expect more of
them? Presumably, we need not aspire to require superhuman virtues,
such as angels might possess. But should they at least be saints?
Against whose account of sainthood? Once again, the panorama of
alternative philosophical traditions opens up for exploration down
this road, offering no quick resolution for policy.


However, it is worth remembering at this point that particular
biomedical enhancements will never yield comprehensive improvements in
moral character, if only because moral character is not reducible to
its biological substrates in people's brains and
genes. Instead, enhancement will at best be able to change
specific biological functions in ways that improve the chances that a
person will act in a particular manner, like telling the truth, at the
expense of reducing the chances of some other reaction, like lying,
which, in particular circumstances, may actually be the more virtuous
thing to do. This piecemeal, double-edged feature of biomedical
enhancement means that every morally enhancing intervention runs the
risk of being a morally disabling intervention at the same
time.


This point suggests a third observation from our review: despite
the claims of its defenders, biomedical enhancement is not a practice
that is not always especially well-suited to a melioristic ethic aimed
at improving human welfare. Often a step forward for some purposes is
also a step back in other contexts. Many enhanced people are
correspondingly disabled, and so by extension are their teams,
families, communities, etc. Consider, for example, an enhancement that
makes our reflexes faster. Such an enhancement might increase the
risk of making mistakes in ways that would be considered an acceptable
trade-off for military pilots on solo combat missions, but not for
commercial pilots ferrying hundreds of passengers. If our policies
were to focus on reminding us that most enhancements come with
trade-offs, we might be able to orient our public policy away from
either regulatory or compensatory approaches keyed to
"enhancement" in the abstract, and towards the specific
social and institutional contexts in which particular enhancement
interventions might be considered too risky or unfair. Should, for
example, the Air Force consider the post-service consequences of a
hyper-reflex enhancement for pilots in deciding whether to adopt such
an intervention? Should enhanced veterans be able to claim
accommodation from employers for their service-induced
hyper-responsiveness?


Focusing on trade-offs does not imply that no change is the best
policy; there is nothing sacred about the biology we inherit. Some
enhancements may well be worth attendant deficits in particular
situations for particular individuals. But just as our inherited
biology provides no definitive criteria for "human nature"
that can be used to curtail enhancement, enhancement cannot take our
future biology down any path that offers unequivocal improvement in
the human condition.


But would a pluralistic and piecemeal approach to governing the
enhancement uses of medical technologies serve the broader needs of
distributive justice with respect to enhancement interventions that
are deemed acceptable in particular settings? As the enhanced use
their improved capacities to gain power, wealth and status, justice
might require that access to those enhancements be afforded more
broadly, at least for those willing to bear the corresponding deficits
(Sparrow 2016). Some authors have argued that a fair system of
allocating enhancement opportunities will require a centralized,
global agency akin to the World Trade Organization or the
International Monetary Fund, capable of adjudicating all the interests
involved (Buchanan 2011). But the assumption behind such proposals
remains that "enhancements" will always give people
fungible advantages over others, like wealth does. It remains to be
seen how true this is.


Understanding that enhancements are specific, often double-edged
changes--beneficial in some settings for some purposes but not in
others--suggests that a better analogy here may be the governance
of health care itself. Good health care on the one hand and
power, wealth and status on the other are positively correlated,
through the expanded opportunity range that meeting specific health
needs can provide. That correlation helps support the case for
equitable access to health care. But not all health care needs are
equally "profitable" in leveraging other social goods, and
it is not the goal of a needs-based health care system to address
*that* disparity. Just as a fair system of health care
should be able to provide need-based access to specific therapeutic
interventions, a fair biomedical enhancement allocation system should
be geared to needs of people facing particular life challenges. In
fact, in the end, as this tour of the enhancement literature suggests,
with sufficient renegotiation of the boundaries of health care, it
could be the *same* system. Again, the task of realizing
such a system will continue to be daunting. But it is doubtful that
this will require a Brave New World of centralized global moral
enhancement schemes: instead, managing our emerging biomedical
enhancement abilities begins with the tedious real world tasks of
learning to live with human difference and meet human needs.