Therapy Versus Enhancement:
Not as Simple as It Sounds
by Gregor Wolbring

June 15 , 2006

One of the most consequential outcomes of NBICS (nano-bio-info-cogno-synbio) is the generation of products, processes and knowledge which allow for "improvement" and modification of  the human body (structure, function, capabilities) beyond its species-typical boundaries -- and in the end the modification, generation and design of other species.

Many different enhancements exist with different labels. Some of them are:

• Somatic genetic enhancement;
• Germline genetic enhancement;
• Enhancement for medical reasons/therapeutic enhancement;
• Enhancement for social reasons/ non-therapeutic enhancement;
• Positional enhancement;
• Intrinsically good enhancement;
• Body structure enhancement;
• Body function enhancement;
• Neuro structure and function enhancement;
• Ex ante enhancement; and
• Ex post enhancement.

An increasing number of people believe we can, will and should try to overcome our biological limitations by means of reason, science, and technology, and that the move toward enhancement of the human body is not preventable. (For a debate around the design of organisms see my column Synthetic Biology 2.0.)

So far, the debate around enhancements -- especially non-genetic enhancements and its many global and local implications -- takes place mostly within academia, and in some subgroups such as the transhumanists and disabled people. It is not a debate that is entered into by the broader public. That hopefully changes after the AAAS Conference on Emerging Technologies for Enhancement, which took place on June 1-2, 2006, in Washington, D.C.

Many arguments exist for and against enhancement (see my recent publication).
In an article about the AAAS Conference, the following arguments in favor of enhancement can be identified.

(1) We have performed enhancement as long as humans have existed.

"Since the advent of simple tools, humans have been expanding their capacities. Cognitive enhancement dates back to the written word, a primitive process for downloading information from our minds to the hard drive of parchment."

(2)   Natural talent is as unfair as the inequality of access to enhancement products.

"While no one may deserve their success if they achieve it without effort, no one deserved their natural talents either."

(3) Enhancement boosts the economy and business competitiveness, and lowers the cost of doing business.

"Yet developments in human enhancement could also boost the economy and keep businesses competitive, Lynch said, by preventing diseases that cost work hours and healthcare expense and increasing employee learning capacity and efficiency."

(4) We are already changing what it means to be human.

"He noted a 2005 report recently cited by British Prime Minister Tony Blair that linked chronic violent video-game exposure to altered brain activity. This fundamental cognitive shift, the report concluded, led to desensitization and increased aggression."

(5) Enhancement is a private individual choice. (I will discuss freedom of choice and morphological freedom in a later column.)

"Should people's vague anxieties about the way things are going keep me from taking a drug that allows me to think better, that allows me to live an extra 20 years of life?' Hughes asked. 'All of those are very private decisions that don’t harm other people.'"

(6) There is a blurry line between therapy and enhancement.

"There is a blurry line between enhancement and therapy, Hughes said. Is it enhancement to improve someone`s body in a way that slows aging and inhibits certain diseases, or is it preventative treatment for those ailments?"

(7) One can't deal with enhancement in a blanket way, but has to do it on a case-by-case basis. (In my view, this leads to no action because there are insufficient financial and human resources available to deal with every individual enhancement.)

"'One of the best ways to deal with (human enhancement) is to promote as much transparency as possible and open dialogue,' Amy Patterson, director of the Office of Biotechnology Activity at the National Institutes of Health, told UPI. She added that the issue is best considered within the context of individual drugs, since the separate effects of each warrant different actions."

The most visible argument against enhancement in the limited public discourse is that one can and should draw a line between therapeutic and enhancement interventions. I believe that might not be as easy as it sounds, if not imposssible, since many therapies have aspects of enhancement and many enhancements can be classified as therapies.

A variation of the theme states that one can and should draw a line between therapeutic and non-therapeutic enhancements. I believe the line is impossible to draw, as many therapeutic interventions can and are used later for non-therapeutic purposes. There are many examples in my publication.

Modafinil, sold in Canada as Alertec, was developed for the treatment of narcolepsy. In September 2003, an advisory panel to the FDA endorsed its use for treating shift-work sleep disorder and obstructive sleep apnea. Modafinil is also attracting attention from the military and from "healthy" people as a possible alertness drug. There are about 150,000 Americans with narcolepsy, but as many as 250,000 Americans are using modafinil. The drug is increasingly used to alleviate sleepiness due to many causes, including depression, jet lag, or working long hours with too little sleep.

The line between therapeutic and non-therapeutic enhancements is also very hard to draw because of the very fluid view of the term "therapeutic" and the dynamic of medicalization. However the link between the justification and acceptability of enhancement and the concept of health, therapy and the dynamic of medicalization is very rarely discussed. I deal with this extensively in my publication in terms of the three steps described below.

Step 1: Change the meaning of the term "health"...

Many people know about the medical and social model of health. However, most people are unfamiliar with the transhumanist model of health.

In the transhumanist enhancement model, "health" no longer has the endpoint where someone is healthy if biological systems function within species-typical, normative frameworks. In this model, all Homo sapiens -- no matter how conventionally "medically healthy" -- are defined as limited, defective, and in need of constant improvement made possible by new technologies. (A little bit like the constant software upgrades we do on our computers.)  "Health" in this model means having obtained maximum (at any given time) enhancement (improvement) of one's abilities, functioning, and body structure. "Disease" is identified in accordance with negative self-perceptions of one's non-enhanced body.

Interventions on the level of the individual that add new abilities or improve on the existing abilities of Homo sapiens are seen as the remedy for ill medical health. Enhancement medicine is the new field providing the remedy through surgery, pharmaceuticals, implants and other means. Notions of disease prevention, public health, healthy community, health promotion, and the actions they entail, all change substantially in the transhumanist enhancement model.

Step 2: Make "healthy" people feel bad about themselves...

More and more variations of human body structure and functioning are labelled as diseases (dynamic of medicalization). A growing number of medical technologies are employed to improve the looks, performance, and psychological well-being of people who are healthy. The traditional form of medicalization artificially assigned a subnormal label to normal variations in human characteristics.

Step 3: The transhumanization of medicalization...

The transhumanist model of health and disease defines the human body in general as defective, or as a work in progress, elevating medicalization to its ultimate endpoint; namely, to see enhancement beyond species-typical body structures and functioning as a therapeutic intervention (transhumanization of medicalization). This moves medicalization to its logical conclusion by adding the enhancement of body appearance and functioning above species-typical norms and boundaries to the mix.

The Choice is Yours

Simple prohibition of enhancement -- drawing a line in the sand between therapeutic (yes) and non-therapeutic (no) -- will not work to govern the development and use of enhancements as long as the dynamics of step 1-3 are in place. These dynamics can't be eliminated by laws per se, only by decrease in demand.

It is your choice to look beyond the obvious easy-at-first-glance but untenable solution of line drawing, to find a more tenable way to govern enhancement. Without questioning "able-ism" one can not take on the issue of enhancement. According to Fiona Campbell, able-ism is a network of beliefs, processes and practices that produce a particular kind of self and body -- the corporeal standard -- that is projected as perfect, species-typical and therefore essential and fully human. Disability/ impairment is then a diminished state of being human. (Able-ism will be the topic of a future column.)

If we do not question able-ism, we will have a hard time questioning the tenets of transhumanism, for in the end one is the extension of the other. 

Gregor Wolbring is a biochemist, bioethicist, science and technology ethicist, disability/vari-ability studies scholar, and health policy and science and technology studies researcher at the University of Calgary. He is a member of the Center for Nanotechnology and Society at Arizona State University; Member CAC/ISO - Canadian Advisory Committees for the International Organization for Standardization section TC229 Nanotechnologies; Member of the editorial team for the Nanotechnology for Development portal of the Development Gateway Foundation; Chair of the Bioethics Taskforce of Disabled People's International; and Member of the Executive of the Canadian Commission for UNESCO. He publishes the Bioethics, Culture and Disability website.

©Gregor Wolbring, All Rights Reserved, 2006. Reprinted with permission.