Last fall osteoarthritis patient Adrienne de Forrest of Colorado had her hip resurfaced in Chennai, India, by orthopedic surgeon Vijay Bose. Texas contractor David Jones had triple heart bypass surgery in New Delhi. Both surgeries for the uninsured Americans were arranged by the Massachusetts-based medical tourism company Healthbase.
De Forrest’s surgery cost $8,000, and Jones paid $16,000 including travel. In the U.S., where a host of regulatory distortions have raised the price of health care, De Forrest would have paid about $45,000, and Jones’ bill could have been as high as $250,000.
The uninsured are not the only Americans going abroad. The Mumbai-based PlanetHospital is now offering surrogacy services for gay couples. In November the health insurer Wellpoint launched a pilot program in which patients who choose elective surgery in India pay no out-of-pocket medical costs and get free travel for both the patient and a companion. And for years, Americans who live near Mexico have been taking advantage of the cheaper dental and other medical services available south of the border.
A recent study by the New York–based consultancy Deloitte estimates that 750,000 Americans traveled aboard in 2007 for medical care and predicts that the number would balloon to 15 million by 2017. The management consulting firm McKinsey & Company offered a more conservative estimate of 60,000 to 85,000 global inpatient medical travelers in 2007, but that figure does not include outpatient services such as dental care or elective cosmetic surgery.
Below is a paper I presented at the Arizona State University’s Center for the Study of Religion and Conflict Workshop on Transhumanism and the Future of Democracy last week. The workshop was directed by ASU history professor Hava Tirosh-Samuelson. My fellow participants were Case Western Reserve University law professor Maxwell Mehlman, Georgetown University law professor Steven Goldberg, University of Southern California law professor Michael Shapiro, University of Chicago political philosopher Jean Bethke Elshtain, Emory University bioethicist Paul Root Wolpe, with a closing response by University of California, Berkeley Nobelist Charles Townes.
The workshop addressed such questions as how does the enhancement of human beings through biotechnology, information technology, and applied cognitive sciences affect our understandings of autonomy, personhood, responsibility and free will? And how much and what type of societal control should be exercised over the use of enhancement technologies?
What is transhumanism? A pretty good definition is offered by bioethicist and transhumanist James Hughes who states that transhumanism is "the idea that humans can use reason to transcend the limitation of the human condition."[i] Specifically, transhumanists welcome the development of intimate technologies that will enable people to boost their life spans, enhance their intellectual capacities, augment their athletic abilities, and choose their preferred emotional states. What’s particularly noteworthy is that Hughes argues that democratic decision-making is central to the task of guiding humanity into the transhuman future.
I will argue that where Hughes and others go wrong is in fetishizing democratic decision-making over the protection of minority rights. Second, I will argue that transhumanism should be accepted as a reasonable comprehensive doctrine and, as such, that it should be tolerated in liberal societies by those who disagree with its goals. Third, I will illustrate the problems of democratic authoritarianism by detailing some of the history of legal interference with reproductive rights. And then, I will briefly outline and analyze various arguments used by opponents of human enhancement which they hope will sway a majority into essentially outlawing the transhumanist enterprise.
Hughes and other would-be democratizers fail to recognize that the Enlightenment project that spawned modern liberal democracies sought to keep certain questions about the transcendent out of the public sphere. To keep the social peace and allow various visions of the human to flourish along side of one another, questions about the ultimate meaning and destiny of humanity were deemed to be private concerns.
Similarly, hostility to biotechnological progress must not to be used as an excuse to breach the Enlightenment understanding of what belongs in the private sphere and what belongs in the public. Technologies dealing with birth, death, and the meaning of life need protection from meddling—even democratic meddling—by those who want to control them as a way to force their visions of right and wrong on the rest of us. One’s fellow citizens shouldn’t get to vote on with whom you have sex, what recreational drugs you ingest, what you read and watch on TV and so forth. Hughes understands that democratic authoritarianism is possible, but discounts the possibility that the majority may well vote to ban the technologies that he believes promise a better world.
In fact, Hughes extols social democracy as the best guarantor of our future biotechnological liberty, while ignoring the fact that it is precisely those social democracies that he praises—Germany, France, Sweden, and Britain—which now, not in the future, outlaw germinal choice, genetic modification, reproductive and therapeutic cloning, and stem cell research. For example, Germany, Austria and Norway ban the creation of human embryonic stem cell lines. Britain outlaws various types of pre-implantation genetic diagnosis to enable parents to choose among embryos. (Despite worrisome political agitation against this type of biotech research, in the United States, private research in these areas remains legal. More recently, President Barack Obama directed the National Institutes of Health to begin formulating guidelines under which embryonic stem cell research might receive federal funding.)
This ideal of political equality arose from the Enlightenment’s insistence that since no one has access to absolute truth, no one has a moral right to impose his or her values and beliefs on others. Or to put it another way, I may or may not have access to some absolute transcendent truth, but I’m pretty damned sure that you don’t.
Under constitutional liberalism, there are questions that should not and cannot be decided by a majority vote. As James Madison eloquently explained in Federalist 51, "It is of great importance in a republic not only to guard the society against the oppression of its rulers, but to guard one part of the society against the injustice of the other part. Different interests necessarily exist in different classes of citizens. If a majority be united by a common interest, the rights of the minority will be insecure."[ii] Alexis De Toqueville made the same point when he asked, "If it be admitted that a man possessing absolute power may misuse that power by wronging his adversaries, why should not a majority be liable to the same reproach?"[iii]
John Rawls updated and extended the arguments supporting these Enlightenment ideals in his Political Liberalism, where he made the case for a limited conception of politics that could reconcile and tolerate diverse "reasonable comprehensive doctrines." According to Rawls, a reasonable comprehensive doctrine has three features: it deals with the major religious, philosophical, and moral aspects of human life in a coherent and consistent fashion; it recognizes certain values as significant, and by giving some primacy of some values over others expresses an intelligible view of the world; and it is not unchanging, but generally evolves slowly over time in light of what its adherents see as good and sufficient reasons.
The result is "that many of our most important judgments are made under conditions where it is not to be expected that conscientious persons with full powers of reason, even after free discussion, will all arrive at the same conclusion. Some conflicting reasonable judgments (especially important are those belonging under people’s comprehensive doctrines) may be true, others false; conceivably all may be false. These burdens of judgment of are the first significance for the democratic idea of toleration."[iv] Because there is no objective way to determine the truth or falsity of diverse beliefs, moral strangers can only get along by tolerating what each would regard as the other’s errors.
Consequently, Rawls argues, "reasonable persons will think it unreasonable to use political power, should they possess it, to repress comprehensive views that are not unreasonable though different from their own." If, however, we insist that all members of a polity should adopt our beliefs because they are "true," then, "when we make such claims others, who are themselves reasonable, must count us unreasonable."[v] In such a case, members of the polity have the right to resist the imposition of views that they do not hold. Rawls concludes, "Once we accept the fact that reasonable pluralism is a permanent condition of public culture under free institutions, the idea of the reasonable is more suitable as part of the basis of public justification for a constitutional regime than the idea of moral truth."[vi]
Arguably, the kind of constitutional regime that is compatible with reasonable pluralism is one in which the powers that government can exercise over the choices of its citizens is limited. While certainly not endorsing it, the German political philosopher Jurgen Habermas describes the point of view of liberalism pretty well when he explains that the dispute between liberalism and radical democracy has "to do with how one can reconcile equality with liberty, unity with diversity, or the right of the majority with the right of the minority. Liberals begin with the legal institutionalization of equal liberties, conceiving these as rights held by individual subjects. In their view, human rights enjoy normative priority over democracy, and the constitutional separation of powers has priority over the will of the democratic legislature."[vii]
So the question is: Is transhumanism a reasonable comprehensive doctrine? Clearly, it fits Rawls’ tripartite definition. Transhumanism deals with the major religious, philosophical, and moral aspects of human life in a coherent and consistent fashion. The transhumanist desire to deploy advanced technologies to increase healthy human life spans and to enhance human physical and intellectual capacities in order to foster excellence and human flourishing coherently addresses major religious and philosophical aspects of human life. Transhumanism recognizes certain values as significant, and by giving some primacy of some values over others expresses an intelligible view of the world.
Nick Bostrom outlines some transhumanist values including the core value of "promot[ing] the quest to develop further so that we can explore hitherto inaccessible realms of value."[viii] Beyond the limits that our current biology and level of technology impose on our physical, emotional, and intellectual capacities lay experiences and knowledge that can only be fully appreciated and understood by enhanced transhumans. Other values implicated in achieving the vision of an open-ended transhuman future, according to Bostrom, include encouraging sufficient global security, a strong advocacy for technological progress, and the opportunity that everyone have access to enhancement technologies.
Crucially, Bostrom adds that "transhumanists typically place emphasis on individual freedom and individual choice in the area of enhancement technologies. Humans differ widely in their conceptions of what their own perfection or improvement would consist in. Some want to develop in one direction, others in different directions, and some prefer to stay the way they are. It would … be morally unacceptable for anybody to impose a single standard to which we would all have to conform. People should have the right to choose which enhancement technologies, if any, they want to use." This view is clearly consonant with Rawls’ argument that in a liberal polity, reasonable persons will not use political power to repress comprehensive doctrines that are different from their own. A core transhumanist value is tolerance, and transhumanists clearly recognize that their fellow citizens adhere to other reasonable comprehensive doctrines.
And transhumanism certainly meets Rawls’ third criterion for being a reasonable comprehensive doctrine since robust debate among its adherents shows that it is clearly not unchanging and is still evolving in light of what its adherents see as good and sufficient reasons
So if one accepts Rawls’ arguments for how liberal societies must operate morally, transhumanism should be accommodated within the constitutional consensus of liberal democratic societies as a reasonable comprehensive doctrine.
But liberal concerns about majoritarian tyranny are far from being merely theoretical. Let’s briefly consider some examples of how parts of what many of us would agree are "reasonable comprehensive doctrines" have been and are being repressed by democratic majorities.
For example, do we really want democratic majorities making and imposing ethical decisions about who people can marry; who can have children, and with whom they may enjoy sexual intimacy without the aim of bearing children? Consider the history of federal and state regulation in these areas. In 1800, abortion was legal in every state until the point of quickening in the womb. In the 1850′s, the newly formed American Medical Association launched a campaign against abortion, in part, because abortion practitioners were competitors and, in part, because some feared that the Protestant majority was being outbred by Catholic immigrants. By 1910, abortion had been democratically criminalized in all but one state.
In 1873, Congress passed the Comstock Laws that outlawed "every obscene, lewd, or lascivious, and every filthy book, pamphlet, picture, paper, letter, writing, print, or other publication of an indecent character, and every article or thing designed, adapted, or intended for preventing conception or producing abortion."[ix] The Comstock Laws authorized the U.S. Post Office to confiscate any publications providing advice on contraception and condoms shipped through the mail.
The first eugenics law was passed in Indiana in 1907 and eventually laws allowing the forced sterilization of "unfit" people were adopted by 30 states. Infamously, the U.S. Supreme Court upheld forced sterilization in the case of Buck v. Bell in 1927. By the 1960s, some 66,000 Americans had been forcibly neutered. In 1924, Virginia passed the Racial Integrity Act that prohibited whites from marrying anyone with "a single drop of Negro blood." By the 1920s, democratically elected legislatures had made marriage between whites and blacks illegal in thirty-eight states.
In the last half of the 20th century, the U.S. Supreme Court finally stepped in to overrule democratically legislated state interference in the reproductive decisions of Americans. In 1965, the Court found unconstitutional the Connecticut law prohibiting use of birth control by married couples in Griswold v. Connecticut. In 1967, the Court ruled in Loving v. Virginia that, "Under our Constitution, the freedom to marry, or not marry, a person of another race resides with the individual and cannot be infringed by the state," striking down the laws in the 16 states that still banned interracial marriage. In 1972, the Court voided in the case of Eisenstadt v. Baird a Massachusetts law prohibiting the sale of contraceptives to unmarried people. And of course, the Supreme Court found prohibitions on abortion unconstitutional in 1973 in Roe v. Wade.
Interestingly, the U.S. Supreme Court has never comprehensively struck down forcible sterilization laws, although in 1942 it did overrule Oklahoma’s Habitual Criminal Sterilization Act in the case of Skinner v. Oklahoma on the grounds that it violated the Constitution’s Equal Protection Clause because it did not apply to white collar crimes like embezzlement. The point is probably moot for now since the last forcible sterilization in the United States reportedly took place in Oregon in 1981.[x] The point is that when all of these legal restrictions on human sexual and reproductive decisions were enacted, they presumably reflected and comported with the views of the majority of citizens. It cannot be emphasized too strongly that these laws were overturned on constitutional grounds of protecting minority rights.
We are still engaged in fighting majoritarian tyranny in the struggle to establish gay civil rights. In 1981, Congress overturned a District of Columbia ordinance that would have decriminalized sodomy. In 1986, the same year a Gallup poll found that more than half of Americans considered homosexuality a sin, the U.S. Supreme Court upheld Georgia’s anti-sodomy law in Bowers v. Hardwick. The Baptist minister Jerry Falwell crowed that the Supreme Court "has issued a clear statement that perverted moral behavior is not accepted practice in this country." It was not until 2003 that the Supreme Court finally overturned Texas’ same-sex anti-sodomy law in the case of Lawrence v. Texas.
As of January 1, 2009, thirty states had democratically adopted constitutional amendments explicitly barring the recognition of same-sex marriage, confining civil marriage to a legal union between a man and a woman. More than 40 states explicitly restrict marriage to two persons of the opposite sex. In addition, Florida categorically prohibits gay parents from adopting, and Mississippi, Nebraska, Oklahoma, Utah, and North Dakota do so as a matter of practice. In 2006, Alabama, Georgia, Kentucky, Tennessee, Ohio, and Missouri were considering constitutional amendments or laws banning gay adoption. Arkansas, Nebraska, and Utah don’t allow gay people to serve as foster parents.[xi]
The urge for democratically imposed restrictions on the use of reproductive technologies has not abated. Recall that the federal government imposed a moratorium in the 1970s on funding any research on in vitro fertilization techniques.[xii] In January, 1980, Sen. Orrin Hatch (R-Utah), alarmed by the opening of the first IVF clinic in the United States, sent a letter to Sen. Ted Kennedy (D-Mass.), who was then chairman of a health and scientific research subcommittee, urging him to convene hearings on the grounds that "prudence and our commitment to public participation in decision-making suggest that the test tube baby laboratory not become fully operational until we have had the opportunity to consider the matter in open congressional hearings."[xiii] Nine states, including New York, currently prohibit gestational surrogacy.
In 1993, President Bill Clinton rejected the recommendations from the NIH’s Human Embryo Research Panel and prohibited federal funding of the creation of human embryos solely for research purposes.[xiv] This ban did not apply to research on spare embryos or privately funded research. In addition, in the wake of the announcement that Scottish researchers had cloned a sheep in 1997, President Clinton announced an immediate moratorium on any human cloning research. In 1998, Clinton urged Congress to ban human cloning experiments for at least five years.[xv] Today 13 states ban reproductive human cloning, and six outlaw therapeutic cloning.[xvi] The House of Representatives twice passed a bill that would have criminalized somatic cell nuclear transfer research and which would have criminalized any American who went abroad to take advantage of therapies developed using that technique—the penalty would have been 10 years in prison and $1 million in fines.
As noted above, democratically imposed restrictions on using advanced biotechnological techniques are not confined to the United States. For example, Britain established the Human Fertilisation and Embryology Authority (HFEA) in 1991 to regulate the use of embryos and gametes in infertility treatment and research. The HFEA has told couples that they could not select the sex of embryos to be implanted. Even now, parents wanting to use PGD to insure that their children will not be burdened with an inherited genetic disease must apply for permission from the HFEA. And the HFEA has banned paying women for providing eggs to be used in research. Crucially, the HFEA can regulate not just on the grounds of ensuring quality, safety, and efficacy, but also on ethical grounds.
Consider the case of the Whitaker family from Sheffield, England, to see just how perilous it is to allow a government agency to interfere in a family’s reproductive decisions. In 2002, Michelle and Jayson Whitaker asked the HFEA for permission to use in vitro fertilization and PGD to produce a tissue-matched sibling for their son Charlie, who suffers from a rare anemia. That disease caused him to need a blood transfusion every three weeks. The HFEA refused, calling the procedure "unlawful and unethical," ruling that tissue matching is not a sufficient reason to attempt embryo selection.[xvii] Desperate, the Whitakers came to the United States, where PGD is still legal. In June 2003, Michelle Whitaker gave birth to James, whose umbilical cord stem cells are immunologically compatible with Charlie’s. The stem cells were transplanted and, six years later, both boys are reported to be healthy. Please keep in mind that taking stem cells from James’ umbilicus in no way endangered or harmed him.
Again, in this case, the HFEA’s refusal was not based on safety or efficacy, but on the moral opinions of the Authority’s governing panel. Such a regulatory authority necessarily turns differences over morality into win/lose propositions, with minority views—and rights—overridden by the majority.
Fortunately, Americans are allowed to use PGD to select "savior siblings" like James Whitaker and also to enable their progeny to avoid the risks of genetic diseases. For example, consider the 2002 case of a married 30-year-old geneticist who will almost certainly lose her mind to early-onset Alzheimer’s disease by age 40 and who chose to have her embryos tested in vitro for the disease gene.[xviii] She then implanted only embryos without the gene into her womb. The result was the birth of a healthy baby girl—one who will not suffer Alzheimer’s in her 40s. The mother in this case certainly knows what would face any child of hers born with the disease gene. Her father, a sister, and a brother have all already succumbed to early Alzheimer’s.
Bioethicist Jeffrey Kahn objected to using PGD in this case arguing, "It’s a social decision. This really speaks to the need for a larger policy discussion, and regulation or some kind of oversight of assisted reproduction."[xix] Kahn is right that parents will someday use PGD to screen embryos for desirable traits such as tougher immune systems, stronger bodies, and smarter brains. It is hard to see what is ethically wrong with parents taking advantage of such testing, since it is aimed at conferring general benefits that any child would want to have (see below for more on the issue of consent).
Kahn is wrong when he claims that the decision to use PGD by prospective parents is a "social decision" requiring more regulation. First of all, in the capacious sense implied by Kahn, any parent’s decision to have a child, even by conventional means, has "social consequences" for us all. So would Kahn have neighbors, regulators, and bioethicists weigh in on everybody’s reproductive decisions? Kahn would doubtless counter that, unlike conventional reproduction, assisted reproduction involves the use of scarce medical resources that could be used for other purposes (which they prefer).
Again, Kahn’s notion of "social" could apply to anything—what if Kahn disapproved of someone buying non-union clothing or vacationing in the Caribbean rather than devoting his resources to building public parks or highways? In this case, the parents using assisted reproduction and PGD are spending their own money for the benefit of their own children to work with doctors who are freely devoting their skills.
Another often-heard objection is that genetic engineering will be imposed on "children-to-be" without their consent. First, I need to remind everyone reading this article that not one of you gave your consent to be born, much less to be born with the specific complement of genes that you bear. Thus, the children born by means of assisted reproductive therapies and those produced more conventionally stand in exactly the same ethical relationship to their parents. Habermas disagrees, claiming, "Eugenic interventions aiming at enhancement reduce ethical freedom insofar as they tie down the person concerned to rejected, but irreversible intentions of third parties, barring him from the spontaneous self-perception of being the undivided author of his own life."[xx] However, Allen Buchanan correctly points out that Habermas does not actually make clear why a person who develops from a genetically enhanced embryo should feel that they are not the "author" of her life or be regarded as being somehow less free by others. Habermas "is assuming that how one’s genome was selected is relevant to one’s moral status as a person. This error is no less fundamental than thinking that a person’s pedigree—for example, whether she is of noble blood or ‘base-born’—determines her moral status," explains Buchanan.[xxi]
Another frequently heard assertion from opponents of enhancement technologies is that a genetically engineered child somehow feel less loved and appreciated than one who was born in the conventional way. Similar fears were expressed by many bioethicists when in vitro fertilization began to be used in the 1970s and 1980s. The good news is that recent research finds that IVF children and their parents are as well-adjusted as those born in the conventional way.[xxii] And this should be the case for enhanced children as well. As Frances Kamm argues, "Not accepting whatever characteristics nature will bring but altering them ex-ante does not show lack of love… This is because no conscious being yet exists who has to work hard to achieve new traits or suffer fears of rejection at the idea they should be changed. Importantly, it is rational and acceptable to seek good characteristics in a new person, even though we know when the child comes to be and we love him or her, many of these characteristics may come and go and we will continue to love the particular person."[xxiii]
The absurdity of a requirement for prenatal consent becomes transparent when you ask proponents of such a requirement if they would forbid fetal surgery to correct spina bifida or fetal heart defects? After all, those fetuses can’t give their consent to those procedures, yet it is certainly the moral thing to do. For that matter, taking this strong position on consent to its logically extreme conclusion would mean that children couldn’t be treated with drugs, or receive vaccinations. So using future biotechnical means to correct genetic diseases like cystic fibrosis or sickle cell anemia at the embryonic stage will similarly be morally laudatory activity. Surely one can assume that the beneficiary—the not-yet-born, possibly even the not-yet-conceived child—would happily have chosen to have those diseases corrected.
But what about enhancements, not just therapeutic biotechnical interventions? Let’s say a parent could choose genes that would guarantee her child a 20 point IQ boost. It is reasonable to presume that the child would be happy to consent to this enhancement of her capacities. How about plugging in genes that would boost her immune system and guarantee that she would never get colon cancer, Alzheimer’s, AIDS, or the common cold? Again, it seems reasonable to assume consent. These enhancements are general capacities that any human being would reasonably want to have. In fact, lots of children already do have these capacities naturally, so it’s hard to see that there is any moral justification for outlawing access to them for others.
Fritz Allhoff has grappled nicely with the issue of consent. Allhoff offers a principle derived from the second formulation of Kant’s categorical imperative[xxiv] that we treat individuals as ends and never merely as means or, more simply, to treat them in ways to which they would rationally consent.[xxv] Allhoff turns next to philosopher John Rawls’ notion of primary goods. In A Theory of Justice Rawls defines primary goods as those goods that every rational person should value, regardless of his conception of the good. These goods include rights, liberties, opportunities, health, intelligence, and imagination.[xxvi] As Allhoff argues, "These are the things that, ex hypothesi, everyone should want; it would be irrational to turn them down when offered. Nobody could be better off with less health or with fewer talents, for example, regardless of her life goals…. Since primary goods are those that, by definition, any rational agent would want regardless of his conception of the good, all rational agents would consent to augmentation of their primary goods."
Allhoff then contends that such enhancements would be permissible if every future generation would consent to them. But the requirement that all future generations must consent adds nothing to the moral force of Allhoff’s arguments since already all rational agents would consent to such enhancements. So again, safe genetic interventions that improve a prospective child’s health, cognition, and so forth would be morally permissible because we can presume consent from the individuals who benefit from the enhancements.
Many opponents of human genetic engineering are either conscious or unconscious genetic determinists. They fear that biotechnological knowledge and practice will somehow undermine human freedom. In a sense, these genetic determinists believe that somehow human freedom resides in the gaps of our knowledge of our genetic makeup. If parents are allowed to choose their children’s genes, then they will have damaged their children’s autonomy and freedom. According to environmentalist Bill McKibben, "The person left without any choice at all [emphasis his] is the one you’ve engineered. You’ve decided, for once and for all, certain things about him: he’ll have genes expressing proteins that send extra dopamine to alter his mood; he’ll have genes expressing proteins to boost his memory; to shape his stature."[xxvii] People like McKibben apparently believe that our freedom and autonomy somehow depend on the unknown and random combinations of genes that a person inherits. But even if they were right—and they are not—genetic ignorance of this type will not last.
Advances in human whole genome testing will likely become available by 2014 so that every person’s entire complement of genes can be scanned and known at his or her physician’s office for as little as $1,000.[xxviii] Once whole genome testing is perfected we will all learn what even our randomly conferred genes may predispose us to do and from what future ills we are likely suffer. Already, my relatively inexpensive genotype scan from 23andMe tells me that I have alleles that give me a somewhat greater risk of developing celiac disease, a lower risk of rheumatoid arthritis, as well as having a higher sensitivity to warfarin, among other traits. With accumulation of genetic understanding, human freedom will then properly be seen as acting to overcome these predispositions, much like a former alcoholic can overcome his thirst for booze. Fortunately, biotech will help here as well as with the development of neuropharmaceuticals to enhance our cognitive abilities and change our moods.
Opponents of using biotechnical means to enhance humans often cite C.S. Lewis’ worry: "If any one age really attains, by eugenics and scientific education, the power to make its descendants what it pleases, all men who live after it are the patients of that power. They are weaker, not stronger: for though we may have put wonderful machines in their hands we have pre-ordained how they are to use them."[xxix] In other words, Lewis asserts that the one decisive generation that first masters genetic technologies will control the fate of all future generations.
But when has it not been true that past generations control the genetic fate of future generations? Our ancestors—through their mating and breeding choices—determined for us the complement of genes that we all bear today. They just didn’t know which specific genes they were picking. Fortunately, our descendants will have at their disposal ever more powerful technologies and the benefit of our own experiences to guide them in their future reproductive and enhancement decisions. In no sense are they prisoners of our decisions now. Of course, there is one case in which future generations would be prisoners of our decisions now, and that’s if we fearfully elect to deny them access to the benefits of biotechnology and safe genetic engineering. The future will not be populated by robots who may look human but who are unable to choose for themselves their own destinies—genetic or otherwise.
Other opponents of human genetic enhancement argue that it is not possible to ethically get from the human present to the transhuman future. Again, consent and the risks inherent in deploying novel biogenetic treatments are cited as reasons.[xxx] The assertion is that genetic enhancement necessarily implies experimentation without consent and this violates bedrock bioethical principles requiring the protection of human subjects. Consequently, there is an unbridgeable gap over which would-be enhancers cannot ethically cross.
This view incorporates a rather static view of what it will be possible for future genetic enhancers to know and test beforehand. Any genetic enhancement technique will first be extensively tested and perfected in animal models. Second, a vastly expanded bioinformatics enterprise will become crucial to understanding the ramifications of proposed genetic interventions.[xxxi] As scientific understanding improves, the risk versus benefit calculations of various prospective genetic enhancements of embryos will shift. The arc of scientific discovery and technological progress strongly suggests that it will happen in the next few decades. One possible threshold for morally acceptable genetic enhancement treatments is the current level of risk involved with current in vitro fertilization techniques.[xxxii]
Defenders of democratically restricting human enhancements often argue that human equality will fall victim to differential access to enhancement technologies, resulting is conflicts between the enhanced and the unenhanced. As bioethicists George Annas, Lori Andrews, and Rosario Isasi laid out in a rather apocalyptic scenario:
"The new species, or ‘posthuman,’ will likely view the old ‘normal’ humans as inferior, even savages, and fit for slavery or slaughter. The normals, on the other hand, may see the posthumans as a threat and if they can, may engage in a preemptive strike by killing the posthumans before they themselves are killed or enslaved by them. It is ultimately this predictable potential for genocide that makes species-altering experiments potential weapons of mass destruction, and makes the unaccountable genetic engineer a potential bioterrorist."[xxxiii]
Let’s take their over-the-top scenario down a notch or two. The enhancements that are likely to be available in the relatively near term to people now living will be pharmacological—pills and shots to increase strength, lighten moods, and improve memory. Consequently, such interventions could be distributed to nearly everybody who wanted them. Later in this century, when safe genetic engineering becomes possible, it will likely be deployed gradually and will enable parents to give their children beneficial genes for improved health and intelligence that other children already get naturally. Thus, the argument can be made that safe genetic engineering in the long run is more likely to ameliorate than to exacerbate human inequality.
In any case, political and moral equality has never rested on the facts of human biology. In prior centuries, when humans were all "naturals," tyranny, aristrocracy, slavery, and purdah were common social and political arrangements. Our biology did not change in the past two centuries, our political ideals did. In fact, political liberalism is already the answer to questions about human and posthuman rights. In liberal societies the law is meant to apply equally to all, no matter how rich or poor, powerful or powerless, brilliant or stupid, enhanced or unenhanced.
One crowning achievement of the Enlightenment is the principle of tolerance, of putting up with people who look differently, talk differently, worship differently, and live differently than we do, or in Rawlsian terms, tolerating those who pursue differing reasonable comprehensive doctrines. In the future, our descendants may not all be natural homo sapiens, but they will still be moral beings who can be held accountable for their actions. There is no a priori reason to think that the same liberal political and moral principles that apply to diverse human beings today wouldn’t apply to relations among future humans and transhumans.[xxxiv]
But what if enhanced posthumans did take the Nietzschean superman option? What if they really did see unenhanced people "as inferior, even savages, and fit for slavery or slaughter"?
It is an unfortunate historical fact that plenty of unenhanced humans have been quite capable of believing that millions of their fellow unenhanced humans were inferiors who needed to be eradicated.[xxxv] However, as liberal political institutions, with their limits on the power of the state, have spread and strengthened, they have increasingly restrained technologically superior groups from automatically wiping out less advanced peoples (which was usual throughout most of history). There is no a priori reason to believe that this dynamic will not continue in the future as biotechnologies, nanotechnologies, and computational technologies progressively increase people’s capabilities and widen their choices.
Opponents of human enhancement focus on the alleged social harms that might result, while overlooking the huge social costs that foregoing the benefits of enhancement technologies would entail. Allen Buchanan posits "that some enhancements will increase human productivity very broadly conceived and thereby create the potential for large-scale increases in human well-being, and that the enhancements that are most likely to attract sufficient resources to become widespread will be those that promise increased productivity and will often exhibit what economists call network effects; the benefit to the individual of being enhanced will depend upon, or at least be greatly augmented by others having the enhancement as well."[xxxvi]
Buchanan points out that much of the ethical debate (cited above) about enhancements focuses on them as positional goods that primarily help an individual to outcompete his rivals. This characterization of enhancements leads quickly and ineluctably to pervasive zero sum thinking in which for every winner there is assumed to be a loser. Instead enhancements could produce substantial positive externalities. "Large numbers of individuals with increased cognitive capabilities will be able to accomplish what a single individual could not, just as one can do much more with a personal computer in a world of many computer users," writes Buchanan.[xxxvii]
Buchanan argues that modern people have already adopted a wide array of enhancements that display these beneficial network effects, including literacy, numeracy, and social institutions that "extend our abilities beyond what is natural for human beings."[xxxviii] Some future biomedical enhancements that would significantly increase both individual and social productivity include those that raise the cognitive capabilities of human beings (memory, attention, and processing speed), increase healthy life spans, and boost our immune systems. Indeed, economist William Nordhaus reports that the huge increase in average life expectancy since 1900 from 47 years to 77 years today has been responsible for about half the increase in our standard of living in the United States.[xxxix]
More disturbingly, Buchanan notes that if biotech enhancements do, in fact, dramatically increase social productivity, then the state and its citizens might be far less interested in imposing limits on enhancements and instead shift to promoting them for everyone. The analogy is that biotech enhancements might be treated like other productivity-boosting enhancements like education and immunization. "If a particular enhancement had very strong productivity-enhancing effects, the failure of the state to ensure that no one lacks access to it might be as culpable as its failure to ensure that all citizens are literate or have access to immunization," suggests Buchanan.[xl] The temptation for democratically imposing enhancements would be hard to resist and would result in imposing a particular vision of human flourishing on those who do not want them.
People should not be forced to use medicines and technologies that they find morally objectionable. Take the case of the Amish. Amish individuals live in an open society—ours—and can opt out of our society or theirs whenever they want. As followers of a reasonable comprehensive doctrine, they have a system for voluntarily deciding among themselves what new technologies they will embrace. The situation of the Amish demonstrates that technological choices don’t have to involve everyone in a given society. (Although Amish practicality has caused them to embrace modern medicine when comes to treating genetic maladies that plague their community.[xli])
Eventually, one can imagine that in the future different treatment and enhancement regimens will be available to accommodate the different values and beliefs held by citizens. Christian Scientists would perhaps reject most of modern biotechnology outright; Jehovah’s Witnesses might remain leery of treatments that they interpret to being akin to using blood products or blood transfusions; Roman Catholics might refuse to use regenerative treatments derived from human embryonic stem cells; and still others will wish to take the fullest advantage of all biomedical enhancements and treatments. In this way, a pluralistic society respects the reasonable comprehensive doctrines of their fellow citizens and enables social peace among moral strangers.
Julian Savulescu is right when he reminds us, "The Nazis sought to interfere directly in people’s reproductive decisions (by forcing them to be sterilized) to promote social ideals, particularly around racial superiority. Not offering selection for nondisease genes would indirectly interfere (by denying choice) to promote social ideals such as equality or ‘population welfare.’ There is no relevant difference between direct and indirect eugenics. The lesson we learned from eugenics is that society should be loath to interfere (directly and indirectly) in reproductive decisionmaking."[xlii]
To the extent that new biotechnologies need regulation, agencies should be limited to deciding, as they have traditionally done, only questions about safety and efficacy. Regulatory agencies also have an important role in protecting research subjects and patients from force and fraud by imposing informed consent requirements on researchers. But when people of good will deeply disagree on moral issues that don’t involve the prevention of force or fraud, it is a fraught exercise to submit their disagreement to a panel of political appointees or a democratic vote. That way leads to intolerance, repression, and social conflict.
The genius of a liberal society is that its citizens have wide scope to pursue their own visions of the good, including transhumanism, without excessive hindrance by their fellow citizens.
Note of gratitude: I would like to thank Professor Hava Tirosh-Samuelson and the Center for inviting me to participate in the workshop. In addition, I want to thank the workshop co-sponsors for their support including the Templeton Foundation, the Metanexus Institute, and the Center for the Study of Religion and Conflict.
[i] James Hughes, Citizen Cyborg: Why Democratic Societies Must Respond To The Redesigned Human Of The Future, Westview Press, 2004.
[vii] Jurgen Habermas, "Popular Sovereignty as Procedure," Deliberative Democracy: Essays on Reason and Politics, edited by James Bohman & William Regh, MIT Press, 1997, p. 44.
[xxiii] Frances Kamm, What Is and Is Not Wrong with Enhancements," Human Enhancement, edited by Nick Bostrom & Julian Savulescu, Oxford University Press, 2008, p. 113.
[xxiv] Immanuel Kant, translated by Herbert James Paton, Moral Law: Groundwork of the Metaphysics of Morals, Routledge, 1991. p. 66.
[xxv] Fritz Allhoff, "Germ-Line Genetic Enhancement and Rawlsian Primary Goods," Journal of Evolution and Technology, Vol. 18 Issue 1, May 2008, pgs 10-26, http://jetpress.org/v18/allhoff.htm
[xxvi] Rawls, John. 1999. A Theory of Justice. Rev. ed. Cambridge, MA: Harvard University Press, pp. 54-55.
[xxxiii] George Annas et al., "Protecting the Endangered Human: Toward an International Treaty Prohibiting Cloning and Inheritable Alterations," American Journal of Law and Medicine, Vol. 28, Number 2&3, 2002 p. 162
[xxxiv] James Wilson, "Transhumanism and Moral Equality," Bioethics, Vol. 21, No. 8, pp. 419-425.
[xxxv] R.J. Rummel, Death by Government, Transactions Publishers, 1994.
[xxxix] Nordhaus, William, "The Health of Nations: The Contribution of Improved Health to Living Standards," in Kevin Murphy and Robert Topel, eds., The Economic Value of Medical Research, University of Chicago Press, Chicago, 2002.
[xlii] Savulescu, Julian.,"In Defense of Selection for Nondisease Genes. The American Journal of Bioethics – Volume 1, Number 1, Winter 2001, pp. 16-19
From Canada, the land of long health care queues, comes a genuinely promising idea for speeding new medicines into the hands of patients—a fast track approval process called progressive licensing. Which is exactly what the U.S. needs. In 2007, the Food and Drug Administration (FDA) approved only 19 new drugs, the lowest number since 1983. Last year saw a minor uptick to just 24 new medicines.
In 2007, Health Canada, the Canadian government’s lead agency on health care issues, launched a national discussion on how to transform the country’s drug approval system. Currently, the Canadian drug approval process operates much like the FDA’s version does. Pharmaceutical companies submit new drug applications to regulators who then set out criteria for securing bureaucratic approval of the drug—including a series of clinical trials to prove that the medicine is safe and effective.
This venerable drug approval model focuses on prohibiting sales until new products have been carefully tested and then approved by regulators. The chief goal is to keep unsafe drugs from reaching patients. As we shall see, regulators are much less worried about mistakenly rejecting safe and effective drugs.
To keep unsafe drugs out of the market, new pharmaceuticals must undergo a series of clinical trials. Phase 1 trials, involving a few subjects, evaluate how a new drug acts in the body and looks for dangerous side effects. Phase 2 tests the new drug for effectiveness in a few patients. Phase 3 expands the trials to confirm effectiveness and to obtain further indications about risks versus benefits. Increasingly, regulators now ask for Phase 4 trials as well, which are post-marketing studies that evaluate the treatment’s risks and benefits once the public has begun using it. Rare side effects frequently don’t show up until the drug has been used by hundreds of thousands of patients.
Part of the domestic slow down in drug approvals comes from the fact that since the 1980s FDA regulators have more than doubled the number of clinical trials required to get a new drug approved from 30 to about 70. This increase in trials has raised the cost of getting a new drug through the regulatory maze to over $1 billion, thus limiting the number of new drugs that pharmaceutical companies can afford to pursue.
This is where progressive licensing could rescue our creaky pharmaceutical regulatory system. While the final regulations in Canada are still being hammered out, one exciting possibility is that drugmakers could submit some of their new medicines for approval after completing relatively fast and inexpensive Phase 1 and 2 trials. Such trials would provide preliminary information about a drug’s safety and efficacy. In exchange for this fast track pre-marketing approval, drugmakers would agree to greater post-marketing surveillance of drug safety. Which means that patients using a new drug would essentially enroll in the equivalent of a Phase 4 trial. This post-marketing information would allow companies and regulators to continually adjust the balance of benefits and risks over the life cycle of new drugs. One important caveat is that such post-marketing scrutiny must not become as costly as the current system of pre-market regulatory review.
Following Canada’s preliminary framework, progressive licensing would initially apply just to drugs that address previously unmet medical needs and in those instances where obtaining extensive clinical information is difficult (such as drugs that treat only a small numbers of patients with rare diseases). But why stop there? Canada’s free-market Fraser Institute thinks progressive licensing has the potential to fix the current over-regulation of all drugs. Every beneficial drug also has accompanying risks, after all; the question is who gets to weigh the risks and the benefits.
Currently, regulators make the crucial decisions about the risks and benefits of treatment. But this leads to unbalanced benefit-risk evaluations. Remember that from the point of view of pharmaceutical regulators it’s far more important to avoid a single highly publicized death from a new drug than it is to worry about the hundreds of unknown patients who die because of delays in approving new life-saving therapies.
In a 2007 report, the Fraser Institute looked at how progressive licensing could be transformed into a more radically open system that allows patients and physicians to evaluate the benefits and risks of new therapies rather than relying on the judgments of timid bureaucrats. In the report, Fraser’s Brent Skinner looked at how the risks of new treatments compare to the risks of alternative treatments that the public already accepts.
For example, consider the case of the over-the-counter pain reliever ibuprofen versus the new drug Vioxx. A novel painkiller introduced in 1999, Vioxx was withdrawn from the market because it was found to increase the risk of heart attacks. But further research indicated that many non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, also increase the risk of heart attacks among users.
Both types of medicine effectively relieve pain, but Vioxx had the benefit of reducing the risk of gastrointestinal bleeding, which NSAIDs exacerbate. But who should weight the risk of dying from heart disease versus the risk of dying from bleeding ulcers versus effective pain relief for rheumatoid arthritis? One 1999 study estimated that there are 103,000 hospitalizations and 16,500 deaths in the United States due to complications from NSAID-associated gastric ulcers. As Skinner notes, a patient who is at high risk from gastrointestinal complications might well choose to take the cardiovascular risks associated with Vioxx. Why not let patients and their physicians have this risk information and choose for themselves?
Progressive licensing could modernize the current process from one where bureaucrats grant extensive permission before new drugs hit the market into a system based on initial indications of safety and effectiveness followed by ongoing risk evaluations. This would give patients greater say in their treatment, allowing those who willing to accept a certain amount of risk early access to the latest treatments, while risk-averse patients and physicians could wait until further information became available. It would also increase the scope for private groups—perhaps along the lines of the Underwriters’ Laboratories certification process—to evaluate benefits and risks.
Progressive licensing might turn out to be just what the doctors (and patients) ordered for reducing the backlog of new drugs awaiting the nod from overly cautious regulators.
