Moral Enhancement and the Public Good

Parker Crutchfield

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000401820
• Edition: 1
• Topic: Medicine
• Subtopic: Health Policy

Currently, humans lack the cognitive and moral capacities to prevent the widespread suffering associated with collective risks, like pandemics, climate change, or even asteroids. In Moral Enhancement and the Public Good, Parker Crutchfield argues for the controversial and initially counterintuitive claim that everyone should be administered a substance that makes us better people. Furthermore, he argues that it should be administered without our knowledge. That is, moral bioenhancement should be both compulsory and covert. Crutchfield demonstrates how our duty to future generations and our epistemic inability to promote the public good highlight the need for compulsory, covert moral bioenhancement. This not only gives us the best chance of preventing widespread suffering, compared to other interventions (or doing nothing), it also best promotes liberty, autonomy, and equality. In a final chapter, Crutchfield addresses the most salient objections to his argument.

Chapter 1

Disease and Treatment

The task of this book is to justify the administration of a covert compulsory moral bioenhancement program. For the project to get off the ground, it cannot be true that all enhancement of human capacities is wrong. This chapter undercuts the assertion that enhancing human capacities is wrong, clearing the way for the rest of the argument. What counts as an enhancement rather than a treatment depends on what counts as health and disease. In this chapter, I develop an account of health and disease that undermines the foundation of any objection to moral enhancement on the grounds that only treatments are permissible.

There are multiple ways one might distinguish health from disease. There are also ways one might distinguish between different accounts of health and disease. One way to distinguish accounts of health and disease is by whether they hold that disease and health are primarily biological (Simon, 2007; Broadbent, 2019; Glackin, 2019). Objectivism is roughly the view that a person is sick, ill, or unhealthy in virtue of the fact that, first, their biology is in some sense malfunctioning and, second, that this malfunction makes their life go worse than it otherwise would. According to objectivism, disease and illness are concepts analyzed primarily biologically. Of course, not all biological malfunction is a disease; the malfunction must also make the person’s life go worse for it to be considered a disease. Whether a person’s life goes worse can be, for objectivists, a biological matter—intractable intense pain intuitively diminishes a person’s well-being. But whether a person’s life is going worse than it otherwise would can also be a matter of how society views that condition and its consequences.

The other view, constructivism, analyzes disease and illness differently. Instead of analyzing disease and illness primarily in biological terms, constructivists hold that being sick is a matter first and foremost of social evaluation of a condition. Once society has determined that a certain set of behaviors or conditions diminishes a person’s well-being, we then go on a search for some biological cause of that condition.

Objectivists and constructivists can agree that being sick is a matter of both descriptive properties of the person, such as properties of their functioning, as well as evaluative properties, such as properties pertaining to how society views certain conditions or behaviors. What they can’t agree on is which is conceptually prior. For objectivists, it’s biological functioning; for constructivists, it’s society’s view of the condition or behavior.

A second way to distinguish types of accounts of health and disease is by whether they include some notion of value in the analysis. Boorse’s biostatistical theory (1976, 1977) is objectivist, but purports to be value-free. However, other objectivist accounts, such as Wakefield’s proper functionalist account (1992), include value-laden conditions. Constructivist accounts are even more value-laden (Reznek, 1987; Cooper, 2002).

A third way to distinguish types of accounts is by whether they are fundamentally comparative. Traditional theories view health as the fundamental concept to be analyzed. Some analyze it by incorporating notions like statistical normalcy, proper function, or social construction. But once health is analyzed, other related concepts, such as “healthier than,” can be analyzed in terms of “health.” But comparative accounts of health reverse this order of explanation. According to comparative accounts, “healthier than” is conceptually prior to “health.” That is, rather than explaining “healthier than” in terms of “health,” comparative accounts explain “health” in terms of “healthier than.” Currently, there is only one comparative account of health and disease, and that comes from S. Andrew Schroeder (2013), who claims that “health” is gradable and comparative like adjectives such as “tall,” “flat,” “old,” and “bald.”

In this chapter, I argue for a contextualist account of health, which builds upon Schroeder’s foundation. Fundamentally, he is right that health is comparative. But his novel account is incomplete, which exposes it to a range of problems and objections. The contextualist account I develop in this chapter not only lacks this exposure, it holds several advantages over other accounts of health and disease, regardless of how one sorts those accounts.

Specifically, I argue that the meanings of terms such as “sick,” “healthy,” “ill,” or “diseased” are context-sensitive. The truth of statements embedding these terms is determined by the context in which those statements are uttered. These terms are like “tall,” “bald,” “old,” “flat,” “empty,” and many other similar terms. They are gradable adjectives whose meaning is determined in part by the class of things they are being compared to. At a college party, a 35-year-old professor is old; at a conference with her peers, she is not old (and might even win an award for being a young scholar). Both attributions of oldness are true. Whether she is old or not old depends in part on the comparison class. For people at a college party, 35 is old. For people at an academic conference, 35 is not old. I think “sick,” “health,” and the like are just like this. For people in the intensive care unit (ICU), those who have a cold are healthy. But that same person in a preschool is not healthy. If this is right, then it makes as much sense to provide a conceptual analysis of sickness as it does to provide a conceptual analysis of oldness, which implies that the traditional theories are looking in the wrong direction.

The first section introduces the purported distinction between treatment and enhancement. In the section that follows I outline Schroeder’s comparative account of health and disease. I then discuss its exposure and weaknesses and the weaknesses of other traditional accounts of health and disease. In the remainder of the sections, I support contextualism about health and disease, show its advantages, and argue that it undermines any objection to moral enhancement on the grounds that moral enhancement runs afoul of the treatment/enhancement distinction.

Treatment and Enhancement

Intuitively, there is some important difference between interventions that treat disease and those that only promote health. There seems to be a difference between repairing something so that it is how it ought to be and making something that is already how it ought to be better. This intuitive difference also seems to have moral significance: it seems better to bring a person back to normal than it does to take a normal person and make them better than they were. This is the moral significance of the treatment/enhancement distinction. The distinction obviously relies on what counts as normal, or on how a person’s health ought to be. The theories of health and disease provide the conditions for when a person’s health is as it should be—when a condition counts as normal and when it doesn’t. In this way, the treatment/enhancement distinction and its moral significance, whatever that significance amounts to, depends on accounts of health and disease. That people can be sick and healthy and that how we intervene on the sick seems different than how we intervene on the healthy are the main reasons to think that there is a distinction between treatment and enhancement.

Whether a given intervention is a treatment or enhancement may vary according to what counts as healthy and what counts as sick. Suppose a condition that results from a malfunctioning organ (perhaps that has developed from genetic mutation) is highly prevalent among a population. For a theory that grounds disease in function, that condition will count as a disease. Interventions upon that condition may then count as treatments. But for a theory that grounds disease in statistical normalcy, that same condition will count as not a disease. Interventions upon that condition may then count as an enhancement. If there is a morally relevant difference between treatment and enhancement, then different accounts of health and disease will imply morally relevant differences in which interventions are permissible or obligatory. For a theory that constructs disease out of values, which interventions count as treatments and which count as enhancements will depend on how those values inform disease. For example, Rachel Cooper argues for an account according to which a disease is a “condition that it is a bad thing to have, that is such that we consider the afflicted person to have been unlucky, and that can potentially be medically treated” (2002, p. 272). On her account, as on mine below, there may still be a morally relevant difference between treatment and enhancement. But where the line is drawn between the two may change according to what is considered “bad” or “unlucky,” whereas for objectivist accounts that line generally won’t move.

There are multiple reasons one might object to enhancement but not to treatment. One reason rests on the claim that the goal of medicine is merely to return a person to how they biologically ought to function. That is, the goal of medicine just is to treat, not to enhance. This goal demarcates the interventions that are medically permissible and those that are not. Interventions outside this boundary are not permissible. Although the primary goal of medicine may be to restore a person to normal, having this goal cannot be a reason to think that enhancements are impermissible. Otherwise, cosmetic surgery would be impermissible. So would vaccines. Vaccines don’t treat anything; they prevent disease. Presuming that cosmetic surgery and vaccines are compatible with goals of medicine, the goals cannot simply be to restore to normal. They must at least also include prevention. But once prevention is compatible with the goals of medicine, it’s less clear that using the goals of medicine to draw the line between permissible treatments and impermissible enhancements is possible. Some interventions aim at preventing suffering rather than alleviating it. Some of those interventions, such as vaccines, may do so by causing a person’s normal function to be greater than it otherwise would be. More generally, once vaccines and cosmetic surgery are included among the interventions compatible with the goals of medicine, it’s not clear that one can draw a morally relevant distinction between treatments and enhancements. If vaccines are permissible because they enhance the functioning of a person’s immune system, why would it be impermissible to enhance the functioning of a person’s cognitive functioning by giving them a drug?

One answer is that vaccines don’t exacerbate unjust social inequalities, but some are concerned that interventions like cognitive enhancements may be more affordable to rich people, which may exacerbate inequality that is already unjust. One might say the same thing for cosmetic surgery. Ugly rich people are better able to use medicine to intervene on their ugliness, which will improve their well-being and further exacerbate the social advantages they already have. I address concerns related to enhancement and egalitarianism in subsequent chapters. But here I note that vaccines would exacerbate unjust social inequalities in very significant ways if they weren’t given to everyone at little to no cost to the person and that they were compulsory. That is, vaccines fail to exacerbate unjust social inequalities because they are provided to people. If they had to be purchased and were as expensive as, for example, cosmetic surgery, rich people would very quickly exacerbate any unjust social inequalities they already enjoy, presumably by living longer, healthier lives.

There may be other ways to draw the line such that vaccines are on the permissible side and interventions on the mind are on the other side. For example, one might think that the relevant difference is that one intervention is on the immune system and the other on the mind, and that the mind maintains morally relevant significance. It’s somehow more closely related to who we are, whereas the immune system is mostly unrelated to our identity or personality. This alleged difference between the immune system and the mind, however, is not a plausible way of distinguishing those interventions that are permissible from those that aren’t. First, drawing the distinction like this would preclude any intervention on the mind, even those that restore function. Second, it can’t support any morally relevant difference between treatment and enhancement. To support such a distinction, one must rely on some account of health and disease.

There is (at least) one more general problem with the claim that we should allow treatments but not enhancements. Bostrom and Ord (2006) introduce the Reversal Test, which is a thought experiment meant to test whether intuitions are grounded in a cognitive bias toward the status quo. They introduced it as a challenge to those objecting to cognitive enhancement, but it works just as well to identify status quo bias in the objection to any enhancement (or even most intuitions). But since this is a book about moral enhancement, I use that as the relevant proposal. The test is a challenge to those who think that we shouldn’t morally enhance. Suppose instead of morally enhancing, we reverse the direction of the intervention or policy such that the proposal is that we downgrade our moral capacities. Then ask, is this moral downgrade intuitively acceptable? Presumably, it is not acceptable to intervene on a person’s moral capacities such that they behave more frequently and more severely immoral. Thus, the opponent of moral enhancement doesn’t want to make our moral capacities better, and they don’t want to make them worse. It thus looks like they have a bias toward the status quo.

The challenge of the Reversal Test is that it requires the opponent of moral enhancement to justify why they think the status quo is a better state of affairs than either widespread moral enhancement or widespread moral downgrade. Why is the status quo morally optimal? The test partly functions to shift the burden of evidence upon the opponent of enhancement. Instead of simply arguing that moral enhancement is wrong, they have to support the notion that the status quo is optimal, which is a difficult task, given all of the bad things that people do and all of the suffering that could be prevented by deviating from the status quo. The task that the opponent of moral enhancement is similar to the task of the person who wants to argue that God exists even though there is a lot of human and animal suffering in the world. A theist has to explain why in spite of all of this suffering this is still the best possible world. The opponent of moral enhancement, by way of the Reversal Test, has to explain why in spite of all the preventable suffering the status quo is morally optimal. Maybe the strategies will be the same. If they are, there is not much hope for the opponent of moral enhancement, given the recurring failure of theodicies. But in the absence of such support, it seems that opposition to moral enhancement is driven by a bias toward the status quo.

Health and Disease

Schroeder’s account of health and disease is comparative. ‘Health’ is defined in terms of “healthier than.” Non-comparative accounts define health and disease first. The two accounts that are most influential are Boorse’s biostatistical theory, which grounds health and disease in statistical normalcy, and Wakefield’s functional account, which grounds health and disease in proper function. Boorse’s theory is the following:

1. (1) The reference class is a natural class of organisms of uniform functional design; specifically, an age group of a sex of a species.
2. (2) A normal function of a part or process within members of the reference class is a statistically typical contribution by it to their individual survival and reproduction.
3. (3) A disease is a type of internal state which is either an impairment of normal functional ability, i.e., a reduction of one or more functional abilities below typical efficiency, or a limitation on functional ability caused by environmental agents.
4. (4) Health is the absence of disease (Boorse, 1997, pp. 7–8).

Boorse first defines disease as a departure from normal function, relative to a reference class. The relevant references class is members of one’s species that are the same age and sex. Whether a condition is a disease depends on whether the condition is statistically typical among that reference class. If the condition is statistically typical, then the condition is not a disease. A four-year-old boy’s condition is a disease if the condition is statistically atypical among four-year-old boys and the condition impairs the boy’s functioning. It doesn’t matter if it is common in adults or men or infants. The relevant reference class is boys of a similar age and how prevalent that condition is among them.

Note that Boorse’s account purports to be value-neutral. None of the conditions embed terms that refer to values. This means that on Boorse’s account, a condition is a disease even if someone wants it, or enjoys, or derives significant pleasure from it, which may be counterintuitive. A condition could both be a disease and improve a person’s well-being on his account. And there’s no way to block this problem, because to do so one of the conditions would need to embed terms relating to desires or well-being, which of course would make it value-laden.

The rejection of any value as a condition of health and disease is what most separates Boorse’s account from Wakefield’s, which is:

A condition is a disorder if and only if (i) the condition causes s...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Preface
• Acknowledgments
• Introduction
• 1 Disease and Treatment
• 2 Preventing Harm
• 3 An Epistemic Argument for Compulsory Moral Bioenhancement
• 4 A Moral Argument for Compulsory Moral Bioenhancement
• 5 The Proposal
• 6 The Epistemology of Moral Bioenhancement
• 7 Covert Moral Bioenhancement
• 8 Transparency
• 9 Libertarian Covert Compulsory Moral Bioenhancement
• 10 Conclusion
• References
• Index