This staff working paper was discussed at the Council's April 2002 meeting. It was prepared by staff
solely to aid discussion, and does not represent the official views of the Council or of the United States Government.|
Staff Working Paper
Distinguishing Therapy and Enhancement
Technologies based on advances in genetics, pharmacology, neuroscience
and related fields of biomedicine have the potential to help the sick
and provide relief to the suffering, but they also have the potential
to be used in ways that lack clear medical benefits or may even prove
to be improper or unethical. Rejecting these new technologies wholesale
would in many cases mean unwisely foregoing genuine medical benefits,
but accepting them wholeheartedly could in many cases pose significant
moral and social harms that we should work to avoid.
We need, therefore, to find ways to distinguish between proper and improper
uses of these new technologies. A frequently suggested basis for telling
them apart is the distinction between those uses of new biomedical technologies
that aim at therapy and those that aim at non-therapeutic enhancement.
Drawing lines between therapy and enhancement may sound like a straightforward
task in the abstract, but in practice the difference is often far from
This working paper explores some sources of the ambiguity involved, but
argues for the importance of nonetheless seeking out a distinction between
therapy and enhancement.
A. The Ambiguity of the Therapy/Enhancement
A therapy, roughly defined, is a treatment for a disorder or deficiency,
which aims to bring an unhealthy person to health. An enhancement is an
improvement or extension of some characteristic, capacity, or activity.
Both definitions assume at least some general sense of a human norm, which
individuals must either be helped to reach, or which they might be aided
in surpassing (and on the problems of this "norm," more below).
The distinction between therapy and enhancement is hard to articulate
for three principal reasons: 1) they are not mutually exclusive, 2) the
activity involved is often the same, and 3) the standard of health and
"improvement" against which the difference between therapy and
enhancement might be measured can be very hard to define.
First, most if not all therapies are also enhancements, though not all
enhancements are therapeutic, in the sense defined above. It is therefore
not possible to simply classify applications of biotechnology into the
categories of "therapy" and "enhancement," since the
categories overlap. To avoid this difficulty, the term "enhancement"
is generally used only when the activity in question is not medically
therapeutic (or, in other words, it used to mean "non-therapeutic
enhancement"). Even under this narrower definition, however, the
term "enhancement," contains its own ambiguities. When referring
to a human function, does enhancing mean making more of it, or making
it better? Does it refer to bringing something out more fully, or to altering
And even if we could clarify the meaning of the term somewhat, we would
of course still be left with the question of the difference between therapy
and enhancement as it applies to particular applications of biotechnology.
The question would remain because the activities we seek to describe do
not themselves provide the distinction between therapy and enhancement.
This is the second major cause of the ambiguity we confront. In both therapy
and enhancement, the activity in question involves an extension or augmentation
of a certain human capacity. The difference between them is not in the
activity, but rather mostly in the starting condition of the person who
is treated, relative to the "norm."
When the human capacity in question is severely abnormal and the individual
involved is harmed by that abnormality -- say, a severe hyperactivity
that may be treated by Ritalin, or a pituitary deficiency that may be
helped by human growth hormone, or a heritable disease that might someday
be avoided through the insertion of synthetic genes -- the augmentation
is considered therapeutic. When the capacity is not particularly degraded
to start with and the augmentation is undertaken for the sake of improvement
alone -- as with the use of Ritalin to improve the concentration of Ivy
League test-takers, or the use of growth hormones to beat back the aging
process, or (someday) genetic engineering to improve endurance in athletes
-- it may be considered a non-therapeutic enhancement.
These examples, intentionally drawn from the contemporary biotechnological
revolution, demonstrate that the same process or use of technique could
be described as either therapy or enhancement, depending largely on the
starting condition of the affected individual. Therapy suggests bringing
one up to the level of adequate human health, capacity, or performance;
while enhancement suggests taking one up beyond one's existing level of
health, capacity, or performance. The question that defines the difference
between them, therefore, is whether ones existing capacity or level
of performance is adequate, but this is a vague and complicated question.
Adequate for what, and by what measure?
This brings us to the third, and perhaps the most serious, source of the
ambiguity of the line between therapy and enhancement. The standard against
which we might determine whether a given procedure aims at therapy or
enhancement which may be roughly described as the standard of health
-- is notoriously difficult to pin down.
This is so for several reasons. First, there has long been some question
about just what the definition of health, or the goal of medicine, ought
to be. Some argue that health is, to quote the famous World Health Organization
definition, "a state of complete physical, mental and social well-being."
By this definition, almost any enhancement may be defined as health-promoting,
and hence "therapeutic," if it serves at least the mental well-being
of the enhanced individual by making him happier. Others put forward a
narrower definition of health, which proposes more specific goals for
medicine. For instance, Norman Daniels has written that "disease
and disability are seen as departures from species-typical normal functional
organization or functioning," so that health is defined by species-typical
capacities. Daniels draws from this definition a rough sense of what the
purpose of therapy or healing is: "to maintain, restore, or compensate
for the restricted opportunity and loss of function caused by disease
and disability." Successful therapy, therefore, "restores people
to the range of opportunities they would have had without the pathological
condition or prevents further deterioration." In this sense, therapy
makes people whole, while enhancement alters the whole.
This understanding of health takes it for granted that people enter the
world with different natural endowments, and argues that the role of medicine
is not to equalize that distribution (which may be a recipe for endless
frustration) but to prevent individuals from falling below that general
distribution, and from suffering pain and serious discomfort.
But even within this narrower definition, some problems present themselves.
While in some cases -- for instance, a chronic disease or a serious injury
-- it is fairly easy to point to a departure from the standard of health,
other cases defy simple classification. First of all, most human capacities
fall along a continuum, or a distribution curve, and individuals who find
themselves near the lower end of the normal distribution may be considered
disadvantaged and therefore unhealthy in comparison with others. Of course,
some who are "average" may also consider themselves disadvantaged
in comparison with some who are near the top of the distribution. At what
point, then, do we determine that an individual is in need of therapy?
And is it reasonable to make such a determination based mainly on a comparison
with others, or with a human average?
Secondly, the distribution curve of any given human characteristic may
tend to change as biomedical advances introduce new therapies, or even
just as living conditions change. As the bottom end of the curve is raised
up, the average, too, moves higher, leaving different people at the bottom.
Thus, the standard of health proves not to be thoroughly fixed in place
in some respects, and therefore may not be the best measure of the distinction
between therapy and enhancement.
Even regarding capacities that do not have a wide distribution, or where
the average stays put, a change "upwards" need not necessarily
be an enhancement. More is not necessarily better. Everything depends
upon an independent norm.
For all of these reasons, the line between therapy and enhancement is
very hard to specify. Yet the blurring of that line may still be a real
concern, and certain sorts of enhancements may be inappropriate, morally
questionable or even dehumanizing.
B. Why Worry About Enhancement?
The distinction between therapy and enhancement is important for several
general reasons. The first, and perhaps most familiar, is based upon an
appeal to excellence, but opens up a far broader set of concerns. In activities
developed to strain the limits of what a human being can do (like running
a race), enhancements change the background against which excellence is
admired. In a race in which all the participants have used performance-enhancing
drugs, we may find it easier to admire the chemists than the athletes,
and the meaning of the accomplishments involved will be greatly diminished.
This is in essence an argument about integrity in the pursuit of excellence,
and as such may have limited force. But we begin with it because it is
a familiar example that points us to a more serious and general concern
about the separation of human effort from human accomplishment.
This second concern has to do with the relation of means and ends, of
efforts to deeds. The means by which certain improvement or changes are
sought are often essential to the goals pursued. Teaching a child to wait
patiently and sit quietly does more than simply keep a classroom orderly.
It also gives the child some experience in self-control and teaches him
or her the importance of restraint. Medicating the child to sit quietly
would have the same effect on classroom order, but might not have the
same effect on the child. The means by which behavior is accomplished
matters, because the performer is distinct from his or her performance.
A good grade on a difficult test has a different meaning when it is accomplished
by strenuous effort and study than when it is accomplished with the aid
of concentration-inducing pharmaceuticals (just as it is when accomplished
by cheating). Self-esteem means something different when it is the product
of work and accomplishment than when it is the product of cosmetic enhancements.
Human life is an ongoing experience, not a static condition, and so the
way that ends are reached -- the experience of change -- often matters
at least as much as the ends themselves. Separating improvement from the
experience of effort and exertion could tend to undermine the meaning
and importance of improvement, and encourage a mechanistic understanding
of human life that would be both inaccurate and dehumanizing. Such an
understanding of humanity could also undermine personal responsibility,
and diminish the significance of human accomplishments. If self-improvement
were easy, it would not be so satisfying. Artificial enhancement may well
prove to be a barrier to genuine self-improvement.
This point raises an important difference between enhancement mediated
by biotechnology and enhancement advanced by social, cultural or educational
means. The first sort tends to act on the body of the individual involved,
while the second addresses itself to the individual's character, experience
and psyche. But of course the line between the two is not always clear.
A third concern involves the risk of distorting the meaning of human normality.
If enhancements of the sort made possible by modern biotechnologies were
to become commonplace, they could surely affect the very standard by which
individuals judge the need for enhancement. Presumably, a primary reason
for seeking such enhancement is the sense that one is below average with
regard to some ability or characteristic. But by the very act of enhancement,
we raise the average, and therefore may increase the pressure on others
to seek the same enhancement (which in turn would only exacerbate this
effect.) In the process, any distinction between necessary therapy and
optional enhancement will be only further obscured, as more of what was
optional yesterday will come to seem essential. As so often happens with
new technologies, our new powers will create new needs.
Fourth, the widespread use of such enhancements might also tend to confuse
our priorities. When we find ourselves armed with the power to do something
new, that thing suddenly begins to appear more important. If some individuals
use new technologies to improve their appearance, or their height, or
their mood, then others, seeing themselves disadvantaged, will place great
importance on obtaining the same enhancements. In the process, those non-therapeutic
uses of biotechnology -- often uses that tend to focus on shallow or cosmetic
matters -- will make shallow cosmetic matters even more important to us
than they already are. This may also tend to blind us to the substance
of the changes we undertake in ourselves, as the standard by which we
might measure change fades away. After all, if we cannot tell enhancement
from therapy, who is to say that we can tell enhancement from degradation?
Finally, the distinction between therapy and enhancement is also important
in the effort to contain the medicalization of various arenas of life,
and to determine what problems and challenges are (or are not) properly
conceived of in terms of medicine. By distinguishing the proper reach
of medicine -- say, for treating clinical depression but not shyness,
or severe disfigurement but not slight imperfection -- we will be better
able to discern its proper limits.
We see, therefore, the importance of distinguishing therapy from enhancement,
even as we see the difficulties involved in doing so. The question that
now confronts us is how such distinctions can be made, and in what standard
they may be grounded.
In the following section, we provide a few brief examples of specific
technologies that challenge us to draw a distinction between therapy and
C. Examples of Enhancement
1. Therapeutic and Enhancement use of human
Recent biotechnological research and development has made possible the
production and sale of recombinant human growth hormone (rhGH). Some young
children who are of short stature with reference to the appropriate height/age
curve because of a deficiency of human growth hormone, can be restored
to more "normal" height through injections of rhGH. This would
meet the definition listed above as therapy. However, administration of
rhGH to young children who are within the "95% envelope" on
the appropriate height/age curve, in an attempt to make them taller, would
raise the question of whether this was enhancement.
2. Exploration of human brain and nerve-computer
Miniaturization of electronics is another current technology trend. Professor
Kevin Warwick at the University of Reading in the U.K. had a second generation
nerve cell-computer system interface chip implanted between his left elbow
and shoulder in March 2002.
Based on plans described in an interview with Wired magazine in 2000,
wires extending from the glass-enclosed chip will make direct contact
with major nerves running from Warwick's brain to his hand. Nerve signals
as Warwick moves his hand will be transmitted from the chip to a computer
and stored for playback. Warwick plans to test whether the recorded nerve
signals, when fed back to the implant by the computer, can cause the same
motion of his hand.
Warwick has multiple questions that he would like to investigate with
this self-experiment. In the same Wired interview, he outlined several
of them as follows:
"I am most curious to find out whether implants could open up a whole
new range of senses. For example, we can't normally process signals like
ultraviolet, X-rays or ultrasound. Infrared detects visible heat given
off by a warm body, though our eyes can't see light in this part of the
spectrum. But what if we fed infrared signals into the nervous system,
bypassing the eyes? Would I be able to learn how the perceive them? Would
I feel or even "see" the warmth? Or would my brain simply be
unable to cope. We don't have any idea -- yet."
Would a new human capability to "see" infrared be an enhancement?
Biotechnological research and development has isolated the gene for human
erythropoietin (EPO) and produced large amounts of recombinant EPO protein.
EPO is a hormone that stimulates the production of red blood cells, so
it is used to treat kidney dialysis patients and others who suffer from
anemia (therapy). However, EPO has also been used by non-anemic athletes
in attempts to improve performance in competitive events where a lot of
oxygen is required by the muscles (cycling, for example). Would this use
of EPO be enhancement?
DNA vector systems designed to produce human EPO when injected into human
cells are being developed as an alternative therapy for kidney dialysis
patients. Athletes may be tempted to get injections of EPO expression
vectors into their muscles as they prepare for sports competitions. Would
this use be enhancement?
The drug Ritalin is widely prescribed and used in the treatment of Attention
Deficit Disorder (ADD). Diagnostic criteria for ADD include "trouble
concentrating" and "overactivity" in motor functions. Since
there are difficulties in specifying the human norm of "ability to
concentrate" and "overactivity in motor functions," the
diagnosis of ADD is more subjective than other medical diagnoses. Since
there is subjectivity in diagnosis and variable degrees of "trouble
concentrating," defining the limits of this disorder and thus determining
those for whom a Ritalin prescription is appropriate therapy is particularly
In addition, however, students who did not meet even the fuzzy diagnostic
criteria for ADD discovered that taking Ritalin seemed to help then concentrate
during exams. Is this use of Ritalin to be considered enhancement? Does
it differ ethically from drinking a cup of coffee or tea before an exam,
thereby using caffeine to stay more alert during the exam?
Other possible examples of enhancement
1. Germ line genetic engineering to improve the genetic characteristics
of future generations.
2. Aging research that seeks substantial increases in the maximum human