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Friday, April 26, 2002

Session 5: Enhancement 1: Therapy Vs. Enhancement



CHAIRMAN KASS: Why don't we get started.

Today we are shifting gears somewhat to take up for the first time two new topics — the question of enhancement versus therapy and questions of regulation — both sessions undertaken as pilot conversations to see whether there is something in either or both of these topics that would warrant serious attention by the Council in the future.

There's a lot to say about this. I will say just a little at this stage, and really want to see how the conversation goes. First, there is a sense in which the two things we'll be talking about today could be seen as not discontinuous with our interest in cloning, which, although we've spent the better part of our time wrestling with the question of cloning for biomedical research, the major interest in this topic to begin with is cloning for producing children.

And one of the reasons why it is of concern is at least some of us see it as the first instance of possible multiple ways in which one generation could exercise genetic selection over the next with a view to its improvement. And also, the discussion we will have about possible regulation of biomedical technologies is one way into the public policy questions of which we also — we have yet to take up in an explicit way with respect to the question of cloning.

In the cloning case, the public policy option at least on the table is one of legislative prohibition, but the public policy options open to us in this field are much broader, and we have yet to have that broader conversation which we will do today.

On the other hand, if there is continuity between the subjects of today there is discontinuity, if not in the subject matter at least in our approach to it. Curiously to at least this observer, the subject of cloning which first became a hot topic several decades ago in the context of possible eugenic possibilities of producing superior human beings or replicating them now is taken up primarily over the — as a matter of a new and benign treatment for infertility in certain cases.

When we take up the question of the possible implications of going down the road of cloning for biomedical research, we think primarily of the benignness of the ends of medical therapy and bracket to the side other possible uses that might be made of the powers that are available here.

And when we take up the ethical questions there, the primary question has been about the ethics of the means, which is to say, what happens to the embryos that are produced in this — in the research?

We have adopted generally a case-by-case approach in thinking about these matters. It's perfectly understandable because these technologies come to us one by one. We are reluctant, at least some of us are reluctant, to look too far ahead, partly because it's uncertain where things are going, partly because we're practical-minded and don't want to engage in speculation where there are clear practical issues before us.

And I sense that at least some members of the panel are unwilling to allow — unwilling is too strong — are nervous of allowing fears about future shock to imperil the present science. And yet I want to suggest that the reason that maybe not — the reason that we are here not necessarily as individuals, but the reason why the public is concerned about the kinds of questions that give rise to the field of bioethics is — and, therefore, too, in a sense, the existence of a panel like this, is a real concern about where biotechnology might be taking us in the large.

And as Charles said at a previous meeting, his concern is less with where these powers come from, but the uses to which they might be put. Not only are we concerned, if we are concerned ethically, about the harm to newborn children made of cloning, or about the embryos that might be lost in the process, but about what we might do to ourselves and to others when we start to use the powers biotechnology makes available for purposes beyond the treatment of individuals with specific diseases and disabilities.

The promise — I think the concern that is on people's minds is if you put it in the extreme form, the promise, if you like it, or the horror of some kind of super or trans or post-human future, where the prospects of — in the mouth of the proponents — some kind of superhumanization or improvement of the race or dehumanization if you worry about the consequences is at issue.

And I think, as it's been said before in the meetings, we somehow recognize whichever side we are on the question of cloning for research that there are powers available here and ideas that are afloat here that will affect what it means to be a human being, not only from the technologies but also from the underlying ideas.

And as it happens, this morning's Washington Post, in the Style section, which indicates where these things get taken up, there's a story on the next generation where bio-cyborg, etcetera, man is introduced, and it shows you what's happening. I mean, I have never, in 25 years of being in a classroom, brought a newspaper — bring some reference of, you know, Rousseau or Tolstoy or something like that.

But here let me just say here are questions put before us about the possibilities of changing our species, not because anybody is heading deliberately to do it. But what would parents do when offered something that would increase their child's SAT scores by 200 points? And I don't think he has in mind genetic engineering, but certain pharmacological things of the sort we might talk about.

What will athletes do when they are encouraged by extreme big-buck leagues to have medical pit crews? What will fat people do when offered an implant that will monitor and alter their metabolism? What will the military do when it can overcome the need for sleep? What will the aging do when offered memory enhancers? What will babyboomers do when it becomes obvious that Botox and Viagra are just the tip of the iceberg for the pharmagenetic sex-appeal industry?

Supposing technology allows us to transcend seemingly impossible barriers, not only for ourselves but exponentially for our children? What price does trans-human wisdom and power demand?

Now, hyperbolic, journalistic we can I think easily detach ourselves from this if we would like. But I would suggest that it is I think incumbent on the Council at least to explore the possibility that there is something here worthy of our attention. And the question comes to us usually in this form. What should we think about, and what should we do about the uses of these powers when they go beyond the accepted medical norms of healing disease and relieving suffering?

And what, if anything, could be done about this, even assuming that we would like to? Hence, the question about enhancement. Hence, the question about regulation. I think this is a natural context for this.

The question about the so-called brave, new world problem usually comes to us in the somewhat tepid form of the distinction between enhancement and therapy. Enhancement is a rather sanitized name perhaps for what in the mouths of some people is a much more grandiose hope and aspiration.

And I think Council members have been sent a very interesting new book by Gregory Stock called Redesigning Humanity. Stock is a physician, scientist, and futurologist of sorts. He at least has the courage to lay out what he thinks is coming for our consideration.

You don't have to like his point of view on it, but I think it's a useful thing to think about. It may be excessive. It may be not. But I'd be interested in your reaction.

For this first session, we're going to have a preliminary go-around on this topic of enhancement, to ask ourselves whether this is a useful distinction therapy versus enhancement, to see whether it matters to us, and then to try to do so in the light of some concrete cases that have been put forth as possible exemplars for consideration of this topic.

The staff has prepared a working paper that you have in your briefing books that, in fact, explores some of the ambiguities in the terms, makes an argument as to why it still should matter to us whether this is the right term or not, and then gives several examples.

And I would just simply like to open the floor for reaction to the working paper and to this topic.

Paul? Paul McHugh?

DR. MCHUGH: Yes. Well, you asked me if I wouldn't try to kick off something. First of all, in the reaction to the working paper, I like the working paper. It does develop ideas sufficiently far for us to carry on a coherent conversation. It makes very useful distinctions in relationship to certain aspects of therapy and enhancement.

What I miss from it and from the other articles here is any understanding or any clear description of just the several domains of therapy. Okay? Before enhancement.

And you said, for example, Leon, to begin that therapies can be construed easily if we think of healing disease and relieving suffering. But the issue of what you call disorder that comes to a doctor and particularly, by the way, to a psychiatrist can have several distinct realms of enterprise and distinct issues in relationship to disorder and health.

And if you just looked at them in a simple order — I don't want to lecture you too much on this — but I do think the important thing before we talk about enhancement is we do know in what ways therapy — appropriate therapy is now available and is used by doctors and everyone accepts these as therapies, even as they begin to merge on the issue of enhancement.

First of all, a therapy for a symptom or sign that can be tied to a structural or functional abnormality of the body is therapy flat out. It is talking about your disease issue. And that would be the therapies, for example, for pain management or, as was nicely shown in the working paper on dwarfism, a growth disorder in which you can show that the person's sign, namely a lack of growth, is due to a lack of hormone. And the replacement of that hormone is an appropriate treatment.

Now, by the way, with further advances in medical science, more and more appropriate disorders that have a pathophysiological basis related to a structural or functional abnormality will come forward, we'll find more of them. But those are not the only therapies that we work on.

For example, there is an appropriate therapy for motivational drives that are strong enough to overwhelm resistance and produce destructive behavior. For example, gastric stapling for the obese and overeating. We think of that as an appropriate treatment now, protecting people from the obesity that brings it — brings with it other disorders.

But there is appropriate treatment for the sleep disorders like narcolepsy. And for those induced disorders such as nicotine habit, we use Nicorette gum. And even with the paraphiliac disorders we are now using Lupron and other things to reduce the sexual drive. And we see them as appropriate therapies.

The third area is therapy for the dispositional traits that hinder adaptation. And here we begin perhaps to think in terms where enhancement comes into play. But there is no question that Ritalin for the condition attention deficit disorder has been useful. And we are still exploring the place of Prozac in relationship to certain neurotic tendencies and disorders.

And although my friend Peter Kramer has talked about cosmetic pharmacotherapy, there probably are psychological dispositions for which an appropriate treatment is available. After all, by the way — and it might not be a therapy — but all of us use — many of us use a compound that helps us to be a little bit more talkative at parties. And one of them was used on me last night, and I was probably a little too talkative.

(Laughter.)

And a little coffee to wake up.

But to go from dispositions — to go from diseases to motivate to drives to dispositions, and then there are therapies for intense human emotional reactions to life stresses. And here you might think in terms of enhancement, but antidepressants used for people in the throes of serious and deep grief and even sometimes sedatives for life tensions that are occasionally abused, but can be justified in some patients.

It's after that that you come to the cosmetic and health therapies — cosmetic and health therapies, again, that we wouldn't — that begin to border on enhancement but, gee, we wouldn't want to do without them for appropriate treatment. I mean, after all, orthodontia is an appropriate cosmetic therapy, but it also has health benefits. Facial, bodily cosmetic surgery, again, you might wonder about them, but encouraging face lifts or encouraging cosmetic facial surgery to help people I think is not simply enhancement.

Viagra now — it's got a bad press, but it is a cosmetic or a health therapy that I think enhances life circumstances in many cases. And then we come to the therapies on demands that are pure enhancements. I want to be taller, stronger, faster, brighter, and it's there that we really can see that the enhancement issue comes into play.

I've had two encounters with both — with those things. One of them was a personal one when I was a small person in Massachusetts, and somebody suggested to my father I should have human growth hormone. And, fortunately, my father said no. And if he had said yes, at that time those — those hormones carried with them in many cases Creutzfeldt-Jakob disorder, as you know, afflicting people who later — who grew but — and my father said he was small and I was going to be small, and it would be all right.

(Laughter.)

And now I talk with you, with the group, is, as you know, there are — and these are — these would be enhancement issues, because I was not outside of the envelope that Richard put nicely together.

The other one is that with ADHD or the attention deficit disorder issue being clear amongst young people, there are — amongst the intensely interested young people, interested in being sure that their SAT scores are high, there are in a number of private schools minor, and sometimes rather major, epidemics in Ritalin use as the Ritalin gets shared around. And I've had several patients who have developed addictions to the drug.

So my point only is that if we're going to talk about enhancement let us be very sure that we know what therapy is and just wrapping it up with the idea that there is — that therapy is for diseases and everything else would be enhancement might make — might close off opportunities to see just what doctors do for benefits of patients.

CHAIRMAN KASS: Thank you very much.

Mary Ann, please.

PROF. GLENDON: I do think it's very important to discuss this aspect of the problem, and I would say not just for the future but right now in our current report. And I thought the paper was wonderful, but there are two dimensions that I hope we would add — demographic and economic. Let me explain what I mean.

I think that we need to, for the purpose of understanding what is likely to happen in the near future in this area, we need to talk about the aging of the baby boom generation and the very likely increased demand for services that are more on the enhancing end than on the therapeutic end.

And on the economic side, I can't help thinking yesterday and today about a conference I attended two weeks ago on globalization and poverty and wondering how these conversations would sound to somebody from a poor developing country, and especially in the area that we take up this morning.

It seems to me that if someone were here from a part of the world where many people don't live long enough to have expensive diseases they might truly be astonished at — and here's where I'm getting into the economic dimension. I don't know exactly how we build this up or whether there's existing research, but I know in our first meeting Dr. Foster and Dr. Dresser both raised this question about how we are allocating resources, who benefits, and if you view our question globally those questions become very acute indeed.

Enhancement for cosmetic purposes, treatment of the very expensive diseases of old age, in a world where many people do not live long enough to either require the former or the latter.

Oh, one other thing is I do think somewhere in our report we ought to have some information about what Dr. Foster raised in our first meeting. Who benefits from the various technologies? Who is investing in them? Just a picture of the whole economic background would be very helpful.

CHAIRMAN KASS: Bill May, Janet, Charles.

DR. MAY: Before the era of pharmacological interventions, the topic of enhancement came up in the thought of that cheerful optimistic Norman Vincent Peale and the power of positive thinking. And a friend of mine wondered what it would be like to see a pole-vaulting contest with two positive thinkers on opposite sides competing with one another. You could never bring the meet to an end.

One thing that doesn't receive as much emphasis but that is there on the margins is the whole question of enhancement in the form of life-extending technologies. I think one faces a very difficult issue when it comes to the issue of the choice of means to knock out adventitious disease and death on the one hand, and the use of some means towards the end of life-extending technologies, to move towards 110, 120, 140 years.

And one may have one view on the question of cloning for biomedical research if one is talking about adventitious disease and death, but quite another view if you're talking about the organization of resources and the mobilization of nascent human life towards the end of life-extending technologies. And it is this dimension of the problem of enhancement that I think has to be part of the discussion.

CHAIRMAN KASS: You mean changing the maximum life span is —

DR. MAY: That's right.

CHAIRMAN KASS: Yes.

DR. MAY: That's right.

CHAIRMAN KASS: Janet, please.

DR. ROWLEY: Well, I think we should really take a rather cautious view of how we extend our discussions in this area. It's true that many individuals, particularly those with resources, can already take advantage of whatever they feel science or other modalities have to enhance aspects of their life. And I think that this is really a matter for individuals to solve for themselves.

I notice that the examples that are included in
working paper 7 — none of them involve embryos. So they're all, at least as far as I could see when I read them —

CHAIRMAN KASS: Deliberately.

DR. ROWLEY: Okay. So this is — that's fine.

CHAIRMAN KASS: Yes.

DR. ROWLEY: But then if one is — because it seems to me that the major concern or a major concern that has been expressed is how we will be able to manipulate DNA such that we will enhance the zygote to develop into a smarter, stronger, to quote Paul, faster human being.

And it's in that area — and I think I mentioned this in the first meeting — all of these traits involve anywhere from 50 to 100 to 200 individual genes working together in a highly regulated, concerted fashion to lead to somebody who is very smart or very tall, or whatever.

We don't have a clue about that. We probably are not going to have a clue about those interactions, both positive and negative, for another 10 or 20 years. So I think that enhancement, in terms of somebody — for reproductive cloning is so far down the line that, again, that's not an issue that we need to take up.

CHAIRMAN KASS: Let me say there has been talk about our report. This is not — this discussion about enhancement is not for the cloning project. I mean, this is question — one of the nice things about this question is that it's not tied to any particular technique, but it is a kind of question that cuts across the board and enables us to ask, how do we begin to think about the uses of powers that go beyond therapy, however broadly we finally decide we should define therapy? What norms and standards should guide us?

And I think Janet's point is very well taken. My own suspicion is that this fine-tuning of the higher human powers through genetic intervention is mostly talk, and certainly talk for a long time. But pharmacological things, things based upon coming trends in neural science, or the use of — and the Olympic Committee is already quite concerned about blood doping the muscle mass of mice.

Using just injection of — using DNA vectors to — in mice has increased their muscle mass some threefold. And the Olympic Committee is already very concerned about the uses of EPO to change performance — in effect, the whole character of the Olympics.

So I think we should — if we are going to take this up, if we take it up, we should be very careful to use examples that are here, plausible, and not simply leap to the things that are far-fetched. I think that's a caution very, very well taken.

I have Charles, Gil, and Elizabeth. Was it on this point, Elizabeth? Because I don't —

DR. BLACKBURN: A very small point.

CHAIRMAN KASS: Please.

DR. BLACKBURN: You said DNA vectors. And I thought since we are in a large group of people with different backgrounds we should just define that. It does not mean introducing DNA into the cells or the genome of people, but simply the DNA is used to make the product that you are talking about.

CHAIRMAN KASS: Yes.

DR. BLACKBURN: I'm not sure if that was clear to everybody. I thought that it was worth clarifying that technical terminology.

CHAIRMAN KASS: Thank you. I lost my place. Charles and then Gil, Michael Sandel, and Dan.

DR. KRAUTHAMMER: It was deeply refreshing to go a half hour without hearing the word "embryo."

(Laughter.)

But that's over now.

(Laughter.)

I agree with you that we ought to concentrate on the here and now, and that means one-shot enhancement versus germ line enhancement. But I'm not sure that one-shot enhancement — I mean, the kinds of things that Dr. McHugh was talking about, are that much unrelated to the age-old enhancement of alcohol.

I mean, we have a paradigm for dealing with enhancement. It's not exactly a new problem. It's got new dimensions. I think what is new is the prospect it could be a decade or two or more away of — germ line enhancement — of changing us permanently. And as a Commission with a wide mandate, I'd like — I'd hope that we could discuss that also. We probably would be the first to think about it officially. We might contribute to people's thinking about it when it becomes more imminent.

And one of the reasons it's important, as Professor Glendon mentioned, there is a question of economics. There's a deep question of, as opposed to international inequality, of national inequality. If we are going to have permanent enhancements of a similar kind to germ line enhancements, it is overwhelmingly likely that it'll be the rich and that those well-positioned who will have access, and what that does is it changes a society with shifting inequalities to a society of permanent inequalities.

And that I think is a deep social issue which will really challenge us in the future. And even though it is in the future, I think it's worth us thinking about now as a way to contribute to people thinking about it when it actually becomes imminent.

CHAIRMAN KASS: Thanks, Charles.

Gil Meilaender?

PROF. MEILAENDER: Yes. I just wanted to think a little bit about where Paul started us, because I really do think if we're going to try to say anything about this, or even just talk about it, it's very puzzling.

If we start at the furthermost reaches of Paul's set of possibilities — I mean, people don't just want to — they don't just say they want to be taller, stronger, brighter. I want to be those things because I'm not happy right now. You know? I'm just not happy with my place in the world. Or maybe if I have taken a philosophy course, I'm feeling alienated even.

So the — if we're not able to make some kind of therapy enhancement distinction, we're not going to know or we're not going to have any sense of kind of what it would be appropriate for a doctor to decline to do, what it would be appropriate to think that somebody — some third party should fund, what it would be appropriate to regulate or not regulate.

And, I mean, Paul presented a series of steps, but I don't think there's any reason to think that what I counted as number 6 in it, you know, has thus far been demonstrated to be enhancement as opposed to therapy.

Now, I think it is, in fact, but one needs an argument more clearly spelled out. And even going farther up, you know, the emotional reactions to life stresses, well, there are a lot of religious thinkers who think that life is always stressful, and that it's not actually wrong to feel alienated in the universe. After all, one needs a certain kind of answers to those questions.

That's not necessarily a medical problem. That might be really keen insight into the nature of things.

So this is just — I mean, this is not to provide an answer but to say that I don't think there is any progress to be made in thinking about the question if somehow or other we don't really clarify that issue, not just talk about it but actually try to clarify for ourselves what it is.

CHAIRMAN KASS: Could I — no, let me hold back. We'll come back to it. Let's go in queue. Michael Sandel and then Dan, Frank, and Rebecca. That's what I have.

PROF. SANDEL: I do think we should take up the topic, and I think we need to address the questions that Gil and others have raised. We have to — apart from deciding where the line is between legitimate therapy and enhancement, and in the course of drawing that line, we'll have to press ourselves, demand of ourselves, that we try to articulate what human goods are at stake in drawing a line, whether for moral or regulatory purposes.

In the case of — and I think that we can do that. I suspect — and this is just initial speculation — that the objections that we will find ourselves articulating to enhancement, whether of the one-shot or of the germ line kind, will have some close kinship with the best reasons to worry about reproductive cloning, which is that in both cases the morally troubling feature is a kind of hubris and a picture — a world picture in which we, as human beings, aspire to mastery or sovereignty or control — ultimate control — over nature and ourselves such that we come to be and to see ourselves as self-creating beings who can make ourselves over according to our desires.

I think that's what's troubling about reproductive cloning because it's cloning for a child of a certain kind, according to our own design and ambition. And I think that's ultimately the moral part of the objection to enhancement.

And in order to draw the distinction, even if that's the underlying moral worry, we are going to have to try to work out some account of what normal human flourishing is, or health, and that might be that account which isn't an easy matter to articulate. That kind of account would have to provide reasons to restrain the drive to self-mastery and self-perfection that may underlie — may animate the drive to enhancement and perfection, and that we would want to reign in.

I would also — so I think that's the fundamental moral issue that we're going to — and I think we should try to take it up, and others may have different ways of accounting for what troubles us about enhancement. But I would just also want to add support to Mary Ann's proposal that we include in these discussions the economic dimension.

Now, there is a certain paradox in having these two discussions, because on the one hand we're saying these various techniques of enhancement are deeply dehumanizing properly understood. And then, with another part of ourselves we say, and, by the way, we also worry that these dehumanizing technologies will only be available to the rich, and that's unfair.

(Laughter.)

So I think there is that paradox. But I don't think the fact that it's paradoxical should lead us to shrink from either part of that discussion, because I think there is something troubling on both poles of that paradox.

DR. KRAUTHAMMER: Ice cream is equally dehumanizing, but everybody wants it.

CHAIRMAN KASS: Please, Janet, a quick point.

DR. ROWLEY: This is just a quick response to Michael, because one of the nice things about Paul's discussion was that he emphasized that this is really a continuum of things about which there would be almost no question to things that we all sort of laugh at and hope that we don't have such a shallow view of ourselves and our place in the universe.

But, you see, Michael continually used the word "line," that there is a line over which you go. There is no line in my view, and the line is going to depend — for each individual case it will be different and the circumstances of those cases. So to deal with this discussion as though there is an absolute answer, which will be applicable across all of these complex situations, I think is not correct.

CHAIRMAN KASS: Well, I'll sit back.

(Laughter.)

That's the trouble with conversation. You really want to continue it, but there's a queue. Dan?

DR. FOSTER: I only want to make one — by the way, I agree with the issues of justice and the other things that have been said, and I certainly think — and I've already told Leon, I think we clearly have to discuss the issue of germ line therapy.

And, by the way, even when you do somatic gene therapy, it's now clear that there's a danger of leak into the gonads. I mean, for the genes that you put into the muscle, there's a clear-cut risk of overflow into the germ cells. So we have to be careful about that.

I only wanted to say in terms of life enhancement and extension of life that — particularly extension of life that Bill spoke about, we know pretty well already how one can extend healthy life from Drosophila through — not absolutely proven in humans, but indirectly, and that is to undereat.

There is no doubt — it was first shown in rats by Donald Massoro 25 years ago at the NIH, that if you semi-starve rats that you increase their lives 20 to 30 — now, if you starve a fruit fly, it's very interesting. This was done and people didn't understand why the flies were living for a long time. Not only did they live, but they were reproductive late into life. They continued to be able to reproduce.

And the key gene involved with that — these gene people always give these cute names to them — it's called INDY. I'm Not Dead Yet. That's the INDY gene —

(Laughter.)

— in the fly. You know, it's just like Tin Man gene in heart development. The Tin Man had no heart, and if this gene is mutated you don't get a heart, you know, so they — so there are things that we can do without any biotechnology or anything else just by healthy things that would allow us presumably to live long. We don't know whether the dementia would be impaired or things of that sort.

You have to be careful, because I get challenged about this sometimes. If you measure the body mass index, which is what everybody uses for obesity and weight, it's just the weight adjusted for height. And a normal body mass index is 25, and obesity is at 27 in this country, 30 in the world. It's a J-shaped curve of excess mortality.

So, in other words, as you go above — as you get more and more obese, then it's a logarithmic increase in deaths from everything from colon cancer to diabetes, and so forth. But it's a J-shaped curve, so if you're BMI is very low, that you have an excess mortality as well. Those are sick people. Those are people with restricting anorexia nervosa, where you have sudden death, or cancer, and so forth. So don't be misled by that J-shaped curve. That's a pathologic — the short curve on that is pathologic.

So my point is that there are an awful lot of things that we could do — we can do to "enhance life" by just being healthy, and I just wanted to make that point.

CHAIRMAN KASS: Thank you.

Frank, Rebecca.

PROF. FUKUYAMA: I wanted to respond to something that Janet said, and then to ask Paul a question. I really think that the whole question of germ line engineering is one that we have to address. I think that — and, in fact, the complexity of genetic causation is actually one of the reasons that we have to address it, because the simple fact that we're not going to understand that complexity in its fullness is I think one of the reasons that it's dangerous.

I don't think that's going to stop people from, you know, going ahead and doing experiments on animals in which they modify, you know, one gene and it produces an effect, and then they will try to, you know, reproduce that in humans. And I think what's really problematic about that is precisely because that causality is so complex that it's not like approving a new drug — you know, the FDA approving a new drug where you have a certain set of side effects you're looking for.

I mean, the side effects of that kind of intervention could be, you know, things that don't show up until the — you know, the subject is 60 years old. I mean, they may be very subtle. It may upset all sorts of different kinds of balance.

So it's — I think that, you know, inherently there's got to be a different, you know, standard for approving that. But that — simply the fact that it's complex is not going to, you know, stop development in that area. And, therefore, I think it is something we need to look at.

My question for Paul is it really does seem that psychiatry is a really different domain. And, for example, I don't really understand the process by which things get entered into the DSM as disorders, because it seems to me that that's basically a political negotiation more than a scientific one.

But I wondered if you could — because in other areas of medicine I think there are things that people pretty much agree are pathologies, and there's good reason — there's an etiology, and so forth. But in psychiatry, that's not true.

DR. MCHUGH: For some psychiatrists it's not true. I'd put it to you that way. I think DSM-IV is the ultimate extension of a problem that we solved — we tried to solve 20 years ago, and it's now a problem in itself, demonstrating that the problems of today are due to the solutions of yesterday.

Let me just make that clear. In the 1970s, psychiatrists couldn't do research, really, because they couldn't agree on what was, for example, schizophrenia. You're called schizophrenia in Baltimore; you'd be called manic depression or maybe panic anxiety in San Diego.

The DSM process was to try to give us a common nomenclature with the idea that we would become more reliable. And, therefore, if I said I did research on schizophrenia and had these results in Baltimore, it would be replicable in Boston as they were trying to find reliability.

But DSM-IV and DSM-III are really a nomenclature that could as easily be organized alphabetically as it could any other way. And now we are really troubled by two things in it. One, that it's drifting away from medicine. We are inventing more and more diseases or disorders in DSM-IV, such that it's expanding exponentially. There are now 2,000 different forms of depression that you could figure out from that book.

And there are also conditions that are invented that are in that book. You have to just get a group of psychiatrists together, and if they say something exists they can put it in the book. I'm surprised — you know, I'm happily surprised that witches aren't in the book. There are criteria for finding a witch, after all, but we had that trouble before. So —

CHAIRMAN KASS: That's not a disorder anymore.

DR. MCHUGH: Excuse me?

CHAIRMAN KASS: I said that's not a disorder anymore.

(Laughter.)

DR. MCHUGH: That's not a disorder anymore, but it's operationalized.

CHAIRMAN KASS: It's a lifestyle.

DR. MCHUGH: I can show you the book in which they show you this is an operationalized term. You drop them in the water. If they sink, they're not a witch. If they float, they are.

(Laughter.)

Massachusetts has a lot to answer for.

(Laughter.)

The future right now, in my opinion — this is a side issue, but it relates to what we're talking about. Psychiatry has to move in a direction of more and more valid conditions that relate to certain kinds of underpinnings that relate to the brain or to other clear human disorders.

And we have not done that, and I think the next 10 years is going to be very interesting in the developing of DSM-V. If DSM-V is identical, or just an extension of DSM-IV, that will be a disaster for this discipline.

DR. KRAUTHAMMER: Could I add a cul-de-sac on that diversion? I worked on DSM-III in the '70s, particularly with Jerry Clerman on the depressive disorders. And you're right, Frank. There's a lot of politics in it in the end. It was — as was pointed out; it was a serious attempt to systematize nosology and to get sort of a reproducible list of symptoms and signs that would model what happens in the rest of medicine.

But in the end, of course, it's politics, unlike — I suppose unlike the criteria for Type 1 diabetes. The criteria for major depression are negotiable, so you negotiate them; you end up with a consensus.

The one virtue is that you establish a preliminary consensus in DSM-III, and then you spend a decade seeing if empirically it separates patients into groups that are therapeutically useful. And that's how over time you eliminate the politics. But as of now, there's a lot of politics in the negotiations.

CHAIRMAN KASS: Rebecca, Mike Gazzaniga.

PROF. DRESSER: When we talk about decision-making about enhancements or borderline conditions, I think we should approach it with the recognition that these decisions will be made at different levels. I doubt if there are many bans. There might be some. But there will be decisions on allocation of resources.

And professional standards — that is, clinicians saying here is what we consider to be legitimate practice of our profession, professional integrity issues — and then decisions by people who are seeking these interventions. And I think the rubber meets the road pretty much on these final two — in these final two areas about — and I think it was in the early '90s I was trying to help draft a statement on use of growth hormone for the American Academy of Pediatrics Bioethics Committee.

And we all agreed that this — the reason people don't want to be short is primarily due to social reasons. That is, if it weren't a stigmatized condition, and if cars and kitchens and so forth were designed to fit people who were short, then this would not be a problem.

On the other hand, the pediatricians say, "What am I supposed to do when the parents come in with their short kid? Everybody is miserable. It looks like the child is going to be short for genetic reasons. How do I say no to those people? You know, I need help."

So the pediatricians need help, and then the people seeking these technologies — I hope that we can help people think better about these choices, because I think a lot of the demand will come from them. So how can we help people be more thoughtful, aware of the risks? And, of course, most of these things will have some risks — and also, the nature of the benefit.

As Gil said, people do these things because they think it will make them happier. And how valid is that belief? Is there anything we can say about that belief?

PROF. DRESSER: Mike?

DR. GAZZANIGA: Well, I want to take credit for having paid for two of Paul's two-shot enhancers last night —

(Laughter.)

— leading to his eloquent opening remarks that really paint a picture. I thought I'd follow up and just get off the germ thing and the clones and the embryos and talk about some of the other gadgets that are around, because I think this is one of the concerns that sort of comes out in the paper, and so forth.

So, in the sphere of high-tech possible aids that are coming down the pike, now being worked on diligently to — for therapy of spinal cord injury, there are people that are working on devices that can somehow read the electrophysiological state of the motor cortex and interpret it through mathematical algorithms that somehow figure out what the motor cortex is trying to say to the spinal cord, and then to physically jump over the lesion the person has at whatever level, plug in the electrodes below the lesion, and by thinking as it were their way through the movement, energize the neurons below the cut and thereby giving rise to mobility.

Now that's a — we're nowhere near there, but there are very, very clever people working hard at this and making advances. Slow, hard advances, I might add, but it's something that's in the tube.

Now, what then comes along is other research that shows that maybe there is some way you can read the desire to figure out what two plus two is by reading your brainwaves and then access this through some artifact that you might have on the side of your head that actually solves the problem for you.

So instead of you struggling with your multiplication tables or your — whatever, this device picks up the essential brain circuitries, pattern of activity, sends it over to this machine, the machine says, oh, he's trying to figure out this problem, the machine figures it out, sends it back to your brain, and the kid raises his hand right as the button — I got the answer before everybody else in the class.

That, too, is a dream at this point. It's talked about, written about, but no one really quite takes it seriously yet. But you can — the way that could work certainly is in the thought processes of some.

But I think this feeds back immediately to the — so there are these things. There are these whole other area of technological developments that the world is going to be hearing about in the press way before it gets solidly built up in the scientific literature.

But, of course, I'm kind of of the view that there isn't a thing that our human species doesn't adapt to once they think about it and absorb into its evolutionary sequence. And we have these enhancements all over the place. The kids now take their graphic calculator in to take the SAT test, and that didn't — that wasn't allowed a few years ago.

So there are environmental enhancers. You can go take the Kaplan test and pretty much bump your score up a couple hundred points if you work hard on it. And all of these things — and I don't think that a reasonable group of people, certainly those of us involved in higher education, see those things as relevant, particularly relevant variables, because what you want to do in science is try to identify the student that is creative, insightful, sees a problem in a way that everybody else in the lab doesn't see it.

And once they have an insight and then do the experiment, all of this sort of elevated notion of being higher on an SAT is just part of the data analysis. And the data analysis is — while it seems opaque and hard to do when you don't know anything about it, that's the easiest part of a scientific exchange is coming up with the idea and the insight on how to proceed is the challenge. And I don't think anybody has a clue about what sort of gene manipulation encourages that kind of thing. It's a rare, rare thing to see.

And, finally, to return to the germ line issue, which is obviously an important issue, there are many — I think the Council would be well advised to have, as we did yesterday, two leaders of this come in. There are certain major molecular biologists — Eric Lander comes to mind at MIT, who is totally against any germ line manipulation, and there are other biologists — I can't think of one right now, who would be the best for promoting it.

But there is major thinking going on in the major intellectual centers on this point, and I think we'd be well informed to hear about them before we go too far in thinking about it from an ethical point of view.

CHAIRMAN KASS: Michael, thank you.

Michael Sandel?

PROF. SANDEL: I wanted to go back to the moral questions associated with the allocation of resources that Mary Ann raised. And I think this is an issue whether we're in the realm of pharmacological or surgical or genetic interventions for enhancement.

There are a couple of ways one could imagine dealing with this problem. One of them struck me when a year or two ago I read an article about a cure for wrinkles, some kind of wrinkle remover that was produced by a cosmetics company and extremely successful financially.

And it turned out that the compound used in the wrinkle treatment if just slightly reformulated was also a cure for sleeping sickness. And the company agreed to work with a foundation and to make available for free through its production facilities this slightly reformulated version of the wrinkle cream which it could produce in massive amounts because of the huge market for enhancement to cure a disease which was far more morally significant but which would never have been invested in had that been the only reason.

When I read about this, I didn't know whether to be heartened or distressed, heartened that it was a creative solution to the problem, the distress that sleeping sickness and similar morally pressing diseases are only attended to insofar as they happen to coincide with a cure for wrinkles, and so that — insofar as there are those opportunities, that would be one way of dealing with the problem.

But I want to go back to the face lifts that Paul raised — low-tech enhancement — and to I think — the germ line questions force our attention to existing practices that may be morally questionable. And as for the face lifts, surgical or through this Botox, it seems to me — well, I'm not sure, Paul, where you put it on your list, but I take it you don't admire it. It's not something you find morally admirable — the purely cosmetic face lift.

One way we might deal with that — and Janet is worried about excessive regulation. We wouldn't need — if we found — of course, in all these cases, if we find something morally troubling it's a further question what the law should do or what regulation should do.

But if we agree that face lifts, for example, are not morally admirable, but yet they don't pose such a grave problem that they should be legally banned, what we might do with them is what we do with alcohol. We can impose a sin tax. We could consider that face lifts are not a crime but a sin, and, therefore, they should be subject to a sin tax, the revenues of which should go toward the health, or the restoring to health in the case of things like sleeping sickness and malaria that wouldn't otherwise get the resources. That's a modest proposal.

DR. MCHUGH: Can I just say what I do think about face-lifts?

(Laughter.)

It's all in this area of facial cosmetics, which go from treatments that I think we would be very happy to offer anybody to ones that we think that vanity is being served. And there is no — I don't see a good, clear line, because, again, orthodontia could be put into that, too.

Lots of people who were poor when they were children and couldn't have orthodontia and are still unhappy about their teeth get it in their forties and fifties. I had a secretary who, fortunately, got some — she began — I would hate to tax her for that, because she was always very distressed about her teeth.

PROF. SANDEL: Orthodontia is not a sin in the way face lifts are, insofar as it does have some relation to health, even though, you know, it may be marginal.

CHAIRMAN KASS: Elizabeth? Bill?

DR. HURLBUT: I think that one of the things that we have to do is to realize that we are already in an era of enhancement in a certain sense in ways that we haven't been fully attentive to as they've unfolded.

I mentioned the first day the issue of contraception, and here I don't bring it up to judge it, just to say that it was a kind of alteration of our natural reality that slipped in along the gradient of apparent human good, or at least a desire, that went — came in fairly unquestioned at the time, had a significant impact on altering our personal lives and our social existence, and now we're slowly getting a perspective on it.

But this brings me to what I really wanted to mention. That is that at the foundation of this whole question of enhancement are deeper philosophical, almost religious questions about, what is nature, and what kind of a mind has this world produced in the creatures that now have the power to govern nature?

Einstein said that the most incomprehensible thing about the world is that it's comprehensible. That's — I think he meant mathematically, but the question is whether it's morally comprehensible in the sense that we understand ourselves. It's clear that we live and will use our new powers along the gradients of our desires, but within the natural mind it seems to me that desires function as impulses toward a direction, not necessarily a destination as such.

So that if desires, like, for example, the desire to eat that Dan was just speaking of, it may be good for you ultimately to eat less, but in our environment of evolution and adaptation we developed a strong tendency to want to eat more. And so now that we have refrigerators we basically have at our hands more than it's good for us to eat. And so now we have an epidemic of obesity.

So that seems to me to be a fundamental issue. We have to figure out how we relate to nature, what is good within the order of nature, and it's going to take not just scientific knowledge but a kind of self-knowledge of what's driving the force that would produce the gradients along which we would move toward our enhancements.

Does that make sense?

CHAIRMAN KASS: Yes. Thank you.

Elizabeth, did you want to — nothing? Bill May, and then I'd like to put myself on the list.

DR. MAY: As I recall, Alasdair MacIntyre a number of years ago wrote a piece responding to Joe Fletcher's essay on the markers of humanhood, which Joe Fletcher had justified designing improvements in human beings' intelligence and the rest.

And MacIntyre puzzled on the question of what kind of humanity you would like to see in future people, and he ultimately decided that the kind of humanity you'd like to see there would be precisely those dispositions that would lead them to renounce the hubris, the arrogance of designing irreversibly their descendants. A very interesting, ironic piece.

I suppose germ line enhancements would give future generations one more reason to resent the overreaching of their parents — their designer parents — unless one could build into the enhancement the disposition to gratitude.

(Laughter.)

CHAIRMAN KASS: Let me make a couple of comments and then try to maybe get a little more focus into the way in which we are proceeding. I think — just a number of observations I guess, not altogether coherent.

First of all, I think we all recognize that there is continuity here with no lines, which makes this very difficult. The people who trot into this discussion by saying enhancement versus therapy haven't thought enough about it, because the area — nevertheless, that there is a twilight doesn't mean that at a certain point you know that it's day and at a certain point that you know that it's night.

And it's incumbent upon us if we think that there is some distinction here, however fuzzy the boundary is, that's worth making — it seems to me it's worth struggling to try to clarify what it is that is at stake and what it is that — how we might evaluate it. That would be point number one.

And I think this point has been made by others, but the fact that there is already precedent — that was in a way the part — the force of Michael Sandel's question to you, Paul. The fact that certain sorts of things are already accepted, and, therefore, might serve as precedent for the next step cuts in two directions.

We might reevaluate where it is we have gone and see it only in the light of hindsight. And the fact that there are environmental kinds of enhancements may or may not be precedent-setting for what to think about enhancements written into the human body or mind, whether reversible or not.

I'm not begging the question. I'm simply raising it. We came to this before when one wondered about, what's the difference between bioengineering and social engineering? And does it have a kind of different moral character for us to consider?

Third comment — and that has to do with I think it's very — it has to do with the business about inequality and justice. And my response to Michael's very astute observation is to say it's very easy I think for us to treat this question in terms of the distributive justice question and to also recognize what a precious — what preciousness there is to be sitting talking about these sorts of things when there are really much more profound human concerns and questions about the uses of our resources, and so on.

But I think we would do ourselves a disservice if we immediately said, look, the real problem here is that some will have and some will not. I think the first question is whether the thing which is sought for is, in fact, desirable because there will be a great deal of pressure to have what this is, if, in fact, it turns out to be good. And all you'd have to do would be to take a look at the example of the Ritalin use for improved test results.

Let's assume for the moment that there is something like this which actually improves attention span and people get wind of it. The pressure, even on the people who have no interest in using it, is comparable to the pressure that is now available to extra tutoring and extra — those sorts of things.

So that even if it — we don't — even if we leave these matters to free, private choice, the social pressure in the direction of using these various kinds of enhancements, at least in this community, would be considerable. So I think it's rather important for us to try to look — to not start with the question of inequality or distribution, but to look at the question of the enhancement itself, or the alleged enhancement itself, and see what one thinks about it and what its human costs might be, assuming that the blessings of it could flow to everybody. Okay?

Now, maybe we could make some progress on this if we took one of the examples here that's been put before us by the staff for discussion. And I don't know which of them would be most fruitful, but —

PROF. FUKUYAMA: Leon?

CHAIRMAN KASS: Please.

PROF. FUKUYAMA: I have a suggestion.

CHAIRMAN KASS: Oh, please, Frank.

PROF. FUKUYAMA: I mean, this — I mean, I actually was going to talk about the Ritalin example, which I think would serve your purpose as an illustration of —

CHAIRMAN KASS: Well, let's do that. Do you want to start off?

PROF. FUKUYAMA: Yes. Well, I mean, this in a way anticipates what I was going to say when we started talking about regulation in the next session. But you already have a case with the drug Ritalin where you basically have a distinction made between therapeutic and enhancement uses.

And, actually, the point I was going to make when I put myself on the queue was that I think that actually it is easier to make that distinction in practice by a regulatory agency than it is to make it theoretically sitting around a table, you know, with very wise people like this, because, in fact, you know, there is no — well, if you take something like Ritalin, it's used to treat this condition ADHD, which it seems to me is a classic case of a socially constructed disease.

I mean, it's not actually a disease, but it's simply the tail of a, you know, distribution of normal behaviors. And when you get far enough out into the tail, you know, by these very subjective diagnostic criteria that are now in the DSM, you say, okay, this kid has ADHD, and then you can — a doctor can prescribe Ritalin.

And I think using your example about the twilight, you know, there is no — people wouldn't have any question about its appropriateness for people way out in the tail. And I think they would also have a lot of question about pure enhancement use when you're simply, you know, cramming for an SAT, and, you know, have no problem with attention normally.

But you've got this big area, you know, in the middle where I think most of the controversy lies about, you know, whether it's being over-prescribed. And so you can't imagine a drug or a condition that is more subject to this fuzzy boundary between therapy and enhancement, and yet we regulate it, and I think we regulate it, you know, not terribly unsuccessfully.

The DEA prescribes it. It's a Schedule II drug, which means that it is controlled by the DEA as a controlled substance because it is an amphetamine, and it is prohibited as illegal to use it for, you know, pure enhancement uses. But it can be prescribed for therapeutic uses by a physician.

And, you know, you can't justify theoretically, you know, why the cutoff line is where these particular regulatory agencies say it is. And then there's obviously a lot of argument back and forth. And yet in practice, you know, we are able to maintain that kind of a distinction. And I would say that in a lot of other areas, as a practical matter, we will be able to do that.

In all regulation, no regulator can really ever justify the line that they make. I mean, they say, you know, eight parts per million rather than 11 parts per million. Well, why? I mean, you know, in fact it could be moved up or down. But, you know, regulation is a political process in which you get various interested parties that push and shove. And if the institution is designed properly, you can actually come up with a kind of social compromise that is not theoretically justifiable, but, in fact, you know, draws that distinction.

And I think that, you know, as a matter of, you know — I mean, there will be plenty of these fuzzy areas, but I think we already have precedent for society drawing distinctions between, you know, therapeutic and enhancement uses of, you know, psychotropic drugs. And so I don't see why that won't be possible to do in the case of, you know, upcoming technologies as well.

CHAIRMAN KASS: Well, what's your confidence in this? No, I mean, because, I mean, so far the pressures for pushing the boundary have been relatively slight. I mean, well, put it — I guess your question could be followed up in a number of different ways.

Is the implication of this that the philosophical question of where the boundary is, or is it good or bad, is not worth our trouble because the prudent people will somehow intuitively know where it is and take care of it if we give them the proper regulatory mechanism?

Or that the medical profession, which is in charge of prescribing, already has sort of sufficient internalized norms of what is the proper professional use and that they won't give out feel-good pills or, in the elite places, actually administer Ritalin on the side for testing purposes. What follows from this?

PROF. FUKUYAMA: Well, what I draw from this is that you see — you hear a lot of discussions, like the one we've had this morning, in which people quite rightly say, oh, it's very hard to draw a distinction between therapy and enhancement and give lots of examples why that's the case. And the conclusion they draw from that is, therefore, let's not even try to, you know, make that boundary as a practical matter.

And all I'm saying is I don't — I mean, I'm sure there are a lot of cases where it's going to be very difficult to draw that boundary as a practical issue. But we shouldn't give up on trying to design institutions that can maintain that distinction on the basis of a theoretical puzzlement about, you know, where that boundary, you know, precisely can be drawn.

CHAIRMAN KASS: Jim, to this?

DR. WILSON: Yes.

CHAIRMAN KASS: Please.

DR. WILSON: I very much agree with Frank's view. My sense of regulation is that you don't regulate until you have a concrete problem. Regulation in advance, creating entities designed to solve large problems, is creating great mischief in the country.

We created the Interstate Commerce Commission allegedly to regulate the flow of goods across the states — an ambitious title. It worked reasonably well with respect to railroads, and, in particular, it worked reasonably well in getting railroads that took people for short distances, not to charge them more money than other railroads that took people for longer distances. This is a way of ending cartelization and short haul railroads.

But then, lo and behold, trucking came along. Instead of thinking of trucking as a problem, we gave it to the ICC, which made a terrible mess of it. The Federal Communications Commission was started to deal with the problem of radio, but then television came along, and then cable television came along. And the FCC made a mess of handling these other things.

The lesson I draw as a narrow gauge, unphilosophical, political scientist is that society, at least in this country, operates best when it has a concrete problem to worry about.

Now, the Ritalin example that Frank gave I think is a pretty good example. Ritalin comes into use, and after some pulling and hauling, people decide there's some good uses and some bad uses. And they create a kind of regulatory regime around it, which allows mistakes to be made — this will always happen — but by and large probably tries to allocate it in the right way.

But much of what we've talked about this morning, these distant, remote — as Janet Rowley put it out — possibilities for doing X, Y, and Z, I don't think we can draw any political or regulatory implications from these statements at all.

CHAIRMAN KASS: Well, could we separate — since the regulatory question comes after the break, could we bracket that for the moment and stay — I mean, stay either with the Ritalin example — and, Gil, do you want to go back to Frank's comment or — please.

PROF. MEILAENDER: If that's okay.

CHAIRMAN KASS: Please.

PROF. MEILAENDER: Just, I mean, I think it — I think you're right, Frank, that there is a sense in which almost any line drawn is often, in a certain sense, arbitrary — at least in the sense that it could reasonably be drawn at some other places, and so forth.

But I'd be sorry to think that meant that the theoretical discussion was unnecessary. I mean, partly just I'd like to keep drawing my salary. But we want to know why somebody should be drawing a line on this matter in the first place. Don't we? Even granting that there is going to be a slightly haphazard quality to where the line comes down, and that one could argue for different places.

But we want to know why we shouldn't just do as we please in this matter. And in order to answer that question, it seems to me we are going to have to — we're going to have to think about the theoretical question. I mean, so it seems to me it's possible to agree in some considerable measure with your point, but not think that that means that the theoretical discussion is, so to speak, beside the point or unnecessary. I mean, both aspects are going to be necessary.

CHAIRMAN KASS: Yes. Good. Let me try you, Frank. And why — let's take the Ritalin example and leave the regulatory question alone, but just try to think it through. Why should we not allow people freely or — that makes it into a legal question. What's morally questionable, or why should we have any doubts about allowing people to use Ritalin for attention-improving — just for increased attention span, never mind for tests? Why shouldn't they simply be allowed to use it for non-therapeutic ends? But — because it makes them more alert.

PROF. FUKUYAMA: Well, now I — you know, by my previous intervention, I didn't mean to cut off the philosophical discussion, because I think I absolutely agree it's very important. So I'm glad you're drawing us back to that.

I mean, in my view, what's problematic about the enhancement use of Ritalin is that it, you know, challenges certain moral ideas we have about personality and about character, which is that, you know, we learn, for example, attention and focus and putting certain things above certain other things as a result of a, you know, process of education and socialization that allows us to, you know, over time do things — you know, shape our characters in ways that we're potentially there at birth, but — you know, but required a certain kind of moral education.

And, you know, the Ritalin in many cases seems to be a convenient shortcut or a medical shortcut around that that may produce, you know, something like the effect, but doesn't have the — you know, the same effect on character. And, you know, I think it challenges, in a certain way, our traditional understanding of character.

Now, that then begs the, you know, prior question of, why is that traditional understanding of character, you know, something that we want to protect? And, you know, I think that's a worthwhile discussion as well.

CHAIRMAN KASS: Please.

DR. WILSON: Frank, how would you distinguish the use of Ritalin for enhancing one's attentiveness from using a pocket calculator? I mean, was there a moral significance attached to memorizing the multiplication tables which has now been set aside, or what's the difference here between memorizing the multiplication tables or being more attentive during a test? This is a genuine question.

PROF. FUKUYAMA: Yes. No, I — because I think that moral character traditionally had to do with the learning of certain internal habits that, you know, related to, you know, basically being able to, you know, put long-term goals ahead of short-term goals, you know, being able to defer immediate gratifications, you know, for the sake of longer-term things, being able to try to, you know, concentrate one's energies on certain things, and that these are, you know, kind of permanently valuable traits if — you know, if they in fact become habits, you know, that an individual has.

Now, I suppose you could say knowing the multiplication tables and not having to use a calculator is — you know, is a handy thing, but I do think that somehow that internal shaping of character, you know, is more essential to our understanding of what, you know, human goods, you know, just in themselves are than, you know, being able to calculate things in your head.

CHAIRMAN KASS: Mike?

DR. GAZZANIGA: Okay. Let's do a case history here. Leon is chair of this panel. It's beginning to get to him. He's working the midnight oil to 2:00. He's up at 6:00. The White House is calling him. He's got this panel that's not agreeing with him. He's working like crazy to make it all work. This goes on for months.

CHAIRMAN KASS: You could fix that, you know?

(Laughter.)

DR. GAZZANIGA: It goes on for months, and he finally calls up Paul and he says, "Paul, I've got this problem."

(Laughter.)

"Around 2:00 to 4:00, 5:00, every afternoon, I have lassitude. I just, you know, I just can't concentrate." And Paul says, "You know, I can fix that. I can fix that. We'll just pop a little Ritalin in there, and you'll just get through 2:00 to 5:00, and you will be — continue your high level of productivity for these highly moral questions you're working on."

(Laughter.)

Would you take it?

CHAIRMAN KASS: I've been to see him.

(Laughter.)

DR. MCHUGH: I wouldn't prescribe it, but how many —

CHAIRMAN KASS: I went to somebody else.

DR. MCHUGH: Excuse me, Mike?

DR. GAZZANIGA: What's your take on how many physicians would say, "Fine, take a little Ritalin"?

DR. MCHUGH: Well, it's turning out over time that there are some physicians — you can find physicians to do almost anything, obviously. And so some might well do that and, by the way, then get Leon addicted to an amphetamine-like drug, and ultimately get him quite sick.

CHAIRMAN KASS: See, we have to clean this up. Let's not make it easy for ourselves by introducing the problem of addiction. Okay? Now, it might very well be that any of these drugs that are powerful enough to make the kinds of changes that we're talking about — I mean, any prudent person will say anything that's powerful enough to make that kind of a change is a dangerous drug. If it's going to mess with your brain, be careful.

But let's not make it easy for ourself by talking about the secondary consequences either of addiction, or it's bad for my liver, or something like that. But to get, really, to the direct point of what the difficulty with this is.

And I think — let me try it. I'm not sure I can do this very well, although the draft that the staff prepared has something about this. I'm not sure I would put it in terms of moral character as much as I would try to put it in terms of what the issue is. I'm not — not the final judgment. But the question has something to do with the deep structure of what it means to be humanly active.

I think one could affect the outcome of certain kinds of performances and achievements, but they might be less the achievements of the person that — and this is not so much a moral claim that effort is good for you, though I would be willing to make that separately. But it's a different activity if it is not somehow the activity of the embodied and soul delighted human being trying to be at work and doing the work, if you somehow detach the end result from the agent.

So that I can see how you might get different achievements but they — it's not so clear that they would be the achievement of the agent. There's a certain line I think in the staff presentation where if you doped up several athletes — and this is not just a competition point, but what you'd really be praising would be the chemists rather than the agents. And I know what's coming next, because we're just bags of chemicals and it's very complicated.

But I think what one is most concerned here about is not just the unfair advantage that some might have over others, but the tendency to dissociate and disaggregate the deep structure of human activity, the changing — the relation between effort and activity, the changing of the relation between satisfaction and the activity that produces the satisfaction, and the preoccupation with the deed and the achievement separate from its being the achievement of the human agent at work. It's —

DR. GAZZANIGA: Wait a minute. Come on, that's a little too heavy. We're talking about just having you awake.

CHAIRMAN KASS: No, no. I understand.

(Laughter.)

No, I understand. And I think you've put it very nicely, because it seems to me that some of these kinds of things — that would be a perfect one — would be not so much an intervention that would produce a certain result, but would be an intervention that might make me much more fit to be who I am alertly. Right?

DR. KRAUTHAMMER: But what —

CHAIRMAN KASS: I'd just — I mean, to be is to be awake. And if I am flagging, then all kinds of human possibilities are imperiled.

DR. KRAUTHAMMER: But what if his problem is not wakedness but he wants distraction and a bit of a buzz? Isn't this the same question as, why do we not allow people to take marijuana if they want to achieve "happiness" that way? I mean, we have decided as a society that's not a good idea. Is that that different a question?

DR. BLACKBURN: I'd just extend it the other way. Caffeine and coffee — we all, you know, very frequently use it. And I think that's a very interesting example because it has parallels with Ritalin because it, you know, really does have a pharmacological effect, and it's sort of on the other side.

I think we have the difficulty of a continuum of things to think about, and Ritalin seems a little more extreme, because, of course, there is a risk of addiction, and we know there's a risk of caffeine addiction. But I think apart from road rage nothing has been attributed to — you know, there aren't really bad social effects necessarily from —

DR. GEORGE: Leon, just on this point? Or is it — it's Robby.

CHAIRMAN KASS: Robby. Sorry, Robby.

DR. GEORGE: Elizabeth, the parallel with Ritalin in one respect may be even more exact than you think. A few years ago there was some study done that was reported in one of the magazines that comes with so many newspapers — I think it might have been Parade magazine — that seemed to indicate that coffee and caffeine before taking SAT tests improved measurably students' performance on tests.

Well, you can imagine what the result of this was. Kids who never drank coffee were given a cup of coffee before going in to the exam. And, of course, since the Lord works in not so mysterious ways sometimes his wonders to perform, the kids all had stomach pain and didn't do so well on —

(Laughter.)

DR. BLACKBURN: It's the sin tax, right?

CHAIRMAN KASS: Gil? Frank?

PROF. MEILAENDER: Yes. This is relating to this discussion, but it comes back to a point that Rebecca had raised earlier. She said, you know, we need to think about what the benefit really is, and so forth.

And, I mean, we don't want to sound like sort of a moral nanny in some ways, but —

PROF. SANDEL: It's a little late in the day to be making —

(Laughter.)

— that disclaimer, isn't it?

PROF. MEILAENDER: Well, I was making it on your behalf.

(Laughter.)

Sorry. But — and this is by no means a full solution to the problem. I don't mean it in that way at all. I mean, I don't think it gets us off the hook for thinking about the therapy enhancement distinction or anything like that.

But if you think about the thing that Michael raised, we would have far less to fear from these matters if we were better people. And, I mean, there should be some way to say that without just sounding moralistic. In other words, if you're going to bed at 2:00 and getting up at 6:00 because you think the bioethical future of the country rests on what you do, well, then, let's think about that and a virtue like humility, for instance.

(Laughter.)

If you fear for the future if this Council doesn't accomplish some of the good — well, let's think about virtues like hope or courage, you know. And as I said, I don't know how to —

CHAIRMAN KASS: Do they come in a bottle?

(Laughter.)

PROF. MEILAENDER: Well, no, they don't, in fact. And we would have less to fear about these questions, or even about Paul, on one particular occasion, maybe giving you — prescribing the Ritalin if we were better people in a way. Now, that doesn't solve the problem. We're not going to become better people just all of a sudden.

But I think in some way it wouldn't be a complete thinking through of the issue if we didn't take account of that.

CHAIRMAN KASS: Would someone like to join that?

DR. MCHUGH: I'd like to join that and agree with it.

CHAIRMAN KASS: Please.

DR. MCHUGH: And point out that what Michael has described is what happens quite frequently now in my office. I have a lot of people coming in and telling me what I should prescribe to them. They've picked it up on the newspaper or on the ads, and I'm always throwing it back onto the very things that Gil is talking about.

The similar thing was raised by Rebecca when she says you bring kids in. At least three times a year I have very distinguished people bring their what I consider wonderful young son in. They're all Phi Beta Kappa, Harvard graduates, and the like, and the kid's IQ is 110. You know, he's reverted towards the mean.

And the fact is that he's six foot tall, he can hit — you know, all net from the center of the basketball field, handsome as the devil, but they are so sorry that he's not valedictorian or things of that. And my job is to give them hope by telling them —

(Laughter.)

— what a wonderful kid this is. Okay? So that very often I avoid this process of offering medication by talking to people about the meaning of what they're doing, how they are doing it, offering them alternative ways of looking at what they're doing, and some of them are pleased.

(Laughter.)

I emphasize some because —

(Laughter.)

— there are quite a few who go and find another doctor to do exactly what they want done.

CHAIRMAN KASS: Bill?

DR. HURLBUT: So, Gil, do I understand you saying that what makes an enhancement legitimate is the sort of final goal toward which it is set within the larger picture of what human existence is for? What I'm thinking of here is beta blockers, for example, are — they calm your hands, okay? And people use them for a wide variety of things.

I went to a guitar concert once and then found out that the guitarist was using beta blockers. And, you know, half the fun of going to a concert is to see if they can do it in front of an audience.

On the other hand, if my child were in for eye surgery, I wouldn't mind if the surgeon used beta blockers. So it seems to me that behind this whole thing — that's why I said this thing about desire earlier. Desire is — Leon wrote, "Desire, not DNA, is the deepest principle of life." But if that's true, then our desires have to be — form a very coherent cosmology that it's — is it once in the service of our individual life and the benefits of our collective lives?

Because so much of what drives the human psyche underneath is — I don't know what Mike thinks about theories of unconsciousness, and so forth, but I — there's an awful lot of discussion now in neuroscience and related cognitive psychology that a lot of what we desire is driven by things under the surface that nature has put the surface goal into our mind, but behind it connected a lot of things.

That's why I brought the issue of contraception, because there's an example where we feel a desire for one thing but nature brings along a second thing with it. Well, it's just an example. I don't want to use it for anything more than that right now, but the point is that that's a major disconnect in human history — to disconnect a desire from its natural end.

And so somehow we need — I think behind this whole question is a deep question of nature, a deep question of the degree to which we know what is good in nature, and how much we dare to intervene to promote what we think on the surface is what our lives are about and perhaps then miss the thing that they're really about.

I said the first day — I promise this is the last time I'll say this, Leon — but I think we could put ourselves in danger of walking ourselves right off the stage of the drama of our deepest significance.

CHAIRMAN KASS: Let me make a suggestion. I don't know that I can digest this conversation either now. Fortunately, we'll have a transcript. And if we are more efficient this time than we've been in the past, which means if the people at HHS actually will post what we give them, within a week or so we will have a transcript so people can revisit some of these things and think more about it.

I take it that there is encouragement here for at least exploring this topic down the road. There are risks in how we formulate it. We have to pick our topics — the subtopics carefully. Let me say for myself, I'm not sure that the language of enhancement versus therapy is the optimum way to do this.

It might be better to leave that language alone and to ask ourselves, really, the question of, what, if any, are the boundaries between the admirable and the less admirable users of these powers without having to tie it into some definitional thing of what you mean by an enhancement or not.

And part of what's at stake there I think is — and I'm not sure that — Bill, that this would be a way that you would — a reformulation of the point you're making. That would be friendly.

But it does seem to me that thinking about the question of better and worse uses or admirable or less admirable uses or unadmirable uses or degrading uses is some kind of notion explicit — tacit if not explicit — of what it would mean actually to conduce to human flourishing and our fulfillment, which is not a simple matter and it's not for governmental commissions to settle. But at least we can be mindful of the fact that some tacit answer to that question is somehow implied in how one thinks through what norms are we to use when we're not engaged in the business of healing or assisting.

So let — Michael, please.

PROF. SANDEL: Could I just add, along these lines, as I've heard this discussion, I think that however we came at it there is real enthusiasm for exploring the human and the moral implications of enhancements or of — or going beyond aiming at perfection.

And if I could just add a small correction. Before when you chastised those of us who raised the moral questions of allocation for putting that ahead of the underlying moral questions of enhancement, I didn't hear any of that. I didn't hear any suggestion that that should somehow substitute or preempt a discussion of the human consequences and the moral consequences of aiming at perfection. I thought that had been emphasized by everyone who spoke, and I hope that we take that up.

CHAIRMAN KASS: Yes. Thank you. It wasn't a chastisement. If it came across that way, I didn't — it wasn't meant that way. But thank you.

Charles, do you want a word? And then we should stop.

DR. KRAUTHAMMER: Yes. Just one word and a caution. I think as we think about this it's important for us to understand how our discussion will differ from the decades-long debate that the country has had on recreational drugs, which is a sort of paradigm I think of this question. So what are we contributing?

I mean, obviously, we'll be looking at other aspects of this. But fundamentally, I am yet to see how our debate about enhancement and all the issues that we have raised differ from the debate that people have about whether or not people ought to be able to use stuff that makes them feel better, and whether that should be legal or not.

It's an old debate. I'm not sure what's new.

CHAIRMAN KASS: Well, let me say a quick word on this. I mean, it — the temptation is to go either into euphorian drugs or cosmetic surgery, and things of that sort, which are — one could have one's opinions about it, but I take it there are serious people seriously thinking not about just having — letting people have their jollies, but actually doing things that might improve what we are constitutionally, whether it be through computer implants or neuropharmacological interventions, that would actually not just do things that would make us feel better but that might actually transfer in some structural way what we're capable of.

DR. KRAUTHAMMER: Well, that's precisely where I think we ought to focus, because otherwise we would be recreating an old debate.

CHAIRMAN KASS: Yes. But that —

DR. KRAUTHAMMER: It should precisely be about changing human capacities.

PROF. SANDEL: Well, the other difference is the next generation.

DR. KRAUTHAMMER: Right. In germ line, which I was advocating that we emphasize. But since other people have been arguing that it's too long, good term, and perhaps theoretical, I was asking in that case what — how would our debate differ from the older debate here?

CHAIRMAN KASS: Okay. We could use some help at headquarters on this topic. I mean, I don't know — I haven't heard anybody say this is not interesting or not important. The question is how to do it and to do it well.

And since you have an assignment for something on the other topic due in two weeks, let's make this optional. But it would be very nice if there were a subgroup of this — of the members who are especially interested in this if we could hear from you just by letter of either reflections on this conversation, suggestions for how to proceed, and we will try to, in light of that, see where we should go next on this topic and how to do it fruitfully and usefully.

With the usual kind of lack of clear and coherent structure of such a preliminary conversation, let's declare this one a success, take a break, and come back, oh, at 25 of 11:00 for the regulatory discussion.

(Whereupon, the proceedings in the foregoing matter went off the record at 10:17 a.m. and went back on the record at 10:44 a.m.)

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